Literature Review – Upper Limb Pain and Computer Employment – the question of bias!

In my October 2018 article Time to Revisit “RSI”, I referred to a literature review I had conducted. What the review highlighted was the need to try and replicate some Danish studies that suggested many cases of upper limb pain related to computer employment represent Brachial Plexus Neuropathy and that a careful clinical assessment can reliably identify such conditions. Previous studies exploring a causal association between upper limb pain and computer work have been dogged by the lack of a specific verifiable diagnosis in a significant proportion of cases to make firm conclusions about causation.

This article is about my journey since I have prepared and disseminated that review.

As explained in the above article, the motivation to conduct the review was in response to my ongoing interest in the subject since the time of the “RSI Epidemic”, my observation of frequent wide divergence in opinion between medical experts and the high level of disability I observed affecting workers (particularly young workers early in their careers) seen at my practice. There did not seem to be any recent publication looking globally at the issue. Arguments before the various courts and tribunals seem to be waged between very disparate medical viewpoints often referring to only a very limited number of publications or “learned opinions”, many of which dated back 20 or 30 years.

It became clear to me after presenting evidence before the AAT in relation to specific cases, that there was little published recently that explained theories of causation in an organised manner. A senior legal practitioner indicated to me that there would be value in a publications on this subject, emphasising the importance to publish through a respected research / academic institution. Unfortunately, I had not been able to identify an academic institution with a specific interest in this subject. Hence, when an opportunity arose through a request for literature on the subject from a plaintiff legal firm, I look the opportunity to undertake an initial review of relevant literature. The literature review was only ever intended as a starting point, with a view to a more comprehensive review and eventual publication in some form.

Since preparing the review, AAT Member Mark Hyman in Skobelkin-Mulcair & Comcare 2019 (CSIRO) has reinforced the need for clarity:

“…..it is not helpful to a decision-maker to have medical evidence that represents what appears to be the poles of current opinion, rather than to hear from doctors who are prepared to debate the possibilities and not leap to certainties”

The review included literature on a wide range of topics I considered were relevant to the topic, but there was no suggestion the review was an academic systematic review capturing all the literature and analysing such literature in an organised and systematic manner.

While I spent about 50 hours of my time reviewing literature and preparing the report (with some administrative support from my practice staff), my academic colleagues tell me to conduct a proper systematic review on even a narrow subject requires an order of magnitude (500 hours +) greater investment of time. The title:

UPPER EXTREMITY DISORDERS AND COMPUTER WORK – A clinician’s focused literature review in relation to a neurological explanation for non-specific upper extremity disorders and the relationship to use of computers

was intended to convey this was a review by a clinician, not an academic, and not a systematic review of all relevant literature – a virtually impossible task.

A peer-reviewed journal editor told me that to be published in that space you need to have conducted a systematic literature review.

Leaving aside the impracticalities of having the necessary amount of time in a busy clinical practice, obtaining funding to prepare even the limited review or a small clinical study, is also difficult in my experience.

I accepted an offer of part-funding from a plaintiff legal firm. That lead to expression of concern that I was conflicted by virtue of the funding arrangement. I expect however that no matter the source of funding, there will always be a concern that the funding arrangement might skew the outcome. Even Government, should they contribute funding, might have an interest in the outcome one way or the other given the large number of government employees in computer-based employment and government underwriting of the social security system.

Since I prepared the literature review, I have disseminated my conclusions through various channels:

  • Hobart workplace rehabilitation provider educational meeting
  • Occupational Physician meetings in Canberra and Hobart
  • A presentation for workers, lawyers and insurers in Canberra
  • Reference to the review in various medico-legal reports I have prepared

Mostly comments I have received could be summarised as “mmmm…Interesting”, but very little critical analysis by any practitioner who can demonstrate an understanding of the literature and familiarity with the condition. An occupational physician did alert me to another possible biomedical explanation for the “RSI” phenomenon, that I wasn’t previously aware of, so some value has come from the dissemination process so far. I did receive a blunt, almost rude, rebuttal of my review from a practitioner who referred only to one or two very outdated low level evidence documents, but not much gained from that.

Recently I was gratified to receive more constructive feedback demonstrating relevant literature knowledge. While the thrust was to reject my analysis and conclusions, I welcomed such feedback to enable consideration of a wider range of evidence that I had not considered.

