Occupational Musculoskeletal Disorders. Nortin M. Hadler. Raven Press, NY, 1992. Pages: 287. Price: $70.
Neurological surgeons are often involved in the evaluation of musculoskeletal disorders, which are often work related. Work incapacity as a result of these problems is a topic that is not greatly discussed in most residencies. However, it is an issue that neurosurgeons must deal with from the start of practice.
Most new physicians who are asked to render an opinion concerning work-related injuries have little understanding of regional or systemic musculoskeletal disorders and are not prepared to offer such counsel. Many find themselves surrounded by new definitions that are often poorly defined. Add a rather difficult patient who is running the gauntlet of workman's compensation, and the experience is quite frustrating. Dr. Hadler has elucidated this rather complex topic.
The introduction to the book provides an algorithm for evaluating regional musculoskeletal symptoms. When these pains become unbearable, the individual progresses from a well person to a person with a predicament. Somewhere along the line, the person with a predicament turns into a patient with an illness who will seek medical attention. The patient with an illness in the workplace becomes a claimant seeking support from an insurance program. We physicians may not think of a certain patient as a claimant. But the patient/claimant is a fact and a definition that we must understand. The algorithm proves to be helpful in such a situation.
The book is divided into three sections. Section 1 is entitled “The Predicament of Musculoskeletal Morbidity” and includes four chapters. A historical review provides some insight into the development of the complex entity known as regional backache. At the turn of the 20th century, there were many different types of medical providers, different theories of causation, various types of treatments, and advice for almost every predicament. These different schools of theory each considered regional back pain to be within their purview. (These alternative care providers still exist today.) Many times a patient will go from one provider to another seeking relief, which may never come about.
The next chapter defines what each of us deal with on a daily basis–workman's compensation insurance programs. It is pointed out that an injured worker is a patient who becomes a claimant and whose veracity is often in question. In fact, it is up to the worker to convince others that he or she is indeed ill. Dr. Hadler characterizes worker's compensation as a gauntlet in the guise of entitlement that the patient must travel. This chapter provides the novice consulting physician some insight into the difficult environment of worker's compensation.
Another chapter in this section is entitled “The Dangers of the Diagnostic Process.” We are reminded that a patient with a predicament or a claimant will seek a physician, and together they must discuss a given diagnostic label. The patient wants a diagnosis and wants to know what is wrong. Providing a diagnosis for this reason can be quite harmful–a fact with which we must be familiar. This chapter also discusses fibromyalgia. The criteria defined by the American College of Rheumatology must be understood by proponents of the fibromyalgia syndrome. The difference between tender point versus trigger point is an interesting topic, and one that an examiner must be aware of when trying to arrive at a diagnosis of fibromyalgia.
Another fascinating chapter is entitled “All Those Pills.” It deals with the nonsteroidal anti-inflammatory agents, which are often used by physicians dealing with back discomfort. It reviews the history of the nonsteroidal anti-inflammatory medications, beginning with the miracle drug of the 17th century, quinine. The development of the synthesis of these agents is also well presented. The history of the regulation of the drugs' release, including the Food and Drug Administration's approval process, is certainly very worthwhile reading. Many of us are not aware of how difficult and complex this process is for those wishing to submit a new drug for investigation. The risk-benefit ratio of nonsteroidal anti-inflammatory agents is discussed. Several clinical trials of various agents are presented and discussed, particularly in regard to gastropathy. There is no doubt that the elderly are at risk, and the author puts forth the question of why elderly women are exposed to nonsteroidal anti-inflammatory agents in the first place. This is must reading for those prescribing these agents.
Section II is entitled “The Patient with Regional Musculoskeletal Symptoms” and includes five chapters. The concept of regional musculoskeletal illness is clearly defined in Chapter 6 by Dr. Hadler: “The moment the person with a musculoskeletal predicament shares coping with a physician, that person becomes a patient and the predicament becomes an illness. If there is no overt traumatic precipitant, if there is no relevant underlying systemic disease so that the person would be well were it not for the musculoskeletal region that is involved, the illness is a regional musculoskeletal illness.”
The discussion of the axial syndrome in Chapter 7 will be a review for the neurosurgeon who often treats these problems. The axial syndrome will without doubt compose the vast majority of the musculoskeletal illnesses.
Chapters 8 and 9 cover topics of which the neurosurgeon may or may not be aware. They deal with upper extremity regional musculoskeletal illnesses (shoulder, elbow, wrist, and hand) and lower extremity regional musculoskeletal illnesses (hip, knee, ankle, and foot). After reading these chapters, one's vocabulary and diagnostic ability will certainly increase. These chapters are also good reference sources. The entrapment neuropathies are also well described, and this discussion will be a review for the neurosurgeon.
Section III (five chapters) deals with the claimant with musculoskeletal disability. When an individual is injured in the course of employment, he is indemnified by a workman's compensation insurance policy. These insurance programs are administered on a state-by-state basis and are often employed to pay for back pain and musculoskeletal problems. Chapter 11 is entitled “Torts and Musculoskeletal Disease.” The discussion of the medical legal conundrums is important reading for the neurosurgeon.
Chapter 12, “Worker's Compensation and Regional Back Pain,” is a chapter that one may wish to go to right away, A short history of the worker's compensation insurance program is covered and gives insight into this rather complex type of insurance in the United States. Definitions of the work place and back injury are must reading. The section entitled “The Contest of Causation” is enlightening, especially for the beginner.
Another important topic is “Coping with Arm Pain in the Work Place” (Chapter 13). Several studies are described. The author goes into multivariate studies of risk and studies of ergonomic intervention and gives a critical analysis of these studies. People dealing with arm pain and work-related problems must be aware of the government department known as The National Institute for Occupational Safety and Health. Cumulative trauma disorders are now introduced. We as neurosurgeons see injuries that may be classified under cumulative trauma disorders, such as the carpal tunnel syndrome, on a rather frequent basis.
The final chapter entitled “Disability Determination in America” is an excellent review of Social Security and the process of pensioning the invalid. It also covers impairment rating. It does not give an in-depth analysis of how to do disability or impairment, but it does introduce the reader to the American Medical Association Guidelines for Evaluation of Permanent Impairment. For the individual just entering into the world of disability determination, this is a good starting point.
I would certainly recommend this book to the neurosurgical community. The book is quite readable and even enjoyable. Although the problems it discusses will remain frustrating and complex, at least one will have a better understanding and a better working vocabulary. If there is one criticism that I have for this book, it is that there is, on occasion, some editorializing by the author, but one must remember that this topic certainly will evoke an emotional response from all of us.