NOTE: This document is provided for historical purposes only.
Question and Answer Session
DR. EVANOFF: At this point you may feel like you have been trying to take a sip out of a firehose. And we would like to open up the floor to questions to any of the panelists at this point.
Q : I guess I would be curious to know, of particularly the two doctors, how many diagnoses of reflex sympathetic dystrophy and thoracic outlet syndrome you have made in addition to the carpal tunnel, which is apparently more obvious. I am also interested in knowing if you have read in the American Journal of Industrial Medicine the report by Dr. Bingham, Rosenkrantz and Cook, related to the prevalence of abnormal median nerve conduction in applicants for industry. And if you could comment on that if you are familiar with it.
DR. EVANOFF: I diagnose reflex sympathetic dystrophy or thoracic outlet syndrome extremely infrequently. As you may know, these are controversial diagnoses. They are often used as diagnoses of last resort, but sometimes are applied liberally.
Particularly with thoracic outlet syndrome, I would urge reviewing Gary Franklin's data from Washington State. He found that they often have many diagnoses applied before they arrive at that diagnosis. That is the single most expensive diagnosis for the Washington State Workers' Compensation system.
DR. HEGMAN: I have made diagnoses of reflex sympathetic dystrophy. I have had also evaluated cases that were actually rather severe. But those are extremely rare. Mostly at an academic institution, a patient has seen many prior practitioners who usually accurately diagnose. Regarding thoracic outlet syndrome, I have never made that diagnosis.
DR. MORELAND: I was also going to say, from the surveillance perspective, certainly we look at different types of symptoms that may be related to body parts, to shoulder, to other types of things, so that we don't get into the issue of diagnosis. But certainly that there are early ways to begin to get a feel for it, if there is damage or if there is something going on, that someone is lifting their elbow, lifting their shoulder up too high, so that there are certain interventions that we can do before people actually have disability or trauma.
From the issue of some of the median nerve types of issues, we certainly had the debate and had the discussion about whether nerve conduction is considered a surveillance or a screening tool. I think you have to look at the issue of whether or not it is acceptable. There are a lot of issues that come into play with nerve conduction, such as temperature, placement of electrodes, all these other types of things.
So from the surveillance or the screening perspective, we certainly haven't found it to be an effective type of tool. We know what happens when different individuals actually have the problem, but again it is not one that should be used in the workplace.
Q : Is either doctor familiar with the study that was done looking at pre-employment nerve conduction studies?
DR. EVANOFF: This is the one in the poultry industry?
Q : Yes. Well, actually it was more than the poultry industry, but --
DR. EVANOFF: Right. I think the more we learn, and particularly looking at, say, Al Franzblau's data from the University of Michigan, it shows actually a large number of people in the general population have abnormalities in median nerve conduction, partly because of the issues that Becky just addressed. There is a great deal of variability in how they are performed.
Carpal tunnel syndrome is a syndrome, and I am one of those who believe that the diagnosis is not made solely on the basis of median nerve conduction. It has to be made in the context of appropriate symptoms, as well, and perhaps physical diagnostic findings.
Q : I find, Doctor, that most of our practitioners, particularly in rural areas, have a tendency to label disorders. It makes the patient feel better if they go home and say, "My muscles ache," and they say, "Fine, what's for dinner?" If they come back and say, "I have reflex sympathetic dystrophy," it is, "Oh, my God, are you going to survive," and, "Gee, don't you think you ought to go lay on the couch for a while."
But I am concerned over this issue. I believe Dr. Sandler is a person who feels that there are many people who are asymptomatic and yet who once they enter a workplace and the symptoms are exaggerated or exacerbated by the repetitive type work, that the industry then picks up the cost of rehabilitation and/or surgery and/or any other medical treatment. I feel that post-offer pre-employment nerve conduction studies are a valid test to identify those people who are asymptomatic but who do have latency within their median nerve.
