Annals ofthe Rheumatic Diseases 1995; 54: 859-860 859

some two years after the Australian RSI epi- nation. The undertaking of excessive or demic had started.7 A significant neurogenic unnecessary investigations and failure

MATTERS contribution to the symptomatology of RSI appropriately to reassure may serve to alarm Ann Rheum Dis: first published as 10.1136/ard.54.10.859-a on 1 October 1995. Downloaded from was already obvious on clinical grounds long the patient, reinforce illness conviction, and ARISING before the responses to the BPTT in these perpetuate illness behaviour. patients became widely known.' Other Whatever the genesis of pain in myofascial authors using different examination tech- pain syndrome and fibromyalgia syndrome, niques have commented upon the increased data published subsequent to the submission mechanosensitivity of upper limb neural of my manuscript suggest that emotional Different concepts of tissues present in many of these patients.9 trauma and somatisation play a significant musculoskeletal pain A close reading of the paper by Cohen et aetiological role.'-' al'° fails to reveal any mention of the BPTlT. The Australian repetitive strain injury In his leading article, Dr Awerbuch' purports These authors have assembled cogent (RSI) epidemic was unique in a number of to address the problem for the clinician of evidence in support of a 'neuropathic' basis respects, not least ofwhich was the sheer size patients who present with pain but in whom for clinical features of what they prefer to call of the epidemic. Whereas epidemiological there is no abnormality detected on physical 'Refractory Cervicobrachial Pain Syndrome'. data from other parts of the world indicated examination. Whereas in former times these For a reviewer to invoke non-disease and an incidence of neck and arm pain in the same patients may have been labelled somatisation in the face of this evidence workplace of about 10%,45 in some 'hysterics, hypochondriacs or malingerers', borders upon the solipsistic. Whether or not Australian workplaces this reached 80%.6 In Dr Awerbuch suggests that they now be this particular pain syndrome is 'neurogenic', 1985 the then Federal Minister for categorised as 'somatising patients'. Whilst as has been proposed," remains unresolved. Employment and Industrial Relations was this formulation might allow some clinicians Dr Awerbuch's assertion that physical moved to express his alarm that 'Australian to move back inside their particular 'comfort examination remains the bedrock of clinical workers are being affected by a higher zone', it may also mean that their patients are rheumatology is a truism. An explosion of incidence of RSI than workers in other denied proper diagnosis and treatment. knowledge in the area of pain patho- countries'.7 This was no epidemic of teno- The specific examples of 'non-disease' and physiology'2 has presented those of us synovitis, tendinitis, epicondylitis, entrap- 'somatisation' provided by Dr Awerbuch are engaged in neuromusculoskeletal medicine ment neuropathies, or other well defined and rather a mixed bag and deserving of further with a formidable challenge. We will serve our recognisable medical disorders. This was a comment. His warning on the clinical mis- patients well if we accept this challenge and, new phenomenon an epidemic of diffuse interpretation of abnormalities frequently in so doing, we will enlarge our own comfort arm pain which transcended age, occupation, found in various imaging studies is timely. In zones. nature and duration of activity, and pattern the context of chronic spinal pain, the term of arm usage. A new name was needed. The 'soft tissue injury' is indeed epistemologically JOHN QUINTNER term RSI was born in Australia in 1982, first St John of God Medical Centre, unsound. It signifies the state of ignorance of 175 Cambridge Street, appearing in a National Health and Medical the clinician as to the true pathophysiological Wembley 6014, Australia Research Council booklet entitled Approved diagnosis, but gives no insight into the state occupational health guide repetition strain 1 Awerbuch M. Different concepts of chronic have ofmind ofthe sufferer. No diagnosis does not musculoskeletal pain. Ann Rheum Dis 1995; injuries. In 1985 one could not envisaged imply the presence of non-disease or 54: 331-2. that RSI would one day prove to be one of somatisation. 2 Awerbuch M. RSI or "Kangaroo paw" [letter]. Australia's more successful exports. Happily Dr Awerbuch points to the current state of Med3'Aust 1985; 142: 237-8. for Australian workers, not to mention the 3 Elvey R L. Brachial plexus tension tests and the uncertainty that exists over both diagnosis. pathoanatomical origin of arm pain. In: Australian economy, the epidemic died out in and pathophysiology of 'myofascial pain syn- Glasgow E F, Twomey L, eds. Aspects of the mid 1980s for reasons as mysterious as drome' (MPS) and of 'fibromyalgia syn- manipulative therapy. Melbourne: Lincoln those surrounding its birth. The cause was Institute of Health Sciences, 1979; 105-10. never found and 1987 researchers were drome' (FS). His preferred therapeutic 4 Selvaramam P J, Matyas T A, Glasgow E F. by approach is to acknowledge the 'legitimacy' Noninvasive discrimination of brachial plexus unable to find sufficient new cases of RSI to of the pain experience of these patients and involvement in upper limb pain. Spine 1994; undertake further studies.8 As late as 1992, to then address underlying causation. How- 19: 26-33. papers such as the one cited by Dr Quintner http://ard.bmj.com/ 5 Kenneally M, Rubenach H, Elvey R L. The ever, Dr Awerbuch provides no insights into upper limb tension test: the SLR test of the were appearing in the Medical Journal of causation of MPS and FS (apart from a arm. In: Grant R, ed. Physical therapy of the Australia under the heading 'Hypothesis' in suggestion of iatrogenesis), and resiles from cervical and thoracic spine. Clinics in physical an attempt to explain the phenomenon.9 therapy 17. Edinburgh: Churchill Livingstone, the theme of his article by failing to discuss 1988; 167-94. However, the neuropathic pain hypothesis whether they are in reality part of the syn- 6 Elvey R L, QuintnerJ L, Thomas A T. A clinical which was proposed is untenable on drome of somatisation or further examples of study of RSI. Aust Fam Physician 1986; 10: epidemiological grounds alone. As long as the non-disease. 1314-22. pathogenesis of so called RSI remains

