Editor's Note: Nick of Time

Does anybody remember RSI? A year ago, even the few of us unsure of what the dread acronym stood for (for the record, both repetitive strain injury and repetitive stress injury are correct) knew enough to tremble at the slightest twinge in our wrists. Idle hands would lapse unconsciously into the aptly-named "prayer stretch" as we invoked our various patron saints to protect us from the debilitating disease. These days, however, as the "RSI Action Group" mousepads at email terminals start to fray at the edges, the former scourge of the keyboard seems about as threatening as scurvy to most of us. In the words of one anonymous senior, it is "last year s disease."

First the fall semester exam period then thesis season passed without an explosion of publicity about new cases. The near-hysteria of last year s perceived epidemic remained just a memory. Now, a year after the first rash of publicity, it seems appropriate to ask just what happened. Was it just some sort of premature millenial outbreak? God s belated answer to the prayers of the Luddites? Or is the the perceived drop-off merely a mirage, a product of the short attention span of our own Fourth Estate? The fact is, no one really knows.

NUMBERS

Dr. Chris Coley is the closest thing there is to an authority on RSI (or, to be technically correct, RSIs; RSI is, in the words of a Harvard-Radcliffe RSI Action Group handout, "an umbrella term for a variety of injuries: tendinitis, carpal tunnel syndrome, cubital tunnel syndrome, etc.") at Harvard. A physician at University Health Services (UHS), Dr. Coley has made a professional hobby of the disease. He candidly admits that "It s really something that most physicians know very little about." A survey he has conducted collaboratively with the Computer Science Department will, once examined, hopefully provide a quantitative portrait of the disease, a description of trends and percentages that will rescue RSIs from much of the conjecture and guesswork that characterize discussions of it here at Harvard.

Progress on analyzing the results is slow since Dr. Coley, lacking research assistants, runs the numbers by himself in his free time. So far, however, they do reflect the feeling around campus, or what Dr. Coley more clinically refers to as the "anecdotal experience of Harvard undergraduates." It looks, he reported, "like the number of new cases this year compared to last is actually less." This result is far from decisive, but it is the clearest index of a change that is available since both UHS and the Student Disabilities Office refused to release any numbers for publication.

Not everyone sees a drop, however. Rachel W. Podolsky 00, co-chair of the RSI Action Group, attests that there is a significant number of students who are reporting RSIs this year, a population she labels a "large but silent majority." Indeed, Dr. Coley s numbers do not show a total disappearance, merely a dip. Even this trend, however, is puzzling. Why, in a student population that uses computers every bit as much as it did last year, should the RSI flag? Where, for that matter, did it come from in the first place?

GENEALOGY

Perhaps the most often-asked question about RSIs is one of origins. Why haven t we heard of it before? Dr. Coley answers that RSIs are not new. In fact, "cumulative stress disorders," as he calls them, have been "well-known in a few professions for a long time. Meatpackers, as well as truck drivers and seamstresses, have had to deal with RSIs for years. The best known among those trades was carpal tunnel syndrome, an inflammation of the nerves in the forearm that often resulted from strenuous work with heavy vibrations-something along the lines of working a jackhammer. Only now that everybody habitually performs the repetitive action of typing and "mousing" out memoes and papers and emails and spreadsheets and impassioned contributions to chatrooms has the non jackhammer-wielding public been introduced to the problem.

But why not secretaries? Indeed, a skeptic at the most recent RSI Action meeting wondered just that. Secretaries have been taking dictation, dashing off letters, typing out memoes and generally making their living by typing for over a hundred years. Why haven t they reported RSIs? One explanation is that computer keyboards are, in a sense, too easy to type on. Unlike the unbroken skittering of keyboard touchtyping, the motion of typing on a typewriter is a larger one, involving more than just the muscles of the fingers. In addition, the need to reset the page at the end of each line and then to feed in a new sheet at the end of each page provide "micro-breaks" of the sort that doctors and physical therapists recommend for RSI prevention (the study remains to be done on the comparative incidence of RSI in touch-typers versus "hunt-and-peck"-ers, but it might prove instructional).

Also, secretaries offices, unlike dorm rooms, were and are configured ergonomically. Before computers became office fixtures, secretaries had both a typing table and a writing desk, the former shorter than the latter so that typing didn t involve the praying mantis posture that Harvard desks necessitate. The Sisyphean struggle of the scrivener Nipper in Herman Melville s "Bartleby the Scrivener"-first tilting his writing table to angle of the "steep roof of a Dutch house" to ease his back, then lowering the table "to his waistbands" and stooping over when it stopped the circulation in his arms, then again tilting the table up-show that the issue of ergonomics in the workplace predates even the typewriter.