DR. EVANOFF: But actually there is another interesting thing about Al Franzblau's data which was just presented some data in Ann Arbor about a month and a half ago. It showed that of about 15 percent of the people who they found who were asymptomatic people with nerve connection abnormalities, actually after 2 or 3 follow-ups, there was no increased incidence of carpal tunnel syndrome in the people who had abnormalities. So the abnormalities were not predictive of progression to symptoms of carpal tunnel syndrome.
My hope is that in the future we get away from reliance strictly on this one number. I think it is back to the technological quick-fix point. You can't take one number and use that to define a problem or address the issues.
Q : And yet that is the number that is used in the worker compensation system for compensation.
DR. EVANOFF: In some settings, at least. And let's hope that we will get away from that.
Q : I have two questions. One is for Kurt regarding not differentiating between occupational and nonoccupational low back pain. I am not sure how much this is a state phenomenon, but in my experience I find that a lot of personal physicians are more willing to let somebody in occupational medicine manage occupational low back pain because of the familiarity with workplace issues plus the workers' compensation statutes. Whereas, they seem more unwilling to do that with nonoccupational low back pain. They view that more as infringing upon the patient-physician relationship. I would like to hear something about your experience with that.
The second thing is, and I am not sure who, if any of you, can answer this question or if you have had a similar experience. My partner and I provide medical services for a large manufacturing facility in a rural area. In 1990, we started services there, there were ten to fifteen putative cases of carpal tunnel syndrome diagnosed a month. They were supposedly confirmed by EMG NCV, by a physician who was not actually board certified in physiatry or neurology. Sixty percent of the cases went to her husband for the surgical release. Neither obtained any kind of job history besides, "they used their hands at work".
We started going there to provide medical services, and the management there was really open to a new approach. If they were not, we would not have been there. We examined these people, analyzed their jobs, performed a complete examination, as well as obtained electrodiagnostic studies from a different individual who was actually trained to perform them correctly. We found only about six cases in the entire year and about two appeared to be related to the job.
I guess I am looking for an impression as to how much of that do you think might be going on in industry as a whole? How much of that do you think you might be increasing to these BLS statistics that we see jumping up all the time.
DR. HEGMAN: There are significant differences in workers' compensation from state to state. You are to operate in and/or are constrained by your state. But regardless, there still are tools for you to use that are usually available.
Wisconsin is a state in which the patient can see a physician of their choice for the first visit. Even in that kind of setting, a plant nurse who can call the patients and request that they come in to see the plant physician. Barring that, the union contract may be invoked. There are always tools to use in your state, you just have to know what they are and use them as needed.
Regarding the nonoccupational low back pain question, my experience with most physicians is that they do not like to manage back pain regardless of cause and that they actually are delighted that I like to manage back pain. Thus, I have not found that to be too much of an issue. If Master Lock ever did try to manage each nonoccupational case and provide restrictions and accommodation, that may become more of an issue.
I heard of a similar kind of case of a husband/wife duo except it was not Aurora. Perhaps we have the same couple. I heard that many people in the plant were getting diagnosed and treated with carpal tunnel releases. Some people supposedly did not even have symptoms consistent with CTS at all.
I practice in a fairly large area, a 1.8 million person metropolitan area, and consequently I do not see that type of problem. An insurance company will refer for a second opinion/independent medical examination. This type of problem is more likely to occur in a small town.
DR. MORELAND: We will just quickly comment that we know we were in trouble when we all of a sudden hear different individuals talk about carpal tunnel syndrome as the back of the '90s. We had a feeling for there was going to be this increase interest.
In the same situation in Baltimore, again, there were certainly similar types of situations here, we found that a number of industries banded together and took a look at the experience that we were seeing and the same type of consistency with experience as far as the conflict of interest and those types of issues. It was managed from a group perspective in a very comprehensive and concise way, as well.
