Reliability of the Southampton examination schedule for the diagnosis of upper limb disorders in the general population

Chronic lateral elbow tendinopathy with a supervised graded exercise protocol

STUDY DESIGN

Prospective Case Series.

BACKGROUND

Variety of studies inquired the effectiveness of exercise treatment in LET (Lateral Elbow Tendinopathy). The research on the effectiveness of these approaches are still ongoing and very much needed due to the uncertainty of the subject.

PURPOSE

We aimed to understand how the application of exercises in a graded manner affect the treatment outcomes in terms of pain and function.

METHODS

This study is completed by 28 patients with LET and it was planned as a prospective case series. Thirty participants were included to participate in the exercise group. Basic Exercises (Grade 1) were performed for four weeks. Advanced Exercises (Grade 2) were performed for another four weeks. The VAS (Visual Analog Scale), pressure algometer, the PRTEE (Patient-Rated Tennis Elbow Evaluation) and a grip strength dynamometer were used to measure outcomes. The measurements were performed at baseline, at the end of four weeks and at the end of eight weeks.

RESULTS

Investigation of the pain scores revealed that all VAS scores (p < 0.05, ES = 1.35; 0.72; 0,73 activity, rest, and night respectively) and pressure algometer results were improved both during basic (p < 0.05, ES = 0.91) and advanced exercises (p < 0.05, ES = 0,41). PRTEE scores were found to be improved in patients with LET after basic and advanced exercises (p > 0.001, ES = 1.15; p > 0.001, ES = 1.56 respectively). The grip strength only changed after basic exercises (p = 0.003, ES = 0.56).

CONCLUSIONS

The basic exercises were beneficial for both pain and function. However, advanced exercises are required for obtaining further improvements in terms of pain, function, and grip strength.

Advice to remain active with arm pain reduces disability

BACKGROUND

Arm pain is common amongst working-aged adults and causes substantial work disability. The results of a population-based randomized controlled trial (the ARM trial) suggested that advice to remain active reduced disability after 6 months.

AIMS

To verify ARM trial results amongst people in paid employment.

METHODS

The ARM trial recruited adults with distal arm pain referred for physiotherapy and randomized equally to three groups: wait-listed for physiotherapy (advised to rest); wait-listed for physiotherapy (advised to remain active) or early physiotherapy. The primary outcome was absence of disability at 26 weeks. Secondary analyses were undertaken amongst participants in paid employment.

RESULTS

Amongst 538 trial participants, 347 (64%) were in paid employment, mean age 46.1 years and 47% in manual work. Employed participants were randomized equally to the three arms. Amongst the 271 (78% workers with 26-week data), 43% of those advised to remain active were free from disability, as compared with 37% of those advised to rest. Forty per cent of those who waited for physiotherapy were disability-free as compared with 35% of those treated rapidly. Advice to rest was associated with lower chances of recovery amongst workers who lift/carry weights and those who believed work had caused their symptoms (P = 0.023).

CONCLUSIONS

Although not powered as a trial for workers only, our findings suggest that advising activity was as beneficial for people currently in paid work and may be superior to advice to rest in reducing disability. Addressing harmful beliefs about causation of symptoms has the potential to reduce disability.

Construct validity of the Single Arm Military Press (SAMP) test for upper limb function in patients with neck pain

BACKGROUND

Neck pain (NP) is often associated with upper limb disability (ULD). A clinically feasible measure to evaluate ULD in NP patients is necessary. The Single Arm Military Press (SAMP) is a ULD performance-based measure, specifically for NP patients. The validity of the SAMP in patients is still unknown.

OBJECTIVE

To explore the construct validity (hypotheses testing) of the SAMP in NP patients.

METHODS

A total of 210 NP patients and 81 controls were recruited. The SAMP; Disability of the Arm, Shoulder, and Hand (DASH); and Neck Disability Index (NDI) were completed at baseline and 4-7 days later. The Visual Analogue Scale (VAS) was used to measure NP and ULD severity pre-testing in both occasions. Patients were divided into 4-subgroups based on their NDI score. Convergent validity was examined using Pearson correlation. The t-test and analysis of variance (ANOVA) were used to evaluate discriminant and known groups' validity. To determine SAMP cut-off scores, the sensitivity and specificity were explored.

