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Industrial rheumatology.

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1019
CURRENT COMMENT
INDUSTRIAL RHEUMATOLOGY
CLINICAL INVESTIGATIONS INTO THE INFLUENCE OF THE
PATTERN OF USAGE ON THE PATTERN OF REGIONAL
MUSCULOSKELETAL DISEASE
NORTIN M. HADLER
Regional musculoskeletal diseases are exceedingly
common in all segments of society, and dramatically so in
industry. For generations, medicine has assumed that
many such entities are use-associated. A critical review of
several examples of back and upper extremity disease
demonstrates that the literature supporting these assumptions is almost entirely anecdotal. It is argued that if
defined patterns of usage were associated with defined
clinical syndromes, such knowledge would have considerable therapeutic and prophylactic potential. Industrial
rheumatology is proposed as an investigative discipline for
the study of such relationships. The prerequisites in terms
of assumptions and methods as well as potential fallacies
and pitfalls are discussed.
The morbidity of some regional musculoskeletal
disease and the pattern of usage are clinical correlates.
Witness the implications of such time-honored diagnoses
as “tennis elbow,” “housemaid’s knee,” and so on. Even
these clinical correlates-are anecdotal and do not prove
the pathogenetic role of the pattern of usage implied.
From the Department of Medicine. University of North Carolina School of Medicine, Chapel Hill, North Carolina.
Nortin M. Hadler, M.D.: Assistant Professor of Medicine
and Bacteriology (Immunology), and recipient of an Established Investigatorship from the American Heart Association.
Address reprint requests t o Nortin M. Hadler, M.D., Department of Medicine, University of North Carolina School of Medicine,
Chapel Hill, North Carolina 27514.
Submitted for publication November I , 1976; accepted December 13, 1976.
Arthritis and Rheumatism, Vol. 20,
No. 4 (May 1977)
They may be describing a pattern of usage likely t o
cause the disease process to be manifest. Regardless, the
description of the associated pattern of usage is clinically useful in suggesting the palliative and perhaps
prophylactic proscription of the implicated motion or
usage.
For other syndromes of extraarticular rheumatism a precipitating, if not causative, pattern of usage
remains elusive. There are some data relevant to tenosynovitis at the wrist, but precious little relevant to
the common periarthritis syndromes at the shoulder.
When one comes to consider degenerative joint disease
(DJD) itself, the role of usage becomes an issue of some
debate. Clearly usage must be involved, at least to the
extent of precipitating morbidity, because morbidity in
part is defined by the functional impairment. Whether
usage accelerates cartilage degeneration (1-3) or is even
a primary pathogenetic insult ( 4 3 ) is not clear. What is
further confusing is the role, if any, of the pattern of
usage on the pattern of DJD. The argument remains
that if the pattern of usage contributes at any level to the
clinical syndrome, then the definition of such a pattern
may have therapeutic and perhaps prophylactic import.
The purpose of this paper is to review briefly the
available information that relates pattern of usage to
regional musculoskeletal syndromes at the back and
upper extremity. Such information is in fact scant. However information of this nature can be gathered from
carefully designed clinical studies in appropriately chosen and defined populations.
HADLER
1020
THE ACHING BACK
Back disease as a universal fate of mankind antedates recorded history (6). This reproach to medical
sciences has provoked the accumulation of a large body
of relevant data, replete with biases of selection and
perspective. Such biases are almost unavoidable as long
as the definition of back disease remains not only inexact but operational. It is unlikely that any exhaustive
or critical review can cull valid generalizations from this
database. A definition of the problem will be attempted.
Prevalence of Morbidity
The most readily accessible data on the prevalence of morbidity from low back disease is in industry.
I f morbidity is manifest in the job setting, it may be
interpreted as an “accident” causally related at some
level to that work setting, and perhaps “disabling” in
the context of that work setting. The numbers are impressive indeed-millions of days lost from work, millions of dollars of lost productivity and compensation
claims (7-9), and an incalculable quantity of pain. However such data concern the prevalence of back ”disease”
defined in a highly specialized and selective fashion and
are clearly subject to biases in interpretation: The age
distribution for low back injuries, particularly in male
employees, reveals a peak incidence between the ages of
30 and 40 and an association with tasks that require
materials handling and lifting (10). The decline after age
40 may well reflect selection inherent in attrition, in
hiring practices, or in the seniority system. Furthermore,
the association with materials handling (1 1) need not
imply a primary pathogenetic influence for this mode of
usage, but a setting in which underlying disease becomes
manifest.
