Occupational Injury.To the Editor: "Cause, Prevalence, and Response to Occupational Musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles. mus·cu·lo·skel·e·tal adj. Relating to or involving the muscles and the skeleton. Injuries Reported by Physical Therapists and Physical Therapist Assistants" by Holder and colleagues (July 1999) presented all analysis of what has been defined by the US Department of Labor as an "occupational injury.[1] Unfortunately, Holder and colleagues committed an error of external validity External validity is a form of experimental validity.[1] An experiment is said to possess external validity if the experiment’s results hold across different experimental settings, procedures and participants. when they perpetuated the myth surrounding the description of "injuries" as they pertain to pertain to verb relate to, concern, refer to, regard, be part of, belong to, apply to, bear on, befit, be relevant to, be appropriate to, appertain to the performance of work-related tasks. The problem evolves from the operational definition of an "occupational injury,"[1] and, more directly, of the word "injury." The word "injury" is now commonly used as a diagnostic label for pathology.[2] I contend that the term "occupational injury," in the absence of overt trauma, is a misnomer misnomer n. the wrong name. MISNOMER. The act of using a wrong name. 2. Misnomers, may be considered with regard to contracts, to devises and bequests, and to suits or actions. 3.-1. that has not yet been defined medically and cannot currently be legally defended. Injury is defined as "harm done or sustained."[3(p733)] Harm is defined as "injury; damage; hurt."[3(p647)] As schoolchildren schoolchildren school npl → écoliers mpl; (at secondary school) → collégiens mpl; lycéens mpl schoolchildren school , we were taught to be suspect of definitions containing the word being defined because they are circular arguments providing no support for either term. The terms "damage" ("injury or harm that impairs value or usefulness"[3(p365)] and "hurt" ("injury, damage or harm"[3(p365)]) do not help. If one relates damage to pathology, there are signs of clarity. However, without overt trauma resulting in specific pathology, the term "injury" is not currently definable.[4] The reader should examine the referenced definition from Holder and colleagues: "An occupational injury can be defined as an injury that results from a work-related event or from a single instantaneous exposure in the work environment leading to death, lost work time, medical treatment other than first aid, loss of consciousness, work restriction, or transfer to another job."[1] This definition is based on law rather than science.[5] Even for its intended purpose, it is unclear and circular. This definition contains the word being defined. The word "injury," which Holder and colleagues did not clearly define, is linked to its cause, the examples of which are likewise not defendable. As an example, let us examine the symptom of low back pain, which had the highest prevalence in this study. There are a myriad of reasons for lost work time, many of which have nothing to do with symptoms or "injuries."[6] Reasons for seeking medical treatment other than first aid are frequently associated with factors unrelated to medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. within the incentive-driven workers' compensation workers' compensation, payment by employers for some part of the cost of injuries, or in some cases of occupational diseases, received by employees in the course of their work. system.[4] The Secretary of Labor v Beverly Enterprises Inc case stands as a graphic example supporting my contention.[7,8] The Occupational Safety and Health Administration Occupational Safety and Health Administration (OSHA), U.S. agency established (1970) in the Dept. of Labor (see Labor, United States Department of) to develop and enforce regulations for the safety and health of workers in businesses that are engaged in interstate charged Beverly Enterprises with exposing employees in nursing homes to the hazard of lilting patients in an unsafe manner along with other strenuous activities, which allegedly caused, aggravated, or precipitated employee "injuries" to the trunk and upper extremities.[7] In reference to low back pain syndromes, some of the legal conclusions from a hotly contested medical debate were as follows. Low back pain: 1) Is a symptom that affects 80% of the general population, regardless of occupation.[9] 2) May not be related to objective medical findings or patho-anatomic damage or injury.[10] 3) Resolves within a matter of days or weeks in the vast majority of cases.[6] 4) Has been related to a myriad of risk factors, the relative magnitude of which are unknown, and many are nonphysical and nonoccupational.[11] 5) Is a subjective entity, making definition in a manner that will inform Beverly Enterprises of its obligations most difficult. 