Dr John Quintner has asked that I post his article on this site. I welcome the opportunity to facilitate constructive discussion and debate on this issue!
See also references to Dr Quintner’s work on thetipssite
Here is the article:
FIBROMYALGIA AND NEW ZEALAND’S ACCIDENT COMPENSATION SCHEME
Since 1974 the New Zealand Accident Compensation scheme has provided the only form of workers’ compensation available. It replaced the separate workers’ compensation legislation and the common law right to sue for personal injury.
Despite its name, the Accident Compensation Act provides cover for personal injury resulting from work-related accidents and work-related gradual process conditions.
In 2003, the Accident Compensation Corporation (ACC) obtained a High Court decision (Teen v ARCIC, unreported, High Court, Wellington CIV 2003-485-1478, Wild J) that a pain syndrome developed by an office worker whose tasks included intensive data entry did not constitute personal injury and was therefore excluded from ACC cover.
Varying medical opinions were offered for the appellant’s symptoms: that the claimant had developed fibromyalgia syndrome, implying pain without tissue injury as a result of prolonged repetitive mouse and keyboard use “with the adoption of constrained statically loaded postures inducing tension and lactic acid overload in the muscles”; “regional pain syndrome” of the upper body related to psychosocial risk factors including “fear avoidance behaviour” and “catastrophising” beliefs about pain; and a chronic pain syndrome that could probably be subclassified as fibromyalgia [“FMS”].
The Teen case involved a telecommunications worker. Her symptoms were extensively canvassed in an earlier District Court decision (Teen v ACC and Telecom NZ Ltd [2002] NZACC 244 3 September 2002) which defined fibromyalgia as “abnormal pain and tenderness of normal tissue involving abnormal pain perception in the central nervous system, a condition in which treatment directed at (non-existent) tissue damage in the arms, such as physiotherapy, rest and anti-inflammatory medication, failed to effect a cure; recovery did not occur in the expected time-frame as there was no damaged tissue to recover”.
The case-law following the Teen decision has therefore followed the view that a pain syndrome which developed in the context of repetitive work under stress in an office situation may occur without a discrete physical injury, and is not covered by the ACC. The term “fibromyalgia” is no longer used to describe the constellation of symptoms developed by office workers using computers. The current term is “regional pain syndrome”.
The Courts of Law in Teen and similar cases involving telecommunications workers were not advised of the extensive debate that had occurred in Australia in the 1980s over the so-called “RSI epidemic”. Nor were they advised that the view put forward by the ACC was based on conjectures promulgated by Dr Geoffrey Littlejohn, an Australian rheumatologist. Interestingly, Dr Littlejohn had given a keynote presentation at a consensus meeting of ACC officials and medical professionals held in February 1998 [1].
Perhaps even more significantly, the New Zealand courts were not advised that NIOSH investigators in the United States had published their findings on telecommunications workers in terms of discrete musculoskeletal conditions [2]. There was a striking similarity between the types of symptoms described in the 2002 District Court decision in Teen and the physical findings described by Hales et al [2], namely “rotator cuff tendinitis, bicipital tendinitis, epicondylitis, proximal tendinitis, distal tendinitis, deQuervain’s disease, trigger finger, cervical root syndrome, thoracic outlet syndrome, radial tunnel syndrome, carpal tunnel syndrome, Guyon tunnel syndrome, ganglion cysts, probable joint-related, muscle-related (tension neck syndrome and neck trigger points).”
In a Viewpoint article [3], Professor Des Gorman, a New Zealand occupational physician, stated that there were “no objective data to show that mechanical work process alone can cause any of the chronic pain syndromes. Current epidemiological data show that while keyboard workers have an increased prevalence of neck, shoulder and elbow pain, there is no dose relationship between this pain and their work process and they do not have an increased prevalence of any discrete musculoskeletal disorder. The end result is a group of patients who will be “in limbo” – neither acceptable to the ACC as a domestic, recreational, or motor vehicle accident, nor able to prove to the insurance company concerned that a mechanical work process has caused their problem.”
Again Gorman made no reference to the report by Hales et al, or to NIOSH’s collection of epidemiological literature relating to video display terminals (NIOSH 99-135 at www.cdc.gov), or even to NIOSH’s publications on ergonomics (NIOSH 97-117 at www.cdc.gov). Nor did he make any mention of other epidemiological reviews concluding that there was indeed a relationship between musculoskeletal disorders and computer use.
