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Cumulative trauma disorders
Cumulative trauma disorders Dean S. Louis, M.D., Ann Arbor, Mich.
Cumulative trauma disorders, also known as repetitive strain disorders, overuse syndromes, and repetitive motion disorders are not truly new clinical syndromes in the sense that they are solely a product of modem technology. As far back as the 17th century, Ramazzini I. 2 recognized the problems of workers and detailed them in his classic work, Diseases of Workers. "When you come to a patient's house, you should ask him what sort of pains he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats?" So says Hippocrates in his work, Affections. "I may venture to add one more question, "What occupation does he follow?" Ramazzini also observed, 'The mortality of those who dig minerals in mines is very great, and women who marry men of this sort marry again and again. According to Agricola at the mines in the Carpathian Mountains, women have been known to marry seven times." Canadian Henry Sigerise stated in 1958, "The development of industry has created many new sources of danger. Occupational diseases are socially different from other diseases, but not biologically." In 1984, the American Academy of Orthopaedic Surgeons conducted a study that used four data sources: (I) the National Health Interview Survey, (2) the National Hospital Discharge Survey, (3) the National Ambulatory Care Survey, and (4) the Health and Nutrition Survey.4 Their estimates suggested that the direct costs for all musculoskeletal injuries were in excess of $22,186,550,000. The indirect costs for these same conditions were in excess of $5,227,930,000. The total of direct and indirect costs for all other musculoskeletal conditions was in the neighborhood of $38 billion. The combined total for musculoskeletal injuries and all other musculoskeletal conditions was in excess of $65 billion. Looked at this way, the magnitude of the problem as far as the totality of musculoskeletal conditions is concerned is enormous. It must be remembered that the From the Orthopaedic Hand Service. University of Michigan Hospitals, Ann Arbor. Mich. Reprint requests: Dean S. Louis. M.D .• Orthopaedic Hand Service. University of Michigan Hospitals. 1405 E. Ann St.. Ann Arbor. MI48109.
estimates are only in dollar amounts and does not take into consideration the emotional and psychologic impact on a family having to deal with a person who is afflicted with a musculoskeletal condition or injury. In 1980, Kelsey et al. 5 reported on their survey of the frequency and cost in the United States of upper extremity disorders. They concluded that each year 16 million injuries occurred, there were 90 million days of restricted activities, and 16 million work days lost. They concluded further that there were 6 million visits to the emergency room, 500,000 inpatient hospitalizations, and 12 million visits to physicians. They also concluded that there were 3 million consumer product injuries, and 20% of the total involved sports injuries, 33% involved farm injuries, and one third of all disabling industrial injuries involved the upper extremities. Studies from other countries have also suggested that injuries to workers are frequent and approximately one third of all of these injuries involve the hand and upper extremity. Tubiana in 1979 reported this from France, Pardini in 1975 from Brazil, Millesi in 1982 from Austria, Biddulph in 1979 from South Africa, and in the United States, in 1981 the National Safety Council reported similar results. 6
Incidence of cumulative trauma disorders Injuries are relatively easy to document, and statistics involving industrial injuries are numerous, as suggested previously. The incidences of cumulative trauma disorders nationwide are difficult to obtain and involve numerous reasons. In some situations, a cumulative trauma disorder, such as the carpal tunnel syndrome may be reported as an industrial injury, when in fact there has been no frank tissue loss, such as one would see in a punch press injury for example. In other circumstances, they may be classified by entirely different means, which, of course, may have significant impact on insurance costs. In 1984 in the state of Oregon,1607 claims were settled relating to the industrial carpal tunnel syndrome. The average cost per case was $2,204. The average time lost cost per case, or the indirect costs, were $2,467. The total average cost per case was estimated at $5,057 per settled claim. By comparison, THE JOURNAL OF HAND SURGERY
823
824
The Journal of HAND SURGERY
Louis
SYMPTOMS
"
Plant Nurse
Ad Nauseam
Plont M.D. /'
Another M.D.
/
Rest-Splint. etc.
I
"-
Rehab. Nurse
R.T.W.
\
\
Lawyer
!
SX's Return
'\
'"
WC
/ .
