RSI or WRULDs are caused by the overuse or misuse of the soft tissues and bones of the upper limbs which, for centuries, have reflected the changing nature of work in agriculture, industry, commerce and communications. Each occupation had, and often still has, its own working techniques — and injuries. Hundreds of different occupations are recorded as having injured the upper limbs of the workers including, tailoring, drapery, enamelling, cotton twisting, compositing, sail making, watch making, cheque counting, banking, hairdressing, cigar rolling, plastering, cash registering and, very relevant to the 21st century, the use of computers.

The 17th century Italian physician Ramazzini in his book “The Disease of Scribes and Notaries” recorded upper limb symptoms and signs which today’s keyboard and mouse users would recognise as RSI or WRULDs.

Upper limb disorders caused much disability to clerks and bookkeepers from the 17th to the 20th century and were investigated by many of the leading physicians of the day. Sir Charles Bell (1820), Dr G V Pore (1877), Dr W R Gower (1893), and Sir William Osler (1900) all wrote descriptions of what became known as ‘writing neurosis’, ‘scrivener’s palsies’, ‘graphospasms’ and ‘telegraphers cramp’ – which, in 1908, effectively, became the first of the Prescribed Diseases of the upper limbs recognised by the UK government.

The Morse key was a significant advance in communications but it also led to the majority of operators suffering the debilitating telegrapher’s cramp. The official reports on the Morse key operators use the terms ‘nervous instability’, ‘neurasthenia’, ‘highly strung’, ‘psychoneurosis’ and other derogatory terms for what was an overuse syndrome with symptoms identical to those of today’s WRULD sufferers.

WRULDs can cause disability, loss of employment and financial insecurity but the psychological problems which follow are the result, not the cause, of the upper limb disorders.

The typewriter was also a major development but there were few upper limb problems among typists who made full use of both hands and arms in a wide range of protective movements.

All this changed with the arrival of the computer in the 1980s and upper limb disorders soon appeared. Keyboard and mouse operators can now sit for many hours in ergonomically unsound workstations, taking few breaks, whilst making up to 25,000 key depressions an hour.

Reactions

The human body was not designed for such abuse and the overused soft tissues respond with swelling, weakness, numbness, tingling, and generalised discomfort in the hands and arms.

Individual workers can react differently to the same conditions. Some will go for years without problems and then, following changes in management or working procedures, will develop symptoms in their hands and arms. The symptoms usually come on towards the end of the working week, recede at weekends, but gradually appear earlier and earlier until finally they are present at all times. Many employees, working to deadlines, or worried about unemployment, will mask their symptoms with painkillers — and an acute condition can become a chronic condition.

Prescribed Disease

Six well defined upper limb disorders are recognised by the UK government as ‘Prescribed’ in relation to specific occupations - thus acknowledging the link between work and diseases.

The diseases are:-

TABLE 1

Although in recent years the number of confirmed cases of other prescribed industrial diseases has, generally, remained constant the number of prescribed upper limb disorders have increased year on year.

Many other WRULDs, and their provoking occupations, have yet to be prescribed as the Industrial Injuries Advisory Council (IIAC) has insufficient research material to recommend prescription. Prescription carries legal, financial and compensatory obligations which will oblige the IIAC to continue to be cautious in its recommendations.

Besides keyboard operators the following occupations are most at risk to WRULDs.

Electronics and communications; construction; poultry and food processing; garment, carpet and domestic appliance manufacturing; packing; cleaning operations; supermarket checkouts and laboratory technicians.

Prevalence

It is difficult to assess the prevalence of WRULDs but government statistics put them at a conservative 500,000 cases a year. They are certainly here to stay as computer use is constantly on the increase, and computer games, mobile telephones and hand held electronic devices add to the problem. Much the same goes for industry.

The loss of much of the UK’s manufacturing industry, and changes in commerce and agriculture, could have reduced the number of WRULDs — but this did not happen. Industrial changes have often led to deskilling and to much work of a repetitive manual nature. For example, turkey carcass processors can carry out 12,000 cuts a shift; mail sorters do over 64,000 key strokes each shift; workers in the potteries handle up to 2,000 items an hour, cotton workers can make over 2,000 thread connections each hour and potato sorters are expected to identify and reject up to 200 potatoes a minute.

