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Books, Journals, New Media
January 12, 2000

Musculoskeletal Disorders: Occupational Musculoskeletal Disorders

Author Affiliations

Harriet S.MeyerMD, Contributing EditorJonathan D.EldredgeMLS, PhD, Journal Review EditorRobertHoganMD, adviser for new media


Not Available

JAMA. 2000;283(2):260-261. doi:10.1001/jama.283.2.260-JBK0112-2-1

When Archimedes elaborated the principle of the lever, he could rightly claim that if given a place to stand, he would move the world. Nortin Hadler makes no such hubristic claim in this second edition of his notable book, but if read by physicians, lawyers, lawmakers, and administrators in and out of the government, it would change the way we diagnose, treat, and even look at medicine as it pertains to the musculoskeletal system.

Like Francis Fukuyama, whose latest book, The Great Disruption, calls for "biologically informed approaches to psychology and anthropology," Hadler calls for that and more. The emperor of nosology wears no clothes; such terms as fibromyalgia and repetitive strain syndrome are meaningless descriptors based on flawed research, leading to much mischief and cost. Such terms can convince suffers that they are sick and disabled when instead they may be experiencing transient discomfort, bringing the might of government and tort law into play in the wrong arenas. With erudite historical perspective, Hadler deconstructs maladies now termed injuries. He shows how the appellation ruptured disc suggests cataclysmic events when the discal herniation may not be a major contributor to back symptoms. He shows how an industry of invasive surgery to the back and wrists grew out of unproven attributions, and how disability may grow out of disaffection and dissatisfaction. In other words, don't let the title fool you: this is a book of philosophy, with strong personal opinions unapologetically delivered by an author not afraid to speak in the first person and willing to back up assertions with documentation.

Hadler is well known in medical and legal circles. He has been appointed to national commissions by Congress, the Social Security Administration, and the Public Health Service, among others, and has been consulted by panels charged with justifying treatments. He is a sought-after guest speaker internationally at congresses and symposia and is a skilled debater who has studied governmental systems personally in Japan, England, the European continent, and the Americas. He seems to have read almost everything pertaining to the subject of disability, now and in the past.

Hadler can explain why low back pain is usually misdiagnosed and even more commonly treated incorrectly. He shows how carpal tunnel syndrome and other entrapments were wrongly attributed to computer use, leading to epidemics of invalidism, horrendous fines against manufacturers and employers, and treatments that rarely succeeded in resolving the problems. How can so many usually well-intentioned people go so wrong? Hadler shows how that can—and does—happen. A true humanitarian, his sympathy is with the sufferer, but he also recognizes that distortions and misconstructions have made matters worse. Yet the book is no polemic but rather a rational dissection of a diagnostic system gone woefully wrong, a compensation system without logic, and a medical and surgical establishment that might as well be advocating the revival of bleeding, purging, and cupping for all the logic our present treatments and imputations have.

Would you believe I took this book on vacation to read, eschewing mysteries, novels, and histories, my usual choices? When was the last time a medical book could serve as a leisure-time companion so enjoyably? When was the last time a technical book made you think, besides contributing to your knowledge? What other book has asked what logic supports assertions that when we use our muscles and supportive structures for their intended use, we thereby create injuries? Matthew Arnold asked:

Nor bring, to watch me cease to live Some doctor, full of phrase and fame To shake his sapient head and give The ill he cannot cure a name.

Well, we certainly have given names to collections of symptoms, many self-reported but not anatomically or physiologically based, defying logic and yet capturing the attention of the media and the public because, let's face it, most of us suffer some symptoms some of the time, and the facile explanations serve when the symptoms become surrogates for social, emotional, and political problems. So Hadler covers regional syndromes, syndromes inferred as resulting from occupational exposures, compensation systems and determinations, and the role of the physician. In his poem "A Considerable Speck" Frost concludes " . . . how rare it is to find/On any page a little piece of mind."

This book offers facts and conjecture, the latter supported by fact, and speaks directly to the mind of the reader. Anyone who diagnoses, treats, or insures must read it. Need one agree with Hadler on every point? Of course not. But what ultimately sticks in the mind, what makes the most sense, is his argument that segregating symptoms of the worker, attributing them to the work, making the worker prove that illness and disability exist, and compensating therefor by some formula, when the same symptoms and diagnoses in someone in whom work is not implicated come under a different rubric of health care or are not compensated or covered, is not only illogical but morally wrong. As he titled one of his papers, if you have to prove you are ill you can't get well. When we distinguish between a patient and a claimant and use different algorithms for the same thing, we have fallen into a trap that has historical antecedents. To paraphrase Santayana, to forget the past is to be condemned to repeat it, without understanding why and how it came about or examining if it is at all relevant. This book raises the questions we should all have been asking and even attempts some answers.