This paper was presented by Dr Yolande Lucire as part of a debate against a surgeon who promoted RSI. It has been published in the Proceedings of the NSW Medico legal society in 1988.

"RSI", An Epidemic Of Craft Palsy

The epidemic of telegraphists' cramp, 1911

In 1908, telegraphists' cramp,[1][2] a disorder with a low sporadic incidence, was added to the list of diseases to be compensated under the Workmans' Compensation Act [1906], on the evidence of the Union's doctor that cramp was muscular failure caused by the rapid repetitive movements of Morse telegraphy. An epidemic ensued and within four years 30% of the work force was reporting "symptoms," the incidence rising to 60% in some offices. This situation is duplicated in some sections of the Australian Public Service in the middle of the nineteen eighties. Prevalence studies were undertaken on the Continent but sporadic cases only were found and in the United States, where cramp was known as 'losing your grip', four to ten percent of telegraphic staff reported symptoms though work loads were three times those of British workers.

Contemporary medical opinion

Medical opinion of the time was confused and numerous other theories of causation were proposed.

Some thought cramp was an inflammation of tendons, but it was rarely localized and it neither resolved, as did, nor did it lead to stenosis. Sensory symptoms of various kinds involved the unused arm and even the legs and back, contradicting a local origin for them.

Some thought cramp was a disease of peripheral nerve entrapments, but agreement could not be reached as to whether these were at the wrist, the elbow, or in the brachial plexus, or whether the nerves of the arm were somehow compromised as they left the spinal column. Such problems could not be related to occupational tasks, nor could they account for the epidemiology of the disorder. Medical and surgical interventions based on all these theories of causation abounded, yet the increasing prevalence of cramp became testimony to their lack of success.

Departmental committee into telegraphists' cramp

A departmental inquiry was called in 1911 and the Postal Telegraphist Clerks' Union in its submission initially proposed that cramp was due to excessive workload. However, extensive studies of cases and workloads failed to confirm this correlation; rather the contrary was the case with the fastest night shift news telegraphists, who worked for bonuses, not providing a single case. The Union then shifted ground and proposed that the culpable entities were tables and chairs of the wrong height, poor design of keyboards, poor lighting, inadequate working accommodation, too early responsibility, constitutional weakness, inaptitude for telegraphic work and stress.

The inquiry found that none of these was a cause of cramp which they attributed to a personal factor, operating together with fatigue. The amount of work necessary to produce fatigue was found to be a function of the same personal factor.

After extensive evaluation of cases the inquiry concluded that cramp was a neurosis. This report introduced a new expression into the English language in calling cramp " a nervous breakdown" "which was defined as "a weakening or breakdown in the central controlling mechanism of the brain."

The inquiry failed to acknowledge that mind and will are the "controlling mechanisms" of the brain and there was no consultation with psychiatrists even though the psychogenic nature of the neuroses was already internationally acknowledged.

International nomenclature of epidemic cramp

The "new" Australian epidemic disorder locally known as "RSI" or "teno" is reported internationally in textbooks of neurology, medicine, psychiatry and occupational health, in both epidemic and sporadic form as writers' cramp, craft palsy, or, generically, occupation neurosis.2 Cramp has been described in over one hundred occupations, most characterized by neither rapid movements nor repetitive work.

The history of the construction, "RSI"

The first recorded use of the term "RSI" was in a typed document called the "approved occupational health guide - Repetition Strain Injuries", adopted in June of 1982 by the Australian National Health and Medical Research Council,3 which later became a policy document for the newly formed National Occupational Health and Safety Commission. This document described, under the label "RSI", a number of otherwise well known arm conditions of various pathologies and suggested that they might be avoided by extensive alteration of work practices. There followed two papers in the Medical Journal of Australia which introduced some new ideas to the Australian medical profession.[3]

Arm symptoms of obscure origin in a working population were said to be the product of an "injury" caused by the strain of repetitive movement, or, in workers who had not moved repetitively, the product of static strain of having maintained a position in the course of work. The umbrella term "RSI" soon came to be used indiscriminately for any acute pain, cramp, spasm or fatigue, any extended fatigue syndrome, for all organic conditions presenting as arm pain and for the chronic, long term functional disorder otherwise known as writers' cramp, craft palsy or occupation neurosis.

