Chapter on RSI
This so called 'new' industrial epidemic disorder[1]
of symptoms in the arms originated in Australia as repetitive strain injury,
'RSI,' Occupational Overuse Syndrome or 'OOS' and 'teno'.[2][3]
Undiagnosable arm symptoms has formerly been reported in the medical and other
literatures, in both sporadic and epidemic forms as 'occupation neurosis',
'craft palsy'[4] and as its
standard examples, 'writers'' and 'telegraphists' cramp'.
[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]
This functional disorder has long been recognised to signal emotional distress,
conflict about endeavour and has been classed as an 'neurosis' in neurological,
psychiatric and occupational health textbooks since 1888.[31]
The first epidemics of writers' cramp that were reported in the 1830s among
male clerks of the British Civil Service were attributed to the new technology,
the steel nib. Greater individual output was expected than had been possible
while using a quill; then as now there were demands for greater productivity in
a work force fearful of job losses and of re-skilling. Dr Fulton described
telegraphists' cramp in 1875, and the incidence of this disorder, originally
considered 'rare' increased to epidemic proportions in both England and the
United States in the late 1880s and several very large series of cases were
reported. The public health activist George Vivian Poore reported first on a
single case, then on 75 cases of cramp, most of whom had not done much writing
at all. In the United States, George Beard, known for the popularisation of
neurasthenia as a 'genuine' disease' reported on how he had treated 125 cramp
subjects with the nostrums of the period, but he made no comment on their
recovery rates. In 1888, Gowers coined the term 'occupational neurosis.' With
this, he effected a shift away from the notion that cramp was the consequence
of writing, to the idea that it was a product of personal troubles and
anxieties combined with fear. He advocated relaxation and re-education, now
called 'behaviour therapy,' the only successful treatment that has been
reported. It is arguable whether 'neurosis' was considered by Gowers to be
entirely psychogenic or whether the term was simply used for a condition
considered to be of central nervous system origin. Freud and Breuer had
published their 'Studies in Hysteria' and the psychogenic theory of the origins
of neurosis was well established in neuropsychiatric circles and neurology in
England was a most advanced body of knowledge. In 1908, telegraphists' cramp
was added to the schedule of diseases covered by the British Workman's
Compensation Act, (1906) following the evidence of the Union's physician, Dr.
Sinclair, who gave evidence to the court that cramp was 'muscular failure
caused by the rapid repetitive movements of telegraphy.' Within four years, up
to 60% of the work force were reporting symptoms; 30% had difficulties in
manipulation. A committee, including several eminent physicians of the day, was
commissioned 'to inquire into the prevalence and causes of the disease known as
telegraphists' cramp and to report what means may be adopted for its
prevention.' The committee investigated all the popular attributions of cramp;
these included constitutional weakness, inaptitude for telegraphic work, the
nature and amount of a telegraphist's work, the construction of Morse keys, the
design of keyboards, inadequate working accommodation and the design of
furniture. It examined all peripheral and central causal hypotheses, which were
again circulating, including 'muscular failure.' However, during the inquiry as
the cases came under examination, the Postal Telegraphist Clerks' Association
was forced to abandon its attribution theories and propose that 'stress' was
the cause of cramp. The committee's conclusion was that cramp was a neurosis.
There was little doubt that British physicians in 1911 were aware of the
ideogenic theory of neurosis.
The origins of the concept of RSI
The epidemic of arm symptoms started in Australia in the very early nineteen
eighties, against a background of concern about occupational health. The first
announcement of 'RSI' in an orthodox medical journal was in December of 1983
with the publication of Dr. William Stone's paper called 'Repetitive Strain
Injuries' However the social construction of medical knowledge about 'RSI' was
complete before it was announced in the Medical Journal of Australia in
November of 1983.[32] The injury
theory been assembled outside of mainstream medicine by a handful of doctors in
NSW, Victoria and the Australian Capital Territory, with the assistance of a
physiotherapist employed within an academic department of Occupational Medicine[33][34]
some ergonomists who claimed to know how to prevent it
[35][36] and a union
activist researcher (M. Pitcher) in concert with a social medicine academic (R.
