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‘Repetitive strain injury’: From Australia to the UK
Journal of Psychosomatic Research, Vol. 39, No. 6, pp. 783 788, 1995 Elsevier Science Ltd Printed in Great Britain 0022 3999/95 $9.50+.00
Pergamon 0022-3999(95)00030-5
'REPETITIVE STRAIN INJURY': F R O M AUSTRALIA TO THE UK P A U L A. R E I L L Y Abstract--The UK is now experiencing an epidemic of upper limb pain similar to that which affected Australia in the 1980s. The pain is often non-specific, and does not conform to the pattern of various well-recognized rheumatological entities. The syndrome is known by a number of terms, some of which imply an aetiological link to workplace activities unsubstantiated by hard evidence. The syndromemay well be largely psychosocial, and analogous to the chronic fatigue syndrome. It is currently the cause of many contentious and well-publicized medico-legal cases. Possible factors behind the epidemic will be discussed, and an approach to management suggested.
Keywords: Repetitive strain injury; Work-related upper limb disorder; Regional pain syndrome; Occupational cervicobrachial syndrome. BRIEF HISTORY OF WORK-RELATED UPPER LIMB PAIN Upper limb pain in scribes and notaries was described by Ramazzini in the early 18th century, and was attributed to constant use of quill pens for writing, poor seating and 'excessive mental labour'. The scribes had few breaks, 'so that they would not cause their master any financial loss' [1]. This triad of repetitive use, faulty ergonomics, and a stressful environment was to feature in more recent descriptions of upper limb pain. During the 19th and early 20th centuries massive outbreaks of arm pain were attributed to the introduction of new technology. 'Writers' cramp' was described by neurologist Sir Charles Bell as a condition affecting Civil Service clerks, and possibly due to the introduction of steel-nibbed pens [2]. The use of the telegraphy keypad was soon followed by an epidemic of 'telegraphists' cramp' in both America and Britain. An extensive study was made, and the Report of the Departmental Committee in 1911 identified no obvious relationship between the pain and such factors as age, length of service, hours worked, seating or desk arrangement. This report first introduced us to a pseudomedical term now part of our everyday lexicon: " . . . the nervous breakdown known as telegraphists' cramp is due to a combination of two factors, one a nervous instability on the part of the operator, and the other repeated fatigue during complicated movements required for sending messages" [3]. This psychosomatic basis for chronic pain was also believed by neurologist Sir William Gowers, who described those with writers' cramp as being of a "distinctly nervous temperament, irritable, sensitive, and bearing overwork and anxiety badly" [4]. Many
Consultant in Rheumatologyand Pain Management, Frimley Park NHS Trust Hospital, Portsmouth Road, Camberley, Surrey GUI6 5UJ, UK. 783
784
P.A. REILLY Table I. Synonymsfor regional upper limb pain syndrome Occupational cramp/occupationalneurosis Writers' cramp/telegraphists'cramp Occupational overuse syndrome Cumulative trauma disorder (CTD) Rapid movementdisease Repetitive strain injury (RSI) Occupational cervicobrachialsyndrome Regional fibrositissyndrome Work-related upper limb disorder Golden wrist/kangaroopaw RSI (rampant social iatrogenesis) RSI (retrospective salary increase)
occupational disorders were felt to be examples of neurosis, and again this concept resurfaced during the more recent Australian epidemic. A huge number of terms have been used to describe what is essentially the same chronic pain syndrome (Table I). In general, in the absence of features of a specific musculoskeletal disorder, it is better to use descriptive terminology, rather than a pseudomedical name with uncertain basis in fact. 'Repetitive strain injury' ('RSI') was an Australian invention, but subsequently changed to lregional pain syndrome'. (Less charitable interpretations of the acronym 'RSI' also exist, Table I.) Although it lends itself less easily to an acronymic abbreviation, "regional pain" at least avoids implying an aetiology which remains unproven, and tissue damage which is usually unconfirmable. The term currently favoured in the U K is work-related upper limb disorder (WRULD), although this too implies an understanding of the aetiology. THE AUSTRALIANEXPERIENCE This has been well reported in an Australian literature which has remained largely unread in the U K even by those with forthright opinions on the subject [5-14]. Ferguson described cramp-like arm pain in keyboard telegraphists employed by Telecom Australia, and postulated that fast, repetitive movements were responsible [5]. Further reports followed, and interest was stimulated by sensationalist media