Assessment of (un)fitness for work 371
The words ‘expert assessment’ here refer to any medical evaluation of a patient in terms of fitness for work and potential employment and in terms of any insurance-related issues in the particular case in question.
9.1. Assessment of (un)fitness for work
The most numerous category of patients suffering from pain originating in the locomotor system comprises those with back pain. While their lives are not endangered, they may nevertheless not be fit for the work they are expected to perform, temporarily or permanently, and in some cases they are even threatened with invalidity. In addition, there is the question of harm traceable to the type of work they do, or to occupational injury, sometimes involving litigation with claims for compensation. All these aspects have to be assessed by an expert.
If the assessment is to be scientifically based, it must take account of the pathogenesis, evolution, and prognosis of the condition. Our experience with reflex therapy and with manual therapy in particular has modified our views concerning pathogenesis, leading us to conclude that function is the decisive factor here. Since it is precisely this aspect that must be reflected in any expert assessment, the considerable difficulties are obvious.
One problem is that patients have often not received either adequate therapy or rehabilitation. This scenario will continue for as long as there are only relatively few physicians who understand how to diagnose and treat locomotor system dysfunctions adequately. In this highly regrettable situation significant lesions may pass unnoticed, and this is a particularly serious consequence in view of the principal symptom, that is pain. A physician who is unfamiliar with the diagnosis of painful trigger points (TrPs), tension, and resistance in the tissues has to rely on the patient’s own description of the symptoms. The physician then has the choice of either believing the patient or not. When called upon to provide an expert opinion, the physician tends to search for objective criteria, in the misguided belief that these are supplied by X-ray examination findings. However, any changes detected in that way are primarily morphological. Because this approach is consistent with conventional, received wisdom it is psychologically advantageous. The patient is informed, more often than not, of the changes found on X-ray and these are presented as the true cause of the pain, thus confirming the patient’s own ideas about the significance and potential duration of the underlying condition. It then becomes very difficult to motivate the patient concerning the benefits of an arduous rehabilitation program.
On the other hand, young patients with serious pain that is often of a radicular nature are considered to be malingerers because their X-rays show ‘no degenerative changes’. In recent years, despite significant advances made in the fields of computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound, not much has altered; indeed, if anything, the situation has become even more complicated. It is beyond the capability of any imaging technique to demonstrate the relevance of morphological changes, that is to show whether the patient has a herniated disk or ‘merely’ narrowing of the spinal canal. If no radicular syndrome is present, even a herniated disk may be irrelevant. These findings, obtained using the most up-to-date and most expensive techniques, divert attention away from gross yet highly relevant dysfunctions.
It is therefore important to give some indication here of how an expert assessment can and should be performed with regard to disturbed function. While we cannot deal with all types of pain caused by locomotor disturbance, we will focus primarily on back pain and radicular syndromes, because these are the commonest causes of unfitness for work that necessitate expert assessment. Because expert assessment is chiefly called for in conditions with a chronic or chronic relapsing course, we will deliberately not be considering acute cases. It is also important to exclude pathological conditions such as ankylosing spondylitis, tuberculosis, osteoporosis, etc.
Chronic disease courses without pathomorphological findings are characterized by decompensation due to dysfunctions of muscles, joints, or soft tissues, by faulty statics, or by muscle imbalance. The chief concern must be to correct these, so as to reverse the pattern of dysfunction, while at the same time assessing to what extent the work the patient is expected to perform contributes to this decompensated state. This assessment of the locomotor system has to be performed specifically in each individual case.
For instance, if a patient consistently develops back pain after sitting for extended periods, there should be a (temporary) ban on sedentary work but walking should be encouraged if the patient feels comfortable with this. First, however, a check must be made to ensure that the bad effects of sitting are not due to an unsuitable chair or to a table at the wrong height. Similarly, if the symptoms are produced by bending down, lifting, or carrying loads, it must be established whether the patient’s corresponding movement patterns are at fault – in which case these must be corrected. Steps should also be taken to ensure that the patient returns to work as soon as possible after learning how to perform these activities correctly.
If the symptoms are due to lack of exercise, we should be reluctant to forbid movement, even if it is perceived to be unpleasant. It should not cause a sensation if a patient who is signed off sick from work is spotted walking in the countryside or even moving about on skis so as to get fit.
Sometimes unfitness for work is caused not by the patient’s work itself, but by how the patient travels to and from work, particularly if the journey involves being jolted about.
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