My RSI patients have included bank note counters, fruit pickers, tile makers, plasterers, laundry workers, poultry carcass evisarators iron mould cleaners, packers, letter sorters, chiropodists, laboratory technicians, paper hangers, potato sorters, blanket folders, nail guns users, vibrating tool users, hairdressers, masseurs, sportsmen, musicians, potters, butchers, many assembly line workers, brick makers, brick stackers, cement tile moulders, passport hand stampers, locksmiths, refridgeration workers, and a wide range of other working activities.

There are many other examples of semi skilled work leading to upper limb disorders with which I have been involved.

Diagnosis

Although many different occupations can cause upper limb injury there are a limited number of soft tissues which can be damaged. Thus the number of named upper limb disorders is finite as many different occupations can cause the same injury. In my above list there are over thirty occupations but they account for only six different diagnosable conditions; carpal tunnel syndrome, epicondylitis, rotator cuff syndrome, tenosynovitis, vibration white finger and non-specific pain syndrome.

In certain occupational situations the incriminated soft tissues can be identified even more specifically. In one factory 75% of all car assembly line workers with WRULDs had conditions involving only four muscles. Accurate diagnosis is therefore essential.

Litigation

Never has the old dictum ‘prevention is better than cure’ been more appropriate than when trying to prevent WRULDs, for treatment can often be unrewarding and prevention quite simple. Regular breaks and a well designed workstation can significantly reduce the number of upper limb disorders. But poor working conditions are not uncommon and the prevalence of upper limb disorders will increase — as will the need for litigation.

Litigation is often complicated by lack of a diagnosis and difficulty in establishing causation. Neither RSI nor WRULD are diagnoses. They are umbrella terms covering as few as twelve, or as many as twenty four, different specific conditions — depending on whose opinion is taken. Litigation will need the identification of at least one of these conditions although more than one is frequently present. Diagnosis can be difficult as symptoms and signs fluctuate in both time and severity – further complicating causation. Many upper limb conditions can be unrelated to work, caused by other medical conditions, or by social, domestic and recreational events. Constitutional epicondylitis, tenosynovitis, carpal tunnel syndrome and non-specific pain syndrome can be particularly confusing. Differentiation however, between work induced pathology and other causative factors are essential.

Litigation is thus dependent on medical reports. These must be based on all the general practitioner, hospital and occupational health records; neurophysiological tests; MRI and other scans; and all other relevant investigations. A comprehensive medical history and physical examination by the doctor should exclude other medical conditions and help to identify causation.

The 1999 Wolfe Recommendations reduced the number of Actions brought for upper limb disorders, although they are increasingly supported by no win no fee agreements and there have been some substantial awards in recent years. In 2007 a MOD typist was awarded £484,000 for de Quervain’s tenovaginitis and significant settlements have been agreed for vibration white finger, carpal tunnel syndrome, tenosynovitis, rotator cuff syndrome and non specific pain syndrome.

Prognosis

Advising on prognosis in WRULDs can be complicated as, once established, upper limb disorders are likely to reoccur following a return to the provoking activity. Alternative work, if causation was computer use, can be difficult. Teaching, healthcare, telephonist and reception work can be alternatives although some keyboarding is required in many jobs – but not much in the Church or belly dancing. My women patients have become ministers of religion or nuns and two others, one a legal secretary, became professional belly dancers and joined dance troupes in the Middle East. They enjoy their new careers and neither regret leaving their computers and mice behind.

Upper limb disorders, in all their manifestations, are now a fact of life. They are the commonest cause of sickness absence in the UK, and often lead to long term disability. With the rise in the working population, more upper limb disorders are inevitable and this fascination area of Law and Medicine will become of increasing importance.

This article was originally published in the Solicitors Journal March 2008

And was written by Dr. Paul Macloughlin www.drpaulmacloughlin.co.uk