Time to Revisit “RSI”!

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I would like diverge from the usual theme of this blog by considering a specific occupational health issue – that of what is still often described as “RSI”. Unfortunately that label is both inaccurate and invokes an emotive response, so I try to avoid its use as much as possible, but the term is difficult to avoid because of its entrenched status, popular usage and lack of a suitable alternative term.

I have taken an interest in this subject from the time of the so-called “RSI Epidemic” of the 1980’s. At that time I was the Senior Medical Officer at the Hydro-Electric Commission (now Hydro Tasmania) and that organisation had their share of these problems, although not to the same extent that Telecom (now Telstra) did at the time – as has been described in the literature by Occupational Physician, Dr Bruce Hocking.

In my various roles since that time, I regularly encounter the phenomenon of upper limb disorders in computer operators, that, on the face of it, is caused by the sufferer’s work using computers. Particular problems seem to relate to mouse usage, perhaps more so than with keyboard use, although the underlying common factor appears to be the posture adopted at a computer that restrains normal upper limb movement for sustained periods. Similar problems are encountered with musicians and sonographers. Aggravation in association with driving posture is also widely reported.

While some sufferers have associated psychological disorders, my overwhelming impression is that the majority of sufferers are “normal”, often hard-working and dedicated people who suffer a convincing syndrome of pain and associated neurological symptoms that is temporally related to their use of computers at work. Chronic pain causing long-term disability from these disorders is common.

While there is a relative dearth of objective clinical findings, the presentation is sufficiently convincing in terms of consistency and response to aggravating and relieving factors for me to accept that this probably represents an “organic” condition and is not a primary psychological disorder, fibromyalgia syndrome, hysteria or a socially-caused phenomenon as has been suggested by some commentators.

it is difficult to get accurate official figures on the incidence of these disorders in Australia in recent years. The 2016 statistics for musculoskeletal disorders from SafeWork Australia include the following table:

Screenshot 2018-10-18 08.31.29

This table would suggest that in the period covered there might have been 4,000 or more cases of upper limb overuse syndrome, comprising 1.3%  of claims. If bursitis, tendonitis, epicondylitis and non-traumatic muscle or tendon strain are included the total is potentially much higher i.e. 30,000 or more claims.

What I have observed in recent times, is that Comcare, in particular, have challenged continuing compensation for many sufferers of these disorders. It is difficult to know how many claimants accept Comcare’s determination of entitlements and don’t make a legal challenge, but I am aware from reviewing decisions in the AAT and from contact with doctors and solicitors in Canberra and Hobart that the decisions made by the AAT can vary widely with both acceptance and rejection of upper limb disorders claimed as being related to use of computers. One of the important determinants of the outcome is whether there is a specific diagnosis.

AAT Senior Member DJ Morris in Neville and Comcare (Compensation) [2018] AATA 3738 (5 October 2018) found no reason to even consider evidence about work causation on the basis there was no acceptable medical diagnosis. He states:

“An essential first element in assessing a claim for workers’ compensation is that a person has a medically diagnosed ailment as defined in section 4 of the Act and whether a person has an “injury” in terms of section 5B(1)(a). It is accepted that Mr Neville may have discomfort in his right forearm, but that is not enough. Mr Neville relies on Dr Cooke’s use of the term “overuse/RSI ” as a settled diagnosis, but in his evidence, Dr Cooke himself submitted it was not strictly a diagnosis. “

In contrast, AAT Member S Taglieri in LHHL and Comcare (Compensation) [2018] AATA 3272 (7 September 2018) rejected Comcare’s determination to deny liability in relation to a specific condition (Complex Regional pain Syndrome) related to computer employment. She states:

“The Tribunal is satisfied that the reviewable decision was erroneous in that it concluded that the applicant no longer suffered from the effects of a compensable condition. The Tribunal is of the view that the applicant continued to suffer from the effects of the compensable condition secondary complex regional pain syndrome. For these reasons the decision under review is set aside and the matter is remitted to the respondent to give effect to the determination of the Tribunal.”