RESULTS

A negative correlation between the SAMP and DASH/NDI scores was found in the patient group (r = -0.91 and -0.87, p < 0.01). The t-test revealed substantial differences (t = -23.96) in score between patients and controls. Also, ANOVA revealed substantial differences (f = 20.86) between the patients' subgroups. The area under the curve (AUC) for patients and controls exceeded 0.90 when sensitivity and specificity were at equal importance.

CONCLUSION

The SAMP can distinguish between NP patients and controls, and between different NP disability levels. The responsiveness of the SAMP needs to be investigated.

A Machine Learning Algorithm to Estimate the Probability of a True Scaphoid Fracture After Wrist Trauma

PURPOSE

To identify predictors of a true scaphoid fracture among patients with radial wrist pain following acute trauma, train 5 machine learning (ML) algorithms in predicting scaphoid fracture probability, and design a decision rule to initiate advanced imaging in high-risk patients.

METHODS

Two prospective cohorts including 422 patients with radial wrist pain following wrist trauma were combined. There were 117 scaphoid fractures (28%) confirmed on computed tomography, magnetic resonance imaging, or radiographs. Eighteen fractures (15%) were occult. Predictors of a scaphoid fracture were identified among demographics, mechanism of injury and examination maneuvers. Five ML-algorithms were trained in calculating scaphoid fracture probability. ML-algorithms were assessed on ability to discriminate between patients with and without a fracture (area under the receiver operating characteristic curve), agreement between observed and predicted probabilities (calibration), and overall performance (Brier score). The best performing ML-algorithm was incorporated into a probability calculator. A decision rule was proposed to initiate advanced imaging among patients with negative radiographs.

RESULTS

Pain over the scaphoid on ulnar deviation, sex, age, and mechanism of injury were most strongly associated with a true scaphoid fracture. The best performing ML-algorithm yielded an area under the receiver operating characteristic curve, calibration slope, intercept, and Brier score of 0.77, 0.84, -0.01 and 0.159, respectively. The ML-derived decision rule proposes to initiate advanced imaging in patients with radial-sided wrist pain, negative radiographs, and a fracture probability of ≥10%. When applied to our cohort, this would yield 100% sensitivity, 38% specificity, and would have reduced the number of patients undergoing advanced imaging by 36% without missing a fracture.

CONCLUSIONS

The ML-algorithm accurately calculated scaphoid fracture probability based on scaphoid pain on ulnar deviation, sex, age, and mechanism of injury. The ML-decision rule may reduce the number of patients undergoing advanced imaging by a third with a small risk of missing a fracture. External validation is required before implementation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Interrater and intrarater reliability of the single arm military press (SAMP) test for upper limb function in patients with non-specific neck pain

BACKGROUND

Performance measures that assess the upper limb disability (ULD) in patients with neck pain can provide useful information for making clinical decisions regarding the optimal management of those patients. The Single Arm Military Press (SAMP) test is a performance based ULD measure developed specifically for populations with neck pain. In this test, patients are asked to lift a 1 kg weight repetitively overhead for 30 s with repetitions counting as the score. Whilst the test has been shown to be acceptable and feasible for use by clinicians and patients, its reliability in a patient group is still unknown.

OBJECTIVE

To assess the interrater, intrarater reliability and measurement error of the SAMP test in patients with non-specific neck pain (NSNP).

METHODS

A total of 210 patients with NSNP and 81 healthy subjects were recruited for this study. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Neck Disability Index (NDI) were assessed at baseline to ensure eligibility of the participants. The SAMP test was assessed at baseline and repeated 4-7 days later. A VAS symptom score was used to establish the stability of the participants across time. Interrater, intrarater reliability and measurement error were evaluated using Interclass Correlation Coefficient (ICC2,1) and the standard error of measurement (SEM).

