The Anatomy of the RSI Epidemic
Repetitive Strain Injury (RSI) is fast becoming one of the most common forms of disability in the workplace. In some industries it is already the number one cause of a temporary and permanent disability. In this article I will explain why and how we develop the elusive RSI.
The definition of RSI:
Repetitive strain injury is a medical term used to describe a pain or discomfort of the upper limb. Although a ‘repetitive strain’ can occur in any area of the body, physicians typically apply the term to a pain of the arm unit including the neck, shoulder upper back, arm, forearm and hand, that is related to repetitive tasks. RSI is really an umbrella term used to catch any and all pains of the arm, but the most common forms include tennis and golfer’s elbow, carpal tunnel syndrome, ulnar neuritis, metacarpalgia, rotator cuff of the shoulder, chronic neck and upper back pain and limb numbness.
The signs and symptoms of RSI:
The signs and symptoms of RSI vary depending on the exact areas of the arm and neck involved in the pain syndrome; however, the most common RSI complaints include the following:
Numbness and tingling of the arm and / or hand
Pain and / or weakness of the upper arm and / or forearm, and / or wrist, and / or hand
Reduced range of motion and / or stiffness of the shoulder, elbow, wrist or fingers
Difficulty lifting of objects and / or tendency to drop objects (dropsy)
The tendency of pain and / or numbness to increase with repetitive activity and at rest
Background of RSI:
RSI is considered a soft tissue pain syndrome whereby the pain is derived from a disorder of the muscles and tendons of the neck and limb. To fully understand how muscles can cause disease, it is important to understand the current principles of myofascial pain (MFP) and myofascial dysfunction (MFD).
Muscles shorten and can potentially scar in a shortened position as a result of injury or exercise. This process of shortening is often exaggerated at rest. Therefore, muscles that work repeatedly in a particular action eventually shorten and over time, will develop some form of scar formation in areas of the muscle. These scars can be described as microinfarcts, or more popularly, as trigger points. In traumatic cases, muscles will shorten and scar in a much more accelerated period of time and often more severely.
Muscles shorten persistently if nerve conduction to that muscle is interrupted. This is known as Cannon’s Law, and is very important in understanding how we can develop repetitive strain injury. Walter Cannon was able to clearly demonstrate that muscles become super-sensitive and ultimately persistently shortened with eventual scarring when their nerve conduction is partially interrupted. For example, if the nerve supply to the forearm extensors is interrupted by a disk compressing the C4 or C5 nerve root, the forearm extensors will persistently shorten and cause chronic tennis elbow.
Shortened muscles around a joint will often change the static position of normal movement of the joint.
Furthermore, persistent compression of the joint may occur and contribute to an abnormal and accelerated wear pattern of cartilage and eventually the joint. Joint pain, stiffness and decreased range of motion are common side effects. Over time, destruction of the joint and osteoarthritis are predictable complications. The spine is also affected by these principles of persistent compression when the deep intrinsic spinal muscles are injured and develop shortening and contractures. The vertebral compression will cause disk herniation and spinal stenosis. The vertebrae, disks, nerve roots and the spinal cord can be affected by herniated disks and swollen facet joints.
To explain, these deep spinal muscles change the spinal positioning, cause mal-rotation of the vertebrae and non-movement of the spinal segments. This will lead to premature or accelerated disk wear, disk herniation, arthritis of the facet joints, and increase the risk of compression fractures of the vertebrae. This is true at all locations of the spine, but is more prevalent at the levels of C1 to C2, C4 to C6, T11 to L1 and L4 to S1. In the case of RSI, we are typically seeing compression of the segments of C4 to C7.
Application of these principles:
Let’s look at the typical assembly worker. He or she will often perform the same group of tasks and use the same muscle groups of the neck and arm as much as six hundred times per day. The basic effect is to overwork / exercise the muscles of the neck and arm. The first changes that occur are of typical shortening of the deep spinal muscles of the base of the neck (multifidus and deep rotators) and of the shoulder outlet and forearm muscles. Specifically I see shortening and scarring at the levels of C4 to C7 and of the back of the shoulder (latissimus dorsi and subscapularis) and of the front of the shoulder (pectoral minor and major), shortening and scarring of the forearm and hand muscles (forearm flexors, extensors and hand metacarpals) are all generally affected to some degree.
Early on, the exam will show mild trigger point or tenderness along the muscle groups mentioned above. Some weakness is often present as the muscles are working below their maximum of their efficiency as a result of being shortened. The individual will often have only slightly reduced range of motion of the neck and arm unit. However, over time the range of motion becomes obviously reduced and the pain symptoms increase as the condition progresses. X-ray and CAT scan imaging will show loss of normal curvature of the neck, and examination will show forward rolling of the shoulders, winging of the scapula, decreased pulse with elevation of the limb, and even acute joint swelling of the affected joints.
The loss of normal curvature in the neck indicates prolonged and persistent shortening of the deep spinal muscles of the neck; a so-called tenting effect. As the muscles tighten, they ratchet the neck straight like a tent pole under tension. The effect on the spine is to create a persistent compression on one or more disk and vertebrae. As well, the natural or normal positioning of the vertebrae and disks is altered. The range of motion of the spinal segments becomes obviously reduced as several vertebrae actually fail to move. Disks come under pressure and start to wear at their sidewalls, much like a deflated car tire supporting an over-weighted car. The affected vertebrae will have a slight rotation to the affected side caused by the pull of the intrinsic muscles. Disk bulging and herniation can occur and can also oscillate between bulge and herniation in the early phase of disease. This explains reduced diagnostics of disk herniation during MRI in the supine position as compared to the Standing MRI. Eventually, frank herniation is seen on supine MRI.