coverage. Australian trades unions, a very powerful lobby, sprang to the defence of their members whom, it was felt, were at risk of pain and disability from their employment. The number of affected employees grew rapidly, and cases were identified in many industries, including teachers, nurses, secretaries and other keyboard operators, process and assembly-line workers. In 1982, a report from the Australian National Health and Medical Research Council referred for the first time to 'repetitive strain injury', which was soon popularly abbreviated to 'RSI' [11]. The media, unions, medical, paramedical, legal, governmental and self-help groups went into overdrive. The incidence increased in proportion, as if interest in the condition was actually contributing to its prevalence. Because many more women were affected than men, it became a cause celebre for feminist organizations (including WRIST, Women's Repetitive Injury Support Team). The epidemiology was interesting, and did not follow the pattern seen in most
RSI in the UK
785
epidemics. Although more common in women, it was argued that this was because they were largely employed in 'at-risk' occupations. It was more frequent in some branch offices than others, despite identical activities, furniture and computer hardware. Public service organizations were more affected than those in the private sector, and it was rarely found in self-employed individuals. There was a seasonal variation, onset being more frequent in fruit-pickers as the picking season drew to a close, and in mothers just before schools broke up for summer vacation. When the original report of Ferguson was further scrutinized, the 14% prevalence of arm pain concealed that 25% of telegraphists in Sydney were affected, but only 4% in Melbourne. Both the medical and lay press published articles and extensive correspondence, and opinion became polarized, entrenched positions adopted, and scorn poured on those with opposing viewpoints. Doctors, a product of conventional medical training with its emphasis on diagnosis and disease, searched in vain for the pathology responsible for the chronic pain and disability. Patients were extensively investigated with blood tests, radiographic imaging techniques of many varieties, thermal scans, electromyography, and even tissue biopsy. No reliable organic lesion could be identified. Still following the traditional model linking diagnosis to treatment, many modalities were used in an attempt to bring relief. Such therapies were those normally employed, usually successfully, in the management of soft tissue musculoskeletal disorders. Physiotherapy, anti-inflammatory drugs, splints and slings, electrotherapy, steroid injections, surgical decompressions, were all tried with variable, and usually poor, results. Alternative practitioners of the healing arts moved in, with manipulators, masseurs, reflexologists, aromatherapists, herbalists and homeopaths faring little better than their more conventional colleagues. Meanwhile the fiscal toll of the epidemic was huge, with compensation agencies, private and governmental, paying out vast sums for workplace disability caused by an illness with no obvious organic basis. Insurance premiums rocketed, and many smaller businesses folded under the extra financial burden. Socially the effects were equally destructive upon a young, thrusting nation emerging from the shadow of colonialism. The Australian epidemic peaked in the mid-1980s, and the incidence of new cases began to fall. Several reasons have been proposed, and probably a combination of factors was responsible. A huge sum of money was spent investigating and improving workplace ergonomics, which had not only physical benefits on posture and reduction of dynamic and static musculoskeletal loading, but also psychological benefits. Workers were reassured that their bosses took the problem seriously and cared for their welfare, not just their productivity. Publicity was given to successful claimaints, with apparently severe disability, who were filmed doing other work or recreational activities just as physically demanding as the job alleged to have induced the injury. Several well-publicised court cases went against the litigants, perhaps acting as a disincentive to others. And perhaps doctors, lawyers, and other interested parties began to have some insight into the complex nature of pain, especially in the setting of work. REGIONAL ARM PAIN IN THE UK The Australian experience should have been a salutary lesson for the UK. We should have been better prepared for our own current epidemic of WRULD, been
786
P.A. REILLY
