Publication history, Reflections & comments
Complaints of health problems have become more common among people working with computers as their use in data entry and word processing has increased. During the 1980's, Australia had an epidemic of reports of muscle strain and injury, known as "RSI" or Repetitive Strain Injury, which now appears to be over . It raised many difficult issues of medical diagnosis, as well as the problem of trying to separate scientific questions from political and social ones.
In 1971, a leading Australian occupational physician, David Ferguson, described complaints of pain in process workers, of which half did not fit clear-cut medical diagnoses . In 1985, at the height of the epidemic, he wrote:
"the majority of cases of repetition injury are not of localized syndromes but of a more diffuse order, apparently of muscles. The disorder, whose symptoms are those of aching, weakness and tenderness of muscles (with or without induration, swelling, and heat) is variously termed muscle strain if acute or, if more chronic, occupational myalgia, myositis, myopathy, fibrositis, fibromyositis, muscular rheumatism, non-articular rheumatism, myofascial syndrome or tension myalgia". 
However by 1987 he was to state:
"With hindsight, the gigantic and costly Australian epidemic called 'repetition strain injury' ('RSI') can be seen as a complex psychosocial phenomenon with elements of mass hysteria, that were superimposed on a base of widespread discomfort, fatigue, and morbidity." 
Many other physicians in Australia have had similar hindsight. Now that the same phenomenon is emerging in North America and Europe , it is likely that similar mistakes will be made there, with the added danger of harmful attempts to relieve symptoms by surgery, especially for the mistaken diagnosis of "carpal tunnel syndrome". It is therefore instructive to examine the Australian experience in detail.
During the 1980's, many new computer workstations were put into government departments and businesses in Australia . Within five years, one third of typists employed by Telecom complained of hand and arm pain and other symptoms , sometimes severe enough to stop them working. Labor unions and some physicians [7,8] asserted that physical injury had occurred. The popular diagnosis at first was "tenosynovitis" (rather than "carpal tunnel syndrome" in the current North American epidemic) but later it was generally considered to be some ill-defined chronic strain.
By contrast, specialists in several areas of medicine came to attribute the epidemic to a combination of normal discomfort and publicity leading to chronic pain syndromes, neurosis, or hysteria [9, 10, 11]
In the vigorous national debate which occurred, two strongly different views emerged:
1. Physical injury occurred in practically all cases. The injury was in muscle and due to some unspecified pathology caused by overuse [7,8] or could be confirmed by electron microscope studies , or came from the neck and could be demonstrated by a nerve stretching test , or was due to excess muscle tension . Supporters of each theory appeared to ignore the others.
2. There was no evidence of injury in these cases, and complaints of pain and other symptoms were due to psychological causes. Such views were put forward by the Royal Australian College of Physicians , the Australian Hand Club  (Australian surgeons specializing in surgery of the hand and forearm), orthopaedic surgeons, rheumatologists, psychiatrists, and others [15,9].
Physicians supporting the second view were regarded by the first group as either being ignorant, in the pay of employers and insurance companies, or politically biassed.
Many other groups put forward opinions, including physiotherapists, ergonomists, management consultants, furniture manufacturers, chiropractors, and keyboard designers, each promoting their own specialty as the main factor in diagnosing and solving the problem. Cranks of many kinds made extravagant claims for such causes as magnesium deficiency, fluoride poisoning, and cures by the Alexander technique, secret ointments, special keyboards, wrist rests, and splints of various kinds.
Some researchers tried a synthesis of factors to explain the epidemic , drawing on changes in scientific belief in terms of the "paradigm shift" described by Kuhn . The most powerful beliefs were probably those of clerical workers themselves. These were reflected in popular folklore, newspapers, and doubtless they influenced the responses of family and occupational physicians, physiotherapists, and government rehabilitation and compensation authorities.
This tense debate occurred against a background of other factors:
a. Publicity about hazards at work such as asbestos, industrial chemicals, and concern that radiation might cause fetal abnormalities and miscarriages.
b. The Labor movement's success in putting OHS (occupational health and safety) on the national agenda, starting with the appointment of Dr. John Mathews as first director of the OHS unit of the Australian Council of Trade Unions in 1981 .
c. Economic pressures including unemployment.
d. Popular Australian attitudes towards "sickies" (paid sickness leave from work) and "compo" (money payments for injury often determined by litigation) 
e. The impact of technology and rapid social change - factors not unique to Australia , but evolving in geographical isolation, like the kangaroo.
a. Distrust of professionals. Striking Australian examples of this were the trial of Lindy Chamberlain, for allegedly murdering her baby, also blamed a dingo, and expert conflict about Agent Orange, the subject of a national inquiry which remains controversial.
b. Common ignorance and superstition, for example UFO's (Unidentified Flying Objects) and distrust of orthodox science, combined with technical failures, both spectacular (airplanes) and everyday (computers).
c. Frequent rejection of orthodox medicine, with a turn to alternative medicine and exaggerated holism, and concerns such as allergies, cancers, and stress.
a. Failure of new technology to abolish the tedium and symptoms of factory work, merely replacing them with those of office work .
b. Concern with new values - "Quality of Working Life", empowerment, and the impact of change . Zuboff has described how computers in factories can influence power in one of two opposite directions - more coercive control of employees through monitoring and impoverishment of job content, or enrichment of work through greater worker control and wider variety of job content.