I recently read Work-related Musculoskeletal Disorders in Australia. This report was prepared for Safe Work Australia by Associate Professor Jodi Oakman, Dr Rwth Stuckey and Dr Sam Clune at the Centre for Ergonomics and Human Factors, La Trobe University. There is little in the report directly relevant to the subject of the literature review. The authors do state however:

Some other points of note in Table A.10 are that ‘repetitive movement, with low muscle loading’, a primary focus of intervention advice for many years (Safe Work Australia, 2018c), is a relatively uncommon mechanism in relation to the body stressing category, with Clerical and Administrative workers (not surprisingly, considering their work tasks) most commonly (20%) experiencing this mechanism within their body stressing group, followed by Labourers (10%).

My (obviously anecdotal) experience is that many workers with computer associated chronic pain do not make claims because of the associated stigma of these disorders. While the official statistics that include this subject suggest only 5-10% (or 20% in office-workers) of work-related MSDS’s are due to ‘repetitive movement, with low muscle loading’, the lack of a category for specific computer-associated disorders, limited reporting and inordinate levels of disability often affecting young workers, suggests this area is receiving less attention that might be warranted in terms of real impact on workers and their work capacity.

My anecdotal view of the relative importance of this subject is perhaps reinforced by the number of disputed cases of upper limb pain related to computer work that continue to appear before the AAT each year.

I am hoping with availability of the literature review more widely (click on the link in the first part of the article), I will receive more feedback from a variety of sources with links to evidence that have a bearing on the subject. Perhaps an academic institution will become interested.

Yes, the literature review is not systematic and my view of the literature is coloured by clinical experience, but I remain of the view that it is a useful starting point and valid conclusions are presented. I think clinical experience in managing these conditions is an asset rather than a liability as it provides first hand experience about the natural course of these conditions and responses to various treatment and psychosocial variables that abound in our compensation systems.

I am working on a second version of the Literature Review and look forward to receiving further constructive critical feedback either via comments from other practitioners who review my opinion in the context of specific cases or more general feedback.

Please comment below, email me at peter_sharman@me.com or even give me a call on 0419881519.

 

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Glass, Sugar and Rising Sea Levels!

Another year draws to a close. What can we learn from the world to enhance workplace health and avoid adding insult to injury? Here is my philosophical take at year’s close.

A month ago Deborah Glass declared elements of the Victorian WorkCover system “Immoral and Unethical”  while Gary Fettke continued his crusade about the evils of Sugar and “Big Food” in relation to threats posed by diabetes  and obesity. Even a blog about health issues in the workplace can no longer ignore the emerging climate catastrophe and associated Rising Sea Levels.

GLASS

The Victorian Ombudsman, Deborah Glass recently released her second report into the Victorian WorkCover System declaring that her first report barely scratched the surface. With its focus on long term injured workers, the report –   WorkSafe 2: Follow-up investigation into the management of complex workers compensation claims highlighted the dysfunctional behaviour of WorkSafe Agents in a financially driven system to the detriment of the health and wellbeing of injured workers.

I don’t propose to rehash the findings, rather her most important conclusion about the inherent conflict generated by the way the system operates and what might be done about it. She states:

“…in the case of complex claims, financial reward and penalty measures in agents’ contracts with WorkSafe were driving a focus on terminating and rejecting claims to maximise profit, at the expense of sound decision making.”

My view about the most important aspect of this review is that it questions the very foundations of the Victorian health care system for injured workers.

Her recommendations include:

“……..an independent review of the agent model to determine how and by whom complex claims should be managed”

While the Glass report and many commentators focus negatively on the behaviour of the people administering claims within the system, I think that focus is misplaced and inappropriate.

It is hardly surprising that individual claims staff act the way they do, sometimes with apparent callous disregard for the wellbeing of workers, when the system isolates them from workers and measures their performance using financial outcomes and artificial RTW goals.

Such a system creates a WorkSafe Agent (or insurer) workplace culture that reinforces negative injured worker stereotypes and sucks out any empathy. While more senior management might express a claimant friendly narrative, usually there is tacit management approval for profit-friendly actions. With all these factors operating, it is surprising to me that as many decisions made by claims staff actually do support and assist with the recovery of injured workers, as they do.

The occasional exposure of inappropriate claims decisions by an Ombudsman’s Report is unlikely to change an entrenched culture reinforced by many factors.

Don’t blame claims officers – most inappropriate behaviour is the product of the system!

The development of attitudes by claims staff to injured workers might be an example of what Zimbardo tried to demonstrate with  The Stanford Prison Experiment.

