What is RSI?

RSI is the abbreviation for Repetitive Strain Injury. It’s a collective term for physical pains in the neck, shoulders, arms, wrists and hands. It is a disorder of muscles, tendons and nerves. The cause of RSI is excessive strain due to a combination of repetitive and static movements. RSI injuries are coupled with inflammation, pain, redness, swelling, and eventually, limited movement. RSI is a progressive disorder; the longer you wait for treatment, the longer the recovery will take. When you don’t treat the RSI complaint, then the complaint continues in three stages.

In the beginning phase, the pain is easy to locate. During work, you suffer pain that disappears quickly after you’ve stopped working. After a time, you move into the second phase; then the pain is less easy to locate, radiates to other parts of the body, appears more quickly, and disappears more slowly. In the third phase, the pain is almost always present. It is more extensive, and is very demobilizing. Examples of RSI complaints are tennis elbow, and the carpal tunnel syndrome.

Avoiding RSI complaints means avoiding strain. Typing and working with the mouse for a long time without taking breaks puts pressure on your muscles all the time. Tense muscles have a very low blood circulation, so they are not provided with enough oxygen and nutrients, and also, waste is not removed. This results in weary muscles, cramps, cold hands and pain. Therefore, take a short pause, or a micropause, regularly.

A micropause is a pause of around twenty seconds, which specifically serves to break the continuation of muscle strain. During such a pause, try to stretch your hands, arms, shoulders and neck a few times a day. Thanks to these stretch exercises, the blood circulation will repair itself, and you avoid RSI complaints. Hold all stretch exercises for five seconds, and repeat them three to ten times, depending on the availability of time. Also, always repeat the exercises for both arms.

In order to stretch your lower arm, you hold your arm outstretched, with your palm facing upwards. Stretch your hand down; then, stretch the fingers down. Now you turn your arm round, and stretch your hand outwards. You can stretch your hand muscles in various ways. Stretch your fingers at the same time, and then stretch each finger separately. You can stretch your shoulders by turning them as well. Then, try holding your shoulders with your hands, and pull your hands as close together as possible, and stretch your muscles even more by moving from left to right.

Do you ever experience weakness, numbness, loss of sensation, or loss of control or endurance in your hands and arms? If you said yes, you may be a victim of RSI.

RSI stands for repetitive strain injury, and it is caused by performing the same movement, over and over. It accounts for one-third of all workplace injuries, and it costs employees, employers, and insurance companies over $50 billion a year.

Something needs to be done about these workplace injuries, and with technology advancing and getting smaller, it’s only going to get worse. Computers, gaming consoles, and mobile phones are going to continue to wreak havoc on our physical and mental well-being; something has to be done. Well, what can be done? Steps can be taken to prevent these kinds of injuries.

Step one: employee awareness. Employee awareness can start at time of hire. The best time would be during the orientation process. For existing employees, education can be done on a yearly basis.

Step two: employers should require employees to take breaks after 30 minutes of continual typing or being at the station to prevent these injuries.

Step three: computer software can be installed on workstations. One particular one is WorkRave; it’s free open-source software that can be installed on a computer. It goes on parameters that are set, and it locks out your whole system and it forces you to take breaks, stretch breaks, or microbreaks. There’s also an animated character that comes on-screen; it will tell you to stretch your arms or your neck. They’ll give you the instructions. This is also free, so there’s no cost to the employer. It can be installed on Windows, Unix and Linux software workstations.

Step four: employers can provide occupational and physical therapists to assess workstations, and you have every right and the employer has to meet compliance with the OSHA act section 5 A1, and this act gives you the right to having safe working conditions. This would be beneficial to anybody using the computer over long periods of time – secretarial or clerical, for example. Employers should also implement ergonomic equipment throughout the company.

Now, some of you may be saying this is a waste of time; I wish I had been given this information in my past. During ten years working in the IT field, I developed carpal tunnel in both hands, and pinched nerves in my elbows. It was hard to pinpoint where it started or what caused it, because throughout those ten years, I worked in various places. The insurance company says it’s a workman’s comp claim, so they don’t want to work for it, and the workman’s comp claim insurance doesn’t know where it comes from, so it’s just a constant battle with them. It doesn’t stop there; at night I get numbness in my arms that wakes me up at night, up to 6 times a night, and during the day my activity is limited.