If the definition of back disease is different from
the one stated above, the prevalence and incidence data
are remarkably different. Magora (12) questioned over
3000 employees in eight preselected occupations about
the incidence and quality of low back pain, defined as
any discomfort in the region lasting for more than 3 days
and occurring in the previous year. Defined in this fashion, low back pain, was identified in 429 patients. Onset
before age 30 was as much a feature of bank clerks as of
nurses and heavy industry workers. Furthermore, as
many bus drivers, post office clerks, and nurses were
represented in this patient population as heavy industry
workers.
Another instructive study has been reported from
England ( 1 3). Sixteen general practices were surveyed to
determine the number of patients presenting over a 2-
year period with back disease. There were 478 male and
348 female patients or 22.8 and 15.3 back patients per
1000 respectively. Recent lifting, including occupational
lifting, was denied by 22% of men and 46% of women.
The average time lost from work by this population
approached 2 weeks and correlated with occupation
only for older men employed in heavy jobs.
Studies such as these greatly expand our appreciation of the prevalence of back disease. It is a very
common complaint and appears to affect individuals in
many different occupations, and ostensibly with many
different patterns of usage. But they do not negate the
observations of investigators such as Brown (10) and
Troup ( 1 I ), whose approach is to define more carefully
the industrial setting. Most of the patients with back
disease are involved in materials handling and lifting.
Morbid Anatomy and Radiology
of Back Disease
The pathologic hallmarks of DJD of the spine
accumulate with age so that they become almost universal in late life (3). Radiologic surveys confirm these
pathologic data (14). In a general population as many
subjects with minimal radiographic DJD experience
back pain as those with marked DJD (15). This fact has
led to radiographic surveys seeking correlations with
occupational descriptives and with the particular syndrome of back pain, and seeking radiologic findings able
to predict the incidence of back pain.
In 1955 Lawrence (16) reported the relationships
between X rays, back symptoms and occupational descriptives in British coal miners-a group at high risk
for this occupational “disease.” The complex study design compares seven groups, each employed in different
tasks. Although there are obvious differences in posture
assumed on the job, as well as environmental differences, the tasks are not analyzed in terms of similarities
or differences in patterns of usage. The incidence of
symptoms and incapacity is remarkably uniform in all
groups. The heavy laborers have less severe radiologic
changes and fewer involved discs than the miners, and
are themselves better off than the office workers. These
intriguing findings pose two questions: Why don’t the
radiographic findings correlate with symptoms? Why
did a study of similar design performed in the mines of
Pennsylvania (17) reveal a correlation between the duration of heavy labor and osteophytosis but not disc degeneration? Is the difference in the demographic characteristics of the population, the radiographic criteria, the
height of the coal seam, or the details of the pattern of
usage on the job?
INDUSTRIAL RH EU MATOLOGY
This study is one of a series of studies of similar
design executed in the industrial setting and published in
the two preceding decades (18,19). Anderson (20) has
reviewed in some detail other studies of this nature, as
well as data describing the prevalence of rheumatic “diseases” in industry. These studies are difficult to execute
and are clearly a credit to the ‘investigators involved.
That they raise more questions than they answer is a
result that could not be predicted, and a result that
should serve as a stimulus and object lesson for future
studies.