Apart from employers and workers, many other parties had a stake in this debate. Some were health advisers or union officials, with new careers created by concern about the epidemic. Others were professionals such as ergonomists, physicians, and therapists of many kinds, and businesspeople selling office furniture, ergonomic attachments of various kinds, and well-paid consultants. Just as President Eisenhower warned the world against the military-industrial complex in 1960 in his farewell address to the American electorate , it became timely to warn against this new OHS-industrial complex, however sincere some of its members might be.
At the height of the epidemic, a press agency was able to supply 40 to 50 clippings on the subject each month from major newspapers and periodicals [IBM Australia, personal communication], and there was a spate of articles in medical journals and other periodicals of all kinds. There were discussions about RSI on talk-back radio and documentaries on television, and numerous workshops, seminars, lectures, government papers, and several books on the subject.
Journalists in the print media had a double interest in the Australian RSI epidemic. On the one hand, it was a social issue with all the features for successful reporting, involving widespread injury, incompetent or hostile doctors, controversy, unions, large awards of money to some workers, injustice, high emotions, new technology, and experts who disagreed. On the other hand, some journalists were affected personally (see below).
A woman with RSI committed suicide by hanging in Adelaide , South Australia . Contrary to the headline, it is likely she suffered from undiagnosed or improperly treated depression. Newspaper photographs showed groups of sufferers all wearing splints on their forearms, or waving placards in a street protest against a particular psychiatrist advising the Queensland government. In 1984 NIOSH had carried out a survey of chest pain in video terminal operators in Raleigh , North Carolina . This was reported on the front page of a daily newspaper as angina with the inference that using computers could cause serious heart disease .
Some journalists complained of personal symptoms, severe enough to make them stop work in a few cases. The Australian Journalists Association took a militant stand against newspaper owners, while newspaper owners in turn employed ergonomists and other experts to try and solve these problems. While the Advertiser group of newspapers in Adelaide introduced computer-based text processing without difficulty, the Fairfax group in Sydney had strikes and other problems. This, like several other examples of markedly differing incidence of RSI in similar workplaces (for example pairs of outwardly similar telephone exchanges), was attributed to differences in consultation and management style .
There have since been similar North American outbreaks of RSI at several newspapers, most notably the Los Angeles Times and the Fresno Bee . Speaking at the third conference on Working with Display Units, Lou Lee, science and medical reporter for newspapers in Edmonton , Canada , said she knew of no similar experience at her own company with over 500 staff. Similarly she had studied claims of harmful effects of radiation from computer terminals for ten years without finding any supporting evidence. A widely quoted report of two cases of cataract in young sub-editors on the New York Times  possibly due to radiation from computer terminals were not supported by further experience.
In preparing this paper, five Australian newspaper editors were interviewed at length by telephone - the editor of The Advertiser ( Adelaide ), the editorial writer for The Age (Melbourne), the assistant editor of Computing Australia, the editor of the computer section of The Australian, and the editor of the newspaper of the Australian Journalists' Association.
They were asked about the possible role of the media in influencing attitudes and belief among the public on controversial issues such as RSI. Their general response was that as working journalists they could not give a reliable opinion on such a question, and that the opinion of media academics should be sought. They felt that issues could not be created without some basis in fact - if a story had "legs", it would run, and (using another metaphor), a story would burn more brightly in the "oxygen of publicity". However one editor felt the epidemic of cases had been partly caused by publicity by the Australian Journalists Association, a claim rejected vehemently by that organization.
These beliefs conflicted with the apparent success of unlikely stories such as the "Nullarbor nymph" (reports of a beautiful young naked woman roaming the Australian desert, created as a publicity stunt by a motel proprietor), an Unidentified Flying Object which was claimed to have lifted up a car traveling across the Nullarbor Plain, and many others, examples of sensationalist reporting familiar to observers of American newspapers such as the National Inquirer.
Opinion of academic researchers in the media were sought. Professor Henry Meyer (Media Information Australia) and David Sless (Communication Research Institute of Australia ) were guarded. There are no controlled studies of the effect of the media proving their ability to influence rather than reinforce public opinion and belief.
This absence of academic evidence was reinforced by the general failure of campaigns of public health campaigns on issues such as traffic accidents, tobacco smoking, and prevention of AIDS, where significant influence on target groups is hard to demonstrate. Apparently some public campaigns - early detection or prevention of melanomas and skin cancers - are successful. [Anti-Cancer Council of Victoria, personal communication].
Only one medical study of publicity has been located. Of two neighboring Swiss cantons, one had a newspaper campaign about the common operation of hysterectomy, and how much less often it was really needed. The hysterectomy rate fell by one-quarter after this campaign . "To our knowledge, the present study yields the first convincing evidence that publicity by the mass media can change professional practices and surgical outcomes" influenced both gynecologists and patients.
