THE JOURNAL OF MARCH
1992
HAND SURGERY
VOLUME 17A, NUMBER 2
AMERICAN
Official journal AMERICAN SOCIETY FOR SURGERY OF THE HAND
VOLUME
EDITORIAL
Occupational
disorders-The
1990s: A challenge
F
disease of the
or a bane for hand surgeons
or hand surgeons, the 90s will be known as the decade of work-related disorders. We can accept this as a challenge or look upon it as a plague. If physicians do not take a leadership role in trying to understand the cause and treatment of this new societal epidemic, work-related disorders can become an economic disaster for American industry and for the economy at large. In Massachusetts alone, the cost of work-related disorders to employers has increased from $800 million to more than $2.5 billion in 5 years, and there is no indication that this trend will change.’ Half of the costs are attributed to cumulative trauma disorders in which there is little hard data regarding either etiology or treatment. Some authorities attribute these problems to a changing industrial environment that requires a greater degree of repetitive and/or forceful hand use on the part of the worker.‘, 3 Others think many of the complaints are related to changing work ethics, patient awareness of cumulative trauma disorders, and psychological stresses associated with the work environment.“’ As an industrial society, we are losing the battle regarding work-related disorders. In many states (certainly in Massachusetts) employers think that the cost of workers’ compensation insurance is impeding their ability to compete in the marketplace.’ In Massachusetts the issue has reached crisis proportions. Companies are relocating, and some believe our economic decline is partly related to our workers’ compensation system. The reason we are losing the battle is that workrelated disorders, particularly work-related cumulative
trauma disorders (CTD) are different from non-workrelated disorders and require different treatment.X In contrast to non-work-related disorders, work-related disorders have three components that must be addressed: (1) the musculoskeletal problem, (2) the psychosocial component, and (3) the legal issue. When the psychosocial and legal issues are not resolved, the patient’s medical problem is rarely solved. The importance of the psychosocial forces in treating workers was shown in the Kappa Delta Award-winning paper (Bigos SJ, Battie MC, Spengler DM, et al. A longitudinal prospective study of industrial back injury reporting institution) presented at the American Academy of Orthopedic Surgeons meeting in 1991. In a prospective study on back patients, Bigos et al. found that the most significant factors among patients who did not do well were the perception that they hardly ever enjoyed their job and evidence of depression on the Minnesota Personality Multiphasic Inventory test. These psychosocial issues are related to the job, the insurer, and the physician and concern the patient’s perception of how he or she was treated by the “system.” In many cases the worker/patient perception is that in one of these three areas treatment was inadequate or unfair. Such comments as “the employer never visited me,” ” I told them that the machine needed repair,” or “the doctor spent 2 minutes with me and said nothing was wrong and go back to work’ is often voiced. In this litigious society, patients are quick to turn to lawyers who exacerbate the problem without helping the patients very much, and the workers become more frustrated, angry, confused, depressed. and fearful about returning to work. THE
JOURNAL
OF HAND
SURGERY
193
194
The Journal of HAND SURGERY
Editorial
Hand surgeons are frequently asked to see such a patient after several months of unsuccessful treatment. The worker has pain, usually ill defined in both its nature and its location and far out of proportion to any objective physical findings. The patient may have had weeks of treatment, which included splints, nonsteroida1 anti-inflammatory drugs, cortisone injections, and therapy, without any notable improvement. Hand surgeons who deal with these patients soon realize that the failure to respond is related to the underlying psychosocial components more than anything else. A few carefully posed questions will sometimes produce a barrage of complaints or an emotional outburst regarding the terrible way the patient has been treated by the employer, insurer or previous physicians. Other questions can elicit feelings of frustration, anger, or fear of returning to work and a significant depression. In many cases the patients are unaware of these emotional problems and focus only on the pain. Psychiatrists explain the chronic pain as “equivalents” of fear, anger, frustration, and depression.’ Some persons are unable to manifest these emotions, and their distress is projected into pain. Although there is certainly the secondary gain issue associated with being on workers’ compensation, few of these persons are considered malingerers. The very system that compensates these workers for being disabled is often a deterrent to getting them back to work. The disabled worker is certainly a victim of a system that was originally established to protect him. Many physicians find these patients so difficult to treat, so time consuming and professionally frustrating, that they refuse to treat them. The patients may then seek out those on the fringes of health care who are more happy to treat them seemingly forever and without improvement. What is the solution to this increasingly difficult problem? Reform must occur in many areas. But what is our responsibility as hand surgeons who care for such a large percent of patients with work-related disorders? We must encourage our professional organizations to support studies on epidemiology, etiology, and treatment of these disorders. We must work with mental health professionals to understand these complex issues. Both at professional meetings, such as those of the American Society for Surgery of the Hand and the American Academy of Orthopedic Surgery, and in journals such as this one, increasing time and space are devoted to these problems; this can only help to shed further light on them. As individual hand surgeons, we must admit that many of us are untrained and uninterested in dealing
with these complicated and frustrating psychosocial issues. Some of us are not emotionally attuned to dealing with these problems, and we become frustrated, angry, and defensive when we see these patients. If this is the case, we should appreciate our own limitations and choose not to treat such patients.” However, all of us must understand the unique aspects of work-related disorders and realize that they cannot be “surgically excised.” When the diagnosis is unclear or treatment is not progressing satisfactorily, we should realize that the mind may be playing a greater role than the body. Maybe an MMPI would be more appropriate than an MRI for some chronic wrist pain, or maybe vocational rehabilitation should be considered before an osteotomy of the radius. Treating these patients can be both challenging and rewarding. As soon as you realize that many of the patients have psychosocial factors that impede their recovery, you can begin to solve the problem. There is no area in medicine in which sympathetic listening followed by compassionate questioning is more important. In many cases you will be the first person to explore these nonorthopedic areas. Many workers’ compensation experts emphasize how the physician’s involvement can be critical in resolving sensitive issues.” In areas where they are available, medical rehabilitation nurses can be instrumental in helping the physician direct and manage the multiple factors that enable the patient to return to gainful employment.” These nurses have the training to understand the psychosocial issues and time to explain and implement the medical treatment. Hand therapists often fill this crucial role and certainly can be very helpful in complementing the nurse’s role. As hand surgeons, we have faced and successfully dealt with a number of challenges, ranging from primary flexor tendon repairs to free tissue transfers to reconstructive rheumatoid hand surgery. Today we face a new challenge-one that combines the mind and the body. With commitment and perseverance, we can again be successful. Lewis H. Millender.
MD
REFERENCES Summary and Sectional Analysis of Workers’ Compensation Reform Legislation (H. 11201 S. 64). Filed by Associated Industries of Massachusetts, Boston, Mass.. March 1991. Armstrong TJ, Fine LJ, Goldstein SA, et al. Ergonomics considerations in hand and wrist tendinitis. J HAND SURG 1987;12A(Suppl):830-7. Amdt R. Work pace, stress, and cumulative trauma disorders. J HAND SURC 1987;12A(Suppl):866-9.
Vol. 17A. No. 2 March 1997
4. Hadler NM. Illness in the workplace: the challenge of musculoskeletal symptoms. J HAND SURG 1985: lOA:451-6. 5. Ireland DCR. Psychological and physical aspects of occupational arm pain. J HAND SURG 1988;13B:51-10. 6. Dawson DM, Hallet M, Millender LH. Entrapment neuropathies. 2nd ed. Boston: Little, Brown, 1990:357-74. 7. Hadler NM. Cumulative trauma, carpal tunnel syndrome in the workplace - epidemiological and legal aspects. In: Gelberman RH. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991:949-56. 8. Millender LH. Occupational disorders of the upper extremity: orthopaedic, psychosocial, and legal implications. In: Millender LH. Louis D. Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone, 1992:1-14. 9. Nadelson T. Psychosocial factors in upper extremity dis-
orders: pain as a paradigm. In: Millender LH, Louis D, Simmons B. eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone, 1992:21526. 10. Davis E. Rehabilitation services. In: Millender LH, Louis D. Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone. 1991:277-90. Il. Welch EM. A practical approach to workers’ compensation. In: Millender LH, Louis D, Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone. 1991:57-68. 12. Brain G. Managed care programs. In: Millender LH, Louis D, Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone. 1992:89-100.