Attempts to dissect back “disease” into specific
clinical entities before seeking correlations with occupational history or radiographic changes have met with
little more success. This literature is thoroughly reviewed by Horal (21), whose own study is equally thorough and noteworthy. He randomly selected as probands 243 of the individuals “sick-listed” in Sweden
with a primary diagnosis of lumbar spine disorder. Age,
sex, and income-matched controls not so sick-listed
were selected as well. He then undertook a careful history, physical exam, and radiographic survey of all the
subjects. I will not quarrel with diagnostic classification
of low back syndromes into “low back insufficiency,”
‘‘lumbago,’’ and “sciatica,” because I am uncertain that
other classifications (22,23) are more reliable, let alone
valid. In Horal’s study intense lumbar paidache had
been experienced by 84% of probands and 64% of controls. The probands experienced the more severe pain
syndromes, though persistent symptoms were more frequent in controls. Roentgenologic changes were detected in 97% of probands and 90% of controls, but these
changes, analyzed in some detail, did not correlate with
signs or symptoms in either group.
A recent controversy in industry underscores the
complexity of the problem of understanding back disease. For several years a number of attempts have been
made to use preemployment historical data, physical
examinations, and lumbosacral X rays as screening
methods to identify individuals at greatest risk for back
symptoms in materials handling jobs. The effectiveness
of any known criteria is hotly debated and, at best, far
from dramatic (24-26).
1021
vestigators began to examine the efficiency of the operator in interacting with a given task. For example,
Snook (28,29) has pioneered the field of psychophysics.
Psychophysicists have developed reliable methods for
assessing the task “acceptability” by workers performing model tasks and for studying such variables as
body habitus, load to be maneuvered, position and frequency of maneuvering, temperature, and humidity.
Ergonomics in part assesses biomechanical aspects in terms of force-vector analysis of the operator
performing the task. Mathematical models have been
constructed necessitating several assumptions and relying heavily on scanty experimental data measuring
forces across relevantjoints. Such data based on cadaver
studies and some in vivo experiments with implanted
pressure transducers have been reviewed by Nachemson
(30) and are by themselves dramatically instructive. For
example, a 70 kg individual lifting 20 kg with back bent
and knees straight places a load on the L3 disc of 380 kg!
These models may take into account such physiologic
data as oxygen consumption and electromyographic
analysis of the muscle groups recruited for a given task.
Based on such an analysis, maximal possible performance is predicted and advisable limits are established by
consensus (3 I ,32).
Little attention has been paid to the pathologic
consequences of deviating from such guidelines. A recent series of investigations undertaken by Chaffin and
coworkers (33,34) are ingenious and highly promising.
Several jobs were analyzed to determine the frequency
of the most strength-requiring component, approximated by a force-vector analysis of the task. The individuals performing the tasks were categorized by age,
weight, history of back pain, and measurement of their
isometric lifting strength. In overview, based on a prospective study, Chaffin showed that the more discordant
the worker and the task, the higher the incidence of back
pain. This incidence was dramatic for the weaker, less fit
worker performing the demanding task. It is interesting
that there was a trend to higher incidence of back pain in
the more fit worker performing less demanding tasks.
These studies provide the most encouraging demonstration that the precipitants of back syndromes can some
day be defined.
Contributions of Industrial Engineers
During the past several decades of frustration for
clinical investigators (27), a number of relevant and
interrelated disciplines have developed, particularly in
the field of industrial engineering. These fields are an
outgrowth of time-motion analysis of the components
of the tasks. Instead of analyzing the task alone, in-
THE UPPER EXTREMITY
The prevalence of on-the-job injuries involving
the arm (excluding the hand) is estimated to be onethird that involving the trunk. Compensation for arm
injuries is one-fourth that for the trunk (7). I n a household survey (8), 1 of 10 injuries ascribed to one-time
HADLER
1022
lifting or exertion did not involve simply the trunk.
Syndromes of pain and loss of function particularly at
the shoulder and wrist without overt trauma are a major
cause of morbidity in all segments of the population.
The contention that pattern of usage is causally related
at any level to the manifestation of these syndromes has
not been formally tested.
Any discussion of the upper extremity syndromes
of pain and loss of function must come to grips with the
bewildering array of putatively discrete clinical syndromes (35-37). For the purposes of this discussion,
examples are selected because they can be defined by
reproducible and readily applical clinical methodologies, and therefore are amenable to the experimental
designs to be proposed to assess the influence of patterns
of usage.