RESULTS

The ICCs for interrater and intrarater reliability for the SAMP test ranged from 0.993 to 0.996 in the patient group. The SEM was ≤1 and smaller than the Smallest Detectable Change (SDC) and Bland-Altman plot indicated that the test is accurate.

CONCLUSION

The almost perfect interrater and intrarater reliability and low levels of measurement error indicate that the 1 kg SAMP test has potential for evaluating upper limb functional capacity in female patients with NSNP. Before the test can be fully recommended, further studies are required to evaluate the validity and responsiveness of the SAMP test in population with NSNP and other neck disorders.

High frequency of rheumatic regional pain syndromes in first-degree relatives of patients with rheumatoid arthritis

First-degree relatives (FDR) of patients with rheumatoid arthritis (RA) have a higher risk for the development of RA. In the stages prior to the development of arthritis, nonspecific musculoskeletal (MSK) manifestations may occur. The aim of the study is to describe the frequency of rheumatic regional pain syndromes (RRPS) in FDR of RA patients. A cross-sectional study was carried out from July 2016 to September 2018. Parents, offspring, and siblings of RA patients completed the Community Oriented Program in the Rheumatic Diseases (COPCORD) questionnaire. Rheumatoid factor (RF) IgG, IgM, and IgA; anticitrullinated peptide antibodies (ACPAs); C-reactive protein (CRP); and erythrocyte sedimentation rate (ESR) were determined. All subjects with a positive COPCORD (defined by the presence of musculoskeletal pain) were evaluated and classified. Three hundred thirty-five FDRs participated, 75.8% were female, mean age of 44.15 years; 138 (41.2%) were diagnosed with at least one RRPS; 72 (21.5%) had rotator cuff tendinitis, 51 (15.2%) pes anserine bursitis, and 39 (11.6) lateral epicondylitis; RA was diagnosed in 24 (7.16%) subjects, undifferentiated arthritis (UA) in 30 (8.9%) and inflammatory arthralgia (AI) in 104 (31%). We found anti-CCP positivity in 6.8%, RF IgA in 22.3%, RF IgM in 48.6%, and RF IgG in 8.9%. The presence of RRPS was higher in this RA-FDR group compared to general population. Clinical evaluation of this risk group should include screening for RRPS.

The short-term effectiveness of low-level laser, phonophoresis, and iontophoresis in patients with lateral epicondylosis

STUDY DESIGN

Randomized parallel group trial.

INTRODUCTION

Various treatment options for lateral epicondylosis have been reported in the literature.

PURPOSE OF STUDY

We aimed to compare the effectiveness of low-level laser therapy (LLLT), phonophoresis, and iontophoresis in terms of pain, function, and grip strength.

METHODS

This study that comprised 37 patients with lateral epicondylosis was planned as a prospective randomized parallel group trial. Twelve participants were randomized to the LLLT group, 12 to the phonophoresis group, and 13 to the iontophoresis group. The Visual Analog Scale (VAS), pressure algometer, the Patient-Rated Tennis Elbow Evaluation, and grip strength dynamometer were used to measure outcomes. The measurements were performed at baseline and at the end of 15 sessions.

RESULTS

Investigation of the pain scores revealed that all VAS scores were improved in both the laser and iontophoresis groups (VAS at rest: P = .015, effect size (ES) = 1.49 and P = .016, ES = 0.58, respectively; VAS during activity: P = .008, ES = 1.05 and P = .008, ES = 1.16, respectively; VAS at night: P = .013, ES = 1.01 and P = .016, ES = 0.72, respectively). Only advance in function and grip strength was associated with the iontophoresis group (Patient-Rated Tennis Elbow Evaluation P = .006, ES = 0.78; grip strength with elbow extension P = .011, ES = 1.03; with elbow flexion P = .003, ES = 0.52).

DISCUSSION

The most effective approach could not be highlighted among the existing studies in the literature as they were applied in combination with other therapies.