SUGAR

Tasmanian Orthopaedic Surgeon, Gary Fettke has been vocal in a campaign that highlights  Big Food’s role in spreading misinformation about the role of dietary sugar in chronic disease, particularly its’ role in obesity and diabetes . Without analysing the details of this important issue, this example services to illustrate the potential for an entire generation of health professionals, advisory bodies and government authorities to become falsely convinced about health risks of certain food types with disastrous consequences for public health. Gary highlights how commercial interests can influence scientific conclusions and the systems in place.

RISING SEA LEVELS

While this blog does not normally provide commentary on the debate about environmental issues, it has become such a critical issue for mankind, I will reverse that policy, at least for this article. The science is clear – the effects of man-made rise in CO2 levels on our climate are uncontestable and present an existential threat to many species, including our own.

What is not known accurately is the speed of changes, at what point we reach a “tipping point” with acceleration of trends that become obvious to everyone, everywhere and perhaps most significantly the unanticipated social and political consequences of a changing climate and inundation of low lying areas by sea level rise – not only the direct health consequences. We can debate whether this is a climate “Emergency” in the medical sense, but it is obvious that immediate action is needed by those in control.

While I accept the need for all citizens to do their bit i.e.  to Think Globally – Act Locally the reality is that is that for meaningful change, the system, lead by governments around the world needs to be changed to achieve the necessary change. The Australian Government needs to more than pull its weight globally, given our relative wealth and our per capita contribution to global CO2 emissions.

LEADERSHIP, LEGISLATION AND CULTURAL CHANGE

Whether the objective is better outcomes for injured workers, downward trending national obesity rates or arresting atmospheric CO2 rise, the solution is not to blame individual behaviour.

It is not the primary responsibility of the claims officer, the person with diabetes or the average citizen of the Earth to reverse the trends. The solution is to change the system with a legislative framework that supports a culture that changes and supports individual behaviour that in turn reverses any adverse trend.

We need leaders in politics, government, community and business who understand the evidence and can act for the good of all with agendas for long-term change supported by legislation, irrespective of the issue. Only through changes to the system will cultural shift be achieved that can cause widespread change in individual behaviour.

The same applies to silicosis risk, but that is a topic for another day!

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Split down the middle! – AAT decisions about upper limb pain and its relationship to computer employment

In my article late last year, Time to Revisit “RSI”, I referred to several legal decisions in the AAT relevant to this subject, concluding that not a lot had changed since the 1990’s in relation to the confusion that exists about these conditions, not only in terms of determination of causation, but the very existence of these types of disorders as a physical entity.

During 2019 that confusion has continued, as illustrated by decisions made by the AAT.

In Yasmin and Comcare (Compensation) [2019] AATA 15 (10 January 2019), Woodfield and Telstra Corporation Limited (Compensation) [2019] AATA 1473 (26 June 2019) (a case where I was a witness) and Aylett and Comcare (Compensation) [2019] AATA 1474 (26 June 2019), the decisions were not in favour of work causation, but in another 3 cases the outcomes were more favourable for the worker.

The evidence presented in the above decisions reinforces the confusion that reigns in terms of diagnosis, causation and terminology.

I am presenting an Information Session entitled “What happened to RSI – Upper limb pain in the context of computer work – an occupational physician’s 30-year perspective” in Canberra on 09 October where I will further dissect the recent AAT legal decisions and present my summary of the evidence-based literature relevant to this subject and propose some better diagnostic terms.

I hope to meet Canberra-based health and law practitioners, employers, workers and insurers claims staff at that session. I expect there will be some interesting discussion about this controversial subject. I look forward to meeting those who can attend. I do not like to create a cost barrier for dissemination of information and regret that there is a charge to attend the session, but other sources of funding to run such sessions are few and far between.

 

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Justice AND Harm Minimisation – is that possible? – medical file access by summons or subpoena

Carver and Comcare

I recently published an article, Privacy of Medical Records – What does a recent AAT decision mean for patients and doctors? in the new O.M.I.T. (Occupational Medicine in Tasmania) newsletter. The article refers to a recent AAT decision (Carver and Comcare (Compensation) [2019] AATA 1534 (28 June 2019) about insurer access to medical files via summons.

In that article I summarised the main messages for doctors and highlighted some of the implications for medical practices where insurers invoke compulsory mechanisms through the courts to gain access to medical files.