6) Defined as an "injury," could not be related to the hazard of lifting patients. The judge concluded that the "hazard" or cause of the "injury" of low back pain could not be defined adequately to advise Beverly Enterprises of its obligations to provide a sate working environment and to identify the conditions and practices over which Beverly Enterprises may exercise control to reduce or eliminate the "hazard."[7] In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke" put differently , the term "injury" directly related to occupational exposure was not definable, in practical medical or legal terms. This legal conclusion is supported by the recommendations for clinical outcomes for patients with spinal syndromes. In defining terms for use in outcomes studies, the term "injury" is conspicuous in its absence.[6] If we allow publications that are based on terms that defy medical and legal definition, particularly those that are politically sensitive,[12] we perpetuate a false credibility.[13,14] By attempting to identify the "cause" of a nondefinable entity, the impression that "occupational musculoskeletal injuries" exist is not only perpetuated, but the readers could conclude that Holder and colleagues and their respondents actually know the "cause." This, of course, is not true. People do indeed experience musculoskeletal complaints,[15] but we are only beginning to accurately define the prevalence of actual "injuries" that produce such complaints. There are also problems with the internal validity Internal validity is a form of experimental validity [1]. An experiment is said to possess internal validity if it properly demonstrates a causal relation between two variables [2] [3]. of this study. Holder and colleagues compared their work directly with the work of Bork et al.[16] Although the authors correctly identify the differences in operational definitions between the studies, the Holder et al questionnaire has important internal biases. The questionnaire used in the recent study contained the words "injury" or "injuries" 17 times. It is likely that this language biased the respondents and led them to believe that their musculoskeletal symptoms were "injuries" and that their symptoms were directly related to performance of work-related tasks. There is no published work confirming that the performance of work tasks with ergonomic stressors is related to the development of specific pathology. The Beverly Enterprises case[7] confirms that we cannot even relate the performance of work to the development of low back symptoms. Because of the number of threats to internal and external validity, this study does not clarity the basic problem of operationally defining "occupational injury." One would hope that there are no unfortunate consequences of inaccurate interpretations of data such as this on public policy. One would also hope that readers of this article understand the issues pertaining to operational definitions before accepting carte blanche CARTE BLANCHE. The signature of an individual or more, on a while. paper, with a sufficient space left above it to write a note or other writing. 2. In the course of business, it not unfrequently occurs that for the sake of convenience, signatures in blank are published reports. Dennis L Hart, PhD, PT Director of Consulting and Research Focus On Therapeutic Outcomes Inc Great Falls Great Falls, city (1990 pop. 55,097), seat of Cascade co., N central Mont., second largest city in the state, at the confluence of the Missouri and Sun rivers and near the falls that give the city its name; inc. 1888. , VA 22066 References [1] Occupational Injuries and Illnesses in the United State by Industry, 1992. Washington, DC: US Department of Labor, Bureau of Labor Statistics Bureau of Labor Statistics (BLS) A research agency of the U.S. Department of Labor; it compiles statistics on hours of work, average hourly earnings, employment and unemployment, consumer prices and many other variables. ; 1992. [2] Baldwin ML, Johnson WG, Butler RJ. The error of using returns-to-work to measure the outcomes of health care. Am J Ind Med. 1996;29:632-641. [3] Webster's Unabridged Dictionary of the English Language English language, member of the West Germanic group of the Germanic subfamily of the Indo-European family of languages (see Germanic languages). Spoken by about 470 million people throughout the world, English is the official language of about 45 nations. . New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , NY: Portland House Portland House is a skyscraper in Westminster, London. It is 101 metres tall with 29 floors and was completed in 1963. ; 1989. [4] Hadler NM. Workers' compensation and regional backache back·ache n. Discomfort or a pain in the region of the back or spine. . In: Hadler NM, ed. Occupational Musculoskeletal Disorders Musculoskeletal disorders (MSDs) can affect the body's muscles, joints, tendons, ligaments and nerves. Most-work related MSDs develop over time and are caused either by the work itself or by the employees' working environment. . New York, NY: Raven Press; 1993:172-186. [5] Hadler NM. The disabled, the disallowed, the disaffected and the disavowed. J Occup Environ Med. 1996;38:247-251. [6] Von Korff M. Studying the natural history of back pain. Spine. 