more aware of the pitfalls of inaccurate diagnosis and unproven remedies. Initially the term 'RSI' was commonly used by professional and lay people alike. Implicit in the term is that an injury has occurred, i.e. that there is tissue damage. Also implied is the aetiology (repetitive movements) and the pathophysiology (strain). None of these assumptions are backed by scientific evidence, a fact ignored by those who believe passionately in RSI as an industrial disease. RSI is lumped together with tenosynovitis, epicondylitis, carpal tunnel syndrome and rotator cuff lesions as 'occupational overuse syndromes'. Even for these relatively well understood conditions, the evidence that specific types of work activity are causative remains highly circumstantial [16,17]. The general practitioner, when faced with someone with upper limb pain and who alleges it is work-related, may take the path of least resistance and agree. Extrapolating from the few cases of true tenosynovitis or de Quervain's disease that he has seen, it is assumed that this might still be the problem, or a forme fruste thereof, even when the cardinal features of 'inflammation' are recorded as being absent. The patient is signed off work and provided with a certificate of sickness. The traditional medical model of management is adopted, with prescriptions of drugs and splints, advice on total immobilization of the affected part, referral to physiotherapy, then a specialist clinic for further investigation and treatment, possibly including surgery. It is small wonder that the patient becomes convinced of the presence of disease, and behaves accordingly. The person with a problem has been transformed into the patient with a pathology. The next logical step is to become a litigant with a claim. In such a setting successful rehabilitation is unlikely, the claimant having to constantly prove disability to a succession of medical experts acting for one side or the other. Just as in Australia there has been the adoption of a posture, for or against the condition being 'real', by all those with an axe to grind. Thus Trades Unions may push a reluctant member to take on the bosses and thus set a precedent for future claims. Media coverage has often been intense, as in the Mughal v. Reuters case, the cases at British Telecom and at the turkey plant of Bernard Matthews. Computer magazines, television documentaries, and women's periodicals have featured accounts of the epidemic, possibly leading to an expectation of pain in workers alleged to be at risk. The types of occupation associated with regional arm pain in the UK have been very similar to those affected in Australia. Keyboard operators, especially those working with computers as opposed to standard typewriters, have featured prominently. Thus the major clearing banks, newspaper groups, Inland Revenue, Telecom, larger accountancy and legal firms, have all experienced difficulties. So too, have firms with production line operators, and process workers in manufacturing plants. As in Australia, females are much more affected than males, except among journalists. In the workplace, posters and leaflets from Unions and the Health and Safety Executive alert employees to the potential risks of their job, although it is debatable whether these warnings have served their purpose. Any wrist, hand or arm pain may be viewed as 'Stage 1 RSI', rather than just the kind of transient ache which is so commonly experienced by us all from time to time in everyday life. Strict avoidance of activity may be advised by the company medical officer or personnel department, anxious to prevent deterioration. Once the first sickness certificate is issued, the whole ghastly scenario described above is bound to follow.
RSI in the UK
787
Table II.--Differential diagnosis of upper limb pain Osteoarthritis of I st carpometacarpaljoint de Quervain's stenosing tenovaginitis Flexor or extensor tenosynovitis Peritendinitis crepitans Carpal tunnel syndrome (median nerve compression) Ulnar neuropathy Medial or lateral epicondylitis Adhesive capsulitis (frozen shoulder) Rotator cuff lesion of shoulder Acromioclavicularjoint strain or degeneration Cervical nerve root irritation or compression Thoracic outlet syndrome (e.g. cervicalfibs) Apical lung tumour (Pancoast syndrome)
A RHEUMATOLOGIST'SVIEWPOINT In many ways there are similarities between regional upper limb pain and those other ill-understood conditions, fibromyalgia and chronic fatigue syndromes. Likewise these overlap with equally common and equally enigmatic disorders such as irritable bowel syndrome, tension headaches and pelvic pain. All are more common in females, an observation which defies an adequate explanation. All feature subjective complaints, but a paucity or absence of objective signs and laboratory/radiographic abnormalities. All are subject to the usual fruitless debate about an 'organic' vs. 