The AAT decision drew a distinction between  a doctor’s professional duty and a legal duty, in the following terms:

“There is, in my view, a distinction between what doctors are required to do to discharge their professional duty to patients or to practice according to standards expected by the Medical Board of Australia and that which is required by law when served with a summons” 

It would seem to me that doctors are legally required to act professionally and if there is validity to the above statement, the boundaries between practicing legally and practicing professionally need to be explored further by the medical profession.

Objecting to a Summons or Subpoena

In my experience summoning of medical files is becoming much more common, but at present the practice seems confined to Commonwealth jurisdictions. Well almost, soon after my initial draft of this article, I received a “Notice to Attend” from the Tasmanian Workers Rehabilitation & Compensation Tribunal (TWRCT) to produce a patient’s file.

My practice files have been summoned 5 times in the last year or so. In two of those cases, the patients file had previously been summoned. Due to my concerns, I have explored the legal system response to various approaches to legally opposing the summons.

While I have been obliged to provide my file to the relevant Court/Tribunal in each case, I have had variable success with my objections to the release of consultation notes, particularly that they be withheld from the insurer involved.

Firstly, questioning the validity of a summons duly issued by a Court or Tribunal does not appear to be an effective approach. I now routinely attempt dialogue with the agency requesting the summons, but in one case I was rudely stonewalled when I asked about the purpose of the summons and questioned its scope. I had reason to suspect an ulterior motive by the requesting party. Nevertheless, the Tribunal required the release of my file for their consideration rather than directing, as I had requested, that the requesting party respond to my queries about the basis and scope of the summons.

In another case my entire file was provided to the insurer, but in two other cases the Tribunal determined that my consultation notes be withheld from the insurer. It has not been possible to establish the Tribunal’s reasons, whether the notes were deemed irrelevant or protection of privacy and concerns about potential harm were factors.

In the recent matter before the WRCT, my entire file, including consultation notes, was provided to the solicitors for the insurer, but not to the insurer itself, presumably as a result of my objection. Interestingly, I only found out the Tribunal final decision in relation to my objection when I subsequently appeared as an expert witness in a hearing relating to the same patient and the insurer’s solicitor cross-examined me about my own consultation notes. The parties were informed that my objection to release of consultation notes was dismissed but, as the doctor making the objection, I am yet to be officially notified. The dismissal of my objection however came as no surprise given the Chief Commissioner’s comments when he heard my objection. I will await the formal decision with interest.

Hopefully as a result of the decision in Carver & Comcare, the reasons for future decisions about objections will be provided in writing.

In one of the five cases however,  I was gratified that the insurer actually withdrew the request for my file after I explained to the insurer’s solicitors the basis for my objection, referred to my own conclusions about the implications of the Carver and Comcare Decision and raised the potential need to seek my own legal advice. I am not sure why they withdrew, but I like to think insurers might now consider the necessity of medical file information before embarking on the rather oppressive and intrusive process of forcing a medical practice to release a file.

The Future

I hope that more respectful approaches will be adopted where insurers require medical information from treaters, i.e.  polite written requests accompanied by the patient’s consent or even a request for case conference. If a “forensic” examination of records is important, perhaps they could identify the issue, rather than the intrusive and scattergun approach of a file summons. The term “fishing expedition” comes to mind.

There remains a need for the medical profession to put forward its views on the professional duties of a doctor in relation to confidentiality of medical records and professional obligations in a response to a summons. The RANZCP statement Patient–psychiatrist confidentiality: the issue of subpoenas is a good starting point. The AMA also have some guidelines for their members – Guidelines for Doctors on Disclosing Medical Records to Third Parties

I have had feedback from patients who have experienced unwanted access to their file and felt the unnecessary intrusion. One such patient wrote to me:

“The patient in this process (making a compensation claim) has to waive rights to privacy; their personal medical information is routinely disclosed to their employer, rehab case managers and to other medical practitioners for IME consultations. The patient has no say in who is given what information. While it is important that employers properly manage an injured worker’s injuries and assign appropriate work accordingly, in my experience, disclosures can be to anyone in the organisation and not always for this purpose. Disclosures seem to increase if the patient questions the process. I have routinely annotated consent forms to restrict disclosures of my personal information to only information about my workplace injuries, and only to a limited group of people, but this has caused me problems.”

“These records are not just released to the tribunal, but subsequently to the insurer and their lawyers and may also appear in a publicly available decision document.”

“I am now very careful to divulge only the minimum information required to seek medical intervention as a result, but I rarely go to doctors anymore, despite medical need. I will not tell anyone which doctor I see now. So it’s not just practitioners who are deterred.”

