Himmelstein J S, Andersson G B
Occupational Health Program, University of Massachusetts Medical School, Worcester 01605.
Occup Med. 1988 Apr-Jun;3(2):255-69.
As screening tests in a currently asymptomatic population, all of the available methods for predicting low back pain and disability have serious technical, ethical and legal limitations. From a technical point of view, none of the predictive tests appear to have sufficient sensitivity or specificity to justify routine usage. The most sensitive indicator (a past history of low back pain) lacks reliability and specificity. Muscle strength-testing may be predictive of future musculoskeletal injury as part of a well-designed program that considers specific job demands in relation to specific worker capabilities. Unfortunately, the conditions necessary for a well designed program--a large number of predictable high-risk jobs that have measurable specific demands that can be reproduced reliably in a testing situation--are rarely met. In the future, the use of computer-assisted multivariate models analogous to those used in the prediction of cardiovascular risk may be capable of integrating information about an individual's medical history, physical exam, physical capacity and other tests with specific job requirements to give us a more accurate prediction of the future risk of back pain and disability. If such predictive models are ever developed and verified, it would then be appropriate to examine various interventions and their effectiveness in modifying risks for the population and the individual worker. From a legal point of view, all of the techniques described hold potential for significant discrimination against legally protected groups. Making employment decisions with regard to a past history of low back pain or on the basis of an x-ray will lead to systematic age discrimination and discrimination against the handicapped. The use of muscle strength-testing will systematically discriminate against women and certain ethnic groups. The ethical implications of predictive screening for low back pain clearly depends on what is done with the information that is garnered from such tests. If the information is used only to make a safe job placement for an individual, and this placement does not affect the individual's salary or future job possibilities, then the testing program may have a net social value to the extent that it leads to true prevention of low back pain and disability. If the tests are used merely to reduce employer liability by refusing employment to those who are thought to be at "high risk," the technical, legal and ethical limitations will far outweigh any perceived benefits.
作为针对当前无症状人群的筛查测试，所有现有的预测腰痛和残疾的方法都存在严重的技术、伦理和法律限制。从技术角度来看，没有一种预测测试似乎具有足够的敏感性或特异性来证明其常规使用的合理性。最敏感的指标（腰痛病史）缺乏可靠性和特异性。作为精心设计的计划的一部分，肌肉力量测试可能能够预测未来的肌肉骨骼损伤，该计划会考虑与特定工人能力相关的特定工作要求。不幸的是，精心设计的计划所需的条件——大量可预测的高风险工作，这些工作具有可衡量的特定要求，并且可以在测试环境中可靠地重现——很少得到满足。未来，使用类似于预测心血管风险的计算机辅助多变量模型，可能能够将个人病史、体格检查、身体能力和其他测试的信息与特定工作要求相结合，从而更准确地预测未来背痛和残疾的风险。如果开发并验证了此类预测模型，那么就适合研究各种干预措施及其在改变人群和个体工人风险方面的有效性。从法律角度来看，所描述的所有技术都有可能对受法律保护的群体造成重大歧视。基于腰痛病史或X光片做出就业决定将导致系统性的年龄歧视和对残疾人的歧视。使用肌肉力量测试将系统性地歧视女性和某些种族群体。对腰痛进行预测性筛查的伦理影响显然取决于如何处理从此类测试中获取的信息。如果该信息仅用于为个人进行安全的工作安置，并且这种安置不会影响个人的薪资或未来的工作机会，那么测试计划在能够真正预防腰痛和残疾的程度上可能具有净社会价值。如果这些测试仅仅用于通过拒绝雇佣那些被认为处于“高风险”的人来减少雇主责任，那么技术、法律和伦理限制将远远超过任何感知到的好处。