Moreover, the very words "Repetition Strain Injury" presumed a similar cause for all those symptoms, calling them an injury caused by a task. To name a set of symptoms RSI is to avoid making a formal diagnosis in favour of a causal explanation. The term, "Overuse Syndrome", is similarly presumptive. To "diagnose" is to "see through" circumstantial complexities to pathology or psycho pathology. [dia-through, gnostos-recognize, Greek]

Words are our tools, and as a minimum we should use clean tools; we should know what we mean and what we do not and must forearm ourselves against the traps that language sets us.

An epidemic of apparently incapacitating arm symptoms exploded following the dissemination of this material and by the end of 1985 there were 4000 "cases" in the Australian Public Service [4]within occupational categories including academics and gardeners. Advised by the same injury theorists. it made extensive recommendations regarding prevention and management, nonetheless it made no inroads into the increasing problem. The Insurance Council of Australia expects that RSI claims will cost one billion dollars in the 1986 / 1987 financial year, for cases in private industry and twenty thousand litigants have materialised.

Symptoms of 'RSI'

With epidemic RSI, the nature and distribution of symptoms is different in every case even within a single occupational category such as keyboard work. The symptoms of RSI can move from site to site, sometimes suggesting involvement of the motor nervous system, sometimes the sensory. Each case of RSI attracts any number of diagnostic formulations, with each medical examiner generally fitting one within his or her own specialty and therapeutic jurisdiction. The relationship to the amount or type of work done before development of symptoms is very variable and the duration of the affectation ranges from moments to years. Response to rest and to physical therapies is unpredictable and often paradoxical.

The nature of neurosis

Originally the term "neurosis" referred to physical symptoms for which no pathophysiological mechanism could be found or even postulated. Neuroses are also called "functional disorders" when they suggest or mimic physical illness or injury, or "functional overlay" when they complicate it. Neuroses were recognized by the medical profession and differentiated from the disorders they suggested or mimicked long before their psychological determinants were elucidated, long before the term became "psycho neurosis" and took on its present meaning.

The nature of mind

Neurosis is mediated by the central nervous system through its function of mind. Mind is a function of brain just as noise is a function of a motor bike. One cannot pull a motor bike apart and find the noise and one cannot dissect a brain and find a mind. Mind is not affected by entities in the physical world except where such objects or events have a symbolic meaning. Mind is influenced by ideas, by concepts, by needs and by desires. Mind determines how one's body or an event is experienced. One attribute of mind is will, the directing function of the brain and thereby of the body.

In the normal course of events the processes of thinking, experiencing and willing are influenced by ideas which we turn into beliefs and attitudes, according to our needs.

Ordinary language does not necessarily make the distinction between the physical object or event and the idea for which it is a symbol. In common parlance, one says that a father's death caused one's feelings of depression. However, if one did not know about the death, had no idea of it, one would not suffer depression. Conversely, if one were to be misinformed of such a death, and one's father still lived, one would be appropriately depressed so long as one held the mistaken belief that death had occurred. It then becomes clear that it is not from the death itself but from belief in the meaningful death that the emotional disturbance called depression is derived.

The concept of symptoms from ideas or psychogenic illness

There was a well developed concept of "symptoms from ideas"8 or psychogenic illness in the British Medical Literature twenty years before the work of Freud in Vienna. I wish to address this concept today.

We are all familiar with the bodily sensations that accompany anxiety and depression, the chest pain, the palpitations, the churning stomach, the leaden limbs, the physical symptoms that are not attributable to any disease process and that in general terms signal that we are under stress. The term hysteria is sometimes used by psychiatrists for these conversions of emotion into somatic or bodily symptoms. The diagnosis of an hysterical conversion is not predicated solely on the diagnostician's inability to make an organic diagnosis, any more than hysteria is now thought to have origins exclusively in sexual needs. Indeed conversion or somatisation reactions herald a number of specific and non specific emotional states. To make the diagnosis of hysteria, one does need to identify the primary gain which involves a diversion from some real life problem while attributing all one's distress to one's symptom. Secondary gain comes from being relieved of one's responsibilities and from being paid for it.

