Copyright 1999 Federal News Service, Inc.
Federal News Service
APRIL 21, 1999, WEDNESDAY
SECTION: IN THE NEWS
LENGTH:
3047 words
HEADLINE: PREPARED STATEMENT OF
DR.
MICHAEL VENDER
HAND SURGERY ASSOCIATES
BEFORE THE HOUSE
EDUCATION AND THE WORKFORCE COMMITTEE
WORKFORCE PROTECTIONS SUBCOMMITTEE
SUBJECT - H.R. 987, THE WORK PLACE PRESERVATION ACT
BODY:
Mr. Chairman, Members of Subcommittee on
Work Force Protections and guests. My name is Michael Vender. I am grateful to
have the opportunity to share my thoughts and concerns regarding passage of an
ergonomics program standard by OSHA. Specifically I am here to
support Representative Blunt's bill, H.R. 987, the "Work Place Preservation
Act".
For the last 13 years I have practiced hand and upper extremity
surgery in Chicago. I received my undergraduate schooling at Stanford University
and received my medical degree from University of Illinois. My professional
training in orthopaedic surgery was at Northwestern University in Chicago,
Illinois and hand surgery at the Connecticut Combined Hand Services in Hartford,
Connecticut. I am board certified in orthopaedic surgery and have been certified
for added qualifications in surgery of the hand. I am a co-founder of Hand
Surgery Associates, a six member hand surgery group. I practice full time
clinical medicine involving evaluating patients in the office and performing
surgeries. Being a hand surgeon in Chicago has exposed me to a wide variety of
conditions seen in the hands and upper extremities and has also provided me
significant experience in a variety of industries and occupational settings,
allowing me to understand the activities performed in the workplace and in our
daily lives outside the workplace. Part of my regular clinical experience
involves analyzing jobs and patient's other activities for possible contribution
to the development of upper extremity conditions and to assess the ability of
people to return to normal activity, including their non-job as well as job
activities, with or without restrictions.
Because of the nature of my
practice I have come to develop a special interest and knowledge regarding the
workplace and how the patients that I treat interact with their jobs. In
addition to my clinical practice my professional interests have led me to
participation in various committees of the American Society of Surgery of the
Hand, the foremost hand society in the United States and the world. Specifically
I have participated for several years on the Industrial Injuries and Prevention
Committee and have been chairman of the committee for the last three years.
Physicians evaluate and treat patients for upper extremity musculoskeletal
symptoms and when necessary determine if a condition is related to work
activities. Many different types of physicians are involved, ranging from
primary care physicians to specialists such as hand surgeons. The determination
of work relatedness is often made based on the "expert testimony" of the various
physicians. Unfortunately not only are most of these physicians not experts with
the qualifications to render such opinions, they cannot even identify or define
the various criteria needed to determine a causal relationship between a
particular factor or activity and the development of a musculoskeletal disorder.
NIOSH has described a limited number of these requirements in "A Guide to the
Work Relatedness of Disease". These requirements include, among other criteria,
consideration of evidence of disease, consideration of epidemiologic data,
consideration of evidence of exposure, consideration of other relevant factors,
validity of testimony.
For many physicians involved in such determinations
their knowledge is based on anecdotal experience, superficial reading and
understanding of appropriate medical literature, and frequently information
obtained in the lay press and news media. This makes their training and
knowledge in making such expert determinations not significantly greater than
the average citizen who watches the 10:00 o'clock news and reads magazines and
their local newspapers. As examples, attached are three statements made by three
different physicians regarding patients causal relationship of their conditions
to work activities. These "medical" conclusions are clearly/2 no better than
random words on paper.