The role of publicity in copycat suicide, copycat crime, advertising, and politics is hard to define. However the effect of awareness in mass psychogenic illness is supported by numerous case studies . Unfortunately the very mention of psychological factors as the cause of work-related symptoms often leads to uproar in discussion.
Seating experts from various countries gave different opinions. Coe of New Zealand advocated low seats , conflicting with conventional ergonomic advice from Cakir of Germany , while Mandal of Denmark advocated a forward tilted seat , and Grandjean of Switzerland advocated a more reclining back-support .
For one investigator in Hobart , Tasmania , the cause of RSI was the flat arrangement of the keyboard, and the problem could be cured by sloping it downwards, away from the operator . Another enthusiast was importing specially designed keyboards from the United Kingdom , whose concave shape and rearranged key positions was supposed to prevent the problem .
One visiting American claimed to diagnose "Video Operators Distress Syndrome" which he could prevent by selling users a special shield for the video display screen. Investigations failed to substantiate either his claimed academic credentials or the efficacy of his product, but in the meantime he was featured on national television and in the press, held paid seminars for several hundred people, and worried some of them about the dangers he described.
During this time, ergonomics consultants flourished in Australia , only to decline again. This was followed by the rise of firms specializing in "rehabilitation". This remains a major force in Australia at present, strongly supported by government policy, but some organizations have crashed. One company of this kind grew from two physiotherapists to over 160 staff in almost a dozen regional offices around the country, only to suffer investigation for overpayment , and then collapse seven years after starting.
Vigorous attempts have been made to find a middle course between failure to make a medical diagnosis and labeling victims as neurotic or malingers. One approach has been to emphasize "psychosocial factors", taking the blame off the victim and putting it on the social context in which they work. Another approach is to blame the frightening publicity for creating disability.
More recently, attempts have been made to define new medical causes for pain [37, 38]. These include:
1. Tense habits of work and poor wrist posture. In one early case, obvious tenosynovitis was caused by writing forcefully, and relieved by retraining with a fountain pen .
2. Neck problems due to a poked-forward posture causing tension on the brachial plexus, and diagnosed by the "Brachial Plexus Tension Test" (BPTT) 
Some previously obscure causes of pain can now be accurately attributed to conditions identified only recently - true tendonitis, carpal instability, and many others - as reports accumulate in the medical literature. However in the Australian epidemic most reported cases of RSI lacked symptoms and signs consistent with damage to specific structures, especially reproduction of pain on testing specific movements.
Surgeons are conditioned by their training and by the expectations of patients to diagnose conditions which can be relieved by surgery, and to fear missing an "organic" diagnosis. The recent climate of "RSI" encouraged them to make surgical diagnoses even when these do not apply. One drastic example of this is recent American experience with the failure of treatment for carpal tunnel syndrome, including surgery, carried out on directory assistance operators working for Bell Telephone at Denver , Colorado .
Like the elephant in the poem about six blind Hindu scholars and their opinions about it, the RSI epidemic has been seen from widely different viewpoints. Models of the phenomenon have been described as medical, psychiatric, malingering, and patient-pain . In the last of these,
"Patients who are in essence healthy but experience pain choose and are encouraged to become patients with pain".
There is one further scenario - that anything is justified which improves conditions for workers, even if it means putting a spurious and damaging medical label on the ordinary sensations of everyday activities.
The VDU debate has provided important benefits through timely exposure of neglected issues of OHS, and by focussing attention on questions such as Quality of Working Life. However it has also done great damage. In some cases it has created disability and discredited legitimate issues of OHS. It has led to incorrect medical labels, in extreme cases leading to unnecessary surgery for carpal tunnel syndrome, and contributed unfavorable results even in cases where it has been correctly performed.
If analysis of this experience leads to better job design, better values in society, and more truthful scientific discussion, then its high cost and sadness will have been justified. Two final consequences of great importance remain:
1. Not repeating the mistakes of the Australian experience.
2. Using the lessons for better management of the next industrial epidemic - the epidemic of stress complaints.
1. The problem
2. The debating positions
3. Background factors
3.2 Populist beliefs
3.3 The social context
3.4 Groups with special interests
4. Role of the media
5. Opinions of Australian newspaper editors
6. Opinions of others
7. A personal medical perspective
8. Models of RSI
The Whyalla Hospital
Whyalla , South Australia
From: Work with Display Units 89
L.Berlinguet and D. Berthelette (Editors) © Elsevier Science Publishers B.V. (North-Holland), 1990
This paper wos the last at a big conference - several hundred delegates - dealing partly with RSI. There was a lot of politics, with trade union reps eager to diagnose physical injury, while occupational physicians were just plain confused.
Elsewhere on this website I have presented what I believe to be the physical basis for symptoms in many or most office workers, namely excess muscle muscle tension and a poked-forward neck posture from eyeglasses set to a working distance of 30 cm instead of 60 cm.