1992
HAND SURGERY
VOLUME 17A, NUMBER 2
AMERICAN
Official journal AMERICAN SOCIETY FOR SURGERY OF THE HAND
VOLUME
EDITORIAL
Occupational
disorders-The
1990s: A challenge
F
disease of the
or a bane for hand surgeons
or hand surgeons, the 90s will be known as the decade of work-related disorders. We can accept this as a challenge or look upon it as a plague. If physicians do not take a leadership role in trying to understand the cause and treatment of this new societal epidemic, work-related disorders can become an economic disaster for American industry and for the economy at large. In Massachusetts alone, the cost of work-related disorders to employers has increased from $800 million to more than $2.5 billion in 5 years, and there is no indication that this trend will change.’ Half of the costs are attributed to cumulative trauma disorders in which there is little hard data regarding either etiology or treatment. Some authorities attribute these problems to a changing industrial environment that requires a greater degree of repetitive and/or forceful hand use on the part of the worker.‘, 3 Others think many of the complaints are related to changing work ethics, patient awareness of cumulative trauma disorders, and psychological stresses associated with the work environment.“’ As an industrial society, we are losing the battle regarding work-related disorders. In many states (certainly in Massachusetts) employers think that the cost of workers’ compensation insurance is impeding their ability to compete in the marketplace.’ In Massachusetts the issue has reached crisis proportions. Companies are relocating, and some believe our economic decline is partly related to our workers’ compensation system. The reason we are losing the battle is that workrelated disorders, particularly work-related cumulative
trauma disorders (CTD) are different from non-workrelated disorders and require different treatment.X In contrast to non-work-related disorders, work-related disorders have three components that must be addressed: (1) the musculoskeletal problem, (2) the psychosocial component, and (3) the legal issue. When the psychosocial and legal issues are not resolved, the patient’s medical problem is rarely solved. The importance of the psychosocial forces in treating workers was shown in the Kappa Delta Award-winning paper (Bigos SJ, Battie MC, Spengler DM, et al. A longitudinal prospective study of industrial back injury reporting institution) presented at the American Academy of Orthopedic Surgeons meeting in 1991. In a prospective study on back patients, Bigos et al. found that the most significant factors among patients who did not do well were the perception that they hardly ever enjoyed their job and evidence of depression on the Minnesota Personality Multiphasic Inventory test. These psychosocial issues are related to the job, the insurer, and the physician and concern the patient’s perception of how he or she was treated by the “system.” In many cases the worker/patient perception is that in one of these three areas treatment was inadequate or unfair. Such comments as “the employer never visited me,” ” I told them that the machine needed repair,” or “the doctor spent 2 minutes with me and said nothing was wrong and go back to work’ is often voiced. In this litigious society, patients are quick to turn to lawyers who exacerbate the problem without helping the patients very much, and the workers become more frustrated, angry, confused, depressed. and fearful about returning to work. THE
JOURNAL
OF HAND
SURGERY
193
194
The Journal of HAND SURGERY
Editorial
Hand surgeons are frequently asked to see such a patient after several months of unsuccessful treatment. The worker has pain, usually ill defined in both its nature and its location and far out of proportion to any objective physical findings. The patient may have had weeks of treatment, which included splints, nonsteroida1 anti-inflammatory drugs, cortisone injections, and therapy, without any notable improvement. Hand surgeons who deal with these patients soon realize that the failure to respond is related to the underlying psychosocial components more than anything else. A few carefully posed questions will sometimes produce a barrage of complaints or an emotional outburst regarding the terrible way the patient has been treated by the employer, insurer or previous physicians. Other questions can elicit feelings of frustration, anger, or fear of returning to work and a significant depression. In many cases the patients are unaware of these emotional problems and focus only on the pain. Psychiatrists explain the chronic pain as “equivalents” of fear, anger, frustration, and depression.’ Some persons are unable to manifest these emotions, and their distress is projected into pain. Although there is certainly the secondary gain issue associated with being on workers’ compensation, few of these persons are considered malingerers. The very system that compensates these workers for being disabled is often a deterrent to getting them back to work. The disabled worker is certainly a victim of a system that was originally established to protect him. Many physicians find these patients so difficult to treat, so time consuming and professionally frustrating, that they refuse to treat them. The patients may then seek out those on the fringes of health care who are more happy to treat them seemingly forever and without improvement. What is the solution to this increasingly difficult problem? Reform must occur in many areas. But what is our responsibility as hand surgeons who care for such a large percent of patients with work-related disorders? We must encourage our professional organizations to support studies on epidemiology, etiology, and treatment of these disorders. We must work with mental health professionals to understand these complex issues. Both at professional meetings, such as those of the American Society for Surgery of the Hand and the American Academy of Orthopedic Surgery, and in journals such as this one, increasing time and space are devoted to these problems; this can only help to shed further light on them. As individual hand surgeons, we must admit that many of us are untrained and uninterested in dealing
with these complicated and frustrating psychosocial issues. Some of us are not emotionally attuned to dealing with these problems, and we become frustrated, angry, and defensive when we see these patients. If this is the case, we should appreciate our own limitations and choose not to treat such patients.” However, all of us must understand the unique aspects of work-related disorders and realize that they cannot be “surgically excised.” When the diagnosis is unclear or treatment is not progressing satisfactorily, we should realize that the mind may be playing a greater role than the body. Maybe an MMPI would be more appropriate than an MRI for some chronic wrist pain, or maybe vocational rehabilitation should be considered before an osteotomy of the radius. Treating these patients can be both challenging and rewarding. As soon as you realize that many of the patients have psychosocial factors that impede their recovery, you can begin to solve the problem. There is no area in medicine in which sympathetic listening followed by compassionate questioning is more important. In many cases you will be the first person to explore these nonorthopedic areas. Many workers’ compensation experts emphasize how the physician’s involvement can be critical in resolving sensitive issues.” In areas where they are available, medical rehabilitation nurses can be instrumental in helping the physician direct and manage the multiple factors that enable the patient to return to gainful employment.” These nurses have the training to understand the psychosocial issues and time to explain and implement the medical treatment. Hand therapists often fill this crucial role and certainly can be very helpful in complementing the nurse’s role. As hand surgeons, we have faced and successfully dealt with a number of challenges, ranging from primary flexor tendon repairs to free tissue transfers to reconstructive rheumatoid hand surgery. Today we face a new challenge-one that combines the mind and the body. With commitment and perseverance, we can again be successful. Lewis H. Millender.
MD
REFERENCES Summary and Sectional Analysis of Workers’ Compensation Reform Legislation (H. 11201 S. 64). Filed by Associated Industries of Massachusetts, Boston, Mass.. March 1991. Armstrong TJ, Fine LJ, Goldstein SA, et al. Ergonomics considerations in hand and wrist tendinitis. J HAND SURG 1987;12A(Suppl):830-7. Amdt R. Work pace, stress, and cumulative trauma disorders. J HAND SURC 1987;12A(Suppl):866-9.
Vol. 17A. No. 2 March 1997
4. Hadler NM. Illness in the workplace: the challenge of musculoskeletal symptoms. J HAND SURG 1985: lOA:451-6. 5. Ireland DCR. Psychological and physical aspects of occupational arm pain. J HAND SURG 1988;13B:51-10. 6. Dawson DM, Hallet M, Millender LH. Entrapment neuropathies. 2nd ed. Boston: Little, Brown, 1990:357-74. 7. Hadler NM. Cumulative trauma, carpal tunnel syndrome in the workplace - epidemiological and legal aspects. In: Gelberman RH. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991:949-56. 8. Millender LH. Occupational disorders of the upper extremity: orthopaedic, psychosocial, and legal implications. In: Millender LH. Louis D. Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone, 1992:1-14. 9. Nadelson T. Psychosocial factors in upper extremity dis-
orders: pain as a paradigm. In: Millender LH, Louis D, Simmons B. eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone, 1992:21526. 10. Davis E. Rehabilitation services. In: Millender LH, Louis D. Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone. 1991:277-90. Il. Welch EM. A practical approach to workers’ compensation. In: Millender LH, Louis D, Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone. 1991:57-68. 12. Brain G. Managed care programs. In: Millender LH, Louis D, Simmons B, eds. Occupational disorders of the upper extremity. New York: Churchill Livingstone. 1992:89-100.