In my opinion, the views expressed by Drs Littlejohn and Gorman reflected their limited understanding of the “RSI” phenomenon in Australia [4,5]. There were indeed competing hypotheses, a fact that may not have been made known to the ACC, nor to the New Zealand Courts of Law.
The end result of this tragic omission has been that New Zealand workers who are diagnosed with “fibromyalgia” or “regional pain syndrome” or similar nebulous types of pain syndrome have no legal entitlement to any other compensation if their claims are declined by ACC.
If they are unable to work, they may or may not be able to qualify for subsistence-type social welfare benefits, but they do not have access to ACC-provided medical investigations, treatments, rehabilitation, retraining, or earnings-related compensation. Finally, if the symptoms do happen to be work-related, there is no means of identifying, minimising or preventing hazardous workplace factors to protect future workers from the relative risk of developing these conditions.
References
- Rankin DB. Viewpoint: The Fibromyalgia Syndrome: A Consensus Report, Accident, Rehabilitation and Compensation Corporation, Wellington. NZ Med J 1999; 112: 18-19.
- Hales et al, Musculoskeletal disorders among visual display terminal users in a telecommunications company, Ergonomics 1994, Vol. 37 No. 10, 1603-1621.
- Gorman D. Viewpoint: The Accident Insurance Act – a desirable reform or market madness? NZ Med J 2000; 113: 62-63.
- Quintner JL, Elvey RL. The neurogenic hypothesis of RSI. In: Bammer G, ed. Working Paper No. 24. Canberra: Australian National University, 1991.
- Cohen ML, Arroyo JF, Champion CD, Browne CD. In search of the pathogenesis of refractory cervicobrachial pain syndrome. Med J Aust 1992; 156: 432-436.
Insult and Injury 
The judgment of Wild J in the matter of an Appeal pursuant to Section 97 of the Accident Rehabilitation and Compensation Insurance Act 1992 between Barbara Teen and the Accident Rehabilitation and Compensation Insurance Commission and Telecom NZ Limited makes interesting reading, particularly in relation to some of the medical evidence that “is at the very core of this litigation.”
This evidence was in the main provided by Dr WED Turner (the appellant had developed “… a diffuse myofascial pain syndrome affecting predominantly the postural and phasic muscles of her neck, shoulder and shoulder blades …”), Dr Allchin (“.. there is certainly central nervous system dysfunction. e.g. of the pain transmission neurones in the spinal cord”), Professor Des Gorman (“that the appellant had chronic pain syndrome that could probably be sub-classified as FMS”) and Dr RD Wigley (“RPS due to occupation” and in relation to Professor Gorman treating FMS and RPS as essentially interchangeable, Dr Wigley said “… Dr Gorman evidently does not regard these as being different complaints but rather different distributions and degrees of basically the same problem and I agree on this.”)
The Judge then found that FMS (or RPS) was not an injury. He held that:
(a) It involved a disordering of the nervous system in some unknown way, but not in the way of damage to the nervous system.
(b) There was a heavy psychological emphasis in the creation and continuation of FMS with non-physical stressors playing a major part.
(c) The stress was not physical stress, but was of a non-physical nature and was excluded from coming within the definition of gradual process injury by virtue of s 7(4) of the 1992 Act.
The result of the hearing was that Judge Beattie’s decision that the Corporation correctly revoked the appellant’s cover under the 1992 Act on 5 June 1998 stands.
This important New Zealand case illustrates how the application of nebulous diagnostic labels can have far-reaching implications when they come under close scrutiny in a Court of Law.
Thanks John – not much reaction from across the Tasman yet! What do you think is the best diagnostic label to apply to the neurogenic condition associated with sustained posture at a computer – otherwise known as ‘RSI’ – surely not RPS, FMS or MPS for that matter?
Peter, when I was in clinical practice, the term I used was “Occupational cervicobrachial pain syndrome of presumed neuropathic pathogenesis.”
Since then, the IASP has recommended that “neuropathic” be only used in situations where there is demonstrable damage to the nervous system.
This has left us with a large gap in our taxonomy for chronically painful conditions.