A third reason for the relative paucity of RSI in clerical work is that, in the past, not everybody went into the secretarying (or scrivening) business. If one couldn t type for long periods of time without pain then one chose a different profession. Now, however-and increasingly as figures like President Clinton tout computer ubiquity as the solution to our abysmal public schools-more and more kids grow up rattling away at the keyboard for hours a day.

ETIOLOGY

Perhaps the sudden appearance of RSIs last year could perhaps be explained in terms of this sudden explosion in time spent at the computer. Today there seems to be an almost inverse relationship between age and computer literacy. My father takes about an hour to type out a paragraph-long email, I can with difficulty design a spreadsheet, my twelve-year-old cousin has his own website. In fact, recent articles in technology journals like Wired and PCWeek worry that "Nintendo thumb" in children might prove an early harbinger of future RSI troubles. Podolsky sees this exponential growth in computer time behind what has been perceived as the ephemeral public life of RSIs. "In the past," she pointed out, "it was a bigger deal in grad schools." While the RSI Action Group, an undergraduate organization, was founded this year, its graduate school analog is already four years old. And now that many undergraduates are already dismissing the disease as old news, Podolsky reports meeting first-years who are recovering from RSIs developed in high school. Perhaps the sudden rise and fall of RSI was simply a measure of the rapid decrease in the average age of victims.

Or maybe the RSI story is a success story. Dr. Coley believes that it is. He sees the drop in cases stemming from an increase in awareness and the concomitant employment of preventative measures. These are the beginnings of what he hopes will be a "culture of healthy computing." For him, RSIs are "largely mechanical problems," and the solution is therefore mechanical as well. As he noted, "Recent studies of white-collar work environments show that enforced ergonomic changes have helped with the problem."

A SUCCESS STORY?

The stories of Harvard s own undergraduate RSI sufferers do suggest that ergonomics are a vital aspect of both the chronic injury and its cure. Daniel W. Suleiman 99, a Crimson editor, noticed "something in my hands" a year ago. Pretty soon it was unbearable. "I could not write, I could not type. These tendons were just inflamed and there was nothing to do but nurse them back. The fact is, by the time you notice anything, that s it, you ve already got it."

Now, however, he has largely recovered. There was, he recounts, no one cure. "I think, for me, what healed it was a combination of massages, swimming every day, and not using my hands." When he did start typing again, Suleiman made improvements in his dorm workstation. "When I got back to school, I was worried that it wasn t going to get better. I bought the new keyboard, had the tray, had the chair, and have been typing the whole year. Now my back and neck are still a little problematic but I don t say I have RSI anymore. I have a bad back." If it wants to deal with the problem, he believes, the University has a responsibility to "install the proper workstations in every single room. If they want you to live on campus and they re going to provide you with a desk, they should supply you with the correct desk...since they supply you with a desk you re not going to go out and buy your own." Acting in loco parentis, Harvard needs to make us mind our posture.

But despite his adulant attitude toward his wave keyboard, keyboard tray and ergonomic chair, Suleiman does see more at work than a simple geometry of elbow angle and chair height: "I always knew from the beginning was that I was never typing enough for it to be purely a result of just typing, so this causal relationship between typing and repetitive strain injury is not what I had. Someone who is on the computer 10 hours a day, just banging away, is one thing, but that wasn t me. Mine came, yes, from doing layout at the Crimson, but primarily from poor posture and, also, from stress in general." Suleiman suggests that perhaps RSIs are a matter as much of perception as positioning. "I wouldn t say I have it now," he insists. "I guess I d say I had it, but what s the difference? I mean I still have symptoms of it."

Or, as Dr. Jeffrey Katz, a rheumatologist at Brigham & Women s Hospital, avers, "there is an emotional and psychological component to all illnesses." RSIs are no exception. Podolsky s own experience with RSI-she is slowly recovering from a case she developed last spring-has made her think beyond a merely "structural" model of pain, one that posits that "if it hurts, there must be a tear, or a break." While she is quick to point out that "the injuries are real," she believes that it is more complicated than that. "I definitely believe that a big part of it is stress-related." As an example, she recounted how "when I m dictating with [the voice-activation software] DragonDictate, where you have to pause between each word, I ll start to get really tense and then my arms start to hurt." Or similarly, "Sometimes I find that when I go and meet with another person in the RSI group and we re discussing what we re going to do in the meetings, afterward I feel like I hurt more because I ve been thinking about it."

