RTW Knowledge Base
RTW Knowledge Base
Home Employee Employer Medico Insurer View All Types About Champions Contact
Medical Factors
Repetitive strain injury

At a glance:
Arm soreness is a common condition in the community. At some point in their life, the majority of people have had an upper-limb problem that interfered with their normal activities. At any given time, 10-15% of the population are experiencing arm pain.

Arm pain is more common in people exposed to:

High levels of psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 distress
Arm and wrist movements that involve repetition, force, or prolonged awkward posture
Monotonous work
Low control at work
When an employee has experienced arm pain, several strategies will improve their outcomes. These include:

Identifying the problem early
Good communication
Flexibility in the workplace to accommodate for the injury and help the person return to work quickly


To prevent and manage arm pain, work duties might need to be changed, however they should still allow the person to make a meaningful contribution at work. It is not a good idea to overly restrict duties, since this can increase job stress.
Perspectives:
Employee
Upper limb pain is a common problem.

Staying active and at work will help you recover more quickly. Continued activity will not worsen your condition. However, making changes to the workplace to minimize strain
strain
Injury to a muscle in which the muscle fibres tear or become irritated as a result of overstretching or wrenching
 will make work more comfortable for you, and may prevent your condition recurring. Modification of job tasks or decreasing work load or hours may be necessary to get you back to work as soon as possible. However it is important you feel productive and part of the team at work. Overly restricting tasks is not necessary, and it can cause stress and further problems. Think about what tasks might be causing the problem and what can be put in place to deal with them in another way. Reviewing the workstation and work duties can assist. Talk to your employer and doctor about the changes that are needed to accommodate your injury.

The outlook for this condition is good. The problem generally settles, but can reoccur if the same conditions arise again – such as a high volume of work done to a deadline. Work out strategies to minimise the chance of that happening.
Employer
Upper limb pain is a common problem, especially in people who do repetitive work. Risks for developing upper limb
upper limb
arm
 pain include repetitive movements of the arm and wrist, monotonous work, and low control at work.

Therefore, prevention of these conditions may be possible. This requires discussion with the employee and their supervisor. Strategies include:
  1. An ergonomic
    ergonomic
    Designing activities and the workplace in a way to minimize discomfort. i.e. Adapting work tasks, hours, or workstation to accommodate people. An ergonomic computer workstation allows the person to work in the best position to relieve load on the muscles of the neck and arms.
     review of the job
  2. Regular mini stretch breaks
  3. Job planning to avoid a last minute rush to meet deadlines
  4. Increasing an employees sense of job control
  5. Providing a rotation of tasks
  6. Dealing with any tension in the workplace that may be contributing to the problem.
  7. Ensuring that this the right job for the employee
  8. Supporting the employee to regularly exercise
  9. Good communication channels between the employee and their manager
  10. The attitude of employers/supervisors to workers and their welfare also affects their recovery. Encourage good relationships between co-workers and foster positive attitudes toward the injured worker.
Treater
Non-specific forearm pain should be separated from disorders with a clear medical cause, such as nerve compression (e.g. carpal tunnel
Carpal Tunnel
A tunnel at the wrist made up of the wrist bones and a strong ligament. See carpal tunnel syndrome.
 syndrome), muscle/tendon damage and arthritis. When treating patients with non-specific arm pain encourage activity, reassure the patient they will not harm themselves even if their activities cause pain, and acknowledge the contribution of psychosocial
psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.
 factors in disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 from arm pain.

Effective management of arm pain is best achieved with a comprehensive approach. Strategies include:
  1. Modified duties. This may be through:
    • A period of modified normal duties, i.e. continuing usual duties with some components of the job removed
    • A rotation of tasks, interspersing normal duties with less repetitive tasks
    • Reviewing the way the job is being done and modifying the persons technique (this is the usual approach for sports people with this condition)
    • A period of alternate duties
  2. Mini stretch breaks of 30 seconds, to encourage the person to change posture and stretch the arms. Setting reminders on computer calendars such as Outlook can help ensure people remember to do this. There are also specialised software programs that can help.
  3. Recognise that the person needs to continue with meaningful and productive duties. Overly restrictive duties often prevent people from being productive and can alienate them from their colleagues.
  4. Rehabilitation should occur proactively. When people remain on reduced hours for many months they cease to be part of the normal team. This increases the psychological strains and may perpetuate the condition.
  5. Ensure the patient understands this is a common condition and generally has a good outlook. Problems have occurred because this condition has been ‘medicalised' and people have restricted activity for too long.
Insurer
Ergonomic interventions can prevent recurrence of non-specific arm pain and make workers with upper limb conditions more comfortable in the workplace.

Physiotherapists or occupational therapists with ergonomic training can be helpful in facilitating workplace or job task modifications necessary to get the employee back into work quickly without worsening their injury.

Addressing personal and workplace factors that are barriers to recovery (e.g. beliefs about the illness, depression
depression
A symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer and may recur, but it is generally reversible in the short run.
 or distress, attitudes to the sick worker in the workplace) is also important. A multi-component intervention
intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 (including physical conditioning, work conditioning, pain and stress management, ergonomic consultation and work counselling) may be best for managing people with arm pain who are slow to return to normal activities.
Original Article, Authors & Publication Details:
P. S. Helliwell1 and W. J. Taylor2 (2004). Repetitive strain injury. Postgraduate Medical Journal; 80(946):438-443.