Patients also seem to be disempowered. Again to quote from the same patient:

“There is an imbalance of power in a workers comp case and the patient is already broken and intimidated, while trying to manage an injury/illness, rehab process, legal case, distress, work and family.”

“For patients there is no real avenue or forum for any feedback to the system or for discussion in the public domain of what happens to us.”

From my recent experiences, I see a twofold need:

  • Firstly, insurers and their legal advisers need to be made aware of the repercussions of a legal system that routinely forces doctors to release their files. Not only is there potential for psychological harm to the patient, but such practices undermine patient confidence in the medical system. This might lead to non-disclosure of important information for the doctor’s decision making. Repeated unwelcome legal intrusions might deter some doctors from being prepared to treat compensation patients. What has been labelled “Refusal to Treat” has already been identified by researchers as an issue affecting access to treatment for patients in compensation systems. There is not much published on this subject but some research is emerging. See link:  “Is clinician refusal to treat an emerging problem in injury compensation systems?”
  • Secondly, if the Court system has ultimate control and responsibility for the legal processes that require doctors to release their file (as they do and there is no prospect that that can change), that responsibility should extend beyond just the legal considerations of relevance of the documents to the matter before the courts. The Courts have the power to reject or modify requests from insurers, but I have seen little evidence of the exercise of that power. There needs to be a proper process adopted by tribunals and courts that considers the legal need, along with an assessment of potential harm. Harm can occur both at an individual level and at the level of the overall public interest. The public interest is seriously undermined if patients no longer disclose important confidential information to their doctors or doctors are no longer prepared to treat compensation claimants.

Conclusion

I believe summoning an entire medical file should be a “last resort” where medical information from treaters is essential for justice and alternative means to obtain necessary information have been unsuccessful.

The Carver and Comcare Decision identified some deficiencies in the legislative provisions relating to summoning files. There is an opportunity for a more comprensive review of  Legislation, Practice and Procedure.

In the interim, it seems appropriate for medical professional organisations to publicise this issue amongst their members, explore issues of professional duty and provide education about what options doctors currently have when their medical files are summoned without patient consent.

Further Developments

I recently delivered a presentation – Medical Files – Access by insurers via court demand at an AMA sponsored forum that included consideration of this subject. In preparing my presentation, I contacted the AAT to clarify the procedures relating to the process leading up to the issue of a summons for a medical file.

As I understand it, the party wanting access to a medical file drafts the Summons and makes a request in writing to the Tribunal so that a registrar of the tribunal can consider:

  • the reasons given for requesting the summons;
  • the person to whom the summons is directed; and
  • the description of the documents the person will be required to produce.

The only currently-accepted grounds for rejection of a request include that the information is not relevant to proceedings or if the summons is too broad or incomprehensible. The same principles apparently apply in the TWRCT.

The AAT were not however able to provide any answer to the following query:

“How many Summons requests for medical and other health professional files are issued annually by the AAT? How many are issued as requested, how many are modified and how many are refused completely? Can you summarise the reasons for refusal or modification?”

I understand that there are about 1000 applications each year to the AAT in workers compensation matters. I further understand summons requests are a subset of that group. In my experience summons’ are often issued to multiple health providers as part of a single application, so I expect 100’s (if not more) of medical files are obtained by this process and remain on insurer and lawyers computer servers for long periods. It would be interesting to obtain an accurate answer to my query, if that is possible.

My communication with the AAT did offer some hope. In answer to my query about any plans to review processes relating to summons procedures, I received the following answer:

“We are currently looking at practice and procedure in that area of our work as well as at our practices relating to summonses more generally. We would welcome the views of stakeholders in relation to these matters, including any concerns or suggestions relating to summons procedures. Should you or the AMA wish to provide any views, these can be forwarded to: legalandpolicy@aat.gov.au”

Where To From Here?

I hope that medical organisations will take an interest in this important issue and lobby appropriately. I also hope that the AAT (and other Courts and Tribunals) review their procedures and flag the need for legislative change where the current law presents a barrier to new procedures that take account of harm. Updated procedures should not only consider the relevance to legal proceedings of confidential medical files where an insurer considers that they contain potentially important evidence.

I also think a doctor’s consultation notes need to have special protected status given their primary role is to aid treatment, the inclusion of most sensitive material in those notes and the potential for misinterpretation by non-medical people.

I am interested in any feedback on this issue.

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Surveillance Yet Again!

