‘Repetition strain injury’: An Australian epidemic of upper limb pain

SOC. Sci. Med. Vol. 27, No. 6, pp. 645649. 1988 0277-9536188 $3.00 + 0.00 Printed in Great Britain. All nghts reserved Copyright C 1988 Pergamon Press plc

‘REPETITION STRAIN INJURY’: AN AUSTRALIAN EPIDEMIC OF UPPER LIMB PAIN

WAYNE HALL’ and LOUISE MORROW* ’ School of Psychiatry and *School of Psychology, University of New South Wales,

Prince of Wales Hospital, Randwick, NSW 2031, Australia

Abstract-An analysis is provided of a recent Australian epidemic of an upper limb regional pain syndrome known as ‘repetition strain injury’ (RSI). ‘RSI’ was originally attributed to occupational over-use of the upper limb and biomechanical and ergonomic solutions were sought. More sceptical commentators argued that ‘RSI’ was an epidemic form of hysteria. More recently, a consensus has emerged that the epidemic is attributable to a combination of factors: a change in the perception of endemic symptoms of upper limb pain; the iatrogenic effects of the term ‘RSI’ and the methods used to manage it; and complications of the medico-legal process in which many sufferers became entangled.

Key words-chronic pain, ‘repetition strain injury’

In Australia between 1983 and 1987 there was an epidemic of upper limb regional pain which was concentrated among workers in occupations which involved either repetitive movement, or the adoption of constrained postures for lengthy periods of time (e.g. process workers and keyboard operators). Al- though the phenomenon of upper limb pain was observed among process operators in the late 1960s and early 1970s [I], it only achieved epidemic status in 1983 when the first claims began to be made under worker’s compensation [2]. The rate of claims increased dramatically during 1984 and 1985, persisted through 1986, and then equally dramatically declined in 1987 [3]. The consensus of informed opinion is that the worst of the epidemic has past [4].

Throughout much of the epidemic the syndrome of upper limb pain, numbness, parasthesiae in the hand, arm, forearm, shoulder and neck, was diagnosed as ‘repetition strain injury’. ‘RSI’ was defined by the Occupational Health and Safety Commission as: “a soft tissue disorder caused by the overloading of particular muscle groups from repetitive use or maintenance of constrained postures [which] occurs among workers performing tasks involving either frequent repetitive movements of the limbs or the maintenance of fixed postures for prolonged periods, e.g. process workers, keyboard operators and machinists” (51.

The symptoms of ‘RN’ were attributed to an unspecified injury caused by overuse of the upper limbs. Treatment was accordingly directed to the management of musculoskeletal injury, namely, rest, physiotherapy, anti-inflammatory medication. As the epidemic unravelled, the shortcomings of a purely biomechanical explanation became apparent and it was suggested that social and psychological factors played a major role in the epidemic [6-111. There were four main reasons why such a view gained currency.

First, the symptoms of which most patients com- plained were diffuse and there were only rarely any clinical signs [l, 12-141. Only a minority of patients

had well-defined clinical syndromes (such as carpal tunnel syndrome, tenosynovitis, and epicondylitis); the majority had poorly localised and variable pain in the neck, shoulders, upper arm, forearm, wrist and hands, which may have been accompanied by complaints of numbness, swelling, heaviness, tenderness, and parasthesae. We will be primarily concerned with the explanation of the latter group of cases.

Second, the regional pain symptoms were often accompanied by symptoms of psychological disorder. The most prominent of these were anxiety, depression, and preoccupation with the significance of the symptoms [ 151.

Third, the pain and other symptoms failed to respond to conventional medical management of inflammatory or traumatic soft-tissue injury, namely, anti-inflammatory agents such as cortisone, heat treatment or conventional physiotherapy [ 141. Most patients reported that the only form of management that reduced symptoms was complete rest [16].

Fourth, the epidemiology of ‘RSI’ was inconsistent with the theory that it was an injury caused by repetitive movements or extended static loading in the workplace [6, 111. For example, the incidence of ‘RSI’ varied widely between government depart- ments, including the same government department in different Australian states [3], and between com- panies in private industry which used the same equip- ment [l 1, 131. The prevalence of symptoms did not show the expected dose-response relationship to the putative cause. Hocking [3], for example, found that the prevalence of pain in three occupational groups in Telecom Australia was inversely related to the rates of key stroke. Although similar epidemics have been reported in other countries, especially Japan and the Scandinavian countries [5], ‘RSI’ (or any other synonym) was unknown in other industrialised nations which use the same technology as has been implicated in causing the disorder in Australia [ 131.