1994;19(suppl 18): 2041S-2046S. [7] Secretary of Labor v Beverly Enterprises Inc, OSHRC OSHRC Occupational Safety and Health Review Commission (OSHA) Docket A written list of judicial proceedings set down for trial in a court. To enter the dates of judicial proceedings scheduled for trial in a book kept by a court. No. 91-3344, 92-0238, 92-0819, 92-1257, and 93-0724. [8] Hart DL, Isernhagen SJ, Matheson LN. Confirming job relatedness of symptoms: Secretary of Labor v Beverly Enterprises Inc. Work. 1997;8:305-307. [9] Riihimaki H, Wickstrom G, Hanninen K, et al. Radiographically detectable lumbar degenerative changes as risk indicators of back pain: a cross-sectional epidemiologic study epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect of concrete reinforcement workers and housepainters. Scand J Work Environ Health. 1989;15:280-285. [10] Beattie P. The relationship between symptoms and abnormal magnetic resonance magnetic resonance, in physics and chemistry, phenomenon produced by simultaneously applying a steady magnetic field and electromagnetic radiation (usually radio waves) to a sample of atoms and then adjusting the frequency of the radiation and the strength of the images of lumbar intervertebral intervertebral /in·ter·ver·te·bral/ (-ver´te-bral) situated between two contiguous vertebrae; see under disk. in·ter·ver·te·bral adj. Located between vertebrae. disks. Phys Ther. 1996;76:601-608. [11] Bombardier C, Kerr MS, Shannon HS, Frank JW. A guide to interpreting epidemiologic studies on the etiology of back pain. Spine. 1994;19(suppl 18):2047S-2056S. [12] Industry experts call for immediate action on OSHA's workplace ergonomic standard. PT Bulletin. July 19, 1999. [13] Hart DL, Isernhagen SJ, Matheson LN. Impact of the Dayton Tire case. Work. 1998;11:119-121. [14] Hart DL, Isernhagen SJ, Matheson LN. Witness: the truth please. Work. 1997;9: 295-297. [15] Atroshi I, Gummesson C, Johnsson R, et al. Prevalence of carpal tunnel syndrome carpal tunnel syndrome: see repetitive stress injury. carpal tunnel syndrome (CTS) Painful condition caused by repetitive stress to the wrist over time. in a general population. JAMA JAMA abbr. Journal of the American Medical Association . 1999;282:153-158. [16] Bork BE, Cook TM, Rosecrance JC, et al. Work-related musculoskeletal disorders among physical therapists. Phys Ther. 1996;76:827-835. Author Response: We thank Dr Hart for the information and opinions he provided on the operational definition of the word "injury." The definition we used for occupational injury was the only standardized one we could find--that provided by the US Department of Labor's Bureau of Labor Statistics.[1] Although the use of the term "injury" has many medical and legal interpretations, the term is in common use by physical therapists and other health care professionals. No respondents indicated that they had any difficulty understanding the term "injury" or any of its synonyms (damage or harm that impairs value or usefulness). Nor did the respondents report having difficulty responding to the concept of "injury" sustained while performing an activity related to work. The first question of the survey asked, "Have you sustained any musculoskeletal injuries due to your work within the last 2 years?" Even though the responses to the survey question were self-reported, we have no reason to believe the reporting by physical therapists or physical therapist assistants referred to other than work-related injuries. Although there is room for improvement in this research study, as with any research study, we disagree with Verb 1. disagree with - not be very easily digestible; "Spicy food disagrees with some people" hurt - give trouble or pain to; "This exercise will hurt your back" Dr Hart's statement that there are a "number of threats to internal and external validity." As Dr Hart did not state what his concerns were other than those related to the use of the term "injury," we are unable to comment. Certainly, the relationship between the ergonomics of work and work-related injuries needs much more extensive research. We would be pleased to receive for consideration any alternative operational definition to the term "occupational injury" that would suit the needs for such a study and could be used for future research. Nicole L Holder, PT Staff Physical Therapist Penn Therapy and Fitness at Westampton 798 Woodlane Sq, Suite 11 Westampton, NJ 08060 Holly A Clark, PT Staff Physical Therapist Lehigh Valley Hospital Allentown, Pa John M DiBlasio, PT Staff Physical Therapist Vermont Sports Medicine Center Rutland, Vt Carol L Hughes, PT Staff Physical Therapist Pinnacle Health System Harrisburg, Pa John W Scherpf, PT Staff Physical Therapist VA Medical Center Bay Pines, Fla Linn Harding, PT, OCS Assistant Professor Department of Physical Therapy Temple University Philadelphia, Pa Katherine F Shepard, PhD, PT, FAPTA Professor Department of Physical Therapy Temple University References [1] Occupational Injuries and Illnesses in the United States by Industry, 1992. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 1992.3 |
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