Referral
Out of Work
Operation "--
/
SX's R.turn
RTW Clam. job)
~
O. LOUIS
1987
Fig. 1. Management of patients with cumulative trauma disorders.
the average total cost to treat other occupational diseases was reported as $9,114 at the time of settlement.
Legal precedence There is no uniform consideration of some conditions as occupational diseases . For example, in 1975 8 the Delaware Appellate Court refused to reverse their denial of compensation for a worker at General Motors, saying that he must have a peculiar condition-citing the low incidence of the carpal tunnel syndrome in other workers. By contrast, in 19798 the Missouri court considered the carpal tunnel syndrome to be a compensable disorder, inasmuch as it was not, "an ordinary disease of life. "
The surgeon's dilemma It is important to take an occupational, as well as a recreational history for any patient who presents with a condition that might be a cumulative trauma disorder. Considering just the forearm and hand, the conditions that most commonly would present under this guise would be de Quervain's disease, the carpal tunnel syndrome, compressive neuropathies, including the hypothenar hammer syndrome, ulnar neuropathy at the elbow, radial tunnel syndrome, and anyone of a variety of other conditions, including tenosynovitis involving anyone of the flexor or extensor tendons, lateral epicondylitis, chondromalacia involving the elbow joint or involving anyone of the joints in the wrist, not to exclude ligament ruptures . The hand surgeon's place in the scheme of things in the management of patients with cumulative trauma disorders is a pivotal and critical one.
Fig. 1 illustrates the all too often seen scenario of a person with a cumulative trauma disorder. For example, if one takes the carpal tunnel syndrome as being representative of cumulative trauma disorders as a whole, the pattern that is frequently seen, as depicted in Fig. I, is the predictable and inexorable course of the worker. A variety of classic symptoms, such as numbness and tingling in the median nerve distribution develop in the worker. This frequently awakens him at night and is accentuated by on-the-job exposure that usually involves repetitive or hand-intensive activities. It should be noted in some situations, recreational activities also playa part in the genesis of the symptoms, and is important to elicit this part of the history. In a large factory, the worker may initially see the plant nurse. If the symptoms do not respond to conservative management, a consultation may be sought with the plant physician, who usually will try some work modification and other conservative treatment, such as rest and splints. The symptoms in the early phase may subside after this form of treatment, and the worker may be requested to return to his job. After this, with exposure to the same inciting work-related trauma, the worker may then have a recurrence of his symptoms . At this point, the knowledgeable plant physician, recognizing the clinical symptom complex that is most consistent with the carpal tunnel syndrome, will usually refer the worker to the hand surgeon. Invariably, electromyogram (EMG) and nerve conduction studies will be obtained, and if these are abnormal, the worker will frequently undergo carpal tunnel release. At this point, there is usually relief of all symptoms, and after a period of recovery from the operation itself, the worker may then return to work . However, because of the perogatives of seniority and the limited variety of work activities available in most plants, the worker may then find himself back on the same job. Invariably, with this reexposure, the symptoms will return, and this puts the worker in the middle of a real conundrum. The symptoms developed on the job. He has tried conservative means . It has been suggested that an operation would alleviate his problem, and although it did so temporarily, on return to the job, his symptoms returned. Frequently at this point, the worker is out of work because he cannot maintain his productivity on his usual job, and there is no lighter duty for him. Often, if he applies for workers' compensation, this is denied directly, and then the worker must obtain a lawyer, who will argue his case before the Workers' Compensation Board. There now appears on the scene a rehabilitation nurse, who generally is working for the insurance company that carries the employer's workers' compensation. The
Vol. 12A. No.5. Part 2 September 1987