Now it’s your turn to help. What can you do? Now that you know the dangers, what can you do to help yourself and others? One: if you’re an employee, you can follow the steps that were given to you. Employers implement these steps that were given, and if you’re here to listen to me speak, you can continue and relay my message and educate others.

Professor Moritz van Tulder, from VU University Medical Center in Amsterdam:  RSI is a condition affecting millions of people worldwide. The reality is there is very little scientific evidence to guide us concerning prevention and treatment.

There’s not really a consensus about the terminology of repetitive strain injury; some people call it upper extremity musculoskeletal disorders, or cumulative trauma disorder, and I think that’s also related to the problem that it’s difficult to diagnose, and there doesn’t seem to be a consensus about the best diagnostic tests as well.  It seems to be a complex problem, but it does affect a lot of people, obviously mostly workers, or it’s mostly a work-related condition; therefore, it is also associated with high costs of sick leave.  It varies from about 10% of the workers that may have RSI complaints, to as high as 40% in some specific working populations.

So, it does affect a lot of people, and again it’s difficult to come up with one figure.  I think the most important message is that it does affect a lot of people, and especially workers.  The majority of RSI problems are in the elbow, the wrists and hands, maybe even the fingers, but sometimes in the neck and shoulder pain is included, and especially at the elbow, wrist and hands.  I think it’s often associated with pressure on the nerves.  The physical risk factors at work are repetitive movements, maybe you’re at a job or post that needs a lot of strength; so, it seems to be associated with physical risk factors at work, but there also psychosocial factors.  Maybe a high workload, a high level of stress, job dissatisfaction is sometimes seen as a risk factor for RSI.  It may happen in any job, and as long as it’s associated with repetitive movements, high physical or psychosocial workload, and any of the risk factors that I just mentioned.

There are not really gold-standard interventions that are effective for RSI, and again, it may vary if you have problems in the elbow, or the wrists, or hands.  If you look at the evidence from scientific research, then it seems some interventions are effective for short-term pain relief; for example, for elbow complaints, or corticosteroid injections for carpal tunnel syndrome, and for neck pain and shoulder pain exercises seem to be the most effective.  But there are still many other treatments and/or interventions that are commonly used in daily practice that are not really supported by scientific evidence.  Not necessarily meaning that they are not effective, but there are no large, high-quality studies that have supported their effectiveness.  So, I think it’s especially important to do more high-quality research to find out which interventions and treatments are most effective, maybe not for all patients with RSI, but specifically looking at subgroups that may benefit more from a specific intervention than from other interventions.

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Question: One of the things that comes up for millions of people are repetitive stress injuries.  It’s some joint, it becomes inflamed, it’s  painful, they can’t use it as much; you can’t, maybe, do your work, you can’t do what you like for exercise, for play.  How widespread are these? Do they just happen to us as we get older, do we have to just grin and bear it?

Dr. Charles Carroll, orthopedic surgeon at Northwestern Memorial Hospital: No. Some of it occurs in the younger population.  Some will be involved in those who are in great athletic condition, who play professional sports; others occur in those who are more deconditioned.  You might see it in office workers, you might see it in a factory worker, you might see it in a utility worker who uses a jackhammer to break concrete.  All of these injuries, over time, can affect your muscles, your tendons, your nerves and, as you mentioned, your joints.  They’re very common throughout our population because we’re very active; baby boomers are not wanting to slow down, and as we get older, we continue to push our bodies to the limit.  So these injuries are very common; many of them can be treated simply and with conservative treatment, but some will go on to require surgical care and really significant rehabilitation.  It crosses all spectrum of ages, sexes, colors, creeds, you name it.  You see it everywhere, and that’s something you see a lot of now, in our service-based economy in the United States, in our office of orthopedic surgery.

Question: I was at the supermarket earlier and there’s this woman, May, and she’s worked at the deli department for years, and she was on light duty; they had her just greeting people and helping them as they came into the supermarket, and she had this sort of splint on her wrist.  I said “May, what happened?” And she said well, you know, I’m always chopping and preparing things in the deli, and then I just started to get pain in the joints.  So here she was, chop, chop, chop with those big knives all the time for years; is that an example of repetitive stress injury on the job?