Symptoms from ideas are familiar and carry none of the negative connotations of the term "neurosis", nor should they. The medical practitioners in the audience will all remember when, as students, we became aware of sensations in our bodies which we attributed to the diseases we were studying. We were reassured by our seniors and the symptoms rapidly faded. Have we not all felt sick on hearing something nauseating? Would we not all agree that vomiting triggered by an emotional or ideational stimulus is every bit as real as vomiting that is the result of a peptic ulcer, especially when we have to clean it up? The reality of the symptoms in ideogenic illness is not at issue. At issue are their origins and hence the responsibility for their existence.

Those of us who react to ideas or to emotional states with feelings in our bodies are not neurotic. Such reaction is universal. But where, in the face of absence of any reasonable explanation such symptoms persist and become troublesome and interfere with normal activities, then referral to a psychiatrist is indicated. Certain personality traits which translate into attitudes and other vulnerability factors, together with situations of need or conflict, are known to predispose to the persistence of these and of other normally transient disorders.

Overuse syndromes are common and clearly task related and they steadily recover over a few days in otherwise healthy individuals. Recovery as expected does not occur with epidemic RSI as the accompanying epidemic of work incapacity suggests.

The need for diagnostic accuracy

If a physical diagnosis can be made accommodating all the presented symptoms and signs, then the disorder must be treated in accordance with one's formulation. The patient's illness must then comply with a known pattern or one must be prepared to review one's diagnosis. For example, carpal tunnel syndrome, a rare disorder, was first described in 1895, and again in 19479 . If symptoms and signs are limited to the distribution of the median nerve distal to the place in the wrist where it passes through the carpal tunnel, they will virtually always respond to carpal tunnel release. However if symptoms are only suggestive of carpal tunnel syndrome and involve either more or less than the distribution of the median nerve, then carpal tunnel release will be unsuccessful, and after an initial respite, symptoms will recur in even greater profusion. The unsuccessful surgeon, who originally failed to recognize a functional disorder might then fall back on a diagnosis of "functional overlay."

Characteristics of hysteria

Hysteria presents as a disorder with too many symptoms and too many unrelated signs to make one, two or three physical diagnoses. Hysteria does not have the same response to treatment as the disorders it suggests or mimics. Hysteria is primarily ideogenic, or, as Freud would have it, hysterics suffer mainly from reminiscences, and, finally, hysterical symptoms tend to occur in epidemics when the hysterical beliefs10 that stimulate them prevail.

The nature of a paradigm

Thomas Kuhn, in his seminal text, "The Structure of Scientific Revolutions"[5] introduced the concept of the paradigm, an organising principle that can govern perception itself. The book itself started a revolution in the evaluation of competing theories in the physical sciences. Inter alia, Kuhn told us that a paradigm was a pre-scientific set of ideas which comprised the beliefs of a given society and passed for "common knowledge". A paradigm is what members of a scientific community share, and, conversely, a scientific community consists of people who share a paradigm. A prevailing paradigm will determine the direction of research. What Kuhn called 'normal science' proceeds through a process of paradigm shifts because as knowledge grows, information becomes available which does not fit in with an existing paradigm, and it becomes, as it were, wobbly at the edges, and a new paradigm, a new theoretical framework, is introduced to accommodate inconsistencies and new knowledge gained through observation and scientific research.

There are two irreconcilable paradigms currently operating in relation to the so called diagnosis and treatment of the epidemic of arm symptoms known locally as RSI.

The injury theory

In the first, the injury paradigm, symptoms are regarded as the evidence for a musculo-tendinous injury caused by the preceding task. A person is seen as a physical body, of brain, tissue and muscle, a victim of unavoidable compensable trauma. The epidemic is to be managed by control of traumatizing agents.

The psycho social theory

In the other, the psycho social paradigm, epidemic symptoms are those of a functional disorder, the somatic manifestations of a neurotic disturbance, dependent on idea and manifesting in vulnerable personalities in a situation of conflict. This paradigm conceptualizes a person as an intentional being, with a capacity for choice. It takes into account the forces that act on mind and will with variable degrees of consciousness. Epidemic control has as its first concern prevention of social iatrogenesis, of manufacture of illness by doctors and society.