Taylor).[37][38]
The causes of 'RSI' and the ways in which it was to be prevented were
documented by health activists in the Trade Union movement in 1980,[39]
1981,[40][41][42][43][44][45][46][47][48]
1982[49][50]
1983.[51][52]
"Repetition injuries" had been upheld and compensated by legal judgements well
before the before 'RSI' was introduced to mainstream medicine.[53][54]
Lawyers had written pamphlets about them [55]
and the epidemic was well advanced in those workplaces where the disorder had
been advertised and was being prevented.[56][57][58]
That is to say, before those members of the medical profession who were not
connected with union interests had been informed through the medical press of
what 'RSI' was said to be, there was a large body of literature concerning how
it was caused and how it was to be diagnosed, treated, and prevented[59]
There had been several court decisions which had supported the notion that it
was 'foreseeable.'[60] Before
'RSI' had ever appeared either in a drug company sponsored medical magazine[61]
or in a refereed medical journal there were already many claimants receiving
compensation for it.[62] One year
later in the Australian (Commonwealth) Public Service, thirty-five persons had
been retired under the CE(RR) Act, eight appointments had been annulled and
altogether, 195 persons had left their employment on account of RSI and had
remained on continuing compensation. These retirements were all a consequence
of the unions' promotion of arm symptoms as a debilitating and preventable
disease. The small number of physicians had constructed and subscribed to the
injury theory before November of 1983 and they had provided the relevant
medical evidence and the certificates underpinning an epidemic of an new
traumatic disease. As the epidemic grew, more medical practitioners were
recruited or perhaps enrolled in support of the new theory. By the end of the
epidemic, only a handful in each state maintained their beliefs and the major
proponents of the injury theory had been criticised in legal judgement
Knowledge about RSI did not come from within medicine, but from the documents
of trade unions and from legal judgements, an example, perhaps, of an epidemic
of a juridicogenic rather than iatrogenic The assertions that it was caused by
tasks were heuristic, not based in research and frankly incorrect. The injury
theory of RSI could not account for the epidemiology of the disorder. It did
not respond to treatment for injury and to some naive doctors this gave rise to
therapeutic nihilism. Orthodox medicine has resisted the notion and statements
have been made by numerous medical colleges and individuals concerning the
risks and consequences of using a diagnostic system contrary to one recommended
by the World Health Organisation, that is using a facile acronym incorporating
a causal hypothesis rather than a diagnosis based on individual pathology.
Cases of non-recovering 'tenosynovitis' had started to appear in 1979 in the
New South Wales Compensation statistics following the ascription of this
diagnosis to many cases of arm symptoms by a Workers' Health Clinic. The trade
unions published many booklets listing the symptoms causes and modes of
prevention of 'repetition injury' before mainstream physicians had ever heard
of it. In early 1982 a judge deemed this unknown disorder, then termed
'repetition injury' to have been foreseeable. The flow of cases became a
torrent and the epidemic peaked in the private sector in late 1985. In the
meantime, costs had risen to the extent that many governments changed workers
compensation laws to exclude payment for disability in favour of compensating
only organic impairment only.
Doctors who diagnose RSI and attribute causes
Australian trade unions, backed by a handful of doctors in each state,
attributed causal status to those conditions of the workplace that they sought
to remedy. Such doctors associated themselves closely with lay organisations
promoting occupational health and their services were favoured by such
organisations. They were generous in granting entry into the sick role and
epidemics of occupational illness followed in their wake. They then recommended
that remedies be applied to symptoms, as if they were evidence of a new
traumatic disease. According to sociologist, Elliott Freidson, a physician can
operate as a "moral entrepreneur."[63]
One of a physician's greatest ambitions is to discover a new disease or
syndrome to be immortalised under his name. In Freidson's account, moral
entrepreneurs in medicine, part time practitioners associated with lay
organisations, or technical advisers who commonly give press interviews and
testimony in court, crusade in health matters. The thrust of their activity is
towards political power to implement measures designed to improve what they see
as public health and they are often responsible for legislation. They seem to
want to remove jurisdiction about their issues from society and to place it in
the hands of health professionals. Freidson identified lay interest groups
'sometimes led by, and always including a prominent physicians,
the most flamboyant moral entrepreneurs of health, untrammelled by professional
dignity, crusading against the menace of a specially chosen disease, impairment
or disease producing agent.'