worker may then be required to consult another physician, which in most states is a requirement of workers' compensation laws. And so it goes, around and around and around. In this situation, the people who receive the most benefit from the scenario are the lawyer, and indirectly, the hand surgeon. Surgical thinking has promoted the idea that the carpal tunnel syndrome is a surgical disease. If such a clinical diagnosis is substantiated or objectified by abnormal electromyoneurographic studies, then the tendency is generally to proceed with a carpal tunnel release. After the resolution of symptoms during the early phase, the worker is left in the unenviable position of not being able to pursue the most reasonable alternative-to seek other employment or to accept a less hand-intensive job in his current workplace. To seek other employment might deny the possibility of receiving workers' compensation. Most plants have a limited variety of tasks, and those that are "light duty" command the most seniority. The worker is left without a truly reasonable alternative, i.e., ajob that he can perform without incurring significant disabling symptoms and a means to provide for himself and his family. The mechanisms that are left to him are legal, convoluted, and odious. A system of workers' compensation that was originally designed to protect workers is now working to penalize not only the workers, but all of us-workers, management, and consumers . Unfortunately, this whole matter needs to be reconsidered, and the carpal tunnel syndrome in the workplace needs reappraisal. It has been my experience that
Cumulative trauma disorders
825
in most of these clinical work situations, a beneficial result can be derived from conservative measures. As hand surgeons, we should address surgical problems with diagnostic acumen and applied surgical skills. Nonsurgical problems, such as many of the cumulative trauma disorders that we see, require restraint, understanding, and our advocacy on behalf of the workers who seek our consultation. REFERENCES I. Ramazzini B. De morbis artifican (Diseases of workers). Wright WC (trans). Chicago: University of Chicago Press, 1940:13 . 2. Ramazzini B. De morbis artifican (Diseases of workers). Translated by Wright WC (trans). Chicago: University of Chicago Press, 1940: 17 . 3. Sigerist HE. J Hist Med Allied Sc 1958;13:214. 4. Holbrook TL, Grazier K, Kelsey J, Stauffer R. The frequency of occurrence, impact and cost of selected musculoskeletal conditions in the United States. Chicago: American Academy of Orthopaedic Surgeons. 1984: 1-87. 5. Kelsey J, Post ides H, Kreiger N, Hamar C, Chernow R. Upper extremity disorders-a survey of their frequency and cost in the United States. St. Louis: The CV Mosby Co, 1980:1-70. 6. Blair SJ, Allard KM. Prevention of trauma: A cooperative effort. J HAND SURG 1983;8:644-54. 7. State of Oregon. Evaluation division and insurer cIosurers. 1984. 8. Hadler N. Medical management of the regional musculoskeletal diseases. New York: Grune & Stratton, 1984: 213-28 .
Cumulative trauma disorders, also known as repetitive strain disorders, overuse syndromes, and repetitive motion disorders are not truly new clinical syndromes in the sense that they are solely a product of modem technology. As far back as the 17th century, Ramazzini I. 2 recognized the problems of workers and detailed them in his classic work, Diseases of Workers. "When you come to a patient's house, you should ask him what sort of pains he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats?" So says Hippocrates in his work, Affections. "I may venture to add one more question, "What occupation does he follow?" Ramazzini also observed, 'The mortality of those who dig minerals in mines is very great, and women who marry men of this sort marry again and again. According to Agricola at the mines in the Carpathian Mountains, women have been known to marry seven times." Canadian Henry Sigerise stated in 1958, "The development of industry has created many new sources of danger. Occupational diseases are socially different from other diseases, but not biologically." In 1984, the American Academy of Orthopaedic Surgeons conducted a study that used four data sources: (I) the National Health Interview Survey, (2) the National Hospital Discharge Survey, (3) the National Ambulatory Care Survey, and (4) the Health and Nutrition Survey.4 Their estimates suggested that the direct costs for all musculoskeletal injuries were in excess of $22,186,550,000. The indirect costs for these same conditions were in excess of $5,227,930,000. The total of direct and indirect costs for all other musculoskeletal conditions was in the neighborhood of $38 billion. The combined total for musculoskeletal injuries and all other musculoskeletal conditions was in excess of $65 billion. Looked at this way, the magnitude of the problem as far as the totality of musculoskeletal conditions is concerned is enormous. It must be remembered that the From the Orthopaedic Hand Service. University of Michigan Hospitals, Ann Arbor. Mich. Reprint requests: Dean S. Louis. M.D .• Orthopaedic Hand Service. University of Michigan Hospitals. 1405 E. Ann St.. Ann Arbor. MI48109.
