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’.