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646 WAYNE HALL and GUISE MORROW

To avoid prejudging the issue of cause and to make clear our reservations about the underlying theory implied by ‘RSI’, we will enclose this term in quota- tion marks. This is only to indicate our scepticism about the validity of ‘repetition strain injury’ as an explanation for the majority of cases of ‘RSI’; we do not doubt the suffering of those whose symptoms were so labelled.

EPIDEMIC HYSTERIA?

Epidemic hysteria was proposed as an explanation of the ‘RSI’ epidemic by Lucire [9], who suggested that it was an epidemic form of conversion hysteria in which a psychological conflict between returning to work and being crippled was resolved by being converted into physical symptoms of arm pain. She suggested that powerless and dependent workers who were unable to express their ‘righteous rage’ resorted to the use of symbolic pain and incapacity to commu- nicate their distress.

The epidemic hysteria hypothesis was consistent with some of the features of the ‘RSI’ epidemic which it shared with documented epidemics in which symptoms were misattributed to infectious disease [17] or to toxic reactions to insect bites [18]. ‘RSI’ often occurred among a small number of workers in an industry and these cases were then followed by a rash of reports [19]. There was also an excess of women among cases of ‘RSI’, which is characteristic of epidemic hysteria [ 18, 191, especially in an occupational setting [20].

There were also problems with the hypothesis. Epidemic hysteria is usually an evanescent phenom- ena which occurs among female workers in confined communities. The typical time course of such epidemics [18] is a matter of days, or weeks at most, whereas the ‘RSI’ epidemic has occurred in widely separated places over a period of years.

A second problem with the hypothesis was that the characteristic symptom pattern had been observed in workers in repetitive occupations in other times and places before the current epidemic, including Australia [l, 211. There was also evidence of under-reporting of symptoms in certain occupational groups, e.g. data process operators [22]. The syndrome has also been observed among the self-em- ployed, and in symphonic musicians who have very little to gain from compensation for injury, and much to lose (namely, the pursuit of a highly valued profession), and who consequently do not appear to be candidates for the conflict hypothesised by Lucire [ 161.

Third, the proposed mechanism whereby psychological conflicts produce symptoms of ‘RSI’ was unclear. The mechanism which seems to produce symptoms in many episodes of epidemic hysteria is overbreathing [17]. The symptoms it character- istically produces (nausea, palpitations, headaches, dizziness, malaise) are different from those observed in the ‘RSI’ epidemic.

Fourth, the epidemic hysteria hypothesis ignores the epidemiology of upper limb pain, and the connec- tion between social events and psychological and bodily experience [ 111. It assumes that psychological conflicts produce symptoms de nouo when it may be

more accurate to say that what spread was a misattri- bution of the cause of symptoms which were common in the workplace.

A CHANGE IN PERCEPTION OF ENDEMIC SYMF-TOMS

We support commentators who have argued that the ‘RSI’ epidemic requires an explanation which acknowledges that the symptoms, of which persons with the diagnosis of ‘RSI’ complain, are common in the community and which allows that their prevalence may be related to conditions of employment. If we allow that these symptoms were endemic, we need to explain why they came to medical and public attention, and why they produced substantial disability among some of those who suffered from them.

The prevalence of upper limb pain Research on the prevalence of upper limb pain

suggests that it is very common in the general community. General population surveys of pain suggest that as many as 10% of the population at any one time will suffer from upper limb pain of sufficient severity to interfere with ordinary activity [23]. The life-time prevalence of such pain may be as high as 35% [8].

Surveys of occupations which involve repetitive movement produce even higher rates of symptoms. A Scandinavian study of workers in heavy industry and cash register operators revealed that cervicobrachial symptoms occurred in 45% of those examined [23]. An American study of garment workers and hospital workers found that 42% of the former and 22% of the latter reported experiencing persistent pain, numbness, and tingling with the upper trunk and limbs within the past year [24]. The latter findings were obtained in a setting where there was no well- pubhcised epidemic, and no obvious incentive for over-reporting.

Australian prevalence results are similar. A survey of symptom prevalence in keyboard operators [22] produced the following estimates: 49% reported neck pain, 33% wrist pain, and 23% shoulder pain. Similar estimates of symptoms were obtained among keyboard workers at the Australian National University [25]. Fry’s [ 161 survey of symphonic musicians found a high rate of symptoms, especially among string players, woodwinds, and keyboard players.

Factors promoting increased visibility of the symptoms A consensus has emerged that the creation of the

‘diagnosis’ of ‘RSI’ was a major factor in bringing endemic pain symptoms to medical attention [2, 7,9, 111. ‘RSI’ was a broad, over-inclusive and poorly defined diagnostic label which embodied the causal theory that the symptoms were an injury caused by repetitive movement and overuse. Its creation gave legitimacy to complaints of arm pain as a reason for absence from work and as a basis for claims under workers’ compensation [8].