Many physicians state in their reports that the
literature substantiates their opinions of a positive causal relationship
between workplace factors and the development of conditions for which they are
treating. As evidenced by testimony in numerous legal proceedings, these same
physicians cannot explain a basic understanding of what work factors are
actually present in the job, and what literature supports their assertions. It
is true there is an extensive array of literature that alleges damaging effects
of work-related factors. As scientists we all know that conclusions and opinions
stated in the medical literature do not always prove to be true. Many opinions
and conclusions stated cannot even be substantiated by the contents of the
article itself, let alone be validated by other studies.3
Moreover, the same
factors described as "work-related" are in fact descriptive adjectives that
apply equally to non-job activities. With our present level of understanding, we
cannot distinguish between on- the-job and off-the-job activities because the
quantitative relationships between the factors and the medical conditions have
so far eluded discovery by medical science. That is, we simply don't know how
much is too much. A review examining the nature and extent of the literature
available on the topic of the work relatedness of various musculoskeletal
disorders of the upper extremities was published by me and my colleagues in 1995
in the Journal of Hand Surgery and was titled Upper Extremity Disorders: A
Literature Review to Determine Work-Relatedness.4 The primary conclusion we
reached is that none of the reviewed studies established a causal relationship
between distinct medical entities and work activities. We stated that further
research using well constructed studies incorporating reliable epidemiologic and
more importantly, generally accepted diagnostic criteria are needed. This
article generated significant discussion and debate, as it questioned previously
unchallenged ideas.
The Journal of Hand Surgery in January in 1996 included
a letter to the editor criticizing the published work from July of 1995 along
with a rebuttal to that critique.5&6 Unfortunately the critique which
included many referenced studies, did not provide any more convincing literature
or evidence to substantiate a relationship between workplace factors and
development of musculoskeletal disorders. They merely complained that we failed
to consider the studies they cited.
One concern they raised about the 1995
Journal of Hand Surgery study is that it had only limited depth, as it involved
reviewing fifty-two papers. NIOSH in July of 1997 published a report titled
"Musculoskeletal Disorders and Workplace Factors. A Critical Review of
Epidemiologic Evidence for Work-related Musculoskeletal Disorders of the Neck,
Upper Extremity, and Back."7 The authors of this report of over 500 pages
intended "to examine the epidemiologic evidence of the relationship between
selected musculoskeletal disorders of the upper extremity and the low back and
exposure of physical factors at work".8 Their search strategy of bibliographic
data bases identified more than two thousand studies, of which eventually six
hundred studies were included in their "detailed review process".9 They also
stated that "this document is the most comprehensive compilation to date of the
epidemiologic research on the relation between selected musculoskeletal
disorders and exposure to physical factors at work".10
The researchers
stated "For the upper extremity studies included in this review, those which use
specific diagnostic criteria, including physical examination techniques, were
given greater consideration than studies that used less specific methods to
define health outcomes.
The review focused most strongly on
observational studies whose health outcomes were based on recognized symptoms
and standard methods of clinical examination. For completeness, those
epidemiologic studies that based their health outcomes on reported symptoms
alone were also reviewed".9
These comments document the widely varying
quality of the studies examined, and, more importantly point out the major
design and quality flaws in these studies. Why the authors choose to include
them in spite of their admitted flaws says much about the adequacy of NIOSH's
review.
Even considering the low standards used to select studies, NIOSH was
able to identify only thirty articles of any value discussing relationship of
carpal tunnel syndrome to work activities. NIOSH in the report goes on to
describe the three main areas of study that need to be similar amongst different
papers: (1) The types of populations being studied (2) what kinds of exposures
they are undergoing, and (3) what kind of outcome the patients experience (such
as carpal tunnel syndrome). NIOSH acknowledges utilizing different patient
populations, different definitions of exposure in the workplace, and even
different definitions of the disease outcome in the same analysis. This is a
major and perhaps fatal flaw in their assessment of the literature. When
evaluating each of the individual studies, NIOSH utilized only four basic
criteria. Yet they acknowledge that a full fourteen of the thirty articles they
identified met only one of the four criteria. Only five of thirty met the four
basic criteria.As a clinician I have concerns that OSHA's
proposed draft ergonomics program standard is at best misguided and at worst
counterproductive. Having reviewed the standard, I have several areas as a
clinician that I consider to be problematic.
