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.

 

About Tasworkdoc

As an occupational physician in private medical practice in Hobart, Tasmania - the southernmost state of Australia, I see workers referred by their general practitioners with various types of work-related injuries and diseases. These are mostly musculoskeletal injuries, both of traumatic and gradual onset as well as various associated psychological disorders. With interaction with patients for treatment and providing advice about rehabilitation, I have the opportunity, first-hand, to observe interactions between individual patients and compensation systems. I also conduct independent medical assessments, including impairment assessments for musculoskeletal injuries and asbestos-related disease compensation. This provides another perspective of workers within compensation systems.
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1 Response to Literature Review – Upper Limb Pain and Computer Employment – the question of bias!

  1. jqu33431quintner says:

    Peter, I admire your dedication and your tenacity.

    The reality is that women with chronically painful conditions that have developed in association with their employment have been effectively stigmatised in our society.

    It is therefore relatively easy for third party insurers to find so-called learned medical examiners to argue against you on the basis of flawed material published over 20 years ago.

    In my recent article, which is only available on-line at the moment, I argue that the stigma is deeply embedded in our society and removing or countering it will be well nigh impossible [Quintner 2020]. I first made this point 25 years ago in relation to “RSI” [Quintner 1995].

    But fortunately, through the work of the neurobiologists Geoffrey Bove and Andrew Dilley [2018, 2019], the “neuritis” hypothesis that Bob Elvey and I published some three decades ago has received considerable support [Quintner & Elvey 1991].

    Keep up the good work and eventually your occupational medicine colleagues will come to their senses and see that they have been the all-to-willing tools used by third party insurers.

    References:

    Bove GM, Dilley A. A lesson from classic British literature. Lancet 2019; 393 (10178): 1297-1298. DOI: 10.1016/S0140-6736(18)32533-9

    Quintner JL. The Australian RSI debate: stereotyping and medicine. Disability and Rehabilitation 1995; 5: 256-262.

    Quintner JL, Elvey RL. The neurogenic hypothesis of RSI. In: Bammer G, ed. Working paper number 24. Discussion papers on the diagnosis and treatment of work-related neck and upper limb disorders. Canberra: National Centre for Epidemiology and Population Health, Australian National University, 1991: 1-33.

    Quintner J. Why are women with fibromyalgia so stigmatized? Pain Medicine 2020 Jan 27 2020 [online ahead of print]. DOI: 10.1093/pm/pnz350

    Satkeviciute I, Goodwin G, Bove GM, Dilley A. Time course of ongoing activity during neuritis and following axonal transport disruption. J Neurophysiol 2018;119(5):1993-2000. DOI: 10.1152/jn.00882.2017

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