Upper limb pain in primary care: health beliefs, somatic distress, consulting and patient satisfaction

Sickness absence after carpal tunnel release: a multicentre prospective cohort study

OBJECTIVES

To describe when patients return to different types of work after elective carpal tunnel release (CTR) surgery and identify the factors associated with the duration of sickness absence.

DESIGN

Multicentre prospective observational cohort study.

SETTING AND PARTICIPANTS

Participants were recruited preoperatively from 16 UK centres and clinical, occupational and demographic information were collected. Participants completed a weekly diary and questionnaires at four and 12 weeks postoperatively.

OUTCOMES

The main outcome was duration of work absence from date of surgery to date of first return to work.

RESULTS

254 participants were enrolled in the study and 201 provided the follow-up data. Median duration of sickness absence was 20 days (range 1-99). Earlier return to work was associated with having surgery in primary care and a self-reported work role involving more than 4 hours of daily computer use. Being female and entitlement to more than a month of paid sick leave were both associated with longer work absences. The duration of work absence was strongly associated with the expected duration of leave, as reported by participants before surgery. Earlier return to work was not associated with poorer clinical outcomes reported 12 weeks after CTR.

CONCLUSIONS

There was wide variation in the duration of work absence after CTR across all occupational categories. A combination of occupational, demographic and clinical factors was associated with the duration of work absence, illustrating the complexity of return to work decision making. However, preoperative expectations were strongly associated with the actual duration of leave. We found no evidence that earlier return to work was harmful. Clear, consistent advice from clinicians preoperatively setting expectations of a prompt return to work could reduce unnecessary sickness absence after CTR. To enable this, clinicians need evidence-informed guidance about appropriate timescales for the safe return to different types of work.

Prevalence of upper limb pain and disability and its correlates with demographic and personal factors

Purpose

The present study aimed to assess the prevalence of upper limb pain and disability and to investigate potentially correlated factors among university students in Jordan.

Methods

This was a cross-sectional questionnaire-based survey study that was conducted among university students. The upper limb pain and disability were assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire. The DASH outcome questionnaire was distributed to 2100 students from the population of 2 public and 2 private universities in the north of Jordan. Demographic and personal information were collected. Data were analyzed using descriptive statistics and linear regression analysis.

Results

A total of 1929 DASH outcome questionnaires were returned, with a high response rate of 91.86%. The age of the subjects was between 18–28 years (52% male; 48% female). The majority of subjects (85.2%) used at least one smartphone. The majority of them had been using a smartphone for more than 5 years. The prevalence of upper limb pain and disability among university students was 24%. Several factors were found to be significantly connected with upper limb pain and disability among university students, such as smartphone use, computer use,  the presence of musculoskeletal problems, not living with their families, using public transport (bus), and daily housekeeping.

Conclusion

The results of this study can be used globally to promote the health and well-being of university students, improve their academic performance and future career. Identifying high-risk groups will assist in early identifications and prevention programs for upper limb pain and disability among university students.

Maintained physical activity and physiotherapy in the management of distal arm pain: a randomised controlled trial

Objectives

The epidemiology of distal arm pain and back pain are similar. However, management differs considerably: for back pain, rest is discouraged, whereas patients with distal arm pain are commonly advised to rest and referred to physiotherapy. We hypothesised that remaining active would reduce long-term disability and that fast-track physiotherapy would be superior to physiotherapy after time on a waiting list.

Methods

Adults referred to community-based physiotherapy with distal arm pain were randomised to: advice to remain active while awaiting physiotherapy (typically delivered after 6–8 weeks); advice to rest while awaiting physiotherapy, or immediate treatment. Intention-to-treat analysis determined whether the probability of recovery at 26 weeks was greater among the active advice group, compared with those advised to rest and/or among those receiving immediate versus usually timed physiotherapy.

Results

538 of 1663 patients invited between February 2012 and February 2014 were randomised (active=178; rest=182; immediate physiotherapy=178). 81% provided primary outcome data, and complete recovery was reported by 60 (44%), 46 (32%) and 53 (35%). Those advised to rest experienced a lower probability of recovery (OR: 0.54; 95% CI 0.32 to 0.90) versus advice to remain active. However, there was no benefit of immediate physiotherapy (0.64; 95% CI 0.39 to 1.07).