Dr. Carroll: That’s a very common example; you’ll see it in folks who were in the deli or the meat departments of supermarkets, or in large chain food stores, or in fish markets, for example.  The cutting can do one of a number of things; the first thing it can do would be to cause irritation in the tendons around the wrist. It’s a very common one, and sometimes we see this in young women having babies as well.  It’s called DeQuervain’s tenosynovitis, and that’s a pretty big name to remember, but it’s pain at the base of your thumb and your wrist.  If you can look at your wrist, and imagine what a cutting motion would do, it goes back and forth from the thumb side to the baby finger side of your hand.  There’s a tendon at the base of your thumb that goes through a sheath, and it can get irritated; when they get irritated they hurt, and a splint can be very helpful with diminishing those symptoms.  You might see it in a young mother, or a middle-aged mother (depending on the age of the woman), or sometimes in a husband or father, from lifting children; it’s the same thing, but in reverse.  When you bring the child to your shoulder or your head, you go from the baby finger side of your hand to the thumb side.  Other things that might be affecting May might be carpal tunnel syndrome; use of the hand, grasping and flexing our fingers, sometimes irritates a nerve in the hand, and can cause pain, numbness and tingling.  Other things might be something called a trigger finger, or stenosing tenosynovitis (but trigger finger is easier to remember).  It’s the same mechanism; the tendons that go into your fingers get irritated in their sheath in your palm, and it might crackle, or pop, or snap, or lock.  All of these things can come from that type of work, or work similar to it, or from leisurely activities.  Things like that need to be considered.  Another thing that can occur might be arthritis in the base of your thumb or your wrist; women who crochet or sew or do things like that put a lot of force on the base of the thumb, which can result in arthritis.  So it’s a whole spectrum of things to be looked for.

Question: Now the lady who’s on light duty at the supermarket, she’s hoping that the splint will help her get better, and she can get back to the job she thoroughly likes.  She wants to get off that light duty.  Often – and I know it varies by injury – but can this sort of splinting or rest, or just doing something different, often be the cure?

Dr. Carroll: It can be very much a great help, or a cure, as you said.  A splint can keep an injured area from working in a way it shouldn’t work; certainly avoiding the activity, or changing your activity, may let injured or tired areas rest, and allow them to heal, and it may take 2 or 3 months to do that.  Judicious use of an anti-inflammatory can be very helpful, watching after your stomach and your gastrointestinal tract.  But all these things can work in concert to allow your hand or your arm to heal, and your symptoms to go away.

Question: I had some shoulder problems, and of course when I was a runner, you get a little fanatical about that, and it’s an activity that makes you feel good.  But I started to have pain in the side of my knee, and I think if I’m not mistaken, there’s something called the iliotibial band, so maybe that’s not uncommon in runners.  And there was this sac of fluid, and I just kept making it worse and I remember my knee even kind of locked up on me, and I ended up getting a cortisone shot.  Would that be another kind of intervention?

Dr. Carroll: Certainly.  When I mentioned the activity modification of the splints, that would be your entry-level form of treatment, meaning at the beginning.  Sometimes rehab helps, but if it doesn’t, then after a number of weeks or months your physician might consider giving a cortisone injection which might permanently cut down the inflammation.  In your case, for example, it allowed it to heal, and then you could go back to running, or whatever activities you wanted.

Question: So if somebody gets to the point where their pain is not going away, and it’s affecting their job, or their favorite sport, or picking up their kid – how do we know, first of all, when to seek care, bring it up with our primary care doctor, what we’re doing at home doesn’t seem to be working? and when do you pull the trigger (for lack of a better term) and say well, should I see an orthopedic specialist?

Dr. Charles Carroll: I think most people will give it the school of observation at home (for lack of a better term), or watch it themselves, for a week or two; most people don’t rush off to see a physician.  One, it’s sometimes hard to get in, and two, none of us are inclined to see doctors unnecessarily.  But if something persists over, say, 10 to 14 days, then I think probably it requires some attention if it’s not getting better; unless if, obviously, you fell on something and you might have a fracture that hurts a lot, then you might get in that same day.  But if it’s just tendonitis, or a strain, then you might give it a week.  But if it hasn’t really gotten better in two weeks or so – maybe a little bit less time than that – then you might want to see your primary care, and he or she then may refer you on to speak to an orthopedic surgeon in the office, or see one of them, so it doesn’t get too far afield.  I think in the first week or two, you might keep an eye on it, but after that, it probably warrants some form of attention.

Question: You’re an orthopedic surgeon, but tou are talking about conservative, non-surgical approaches; I’m happy to hear that, from a surgeon, it doesn’t sound like you’re eager to do the surgery when there are other approaches that could do the job.