Professor Milton Cohen and I propose that a demonstrable impairment of function, which on anatomical grounds can be categorised as localised, regional or generalised, could serve as a central reference point.
As you know, the World Health Organization defines “impairment” as any loss or abnormality of psychological, physiologic or anatomic structure or function.
Three categories of clinically determined impairment of function provide the standard titles for this new taxonomy. Importantly, these categories are meant to serve as descriptors and not as definitions:
(a) Nociceptive impairment of function
Operational criteria: (i) pain resulting from noxious stimulation (i.e. inflammation, ischaemia, injury, or invasion) of normal tissue; (ii) with an unimpaired somatosensory system;
(b) Neuropathic impairment of function
Operational criteria: (i) pain associated with evidence of a lesion or disease of the somatosensory nervous system; (ii) a demonstrable lesion or a disease that satisfies established neurological diagnostic criteria.
(c) Nociplastic impairment of function
Operational criteria: (i) where the clinical presentation suggests altered function (i.e altered nociceptive processing) of the somatosensory system;
(ii) the tissue where pain experienced is apparently normal – no evidence of inflammation, ischaemia, injury, invasion; (iii) there are no obvious or detectable signs of neuropathy, sensory or motor (as strictly defined); (iv) there is hyperaesthesia if not frank allodynia to non-noxious mechanical and/or thermal stimuli; (v) there can be subtle motor signs (e.g. weakness, dystonia).
As an example, a patient presenting with a painful, red, swollen and warm wrist joint would attract a diagnosis of “an inflammatory (nociceptive) impairment of the wrist”. A painful wrist in association with clinical features of a peripheral neuropathy would be classed as “a neuropathic impairment of the wrist”. When there is no clinical evidence of inflammation or neuropathy, the clinician would infer “a nociplastic impairment of the wrist”.
In the case of a patient presenting with lumbar spinal pain of unknown aetiology, the appropriate descriptor would be “a nociplastic impairment of the lumbar spine.
When chronic widespread pain is the presenting feature, the diagnostic inference would become “a widespread nociplastic musculoskeletal impairment”.
Advantages of the new taxonomy
Because the descriptors relate to bodily function rather than underlying disease processes, the taxonomy does not automatically stigmatise those patients in whom no disease process is objectively demonstrable.
Furthermore, the emphasis on function provides a rational basis for clinical assessment of the effects of therapy and, in particular, of opioids.
The taxonomy also allows for different disease states and/or pathophysiological processes to be classified under each of the descriptors.
Disadvantages of the new taxonomy
Requires a radical change in medical thinking and diagnostic language.
Conclusion
In our opinion the proposed new taxonomy has merit but we do not know whether the rest of the “pain world” will eventually agree with us. But at the very least, we hope it will encourage much needed discussion of this important topic.
Peter, in answer to your question, in this case I would diagnose “a nociplastic impairment of the upper limb”. I would expect to find that some or all of the upper limb nerve trunks of this patient exhibited mechanical allodynia. But the conventional orthopaedic examination of the upper limb does not include an assessment of mechanosensitivity of upper limb nerve trunks. The neurologists would also have difficulty with this formulation, but may need to be reminded that their 19th century forebears did include palpation of upper limb nerve trunks as an important part of their clinical examination.
Thanks John
Your proposed taxonomy makes sense to me, but it would certainly be a challenge for it to be accepted. As I think I have said before it is best to avoid terms like occupational in the diagnostic label. With ‘RSI’ disorders it is likely that there will be more and non-occupational cases in the future.
I wonder what you think of a term like Postural Cervico Brachial Neuralgia (or perhaps nociplastopathy!) for what would have been termed RSI in the past?
The challenges in the compensation area are multiple:
Firstly, there is a need for ‘objectivity’ to convince 3rd party payers there is a clinical entity at all i.e. a reliable clinical test or preferably an investigation to confirm the diagnosis.
Secondly, accepted clinical practice does not incorporate the tests of nerve mechanosensitivity as you have pointed out. i.e. it is difficult to even get to ‘first base’ with a third party payer until this is recognised.
The first challenge is to get more widespread acceptance by doctors of the validity of the underlying medical concepts.
Peter, I cannot accept the proposition that cervicobrachial pain syndromes do not develop in the context of certain types of employment that necessitate the maintenance of sustained postures of the head and neck whilst performing repetitive manual activities.
