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Occupational musculoskeletal disorders, second edition
  1. KEITH PALMER

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    Occupational musculoskeletal disorders, second edition Edited by: nortin m hadler, joyce-rachel john, michelle laplante. (Pp 433; $75.00) 1999. Philadelphia, PA: Lippincott Williams and Wilkins. ISBN0-7817-1495-8.

    The preface to this book indicates that its intended readership includes practising occupational physicians and nurses, specialists in musculoskeletal disease, family practitioners, and members of the health insurance industry. But to some extent its content belies the stated target. This is not a practical primer, nor a scholarly and dispassionate review of the relation between work and musculoskeletal disease. Instead it is a very honest, brave, and personal view of how the author thinks such diseases arise in the main from illness behaviour and illness labelling.

    Their basic tenet is that musculoskeletal symptoms are ubiquitous and generally benign, but can become incapacitating as the patient and the physician seek a medical explanation and supply a diagnostic label. They also seeks to dispute much received medical wisdom, the evidential basis of which they dispute. Chapter headings such as “the dangers of the diagnostic process”, “iatrogenic labelling as in the fibromyalgia paralogism”, “the disabled, the disallowed, the disaffected, and the disavowed” and “hand-arm vibration syndrome: a revisionist historiography” reflect these twin viewpoints, which give rise to passages such as: ”..Raynaud's phenomenon denotes a personality trait; it's not a disorder”, and headings such as “carpal tunnel syndrome is not a cumulative trauma disorder”. This eclectic book is striking in the enthusiasm with which it embraces the psychosocial model of musculoskeletal illness and disparages the mechanical-biological model. It is well referenced and informative, with critiques that are both energetic and relentless, but ultimately the authors' stance of unashamed bias colours the whole.

    This is a pity. Many of the ideas expressed on causation are compatible with widely held views of illness behaviour (although forcibly expressed). There are also interesting and potentially useful chapters on workers' compensation schemes and coping with arm pain in the workplace.

    But lack of balance is not the book's only shortcoming. Given its title, there are also several surprising omissions. For example, the clinical chapters (on the neck, back, upper limb, and lower limb) provide little information on putative occupational risk factors and the epidemiological evidence surrounding these. As befits a textbook which reflects the American care model in occupational health, there are passages on therapeutics—such as the side effects of salicylates—and information on homeopathy, osteopathy, and chiropractice; but the bias is towards the clinical rather than the occupational health management of musculoskeletal disorders, and this too was something of a surprise and a disappointment. Fitness for work and its assessment is not considered in a meaningful way.

    The question is whether the good outweighs the bad. You pay your money and take your choice: if you want a healthy dose of scepticism, this is the place to look; however, there is a danger you may receive an overdose, and if you prefer a balanced or more dispassionate account you should look elsewhere.

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