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American Pain Society
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Ernest Volinn, Department Editor
George Brogmus, MS CPE
Cumulative trauma disorders of the upper extremities (CTDUEs) is a term that describes a collection of painful impairments affecting any part of the body from the fingers to the base of the neck and having as a contributing cause repetitive manual work (Putz-Anderson, 1988). CTDUEs have attracted much attention in the United States over the past 10 years among safety and health practitioners, researchers, medical services providers, and government leaders. Interest in CTDUEs first prompted the development of voluntary standards such as Ergonomics Program Management Guidelines for Meatpacking Plants (Occupational Safety and Health Administration, 1990) and the American National Standards Institute's Control of Work-Related Cumulative Trauma Disorders (1997). More recently, California passed an ergonomics law, Repetitive Motion Injuries Act (1997).
The widespread interest in CTDUEs stems from four assumptions:
1. The incidence and prevalence of CTDUEs are great. The first assumption arises largely from the manner in which the U.S. Department of Labor's Bureau of Labor Statistics (BLS) has traditionally categorized and reported CTDUEs. BLS has treated CTDUE as an illness, as opposed to an injury (The Bureau of National Affairs, Inc., 1993). While injuries pertain to "one-point-in-time” accidents like falls, cuts, and broken bones, illnesses arise from exposure over time, as with CTDUEs. Illnesses constitute only about 5% to 8% of all cases reported to BLS over the past several years; injuries have made up the remaining 92% to 95%. Until very recently, BLS has reported CTDUEs only as an illness. Consequently, when a hurried reporter reads something like, “Nearly two-thirds of the workplace illnesses were disorders associated with repeated trauma (332,000), such as carpal tunnel syndrome,” (BLS, press release, December 15, 1995) instead of accurately reporting the fact that these disorders represent only about 4% of all cases reported to the BLS, the reporter might say something like this: “Such repetitive motion injuries are soaring, from just 18% of all workplace maladies in 1981 to 48% in 1988” (Riordan, 1990). Such misinterpretations have led even skilled researchers and government leaders to overestimate the true scope of CTDUEs. Indeed, peer-reviewed literature often contains statements such as, “Upper-extremity cumulative trauma disorders are identified by the National Institute for Occupational Safety and Health as one of the ten most significant occupational health problems in the United States, accounting for 56% of all occupational injuries that affect 15% to 20% of all Americans” (Melhorn, 1996).
None of this is to say that CTDUEs are a small problem. On the contrary, it is clear that for certain industries, certain companies, certain jobs, and certain tasks, CTDUEs may be the type of case most frequently reported. In addition, CTDUEs are known to be more costly in terms of lost time, medical treatment, and lost wages than most other types of cases (Brogmus, Sorock, & Webster, 1996). However, 62% is still quite different from 4%!
2. CTDUEs are underreported. The second assumption seems to arise from studies focusing entirely on the impact of CTDUEs. The companies selected for such studies may constitute a highly biased sample of companies that have a relatively high proportion of CTDUEs. In addition, reporting of CTDUEs at these companies may have been minimal because of lack of awareness of CTDUE work-relatedness and because of reporting through group medical systems rather than through workers' compensation or OSHA mechanisms. Most, if not all, of these studies were conducted during the 1980s or early 1990s, when awareness of CTDUE work-relatedness was still low. In addition, the studies that support a theory of CTDUE underreporting usually don't examine or focus on the underreporting of other types of potential work-related disorders, such as back pain. Examination of CTDUEs and back pain at the same time has revealed that the prevalence of back pain is much greater than hand-and-wrist disorders. For example, a large-scale national survey reported that “repeated trouble with neck, back, or spine” accounted for 19.1% of reported health conditions and carpal tunnel syndrome combined with tendonitis accounted for only 4.8% of all health conditions reported (Park, Wagener, Winn, & Pierce, 1993). This survey used different definitions to describe wrist disorders and back disorders; these definitions favored a more inclusive definition of wrist disorders, which may have artificially inflated the reporting of wrist-related disorders. Clearly workers' compensation and BLS data “underreport” pain. What becomes misleading is the implication that CTDUEs are disproportionally underreported compared with other types of work-related disorders. One recent study found that while only 2.3% of an industrial population lost time from work (under workers' compensation rules) during a 1-year period, 27% sought medical attention and 69% reported having low back pain. (Fefferson & McGrath, 1996).