Such entrepreneurs are prone to see the environment as more dangerous to health
than the layman, are prone to emphasise the seriousness of the health problem
preoccupying them by estimating the cases probably undiagnosed and therefore
untreated. They are prone to see mental illness where the layman sees
nervousness, see illness where the layman sees variations within the broad
range of normality, to see a serious problem where the layman sees a minor one.
They are biased towards sick roles as such and create sick roles where there
were formerly only symptoms. Freidson had described such crusading physicians
as 'moral entrepreneurs of health' and noted their proneness to create sick
role behaviour.[64] The RSI
epidemic could be measured only by the years of disability attributed to it and
the compensation paid out for it. Many diagnoses were recorded on files and by
commissions, as RSI was subsumed into various categories of 'soft tissue
disorders of upper limbs.' RSI was understood within the framework of an injury
model in which symptoms were assumed to have been the consequence of
occupational tasks or conditions. The author of this report recognised an
epidemic of occupation neurosis or somatization.
The concept of somatization
In the late nineteenth century, the term 'neurosis' referred to physical
symptoms with no visible cause. As the emotional causes of such symptoms were
elucidated, the term became 'psychoneurosis' and took on its present meaning.
More recently, the motor and sensory symptoms associated with emotional states
have been called somatization and the term 'neurosis' has been replaced by
anxiety, dysthymic and depressive disorders. Somatization encompasses
inexplicable symptoms: prolongation of illness and excessive suffering; a
clinical picture where bodily symptoms are judged to be overly dominant, overly
persistent or the subject of abnormal preoccupation. The concept embraces
psycho-social distress presented as bodily symptoms, as well as somatic
presentation of disorders involving depression and anxiety, and pre-occupation
with illness (hypochondriasis). The concept is brought into play when the
clinical picture does not match objective findings. Those whose illness does
not conform to the norms prevalent in their social groups could be said to
somatize; or alternatively, certain social or ethnic groups somatize by
comparison with other social groupings or segments of the population . The
concept is accordingly evaluative, value-laden, culturally and socially
sensitive and extremely vulnerable to changes in norms, values and expectations
of both physicians and patients. 'Occupational' refers to the context in which
symptoms appear. Neurosis is ideogenic and cannot be caused by a task; the
belief that the task can do harm causes the neurosis.
How might this epidemic be understood?
An epidemic such as the epidemic of RSI can be explained by reference to
psychosocial phenomena which might be of two types: either they could be due to
epidemic hysteria on the part of patients, or be the result of an altered
perception and management of endemic symptoms in the community. My own
researches have confirmed that both factors were operating, with the changed
interpretation and management of endemic symptoms giving rise to epidemic
hysteria. A theory of physical causation fails to accommodate the epidemiology
of the occupational neuroses, of cramp, of nystagmus, of RSI; it fails to
account for the symptoms, their distribution and the natural history. A
sociological theory of illness behaviour involves consideration of an
individual's needs and desires and their achievement in accordance with
societal norms and personal values. All parties, patients and doctors involved
can be viewed as moral agents with needs, desires, reasons, grounds, motives
and intentions to account for their illness behaviour and diagnosis behaviour.
The desire or need for the sick role, in combination with the ready
availability of a legitimated entry to it, were the 'sine qua non' aetiological
factors involved in generating the affliction. The benefits of the sick role
are generally seen as 'secondary gain.' It might be that the desire for
secondary gain is the primary cause of getting ill. A reason for needing the
sick role becomes a motive for entering it. The attribution of a new meaning,
injury, to pre-existing somatization symptoms or to transient sensations
amplifies them while inducing a deep-seated belief in their new attribution.