7 Ferguson D. The "new" industrial epidemic on October 1, 2021 by guest. Protected copyright. The danger that clinicians can be seduced [editorial]. Med_JAust 1984; 140: 318-9. hypothetical, it is unlikely that any clinical by a 'special test' into making an incorrect 8 Browne C D, Nolan B M, Faithfull D K. tests will be embraced by serious scholars. diagnosis is highlighted by Dr Awerbuch. He Occupational repetition strain injuries. MedJ3 Dr Quintner undermines his own Aust 1984; 140: 329-32. gives as an example of this phenomenon the 9 Champion G D, Cornell J, Browne C D, argument on the BPT' by citing the paper use of the upper limb or brachial plexus Garrick R, Herbert T J. Clinical observations of which he was a co-author.'0 This study tension test (BPTT) in the diagnosis of the of patients with the clinical syndrome (with no controls), consisted of 60 self pain syndrome known as Repetition Strain 'repetition strain injury'. J Occup Health Safety selected patients, 33 of whom attended the Aust NZ 1986; 2: 107-13. Injury (RSI), a pain syndrome which Dr 10 Cohen M L, Arroyo J F, Champion G D, practice of one of the authors (a general Awerbuch has declared to be a 'unique Browne C D. In search of the pathogenesis of practitioner) and 27 of whom attended Dr Aussie disease', perhaps to be remembered refractory cervicobrachial pain syndrome. Quintner's practice. The diagnosis of RSI Med JAust 1992; 156: 432-6. under the eponym 'Kangaroo Paw'.2 His 11 Quintner J L, Elvey R L. Understanding "RSI": was a fait accompli before the study started; claim that the BPTT was developed before a review of the role of peripheral neural pain indeed, it was a prerequisite: '60 patients who the formulation of the RSI concept is true. and hyperalgesia. Journal of Manual and complained predominantly of arm and hand The BPTT was originally devised by Elvey, Manipulative Therapy 1993; 1: 99-105. symptoms (pain, aching, burning, heaviness, 12 Coderre T J, Katz J, Vaccarino A L, Melzack R. an Australian manipulative therapist, specifi- Contribution of central neuroplasticity to tingling, numbness) and of neck, upper back cally to assist examiners in the differential pathological pain: review of clinical and and shoulder symptoms who were receiving diagnosis of shoulder pain.3 A recent inde- experimental evidence. Pain 1993; 52: worker's compensation payments, agreed to pendent study suggests that the test does 259-85. take part in the study'. Little wonder then have discriminative validity when used in this that 59 of the 60 patients had a notionally clinical context.4 positive BPT1T. In so far as it appears that the BPTT does In another paper cited by Dr Quintner give an indication of the mechanosensitivity AUTrHoRs' REPLY: Dr Quintner raises a there was also no control group. This was a of those neural tissues which span the neck number of issues. Somatisation disorder, retrospective study consisting of 100 self and wrist, it is a test which is similar to the while not a rheumatological disorder is none selected RSI patients: 'criteria for inclusion straight-leg-raising test.5 It was not until 1986 the less a 'proper diagnosis' worthy of treat- were persistent (greater than 6 months) pain that the BPTT was reported to be useful in ment. Fortunately, most cases resolve in an upper limb evidently resulting from the diagnosis of a group ofpatients with RSI,6 spontaneously or after appropriate expla- overuse at work and for which a worker's