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I don’t think much has really changed since I wrote an article about surveillance entitled Sharp Focus or Blunt Instrument on this site in 2014. This article discussed the potential for harm from video surveillance of personal injury and workers compensation claimants. There has been some publicity about the negative effects of surveillance on people with mental health claims, particularly in NSW, but nothing much happening in this space in Tasmania.

A recent ABC article I was a private investigator for insurance companies really brought the issue into focus again, with a credible source from within the industry reinforcing what some people already realise – that the practice is potentially very harmful, is often undertaken at the whim of a junior insurance company claims officer and is mostly a waste of time and resources.

I think there is a place for surveillance in very limited circumstances, but a decision to film an unsuspecting person and intrude of their privacy (and often those around them too) should only be undertaken for a very good reason. As I have previously stated, I think an independent responsible person, who can properly assess the risks and benefits should authorise any planned surveillance.

COVERT SURVEILLANCE SHOULD REQUIRE A COURT ORDER!

 

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What’s happening at the Frontline?

Screenshot 2018-11-08 08.06.32

 

 

The Tasmanian Minister for Primary Industries, Building & Construction and Veteran’s Affairs, Guy Barnett recently announced in a Media Release about PTSD Reform

“that Tasmania will become the first jurisdiction in Australia to legislate a presumptive provision for workers compensation claims arising from diagnosed Post-Traumatic Stress Disorder.”

He confirmed the government’s commitment in the following terms:

“….. Hodgman Liberal Government is committed to seeing first responders provided with a fair and reasonable access to workers compensation for work-related PTSD.”

Mr Barnett has also expressed his support for Veterans in the following Media Release:

New Proposals to Assist Veterans

These announcements have been generally well-received, although I have heard some concerns expressed that opening up presumptive provisions across the entire State Service might encourage claims from undeserving workers and create additional unanticipated problems. We are yet to see the detail about how the legislative amendments will work. Hopefully there will be consultation with the consumers and practitioners who work within the system regarding implementation.

There are however issues about how our Front-line “First Responder” workers are being treated where they have been accepted by the compensation system. A recent Channel 9 News Article highlighted the issue of a Fire Service employee denied  important treatment recommended by his treating doctors despite having suffered a serious injury.

While I have no knowledge of the case highlighted above, I have observed in a number of recent cases the adverse effects of an adversarial claims management approach towards Police, Ambulance, Hospital and Fire Service employees who have sustained serious physical and psychological injuries in the course of their front-line work.

The most common scenario is that funding for important treatment is denied, usually based on the opinion of an “independent” doctor who spends a relatively brief time assessing the worker. Many of these independent doctors have not practiced in the relevant field of medicine for many years and are reliant for repeat business from insurers according to the value to the insurer of the opinions they express.

The insurer (in the case of the State Service – a Self-Insurer) chooses the opinion of that doctor in preference to the opinion of the treatment team who know the worker’s condition best through multiple contacts over a period of time. Lengthy destructive legal processes are necessary to re-instate treatment.

If barriers to claims for PTSD by front-line workers are lifted, it will become increasingly important that the systems to support and assist workers managed within the compensation system are reviewed to avoid an increasing number of front-line workers being adversely affected by the system meant to support them.

Recently two important National reports have been released relevant to Workers Compensation in Tasmania.

The ABS Report – Work-related Injuries Australia July 2017 to June 2018 provides  interesting reading about the number of injuries, but highlights the relatively low number of people who actually make claims and have their conditions managed through our workers compensation schemes. While there is no breakdown by state, nationally only 55% of workers who experienced a work-related injury applied for workers compensation.

The 2018 National Return to Work Survey provides increasingly useful data about some of the outcomes for injured workers in compensation systems around Australia, including comparison between the states. While the official Return to Work rates around Australia of just over 80% (Tasmania is on a par with other states at 79.3%) are relatively stable,  some new information in the current survey is interesting. While Tasmania fares reasonably well on a number of measures, the rates of reported persistent pain and psychological distress are somewhat higher than most other jurisdictions.

The report states:

“While there is no statistically significant differences between jurisdictions, it appears that a higher proportion of workers from Tasmania and Comcare have experienced persistent pain than those from other jurisdictions”

“A significantly higher proportion of workers from Victoria (15.6%) had a Kessler 6 score indicating probable serious mental illness. Workers from Queensland and Tasmania also had a relatively high incidence of workers with ‘probable serious mental illness’ (11.5% and 11.8% respectively), although these results were not significantly higher than other jurisdictions”

Some of the Workplace Domain measures for Tasmania were also of concern, perhaps reflecting the relatively greater proportion of smaller employers in Tasmania.