The remembered sensation has a new meaning that carries new implications. The
mind reacts, not to an injury, but to the idea that there is an injury and
continues to issue warnings in the form of signals in the body, for as long as
the consequences of that idea serve a useful purpose. New experts on RSI, on
its causes and remedies, developed new norms of diagnosis and treatment and
behaviour, both mediated by their personal values and morals. These new norms
occasionally ratified by legal decisions, influenced some doctors to issue
certificates for prolonged disability on behalf of symptoms formerly regarded
as trivial. Seeking out such doctors and taking work disability were options
influenced by that individual's personal values and expressed in the context of
new social norms. How a person behaves in the event of developing symptoms is a
moral decision, most clearly understood in the simplest case: how much time, if
any does on take off work if one has influenza? This epidemic has been a public
health problem. Somatizing subjects are disabled by the advice of their
doctors, removed from their tasks and treated with physical remedies.[65]
Case file revealed numerous diagnostic formulations involving causal
attributions and similar numbers of therapeutic interventions had been
attempted. Simulation of injury in the patient attracted collusion by the
diagnostician, a basic transaction in the production of social and clinical
iatrogenesis.[66] Guidelines
developed for the prevention of occupational injuries promoted the development
of psychogenic disorder by redefining innocuous tasks as potentially harmful.
While warning notices might prevent a physical injury happening to someone who
thinks twice before lifting alone, warnings about the pathogenic capacity of a
keyboard generate the very ideas which promote the development of occupation
neurosis.. Prior to its definition as RSI the only affliction which had been
reported in keyboard workers was cramp, and that cannot be prevented by
physical means.[67] Its
misdiagnosis as a physical injury has contributed to the epidemic. Legislation
based on information which was known to be medically incorrect, but politically
expedient when it was drafted nearly 100 years ago needs to be reviewed
Dr. Yolande Lucire
Consultant Psychiatrist
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[2] Stone WE. Repetitive strain injuries.
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[3] Browne CD, Nolan BM, Faithfull DK.
Occupational repetition strain injuries. Guide-lines for diagnosis and
management. Med J Aust 1984; 329-332.
[4] The term 'craft palsy was already in
use in 1875, and is a generally recognised generic term, especially useful for
the cases where apparent inhibition of activity is a prominent feature of the
presentation.
[5] Bell C. Partial paralysis of the
muscles of the extremities. The nervous system of the human body. Washington:
Duff Green, 1833: 221.
[6] Solly S. Clinical lectures on
scriveners' palsy, or the paralysis of writers. Lancet 1864; 2: 709-711.
[7] On a case of "writer's cramp" and
subsequent general spasm of the right arm, treated by the joint use of
continuous galvanic current and the rhythmical exercise of the affected
muscles. Poore GV, The Practitioner, September 1872 129-137.
[8]Poore GV. An analysis of 75 cases of
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[9] Beard GM. Conclusions from the study of
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224-247.
[10] Gowers WR. A manual of diseases of
the nervous system. Vol 2. London: Churchill, 1888: 656-676.
[11] Meige H. Crampes professionelles.
In: Traite de médicine, 12edn. Paris: Masson et Lie, 1905; 351.
[12] Jelliffe SE. A system of medicine.
London: Oxford University Press, 1910: 786-795.
[13]. Great Britain and
Ireland Post Office. Departmental Committee on telegraphists' cramp report.
London: His Majesty's Stationary Office, 1911.
[14] Price FW. A textbook of
the practice of medicine. London: Oxford University Press: 1922; 1st edn:
1462-1466, 1966; 10th ed: 1096-1097.
[15] May Smith, Millais
Culpin, Eric Farmer E. A study of telegraphists' cramp. Medical Research
Council; Industrial Fatigue Research Board. London: His Majesty's Stationary
Office, 1927.
[16] Culpin H. Recent advances in the
study of psychoneuroses. London: Churchill-Livingstone, 1931: 178.
