Back Pain in the Workplace

IN 1911, NEW YORK WAS THE FIRST STATE TO LEGISLATE “workmen’s compensation insurance.” By 1949, all states independently administered workers’ compensation insurance programs. Several stipulations were common to these statutes and remain so today. Foremost is to indemnify medical costs and lost wages when a worker has experienced a work-related personal injury, generally defined as an injury that arose “out of and in the course of employment.” The intent of these schemes is to minimize the financial toll that compounds such injuries. From the outset, the notion of “injury” was contentious. For instance, if an inguinal hernia is first noticed at work, is that a compensable injury? It became so when “rupture” became parlance. Regional back pain frequently affects adults who are generally otherwise well and who experienced no unusual, let alone traumatic, precipitant. Regional back pain was not considered an injury until the mid 1930s when Mixter and Ayer ascribed cauda equina syndrome, if not all backache, to disk “rupture” and described a surgical remedy. “Rupture” captured the attention of all workers’ compensation administrators and adjudicators, as well as others involved in workplace safety and in providing a remedy whenever safeguards failed. If the outcome is a “rupture,” even if the precipitant is an activity that is customary and customarily comfortable, the worker has sustained a compensable back “injury.” Ever since, back “injury” has hung like Damocles’ sword over the resource-advantaged world, inside and outside the workplace, wreaking havoc on the lives of workers with disabling backache for whom workers’ compensation insurance is designed to provide a remedy. Over the past few decades, the construct, the diagnosis, and many of its ramifications have been systematically studied. Diskal “rupture” is a flawed pathogenetic theory and compensable back “injury” an iatrogenic sophism. The causes of regional back pain continue to elude scientific inquiry. The degenerative changes that characterize spinal pathoanatomy escalate in incidence with each passing decade until they are ubiquitous but have almost nothing to do with life activities. The age of onset and the degree of degenerative change are largely genetically determined; the contributions of environmental influences are barely discernable. Age-appropriate spines, however hoary, do not bear witness to a life of damaging trauma, nor do they offer anatomical clues as to the cause of backache. They mark longevity, not decrepitude. Therefore, “wear and tear” and “injury” are no longer tenable pathogenetic inferences. The common cold can arise both in the course of working and out of the course of working because exposure to droplet infections occurs in the workplace. The common cold can be a transiently disabling illness but is not considered an injury or even an occupational disease. Certainly regional backache can also occur in the course of working. But can backache also “arise out of the course of working,” as an injury? Can biomechanical stressors that are usually comfortable turn pathogenic? After all, regional back pain is mechanical; pain increases when biomechanical strain is exerted across the hurting back simply by leaning forward. Tasks that were always comfortable at work and at home become more daunting, if not prohibitive. The back “injury” construct holds that physical demands that render the pain less tolerable are the proximate cause of the back pain and hence the agent of “injury.” This is a damaging misconception for the medical and workers’ compensation systems. Multiple cohort studies in the contemporary workplace can discern little if any influence of a vast array of task demands on the incidence of disabling backache. As is true of spinal pathoanatomy, the incidence of backache has almost nothing to do with “minor trauma.” Furthermore, the incidence of back “injury” has proved refractory to successive waves of ergonomic advice and devices, of clinical and rehabilitative inventiveness, and of regulatory and legal machinations in the United States and across the resource-advantaged world. Regional backache is a common predicament inside or outside the workplace. Whatever the biomechanical precipitants, they cannot be shown to be more specific to the workplace than the viruses that cause upper respiratory tract infection. Backache is the bane of many individuals; back “injury” remains the bane of the workforce even though tasks in the modern workplace are far less physically demanding than