Origins Of The Concept Of RSI
The first referenced use of the term Repetitive Strain Injury,
was to a typed document of that name called the "approved guide to occupational
health" adopted in June of 1982 by the National Health and Medical Research
Council.[1]
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
the Medical Journal of Australia which introduced some new ideas into the
Australian medical profession.[2][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, by the static strain of having maintained a posture in the course
of work.
The umbrella term "RSI" soon came to be used indiscriminately
for any acute pain, cramp, spasm or fatigue, all occupational myalgias, 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.
This publication of allegedly preventive measures heralded
an epidemic of occupational illness and work disability under that eponym.
In 1985, RSI accounted for over 80% of reported compensation claims for females
Australia wide.[4]
By the end of 1985 there were over 4000 ''cases" in the Australian public
service alone[5] and twenty thousand litigants had materialised.
The Insurance Council of Australia estimated a cost of one billion dollars
in the 1986/7 financial year for the public sector alone.
The term RSI is limited to the Australian medical literature.
. The NH&MRC guide became a policy document for the newly formed National
Occupational Health & Safety Commission (since renamed Workcare).
As late as May 1986 by a vote of vested interests and laymen
and against advice of some of its medical advise, NOHSC went on to recommend
endorsement of the following definition of RSI:
Repetition Strain Injury (RSI), also known
as Occupational Overuse Syndrome, is a collective term for a range of conditions
characterised by discomfort or persistent pain in muscles, tendons and other
soft tissues, with or without physical manifestations. Repetition Strain Injury
is usually caused or aggravated by work and is associated with repetitive
movement, sustained or constrained postures and/or forceful movements. Psycho-social
factors, including stress in the working environment, may be important in
the development of Repetition Strain Injury. Some conditions which fall within
the scope of Repetition Strain Injury are well-defined and understood medically,
but many are not, and the basis for their cause and development is yet to
be determined. It occurs among workers performing tasks involving either frequent
repetitive and/or forceful movements of the limbs and the maintenance of fixed
postures for prolonged periods, eg. process workers, keyboard operators and
machinists.
This definition revealed little understanding of the functional
disorders of which the Commission had been informed, and disregarded advice
about earlier epidemics. It was not an expert's document, but a committee
agreement heavily influenced by trade union views.
Physical causation of "RSI", as defined by Workcare
could not be sustained in view of information available about its symptomatology,
natural history and response to treatment and overwhelmingly its epidemiology.
Symptoms are different in every case, even within the same
occupational category. The tissues apparently affected are not necessarily
tissues used.'
Symptoms spread to an unused limb in people who have used only one hand in
a task such as writing. (Injury theorist say this is due to overuse of the
second limb while protecting the first!) Whilst the "overuse" theory
sounds plausible when the worker did enough to get tired, it becomes harder
to explain the onset of identical symptoms in hairdressers and clerks. Physical
theories of causation cannot account for the appearance of many new cases
of this incapacitating syndrome in situations where work conditions have not
changed for years.
One must ask, if this is such a disabling injury, why is
information about it limited to the Australian medical literature after 1982?
[6] World epidemiology studies
find neck and arm symptoms have an 8-12% prevalence in both working and non
working populations, [7]while in some Australian workplaces up
to 80% of workers have reported symptoms in point prevalence studies. Physical
theories of causation do not explain why can have such variable rates of incidence
in physically similar workplaces , why RSI should be costing the Australian
National University over one million dollars a year, whilst Flinders University
in South Australia has only one employee off work with the condition.[8] If it be causally related to movement,
it becomes impossible to explain why was the highest rate of affectation in
Telecom is amongst its keyboard telephonists, who do several hundred keystrokes
an hour rather than amongst its word processor operators who do several thousand
keystrokes an hour? If RSI can be prevented by physical means, why did its
incidence, (as measured by work disability), increase rather than decrease
following circulation of measures pertaining to its early identification and
prevention?