3. The growth in the incidence and prevalence of CTDUEs is largely due to the increase in workplace computer use. Brogmus et al. (1996) show that the third assumption is unlikely to be true. Most of the CTDUE increase over the past decade has come from manufacturing and noncomputer-related tasks.
4. The incidence and prevalence of CTDUEs are increasing rapidly. The fourth assumption was justified during the late 1980s and early 1990s but does not now appear to be so. Figure 1 draws workers' compensation CTDUE reporting to a large insurance company over the past 10 years. (For a discussion of the representativeness of these data, see Brogmus et al., 1996.) A rapid increase is present between 1987 and 1993, with a clear leveling off since then. Figure 2 shows the contribution of claims related to computer use. While reporting of computer-related CTDUEs has increased since 1989, computer-related claims continue to represent a minority of all CTDUE claims--at most, only one-quarter. (e.g., in 1996, computer-related CTDUEs represented 20% of all CTDUE claims of the overall CTDUEs reported). Figure 3 shows the CTDUE trend with computer-related claims removed. CTDUE reporting not related to computer use has decreased slightly since 1994; computer-related CTDUE claims have increased while noncomputer-related CTDUE claims have decreased. The overall effect is relatively level reporting of CTDUEs(as a percentage of all cases reported) since 1993. The comparable BLS data in Figure 4 show a slight drop in 1995 repeated trauma cases as a percentage of all cases. (The raw number of cases also dropped.) The BLS and insurance data both show a pattern of slowing of the increase in reporting over the last several years (Brogmus, 1995). The present leveling or dropping off is therefore not likely to be an anomaly (Brogmus, 1995).
The four common assumptions that have supported an increased interest in CDUEs are ill-founded. It is not likely, however, that popular opinion will change in response to the recent downturn in reported CTDUEs. The message should be clear: Check the facts and distinguish a reporting fad from a problem that deserves attention. For a particular organization, the problem may be CTDUEs, back pain, or something else. Find out what the problem is before developing costly interventions, research, or administrative structures.
American National Standards Institute. (1997). Control of work-related cumulative trauma disorders (Z-365). Itasca, IL: National Safety Council.
Brogmus, G.E. (1995). Reporting of cumulative trauma disorders of the upper extremities may be leveling off in the U.S. Proceedings of the Human Factors and Ergonomics Society 39th Annual Meeting, 591-594.
Brogmus, G.E., Sorock, G.S., & Webster, B.S., (1996). Recent trends in work-related cumulative trauma disorders of the upper extremities in the United States: An evaluation of possible reasons. Journal of Environmental and Occupational Medicine, 38, 401-411.
The Bureau of National Affairs, Inc. (1993, March 10). Analysis and perspective: Digest of official interpretations of the Bureau of Labor Statistics recordkeeping guidelines for occupational injuries and illnesses, February 1993. Occupational Safety and Health Reporter, 1, 714-1,715.
Fefferson, J.R., & McGrath, P.J. (1996). Back pain and peripheral joint pain in an industrial setting. Archives of Physical Medicine and Rehabilitation, 77, 385-390.
Melhorn, J.M. (1996). A prospective study for upper-extremity cumulative trauma disorders of workers in aircraft manufacturing. Journal of Occupational and Environmental Medicine, 38, 1264-1271.
Occupational Safety and Health Administration. (1990). Ergonomic program management guidelines for meatpacking plants (OSHA 3121). Washington, DC: U.S. Government Printing Office.
Park, C.H., Wagener, D.K., Winn, D.M. & Pierce, J.P.
(1993). Health conditions among the currently employed: United States, 1988. Vital Health Statistics, 10(186), 31.
Putz-Anderson, V. (1988). Cumulative trauma disorders: A manual for musculoskeletal diseases of the upper limbs. London: Taylor & Francis.
Repetitive Motion Injuries Act, ß 5110 CA Labor Code (1997).
Riordan, T. (1990, May 7). Technology can be a pain when it leads to carpal tunnel syndrome. People.
George Brogmus, MS CPE, is director of ergonomics in the Risk Services Department at Liberty Mutual Insurance Group in Hopkinton, MA.
