The Australian experience

When RSI became a major occupational health problem in Australia in the early 1980s, Ferguson (1984) first drew attention to the similarity between this pain syndrome and occupational cramp ("craft palsy"), which he considered to be "a major variant of repetition injury". Reflecting his belief at the time that RSI was somatically-based, Ferguson did not mention the possible role of psychological factors. However, an analysis of his earlier work (1971a, 1971b) illustrates the extent of ambivalent thinking concerning this disorder.
In the preface to his study of telegraphists' cramp in Australia, Ferguson (1971a) endorsed the prevailing neurological opinion that symptoms of a "functional" nature (cramp, myalgia) peculiar to specific occupations were strongly associated with emotional instability, that is, psychoneurosis (vide supra). When he found that upper limb cramp and muscle pain were both strongly associated with "neurosis" (defined as a clinically recognisable disturbance of mental function conforming to a standard pattern and severe enough to cause loss of working or social capacity), this preconceived opinion was of course confirmed. Ferguson concluded that, although neuromuscular load on the forearm of the telegraphist was probably the precipitating stress and that other ergonomic factors may have been aetiologically important ("commotion"), in the majority of his cases neurosis was the sole factor in evidence ("predisposition").

However, in the same year, Ferguson (1971b) reached a diametrically opposed conclusion in a study of women process workers with various localised and diffuse chronic pain syndromes of the upper limb which had been diagnosed as occupational injuries by their treating doctors (emphasis added). In these cases psychosocial factors were considered insufficient to explain the prolonged absences from work. By contrast, in an attempt to explain the widespread and intractable symptoms of many workers, Ferguson postulated the presence of pathophysiological changes involving either brachial plexus or cervical nerve roots. It is relevant to postulate that the use of the term "injury" rather than "Occupation Neurosis" may have biased his conclusions in this study.

In discharging an editorial responsibility to "put to rest" the RSI epidemic, Ferguson (1987) remarked upon the rediscovery of mental (psychosocial) factors in this syndrome, a remarkable and unexplained "turn-around" in his views over 3 years.

The misconstruction of occupation neurosis

The main proponents of the psychogenic aetiology of RSI-as-an-occupation-neurosis (Lucire, 1986; Ireland, 1988; Bell, 1989) adopted the 19th century usage of the term (any group of physical symptoms, without localizing signs, for which no pathophysiological mechanism could be found or postulated) without recognising that, at that time, many poorly understood neurological (and other somatic) disorders were subsumed in the "neurosis" construct. That is, not only did they fail to acknowledge that the evolution into "psychoneurosis", which depended upon the idea of "dissociation" of ideas from somatic input, occurred after the proposition of occupation neurosis, but also they appeared to be unaware of the growing disquiet in the neurological and psychiatric literature concerning the lack of evidence for psychogenesis. This was a gross misconstruction of the concept of Gowers (1892) and Oppenheim (1901).

It is instructive to examine how Gowers was misrepresented by these authors. "Writers' cramp is a disease that is readily imagined" (Gowers, 1892) was readily seized upon, his continuation, "In most cases of the fancied disease, when the patients are reassured, the discomfort quickly ceases to be noticed" being ignored. There is no evidence that any patients with RSI have been relieved of their pain by reassurance. Gowers did observe that writer's cramp subjects are frequently "of distinctly 'nervous' temperament, irritable, sensitive and bearing overwork and anxiety badly", out of which a number of authors inferred a psychological "predisposition" (again) for RSI, thus failing to recognise the fallacy of assuming that association means causation. Gowers did give an uncertain and often unfavourable prognosis for his patients with writers' cramp, which is just as valid an association for their "temperament" as any other.

RSI is an occupation neurosis

Based on historical and clinical evidence, it is postulated that RSI closely resembles the neuralgic form of writers' cramp and, as such, qualifies as an occupation neurosis. (Quintner, 1991). Furthermore there is strong evidence that RSI, as a syndrome of chronic cervicobrachial pain, may be of neuropathic pathogenesis in which sustained activation of pain pathways over time may play an important pathogenetic role, but also in which the interaction of the sufferer with existing concepts and structures in society has a major modulating influence (Cohen et al., 1992; Champion, Cohen and Quintner, 1993).

Next: Conclusion

Patient's Pain Communication Tool