Upper limb neuropathy in computer operators? A clinical case study of 21 patients

Jepsen reports about 21 RSI cases in a small study he did in 2004.


Fulltext article is available at:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=516037



Article abstract:

BACKGROUND: The character of upper limb disorder in computer operators remains obscure and their treatment and prevention have had limited success. Symptoms tend to be mostly perceived as relating to pathology in muscles, tendons or insertions. However, the conception of a neuropathic disorder would be supported by objective findings reflecting the common complaints of pain, subjective weakness, and numbness/tingling. By examining characteristics in terms of symptoms, signs, and course, this study aimed at forming a hypothesis concerning the nature and consequences of the disorder. METHODS: I have studied a consecutive series of 21 heavily exposed and severely handicapped computer-aided designers. Their history was recorded and questionnaire information was collected, encompassing their status 1/2 - 1 1/2 years after the initial clinical contact. The physical examination included an assessment of the following items: Isometric strength in ten upper limb muscles; sensibility in five homonymously innervated territories; and the presence of abnormal tenderness along nerve trunks at 14 locations. RESULTS: Rather uniform physical findings in all patients suggested a brachial plexus neuropathy combined with median and posterior interosseous neuropathy at elbow level. In spite of reduced symptoms at follow-up, the prognosis was serious in terms of work-status and persisting pain. CONCLUSIONS: This small-scale study of a clinical case series suggests the association of symptoms to focal neuropathy with specific locations. The inclusion of a detailed neurological examination would appear to be advantageous with upper limb symptoms in computer operators.

Helliwell:Review:Repetitive strain injury

Helliwell:Review:Repetitive strain injury

http://pmj.bmj.com/cgi/reprint/80/946/438

Article abstract:
Pain in the forearm is relatively common in the community. In the workplace forearm pain is associated with work involving frequent repetition, high forces, and prolonged abnormal postures. Nevertheless, other factors are involved in the presentation and the continuation of the pain. Notable among these factors are psychosocial issues and the workplace environment - the attitude to workers and their welfare, the physical conditions, and design of the job. Primary prevention may be effective but active surveillance is important with early intervention and an active management approach. Physical treatments have not been extensively evaluated. In the established case, management should be multidisciplinary, addressing physical aspects of the job but also addressing the ‘‘yellow, blue, and black flags’’ which should be viewed as obstacles to recovery. For the worker ‘‘on sick’’ a dialogue should be established between the worker, the primary care physician, and the workplace. Return to work should be encouraged and facilitated by medical interventions and light duty options. Rehabilitation programmes may be of use in chronic cases.

RSIdoctor's comments:
Helliwell's review mentions nicely the problem of the name. It nicely summarizes the pathophysiology of RSI.

Sharma et al (1997):Thermographic changes in keyboard operators with chronic forearm pain

Sharma et al (1997):Thermographic changes in keyboard operators with chronic forearm pain

Full text (free): http://www.bmj.com/cgi/content/full/314/7074/118

RSIdoctor's comments: short article which desribes results of applying termography before and after typing to RSI patients and controls.
Their conclusion is: "We conclude that thermography needs further evaluation as a diagnostic tool in evaluating repetitive strain injury. It may prove more useful in follow up, particularly in measuring response to treatment, some of which has been prescribed at enormous cost and with little evidence of benefit."

The article is fairly short, hence

Full text of the whole article:
Introduction
Chronic incapacitating forearm pain and disability in the context of repetitive action has caused much debate. Lack of objective measurements in a condition with diverse symptoms, few physical signs, and uncertain pathology is a major problem.1 2 Clinical observations have suggested the presence of vasomotor changes in repetitive strain injury, so we used computer assisted thermography to assess this.

Ten consecutive keyboard operators (six women) with chronic forearm pain exacerbated by keyboard work presenting for rheumatological assessment and 21 (12 women) asymptomatic controls matched for sex and typing speed (30-50 words/min) were recruited from rheumatology outpatient clinics. All the patients had had diffuse forearm pain for at least three months. We excluded patients with Raynaud's syndrome, neurological causes, compartment syndromes, inflammatory conditions, epicondylitis, algodystrophy, trauma, and diabetes mellitus.

We used a Talytherm infrared camera unit with thermal emission measurement software (Rank Taylor Hobson UK Ltd). Ambient temperature was controlled at 22-24° C. Baseline images were taken after acclimatisation for five minutes; the subjects then typed at their usual speed from a standard text for five minutes, and another thermogram was taken immediately afterwards. Thermograms were taken over 200-350 pixels on the 2nd, 3rd, and 4th proximal phalanges of both hands, avoiding large muscle masses which might interfere with the readings. Mean readings were recorded. All the patients were asked to return after a mean of nine months to assess reproducibility, though one refused further evaluation because of pain, two had moved away, and two did not respond. Differences between means in patients before and after typing were assessed with Student's paired t test and the unpaired test for intergroup means.

After typing all the patients had symptoms. In each patient the mean temperature readings after typing were significantly reduced (fig 1) (mean 2.11°C, range 0.45-3.44°C, 95% confidence interval 1.35 to 2.26°C; P<>0.05), though significantly different afterwards (P<0.001). Only four controls showed cooling (mean 0.55°C, range 0.35-1); the 95% confidence interval of the differences between the means before and after typing in the two groups was 0.93 to 2.59°C. Of the five patients who were reassessed, four again showed cooling, while the fifth, who had clinically recovered, did not.


Comment
The changes we have described are reproducible and the method is non-invasive. It was notable that the temperature readings in the one patient who became asymptomatic changed significantly at his reassessment. Cooling in symptomatic patients may be secondary to sympathetic overactivity as a result of nociceptor and mechanoreceptor stimulation leading to a reflex neuropathic state; however, cooling after challenge suggests that it is a result rather than a cause.

Many attempts have been made to explain the relation between pain and sympathetic overactivity, mostly in algodystrophy. These suggest a central sensitisation of wide dynamic neurones within the spinal cord.345 This sensitisation is thought to arise via afferents arising in peripheral nociceptors, resulting in increased sympathetic efferent activity leading to painful response rates to subsequent afferents. This results in further sensitisation, setting up a vicious circle of sympathetically maintained pain. This is unlikely to be the sole explanation, however, as sympathetic blockade has not been successful in repetitive strain injury.

We conclude that thermography needs further evaluation as a diagnostic tool in evaluating repetitive strain injury. It may prove more useful in follow up, particularly in measuring response to treatment, some of which has been prescribed at enormous cost and with little evidence of benefit.

How to do a smart search in Pubmed for RSI

How to do a smart search in Pubmed for RSI

...using the MeSH terminology.
MeSH code for RSI is "D012090"
You can not search Pubmed using the code. You have to use one of the textual terms.
RSI is immediately translated into "Cumulative Trauma Disorders"
NoExp parameter will prevent the expansion of thesearch to children terms of D012090. (which are in this case not desirable results)


Use some of the following search strings:

("Cumulative Trauma Disorders"[Majr:NoExp]) AND (Helliwell PS[Auth])
("Cumulative Trauma Disorders"[Majr:NoExp]) AND (Helliwell[Auth]) (same results)


("Cumulative Trauma Disorders"[Majr:NoExp]) AND (greening[Auth])


RSIDOCTOR