Clearly, although the Bureau of Labor statistics or OSHA 200 forms, the counts may go up of people reporting symptoms, people reporting perhaps small changes in physical exam. I think as we begin to look at those incident rates compared to severity indexes, and in particular severity looking at workers' compensation cases and looking at lost time restricted days, the fact that we are seeing certain workers complain about or give us symptoms, we are seeing our conservative therapies working. Again, it is how do you look at the numbers and what information do you have in a surveillance system at your place of employment that can better guide you.
Q : Since Dr. Hegmann brought up the back belts, I know we can't make it through the conference without addressing the new study on the 32,000 Home Depot employees done by U.C.L.A. Could you please address that? Because that changes everything. Now it is in The Wall Street Journal. Those of us in the profession are being bombarded by employees and managers as far as what to do about this new back belt study.
DR. EVANOFF: That is really a primary prevention question. This is a session on medical management, so we don't have to talk about it.
I am actually not sure that study changes everything. I think it is one study in a whole group of studies that have been done. There are methodologically a number of problems with that study. For instance, the employees, I believe, also received training in prevention at the same time they got their back belts.
And in particular, I can't believe that they got those changes without making changes in their case management and medical management at the same time. It will be very interesting to see, for instance, what happened to their neck injury, shoulder injury, foot injury data. If those all stay constant, then I think that decline of back injuries is more believable. But at least in our hospital setting when we have done any primary intervention, we have seen a decline in multiple injuries. So if there is decline in other injuries, it would be less believable.
The other problem with that is they did a lot of new hires. They greatly expanded the company. What we have seen in other settings is that new hires that come in often have a different injury rate than the older work force that was there before. So it is evidence on the positive for back belts, but it is by no means a definitive study that should prompt us all to run out and buy them.
If you look at the whole body of literature, it has to be balanced against other studies. I think it certainly opens a door that I think was pretty much closed before it came out. I don't think it is enough to really completely reverse our thinking. That is my opinion.
DR. HEGMAN: I agree. Well said.
DR. MORELAND: I think it also moves the point again that if we choose just one particular item, one particular piece of the puzzle to view to find out exactly what contribution it has, as we are looking at the conference in Chicago these next two days, hopefully we are looking at a comprehensive type of approach that includes all the different types of components that we have talked about.
The training and education, how to use it, work postures, counseling, all of these types of pieces go together with that to give us an outcome. It is still that comprehensive process, it just gives us another point of dialogue to begin to discuss together.
DR. EVANOFF: Actually, I would be happy if they are very effective, because then I could quit worrying about backs and start worrying about necks, upper extremities and everything else. Even if there is one item that really works well, I don't think it takes away from the need for a comprehensive program and the need to appropriately manage those cases and still become injured.
Q : I am a registered nurse. I am also a certified ergonomic compliance director. I actually have a comment and a question that goes along with this comment.
Let's strip away all the rhetoric about ergonomics. It is about work-related musculoskeletal disorders, it is about cumulative trauma disorders, it is about carpal tunnel syndrome, thoracic outlet syndrome, it is about tendinitis, tenosynovitis. When and how is the medical community going to step up and take charge and take leadership in this area? We are talking about medical injuries, we are not talking about just establishing a workstation that is ergonomically correct from an engineering perspective. We are talking about how a human being interfaces with equipment, how they interface with processes for performing work, and what that effect is on their body over a long period of time, as well as in a short period of time.
I think your comment earlier about this is medical management not prevention. I think prevention is a medical issue at this point. Statistics show us that over the last two decades cumulative trauma disorders have skyrocketed, following primarily an engineering design program. And from my experience in dealing with these issues and dealing with other physicians, surgeons, orthopedic specialists, we tend to use a more restrictive model in terms of limitations that we allow the body to be exposed to.
It has been also my experience on a very small basis that those restrictions actually are improving the results and get the kind of results that we see when you put up your charts on how we reduce cumulative trauma disorders.
