| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Letters and Responses |
"Cause, Prevalence, and Response to Occupational Musculoskeletal Injuries Reported by Physical Therapists and Physical Therapist Assistants" by Holder and colleagues (July 1999) presented an 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 when they perpetuated the myth surrounding the description of "injuries" as they pertain 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 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, 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(p694)) 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 within the incentive-driven workers' compensation system.4 The Secretary of Labor v Beverly Enterprises Inc. case stands as a graphic example supporting my contention.7,8 The Occuptional Safety and Health Administration charged Beverly Enterprises with exposing employees in nursing homes to the hazard of lifting 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:
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 safe 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, 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 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 case7 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 clarify 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 published reports.
Director of Consulting and Research
Focus On Therapeutic Outcomes Inc
Great Falls, VA 22066
References
Although there is room for improvement in this research study, as with any research study, we disagree with 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.
Staff Physical Therapist
Penn Therapy and Fitness at Westampton
798 Woodlane Sq, Suite 11
Westampton, NJ 08060
Staff Physical Therapist
Lehigh Valley Hospital
Allentown, Pa
Staff Physical Therapist
Vermont Sports Medicine Center
Rutland, Vt
Staff Physical Therapist
Pinnacle Health System
Harrisburg, Pa
Staff Physical Therapist
VA Medical Center
Bay Pines, Fla
Assistant Professor
Department of Physical Therapy
Temple University
Philadelphia, Pa
Professor
Department of Physical Therapy
Temple University
References
This article has been cited by other articles:
|
|
 |
|
  J. E Cromie, V. J Robertson, and M. O Best Physical Therapists Who Claimed Workers' Compensation: A Qualitative Study Physical Therapy, December 1, 2003; 83(12): 1080 - 1089. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L Hart Too Many Variables, Not Enough Equations Physical Therapy, June 1, 2000; 80(6): 621 - 622. [Full Text]
|
|
|
|
|
|
J. E Cromie, V. J Robertson, and M. O Best Occupational Injuries in PTs Physical Therapy, May 1, 2000; 80(5): 529 - 530. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