It seems that in New Zealand, the occupational medicine physicians are following the party line that was enuncaited by Professor Gorman in the evidence he gave in the case I reviewed. But as I have not seen any of his publications in the Pain Medicine literature, I have no way of reviewing the evidence he has evidently produced in support of them. However, I did find it quite remarkable that when he gave his evidence and stated his views, Professor Gorman did so without having examined the plaintiff.
As you would surely agree, the practice of medicine is built upon the twin foundations – of listening to the patient and then performing a comprehensive physical examination. I hope that Professor Gorman’s New Zealand colleagues have not departed from this practice.
PETER. Sorry for typo. It should be “enunciated’.
Thanks John
I agree many, if not most, of these cervicobrachial pain syndromes associated with forward posture are ‘occupational’ and are clearly work-related and should be compensable.
My concern about a diagnostic term with ‘occupational’ in the label is that these conditions can also be ‘recreational’ – associated with computer activities at home etc.
The diagnostic label should reflect the pathology rather than the setting in which they most commonly occur in the same way you probably wouldn’t call carcinoma of the lung ‘tobacco’ cancer even though it usually occurs in that context.
Peter, that has always been, and still is, the problem – that of defining the pathology. The same pain syndrome can be seen to follow neck injuries sustained in motor vehicle crashes, following stretch injuries to the cervical nerve roots and brachial plexus, and of course can be seen in the recreational context that you have identified. We can also observe a more widespread (cervicobrachial) pain syndrome developing in some patients after a localised injury or insult to a peripheral nerve.
The relative risks of developing cervicobrachial pain in different occupational settings would be well known to you.
But by an unfortunate accident of history, the New Zealand Accident and Compensation Corporation (ACC) came to love the diagnosis of “fibromyalgia,” as it could be used to deny workers’ compensation to claimants presenting with cervicobrachial pain syndromes that had developed in an occupational context.
At the ACC’s 1998 Consensus Meeting, my rheumatologist colleague Geoffrey Littlejohn appears to have conflated “fibromyalgia” with “regional pain syndrome,” with both coming under his heading of “pain amplification syndromes” [1].
“Regional pain syndrome” was being put forward as a term to replace “RSI” (repetitive strain injury) and “OOS” (occupational overuse syndrome). Evidently Littlejohn’s views held sway that these conditions were to be categorised as “regional fibromyalgia” and were not attributable to tissue damage or injury [1,2].
In retrospect, it seems to me that in New Zealand Littlejohn’s conjectures were being passed off in as established knowledge or truth and, as a consequence, the ACC’s medical authorities failed to detect his fallacious reasoning.
References:
1. Littlejohn GO. Fibromyalgia. What is it and how do we treat it? Aust Fam Physician 2001; 30: 327-333.
2. Rankin DB. Viewpoint: The Fibromyalgia Syndrome: A Consensus Report. NZ Med J 1999; 112: 18019.
Addendum:
Readers interested in learning about the contrasting views being held on fibromyalgia in 1998 are directed to two papers published by the Medical Journal of Australia under the banner “Controversies in Health Care”. The more I delve into the New Zealand experience, the more I am convinced that the attempts to arrive at a Consensus on Fibromyalgia Syndrome were entirely misdirected.
Geoffrey Littlejohn’s invention of “regional or localised fibromyalgia” drew attention away from the advances in neuroscience that would help to explain the clinical phenomena that patients were reporting as having developed in the context of their respective occupations [1].
Cohen and Quintner [2] concluded: “Fibromyalgia syndrome is a bogus construct which has been so abused that it has become the “new” psychogenic rheumatism. It has failed medicine by not delivering meaningful explanations, and it has failed sufferers by not conferring diagnostic credibility. Can the traditional roles of medical science and of physicians be reclaimed by refocusing on the neurobiology of pain itself? We believe so.”
Of course, judging by what has happened in New Zealand since then, we were quite wrong!
References:
1. Littlejohn GO. Fibromyalgia syndrome and disability: the neurogenic model. Med J Aust 1998; 168: 398-401.
2. Cohen ML, Quintner JL. Fibromyalgia syndrome and disability: a failed construct fails those in pain. Med J Aust 1998; 168: 402-404.