When is the medical community going to step up and establish standards by which consultants such as myself can go out and use and point to these communities? NIOSH has their standard of cumulative trauma or proper upper body posture. I took 25 workstations of people who had actual injuries, compared and took measurements of every one of those individuals, and found that 95 percent of them complied with NIOSH's recommendation. But all of them had injuries.
So my question is, what is going to happen on a government level, what is going to happen on a political level, and when is the medical community going to step up in leadership on this whole issue?
DR. EVANOFF: I think one point is that it is a mistake to think that there is such a thing as the medical community. The medical physicians and nurses and other health care providers belong to different groups with different political agendas. For instance, if you contrast the American Medical Association's stand on OSHA reform with that of the American College of Occupational and Environmental Medicine, they are diametrically opposed. Many people in ACOEM are also members of the AMA. We can be members of two organizations that have diametrically opposite views on something that is very important.
Q : Then how do we move to consensus?
DR. EVANOFF: There are a number of moves towards consensus, particularly in the American College of Occupational and Environmental Medicine, which for an organization which is basically pretty conservative has been progressive in terms of recognizing the problems of work with musculoskeletal disorders.
The political agenda is going to be driven by the things that drive political agendas. The last piece is going to be more education of physicians, both trainees and practicing physicians, because most medical schools do a woefully inadequate job of training physicians to recognize workplace hazards. Continuing education for medical professionals is a critical part of this whole piece.
DR. MORELAND: I continue to support that. As you have suggested, we may expand your definition of medical community to be the health community. And I don't think any of us can say that we are not a definite part of what this means.
The usual case definition of any musculoskeletal disorder is numerous. Again, there are various stages that we probably are going to end up looking at. But that is the purpose of this particular forum, is to move the discussion further so that we can finally begin to look at case definition, to look at different types of standards of practice for all health care professionals, whether they be PAs, nurses, physicians, those that have occupational health-related types of things, too.
We still have a good ways to move, but the sooner we do that, then the more we are going to understand our numbers and understand our rates and understand the epidemiology of what is going on, as well.
DR. EVANOFF: So we will take two hopefully quick questions from the person in --
Q: Neal Taslitz, Executive Director of the National Repetitive Strain Injury Foundation.
One of the important unspoken issues that we have discovered over the past several years is that there are an increasing number of individuals that are suffering from early symptoms that are quite fearful of reporting this to the occupational physicians or to the employer because they are worried about either being labeled as having a problem and that having a future effect on their employment or on their own perception amongst their managers and their other colleagues. Also, many people fear through the screening process that they eventually will be screened out of the system. And we have seen that.
What experience have you had or have you implemented or suggested, some of the anonymous surveys, for instance, the type of surveys that I think NIOSH recommended that were taken at the Los Angeles Times at an early stage, and how has management been receptive to doing anonymous surveys of all workers for symptoms?
DR. MORELAND: What my experience has been is that if indeed there is an objective, if there is a goal, are we attempting to find out if there is a problem here, do we already know there is a problem because of the workers' compensation costs, that they have skyrocketed, those particular managers or those employers have been very anxious to get a better feel for and a better understanding of what these rates mean and what is driving them.
So from the perspective of a commitment to looking at how can we begin to establish a program, what baseline data do we have to know as we endeavor into this ergonomics program, can we make people better or can we make them worse or what happens. Almost without question, as has been stated throughout the room, once this anonymous survey is done, it usually is the key point in which a program is established and forge that communication, that we can develop a protocol and a program, a paradigm that is going to say with individuals that have symptoms what is going to happen to them.
The program is then again an active part of employee, union, management, those types of individuals, so that some of the fear is at least talked about, is communicated, and there is an appropriate step that we can make.
From there then, I think certainly to look at interviews, to look at each individual directly, because again if you know that there all these people that are supposedly claiming they have these particular symptoms, you afford them the opportunity to come to the plant nurse or to come to the plant physician. Again, that is where we can begin to tease out part of this, too. But you go into it knowing that there is probably going to be an initial increase, but given that initial increase it immediately begins to dissipate pretty quickly as everyone finds their particular role to play in this big phenomenon of ergonomics and repetitive stress injuries.