For example there are key terms
that are vague and not definable based on current knowledge. The standard refers
to hazards, but refer to routine activities performed by people every day. There
is no description of what it is about these activities that make them dangerous
or hazardous.
For example, the basic premise of ergonomics is that use of
the hands and upper extremities is detrimental. This would lead to the
conclusion that the optimal amount of hand use is no use. This is opposite to
the clinical experience of placing a patient's arm or leg in a cast and creating
the disease of disuse atrophy and osteoporosis. This is counter to all the basic
concepts of rehabilitation including cardiac rehabilitation, occupational
therapy, and physical therapy. In these fields, along with exercise physiology,
sports and conditioning, repetitive forceful use is utilized to rehabilitate and
improve ones state of health. OSHA's premise is that physical
use of the musculoskeletal system is "cumulative" and detrimental. The
conclusion, absurd as it may seem, is the elimination of all physical use and
activity is the best way to prevent work-related MSD. There is no scientific
reconciliation of the contradiction that some upper extremity use is reportedly
bad at work yet is encouraged for conditioning and rehabilitation. Again, how
much is too much.
My clinical experience demonstrates a very poor
correlation between physical activity and the development of identifiable
medical conditions. Of the patients that I see, the workers involved in the most
physically intense jobs have the fewest and most specific complaints. They have
only very limited corresponding disability. On the other hand the more difficult
patients to evaluate and treat are frequently those with low activity jobs.
People with the greatest physical activity have the fewest complaints. This is
not the result I would expect based on the hypothesis that physical activity
causes injury, upon which OSHA's standard is predicated. I have
great concern that OSHA is contributing to the ever growing
epidemic of somatization and medicalization. 11 This epidemic is resulting in
patients becoming more vocal and persistent regarding subjective complaints
despite being told of no pathologic or physiologic evidence of disease
(somatization). Physicians naturally try to explain the symptoms that are not
able to be placed in traditional diagnostic categories, and provide new names in
an attempt to categorize and legitimize (medicalization). In addition to
non-defined entities such as cumulative trauma disorder and repetitive
stress injury, there are other problematic descriptive categories such
as fibromyalgia. OSHA is now contributing to the creation of a
new disease of work-related musculoskeletal disorder without allowing for the
kind of rigorous scientific observation and testing in which we have placed our
faith now for more than 150 years.
The impact of these and other
pseudo-disease categories, such as myofascial pain syndrome on the people
involved should not be taken lightly. Unnecessarily labeling a patient with a
nonexistent disease can lead to significant adverse effects, including
iatrogenesis (disease caused by medical intervention).11&12
But to
suggest that a federal standard is justified to try to prevent these cases is
unscientific and lacks adequate epidemiologic and medical support. I also
believe the OSHA standard takes a significant step into
intruding in the professional standards of a physician's office. It states that
an employer must ensure employee privacy and confidentiality regarding medical
conditions identified during medical management. The employer must instruct the
doctor, over whom there is no control, not to reveal findings, diagnoses or
information that is not related to WMSD hazards in the employees job. Many
physicians feel there are numerous contributions to musculoskeletal complaints
such as diabetes, thyroid disorder, connective tissue disease, smoking habits,
alcoholism, drug abuse, physical abuse, psychiatric illness, etcetera and that
patients need to be counseled about these factors. Employers will need to know
about some of these conditions to manage their work force properly. Will
OSHA consider these non-related conditions and therefore a
violation of privacy and confidentiality?
The OSHA
ergonomics program would be required when one WMSD is identified in a workplace.