With increasing neck compression the nerve conduction in the neck supplying the arm becomes more and more affected. Initially the nerve is temporarily and only partially interrupted. Over time, as the spinal compression and rotation deepens, the nerve interruption becomes more constant and severe. Muscles down the affected arm will shorten following a supply pattern according to nerve roots affected (Cannon’s Law). As well, repeated local muscle injury from continued repetitive work will contribute to further limb muscle shortening.
Certain Muscle groups will contribute to different symptoms of numbness, tingling, pain and weakness of the arm. In carpal tunnel, the pectoral (chest muscle) shortening will cause a traction injury to the median nerve at the front of the shoulder. This in turn, causes a pulling effect on the nerve which translates to the nerve being lifted and then caught at the undersurface of the carpal tunnel. Entrapment and swelling of the nerve will then cause numbness, tingling and pain of the thumb, index, middle and half of the ring finger recreating the ever popular pattern of carpal tunnel syndrome.
In ulnar neuritis, the lattissimus dorsi and the subscapularis muscles will shorten from reduced nerve supply of C6 to T1. This shortening will then cause a similar traction phenomenon of the ulnar nerve at the back of the shoulder. This traction will then cause the ulnar nerve to catch at the elbow causing golfers-like elbow pain and pain over the nerve when leaning on the elbow. As this progresses, the ulnar nerve actually rolls over the inner elbow or medial epicondyle and can be felt by examination by palpating the medial epicondyle and while flexing the elbow. This indicates very significant traction of the ulnar nerve coming from the back of the shoulder – otherwise known as posterior thoracic outlet syndrome. The classical symptoms will be of numbness and tingling of the little fingers and eventually pain in the fingers and ulnar side of the hand.
In tennis elbow, the outer elbow (extensors) can shorten and scar as a result of compression of C4 to C6 in the neck (due to contractures within deep intrinsic muscles of the neck at these levels) . The forearm shortening will cause persistent tension of the extensor tendon which causes inflammation of the tendon. The persistent shortening of the extensor group will apply traction to the lateral epicondyle of the affected arm causing pain, swelling and bony changes over the elbow. This mechanism helps to explain the difficult nature in treating tennis elbow, as well as the high failure rate with local elbow therapy.
Golfer’s elbow has a similar mechanism to tennis elbow, only the spinal segments involved are typically C6 to T1. Often golfer elbow is associated with ulnar neuritis as the same spinal segments are involved. Other conditions can be recreated by similar spinal and limb muscle patterns.
Computer-related RSI often proves to be more ominous than assembly work. The problem is that keyboarding is a static injury. It is evident that static repetitive work is possibly the worst case scenario, as static muscles not only shorten after injury, but also at the time of injury. In this case the weakness of the muscles can be more exaggerated as the static repetitive action does not allow for increase in muscle strength as compared with standard active repetitive work.
Furthermore, the computer-related RSI often affects the upper back area (thoracic spine); an area which has secondary nerve supply to the arm. The thoracic spine can be extraordinary to treat particularly in the presence of kyphosis. The end result of computer-related RSI is a person with a hump back, forward neck, forward shoulders, compressed disks, suffering diffuse muscle shortening and multiple entrapped nerves, and typically affecting both arms.
The Treatment of RSI:
*The treatment of a complicated/chronic RSI begins with a detailed history and examination often indicating far more disease than initially thought.
*Detailed patient education of the mechanism and exercise physiology is important such that they ca be aware of aggravating factors and to succeed with personal exercises.
*Physicians and nurses need be more aware of the various patterns of RSI for their early recognition and proper treatment.
*The key part of actual therapy must include the implementation of spine and limb “neuropathic” stretching and resistance training (the Lamb Program) that allows for all muscle groups affected to be treated, and for spinal and limb segments to be properly repositioned.
*It is important to recognize the limitations of imaging technology, i.e. MRI fails to detect an estimated 40% of disk disease.
*The Implementation of injury avoidance and education of RSI-injury factors for the patient helps to reduce re-injury and progression of disease.
*The use of specialized injection technologies-surgical dry needling, the Patented Lamb Method of Spinal Botox, injectable NSAIDS can drastically reverse the compressive effect within the spinal anatomy and help most RSI’s and other pain syndromes.
*Specialized relaxation training systems help to reduce RSI-related muscle tension (i.e. ASeRT Systems).
*Positional education for sitting, standing and sleeping, as well as proper sleep education help to reduce the progressive pattern of bad sleep and bad pain.
*The implementation of laser/magnetic combination therapy and MET has demonstrated effectiveness as an adjunct to various pain syndromes including RSI.
*MET or micro-current therapy is the latest in electronic or electro-medicine that properly addresses the abnormal electrical potential concerns in chronic pain and RSI versus TENS or EMS which are demonstrating oxidizing potential of soft tissue with repeated use.
*Obviously the addition of medications can be a major adjunct to RSI and other chronic pains, and I will quickly comment on two medications.
*Anti-inflammatories have a beneficial effect in RSI, but must be tapered when stopping, otherwise reactive inflammation and spasm can occur. Lyrica, a new “anti-neuropathic” agent has been helpful in chronic pain. I have found improvement in deep spinal muscle pathology in many patients indicating that cessation of transmission of pain information has a relaxing effect upon spinal and skeletal muscles.