Conclusions

Among patients awaiting physiotherapy for distal arm pain, advice to remain active results in better 26-week functional outcome, compared with advice to rest. Also, immediate physiotherapy confers no additional benefit in terms of disability, compared with physiotherapy delivered after 6–8 weeks waiting time. These findings question current guidance for the management of distal arm pain.

Constructs of health belief and disabling distal upper limb pain

BACKGROUND

Musculoskeletal pain in the distal upper limb is common and is a cause of disability and healthcare consultation. At the time of presentation individuals reporting similar pain severities may report different levels of related disability. The biopsychosocial model proposes that health beliefs may help explain this difference. The aim of this cross-sectional study was to identify underlying constructs of health belief in those referred to physiotherapy with pain in the distal upper limb and investigate whether these constructs moderated the relationship between pain severity and extent of disability.

METHOD

Health beliefs were assessed using an instrument included in a questionnaire completed before randomisation to the Arm Pain Trial (ISRCTN79085082). Ordinal responses to statements about health beliefs were used to generate a polychoric correlation matrix. The output from this matrix was then used for Exploratory Factor Analysis to determine underlying constructs. The moderating influence of the identified health belief constructs was then tested using interaction terms in linear regression models.

RESULTS

476 trial participants contributed data, age range 18-85 (mean 48.8, SD 13.7), 54% female. Five health belief constructs were identified: beliefs about hereditary factors, beliefs about movement and pain, beliefs about locus of control, beliefs about the role of lifecourse/lifestyle factors, and beliefs about prognosis. The only health belief construct found to moderate the pain-disability relationship was beliefs about prognosis, with greater pessimism resulting in higher levels of disability at mild-to-moderate levels of pain severity (B -0.17, 95% CI -0.30, -0.036).

CONCLUSION

This exploratory cross-sectional study identified five constructs of health belief from responses to a previously used set of statements investigating fear avoidance and illness beliefs in a clinical population with pain in the distal upper limb. Of these constructs, beliefs about prognosis were found to moderate the relationship between pain and disability.

IMPLICATIONS

At the time of referral to physiotherapy it may be beneficial to assess patients' perception of prognosis. For those with higher than expected disability for the presenting level of pain, and pessimism about prognosis, focused reassurance may play an important part in initial consultation. Longitudinal study is required to support the findings from this study and investigate whether a causal relationship exists. Future investigations should confirm the health belief constructs proposed.

Descriptive Epidemiology of Somatising Tendency: Findings from the CUPID Study

Somatising tendency, defined as a predisposition to worry about common somatic symptoms, is importantly associated with various aspects of health and health-related behaviour, including musculoskeletal pain and associated disability. To explore its epidemiological characteristics, and how it can be specified most efficiently, we analysed data from an international longitudinal study. A baseline questionnaire, which included questions from the Brief Symptom Inventory about seven common symptoms, was completed by 12,072 participants aged 20-59 from 46 occupational groups in 18 countries (response rate 70%). The seven symptoms were all mutually associated (odds ratios for pairwise associations 3.4 to 9.3), and each contributed to a measure of somatising tendency that exhibited an exposure-response relationship both with multi-site pain (prevalence rate ratios up to six), and also with sickness absence for non-musculoskeletal reasons. In most participants, the level of somatising tendency was little changed when reassessed after a mean interval of 14 months (75% having a change of 0 or 1 in their symptom count), although the specific symptoms reported at follow-up often differed from those at baseline. Somatising tendency was more common in women than men, especially at older ages, and varied markedly across the 46 occupational groups studied, with higher rates in South and Central America. It was weakly associated with smoking, but not with level of education. Our study supports the use of questions from the Brief Symptom Inventory as a method for measuring somatising tendency, and suggests that in adults of working age, it is a fairly stable trait.

Symptoms as the main problem: a cross- sectional study of patient experience in primary care

Background

Symptoms are common in primary care. Besides providing thorough assessment of possible severe disease, the general practitioner (GP) must ensure good health care to all patients, irrespective of diagnoses. We aimed to explore patient satisfaction with the provided care and how well expectations in patients were met when no diagnosis was made during the consultation.

Method

Cross-sectional study based on a questionnaire survey conducted in 2008–2009 among 377 GPs and their patients in the Central Denmark Region. A total of 2286 patients completed a questionnaire after the consultation (response rate: 54 %). The questionnaire included four satisfaction items from the EUROPEP instrument and a question about unmet expectations. For each patient, the GP answered a one-page registration form including information about the main problem in the consultation, chronic disorders and assessment of prognosis. Statistical analyses were adjusted for patient characteristics and GP clustering.

