There’s Really Nothing New – A Brief History of Yuppie Diagnosis

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By Susan E. Clarke
Staff Writer

An article in the May 1995 issue of the Journal of Hand Surgery discussing the Australian experience with repetition strain injury (RSI) has interesting implications for the American insurance industry.

Written by Damian C.R. Ireland, FRCS, a physician with the Melbourne Hand Surgery and Rehabilitation Center, the article documents the phenomenal increase that occurred in the early 1980s in the occupational injury commonly known as RSI. By 1985 over 2,000 cases had been reported in the state of Victoria. In 1985 alone, 34 percent of the country’s telephone operators complained of RSI. Hand surgeons found it difficult to keep up with the burgeoning caseload.

The first step in stopping this epidemic was to pin down the diagnosis. While the name of the condition was “repetition strain injury,” a closer look at patient histories revealed that it was not closely associated with the performance of repetitious tasks. Patients came from a wide spectrum of occupations, with different tasks, where different muscles were used and where the degree of difficulty varied. Others had determined that the highest incidence of RSI occurred in telephone operators, with a relatively low key stroke rate, while the lowest incidence was in keyboard workers, who had a much higher keyboard stroke rate. The term “strain” was also considered inappropriate. Strain connotes deformation of tissue, but there was no evidence of any abnormalities. There was no history of physical injury and there were no sequelae of tissue trauma: no swelling, bruising, redness, or increased temperature.

Patients were generally young to middle-aged and were employed in low paying, monotonous and low-prestige occupations. The symptoms were consistent for any given patient but were inconsistent between patients. The primary objective finding was tenderness, often of the entire upper extremity; clinical examinations were negative. There was little if any response to treatment; therapy and medications often resulted in deterioration of subjective symptoms.

Historically, there have been similar epidemics of occupational complaints. Occupational cervicobrachial disorder was noted in Japan, Sweden and Switzerland in the 1960s; occupational disorder 2101 occurred in Germany, and tension headache and occupational disorder in Finland during the same period; writer’s cramp was common in the early 19th century and telegraphist’s cramp in the late 19th century; and miner’s nystagmus occurred in early 20th century Britain.

All of these conditions had one thing in common: there was a concurrent change in the technological aspects of the job. Writer’s cramp coincided with a change from feather quill pens to a more productive steel nib. Telegraphist’s cramp coincided with the development of the Morse code key. Miner’s nystagmus coincided with the introduction of pneumatic picks and battery-operated helmet lamps. When the nonphysical nature of these conditions became apparent, the conditions disappeared.

According to Ireland, there are striking similarities between RSI in Australia and cumulative trauma disorder (CTD) in the United States:

1. An epidemic spread and increase without a plausible explanation in terms of detrimental changes in work practices, work technology or work stations.

2. Expansion of the definition to include both physical and nonphysical occupational arm pain, lending legitimacy to the nonphysical aspects.

3. Reports of successful CTD treatment—either conservative or surgical—are rare.

4. The condition rarely affects the self-employed. Most CTD patients are employed in repetitive, monotonous, low-paid, low-prestige tasks, with low job satisfaction.

Why did the phenomenon occur in Australia and why is it now occurring in the United States? The physicians who first diagnosed the condition were soon supplanted by other vested interests according to Ireland.

1. Selected portions of the medical profession — industrial rehabilitation specialists and their clinics—grew rapidly in the 1980s. Ireland notes, “The required periodic certification of continuing unfitness for work as a result of a condition invented by the certifier, for which there was no successful treatment, has been likened to placing ‘Dracula in charge of the blood-bank.”

2. Seeing the potential for employer negligence litigation, some legal professionals solicited clients to submit claims for RSI negligence.

3. The condition was used by unions to negotiate for more work breaks. A pamphlet was distributed to members, “The Sufferer’s Hand Book.”

4. The paramedical industry benefited greatly from the trend. Occupational and physical therapy providers and ergometric furniture designers were in demand. The workplace—furniture, work stations, equipment—was redesigned to accommodate the injured and to avoid future cases.

5. Stories broadcast by the media about RSI fueled the epidemic.

6. Government resources were directed to a large group of workers and specialists who had come to depend on RSI for their livelihoods.

The rise and decline of RSI paralleled the history of writer’s cramp, telegraphist’s cramp and miner’s nystagmus. Once the condition was determined to be primarily a nonphysical phenomenon, doctors became less willing to certify patients as unable to work. When the secondary gain was taken away, the incidence declined.

Ireland found very few malingerers among his patients: in his opinion they genuinely experienced the pain they complained of. This was exacerbated by the vested interests who targeted highly suggestible employees, who were trapped in low paying, boring, low-prestige jobs and who truly believed that their work had caused their injuries. Once the secondary gain was removed, Ireland says, the patients were dumped by those who had stood to gain from RSI, and the condition disappeared. Ireland believes most of the patients and their physicians were simply pawns of those who wished to benefit “from the unproven notion that repetitious tasks cause injurious tissue strain and that the effect of soft tissue trauma is cumulative and represents a disorder.”

 Copyright 1995 The John Cooke Fraud Report