I hope to provide a more detailed analysis of these reports from a Tasmanian perspective soon but, irrespective of inter-jurisdictional comparisons, the rates of persistent pain and psychological distress are a cause for concern.

Measures to improve the mechanisms to support injured front-line workers are important. This should not only include improved access to compensation system support, but also ensure that compensation schemes do actually support injured workers as intended.

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Time to Revisit “RSI”!

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I would like diverge from the usual theme of this blog by considering a specific occupational health issue – that of what is still often described as “RSI”. Unfortunately that label is both inaccurate and invokes an emotive response, so I try to avoid its use as much as possible, but the term is difficult to avoid because of its entrenched status, popular usage and lack of a suitable alternative term.

I have taken an interest in this subject from the time of the so-called “RSI Epidemic” of the 1980’s. At that time I was the Senior Medical Officer at the Hydro-Electric Commission (now Hydro Tasmania) and that organisation had their share of these problems, although not to the same extent that Telecom (now Telstra) did at the time – as has been described in the literature by Occupational Physician, Dr Bruce Hocking.

In my various roles since that time, I regularly encounter the phenomenon of upper limb disorders in computer operators, that, on the face of it, is caused by the sufferer’s work using computers. Particular problems seem to relate to mouse usage, perhaps more so than with keyboard use, although the underlying common factor appears to be the posture adopted at a computer that restrains normal upper limb movement for sustained periods. Similar problems are encountered with musicians and sonographers. Aggravation in association with driving posture is also widely reported.

While some sufferers have associated psychological disorders, my overwhelming impression is that the majority of sufferers are “normal”, often hard-working and dedicated people who suffer a convincing syndrome of pain and associated neurological symptoms that is temporally related to their use of computers at work. Chronic pain causing long-term disability from these disorders is common.

While there is a relative dearth of objective clinical findings, the presentation is sufficiently convincing in terms of consistency and response to aggravating and relieving factors for me to accept that this probably represents an “organic” condition and is not a primary psychological disorder, fibromyalgia syndrome, hysteria or a socially-caused phenomenon as has been suggested by some commentators.

it is difficult to get accurate official figures on the incidence of these disorders in Australia in recent years. The 2016 statistics for musculoskeletal disorders from SafeWork Australia include the following table:

Screenshot 2018-10-18 08.31.29

This table would suggest that in the period covered there might have been 4,000 or more cases of upper limb overuse syndrome, comprising 1.3%  of claims. If bursitis, tendonitis, epicondylitis and non-traumatic muscle or tendon strain are included the total is potentially much higher i.e. 30,000 or more claims.

What I have observed in recent times, is that Comcare, in particular, have challenged continuing compensation for many sufferers of these disorders. It is difficult to know how many claimants accept Comcare’s determination of entitlements and don’t make a legal challenge, but I am aware from reviewing decisions in the AAT and from contact with doctors and solicitors in Canberra and Hobart that the decisions made by the AAT can vary widely with both acceptance and rejection of upper limb disorders claimed as being related to use of computers. One of the important determinants of the outcome is whether there is a specific diagnosis.

AAT Senior Member DJ Morris in Neville and Comcare (Compensation) [2018] AATA 3738 (5 October 2018) found no reason to even consider evidence about work causation on the basis there was no acceptable medical diagnosis. He states:

“An essential first element in assessing a claim for workers’ compensation is that a person has a medically diagnosed ailment as defined in section 4 of the Act and whether a person has an “injury” in terms of section 5B(1)(a). It is accepted that Mr Neville may have discomfort in his right forearm, but that is not enough. Mr Neville relies on Dr Cooke’s use of the term “overuse/RSI ” as a settled diagnosis, but in his evidence, Dr Cooke himself submitted it was not strictly a diagnosis. “

In contrast, AAT Member S Taglieri in LHHL and Comcare (Compensation) [2018] AATA 3272 (7 September 2018) rejected Comcare’s determination to deny liability in relation to a specific condition (Complex Regional pain Syndrome) related to computer employment. She states:

“The Tribunal is satisfied that the reviewable decision was erroneous in that it concluded that the applicant no longer suffered from the effects of a compensable condition. The Tribunal is of the view that the applicant continued to suffer from the effects of the compensable condition secondary complex regional pain syndrome. For these reasons the decision under review is set aside and the matter is remitted to the respondent to give effect to the determination of the Tribunal.”