Results

A higher proportion of patients reported illness worry (20 vs. 17 %, p-value: 0.005), unmet expectations (17 vs. 13 %, p-value: 0.019) and dissatisfaction with their GP after the consultation when no diagnosis was made. Dissatisfaction was primarily related to the medical examination (adjusted OR 1.30; 95 % CI: 1.06–1.60) and GP explanations (adjusted OR 1.40; 95 % CI: 1.14–1.71). Exploratory analyses revealed an association between dissatisfaction with examination and the GP assessment that symptoms were unrelated to biomedical disease. This association was found both in patients with ‘symptoms only’ and patients given a specific diagnosis.

Conclusion

GPs are challenged by patients presenting symptoms that do not fit the patterns of biomedical diagnoses. The current study demonstrates more illness worry, unmet expectations and dissatisfaction with the consultation in these patients compared to patients receiving a diagnosis. This trend is true for all patients assessed as having ‘symptoms only’ at the end of a consultation and not only for the minority group with ‘medically unexplained symptoms’. As primary care is the frontline of the health-care system, symptoms are managed as the main problem in almost one in three consultations. It is about time that we take the same professional approach to symptoms as we have done for years to biomedical disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0429-8) contains supplementary material, which is available to authorized users.

A systematic review of prognostic factors for distal upper limb pain

BACKGROUND

Musculoskeletal pain in the distal upper limb is relatively common, can be a cause of disability, presents a high cost to society and is clinically important. Previous reviews of prognostic factors have focused on pain in the proximal upper limb, whole upper extremity or isolated regions of the distal upper limb.

AIM

To identify factors that predict outcome of distal upper limb pain.

STUDY DESIGN

Systematic review.

METHOD

Eight bibliographic databases were searched from inception to March 2014. Eligible articles included adults with pain anywhere in the distal upper limb at baseline from randomised controlled trials with a waiting list, expectant policy or usual care group, or observational studies where no treatment or usual care was provided. Data describing the association between a putative prognostic factor and pain or functional outcome at follow-up were required. Quality was assessed using the Quality in Prognostic Studies tool.

RESULTS

Seven articles reporting on six studies were identified. Heterogeneity of study populations and outcome measures prevented a meta-analysis so a narrative synthesis of results was undertaken. Three factors (being female, a longer duration of the complaint at initial presentation and having musculoskeletal pain in multiple locations) were significantly associated with poor pain outcome in more than one study. Being female was the only factor significantly associated with poor functional outcome in more than one study.

CONCLUSIONS

A range of sociodemographic, pain-related, occupational and psychosocial prognostic factors for distal upper limb pain outcomes were investigated in studies included in the review. However, due to the lack of commonality of factors investigated and lack of consistency of results across studies, there is limited evidence for predictors of distal upper limb pain outcomes. Further research is required to identify prognostic factors of distal upper limb pain, particularly modifiable factors that may influence management.

Psychological and psychosocial determinants of musculoskeletal pain and associated disability

Although much attention has been given to the physical determinants of common musculoskeletal complaints such as back and arm pain, research points to a stronger influence of psychological factors. Multiple studies have implicated poor mental health and somatisation (a tendency to worry about the common somatic symptoms) in the incidence and chronicity of musculoskeletal pain and associated disability. Also important are adverse beliefs about the prognosis of such disorders, and about the role of physical activity in their development and persistence. Differences in societal beliefs may have contributed to major variation in the prevalence of disabling musculoskeletal pain that has been observed between countries and in the same countries over time. Psychosocial aspects of work have also been linked with musculoskeletal pain, although relative risks have generally been smaller. There is a need to take account of psychological factors in the clinical management of patients with back, neck and arm pain.

Maintained physical activity and physiotherapy in the management of distal upper limb pain - a protocol for a randomised controlled trial (the arm pain trial)

Background

Distal upper limb pain (pain affecting the elbow, forearm, wrist, or hand) can be non-specific, or can arise from specific musculoskeletal disorders. It is clinically important and costly, the best approach to clinical management is unclear. Physiotherapy is the standard treatment and, while awaiting treatment, advice is often given to rest and avoid strenuous activities, but there is no evidence base to support these strategies. This paper describes the protocol of a randomised controlled trial to determine, among patients awaiting physiotherapy for distal arm pain, (a) whether advice to remain active and maintain usual activities results in a long-term reduction in arm pain and disability, compared with advice to rest; and (b) whether immediate physiotherapy results in a long-term reduction in arm pain and disability, compared with physiotherapy delivered after a seven week waiting list period.