[17] Pai MN. The nature and treatment of
"writer's cramp". J Ment Sci 1947; 93:68-81.
[18]
Liversedge LA, Sylvester JD. Conditioning techniques in the treatment of
writer's cramp. Lancet 1955; 1: 1147-1149.
[19]
Beech HR. The symptomatic treatment of writer's cramp. In: Eysenck HJ, ed.
Behaviour therapy and the neuroses. Oxford: Pergamon Press, 1960: 334-348.
[20]
Sylvester JD, Liversedge JA. Conditioning and the occupational cramps. In:
Eysenck HJ, ed.Behaviour therapy and the neuroses. Oxford: Pergamon Press,
1960: 334-348.
[21]
Brain RW. Occupational neuroses. In: Brain RW, ed. Diseases of the nervous
system. 6th edn. London: Oxford University Press, 1962: 852-854.
[22]
Schachter M. Contribution a l'étude clinique de la crampe des écrivains. J Med
Lyon 1962; 43; 273-298.
[23]
Crisp AH, Moldofsky H. A psychosomatic study of writer's cramp. Br J Psychiatry
1965; 111: 841-858.
[24]
Moldofsky H. Occupational cramp. J Psychosomat Res 1970; 15: 439-444.
[25]
Ferguson D. An Australian study of telegraphist's cramp. Br J Ind Med 1971; 28:
280-285.
[26]
Hunter Donald. The diseases of occupations. London: The English Universities
Press Ltd, 1971.
[27]
Sarkari NBS, Mahendru RK, Singh SS, et al. An epidemiological and
neuropsychiatric study of writer's cramp. J Assoc Physicians India 1976; 24:
587-591.
[28]
Sheehy MP, Marsden CD. Writers' cramp - a focal dystonia. Brain 1982; 105:
461-480.
[29]
Cottraux JA, Juenet C, Collet L. The treatment of writer's cramp with
multi-modal behaviour therapy and biofeedback: a study of 15 cases. Br J
Psychiatry 1983; 142: 180-183.
[30]
Greenberg D. Writer's cramp - a habit for reversal? J Behav Ther Exp Psychiatry
1983; 14: 233-239.
[31]
Lucire, Y., Neurosis in the workplace. Medical Journal of Australia, 1986.
145(7):323-327.
[32]
For other examples of this phenomenon, see Wright P, Treacher A. The Problem of
Medical Knowledge: Examining the social construction of medicine. Edinburgh
University Press, 1982
[33]
McPhee B. Tenosynovitis: the physiotherapist's viewpoint. Proceedings of the
20th N.S.W. Industrial Safety Convention and Exhibition. Sydney: Organising
Committee, 1980.
[34]
McPhee B. The mechanism of repetition strains. Seminar on Tenosynovitis.
Sydney: Manly-Warringah Productivity Group, 1981. opp cit.
[35]
Chan P. Prevention of tenosynovitis in industry. 17th Conference of the
Ergonomics Society of Australia and New Zealand. Sydney: , 1980:
[36]
Paidya KN, Stevenson MG. The cost to industry of tenosynovitis and related
diseases associated with repetitive work. Australian and New Zealand
Association for the Advancement of Science, 52nd Congress. Sydney: , 1982.
[37]
Taylor R, Pitcher M. Repetition injury in process workers. Community Health
Studies 1982;6(1):7-13.
[38]
Taylor could not be seen as naive. He had already published Taylor R. Medicine
Out of Control: The anatomy of a malignant technology. Melbourne: Sun Books,
1979. He was to become professor of Community Health at later
[39]
Repetition injuries - rapid repetitive work may cause you permanent injury. In:
Australian Public Service Association (Fourth Division Officers), 1980:
[40]
Repetition injuries among keyboard workers - a case study. In: Australian
Public Service Association, 1981
[41]
Dressing P. A risk management approach in dealing with repetitive type movement
claims. Melbourne Chamber of Commerce, 1981:
[42]
Guidelines for the prevention of repetitive strain injuries (RSI). Health and
Safety Bulletin 1981;(18):1-33.