An untenable theory

I submit to you, ladies and gentlemen, that the new found paradigm of the physical causation of this new Australian disease, "RSI" is already seen as a bit wobbly around the edges as it does not accommodate some very basic information. Physical theories of causation do not provide answers to these questions:

1. Why do studies of compensation statistics show that claims for arm symptoms were rare prior to the 1980's?

2. Why is information about this apparently common disease limited to the Australian medical literature, after 1982?

3. Why do worldwide symptom epidemiology studies looking at neck and arm symptoms in workers and non-workers show a consistent prevalence of around 8% to 12%[6] while in some workplaces in Australia up to 80% of the work force is reporting symptoms?

4. Why are there such variable rates of affectation between workplaces that are physically similar? Why is RSI costing the Australian National University more than a million dollars a year, whilst Flinders University in South Australia has only one employee off work with this condition?[7]

5. Why are such symptoms absent in large typing pools in the USA?[8]

6. Why do symptoms appear to spread from one person to another in the manner of a contagious disease?

7 Why did some workers develop symptoms early in their working careers, and others late? Why are workers with identical workloads not similarly affected?

8. Why did work incapacity attributable to RSI increase rather than decrease following the circulation, in mid 1982, of information pertaining to its early identification and prevention?

9. Why does Australia have a substantial medical and paramedical industry devoted to the rehabilitation of a disorder which is unknown and, where it is recognized, is only sporadic in the rest of the world?

10. And if it is related causally to movement, why was the highest rate of RSI in Telecom reported amongst keyboard telephonists who perform only several hundred keyboard strokes per hour rather than among word processor operators with a keystroke rate of 17,000 keystrokes an hour?[9]

Neurosis and will

Whilst most of us recognize the benefits of work and desire it, there are individuals in any given population whose stresses, conflicts and personal situations make it quite attractive for them to be ill. If for those people, one adds the prospect of being paid for it, then the adoption of a medically, socially and judicially legitimated sick role becomes very attractive indeed. An ocular variant of occupation neurosis, miners' nystagmus, tends to reach epidemic incidence in mines under threat of closure, but only if its functional nature is unrecognised.

In 1873, Paget elucidated the volitional elements that make neurosis more incapacitating than the symptoms it generates or injuries it mimics. He said: "They say 'I cannot'. It looks like 'I will not'. But it is _ 'I cannot will.'"[10]

Will can be influenced by countervailing desires. One must examine both the will and the counter-will to see what ideas, needs and conflicts are acting on a person to inhibit the realization of a stated and credible intention to work.

Necessary but insufficient conditions

Predisposing personal vulnerability is common. Movement and strain are universal. Occupational stress, fear of technological advances and mediocre working conditions are not new, nor will this episode eliminate them. The conflicts and difficulties of everyday life are widespread, yet occupation neurosis is at present epidemic in Australia where it was rare before the nineteen eighties. and only sporadic and localized in the rest of the world

The essential element, the hysterical belief

The essential ingredient in the development of this epidemic neurosis is the availability of legitimation for the hysterical belief that one can be injured by one's task. I submit that ideas that are contained in the mythology of RSI, ideas that alter the meaning of universal sensations, have a similar relationship to an epidemic of this disorder as an introduced virus has to an epidemic of influenza. These ideas have the same relationship to a bush fire as does the introduction of a lighted match to a dry substrate.

Situational vulnerability factors such as the presence of high wind, dry wood and grass, are insufficient of themselves for a conflagration to erupt. .The efforts of those attempting to control workplace conditions can be likened to removal of grass while encouraging the lighting matches and fanning of flames. Removal of susceptible material is not allowed and indeed almost all is possibly vulnerable, under the conditions that prevail.

Causation in psychiatry and law

Whenever we say that an individual is responsible for some harm, we may be challenged on the issue of causation. At the heart of the matter is what we mean by a cause when the cause is an act. Causation in a theory of responsibility is very different to causation in physical matters. [11] In using the word, "cause", we must again beware of the snares of language. There is a categorial difference between the word "cause" referring to the invariant laws of interaction in a world of inanimate objects and its use referring to the regularities of behaviour mediated through meaning and language in a world of intentional subjects.

In other words, we are looking at how the things some people do and say influence the way others behave and feel.