Calcific Tendonitis
The radiographic demonstration of calcification
in the region of the rotator cuff is commonplace. In the
1930s Bosworth (38) X-rayed the shoulders of employees of a large insurance company during their annual
physical examination. Most of the subjects were females
below age 40. Of 5061 employees, calcium deposits were
detected in the shoulders of 2.7%.Because such deposits
were more frequent in female typists than clerical workers, a causal role for abduction was postulated. There
was an increased prevalence of calcific tendonitis in the
minority of employees who were male and who, of either
sex, were over 40. Most of the persons affected recalled
some trouble with their shoulder. No account of symptoms in employees without demonstrable calcific tendonitis was offered.
There have been several careful studies of the
surgical pathology of this lesion (39-41). The earliest
lesion is found in the tendons of the rotator cuff near the
musculotendinous junction. Dystrophic fibrillation is
described with microscopic deposits of calcium salts and
a slight chronic inflammatory infiltrate with some giant
cells. Particulirly in patients with severe pain, the deposits are larger and contain “toothpaste-like” material
under pressure. Rarely was tendon rupture present or
was there any evidence of inflammation in the subdeltoid bursa proper or other adjacent structures.
Based on these pathologic observations and anecdotal historical information, the argument is offered
that the calcification is secondary to the dystrophic tendinous changes. Furthermore, both the primary changes
in the tendons and the symptoms are ascribed to microtrauma inherent in usage. Such assertions remain hy-
potheses. Pinals and Short (42) have described cases of
calcific periarthritis involving multiple sites, suggesting
that the underlying pathogenetic mechanism(s) may be
more generalized. The calcifications may be transient
and symptoms present only when they are radiologically
apparent, suggesting that the deposits may have phlogistic properties. This suggestion gains some credence in
that crystalline apatite in these lesions, both free and
within phagocytes, has been demonstrated in a few
patients (43).
Bicipital Tendonitis
Bicipital tendonitis is another pathologic entity
(44) for which reasonably reliable clinical criteria are
available (37). It is arguably one of the more common
causes of severe pain and functional incapacity at the
shoulder, but there are no data on its prevalence (45). Its
pathogenesis is also unclear, though the combined influence of anatomic aberration and the microtrauma of
use has long been asserted (45,46).
Carpal Tunnel Syndrome
The carpal tunnel syndrome can be defined clinically with some reliability and confirmed electrodiagnostically in 77% (47). The syndrome may result
from fractures of adjacent bones or from encroachment
of the carpal tunnel in a number of pathologic states as
diverse as rheumatoid arthritis (48), acromegaly (49).
and tuberculous arthritis (50). I n the vast majority of
cases no such underlying systemic illness is causative,
and the surgical pathology at most documents nonspecific synovitis (47,5132). It is the impression of some
observers (51,52), but not all (47), that this syndrome is
precipitated, if not caused by stereotyped usage involving a power grip.
Tenosynovitis at the Wrist
Wrist tenosynovitis is quite common in industry,
where it is responsible for considerable, albeit transient,
morbidity and functional impairment. It is said that
these syndromes are precipitated by the initiation of
intense repetitive stereotyped usage (53). The tendon
and sheath of the flexor carpi radialis are frequently
involved. A nonspecific tenosynovitis has been demonstrated histologically, and associated DJD of the
scapho-trapezoid joint has been demonstrated radiographically. This clinical lesion is said to be associated
with a repetitive wringing motion (54). The great major-
INDUSTRIAL RHEUMATOLOGY
ity of patients with DeQuervain’s disease (55) are
women who, it is asserted, perform repetitive manual
tasks involving a firm grip together with radial direction
of hand movement (55,56). In the nineteenth century
this syndrome was referred to as washerwoman’s sprain.
DeQuervain’s disease tends to be more chronic and
disabling than most forms of tenosynovitis as judged by
the experience of the consulting orthopedic surgeon
(55,56), although a bias is caused by patient selection.
Most instances of tenosynovitis are transient,
and morbidity is manifest only in terms of particular
modes of usage. It is in this area, however, that ergonomics has had its greatest impact to date. Tichauer,
who has pioneered this field, has evaluated a number of
manual tasks involving hand tools. He then redesigned
these tools to increase biomechanical efficiency. Utilizing such tools enhanced performance and, in some
cases, dramatically decreased the prevalence of epicondylitis and of symptoms of tenosynovitis about the
wrist (57).