[43]
Elenor R. Tenosynovitis and other repetition injuries of the upper limb: a
report. In: NSW Department of Industrial Relations. Sydney: Central Planning
and Research Unit, 1981. This paper was cited as a primary reference in Browne
et al, opp cit. (Browne CD, Nolan BM, Faithfull DK. Occupational repetition
strain injuries. Medical Journal of Australia 1984;140(6):329-332.) but when I
requested to see it, I was told that it was an "internal document" and not
available for public inspection.
[44]
Occupational Health and Safety Group Tenosynovitis and Overuse Injuries. A plan
for action. Melbourne: 1981; vol 1
[45]
Manly Warringah Productivity Seminar on tenosynovitis. Productivity Promotion
Council of Australia, July 20. Sydney, 1981:
[46]
McPhee B. The mechanism of repetition strains. Seminar on Tenosynovitis.
Sydney: Manly-Warringah Productivity Group, 1981:
[47]
Taylor R. Repetition injury survey progress report. Australian Public Service
Association, 1981:
[48]
Amalgamated metal workers and shipwrights union Process workers beware!
Tenosynovitis cripples the hands, arms and legs of thousands of Australian
workers each year. Pamphlet 1981:
[49]
Taylor R, Pitcher M. opp. cit.
[50]
Tenosynovitis and other occupational over-use injuries. Workers Health Centre,
1982:
[51]
Western Region Centre for Working Women Co-operative Limited. They used to call
it 'process workers' arm': a report on repetition injury amongst women in the
manufacturing work force. In: Western Region Centre for Working Women
Co-operative Limited, 1983:
[52]
ACTU-VHTC Occupational Health and Safety Unit, ACTU Health and safety policy :
prevention of repetitive strain injury. Health and Safety Bulletin 1983;29:1-4.
[53] Supreme Court of New South Wales. Lashford
v. Plessey
, Australia Pty. Ltd. 1981:
[54]
Bristow J. Burgess v Thorn Consumer Electronics. High Court of England, Queen's
Bench Division, 1983
[55]
Stevens F, Dawson R. Damages for the industrial injury of tenosynovitis. In:
Work Health Co Pty. Ltd., 1982
[56]
RSI Task Force. In: Repetition strain injury in the Australian Public Service
Australian Government Publishing Service, 1985: Report on the Census of
Australian Public Service Staff suffering from "RSI" as at 31 December 1984. p
303 et sequi.
[57]
The epidemic peaked in Telecom and in the Australian Public service in the
December quarter of 1984. Hocking B. Epidemiological data on the Australian
epidemic. Medical Journal of Australia 1986;144(April 28):500-501.231.
[58]
Hocking B. Epidemiological aspects of 'repetition strain injury' in Telecom
Australia. Medical Journal of Australia 1987;147(5):218-222.
[59]
Guidelines for the prevention of repetitive strain injuries (RSI). Health and
Safety Bulletin 1981;(18):1-33.
[60]Lashford v Plessey
Supreme Court of NSW 1981
[61]
Stone WE. Occupational repetitive strain injuries. Australian Family Physician
1984;13(9):681-684.
[62]
Board PS. Census of Repetition Strain Injuries in the Australian Public Service
December Quarter 1986. Canberra: Public Service Board, 1987
[63]
Freidson E. Profession of Medicine.Chicago: University of Chicago Press, 1970.
p. 252
[64]
Freidson E. opp. cit.p 255.
[65]
Lucire, Y., Social iatrogenesis of the Australian disease, 'RSI'. Community
Health Studies, 1988. 12(2): p. 146-150
[66]
Illich, I., Medical nemesis. The Lancet, 1974. 1(863): p. 918-921.7 and Illich,
I., Medical Nemesis: The expropriation of health. 1975, London: Marion Boyers.
[67] A Medlars search of the literature
in 1984 revealed this. As cramp was misdiagnosed as tenosynovitis, and many
other diseases, the literature of RSI has included them.
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