The concept of symptoms from ideas
The legal philosopher, J. L. Austin reminds us that:
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.[9]
Doctors who transmit illness
I wish to suggest is that we are not using clean tools when
we call symptoms that we cannot explain by their pathology, an "injury",
and to suggest, as did Semmelweiss that it is the use of such unclean tools
that causes illness.
Semmelweiss noted the epidemiology of puerperal fever, a
phenomenon well known to the population but apparently not acknowledged by
the medical profession of the time. To put it bluntly, it was well recognised
that maternity hospitals were dangerous and women treated in them frequently
died of puerperal sepsis, whilst those delivered at home did not. Some 60
years before Pasteur identified bacteria, (while funded by the French wine
industry) Semmelweiss postulated that doctors themselves brought in the cause
of puerperal fever on their dirty hands. Semmelweiss was ostracised by his
colleagues in Vienna, even though he conclusively demonstrated the worth of
his ideas by introducing aseptic procedures into a new hospital and reducing
the incidence of puerperal sepsis to that which currently prevails.
Social iatrogenesis- the creation of illness by doctors and society
Iatrogenesis is the causation of 'illness' by doctors and
it is brilliantly and lucidly documented by Ivan Illich, the critic of Western
medicine. He identified the problems in his classic text Medical Nemesis
now reprinted as Limits to Medicine .[10]
Referring the headings of the three chapters of the first section entitled
"The Epidemics of Modern Medicine" ("Doctors Effectiveness
- and Illusion", "Useless Medical Treatment" and "Doctor
Inflicted Injuries") the Lancet's reviewer said,
"[They] read like a volley of grapeshot
across the bows of our mechanistic philosophy of health care....There is indeed
a strong case to answer".
Illich made no case studies, yet this epidemic of RSI could
be a case study of social iatrogenesis or the manufacture of the illness by
society and doctors. Iatrogenesis is not fraud or over servicing, and attempts
to over-simplify the issues to that extent result in fruitless doctor bashing
and unsuccessful litigation and provide no resolution to this problem. Iatrogenesis
seems to include the non recognition of somatization and conversion together
with the practice of unsuccessful treatment of it in accordance with a strict
medical model.
To call a set of symptoms "RSI" is to avoid diagnosis,
in favour of a presumed causal explanation but to "diagnose" is
to "see through" circumstantial complexities to pathology or psychopathology.
It comes from the Greek, dia-through, gnostos-recognise.
Symptoms come from both organic and functional problems.
The former have localising signs, specific criteria, and ought to be given
a specific and relevant diagnosis . Their natural history is known and predictable,
and most recover in the normal course of events, responding to the treatments
appropriate to injury illness, that is to say that they are commonly and successfully
treated by medical means.
Functional symptoms, on the other hand , cannot be explained
by any pathophysiological mechanism, but involve functional units such as
an arm or leg or digestive or respiratory system. They have too many symptoms
and unrelated signs to make one two or three diagnoses. Functional disorders
do not respond to treatment like the illnesses or injuries they suggest or
mimic. Acute functional disorder, that is transient somatization is commonplace.
Cramp, spasm, vomiting in response to an idea or a smell, left sided chest
pain in the absence of pathology, and the common somatic symptoms of heaviness,
fatigue, associated with anxiety or exhaustion are familiar to all of us.
Such symptoms warrant observation and reassurance, and should not attract
medical or surgical treatments that might be appropriate if their pathology
were all ready identified. Psychological factors need to be considered as
there are certain personality traits, which translate into attitudes, operating
together with situations of need or conflict, that predispose to chronicity
in these and other normally transient disorders.
The origins of the term "neurosis"
Originally the word 'neurosis' referred to a set of physical
symptoms which could not be explained by any postulated organic mechanism.
Neuroses are mediated through the central nervous system through its function
of mind and as the psychosocial causes of these disorders were recognised,
the word took on its present meaning which generally refers to the mental
state found in association with such symptoms, and with other forms of emotional
disturbance. Physical presentation of emotional distress is called "somatization"
and hysterical conversion is a subset of this category of illness behaviour.