We have to consider the inequalities in the power relationship between the doctor and patient and whether or not we will exonerate the patient from responsibility for health maintenance and continue rewarding the physician for misdiagnosis and for administration of treatments which were reported as unsuccessful over one hundred years ago.[12]

The relationship of the syndrome to work is solely that it occurs in the context of working; work is not causal. The disorder is a physical manifestation of a conflict about working. Conversion disorder is a conflict neurosis, not a traumatic neurosis, hence not the result of either physical or emotional trauma.

Causation in functional illness can be appreciated in terms of both or either of underlying "mechanism" or "precipitating circumstance" Briefly the "mechanism" of causation of this neurosis is the adoption of an hysterical belief. The idea is the necessary prerequisite, and its legitimation by authority can be likened to the lighting of fire. Precipitating circumstance refers to personal or Situational vulnerability factors, which are ubiquitous and on their own have no more causal status than do hot weather, dry wood and high wind in the occurrence of bush fire.

culpability: whom to blame?

Blame worthiness can be attributed, according to one's prejudices, largely to the institutions which believe themselves to be in the business of prevention. The institutions presently legitimating "RSI" include government departments, trade unions, the medical profession and the legal system which provides compensation. Their activities are underpinned by unsubstantiated causal hypotheses, by unverified hysterical beliefs.

the role of the expert

Our colleagues in psychology and sociology can now provide a more comprehensive theoretical framework for the law to operate in than so called experts did when the Abbe Grandier was executed for no more than being the subject of the Ursuline nuns' hysterical belief that he had seduced them.[13]

Trade unions must work to protect their members interests, but this is being done by sacrificing the health of some, termed 'victims of RSI'. Our society is rewarding people for dysfunctional behaviour and is rewarding those who encourage it. Uncritical acceptance of unverified beliefs regarding "cause" simply encourages their dissemination by vested interests.

The real costs of this epidemic will be borne by the physically injured workers of the future if their entitlements are restricted at common law.

In conclusion, there are strong arguments for believing there where there are not simply misdiagnosis of well known physical disabilities the cases of incidence of so-called "RSI" represent an epidemic of ideogenic or psychogenic illness, of hysterical conversion, a phenomenon well known to psychiatric medicine and documented over centuries.

It was not the intention of the legislation, nor is it financially feasible in an employer funded scheme, that functional disorders manifesting in the workplace should attract compensation as if they were conditions indistinguishable from injuries caused by tasks and traumas.

[1]   Great Britain and Ireland Post Office. Departmental Committee on telegraphists' cramp report, London: His Majesty's Stationary Office 1911.

[2]   Lucire, Yolande. Neurosis in the workplace. 1986, Med. J. Aust;323-327.

3   Anonymous "approved guide to occupational health" adopted at the ninety third session of the council, June 1982 The National Health and Medical Research Council 1982.

[3]   Stone WE Repetitive strain injuries. Med. J. Aust. 1983; 2: 616-618.

[4]   Task Force. Repetition Strain Injury in the Australian Public Service. Canberra: AGPS 1985.

8   Reynolds JR 1869. Remarks on paralysis and other disorders of motion and sensation dependent on idea. Br. Med. J.,ii 483-5

9   Brain RW Diseases of the Nervous system. London University Press, 1962.

10   Smelser, Neil Theory of collective behavior. London, , Routlege Keegan Paul, 1962, 1970. [ Smelser defines an hysterical belief as "one which empowers an ambiguous element in the environment with the power to threaten or destroy"]

[5]   Kuhn Thomas S. The Structure of Scientific Revolutions The Chicago University Press, 1962, 1970.

[6]   Hadler NM. Illness in the workplace: the challenge of musculoskeletal symptoms. Journal of Hand Surgery 1985;10a(4):451-456.

[7]   Wright, Graham Student Health Service, Flinders University. Personal communication.

[8]        4 Corners

[9]   Hocking B Med. L Aust.1986, 144: 500-501.

[10]   Paget, J. 1873 Nervous mimicry of organic diseases Lecture 1, Lancet, ii 511-513.

[11]   Fineberg, Joel. Gross, Hyman. Philosophy of Law, Dickinson Publishing Company 1975.

[12]   Gowers WR. Occupational neurosis, writers' cramp A manual of diseases of the nervous system. Vol. 11. London: Churchill, 1988: 656-676

[13]   Huxley, Aldous. The Devils of Loudon, Penguin books.

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