Sunday, 11 November 2012

Lessons from history #4: RSI


Repetitive Strain (or ‘Stress’) Injury (RSI) is a syndrome of arm / hand pain associated with certain activities. It is not a disease. It is not an injury, there is no physical evidence of stress or strain, and it bears little correlation with repetitive use. It is a social construct, influenced more by psychosocial factors than mechanical factors, and has no clear biological basis. Its history shows us how ‘unstable’ such labels are. Yet despite being easy to refute, labels like these persist. They persist because they serve a purpose and appear to fill a gap in our knowledge, and they are more socially acceptable and easy to understand than the truth. They are examples of medicalization.

The incidence of RSI rose rapidly in the mid 1980’s in Australia, particularly in Canberra and Sydney where it reached epidemic proportions (here and here). The condition was diagnosed through subjective complaints from workers, as there were no tests available and there was no discernable underlying pathology, despite theories regarding inflammation and nerve injury. At the time, RSI was attributed to the introduction of the computer keyboard, which replaced the typewriter in the 1980s. As computers allowed faster keystrokes than a typewriter, it was felt that the increased typing speed caused an injury to the structures in the hand and wrist. It was a good example of something that ‘made sense’ if you didn’t think about it too hard or for too long, and it was therefore assumed to be true.
It is interesting to note the similarity between RSI and writer’s cramp and telegraphers’ cramp (from a century earlier) in that they were all associated with the introduction of new technology (steel tip nib and telegraph), and all appeared to be transmitted by line-of-sight. That is, the incidence of both diseases was largely confined to groups of workers, usually in one building or company. The clumping of these diseases has led to causative theories relating not to any biomechanical factors, but to hysteria, employee-employer relations (here, item 15), and malingering.

Occurring mainly in the workplace, RSI fell under workers compensation. Like many other conditions associated with compensation, physical theories have been put forward, but none were proven or widely accepted. And like these other conditions again, RSI was thought to be associated with many psychosocial factors. Tertiary gain by health professionals, including doctors, physiotherapists and occupational therapists, all of whom stood to gain from having RSI established as a medical, and work-related condition, was thought to be a contributing factor. Concern from the union movement (which resulted in workplace lectures and publications such as “The sufferer’s handbook”) and misinformation and exposure in the media were also thought to contribute (here, item 15). As an example, one media headline at the time read: “Hi-tech epidemic. Victims of a bright new technology that maims” (National Times, Oct 12 1984), and another read: “A crippling new epidemic in industry” (New Doctor 1979, 13:19-21).

Although RSI reached epidemic proportions in the 1980s, in Australia compensation for the condition was eventually denied due to a lack of physical evidence of a disease process, epidemiological evidence of the condition occurring in distinct clusters, and being unrelated to workplace conditions such as the typing speed or the number of keystrokes used (here, here and here). There was a rapid decline in the incidence of the condition after claims for compensation were rejected.

A review of the literature regarding risk factors for upper limb pain concluded that perceived high job stress and non-work related stress were consistently associated with all upper extremity problems, and that the association with physical job demands was often not significant.

The search for biological abnormalities and medical treatments for symptoms that are expressions of ‘dis-ease’ (unease, anxiety, workplace conflict and other psychosocial phenomena) rather than disease is an example of our tendency to medicalize any ‘complaint’.

9 comments:

  1. In that last review it stated "Although not often studied, non-work-related stress was also consistently associated with Upper Extremity Pain." This is consistent with an anxiety disorder pre-dating onset of chronic pain, as shown in Gupta A et al. Rheumatology 2007. This showed that anxiety disorder is present in 95% of new chronic pain patients before they get the pain.

    If you add to anxiety and chronic pain the known effects of disuse atrophy then you get the clinical picture of RSI. We still have doctors treating it like a medical-only complaint however.

    Keep up the good work Dr S.
    Dr JC

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    1. Thanks. The role of a person's pre-morbid psychological profile is interesting. DIfficult to measure, but very important. Most would agree that certain "types" of people are more likely to develop these conditions.

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  2. RSI is in some ways the "railway spine" of the 1980s, driven by new technology and social contexts.

    I've been meaning to read Constructing RSI since Carl Elliott reviewed it in LRB, alongside Moerman's book on placebos that's been a jumping off point for me for a lot of things.

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    1. Thanks Plasmon,

      Constructing RSI is a good book and covers the scene from Australia well. I will look up Moerman's book - sounds like something I might like.

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  3. Good post. There are quite a few conditions that are not correlated with anatomical or biochemical abnormalities: low back pain (nothing is found with imaging in up to 70% of patients), chronic fatigue syndrome, chronic pain conditions etc. Finding something to throw a pill at doesn't always work.

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    1. Thanks, and there is also a risk involved with labelling (diagnosing) things that we not certain about. Apart from the effect on the patient, we then provide a compartment into which other patients may be fitted.

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  4. I'm 74, have osteoarthritis - knees, neck, hands - with hobbies of crocheting, hand sewing, and polishing old aluminum kitchen collectibles with steel wool (that sometimes for hours.) Pain in my hand and wrist have made me stop these activities for short periods until I just have to get back at it. I've had arthroscopy on one knee about 8 years ago when I was told I was buying time for replacement. It was suggested by three doctors that I try glucosamine-chondroitin. I did - I've been taking Osteo-Biflex ever since then, with almost miraculous results, especially in my neck. Mind over matter? I don't know, the difference is amazing. My knees seem better, although I know my limits and adjust accordingly. But recently I've developed pain up my arm into my shoulder where it's worse after stitching for five minutes or so. I was thinking it's repetitive motion injury, and have decided that only rest will help. The pain subsides or goes away when I'm not moving my arm. Or are my days of using/abusing my hand/arm movement over? Would you call this repetitive motion injury?

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    1. If you have pain that limits your ability to perform your daily activities and it is bothering you, it is reasonable to seek advice from your doctor regarding the possible cause and possible treatment. You could have a treatable condition.

      However, many conditions, like arthritis for example, cause pain with movement. It is the underlying condition that causes the pain, rather than the movement per se. Therefore, it is not reasonable to attribute pain with movement to a "repetitive movement injury". It just hurts to move, we don't need any new diagnoses or labels to add to our already impressive collection.

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    2. I would hope you would all read Dr. John Sarnos books. He explains the basis of psychosomatic pain better than anybody I have read.

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