An historical perspective of RSI
The new Australian epidemic disorder known as RSI or "teno"
is the prolonged functional syndrome reported in textbooks of medicine, neurology
and occupational health, in both epidemic an sporadic form as writers', telegraphists',
process workers', seamstresses' and pianists cramp or occupational neurosis,
and its epidemiology , natural history and multi-modal symptomatology are
unknown in any organic disorder or injury. [11]
Such an epidemic of a new disorder (whose name incorporates
a new and frightening cause) is made up of two factors: hysteria in the patients,
and impaired medical perception of endemic symptomatology, with the latter
a contributing cause to the former.
Neurosis and will
The benefits of health and the satisfaction's of work are
taken for granted. However there are some individuals whose lives, circumstances
and difficulties, make it more attractive for them to be ill than well. Their
problems might be long term and caused by neurotic personality traits or by
long standing lack of success; or could be transient and temporarily solved
by being ill, by being able to give up their work for having children and
to look families and attending to other duties. However, if for those who
should be having a transient disturbance one adds the advantages of being
paid for so doing then the adoption of the behaviour and symptoms of a sick
person can be very attractive indeed.
'the situation is, "arm pains in workers are due to
injuries caused by work". Put simply, this hysterical belief can be expressed
in two words - movements maim. Superficially,
at least, it would appear that the risk of injury at the keyboard is greater
than on a battlefield, and that "injuries" caused by typewriters
take longer to heal.
The role of legitimation of 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 does the introduced
streptococcus to an epidemic of puerperal fever.
The almost random determination by courts that factors,
which are no more than substrate vulnerability are "causal" will
encourage the activity of eliminating them, and ultimately those considered
to be at risk will not gain employment. Whilst changes which increase comfort
are commendable, they do little to eradicate neurosis. Medical implementation
of false causal theory leads to treatment which is ineffective or worse and
the vulnerable emerge and their march into chronic invalidity
It has long been established that neurosis should be treated
as an illness on the same level as any medical illness but by different means.
If there is a disturbing idea in the mind, one must ask how it came to be
there and why it was able to take root and why the idea was accepted by some
patients and rejected by others.
Who develops somatization symptoms?
The factors that contribute to conversion neurosis can be
summed up as "ideas" and "personal vulnerability". Vulnerability
may come from traits or circumstances.
Onset is triggered by any stress which generates a conflict
about working. The stress may come from the workplace or it may come from
home, and simply manifest in the workplace.
In situations of personal vulnerability, the symptoms of
neuroses are determined by ideas and so they appear in epidemics when such
ideas prevail. The problem is compounded when the medical profession becomes
confused and fails to distinguish the signs of injury or illness from the
psychogenic symptoms that mimic them.
Neuroses are psychogenic, that is, caused by emotionally
charged ideas. Movement, a physical phenomenon, can not be a "cause"
of neurosis. It is the belief that movement can cause injury that causes the
neurosis, and while that belief persists (and the hope of monetary reward
that goes with it) symptoms will persist and epidemics of this disorder will
recur whenever a new vulnerable population is exposed to hysterical beliefs.
Power and knowledge in medicine
There is a further gimmick in the interpretation of each
arm sensation, each cramp spasm and fatigue as stage I of "RSI"
where stage III is total incapacity. Holding jurisdiction over this set of
beliefs gives a doctor enormous power.
By the act of writing of a certificate the patient is removed
from the invisible risk inherent in the continuation of a task now circuitously
defined as "dangerous". The doctor has a grateful passive and dependent
patient. The patient has the certificate which deems the employer culpable
with the stroke of a pen. The lawyer has a case and nearly everyone is happy.
But some one pays, and I suspect we all pay. We are paying some one to become
ill and stay ill. We pay the doctor for creating an illness, then for pretending
to treat it with treatment which is unvalidated, unsuccessful and theoretically
unsound.
Indeed the literature on writers' cramp provides numerous
accounts of the failure of the physical treatments which are in use today.
People recover from sensations, fatigue, cramps, spasms,
organic disorders and even from neuroses in due course, but the amount of
work disability attributed to this disorder "RSI" must stand sentinel
to the counter-productiveness of its so called treatments".