Methods/Design

Between January 2012 and January 2014, new referrals to 14 out-patient physiotherapy departments were screened for potential eligibility. Eligible and consenting patients were randomly allocated to one of the following three groups in equal numbers: 1) advice to remain active, 2) advice to rest, 3) immediate physiotherapy. Patients were and followed up at 6, 13, and 26 weeks post-randomisation by self-complete postal questionnaire and, at six weeks, patients who had not received physiotherapy were offered it at this time. The primary outcome is the proportion of patients free of disability at 26 weeks, as determined by the modified DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire.

We hypothesise (a) that advice to maintain usual activities while awaiting physiotherapy will be superior than advice to rest the arm; and (b) that fast-track physiotherapy will be superior to normal (waiting list) physiotherapy. These hypotheses will be examined using an intention-to-treat analysis.

Discussion

Results from this trial will contribute to the evidence base underpinning the clinical management of patients with distal upper limb pain, and in particular, will provide guidance on whether they should be advised to rest the arm or remain active within the limits imposed by their symptoms.

Trial registration

Registered on http://www.controlled-trials.com (reference number: ISRCTN79085082).

Professional driving and prolapsed lumbar intervertebral disc diagnosed by magnetic resonance imaging: a case-control study

OBJECTIVES

The aim of this study was to investigate whether whole-body vibration (WBV) is associated with prolapsed lumbar intervertebral disc (PID) and nerve root entrapment among patients with low-back pain (LBP) undergoing magnetic resonance imaging (MRI).

METHODS

A consecutive series of patients referred for lumbar MRI because of LBP were compared with controls X-rayed for other reasons. Subjects were questioned about occupational activities loading the spine, psychosocial factors, driving, personal characteristics, mental health, and certain beliefs about LBP. Exposure to WBV was assessed by six measures, including weekly duration of professional driving, hours driven at a spell, and current 8-hour daily equivalent root-mean-square acceleration A(8). Cases were sub-classified according to whether or not PID/nerve root entrapment was present. Associations with WBV were examined separately for cases with and without these MRI findings, with adjustment for age, sex, and other potential confounders.

RESULTS

Altogether 237 cases and 820 controls were studied, including 183 professional drivers and 176 cases with PID and/or nerve root entrapment. Risks associated with WBV tended to be lower for LBP with PID/nerve root entrapment but somewhat higher for risks of LBP without these abnormalities. However, associations with the six metrics of exposure were all weak and not statistically significant. Neither exposure-response relationships nor increased risk of PID/nerve root entrapment from professional driving or exposure at an A(8) above the European Union daily exposure action level were found.

CONCLUSIONS

WBV may be a cause of LBP but it was not associated with PID or nerve root entrapment in this study.

Prevalence and impact of musculoskeletal disorders in New Zealand nurses, postal workers and office workers

OBJECTIVES

To describe the prevalence, characteristics and impact of musculoskeletal disorders (MSDs) in New Zealand nurses, postal workers and office workers.

METHODS

A postal survey asked participants about MSDs, (low back, neck, shoulder, elbow, wrist/hand or knee pain lasting longer than one day), and demographic, physical and psychosocial factors. Nurses were randomly selected from the Nursing Council database, postal workers from their employer's database and office workers from the 2005 electoral roll.

RESULTS

The response rate of potentially eligible participants was 58% (n=443). Participants were aged 20-59 years; 86% were female. Over the 12 months prior to the survey 88% of respondents had at least one MSD lasting longer than a day and 72% reported an MSD present for at least seven days. Of the 1,003 MSDs reported, 18% required time off work and 24% required modified work duties. In the month prior to the survey 17% of MSDs made functional tasks difficult or impossible. Low back, neck and shoulder pain prevalence did not differ by occupation. Postal workers had the highest prevalence of elbow and wrist/hand pain; nurses of knee pain.

CONCLUSIONS

The high prevalence of MSDs among these workers indicates that they are indeed in 'at risk' occupations. In each occupational group MSDs encompass a range of anatomical sites, however the overall pattern of MSDs differs by occupation. MSDs have a significant impact on activities at work and home.

IMPLICATIONS

Primary and secondary prevention strategies should encompass a range of anatomical sites and specifically target different occupational groups.