'psychogenic' basis, when all are more likely to be 'psychosomatic'. People with regional arm pain are certainly ill and often disabled. Such illness is not feigned, but it may well be subconsciously exaggerated in a desperate attempt to be taken seriously by the medical and legal professions. A rational approach to management is to take a careful history and perform a thorough clinical examination. There may well be an obvious locomotor condition which has been unmasked by a particular workplace activity. Examples would include carpal tunnel syndrome and osteoarthritis of the carpometacarpal joint at the base of the thumb. These require appropriate treatment. When no such pathology is found, one must then look for features of a regional pain syndrome. Is pain felt widely in the limb and adjacent neck muscles? Is there paraesthesia in a nondermatomal distribution, and not conforming to the area of one peripheral nerve? Are palpated muscles tight and non-compliant, and are there numerous 'tender points'? Have there been inappropriate effects on sleep, mood and function? My own practice is to consider the differential diagnoses (Table II). If tingling of the digits is a problem, then de Quervain's disease is not the problem. If tingling affects the little finger, then median nerve compression can be excluded. If the epicondyles are tender, but resisted forearm muscle contraction is not painful, then epicondylitis is unlikely. If the cervical spine is painfully restricted in all directions, distal limb pain may well be referred from the neck in a sclerotomal pattern. Having excluded to my own satisfaction the presence of a discreet lesion with a recognized management strategy, I discuss with the patient the nature of regional pain, the importance of correct neck and arm posture, stretching exercises for muscles and ligaments, and general fitness. I also take an account of the design of their
788
P.A. REILLY
workstation, and suggest some appropriate modifications. Although drugs and splints are best avoided, I occasionally refer for a trial of acupuncture (now widely available from our physiotherapists). Where feasible I encourage gradual re-introduction to work, on-the-job rehabilitation, and sensible task rotation. I discourage litigation: it can perpetuate pain by increasing anxiety and insecurity, and serves to discourage clinical improvement. PROGNOSIS
If seen at a relatively early stage, an individual with regional pain can certainly be helped. When seen later, and particularly when litigation proceedings are under way, the outlook is bleak. The prognosis for industry in general must ultimately be considered fair. Although of epidemic proportions in their day, neither writers' nor telegraphists' cramp are now common. The threat of new technology and work practices eventually must diminish, as yesterday's innovation becomes today's standard tool. 'RSI' is not the problem in Australia that it was a decade ago, and the majority of those affected are back at work. The U K is currently experiencing the storm before the calm; if the crew maintains its discipline then few passengers will be lost. REFERENCES 1. RAMAZZINI B. De morbis artificum. Diatriba. Padua, 1713. (Translated by Wright WC). Chicago: University of Chicago Press, 1940). 2. BELL C. Partial Paralysis of the Muscles of the Extremities. The Nervous System of the Human Body. Washington: Duff Green, 1833. 3. GREAT BRITAIN AND IRELAND POST OFFICE. Departmental Committee on Telegraphists" Cramp Report. London: HMSO, 1911. 4. GOWERS WR. A Manual of Diseases of the Nervous System, Vol 2, pp. 65~676. London: Churchill, 1888. 5. FERGUSON D. An Australian study of telegraphists' cramp. Br J Ind Med 1971; 28: 280-285. 6. LITTLEJOHN GO. Repetitive strain syndrome: An Australian experience. J Rheumatol 1986; 13: 1004-1006. 7. LITTLEJOHN GO. Fibrositis/fibromyalgia in the workplace. Rheum Dis Clin Am 1989; 15:45 60. 8. HADLER NM. Industrial rheumatology. The Australian and New Zealand experiences with arm pain and backache in the workplace. Med J Aust 1986; 144: 191-195. 9. LUCIRE Y. Neurosis in the workplace. Med J Aust 1986; 145: 323-327. 10. CLELAND L. "RSI": a model of social iatrogenesis. Med J Aust 1987; 147: 236-239. 11. WRIGHT GD. The failure of the "RSI" concept. Med J Aust 1987; 14/: 233-236. 12. BELL DS. "Repetition strain injury": an iatrogenic epidemic of simulated injury. Med J Aust 1989; 151: 280-284. 13. HOCKING B. Epidemiological aspects of "repetition strain injury" in Telecom Australia. Med J Aust 1987; 147:218 222. 14. FERGUSON DA. "RSI": putting the epidemic to rest. Med J Aust 1987; 147: 213-214. 15. ANONYMOUS. Approved Guide to Occupational Health Adopted at the 93rd Session of Council, June 1982. Canberra: The National Health and Medical Research Council, 1982. 16. HADLER NM. The roles of work and of working in disorders of the upper extremity. Bailliere's Clin Rheumatol 1989; 3:121 141. 17. HADLER NM. Occupational Musculoskeletal Disorders. New York: Raven Press, 1993.