She is not saying that the disorder is made up. Far from it. Both Suleiman and Podolsky have developed a strong faith in the complicated, fungible nature of the pain they experienced and still experience. Dr. Coley sees factors as abstract as "the amount of control someone has over their work situation" contributing to cases of chronic injury. Perhaps, therefore, micro-breaks and wrist stretches are not enough. In an environment as manic as Harvard, maybe there is something more than mechanical to RSIs. "I hadn t ever heard of [RSI] before I developed it." Suleiman recalls. "All of a sudden people started talking about it and it literally became kind of trendy, except that it was real also, it was all so real."

ALTERNATIVES

The teachings of various "mind over matter" schools of medicine have traditionally been viewed with extreme skepticism by the Western medical extablishment. Especially in Boston, such dogma smacks of Mary Baker Eddy s Christian Science Movement (especially in the light of recent highly publicized cases where Christian Scientist parents let their children die for want of medical care). Up until the 1960s, the accepted model of how pain worked was the one proposed by Descartes in the 17th Century. According to Descartes, a painful sensation is strictly a physical and mechanical phenomenon, as simple as pressing a piano key and getting a tone. As a result, doctors assumed a direct correlation between tissue trauma and perceived pain.

The reality, however, may be less like a piano and more like something imagined by Rube Goldberg. Especially in back problems, doctors are increasingly faced with patients experiencing excrutiating pain that has no discernable physical origins. An October article in The New Yorker by Atul Gawande detailed the story of Rowland Scott Quinlan, an architect who experienced back pain so acute that he would vomit and for whom movement was so painful that he would often soil himself instead of getting up to go to the bathroom. But X-rays, C.T. scans and myriad other tests revealed nothing that could possibly account for the pain. Gawande s article also quoted several studies showing that pain perception varied widely between people undergoing identical experiences (e.g. surgical operations, war wounds, etc.). In other words, a stimulus that would cause one person severe pain would be only a minor annoyance to another. The point here is not that some people are "tougher" than others, that some people can just bite the bullet while others run whimpering to the medicine cabinet or even to the doctor s office. The point is that pain is complicated, that the same pressure applied twice to the same piano key came produce a deafening roar one time and a barely audible peep the next.

The Cartesian model of pain, like the Cartesian model of consciousness, began to be seriously challenged in the 60s. In 1965, Ronald Melzack and Patrick Wall proposed the "gate-control" model of pain, which involved a gate in the spinal cord that could increase or decrease pain impulses. What was most revolutionary about the model was not the idea of the gate per se, but the contention that the gate was controlled not just by sensory impulses, but signals that came from the brain, signals, for example, like emotions. How we felt could control what we felt.

In a newer model the point of the perception of pain is not the mid-point of the spinal cord but the brain itself. According to this theory, the pain impulse doesn t go through a gate. In fact, it doesn t go anywhere. It is produced where it is perceived: in the brain. The stimulus arriving from the sensory nerve alerts the brain, which produces the pain experience on its own. The pain perceptions are like the tracks on a record or compact disk, waiting to be "played." The arrival of the nerve stimulus, as Gawande writes, simply hits the play button. "And," he adds, "a great many things can press the button."

CONTEXTUALIZING PAIN

Whichever model one accepts, it is hard to deny the importance of emotional and mental factors in pain. Professor Anne Harrington of Harvard s History of Science Department has written extensively on the cultural and scientific nuances of pain. For her there is no doubt that pain is "mutable" and "porous to cultural expectations." Indeed, "The idea of a context-free human biology is an outmoded proposition."

Prof. Harrington s introduction of a cultural context might, it seems, be usefully applied to the discussion of RSIs at Harvard. One of the central RSI mysteries is its reputation as a strictly Harvard problem. Last year, even as the least fatalistic Harvard undergraduates began to resign themselves to the inevitability of voice-activation software and scribes (a combination of high-tech wizardry and ancient luxury that did have a certain appeal), it was hard to ignore the fact that our long-distance boyfriends and high school roommates and co-salutatorians attending other similarly stressful and high-powered colleges had never heard of it. Even Harvard students had trouble believing they were that exceptional.

For one thing, this perception of uniqueness is only partially true. A study by Dr. David Diamond at MIT reveals "similar proportions"-both of students reporting pain and seeking treatment-as those found at Harvard. And the real world has its own share of RSI problems: with 20 million people affected, RSIs are the nations foremost work-related injury. Yet disparities remain. Sarita M. James 98 is in her first year of working at Microsoft. "None of the Microsoftees that I ve met have RSI," she wrote in an email, "which is rather surprising, considering the pervasive Microsoft slouch. " Similarly incongruous is the report of Karen Gordon, at the Princeton University Health Center. This year she has seen "an increase in the number of cases reported both in students and employees." However, she adds, "from my understanding, we do not have the sort of numbers that Harvard has." In an informal study, several dozen undergraduates and graduate students interviewed from Yale, Princeton, Brown, University of Pennsylvania, Cornell, and Williams, only six had heard of it and only one knew of a fellow student who had had it. In a similar survey conducted at Harvard, all 30 students questioned had heard of RSIs and all but five knew someone who had had it in some form.

