Repetitive strain injury (RSI), also known as Cumulative Trauma Disorder (CTD), occupational overuse syndrome, or work related upper limb disorder (WRULD), is the most recent manifestation of illness concepts that link use of the arm to injury or disease. Prior to typewriters or computers there was the concept of "writer's cramp".

The basis for this illness concept is the idea that one can overuse a tool, such as a computer keyboard or musical instrument in a way that causes tissue damage leading to pain. Conditions such as RSI tend to be associated with both physical and psychosocial stressors.

[edit] The Illness

[edit] Symptoms

The following complaints are typical in patients that might receive a diagnosis of RSI^[1]:

• Pain in the arm (typically diffuse--i.e. spread over many areas).
• The pain is worse with activity.
• Weakness, lack of endurance.
• Muscles in the arms and shoulders feel hard and wiry when palpated.

The symptoms tend to be diffuse and non-anatomical, crossing the distribution of nerves, tendons, etc. They tend not to be characteristic of any discrete pathological conditions.

[edit] Illness concepts/beliefs

The typical patient presents with a strong intuition that their pain indicates existing and ongoing tissue damage.^[2] A good way to understand this is that they have a strong "pain alarm"--pain tends to be accepted as a sign of danger and they have difficulty modulating this intuitive uneasiness with pain (e.g. turning down or turning off the "pain alarm".^[3]

[edit] Physical Examination and Diagnostic Testing

The physical examination discloses only tenderness and diminished performance on effort-based tests such as grip and pinch strength--no other objective abnormalities are present. Diagnostic tests (radiological, electrophysiological, etc.) are normal. In short, RSI is best understood as a healthy arm that hurts.

[edit] Psychosocial Aspects

Pain and pain-related disability have been associated with job stress. Job demands, poor support from colleagues, and work dissatisfaction all correlate with increased pain.^[4]

There are three common mechanisms, by which a normally functioning human mind increases pain and pain-related disability.

• Psychological distress (depression and anxiety) make pain seem worse.^[5]
• Misinterpretation or over-interpretation of pain signals. Psychologist refer to this as pain catastrophizing (the tendency to think the worst when one feels pain).^[6]
• A sense that something is seriously wrong that does not lessen with normal test results and reassurance from health professionals.^[7] Psychologists call this heightened illness concern or health anxiety.

[edit] Behavioral Aspects

There is substantial evidence that behavior influences health perception.^{[8] [9] [10]}Acting ill can increase feelings of unwellness. On the converse, wellness is in large part a way of behaving and thinking. For instance, avoidant behavior--stopping or limiting a painful activity--can reinforce beliefs that a specific activity is harmful via both physiological (anxiety response) and psychological mechanisms. In contrast, accomplishing and activity in spite of pain can reinforce the fact that the arm continues to function and serious disease is absent.

[edit] Uses of the concept of RSI

The term "repetitive strain injury" is most commonly used to refer to patients in whom there is no discrete, objective, pathophysiology that corresponds with the pain complaints.

Others seem to use it as an umbrella term incorporating other discrete diagnoses that have (mostly unfairly) been associated with activity related arm pain such as Carpal tunnel syndrome,Cubital tunnel syndrome, a form of Ulnar nerve entrapment, true Thoracic Outlet Syndrome, DeQuervain's syndrome, Stenosing tenosynovitis/Trigger finger/thumb, Intersection syndrome,Golfer's elbow (medial epicondylosis), Tennis elbow (lateral epicondylosis), or Focal dystonia. Arm use is a speculative etiological factor for these diagnosis that remains unproved and debatable.

For example, the association of Carpal tunnel syndrome with arm use is disproportionately commonplace given that it is not well-established.[1] It is important not to confuse carpal tunnel syndrome (which causes numbness) with activity-related arm pains. Typing has long been stigmatized as a cause of carpal tunnel syndrome[2], but recent evidence suggests that, if anything, typing may be protective.^[11]

Finally RSI is also used as an alternative or an umbrella term for other non-specific illnesses or general terms defined in part by unverifiable pathology such as Reflex sympathetic dystrophy syndrome (RSDS), Blackberry thumb, disputed Thoracic Outlet Syndrome, Radial tunnel syndrome, "Gamer's thumb" (a slight swelling of the thumb caused by excessive use of a gamepad), "Rubik's wrist" or "cuber's thumb" (tendinitis, carpal tunnel syndrome, or other ailments associated with repetitive use of a Rubik's Cube for speedcubing), "Stylus Finger" (Swelling of the hand caused by repetive use of mobile devices and mobile device testing. Mobile Device), "Raver's wrist", caused by repeated rotation of the hands for many hours (for example while holding glow sticks during a rave). A common theme among many of these terms is a stigmatization and demonization of hand use. Illness concepts that stigmatize hand use have the potential to create more illness as well-documented in the experience with the Austrailian RSI epidemic. ^[12]

Although Tendinitis and Tenosynovitis are discrete pathophysiological processes, one must be careful because they are also terms that doctors often use to refer to non-specific or medically unexplained pain.