DR. EVANOFF: We have had experience in several different work groups in doing anonymous surveys. You need to establish credibility with the workers, that it really is anonymous and that management will receive only summary data, and no data in a way that can allow the identification of individual workers. If you don't achieve that trust, you get a very low participation rate. If you do achieve that trust, we have seen 95-percent participation rates in some of our areas.
Actually, in my experience, management has not been as impressed by numbers about symptoms as they are numbers about dollars. I think having symptom information is useful. You may say 50 percent of workers in this job have symptoms. That may be useful, but to many managers a dollar sign seems to say more.
Q : The questions I have aren't extremely technical. I have gone from being a nurse on a regular hospital floor to an industrial setting within the last year. A year ago I had no idea what ergonomics meant when I was hiring in for the job.
I have some questions dealing with carpal tunnel syndrome. What percentage would you say you have seen or heard from in studies that are actually influenced strongly by post-menopausal women with their hormone changes?
DR. EVANOFF: Let me make two comments on that. The first one is your point of going from one environment to the other. Actually, you oftentimes will have gone from the more hazardous environment to the safer one, because the manual materials handling tasks of somebody who takes care of a patient and the mismatch, because it is mostly female, versus their job requirements are way out of whack compared with most manufacturing, which is relatively light.
Q : Not in my case. We build trailer vans that semis pull. It is extremely labor-intensive.
DR. HEGMAN: The other question is essentially addressing what percent of carpal tunnel is work related. Nobody can say zero percent and nobody can say 100 percent. It is probably someplace in between although it should be recognized that some feel it is never occupational. This is true of carpal tunnel syndrome, shoulder tendinitis, and this is also true of the back, unfortunately.
DR. MORELAND: Let me make just one quick comment. In my work I completed in 1985 in which we looked at carpal tunnel syndrome only, we had a definite definition of carpal tunnel syndrome which was abnormal nerve conduction studies. I purposely chose a working population that included 50 percent men and 50 percent women. It was a floor tile manufacturing facility in which everyone was doing the same thing.
It is very difficult to find an employee population in which there are equal numbers of each sex, especially as they complete the different aspects of their task. The employee populations were either strictly men, such as in red meat packing, or they were strictly women such as in upholstery, electronics and those types of things.
In this community we found that if you calculated carpal tunnel syndrome by nerve conduction studies, men and women working side by side doing exactly the same task had exactly the same rates of carpal tunnel syndrome. The outcome of that was that as far as -- to answer the question that was asked earlier -- those that were still subclinical and that were asymptomatic, there was clearly a very gender bias in reference to who was willing to report different types of changes in strength, changes in sensitivity, women versus men. Those issues certainly came up.
If indeed you look at the ergonomic stressors, what is causing different people to change, and you have a definite way that you can define that, we don't find the different types of health aspects or the hormonal status to really prove out.
Q : One more quick question for Kurt. You were talking about accommodating work restrictions for nonoccupational illnesses and injuries. Ours is relatively higher than the six percent. I have calculated it at sixteen percent. What is one easy way that I can get my top management, which is my plant manager, to see that we need to accommodate restrictions for nonoccupational problems? Everything is in conflict with the union and who we are going to upset about it and who we are not.
DR. HEGMAN: If you can get dollars and label it with dollars, that is the way you get anybody's attention. If you cannot do that, you are really not talking about just a second or third best option. Then, you need to get numbers and try to compare them just as I did here to show that you do have a problem. I think that until you get management behind you, you cannot even bother going on to the next step of how do we address the union issue.
DR. EVANOFF: If you find one easy way to get management behind you, please let us all know. I think it is a long iterative process. You need to show them gains in one area before you can start talking to them about spending money in one way or another to achieve gains in another.
Well, thank you very much for your participation and your attention.
(Whereupon, the session ended.)