Not a lot seems to have changed since the time of the case Maree Verna Tyrrell and Westpac Banking Corporation [No 2924 of 1990] (14 December 1992) when Judge Barlow concluded:

“However, the plaintiff has failed to persuade me the nature and conditions of her employment constituted a hazard and risk to her health, that is to say a risk of injury, and in particular a risk of sustaining a condition or injury referred to as RSI” .

 “I am inclined to the view their lack of objectivity has led them, subconsciously at least, to develop a hypothesis to fit their theory that pain syndromes, of the type which the plaintiff claims to suffer, have a neurogenic cause. In reaching this conclusion I have not overlooked Professor Mastaglia’s comments, that the contents of Professor Helme’s paper [1]could be the beginning of objective evidence of an organic basis for this type of pain syndrome” .

 “My findings do not exclude the possibility of there being a neurogenic factor, to pain syndromes of the type which the plaintiff claims to suffer. Research yet to be done and testing techniques and equipment yet to be devised may reveal the presence of a neurogenic factor or cause”.

It would seem that the Tasmanian Workers Compensation Tribunal is having difficulty with decisions on this subject. No decision has been made about a case of upper limb pain related to computer employment where the hearing was conducted in February this year (or maybe the Tribunal is just under resourced).

What was previously called “RSI” is currently often described as “non-specific” arm pain. Lack of agreed diagnostic criteria means it is difficult, if not impossible, to accurately explore relationships to workplace factors. On that basis proof to a high degree of scientific certainty about occupational causation for “RSI” has remained elusive. If it were established that there is a specific diagnosable disorder, causative factors can be scientifically examined.

When I listen to the evidence delivered by practitioners who deny the possibility that computer work can cause such disorders, there seems to be a heavy reliance on the evidence and opinions from the time of the “RSI Epidemic” rather than referring to up-to-date evidence about the mechanisms of chronic pain or occupational epidemiological studies.

Recently I have spent more than 50 hours preparing a literature review related to the above subject. In particular, I looked at literature relevant to the question whether brachial plexus neuropathy (BPN) might constitute a specific diagnosable condition and provide an explanation for many cases of upper limb pain related to computer employment.

Dr Jorgen Jepsen in Denmark has done some work that seems to suggest that BPN might be a specific disorder that can be diagnosed reliably by a careful detailed clinical neurological examination, building on the earlier hypothesis of the West Australian Rheumatologist, Dr John Quintner of a neurological basis of “RSI”.

The work of Dr Jepsen needs to be replicated by other researchers, but his work does provide evidence of a disorder plausibly related to the postural demands of computer work, worthy of further research.

I suspect there is reluctance on the part of many organisations to further explore this subject because of the very significant implications for employers and compensation providers should incontrovertible evidence emerge of a causative relationship between the common upper limb pain  syndromes and computer employment.

In a 2014 article in The Conversation, entitled Repetitive strain injury: is it real or imagined? the author suggested the science was settled while recognising continuing negative connotations from the disorder, as follows:

“While the term RSI, which implies an injury which has been caused by physical factors, has long-since been replaced by the term occupational overuse syndrome (OOS), its use, and the negative connotations associated with it, persist.

Fortunately, diagnostic criteria have now improved. Workplace injuries and conditions which would previously have been classified as RSI are now more accurately diagnosed. This, along with greater acceptance of the role of psychosocial factors has led to improvements in the management – and the outcomes – of these injuries.

All we need now is to improve our recognition of the importance of these factors in the prevention of injuries – but that’s another story.”

I would not accept the conclusions about accurate diagnosis and improved outcomes, at least from my perspective of a practicing physician who regularly sees these cases, the wide variety of diagnostic labels that are applied, the confusion about entitlement to compensation and sometimes poor outcomes.

These questions are important to settle, not only from the perspective of responsibility for rehabilitation and compensation where cause-based compensation systems exist, but also from the perspective of evidence-based prevention, in a world where there is growing use of computers and related devices in schools, homes and workplaces.