Pergamon 0022-3999(95)00030-5
'REPETITIVE STRAIN INJURY': F R O M AUSTRALIA TO THE UK P A U L A. R E I L L Y Abstract--The UK is now experiencing an epidemic of upper limb pain similar to that which affected Australia in the 1980s. The pain is often non-specific, and does not conform to the pattern of various well-recognized rheumatological entities. The syndrome is known by a number of terms, some of which imply an aetiological link to workplace activities unsubstantiated by hard evidence. The syndromemay well be largely psychosocial, and analogous to the chronic fatigue syndrome. It is currently the cause of many contentious and well-publicized medico-legal cases. Possible factors behind the epidemic will be discussed, and an approach to management suggested.
Keywords: Repetitive strain injury; Work-related upper limb disorder; Regional pain syndrome; Occupational cervicobrachial syndrome. BRIEF HISTORY OF WORK-RELATED UPPER LIMB PAIN Upper limb pain in scribes and notaries was described by Ramazzini in the early 18th century, and was attributed to constant use of quill pens for writing, poor seating and 'excessive mental labour'. The scribes had few breaks, 'so that they would not cause their master any financial loss' [1]. This triad of repetitive use, faulty ergonomics, and a stressful environment was to feature in more recent descriptions of upper limb pain. During the 19th and early 20th centuries massive outbreaks of arm pain were attributed to the introduction of new technology. 'Writers' cramp' was described by neurologist Sir Charles Bell as a condition affecting Civil Service clerks, and possibly due to the introduction of steel-nibbed pens [2]. The use of the telegraphy keypad was soon followed by an epidemic of 'telegraphists' cramp' in both America and Britain. An extensive study was made, and the Report of the Departmental Committee in 1911 identified no obvious relationship between the pain and such factors as age, length of service, hours worked, seating or desk arrangement. This report first introduced us to a pseudomedical term now part of our everyday lexicon: " . . . the nervous breakdown known as telegraphists' cramp is due to a combination of two factors, one a nervous instability on the part of the operator, and the other repeated fatigue during complicated movements required for sending messages" [3]. This psychosomatic basis for chronic pain was also believed by neurologist Sir William Gowers, who described those with writers' cramp as being of a "distinctly nervous temperament, irritable, sensitive, and bearing overwork and anxiety badly" [4]. Many
Consultant in Rheumatologyand Pain Management, Frimley Park NHS Trust Hospital, Portsmouth Road, Camberley, Surrey GUI6 5UJ, UK. 783
784
P.A. REILLY Table I. Synonymsfor regional upper limb pain syndrome Occupational cramp/occupationalneurosis Writers' cramp/telegraphists'cramp Occupational overuse syndrome Cumulative trauma disorder (CTD) Rapid movementdisease Repetitive strain injury (RSI) Occupational cervicobrachialsyndrome Regional fibrositissyndrome Work-related upper limb disorder Golden wrist/kangaroopaw RSI (rampant social iatrogenesis) RSI (retrospective salary increase)
occupational disorders were felt to be examples of neurosis, and again this concept resurfaced during the more recent Australian epidemic. A huge number of terms have been used to describe what is essentially the same chronic pain syndrome (Table I). In general, in the absence of features of a specific musculoskeletal disorder, it is better to use descriptive terminology, rather than a pseudomedical name with uncertain basis in fact. 'Repetitive strain injury' ('RSI') was an Australian invention, but subsequently changed to lregional pain syndrome'. (Less charitable interpretations of the acronym 'RSI' also exist, Table I.) Although it lends itself less easily to an acronymic abbreviation, "regional pain" at least avoids implying an aetiology which remains unproven, and tissue damage which is usually unconfirmable. The term currently favoured in the U K is work-related upper limb disorder (WRULD), although this too implies an understanding of the aetiology. THE AUSTRALIANEXPERIENCE This has been well reported in an Australian literature which has remained largely unread in the U K even by those with forthright opinions on the subject [5-14]. Ferguson described cramp-like arm pain in keyboard telegraphists employed by Telecom Australia, and postulated that fast, repetitive movements were responsible [5]. Further reports followed, and interest was stimulated by sensationalist media coverage. Australian trades unions, a very powerful lobby, sprang to the defence of their members whom, it was felt, were at risk of pain and disability from their employment. The number