The popularisation of ‘RSI’ owed a great deal to the convergence of a number of different social factors. First, ‘RSI’ was adopted by the emerging occupational health movement which used health issues to improve employees’ working conditions. The newly created National Occupational Health and

‘Repetition strain injury’ 647

Safety Commission (Worksafe) did much to inadver- tantly promote the disorder when it made ‘RSI’ and asbestos-related disease areas of priority [ 111. Work- safe also lent its authority to the existence of the syndrome when it produced guidelines for its diagnosis and management [5].

Second, ‘RSI’ also appeared at a time of increasing unemployment for which new computer technology was being blamed. Fears of job loss and unwelcome changes in the organisation of work created an antipathy to the new technology, which came to be seen as the cause of ‘RSI’. This dissatisfaction was taken up by some unions who campaigned against the introduction of new technology into the work place [22]. The culpability of the employer which was embodied in the diagnosis justified attempts to alter the work environment.

Third, the spread of the disorder was assisted by newspaper and media coverage which gave inflated estimates of the prevalence of the problem, and emphasised its insoluble nature [ll]. Articles appeared with headlines such as: “‘RSI’, the Billion Dollar Riddle”, “‘RSI’, the New Epidemic”, and “Technology Spawns its own disease”. By pubhcising a speculative ‘staging’ of the symptoms of the disorder [26], the media helped to disseminate the view that ‘RSI’ inexorably progressed from minor symptoms to incapacity and invalidism. It is not surprising, that workers with symptoms of pain sought medical reassurance that they did not have the ‘dread’ disease ‘RSI’.

The complex socioeconomic and political situation combined to elevate and redefine preexisting symptoms A form of contagion operated at the level of the workplace [20]: the wide publicity given to the symptom pattern made it an acceptable complaint to present as work-related; when the rate of complaints in a factory increased, other symptomatic workers were encouraged to present their symptoms to doctors.

Factors promoting chronicity and disability A major difference between upper limb pain in the

community and ‘RSI’ is that the majority of ordinary episodes of upper limb pain will resolve, with or without treatment, in approximately a month [8], whereas as many as 15% of persons with ‘RSI’ experienced chronic pain and disability [3]. We be- lieve that a number of factors have combined to push and pull ‘RSI’ patients into disability. The push factors include ‘iatrogenic’ processes, broadly con- strued; the pull factors include the contingencies that operate within the medico-legal system to encourage the persistence of symptoms.

Iatrogenic factors include not only diseases produced by medical treatment but the social and psychological consequences of the way in which patients’ disorders were investigated and managed [27]. In suggesting that iatrogenic factors may have played a role. we do not deny that disabling musculoskeletal syndromes exist; rather, we are attempting to explain why it is that persons who did not have such syndromes were disabled.

The attitude of the doctors of first contact probably played an important role in the early stages of the epidemic. Ferguson [l] suggested that

overconcern on the part of patients’ doctors may have contributed to their invalidism in the cases he observed in 1971. Later in the epidemic, as scepticism about ‘RSI’ grew many patients may have felt obli- gated to demonstrate the sincerity of their complaints by seeking out doctors who were prepared to exhaust all avenues of investigation in search of a diagnosis. The resort to a large number of doctors would have exposed patients to conflicting advice and to the dangers of sustaining iatrogenic damage from unnecessary treatment.

The most commonly prescribed methods of management may also have unintentionally contributed to chronicity. A common recommendation was to have complete rest, to immobilise affected joints in splints, and to remain immobile until symptoms remitted [14]. The initial effect of such a regime was to exacerbate the symptoms of pain and depression [ 161; their long-term effects included disuse disorders [28] and the development of a conviction that sufferers were destined to become invalids.

The regime of complete rest, combined with the false attribution of the cause to the work environment created a dangerous reinforcement contingency [29]. By recommending that the employees did not return to work until they were completely symptom free, they were placed on an open-ended regime of dis- heartening and demorahsing inactivity (301. When symptoms had remitted sufficiently to return to work, a short period of work would suffice to bring them back. After several such cycles of pain, rest, and pain, many employees would have acquired a strong fear of reinjury if they returned to work. Demoralisation would have been complete with the loss of self-esteem which has been observed to follow unemployment in the able-bodied [31, 321.