estimates are only in dollar amounts and does not take into consideration the emotional and psychologic impact on a family having to deal with a person who is afflicted with a musculoskeletal condition or injury. In 1980, Kelsey et al. 5 reported on their survey of the frequency and cost in the United States of upper extremity disorders. They concluded that each year 16 million injuries occurred, there were 90 million days of restricted activities, and 16 million work days lost. They concluded further that there were 6 million visits to the emergency room, 500,000 inpatient hospitalizations, and 12 million visits to physicians. They also concluded that there were 3 million consumer product injuries, and 20% of the total involved sports injuries, 33% involved farm injuries, and one third of all disabling industrial injuries involved the upper extremities. Studies from other countries have also suggested that injuries to workers are frequent and approximately one third of all of these injuries involve the hand and upper extremity. Tubiana in 1979 reported this from France, Pardini in 1975 from Brazil, Millesi in 1982 from Austria, Biddulph in 1979 from South Africa, and in the United States, in 1981 the National Safety Council reported similar results. 6
Incidence of cumulative trauma disorders Injuries are relatively easy to document, and statistics involving industrial injuries are numerous, as suggested previously. The incidences of cumulative trauma disorders nationwide are difficult to obtain and involve numerous reasons. In some situations, a cumulative trauma disorder, such as the carpal tunnel syndrome may be reported as an industrial injury, when in fact there has been no frank tissue loss, such as one would see in a punch press injury for example. In other circumstances, they may be classified by entirely different means, which, of course, may have significant impact on insurance costs. In 1984 in the state of Oregon,1607 claims were settled relating to the industrial carpal tunnel syndrome. The average cost per case was $2,204. The average time lost cost per case, or the indirect costs, were $2,467. The total average cost per case was estimated at $5,057 per settled claim. By comparison, THE JOURNAL OF HAND SURGERY
823
824
The Journal of HAND SURGERY
Louis
SYMPTOMS
"
Plant Nurse
Ad Nauseam
Plont M.D. /'
Another M.D.
/
Rest-Splint. etc.
I
"-
Rehab. Nurse
R.T.W.
\
\
Lawyer
!
SX's Return
'\
'"
WC
/ .
Referral
Out of Work
Operation "--
/
SX's R.turn
RTW Clam. job)
~
O. LOUIS
1987
Fig. 1. Management of patients with cumulative trauma disorders.
the average total cost to treat other occupational diseases was reported as $9,114 at the time of settlement.
Legal precedence There is no uniform consideration of some conditions as occupational diseases . For example, in 1975 8 the Delaware Appellate Court refused to reverse their denial of compensation for a worker at General Motors, saying that he must have a peculiar condition-citing the low incidence of the carpal tunnel syndrome in other workers. By contrast, in 19798 the Missouri court considered the carpal tunnel syndrome to be a compensable disorder, inasmuch as it was not, "an ordinary disease of life. "
The surgeon's dilemma It is important to take an occupational, as well as a recreational history for any patient who presents with a condition that might be a cumulative trauma disorder. Considering just the forearm and hand, the conditions that most commonly would present under this guise would be de Quervain's disease, the carpal tunnel syndrome, compressive neuropathies, including the hypothenar hammer syndrome, ulnar neuropathy at the elbow, radial tunnel syndrome, and anyone of a variety of other conditions, including tenosynovitis involving anyone of the flexor or extensor tendons, lateral epicondylitis, chondromalacia involving the elbow joint or involving anyone of the joints in the wrist, not to exclude ligament ruptures . The hand surgeon's place in the scheme of things in the management of patients with cumulative trauma disorders is a pivotal and critical one.