of affected employees grew rapidly, and cases were identified in many industries, including teachers, nurses, secretaries and other keyboard operators, process and assembly-line workers. In 1982, a report from the Australian National Health and Medical Research Council referred for the first time to 'repetitive strain injury', which was soon popularly abbreviated to 'RSI' [11]. The media, unions, medical, paramedical, legal, governmental and self-help groups went into overdrive. The incidence increased in proportion, as if interest in the condition was actually contributing to its prevalence. Because many more women were affected than men, it became a cause celebre for feminist organizations (including WRIST, Women's Repetitive Injury Support Team). The epidemiology was interesting, and did not follow the pattern seen in most
RSI in the UK
785
epidemics. Although more common in women, it was argued that this was because they were largely employed in 'at-risk' occupations. It was more frequent in some branch offices than others, despite identical activities, furniture and computer hardware. Public service organizations were more affected than those in the private sector, and it was rarely found in self-employed individuals. There was a seasonal variation, onset being more frequent in fruit-pickers as the picking season drew to a close, and in mothers just before schools broke up for summer vacation. When the original report of Ferguson was further scrutinized, the 14% prevalence of arm pain concealed that 25% of telegraphists in Sydney were affected, but only 4% in Melbourne. Both the medical and lay press published articles and extensive correspondence, and opinion became polarized, entrenched positions adopted, and scorn poured on those with opposing viewpoints. Doctors, a product of conventional medical training with its emphasis on diagnosis and disease, searched in vain for the pathology responsible for the chronic pain and disability. Patients were extensively investigated with blood tests, radiographic imaging techniques of many varieties, thermal scans, electromyography, and even tissue biopsy. No reliable organic lesion could be identified. Still following the traditional model linking diagnosis to treatment, many modalities were used in an attempt to bring relief. Such therapies were those normally employed, usually successfully, in the management of soft tissue musculoskeletal disorders. Physiotherapy, anti-inflammatory drugs, splints and slings, electrotherapy, steroid injections, surgical decompressions, were all tried with variable, and usually poor, results. Alternative practitioners of the healing arts moved in, with manipulators, masseurs, reflexologists, aromatherapists, herbalists and homeopaths faring little better than their more conventional colleagues. Meanwhile the fiscal toll of the epidemic was huge, with compensation agencies, private and governmental, paying out vast sums for workplace disability caused by an illness with no obvious organic basis. Insurance premiums rocketed, and many smaller businesses folded under the extra financial burden. Socially the effects were equally destructive upon a young, thrusting nation emerging from the shadow of colonialism. The Australian epidemic peaked in the mid-1980s, and the incidence of new cases began to fall. Several reasons have been proposed, and probably a combination of factors was responsible. A huge sum of money was spent investigating and improving workplace ergonomics, which had not only physical benefits on posture and reduction of dynamic and static musculoskeletal loading, but also psychological benefits. Workers were reassured that their bosses took the problem seriously and cared for their welfare, not just their productivity. Publicity was given to successful claimaints, with apparently severe disability, who were filmed doing other work or recreational activities just as physically demanding as the job alleged to have induced the injury. Several well-publicised court cases went against the litigants, perhaps acting as a disincentive to others. And perhaps doctors, lawyers, and other interested parties began to have some insight into the complex nature of pain, especially in the setting of work. REGIONAL ARM PAIN IN THE UK The Australian experience should have been a salutary lesson for the UK. We should have been better prepared for our own current epidemic of WRULD, been
786
P.A. REILLY