Why then, in other schools where students use computers, slouch, and get stressed out, have so few students even heard of the disease, much less suffered from it themselves? Maybe it is in what Prof. Harrington calls the "context" of a disease. Gordon, with a note of amusement in her voice, describes a herd instinct she has observed in students reporting problems, "Whenever there s an article in the paper about that sort of thing we get a lot of people in here wondering if they have it." If RSI and chronic pain conditions like it are as culturally mutable as recent models suggest, perhaps in a limited sense the fear can aggravate the pain.

This is not to say the pain is imaginary. Like Rowland Quinlan with his searing back pain, RSI sufferers are not making anything up. But as Dr. Howard Fields, a neuroscientist at the University of San Francisco Medical School, explained, expectations might play a part in the perception of pain. In an email, Dr. Fields described the nervous system as unique in that it has what he called "intentionality." This philosophical term means, quite simply, that "it is about something other than itself." Specific neuronal impulses trigger perceptions that are then projected onto the body. "Your finger hurts," he wrote, "but really it is your brain that hurts."

Not only that, but the perception of pain is "related to expectation and brain circuits that replicate past experiences." In more immediate terms, the sight of a fist coming toward your face might trigger the pain perception before the fist actually makes contact. Or, alternately, someone might be so ticklish that they don t even need to be touched to cringe. Even if they don t produce pain on their own, these neural patterns can "lower the stimulus intensity so that normally innocuous stimuli produce pain." In this model, Harvard students, aware of what they see as impending danger of RSI, might jump the gun and anticipate the pain. This would fit what Suleiman described as the almost faddish nature of the disorder, its "trendiness." Students made hyper-aware of the dangers of RSI from a sudden rash of articles in campus publications might therefore be more likely to come down with it themselves.

Both Dr. Katz and Dr. Coley are extremely hesitant to suggest that RSIs are not predominantly mechanical, ergonomic phenomena. For Dr. Katz, there is a danger in implying that the disorder is a psychological one. "There is just as much evidence for biological causation as for most other disorders and more than some." As for the seemingly provincial nature of disease, Dr. Coley responds that diseases often refuse to conform to what we would see as rational patterns. "We had 22 cases of whooping cough this year. It was just one of those blips you see as a clinician."

But the fact remains that Harvard s outbreak is not the first time that RSI has acted out and behaved irrationally. In the early 1980s Australia experienced an RSI pandemic, one which in some places disabled as much as 30 percent of its workforce. In other places, though, it remained unheard of. The incidence rate varied wildly, often among the same professions or even the same company, and no correlation could be found between the repetitiveness of a job or its ergonomics and the number of RSI cases reported. Strangest of all, by 1987, it had virtually disappeared; no one had it any more.

THE MACHINE AND THE MALINGERER

The Harvard-Radcliffe RSI Action Group usually holds its meetings in the Quincy House Junior Common Room. At their most recent meeting, a circle of a dozen students seated on chairs and sofas ringed a coffee table. On its surface were liter bottles of soft drinks, bags of chips and cookies, and unsteady columns of piled plastic cups threatening to tumble over on top of the large University Dining Services fruit and cheese plate which had pushed them to the edge of the round tabletop. Podolsky and Ben Rahn, the other leader of the group, welcomed everyone and then went through an informal outline of facts and tips; along the way both gave testimonials about their experiences with RSI. The atmosphere was casual but subdued, and the soft cadence of the presentation was broken by the occasional question or the rustle of a communal page-flip as everyone looked at the illustrations of proper vs. improper posture on the back of the info sheet. It was not how most people would choose to spend an evening if they didn t have to.

Though they were described in deliberately understated tones, the stories of pain and frustration that many of the students at the meeting recounted were vivid. To suggest that they were in any way fabricated would be patently unfair. But it seems equally unfair to remove all agency from them, to, in Prof. Harrington s words, "make objects instead of subjects out of human beings." RSI sufferers are not hypochondriacs, but neither are they simply machines that have been improperly aligned. Somewhere along the continuum between the two opposing images of the machine and the malingerer is the delicate and distinct balance of will and physiology that can create a disease. At this stage, where that point lies for RSI is hard-if not impossible-to determine.