| Winter 2009
Evidence-Based Medicine and Repetitive Stress
By N. F. Tsourmas, M.D., Medical Director, Texas Mutual Insurance Company
Twenty years ago, older physicians like me took a logical approach to treating workers’ compensation patients. We accepted everything as an acceleration, aggravation (temporary) or exacerbation (permanent) of a pre-existing problem. After all, it didn’t hurt before; it does now, so it must be causally related. That medical conclusion is now being questioned.
There is probably no other venue, other than legal liability and civil litigation, where cause-and-effect relationships are called into question more often.
Physicians who treat workers’ comp patients have to be evidence-based medicine (EBM) experts. There is probably no other venue, other than legal liability and civil litigation, where cause-and-effect relationships are called into question more often.
For the first time, the American Medical Association has published a text on causation that includes the most complete and current bibliography of high-level scientific evidence. The “AMA Guides to Causation of Injury & Illness” examines repetitive stress, its validity and its occurrence.
EBM is of paramount importance to three common diagnoses in the work comp arena: repetitive stress disorder (RSD), post-traumatic arthritis and degenerative disc disease. I will use my brief space in this issue of Comp at Work to discuss what EBM supports and refutes with regard to repetitive stress.
Some people define RSD as having to do the same thing twice by the second day on the job. The AMA Guides define repetition by number of cycles per minute, time required for static posturing and what degree of angle/bend of the joint is required before a repetitive stress should be contemplated.
Certainly, you might expect repetitive stress to produce a tendonitis, a sprain or a strain. These are typically benign soft-tissue, self-limited disorders that disappear when the repetitive trauma or exposure ceases. In most cases, the AMA Guides do not support this conclusion unless certain work-specific, individual-specific factors are noted.
I have examined some 60 articles that address cubital tunnel and causation. They concluded vibration, repetitive activity, forceful, awkward, cold, keyboarding, dominance, DM, psych and length of employment did not affect the condition.
When a Texas Star Network® patient comes to your office complaining of a repetitive stress injury, I encourage you to:
- Review the patient’s job activities and ergonomic workplace.
- Find out the duration and intensity of the repetitive stress.
- Ask what vocational activities the patient participates in.
- Investigate co-morbid health conditions and medications.
After you complete your critical review, you may find that repetitive stress trauma and nerve compression syndromes of the upper extremity are rare.
About the author
Nicholas F. Tsourmas, M.D. is a Board Certified Orthopaedic Surgeon with more than 30 years of clinical experience. He is a founding partner of Southwest Orthopaedic Group and Adjunct Professor at the University of Texas Medical Branch in Galveston.
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