1Musculoskeletal Academic Unit, University of Leeds, Leeds, UK

2Rehabilitation Teaching and Research Unit, Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand
Background, Study Objectives, How It Was Done:
Repetitive strain injury (RSI) is the name often given to arm pain when the specific cause is unknown. The term is generally used when the arm pain is related to the person's job. The term implies that repetitive work has caused the problem. In fact, it is often unknown if this is really the case or not, so the name can be misleading.

Upper limb pain is very common in the general population. 5-20% of the population report having persistent pain in the shoulder, elbow, hand or forearm in the last month. Upper limb pain can cause significant disability in the community: 57% of working age adults report shoulder pain has interfered with their ability to work.

This paper reviewed research about the risks, causes and treatment of forearm pain and provided recommendations to doctors about how to manage the problem.
Study Findings:
Risks and causes of developing forearm pain:

Both physical and psychosocial factors appear to contribute to causing forearm pain. The most important risks seem to be:

High levels of psychological distress
Repetitive movements of the arm and wrist
Monotonous work
Low control at work
There are a number of possible mechanisms by which physical factors cause pain. Heavy lifting may damage muscles or ligaments
ligament
fibrous tissue
tissue
Collection of cells that perform a similar function. e.g. epithelium (skin), connective tissue (blood, bone), muscle
 that connects bones to other bones
 if the load is greater than the strength of the tissue. While lifting fairly low loads, muscle “creep' can occur. This means that the muscle temporarily changes in length, taking several hours to recover from the change. During this time, it is more vulnerable to injury. Non-specific arm pain, however, does not seem to involve tissue damage.

Prolonged force on a muscle could cause increased pressure and reduce blood flow. Some research shows that there are chemical changes within muscles after lifting. One study showed that the structure of muscles is different in people with long-term work-related arm pain, while another showed that people with arm pain have muscles that fatigue more easily than normal.

Another possible explanation is that non-specific arm pain is caused by changes in the nerves. Some researchers have suggested that non-specific pain is caused by confused signals from the nerves. One study showed that in patients with arm pain, certain nerves in the wrist have reduced space and mobility. There is also evidence that in people with non-specific arm pain, there are differences in the way their blood vessels constrict in response to signals from the body.

Diagnosis and treatment of forearm pain:

Non-specific forearm pain should be separated from disorders with a clear medical cause, such as nerve compression (e.g. carpal tunnel syndrome), muscle/tendon damage and arthritis.

Non-specific forearm pain can be treated in a similar way to non-specific low back pain. It's important to consider risk factors for developing pain and obstacles to recovery.

Management strategies include:

Acknowledge the persons symptoms and recognise that the level of discomfort can be high
Identify “red flags' that suggest a different diagnosis
diagnosis
The process of identifying a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of various diagnostic procedures.
 (e.g. nerve problems, swelling). When red flags are present, further investigation and tests are needed
Consider specific diagnoses for which there may be appropriate investigations or treatment (e.g. arthritis, nerve compression)
Identify physical risk factors
Highly repetitive work
Prolonged awkward postures
High force/heavy load
Identify “flags' that may pose obstacles to recovery

“Yellow flags' (psychological)
Beliefs or concerns about their illness that make them “catastrophize' the situation or avoid activities that they think will cause pain
Depression or psychological distress
distress
Severe suffering, pain, anxiety or sorrow
 (the General Health Questionnaire is a good screening tool)

“Blue flags' (workplace issues)
 
Monotonous work
Low degree of control
Poor relationships at work
High work demands

“Black flags' (workplace organisation issues)
Workers compensation issues
Attitudes to the sick worker

Reassure the patient that there is no evidence of damage and that continued activity will not cause damage

Recommend the patient shouldn't take time off work if possible

Communicate with the patient and their work supervisor or employer about temporary modification of work duties to accommodate injury in the workplace

Prescribe pain medication to relieve pain if necessary

Review within 7 days

 
These guidelines emphasize that activity is important. The patient should be reassured that they will not harm themselves even if their activities cause pain. The guidelines also stress that psychological and social factors play a role in disability from arm pain.

Making changes to the layout and procedures in the workplace might make work more comfortable for a person with arm pain. There is evidence that ergonomic interventions prevent repeated episodes of arm pain and disability. Work overload, uncomfortable surroundings and poor relationships between staff and supervisors will make it harder for the employee to tolerate their symptoms and continue working.

All people with arm pain that has lasted for more than four weeks, and is limiting their activity, should be examined and their medical history reviewed. It is important to evaluate these peoples work duties. If the symptoms are likely to be work related, or the condition is making work difficult, it is crucial that the workplace is involved in the person's rehabilitation. Workplace changes or modifications to the workers job tasks might be necessary to get them back to work quickly without worsening their injury. Physiotherapists or occupational therapists with ergonomic training can help with this.

When people with arm pain are taking a long time to return to their normal activities, a multi-component rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 program might be helpful. One study investigated a multi-component program that involved physical conditioning, work conditioning, pain and stress management, ergonomic consultation and work counselling, and found that it increased the likelihood of returning to work.
Conclusions:
Pain in the forearm is a relatively common condition. People performing work that is highly repetitive, requires high force or involves prolonged awkward postures are probably more at risk of both specific and non-specific arm pain. However, other factors also contribute to the development of arm pain. The physical and social environment in the workplace plays a role, as do psychological factors.

The best management for non-specific arm pain seems to be a coordinated approach, with input from a range of health professionals. As with low back pain, it's important not to restrict normal activities and to return to work as quickly as possible.
References:
PubMed Abstract
Total Votes for this Article: 17 Average Rating: 1.5
Poor                               Excellent