Dr. Carroll: I’m a physician first and a surgeon second, so you’re hearing that bias that I have in the way I speak about it.  If you look at organizations like the American Society for Surgery of the Hand, and the American Academy of Orthopedic Surgeons, if you look at the tenets, the things we talk about in those meetings, and the things those organizations try to teach us through courses, we emphasize conservative treatment, and then the failure of that conservative treatment then becomes a reason to operate, as opposed to operate first and then worry about the consequences later.  I think you’re seeing a slightly different approach in terms of philosophy as time has gone on in a lot of physicians – I don’t think I’m the only one.

Question: I think it’s great; if you happen to go to one, not for a life-threatening condition, and they’re recommending surgery, saying I can do that for you next Tuesday, come on down – what’s your opinion about second opinions in that situation?

Dr. Carroll: I encourage patients, personally, to seek second opinions, and sometimes I ask them to when they kind of have that look on their face like they don’t believe or understand what I’m saying.  I try to speak in fairly straightforward, simple terms so that people understand what I’m talking about.  I think second opinions are very helpful and healthy.  I say that for two reasons.  One, from a physician’s standpoint, a highly educated patient is a great one to take care of, and education comes from many sources now.  So, a second opinion is wonderful because the patient might get more education.  Number two, from the patient’s side, if you hear things from two or three different people about the same problem, in a similar fashion, you will probably be somewhat secure in doing something about it; but if you hear dramatically different opinions on that, most of us will go, as people, with the more conservative opinion, if we understand the risks and benefits of the treatment.  So, I think the physician that says to me, as a person, “You need surgery next Tuesday” for a non-threatening or non-traumatic condition, if you’re not so sure, say “Yes doctor, I’ll think about it; I might consider a second opinion.”  The physician, from my perspective, shouldn’t take much umbrage at that, and shouldn’t get upset; they should say, “That would be great, you’ll know more, and if you know more it’ll be easier for you to make that decision and, therefore, go to treatment.”  In my experience, the more educated patients seem to travel through the system a lot easier, have a lot fewer questions, and have a much more positive experience.

Question: Within orthopedics, doctors seem to have special interests or sub-specialties; like, when we talk about hand surgery, I know that’s one of your special interests.  Should that be something that someone should ask the doctor about as well?  So if you have carpal tunnel, maybe you want to find somebody who really treats a lot of that, rather than somebody who specializes in the shoulder, for example.

Dr. Carroll: Well, in a large city you might have a number of specialists around that might specialize in a certain area, so you might have the latitude to request that level of expertise and experience.  If you live in a less populated area, you might not have someone who has quite the same experience because there’s less of the problem around.  I think the things you want to look at are the qualifications of your physician.  Are they board-certified, and if not, why not? Sometimes younger physicians are still working through the process, but are board eligible and are very good; but I think if you have the latitude, clearly if you can find someone who does more of something, the odds are they will have dealt with the problems and the complications, and can probably give you a better chance for a fairly easy transition through the process.  But I don’t want to leave those reading my words thinking that they have to go to a hand surgeon for every hand problem, because a properly-trained orthopedic surgeon may have the skill to do this, some plastic surgeons have the skill to do it and even some general surgeons will take care of hand problems.  The more experience you have, the better you are as a physician; there are areas now in orthopedics of total joint surgery, where hips and knee replacements are done by total joint surgeons.  There are spine surgeons in orthopedics that concentrate only on the spine, and some of them do cervical spine, some do thoracic and lumbar, so there’re some differences there.  Sports medicine covers a lot of different areas; there are pediatric orthopedic surgeons who can take care of the kids. I think you can look at all of these areas, and even the foot and ankle, and find someone who has the experience, training and qualifications to take care of your problem – BUT a very well-trained orthopedic surgeon can take care of many different problems, and not necessarily be a sub-specialist in any of them.

Question: Because these repetitive stress injuries are so common, I think they’re something that all orthopedists see.  Now, you mentioned earlier about the team approach, and I imagine at Northwest you have that, because there are doctors, there are nurses, and there are physical therapists.    So how does that work, at Northwestern, with everybody working together? If you move forward, you try the more conservative approaches, you have assistance there; maybe at some point surgery could come in, and then you have rehabilitation and recovery, and it sounds like you need a whole team.