Entry into the medico-legal maze of workers’ compensation reinforced the invalid role by holding out hope of receiving gain for the symptoms of ‘RSI’. This does not mean that symptoms were simulated for the purposes of gain. Rather, the predicament of the ‘injured’ worker, and the entanglements of the medico-legal process, conspired to promote disability. The management of ‘RSI’ led to lengthy work absence, and return to work was difficult after symptom remission. If the worker was not fearful of returning to work, then employers often opposed the workers’ return. The employee’s history of time lost, and the reason for it, made him or her unattractive to other employers, and hence, unlikely to obtain alternative employment in a tight labour market. It was not surprising, then, that employees resorted to litigation as the best way to recover lost earnings, provide for their families’ future, and to vindicate their claim to injury and disability [8]. Once involved in litigation the claimant was placed in the untherapeutic situation of having to demonstrate illness or disability for the 2 to 3 yrs that settlement took.

CONTROLLING THE EPIDEMIC

The ‘RSI’ epidemic subsided at the same time as medical scepticism about the existence of ‘RSI’ grew and as ergonomic changes were made to reduce pain in the workplace. Although both things probably

648 WAYNE HALL and LOUISE MORROW

played a part in controlling the present epidemic, we conjecture that the former played the greater role.

Psychological research on the processes whereby humans attribute causes to events (331 illuminates the reasons for the gradual shift in medical views about the causes of ‘RSI’. Early in the epidemic symptoms of upper limb pain were widely believed to be almost universal among workers in particular occupations, to be distinctive symptoms of repetitive work, and to be consistently associated with repetitive movement. As the epidemic unfolded, it became clear that although symptoms were common the disabling syndrome of ‘RSI’ was not. As dissenting views about the syndrome received publicity, the view gradually developed that only particular individuals were likely to develop it, and, as such, it came to be seen as the affected workers’ personal responsibility.

With the change in the perception about the causes of the epidemic, many commentators blamed the name ‘RSI’ for the epidemic and accordingly urged that it be changed [7-91. Hadler [8], for example, argued that upper limb pain was best conceived as a form of muscle fatigue which remits with rest. Such a conception, he observed, warranted attempts to improve working conditions without implying that workers have been injured. These arguments were accepted by the Royal Australian College of Physi- cians which recommended that ‘RSI’ be replaced by the more descriptive ‘Regional Pain Syndrome’ [34]. As a consequence of these types of criticism, ‘RSI’ has slowly faded from medical use.

Ergonomists and industrial psychologists had some success in changing the physical conditions and work practices that exacerbated upper limb pain. The emphasis in such modifications to the workplace was on both physical and work conditions, since it was argued that upper limb pain was a consequence of the pattern of use that was encouraged by work sched- ules, supervision, and management practices [2, 131. The extent to which these changes contributed to the decline in the epidemic is uncertain in the absence of controlled studies. Even if they did reduce incidence it is doubtful that they did so solely for the reasons that led to their implementation: the non-specific effects of attention, concern and reassurance are well known in occupational medicine [3,4]. Moreover, the changes recommended may have reduced other aver- sive properties of the jobs which predisposed workers to anxiety, depression and other symptoms which may have been misattributed to overuse [35].

LESSONS OF THE EPIDEMIC

With all the benefits of 20-20 hindsight, a number of lessons can be drawn from the Australian ‘RSI’ epidemic. The major lesson for the specialist medical profession is to be wary of creating diagnostic labels in the absence of reliable evidence. It is especially dangerous to create broad, all encompassing labels which explicitly embody untested aetiological theories [36, 371. Such labels are especially likely to generate an epidemic of illness if they include a heterogeneous collection of commonly occurring symptoms, only a minority of which have a poor outcome. Misleading publicity creates the expectation that disability is a common consequence of the

symptoms. When the adverse outcome of the minority comes to be seen as the common outcome of all those included within the enlarged ‘diagnosis’, the risks of disability are made to seem unrealistically high.

As the point of entry to medical care, general practitioners have an important role to play in pre- venting future epidemics. The dangers of iatrogenic disorder are greatly diminished if the doctor at the first point of contact excludes the possibility of serious disease, authoritatively reassures the person that the condition will not disable them [7], and protects them from the hazards of unnecessary specialist investigation. Reassurance is most likely to be effective if it is accompanied by sensible advice on symptom management, e.g. the desirability of im- proving general physical fitness and reducing stress, especially in the workplace.

Acknowledgements-We gratefully acknowledge the advice, suggestions and comments of the following persons: Allen Christophers, Beryl Hesketh. Donald MacPhee, Gordon Parker. Patricia Strautins. and Ian Webster.

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Documents

‘Repetition strain injury’: An Australian epidemic of upper limb pain