INDUSTRIAL RHEUMATOLOGY
In a critical sense there is little formal proof that
pattern of usage, aside from overt trauma, causes or
precipitates any regional musculoskeletal disease. That
is not to say that if you have such a disease you will not
experience symptoms with usage, or that in the app: :>priate industrial setting you will not be disabled. By
analogy, exertion does not cause emphysema or coronary artery disease, though it may cause dyspnea or
angina to be manifest. For the reasons stated in the
introduction, it is important to attempt to establish such
a relationship if it exists.
The literature is very important in providing a
legacy of fallacies to be avoided by future investigators:
1. We are not studying diseases of industries but
of individuals. What is at issue is not whether people
who work in mines, foundries, banks, etc., have diseases,
but what particular pattern ol’usage is associated with a
particular example of clinical pathology.
2 . The prevalance data currently available in industry are fraught with too many variables to be useful
in establishing a relationship between disease and usage.
For that matter, its reliability as an indicator of the
degree of risk of any particular group is open to question.
3. There is no good control group. lndustrv is
the setting in which one earns one’s living. Even the nonuse of a quadraplegic is associated with musculoskeletal
disease.
1023
4. Cross-sectional studies cannot “prove,” in
general, any cause-effect relationship. The negative
study is uninterpretable; the “positive” study is as likely
to be coincidence as causality, or to reflect the influence
of a variable not measured.
Only prospective studies in which there are few
and defined variables can be interpreted as cogent evidence of causality. But before one can undertake such
studies, there must be some substantive suggestions
about the appropriate variables. The title “industrial
rheumatology” calls for the application of the methods
of clinical investigation to address these issues in the
laboratory setting that industry represents. We must
turn to industry not because it is culpable or because
employees are special examples of mankind; rather it is
because in no other setting is usage as likely to be so
repetitive or stereotyped. The design of the initial crosssectional or retrospective studies is straightforward:
1. Groups of workers should be chosen solely
because they are performing a stereotyped repetitive
task for prolonged periods of time. An interval of decades is a feasible criterion that tends to control for age
and inter-job mobility.
2 . The collaboration of a skilled ergonomicist is
essential if one hopes to adequately describe the pattern
of usage in a biomechanical sense.
3. The measures applied should have some obvious validity and measurable reliability. For example,
symptoms of pain in the past are an unappealing measure compared to the radiographic demonstration of
calcitic tendonitis. Examination of each subject by more
than one observer can test the reliability of the measure.
4. The objectives of the study are to test a null
hypothesis: Within the limits of reliability of the clinical
measures, no difference exists between the study groups.
I n this way inability to reject the null hypothesis is a
meaningful result and as important a bit of data as the
inverse.
N o single study should be assumed to be relevant
to any but the particular groups studied. With this assumption, we can begin to collect reliable bits of datawhere today there are almost none. As these data accumulate, we might find that no such null hypothesis
can be rejected, or that there are clues about the variables that will allow ergonomicists to design jobs in order
to test the influence of the variables prospectively.
With help in design, such data can be accumulated by the medical establishment already in industryoccupational physicians, nurses, industrial engineers,
etc. Furthermore, in 1970 Congress passed the Occupational Safety and Health Act (58) establishing the Na-
HADLER
1024
tional Institute for Occupational Safety and Health
(NIOSH). NIOSH has the responsibility to perform
research for the purpose of recommending safety and
health standards. Perhaps a detailed understanding of
the influence of pattern of usage on the pattern of disease would prove as useful to NIOSH in approaching its
goal as to physicians faced with the clinical dilemmas of
these diseases.
15. Lawrence JS, Bremner J M , Bier F: Osteo-arthrosis: preva-
16.
17.
IS.
ACKNOWLEDGMENTS
19.
The author wishes to express his gratitude to Drs. M.
Battigelli, W. Cromartie, H. R. Imbus, and R . Ney for a
critical review of the manuscript, and to Ms. M. Honeycutt for
excellent editorial and secretarial assistance.
20.
21.
22.
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