Dr. Carroll: You do, and we have all of that at Northwestern.  I guess they do at other institutions as well, but we incorporate through the different practices and groups, a philosophy of good care, collegiality and communication, so I think that we work through the different medical specialties very well here at Northwestern, be it endocrinology and orthopedics, or general surgery and the like.  So, the doctors are on the same page.  In the hospital setting itself, and some of the physicians in their offices will have nurses as well that they work with who help with communication, organizing patient care, and organizing surgical care.  Clearly, in the operating room, when I do a surgical procedure, I have an anesthesiologist or nurse anesthetist, a circulating nurse or technician, and a nurse that also scrubs with me.  So, we work as a team to make that the equipment is there, the patient safely transitions in and out of surgery; we do something at Northwestern called a time-out, where we discuss what we’re doing, who the patient is, and make sure we don’t make any errors with wrong site surgery or anything like that.  Afterwards, the nurses are very helpful in the post-operative recovery area and taking care of you around the floor, if you have to stay at the hospital.  As you transition back to an outpatient setting, physical therapists and occupational therapists are there to educate, facilitate, move your joints, teach you, splint you, help you work through the acute recovery and into the more chronic recovery.  If it works well, it transitions through all of that seamlessly, and the patient does not even know it.

Question: When I think of repetitive stress injuries, I think of maybe a higher level of responsibility of the patient to do what they can – whether it’s cease certain activities, change certain activities, try certain anti-inflammatories, the heat, the cold, the splints that might be recommended, physical therapy before surgery or instead of surgery – it sounds like a partnership, that we as a patient have some work to do to try to get back on our feet, and have the full range of motion or activities that we really want to have.

Dr. Carroll: You summed it up well with the word “partnership”. The most effective healthcare is when the doctor and the patient are in partnership.  The doctor has his or her responsibility, and we touched on some of that, but the optimal recovery for any particular patient will certainly be present when the patient partnered with the doctor and then participated fully like you described.  Without that – all of the education that I give, it won’t work and nothing happens.  So I think if we can partner the patients will have a much better outcome.

Question: There are a few million people with an inflammatory condition, rheumatoid arthritis, and they might have initially some pain in a joint or something like that.  How do we get the proper diagnosis, proper screening to see if it’s simply a repetitive stress injury, or is it something more?

Dr. Carroll: I think that can come fromtwo or three sources.  Your primary care physician, if they see some of the swollen, inflamed, boggy joints, or some deviation of the digits, or changes in your feet or hip or knee problems, they might start to suspect it; if they do, they can draw some blood, testing a rheumatoid factor to see if that shows up.  They, being a primary care physician and talking to the patient, have two options.  They can refer you to a rheumatologist, who would look further at x-rays and examinations and blood tests, and correlate all the findings of the diagnosis, or they could refer you to an orthopedist, who might not do all of the medical management (the blood tests and the medications), but can also make the diagnosis.  Clearly, all three groups of physicians have to work together to modulate medications and preserve joint function.  Now, with our medications being better, often we don’t have to do surgery for rheumatoid arthritis like we used to.  I think the key thing is differentiating the swelling from repetition from rheumatoid arthritis.

Question: Related to repetitive stress injuries –  do you feel that we have a range of approaches now, that can help people, so that it’s not pain we have to live with for the rest of our lives?

Dr. Carroll: I do; I believe that over the past number of years we’ve improved our conservative treatment and our medications have gotten better. We still don’t have the perfect anti-inflammatory. Nevertheless, I think we’re much better at it than we used to be.  With judicious therapy, education, joint preservation activities, I think we’re able to maintain a high level of activity in our lifestyle, with a lot less wear and tear.  The key thing is, we’re now seeing it and recognizing it, rather than just saying: “You’ve just got some rheumatism, I’ll see you later.”

Question: All of us would like to prevent it if we could; Going back to the woman who was in the deli, or the person who sits at a desk all day and types on the computer, are there some things we can do to try to head off the problem before it occurs?

Dr. Carroll: I think the most important thing is to have proper ergonomics, and then during the course of your day, stop every hour or so and stretch and vary your job activity. Other things that I see, as a physician, is a very deconditioned population.  If you’re able to maintain adequate physical activity outside of work, in life – exercise 3-4 times a week doing aerobic and strength training – that makes a big difference, especially as we get older.  One of the things that happens to us, besides getting stiff, is we lose our muscle mass; so if we’re able to maintain cardiovascular activity, maintain weight training so we keep our muscle mass, that makes it easier to prevent these injuries.  The other thing is to think: Am I in a situation where I’m going to get a repetitive stress injury, and I’m not paying attention?  Recognition of the fact that it may occur is just as important, and then seeking out proper healthcare if nessacary.

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