The injury theory
The thinking behind the injury theory involves the perception
of the patient as a passive entity rather than a person capable of intentional
action; an inanimate object which has been damaged by rapid or repetitive
movements at work, by static strain or by any number of causal entities. These
entities are defined as "causal" simply because they preceded the
development of symptoms. Cause and coincidence are unseparated.
Conflict induced by compensation
The conflict generated in a patient at the prospect of compensation
needs to be faced. A person should not be placed lightly in this stream, certainly
not before that person has had the benefit of opinion which might oppose the
work relatedness of their disorder and open up a more effective line of management
of their symptoms.
The factors that prolong symptoms in a compensation setting
are well known. They include individual predisposition, the possibility and
availability of compensation, injudicious early handling, delayed settlement,
the difficulties of making a final settlement. An over-solicitous attitude
to the "injured" can actually prevent them from taking responsibility
for overcoming their handicap.
Treatment of neurosis involves the bringing of any beliefs
as to origins of symptoms to the surface - exposing hysterical beliefs and
enabling a patient to give them up. It also involves assisting with re-attribution
of symptoms to personal factors and giving help to the patient to take responsibility
for her predicament. In the present epidemic, treatment, is often sabotaged
by well meaning lawyers, union officials and medical practitioners who reinforce
in the patient the belief that they have been injured and discourage exploration
of self and motivation to overcome disability.
The secondary gains from the neurosis can conflict with
the wish to recover.
The prevention of such disorders lies in the practice of
good medicine.
A doctor can elicit the complex and changing symptomatology
and the subjective changes of function and sensation. After a thorough physical
examination, the doctor must decide if all symptoms can be accounted for by
a physical condition, or if they are only suggestive of any number of problems.
If an organic mechanism can not be demonstrated for the sensation, nor can
any patho-physiological mechanism be postulated the patient should be told:
"I can find no organic reason for you to be having all these feelings.
Now what's the matter?"
Conversion neuroses occur in situations of conflict or need,
especially if the conflict is such that it can be resolved by a period of
such compensable illness. Somatization also occurs in other emotional disturbances,
most commonly depressive illnesses and psychoses.
Stressors of domestic origin manifest as workplace illness,
and its treatment as an injury often interferes with the search for relevant
help.
Giving a near enough "diagnosis" or positing a
causal hypothesis of movement or "overuse" will fixate the symptoms
and reduce the credulous to immobility.
The identification of personal vulnerability factors and
attention to them discourages illness behaviour as a solution in favour of
reinforcing normal coping mechanisms.
Until this standard of medical practice returns we will
continue to suffer waves of epidemic "RSI" and it will continue
to be known internationally as "The Australian Disease".
The first part of the Hippocratic oath is PRIMUM NON NOCERE-
First Do No Harm. Yet we have an epidemic of man made disease and a great
deal of harm is being done.
When the history of this episode is written the institutions
which have supported the concept of "RSI" will have a lot to answer
for.
[1] Anonymous. approved guide to occupational health adopted
at the ninety third session of council, June 1982.
[2] Stone WE Repetitive Strain Injuries Med J Aust 1983616-618
[3] Browne, CD Nolan BM and Faithful DK Occupational Repetition
Strain Injuries. Guidelines for diagnosis and management 1984; 140: 329-332.
[4] Meckosha, H. Jakubowicz, A. Women suffering RSI: the
hidden relations of gender, the labour process and medicine. J. Occup. Health
and Safety. Aust NZ 1986; 2; 390-401.
[5] Task Force: Repetition Strain Injury in the Australian Public
Service, Canberra AGPS 1985.
[6] Medlars computerised search
[7] Hadler, NM. Illness in the workplaceJ Hand Surg (Am)
1985: 10: 451-456.
[8] Wright, Graham. Personal communication University health
service.
[9] Fineberg, Joel Philosophy of Law, Dickenson Publishing
company 1975
[10] Illich Ivan. Medical Nemesis, The expropriation of health (1976)
Pelican Books 1977
[11] Lucire, Yolande.
Neurosis in the workplace,1986 Med J Aust. 145. 323-327.
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