Back Pain -- Reason for Compensation or Cash Cow?

In the current issue of the Journal of the American Medical Association, Dr. Nortin Hadler, a rheumatologist, and his co-authors present a scathing attack on the use of regional back pain as a way to collect workers' compensation.

Hadler, a professor of medicine at the University of North Carolina at Chapel Hill and author of "The Last Well Person," says backaches are as widespread as the common cold and part of the normal aging process. But while backaches or colds can appear on the job, he says neither is caused by working.

He argues that physicians misdiagnose back pain as "injury," which can cost both employees and their employers dearly. Companies devote 2 percent to 4 percent of their gross earnings to workers' compensation, and workers, for their part, are given a medical diagnosis, even though the majority of the adult population suffers back pain at some point in their life.

Hadler says one in 10,000 workers has received compensation for back claims of at least three days' missed work.

Some Experts Agree

When the ABC News medical unit asked experts to respond to the commentary, many agreed with the assessment:

Richard Deyo, M.D.

Professor of Medicine and of Health Services

University of Washington

There are some obvious exceptions, but by and large, I agree with this argument. Back pain is nearly ubiquitous, and it's often difficult to assign a precipitating cause. We've made the management of back pain in workers unnecessarily adversarial, to no one's benefit.

Harley Goldberg, D.O.

Director, Spine Care Services

Chief, Physical Medicine and Rehabilitation

Kaiser Permanente San Jose Medical Center

In general, the authors' argument is correct. Four in five people will have intermittent recurrent back pain, and more than 90 percent of back pain is uncomplicated. There have been excellent studies demonstrating that simply correcting "expectations" about the natural history of back pain will decrease worker absenteeism.

Oversimplifying is dangerous, though, and it must be remembered that the original intent of workers' compensation was to protect workers clearly injured on the job, who were unable to continue employment because of that injury.

Dan Spengler, M.D.

Professor and Chairman, Department of Orthopaedics and Rehabilitation

Vanderbilt Medical Center

Clearly, there are workers' compensation patients who sustain injuries at work, such as falling off a ladder, crushing their hands in a press, and so forth. These individuals require and deserve the best that our health care system has to offer.

However, the symptom of lower back pain is very prevalent; nearly 80 percent of people experience it at some point in their lives, so to attribute lower back pain symptoms exclusively to "work" is preposterous.

Still, I am skeptical that anything will happen from this exposé, as too many professionals benefit from the system, including doctors, lawyers and chiropractors. Insurance companies also benefit from this dysfunctional system by collecting a percentage of the cost distributions as a management fee. The higher the costs, the higher the fee.

Stephen Freidberg, M.D.

Department of Neurosurgery

Lahey Clinic

I have always thought that the problem of workers' compensation is not the "injury" label pinned by physicians, but that most people don't like their work.

There is a correlation between disability and whether or not a person likes what she or he does. If she likes the work and is invested in it, she will return to work, even with pain. If she has no investment in the work and feels that she is entitled to compensation, she'll never return.

John Kostuik, M.D.

Chief, Spine Divison

The Johns Hopkins Hospital

Past President, North American Spine Society

The current system is broken. One needs to only look at the statistics on the number of people who return to work after receiving workers' compensation. In the late 1970s, about 67 percent of my patients returned to work after having a second surgery. This decreased to 44 percent in the 1980s and to less than 30 percent in the 1990s.

Being required to have legal help to gain compensation is problematic, since the greater the disability payment, the more the lawyer makes -- so, it pays to be ill.

The Other Side of the Argument

Other medical experts, however, took issue with the authors' characterization of the issue:

Stephen Ondra, M.D.

Professor of Neurological Surgery

Northwestern University

This argument seems to be born out of surprisingly faulty logic, personal opinion, frustration with the workers' compensation system, as well as a surprising lack of demonstrated knowledge regarding back pain and back injury.

The authors seem to lump back pain into one large group, but nothing could be further from the truth. It is true that back pain is not a disease or injury; it is a symptom of disease, injury or the degenerative processes of aging. But to imply that back pain is simply a normal part of the aging process is oversimplification on a dangerous level.

Given that logic, hip pain would be a diagnosis and relegated to a normal part of aging. At times, this may be true, but there are also many other causes ranging from tumor to trauma.

There is no argument that there is much abuse throughout the workers' compensation system. The answer is to assess how to improve the workers' compensation system and decrease abuse, not to denigrate and disenfranchise employees who legitimately injure their spine due to trauma or repetitive overuse.

Scott Boden, M.D.

Director, The Emory Spine Center

Emory University

This is actually not a new argument, and while in many instances it is valid, in other situations, workers with real injuries have real pain. Unfortunately, many patients in the workers' compensation system get teamed with lawyers who may have different motivations than getting the worker back to work quickly.