more aware of the pitfalls of inaccurate diagnosis and unproven remedies. Initially the term 'RSI' was commonly used by professional and lay people alike. Implicit in the term is that an injury has occurred, i.e. that there is tissue damage. Also implied is the aetiology (repetitive movements) and the pathophysiology (strain). None of these assumptions are backed by scientific evidence, a fact ignored by those who believe passionately in RSI as an industrial disease. RSI is lumped together with tenosynovitis, epicondylitis, carpal tunnel syndrome and rotator cuff lesions as 'occupational overuse syndromes'. Even for these relatively well understood conditions, the evidence that specific types of work activity are causative remains highly circumstantial [16,17]. The general practitioner, when faced with someone with upper limb pain and who alleges it is work-related, may take the path of least resistance and agree. Extrapolating from the few cases of true tenosynovitis or de Quervain's disease that he has seen, it is assumed that this might still be the problem, or a forme fruste thereof, even when the cardinal features of 'inflammation' are recorded as being absent. The patient is signed off work and provided with a certificate of sickness. The traditional medical model of management is adopted, with prescriptions of drugs and splints, advice on total immobilization of the affected part, referral to physiotherapy, then a specialist clinic for further investigation and treatment, possibly including surgery. It is small wonder that the patient becomes convinced of the presence of disease, and behaves accordingly. The person with a problem has been transformed into the patient with a pathology. The next logical step is to become a litigant with a claim. In such a setting successful rehabilitation is unlikely, the claimant having to constantly prove disability to a succession of medical experts acting for one side or the other. Just as in Australia there has been the adoption of a posture, for or against the condition being 'real', by all those with an axe to grind. Thus Trades Unions may push a reluctant member to take on the bosses and thus set a precedent for future claims. Media coverage has often been intense, as in the Mughal v. Reuters case, the cases at British Telecom and at the turkey plant of Bernard Matthews. Computer magazines, television documentaries, and women's periodicals have featured accounts of the epidemic, possibly leading to an expectation of pain in workers alleged to be at risk. The types of occupation associated with regional arm pain in the UK have been very similar to those affected in Australia. Keyboard operators, especially those working with computers as opposed to standard typewriters, have featured prominently. Thus the major clearing banks, newspaper groups, Inland Revenue, Telecom, larger accountancy and legal firms, have all experienced difficulties. So too, have firms with production line operators, and process workers in manufacturing plants. As in Australia, females are much more affected than males, except among journalists. In the workplace, posters and leaflets from Unions and the Health and Safety Executive alert employees to the potential risks of their job, although it is debatable whether these warnings have served their purpose. Any wrist, hand or arm pain may be viewed as 'Stage 1 RSI', rather than just the kind of transient ache which is so commonly experienced by us all from time to time in everyday life. Strict avoidance of activity may be advised by the company medical officer or personnel department, anxious to prevent deterioration. Once the first sickness certificate is issued, the whole ghastly scenario described above is bound to follow.
RSI in the UK
787
Table II.--Differential diagnosis of upper limb pain Osteoarthritis of I st carpometacarpaljoint de Quervain's stenosing tenovaginitis Flexor or extensor tenosynovitis Peritendinitis crepitans Carpal tunnel syndrome (median nerve compression) Ulnar neuropathy Medial or lateral epicondylitis Adhesive capsulitis (frozen shoulder) Rotator cuff lesion of shoulder Acromioclavicularjoint strain or degeneration Cervical nerve root irritation or compression Thoracic outlet syndrome (e.g. cervicalfibs) Apical lung tumour (Pancoast syndrome)
A RHEUMATOLOGIST'SVIEWPOINT In many ways there are similarities between regional upper limb pain and those other ill-understood conditions, fibromyalgia and chronic fatigue syndromes. Likewise these overlap with equally common and equally enigmatic disorders such as irritable bowel syndrome, tension headaches and pelvic pain. All are more common in females, an observation which defies an adequate explanation. All feature subjective complaints, but a paucity or absence of objective signs and laboratory/radiographic abnormalities. All are subject to the usual fruitless debate about an 'organic' vs. 