Not a lot seems to have changed since the time of the case Maree Verna Tyrrell and Westpac Banking Corporation [No 2924 of 1990] (14 December 1992) when Judge Barlow concluded:

“However, the plaintiff has failed to persuade me the nature and conditions of her employment constituted a hazard and risk to her health, that is to say a risk of injury, and in particular a risk of sustaining a condition or injury referred to as RSI” .

 “I am inclined to the view their lack of objectivity has led them, subconsciously at least, to develop a hypothesis to fit their theory that pain syndromes, of the type which the plaintiff claims to suffer, have a neurogenic cause. In reaching this conclusion I have not overlooked Professor Mastaglia’s comments, that the contents of Professor Helme’s paper [1]could be the beginning of objective evidence of an organic basis for this type of pain syndrome” .

 “My findings do not exclude the possibility of there being a neurogenic factor, to pain syndromes of the type which the plaintiff claims to suffer. Research yet to be done and testing techniques and equipment yet to be devised may reveal the presence of a neurogenic factor or cause”.

It would seem that the Tasmanian Workers Compensation Tribunal is having difficulty with decisions on this subject. No decision has been made about a case of upper limb pain related to computer employment where the hearing was conducted in February this year (or maybe the Tribunal is just under resourced).

What was previously called “RSI” is currently often described as “non-specific” arm pain. Lack of agreed diagnostic criteria means it is difficult, if not impossible, to accurately explore relationships to workplace factors. On that basis proof to a high degree of scientific certainty about occupational causation for “RSI” has remained elusive. If it were established that there is a specific diagnosable disorder, causative factors can be scientifically examined.

When I listen to the evidence delivered by practitioners who deny the possibility that computer work can cause such disorders, there seems to be a heavy reliance on the evidence and opinions from the time of the “RSI Epidemic” rather than referring to up-to-date evidence about the mechanisms of chronic pain or occupational epidemiological studies.

Recently I have spent more than 50 hours preparing a literature review related to the above subject. In particular, I looked at literature relevant to the question whether brachial plexus neuropathy (BPN) might constitute a specific diagnosable condition and provide an explanation for many cases of upper limb pain related to computer employment.

Dr Jorgen Jepsen in Denmark has done some work that seems to suggest that BPN might be a specific disorder that can be diagnosed reliably by a careful detailed clinical neurological examination, building on the earlier hypothesis of the West Australian Rheumatologist, Dr John Quintner of a neurological basis of “RSI”.

The work of Dr Jepsen needs to be replicated by other researchers, but his work does provide evidence of a disorder plausibly related to the postural demands of computer work, worthy of further research.

I suspect there is reluctance on the part of many organisations to further explore this subject because of the very significant implications for employers and compensation providers should incontrovertible evidence emerge of a causative relationship between the common upper limb pain  syndromes and computer employment.

In a 2014 article in The Conversation, entitled Repetitive strain injury: is it real or imagined? the author suggested the science was settled while recognising continuing negative connotations from the disorder, as follows:

“While the term RSI, which implies an injury which has been caused by physical factors, has long-since been replaced by the term occupational overuse syndrome (OOS), its use, and the negative connotations associated with it, persist.

Fortunately, diagnostic criteria have now improved. Workplace injuries and conditions which would previously have been classified as RSI are now more accurately diagnosed. This, along with greater acceptance of the role of psychosocial factors has led to improvements in the management – and the outcomes – of these injuries.

All we need now is to improve our recognition of the importance of these factors in the prevention of injuries – but that’s another story.”

I would not accept the conclusions about accurate diagnosis and improved outcomes, at least from my perspective of a practicing physician who regularly sees these cases, the wide variety of diagnostic labels that are applied, the confusion about entitlement to compensation and sometimes poor outcomes.

These questions are important to settle, not only from the perspective of responsibility for rehabilitation and compensation where cause-based compensation systems exist, but also from the perspective of evidence-based prevention, in a world where there is growing use of computers and related devices in schools, homes and workplaces.

While employers almost universally accept the value of preventative measures to prevent “discomfort” amongst computer operators, elucidation from a scientific perspective of specific medical conditions caused by use of computers and the circumstances in which that can occur can only be of value in prevention of disability,  contribute to a productive workforce and ultimately save costs to the community.

Occupational Physicians have an important role to play in this area and should take the lead in researching and putting forward the evidence, without fear or favour, to allow informed decisions to be made, both at a system and individual case level. These disorders are clearly the province of occupational medicine, rather than other medical specialities.

I THINK THE TIME IS RIGHT TO REVISIT RSI!

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