IS BACK PAIN DUE TO INJURY?
part 2 of 5

A whole body of law surrounds what activity or circumstances of employment are sufficient for a worker's injuries to fall under the workers' compensation statute. What constitutes arising out of employment or in the course of employment is subject to debate and interpretation, with different jurisdictions offering distinctive views. Regardless of any negligence on the part of an employer, the central question is whether employment conditions were the cause of the injury. In many jurisdictions, those conditions must constitute a substantial factor for compensation to be allowed. The problem is particularly complicated in back pain, especially chronic back pain, and a historical perspective on the concept of injury leading to back pain is necessary.

Wadded eloquently outlines the history of back pain through the centuries and its rise to injury status in modern times. Certainly, degenerative changes in the spine have been found in the earliest human remains and deformities and fractures are well documented from the time of Hippocrates. For the most part, however, they have been written about as fleeting pains that affect joints and muscles. Even when terms such as lumbago and rheumatism were used in the last couple of hundred years, disability from chronic back pain was still relatively rare. Curiously, this is the case in many third world countries even today.

A number of factors beginning in the 19th century eventually led to a traumatic link. The first of these is that of spinal irritation, a popular concept now abandoned in which local spinal tenderness from irritations in the vertebral column and nervous system were thought to be the source of back pain. Next, a condition called railway spine, which was thought in part to be due to the speed and the nature of early railway travel, became quite popular. Finally, the discovery of x-rays and later the description of a herniated nucleus pulposus led to aggressive surgical procedures to correct spinal pathology. The term ruptured disc created visualization of a damaging, traumatic event.

However, back pain occurring without any external force is extraordinarily prevalent in all segments of society, and even a ruptured disc often occurs in the course of normal physical activity. Nachemson has concluded that the amount of physical activity necessary is not much more than leaning forward 20 degrees, if structural abnormalities are to be unmasked. Is this, then, really the cause of the herniated disc? It becomes even harder to define if the supposed trauma is of a repetitive or cumulative nature, rather than a single physical motion. Often, patients experience the onset of their symptoms during activity which they have performed hundreds of times previously without a problem. Complicating matters further is the fact that many people have bulging or extruding discs with no pain at all. To distinguish this further, many states have specifically required an accident to have taken place, meaning some unexpected or untoward event. Others have required an unusual precipitant for a back injury to be compensable. But, it is argued by some that a repetitive loading or posturing process might be deemed an accident.

Therefore, establishing causation may need greater scrutiny. Did a pattern of ordinary use only make an underlying disease manifest? If so, what is the cause of the symptoms and disability, i.e. the actual force producing the effect? On the other hand when no definitive diagnosis is possible, as occurs in many cases, should the claimed employment circumstances be even more suspect?

In chronic back pain, although a patient may subjectively describe pain symptoms as beginning at a particular point in time, neither medically nor psychologically does that establish a discreet event that was the cause of those symptoms. It may be that the physical trauma and injury have such a profound effect on the psyche of the individual that he deteriorates emotionally and then physically as a consequence of that trauma. But, the traumatic event may have merely served as an opportunity for pre-existing psychological or psychosocial processes to become operative and now manifest themselves as physical illness. Here, the traumatic event is only incidental. Psychological and social gains from being sick may keep the symptoms alive or allow a face-saving means of resolving psychological conflict.

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