HEALTH / Second Opinion

ONE in 20 people who have to take time off for a work-related illness suffer from repetitive strain injury (RSI), yet recently Judge Prosser ruled that the condition does not exist. Doctors, lawyers and trade union officials are in no doubt that some condition exists that causes their patients/clients to have pain in their arms and wrists, often severe enough to make work impossible. Why, then, is there so much controversy?

In the 19th century, operators of morse keys developed a condition known as telegraphist's wrist and clerks developed writer's cramp. Both were recognised as industrial diseases, but they were rare. In the first half of this century doctors described several distinct causes of pain in the wrist and elbow associated with repeated movements. These included inflammation of the sheaths round the muscle tendons, pressure on the nerves in the wrist and pain in the muscles of the forearm (tennis and golfer's elbow). All of these conditions have physical signs - abnormalities that may be detected by examination and laboratory tests.

Some people with pain brought on by their work do not, however, have any of the physical abnormalities associated with these disorders. In the 1970s the diagnosis RSI began to be given in such cases, and soon became a blanket term for all the arm disorders. RSI became a focus of media attention in the early 1980s, when an epidemic occurred in New South Wales. In 1981 1,000 people were certified as unfit to work from RSI; in 1985 the total was 7,000. Many of those affected were computer keyboard operators but others worked on production lines. The dramatic rise in the number of cases, especially in banking and telecommunications, led Professor David Ferguson of Sydney University to conclude that the disease had become an epidemic due to a 'group hysterical reaction to boring, unsatisfying jobs'.

Experts in Britain have continued to argue about RSI. Their disputes have been acrimonious, the allegations matching those in Ferguson's post-epidemic review in the Medical Journal of Australia: bad ergonomics, greed, hysteria, misdiagnosis, power politics. If RSI is a 'work related upper limb disorder without physical signs', that definition leaves its cause unexplained. As an industrial disorder it spans a remarkable range of jobs, from chicken stuffers to journalists and musicians. The growing consensus is that it is a complex condition with elements of psychogenic illness superimposed on work-related fatigue and discomfort. Bad labour relations and fears of redundancy seem often to play a part. Treatment of those with longstanding symptoms has proved difficult but progress has been made.

The growth in the number of people who go to their doctors saying 'I've got RSI' reflects a familiar pattern in medicine: once a disease is given a name, it becomes more common as doctors and victims are able to put a label on what they've both known was there. Judge Prosser's advisers may be trying to reverse this trend: take away the name and the condition may fade away. RSI will not disappear overnight, but as in Australia it may become less common as more is learnt about the causes of pain in the arm associated with work.