Fig. 1 illustrates the all too often seen scenario of a person with a cumulative trauma disorder. For example, if one takes the carpal tunnel syndrome as being representative of cumulative trauma disorders as a whole, the pattern that is frequently seen, as depicted in Fig. I, is the predictable and inexorable course of the worker. A variety of classic symptoms, such as numbness and tingling in the median nerve distribution develop in the worker. This frequently awakens him at night and is accentuated by on-the-job exposure that usually involves repetitive or hand-intensive activities. It should be noted in some situations, recreational activities also playa part in the genesis of the symptoms, and is important to elicit this part of the history. In a large factory, the worker may initially see the plant nurse. If the symptoms do not respond to conservative management, a consultation may be sought with the plant physician, who usually will try some work modification and other conservative treatment, such as rest and splints. The symptoms in the early phase may subside after this form of treatment, and the worker may be requested to return to his job. After this, with exposure to the same inciting work-related trauma, the worker may then have a recurrence of his symptoms . At this point, the knowledgeable plant physician, recognizing the clinical symptom complex that is most consistent with the carpal tunnel syndrome, will usually refer the worker to the hand surgeon. Invariably, electromyogram (EMG) and nerve conduction studies will be obtained, and if these are abnormal, the worker will frequently undergo carpal tunnel release. At this point, there is usually relief of all symptoms, and after a period of recovery from the operation itself, the worker may then return to work . However, because of the perogatives of seniority and the limited variety of work activities available in most plants, the worker may then find himself back on the same job. Invariably, with this reexposure, the symptoms will return, and this puts the worker in the middle of a real conundrum. The symptoms developed on the job. He has tried conservative means . It has been suggested that an operation would alleviate his problem, and although it did so temporarily, on return to the job, his symptoms returned. Frequently at this point, the worker is out of work because he cannot maintain his productivity on his usual job, and there is no lighter duty for him. Often, if he applies for workers' compensation, this is denied directly, and then the worker must obtain a lawyer, who will argue his case before the Workers' Compensation Board. There now appears on the scene a rehabilitation nurse, who generally is working for the insurance company that carries the employer's workers' compensation. The
Vol. 12A. No.5. Part 2 September 1987
worker may then be required to consult another physician, which in most states is a requirement of workers' compensation laws. And so it goes, around and around and around. In this situation, the people who receive the most benefit from the scenario are the lawyer, and indirectly, the hand surgeon. Surgical thinking has promoted the idea that the carpal tunnel syndrome is a surgical disease. If such a clinical diagnosis is substantiated or objectified by abnormal electromyoneurographic studies, then the tendency is generally to proceed with a carpal tunnel release. After the resolution of symptoms during the early phase, the worker is left in the unenviable position of not being able to pursue the most reasonable alternative-to seek other employment or to accept a less hand-intensive job in his current workplace. To seek other employment might deny the possibility of receiving workers' compensation. Most plants have a limited variety of tasks, and those that are "light duty" command the most seniority. The worker is left without a truly reasonable alternative, i.e., ajob that he can perform without incurring significant disabling symptoms and a means to provide for himself and his family. The mechanisms that are left to him are legal, convoluted, and odious. A system of workers' compensation that was originally designed to protect workers is now working to penalize not only the workers, but all of us-workers, management, and consumers . Unfortunately, this whole matter needs to be reconsidered, and the carpal tunnel syndrome in the workplace needs reappraisal. It has been my experience that
Cumulative trauma disorders
825
in most of these clinical work situations, a beneficial result can be derived from conservative measures. As hand surgeons, we should address surgical problems with diagnostic acumen and applied surgical skills. Nonsurgical problems, such as many of the cumulative trauma disorders that we see, require restraint, understanding, and our advocacy on behalf of the workers who seek our consultation. REFERENCES I. Ramazzini B. De morbis artifican (Diseases of workers). Wright WC (trans). Chicago: University of Chicago Press, 1940:13 . 2. Ramazzini B. De morbis artifican (Diseases of workers). Translated by Wright WC (trans). Chicago: University of Chicago Press, 1940: 17 . 3. Sigerist HE. J Hist Med Allied Sc 1958;13:214. 4. Holbrook TL, Grazier K, Kelsey J, Stauffer R. The frequency of occurrence, impact and cost of selected musculoskeletal conditions in the United States. Chicago: American Academy of Orthopaedic Surgeons. 1984: 1-87. 5. Kelsey J, Post ides H, Kreiger N, Hamar C, Chernow R. Upper extremity disorders-a survey of their frequency and cost in the United States. St. Louis: The CV Mosby Co, 1980:1-70. 6. Blair SJ, Allard KM. Prevention of trauma: A cooperative effort. J HAND SURG 1983;8:644-54. 7. State of Oregon. Evaluation division and insurer cIosurers. 1984. 8. Hadler N. Medical management of the regional musculoskeletal diseases. New York: Grune & Stratton, 1984: 213-28 .