'psychogenic' basis, when all are more likely to be 'psychosomatic'. People with regional arm pain are certainly ill and often disabled. Such illness is not feigned, but it may well be subconsciously exaggerated in a desperate attempt to be taken seriously by the medical and legal professions. A rational approach to management is to take a careful history and perform a thorough clinical examination. There may well be an obvious locomotor condition which has been unmasked by a particular workplace activity. Examples would include carpal tunnel syndrome and osteoarthritis of the carpometacarpal joint at the base of the thumb. These require appropriate treatment. When no such pathology is found, one must then look for features of a regional pain syndrome. Is pain felt widely in the limb and adjacent neck muscles? Is there paraesthesia in a nondermatomal distribution, and not conforming to the area of one peripheral nerve? Are palpated muscles tight and non-compliant, and are there numerous 'tender points'? Have there been inappropriate effects on sleep, mood and function? My own practice is to consider the differential diagnoses (Table II). If tingling of the digits is a problem, then de Quervain's disease is not the problem. If tingling affects the little finger, then median nerve compression can be excluded. If the epicondyles are tender, but resisted forearm muscle contraction is not painful, then epicondylitis is unlikely. If the cervical spine is painfully restricted in all directions, distal limb pain may well be referred from the neck in a sclerotomal pattern. Having excluded to my own satisfaction the presence of a discreet lesion with a recognized management strategy, I discuss with the patient the nature of regional pain, the importance of correct neck and arm posture, stretching exercises for muscles and ligaments, and general fitness. I also take an account of the design of their
788
P.A. REILLY
workstation, and suggest some appropriate modifications. Although drugs and splints are best avoided, I occasionally refer for a trial of acupuncture (now widely available from our physiotherapists). Where feasible I encourage gradual re-introduction to work, on-the-job rehabilitation, and sensible task rotation. I discourage litigation: it can perpetuate pain by increasing anxiety and insecurity, and serves to discourage clinical improvement. PROGNOSIS
If seen at a relatively early stage, an individual with regional pain can certainly be helped. When seen later, and particularly when litigation proceedings are under way, the outlook is bleak. The prognosis for industry in general must ultimately be considered fair. Although of epidemic proportions in their day, neither writers' nor telegraphists' cramp are now common. The threat of new technology and work practices eventually must diminish, as yesterday's innovation becomes today's standard tool. 'RSI' is not the problem in Australia that it was a decade ago, and the majority of those affected are back at work. The U K is currently experiencing the storm before the calm; if the crew maintains its discipline then few passengers will be lost. REFERENCES 1. RAMAZZINI B. De morbis artificum. Diatriba. Padua, 1713. (Translated by Wright WC). Chicago: University of Chicago Press, 1940). 2. BELL C. Partial Paralysis of the Muscles of the Extremities. The Nervous System of the Human Body. Washington: Duff Green, 1833. 3. GREAT BRITAIN AND IRELAND POST OFFICE. Departmental Committee on Telegraphists" Cramp Report. London: HMSO, 1911. 4. GOWERS WR. A Manual of Diseases of the Nervous System, Vol 2, pp. 65~676. London: Churchill, 1888. 5. FERGUSON D. An Australian study of telegraphists' cramp. Br J Ind Med 1971; 28: 280-285. 6. LITTLEJOHN GO. Repetitive strain syndrome: An Australian experience. J Rheumatol 1986; 13: 1004-1006. 7. LITTLEJOHN GO. Fibrositis/fibromyalgia in the workplace. Rheum Dis Clin Am 1989; 15:45 60. 8. HADLER NM. Industrial rheumatology. The Australian and New Zealand experiences with arm pain and backache in the workplace. Med J Aust 1986; 144: 191-195. 9. LUCIRE Y. Neurosis in the workplace. Med J Aust 1986; 145: 323-327. 10. CLELAND L. "RSI": a model of social iatrogenesis. Med J Aust 1987; 147: 236-239. 11. WRIGHT GD. The failure of the "RSI" concept. Med J Aust 1987; 14/: 233-236. 12. BELL DS. "Repetition strain injury": an iatrogenic epidemic of simulated injury. Med J Aust 1989; 151: 280-284. 13. HOCKING B. Epidemiological aspects of "repetition strain injury" in Telecom Australia. Med J Aust 1987; 147:218 222. 14. FERGUSON DA. "RSI": putting the epidemic to rest. Med J Aust 1987; 147: 213-214. 15. ANONYMOUS. Approved Guide to Occupational Health Adopted at the 93rd Session of Council, June 1982. Canberra: The National Health and Medical Research Council, 1982. 16. HADLER NM. The roles of work and of working in disorders of the upper extremity. Bailliere's Clin Rheumatol 1989; 3:121 141. 17. HADLER NM. Occupational Musculoskeletal Disorders. New York: Raven Press, 1993.