The term ‘repetitive strain injury’ has been used to describe a painful upper limb syndrome usually involving the hand and associated with repetitive tasks. Whilst prevention of RSI has received much publicity unfortunately it still occurs, usually originating in the hand but tending to spread. Historically, different terminology has been used to describe this phenomenon such as;
non-specific arm pain
work related upper limb disorder
You astute readers will recognise that this selection of descriptive terminology implies a broad spectrum of pathophysiology with a resulting broad spectrum of treatment
The first important issue to establish is the pathophysiology. Invariably there is a combination of sensitive tissues involving;
and the clinical challenge is to identify the proportion of symptoms which are attributable to each.
The second clinical challenge is to identify the pathomechanics. Whilst the repetitive activities associated with fine dexterous hand use are often key components in the pathophysiology, it is often coupled with sustained continuous static loading of other components of the upper limb or upper quadrant, which also end up symptomatic and become part of the presentation. Therefore, the underlying pathomechanics often involve a combination of static sustained overload and dynamic repetitive overload.
Identifying the stage in the pathological process is of key importance to determine whether graded exposure to provocative activities can still be maintained as part of the clinical management or whether complete removal of aggravating activities is necessary. In my experience the spectrum of presentations is very broad and I only reserve complete removal from aggravating activities if it is obviously clear that it is producing significant exacerbation of symptoms and there are no alternatives for job task/mix activities to alter the level of loading.
It is absolutely essential for treating clinicians to identify evidence of central sensitivity manifesting as part of a symptom pattern. Clinicians should be looking for a clear identifiable link between mechanical provocation and symptom response.
If there is not a clear link then suspicion needs to be aroused of a central sensitivity state producing spontaneous random pain.
Of course there are other markers of central pain states such as; fluctuating pain sites spreading to the non-involved side, sustained / prolonged irritability and the observation of minimal / modest local signs all being important indicators.
The general demeanour of the patient with regard to sleep pattern, fatigue and general exercise tolerance are also key factors, which must be evaluated clinically. In my opinion central sensitivity pain states cannot be managed exclusively with
physiotherapy techniques and require some form of pharmacological assistance as part of the rehabilitation protocol. It is therefore incumbent upon the primary care provider (physiotherapist) to identify these mechanisms.
The other important risk factor for chronicity is the presence of peripheral neuropathic pain, which may act as limiting factor to physical treatment or compromise the ability of the therapist to address mechanical signs as a result of underlying neural hypersensitivity. These factors are essential components to consider as part of the overall management of repetitive strain injuries.
Effective treatment dictates that the symptom descriptors are identified and categorised in order to plan best interventions. Response rates are often slow so it is imperative that the clinician identify the expected recovery profile with recognised “recovery landmarks” to gauge treatment response or indicate alternative management.
Rise to the clinical challenge.