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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

[1] Ferguson D. The "New" Industrial Epidemic. Medical Journal of Australia 1984; 140: 318-319.

[2] Stone WE. Repetitive strain injuries. Medical Journal of Australia 1983; 2: 616-618.

[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 writer's cramp and impaired writing power. Trans R Med Chirurg Soc 1878; 61: 111-145.

[9] Beard GM. Conclusions from the study of 125 cases of writer's cramp and allied affectations. Med. Rec (New York) 1879; 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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