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