Occupational Musculoskeletal Disorders. Ed. 2. Nortin M.
Hadler. Philadelphia, Lippincott Williams and Wilkins, 1999. $75.00,
433 pp.
Hadler reminds us that clinical science, like the law, is "subject
to the political pressures of the day in the formulation of the
hypotheses to be tested and in the frame of reference for interpreting
the results." Well known in legal and medical circles, Hadler has
served on several national commissions on musculoskeletal disorders
in relation to the workplace. In this book, he does not attack but instead
thoughtfully and critically analyzes popular concepts and beliefs
in medicine and a Workers' Compensation system that has gone awry because
it is based on political expediency and not on scientific truth.
Hadler shows how the workplace has been demonized by vested interests
that have created an entirely new list of disorders that do not
have a pathophysiological basis, spawning treatments with little
scientific rationale. Furthermore, he presents a new way of looking
at the doctor-patient relationship. Hadler espouses the concept
that the traditional perspective of clinical medicine offers limited
and skewed insights into the illnesses leading to work incapacity.
In elegant prose, Hadler weaves a fascinating narrative of the
origin, development, and growth of an industry that has created
a system in which the total cost of all compensable back pain in
the United States in 1986 exceeded eleven billion dollars. On the
basis of extensive research of available studies, he eloquently
describes how the zeal to find disease has led to the promulgation
of diagnostic labels that have no scientific basis. He points out how
patients are labeled with terms such as fibromyalgia, chronic fatigue
syndrome, irritable bowel syndrome, repetitive stress injury, and
cumulative trauma disorder. All of these labels share common features,
and all lack any objective anatomical, physiological, biochemical,
or pathological evidence of organic disease. These diagnoses rest
on findings whose accuracy and reliability are dismal and, according
to Hadler, are "only accessible to the finger of faith."
The book is divided into three sections. In the first section,
on musculoskeletal morbidity, the problems of the disease-illness
paradigm and of assigning diagnostic labels are discussed. In the
second section, regional musculoskeletal symptoms that are commonly
seen in the general population are identified. The third section
is about claimants who have a musculoskeletal disability. There
is extensive information on the issue of disability and on Workers'
Compensation in relation to arm, leg, and back pain. Also included
is a chapter on disability determination and the problems of elderly
workers and the working poor.
Hadler provides compelling evidence that we need to reexamine
our methods and styles of practice and to reevaluate the disease-illness
paradigm so that we can avoid perpetuating labels that have no scientific
basis. This will not be easy, given the sizeable medical, legal,
and workplace establishment and the advocacy groups that will be
threatened if there is a change in the way of thinking about the
workplace as a source of illness. However, given the need for all
parties to be involved in and responsible for controlling health-care
costs, this book should be read by all orthopaedic surgeons so that
they can familiarize themselves with the available data on occupational
musculoskeletal diseases.
Leela Rangaswamy, M.D.
Special Projects Editor, The Journal of Bone and Joint Surgery,
Needham, Massachusetts