[edit] Treatment

Modifications of arm use (ergonomics) are often recommended, but they are palliative and there is no evidence of their effectiveness.^[12] Some examples are listed in the next paragraph.

Adaptive technology ranging from special keyboards, mouse replacements and pen tablet interfaces to speech recognition software might be necessary. Pause software reminds the user to pause frequently and/or perform practices while working behind a computer. One such program is Workrave, an open-source free program that assists in the recovery and prevention of Repetitive Strain Injury. The program frequently alerts user to take micro-pauses, rest breaks and restricts user to a predefined daily limit. Switching to a much more ergonomic keyboard layout such as Dvorak^{[citation needed]} or Colemak. Switching to a much more ergonomic mouse, such as a vertical mouse or joystick mouse. Such mice may provide relief, but in chronic RSI they may only result in moving the problem to a different area. Switching from using a mouse to using a stylus pen with graphic tablet. Using a graphic tablet for general pointing, clicking, and dragging (i.e. not drawing) may take some time to get used to. Switching to a trackpad such as a Smart Cat trackpad, which requires no gripping or tensing of the muscles in the arms.

Most treatments including non-narcotic pain medications, braces, therapy, etc. are palliative.^[12]

Given that main stream health providers are still working on the best approach to RSI, it is not surprising that alternative treatments are popular. Some examples follow:

Some people with RSI find relief in specific movement therapies such as t'ai chi ch'üan, yoga, or the Alexander technique Exercise decreases the risk of developing RSI.^[13] Also, doctors often recommend that RSI sufferers engage in specific strengthening exercises, for example to improve posture.

Surgery is never advisable for this diagnosis nor for any non-specific, unverifiable illness concept.

[edit] Footnotes

[edit] References

References that support or promote use of the illness concept of RSI

• Repetitive Strain Injury: A Computer User's Guide; Emil Pascarelli and Deborah Quilter (ISBN 0-471-59533-0)
• It's Not Carpal Tunnel Syndrome! RSI Theory and Therapy for Computer Professionals; Suparna Damany, Jack Bellis (ISBN 0-9655109-9-9)
• Conquering Carpal Tunnel Syndrome & Other Repetitive Strain Injuries, A Self-Care Program; Sharon J. Butler (ISBN 1-57224-039-3)
• The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, Second Edition; Clair Davies, Amber Davies (ISBN 1-57224-375-9)
• Electromyographic Applications in Pain, Physical Medicine and Rehabilitation: Repetitive Strain Injury Computer User Injury With Biofeedback: Assessment and Training Protocol; Erik Peper, Vietta S Wilson et al. The Biofeedback Foundation of Europe, 1997
• van Tulder M, Malmivaara A, Koes B (2007). "Repetitive strain injury". Lancet 369 (9575): 1815–22. doi:10.1016/S0140-6736(07)60820-4. PMID 17531890. 

References that are cautious about the use of the illness concept of RSI

• Szabo RM, King KJ.Repetitive stress injury: diagnosis or self-fulfilling prophecy? J Bone Joint Surg Am. 2000 Sep;82(9):1314-22. Review.
• Ring D, Guss D, Malhotra L, Jupiter JB. Idiopathic arm pain. J Bone Joint Surg Am. 2004 Jul;86-A(7):1387-91.
• Quintner JL.The Australian RSI debate: stereotyping and medicine. Disabil Rehabil. 1995 Jul;17(5):256-62.
• Hall W, Morrow L.'Repetition strain injury': an Australian epidemic of upper limb pain.Soc Sci Med. 1988;27(6):645-9.
• Lucire Y. Constructing RSI: Belief and Desire. University of New South Wales Press. 2001

[edit] External links

• Repetitive Strain Injuries at the Open Directory Project
• Musculoskeletal disorders from the European Agency for Safety and Health at Work (EU-OSHA)
• Workrave application for prevention of RSI
• TalkRSI Community entirely devoted to the topic of RSI
• Repetitive Stress Injury at The Journal of Bone & Joint Surgery