How major change happens in workers comp
published in Risk & Insurance September 2011

In the past hundred years expansion of the concept of work injury or disease comes in surges that extend over roughly fifteen to twenty years, mobilizing advocates among medicine, law, safety and the public.

A spotlight shines upon a troublesome health condition. New safety and medical interventions promise if not to conquer, at least to greatly ameliorate the problem.

Scientific advances in understanding occupational risk and medicine cannot alone propagate and explain these surges. More influential is the full impact of popular beliefs, the peculiar rage for certainty in the workers compensation system, medical entrepreneurism, and social values.

Back pain has been around for millennia. Workers compensation law, work safety reforms and medicine in the early 20th Century enabled the rise of the concept of work-related back injury.

As the states introduced workers compensation laws, injury statistics improved greatly, uncovering for the first time minor impairments many of which were back conditions. Safety professionals began to focus upon the notion that heavy lifting was responsible. The science supporting work causality was weak and hotly disputed. Yet occupational back injuries took on the force of an epidemic.

In the late 1920s x-ray technology was introduced, and not many years thereafter the proposition was made that many vertebral disks shown by x-ray to be irregular were traumatically “ruptured” or “herniated.” This was a welcomed solution to workers compensation courts looking for a plausible explanation of how back pain could be caused at work, especially from an identifiable incident.

The orthopedic profession was ready to correct the traumatic condition. Back surgery flourished starting in the mid 1930s. Workers compensation-funded surgery remains today as a frequent intervention for persistent back pain, even though its benefits are disputed.

In the 1970s cumulative trauma disorders of the wrist and hand attracted attention of industrial unions, safety professionals and occupational doctors. After several years of moderate growth in recorded incidence, these conditions exploded in number in the mid 1980s through early 1990s. Did they fit into the legal definition of work injuries, though? Unions and many doctors adapted the term “cumulative trauma syndrome,” or CTS, as workers compensation courts began to recognize these conditions as compensable.

Testing for cumulative trauma, such as by nerve conduction studies, expanded as workers compensation insurers began demanding gold standard-like evidence.

Cumulative trauma and back injury have never lacked critics on the question of their work causality. The confluence of work and non-work factors is a perpetual Gordian knot. That has not prevented the safety profession from focusing on prevention, lawyers from litigating, and doctors from proposing the next path breaking solution.

These surges draw their sustenance in part from broad societal trends. The Depression helped to broaden concern about the plight of the injured worker. Labor disputes, mainly in the meat processing industry, publicized the extent and severity of cumulative trauma in the 1970s and 1980s.

And societal forces have been strikingly important in propagating a third surge that is today reaching its apex: the emergence of chronic pain as a second-order risk of injury.

A fundamental change in the medical paradigm for pain relief joined with drug innovation and medical consumerism to create a vast expansion of pain management for injured workers. Long-term benefit of treatment is questionable. Workers compensation courts do not have objective measures to determine the level and causality of pain. And yet treatment for pain has soared in the past decade.

This latest surge has essentially nothing to do with work, but is paid for by workers comp premiums. It reveals how much the workers compensation system is tangled up within the culture of medicine today.