This trigger is so low it will pull all places of employment under the mandate
of the standard. This is in contradiction to OSHA's indicated
scope of being "limited to workplaces and general industry", involving
manufacturing or routine manual material handling. The program is to continue
and be continually monitored and amended until all WMSDs are eliminated. I do
not believe it is possible to eliminate musculoskeletal complaints in an aging
working population, let alone a young one?
Employers are thus trapped in a
never-ending cycle of consultants and complaints. The proposed standard from
OSHA sets out to do the impossible, that is to eliminate
musculoskeletal complaints in the workplace. It is not reasonable to assume this
is a realistic goal unless one is able to prevent aging, its effects, and the
other numerous conditions that contribute to musculoskeletal complaints in the
general population. OSHA's proposed ergonomic standard will
wrongly place the burden of this endeavor upon employers and health care
providers. The proposed standard is misguided because it directs the efforts of
these groups and the associated expenditures of time and money towards an
unproven panacea of "ergonomic fixes" and away from numerous other well known
and more thoroughly studied contributors to musculoskeletal disorders.13 As the
authors of The Journal of the American Medical Association editorial said in a
recent discussion of the scientific method and it's application to clinical
medicine, "Ultimately, answering fundamental questions about efficacy, safety,
appropriate clinical applications, and meaningful outcomes for all medical
therapies,., requires critical and objective assessment using accepted
principals of scientific investigation and rigorous standards for evaluation of
scientific evidence. For patients, for physicians and other health care
professionals,...-indeed, for all who share the goal of improving the health of
individuals and of the public - there can be no alternative".14 I couldn't have
said it better myself.
References
1. NIOSH. A guide to the
work-relatedness of disease. U.S. Department of Health, Education and Welfare,
1979: 4.
2. Physician's statements - see attached.
3. Vender MI, Truppa
KL. How meaningful is the literature? Tech in Hand and Upper Extremity Surg
1997; 1:273-276.
4. Vender MI, Kasdan, ML, Truppa KL. Upper extremity
disorders: a literature review to determine work-relatedness. J Hand Surg 1995;
20A: 534-541.
5. Armstong T, Buckle P, Fine L, et al. Letter to the editor:
Can some upper extremity disorders be defined as work-related? J Hand Surgery
1996; 21 A: 727-728.
6. Kasdan ML, Vender MI. Reply from the author. J Hand
Surg 1996; 21A: 728-729.
7. NIOSH. Musculoskeletal Disorders and Workplace
Factors: A critical review of epidemiologic evidence for work-related
musculoskeletal disorders of the neck and upper extremity, and low back. U.S.
Department of Health and Human Services, 1997:
8. NIOSH. Musculoskeletal
disorders and workplace factors: a critical review of epidemiologic evidence for
work-related musculoskeletal disorders of the neck, upper extremity, and low
back. U.S. Department of Health and Human Services, 1997: x.
9. NIOSH.
Musculoskeletal disorders and workplace factors: a critical review of
epidemiologic evidence for work-related musculoskeletal disorders of the neck,
upper extremity, and low back. U.S. Department of Health and Human Services,
1997: xi.
10. NIOSH. Musculoskeletal disorders and workplace factors: a
critical review of epidemiologic evidence for work-related musculoskeletal
disorders of the neck, upper extremity, and low back. U.S. Department of Health
and Human Services, 1997: iii.
11. Barsky AJ, Borus JF: Somatization and
medicalization in the era of managed care. JAMA 1995; 274: 1931-1934.
12.
Hadler NM: Arm pain in the workplace: a small area analysis. J Occup Med 1992;
34: 113-119.
13. Vender MI, Kasdan ML. Work-related upper extremity
complaints. In: Zuckerman JD,ed. Instructional Course Lectures. Vol. 48.
Rosemont: American Academy of Orthopaedic Surgeons, 1999: 693-697.
14.
Fontauarosa PB, Lundberg GD. Editorial - Alternative Medicine Meets Science.
JAMA 1998; 280: 1618-1619.
END
LOAD-DATE: April
22, 1999 