While employers almost universally accept the value of preventative measures to prevent “discomfort” amongst computer operators, elucidation from a scientific perspective of specific medical conditions caused by use of computers and the circumstances in which that can occur can only be of value in prevention of disability,  contribute to a productive workforce and ultimately save costs to the community.

Occupational Physicians have an important role to play in this area and should take the lead in researching and putting forward the evidence, without fear or favour, to allow informed decisions to be made, both at a system and individual case level. These disorders are clearly the province of occupational medicine, rather than other medical specialities.

I THINK THE TIME IS RIGHT TO REVISIT RSI!

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About Tasworkdoc

As an occupational physician in private medical practice in Hobart, Tasmania - the southernmost state of Australia, I see workers referred by their general practitioners with various types of work-related injuries and diseases. These are mostly musculoskeletal injuries, both of traumatic and gradual onset as well as various associated psychological disorders. With interaction with patients for treatment and providing advice about rehabilitation, I have the opportunity, first-hand, to observe interactions between individual patients and compensation systems. I also conduct independent medical assessments, including impairment assessments for musculoskeletal injuries and asbestos-related disease compensation. This provides another perspective of workers within compensation systems.
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6 Responses to Time to Revisit “RSI”!

  1. jqu33431quintner says:

    Peter, I agree it is time to revisit “RSI”.

    In my opinion, the issue of the stigmatisation of those so labeled that occurred is also worth exploring. As one who became heavily involved in the controversy, let me take this opportunity to help put the record straight.

    The debate in the 1980s that took place during the epidemic of the chronic cervicobrachial pain syndrome known as repetition strain injury (RSI) is a relatively recent example of how moral values in the form of stereotypes were injected into scientific medicine (Quintner 1995).

    Despite incontrovertible evidence that RSI was not a new medical condition (Quintner 1991), some commentators portrayed it as a uniquely Australian (non-) disease for which the term ‘kangaroo paw’ was coined (Awerbuch 1985).

    Potentially stigmatising themes that were identified in the scientific medical literature included: women’s lack of fulfillment in their work; being members of a neurotic Australian workforce; becoming “emotionally paralysed, sometimes unable to do her housework”; like “a Victorian cripple having the vapours she demands and gets support if possible” (Lucire 1985); and their overall inability to cope with personal and/or domestic conflicts.

    Lucire (1985), a psychiatrist whose views were prominent during the debate, thought it inappropriate for them to receive workers’ compensation and thereby dip into the same “honey pot” as those with genuine work-related injuries.

    It was indeed unfortunate that as a result of these stern moral judgments visited upon sufferers, Australia lost an excellent opportunity to contribute to the scientific understanding of these complex disorders.

    John Quintner FFPMANZCA

    References:

    Awerbuch M. RSI or ‘Kangaroo paw’. Med J Aus 1985; 142: 237-238.

    Lucire Y. What the community can do about epidemic conversion. Paper presented at the RSI: Medical Mythology seminar. Organised by Social Impacts Pty Ltd, Sydney, 1985, 21 November.

    Quintner J. The RSI syndrome in historical perspective. International Disability Studies 1991; 13 (3): 99-104.

    Quintner JL. The Australian RSI debate: stereotyping and medicine. Disability and Rehabilitation 1995; 5: 256-262.

    • jqu33431quintner says:

      Peter, in relation to the case of “Maree Verna Tyrrell and Westpac Banking Corporation [No 2924 of 1990] (14 December 1992)” it does need to be said that the late Sir George Bedbrook, an eminent West Australian orthopaedic surgeon, supported the plaintiff, but he died just prior to the case being heard.

      Sir George had instigated the research conducted by my colleague the late Robert Elvey, Perth manual therapist, that culminated in the development of what was then known as the “brachial plexus tension test”.

      The problem to be solved in the spinal unit of the Royal Perth Rehabilitation Hospital was why those with quadriplegia developed upper limb pain and paraethesiae when their arms were fixed in an outstretched position, ostensibly to avoid the development of flexion contractures. Bob’s dynamic studies of the brachial plexus in cadavers contributed to the solution.

      Sir George’s evidence would have been crucially important in this case.

  2. Thank you for your insightful comments on what is an extremely complex and important issue.

    From the perspective of legal practitioners representing injured workers, the work that you are undertaking is valuable and important. We agree that the time is right to revisit RSI.

    This work is essential in order to move the discussion on the development of these injuries in the context of computer use forward given the approach currently taken by Comcare to claims (see for example the excellent submission to the Senate by the Australian Lawyers Alliance which we were not involved in: https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjhrojIkZHeAhWZTX0KHefWByUQFjAAegQIAxAC&url=https%3A%2F%2Fwww.aph.gov.au%2FDocumentStore.ashx%3Fid%3D13b6598c-0b7c-4e49-9bc3-d8761af4ce68%26subId%3D564199&usg=AOvVaw2kGNoVnmPKUnV6zEanPKwD).

    As you allude in your blog, we are increasingly seeing insurers (particularly Comcare) forming positions based on the medical opinions of those who do not accept that computer use can cause the types of injuries discussed in your article. In our experience, reports by medico-legal examiners who are sceptical of computer caused injury (or in some cases deny outright that any injury can occur from computer use) are frequently commissioned by Comcare.

    In circumstances where an injured worker cannot afford a lawyer or to commission a medico-legal report in response, they are put in an exceptionally difficult position as the expertise of those who treat (particularly general practitioners) are rarely afforded the same weight by decision makers.

    We confirm that in our experience Comcare is challenging many longstanding claims on the basis of such opinions and even in some cases revisiting whether liability should have been accepted in the first place and raising revocation of liability from the start of a claim.

    This practice places injured workers in the position that they can be asked to repay in some cases hundreds of thousands of dollars in circumstances where there has been no fraud or change in the historical evidence; merely a change in the position of the insurer based on potentially highly problematic medical opinions.

    We encourage all lawyers who represent injured workers to also become involved in this debate and sponsor your work into this important area.

    • jqu33431quintner says:

      By 1995 I had come to this conclusion: “In the case of RSI the powerful stereotypes of working women, which already existed in the community, were reinforced by the ostensibly scientific writings of many of the major proponents in the debate. The social and medical stigmatization of RSI sufferers then became inevitable.”

      From my observations it would appear that the situation in Australia, at least, has not changed.

      The tactics currently being used by Comcare appear to me to reflect our society’s negative attitudes towards women experiencing long-term pain, which Medicine is unwilling to attempt to understand from a scientific viewpoint. A considerable amount of relevant clinical and animal experimental research is now available to facilitate this process.

      In my experience, the medical examiners selected by Comcare to deny claims are remarkable for their inability to offer explanations for clinical phenomena that can easily be elicited had they performed a pain-oriented physical examination. Of course, they are not trained to do so and prefer to rely upon the standard (and limited) orthopaedic examination.

      It therefore comes as no surprise to me when their examiners bypass the clinical phenomena altogether and proceed to vehemently deny the possibility of a causal link existing between the condition known as “RSI” and the employment of the worker.

      Reference: Quintner JL. The Australian RSI debate: stereotyping and medicine. Disability and Rehabilitation 1995; 5: 256-262.

  3. Tasworkdoc says:

    Thanks for all the above comments. I was not aware of the role of Dr Bedbrook is the development of upper limb neural tension testing. Lower limb neural testing testing is a well-accepted clinical test taught universally to medical students. Why similar upper limb tests are assumed useless is difficult to understand. They are more difficult to learn because the upper limb has additional planes of movement and more nerves, but in other ways they are no different to other clinical test, if they are understood in terms of what they represent i.e a useful adjunct to a clinical assessment which must be interpreted in the clinical context.
    I am hoping that some further work can be done to determine the place of a detailed clinical assessment in the workup of patients with reported upper limb symptoms that occurs in the context of computer work.

    • jqu33431quintner says:

      Peter, this is an area of musculoskeletal medicine that has mainly been developed by physiotherapists. There is now a significant body of research that appears to have been studiously ignored by those self-styled experts who conduct medico-legal assessments on behalf of insurers. It has been truly said of them that – “Theirs is the culpability of consciously cultivated ignorance.”

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