CONCLUSION

In our study, we observed that LLLT provides a benefit only for pain, whereas iontophoresis is beneficial for both pain and function. If the effect size is evaluated, LLLT is more influential than iontophoresis for decreasing pain. However, when we compared phonophoresis and iontophoresis in terms of effectiveness, we found that iontophoresis has better effects for pain, function, and grip strength.

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.

The Role of Elbow Tender Point Examination in the Diagnosis of Lateral Epicondylitis

OBJECTIVE

To quantify sensitivity and specificity of the tender points and demonstrate how variability in case definition impacts prevalence of lateral epicondylitis (LE).

METHODS

Baseline data analyzed from 1216 workers from the WISTAH study, a multicenter prospective cohort study of upper extremity musculoskeletal disorders. All workers completed computerized questionnaires, structured interviews, and two independent physical examinations in accordance with an established protocol.

RESULTS

The prevalence of LE differed based on case definition ranging from 4.7% to 12.1%. Sensitivity was low for tender points 1 to 4 ranging from 6.8% to 34.6%. Specificity was high for tender points 1 to 4 ranging from 95.2% to 97.9%.

CONCLUSIONS

The prevalence of lateral epicondylitis differs markedly based on case definition used, ranging more than two-fold. Standardization of a case definition is essential to allow for comparisons across studies.

Lateral Epicondylitis and Physical Exposure at Work? A Review of Prospective Studies and Meta-Analysis

OBJECTIVE

In view of recent published studies, a meta-analysis was undertaken on prospective studies in order to assess any association between lateral epicondylitis and physical exposure at work.

METHODS

Using the key words "lateral epicondylitis" AND "occupational" AND ("cohort" OR "longitudinal," OR "incidence") without limitations on the language or year of publication, original prospective studies were selected from 4 databases (PubMed, Scopus, Web of Science, and Base de Données de Santé Publique) after 2 rounds (valid design, valid association reported, and valid work exposure). Relevant associations between physical exposure at work and incident lateral epicondylitis were extracted from the articles, and a meta-risk was calculated using the generic variance approach (meta-odds ratios [meta-ORs]).

RESULTS

From 2001 to 2014, 5 prospective studies were included. Among 6,922 included subjects (and 3,449 who were followed), 256 cases of incident lateral epicondylitis were diagnosed 2.5-6 years after baseline. All the published studies found a significant estimation of relative risk for a positive association between combined biomechanic exposure involving the wrist and/or elbow and incidence of lateral epicondylitis. The overall meta-OR was 2.6 (95% confidence interval 1.9-3.5), with a low heterogeneity (Q = 1.4, P > 0.05). Funnel plots and Egger's test did not suggest major publication bias.

CONCLUSION

The results of this meta-analysis strongly support the hypothesis of an association between biomechanic exposure involving the wrist and/or elbow at work and incidence of lateral epicondylitis.

Measures of upper limb function for people with neck pain. A systematic review of measurement and practical properties

There is a strong relationship between neck pain (NP) and upper limb disability (ULD). Optimal management of NP should incorporate upper limb rehabilitation and therefore include the use of an ULD measure in the assessment and management process. Clear guidance regarding the suitability of available measures does not exist. The aim of this study was to identify all available measures of ULD for populations with NP, critically evaluate their measurement properties and finally recommend a list of suitable measures. This two-phase systematic review is reported in accordance with the PRISMA statement. Phase one identified clearly reproducible measures of ULD for patients with NP. Phase two identified evidence of their measurement properties. In total, 11 papers evaluating the measurement properties of five instruments were included in this review. The instruments identified were the DASH questionnaire, the QuickDASH questionnaire, the NULI questionnaire, the SFA and the SAMP test. There was limited positive evidence of validity of the DASH, QuickDASH, NULI, SFA and SAMP. There was limited positive evidence of reliability of the NULI, SFA and SAMP. There was unknown evidence of responsiveness of the DASH and QuickDASH. Although all measures are supported by a limited amount of low quality evidence, the DASH, QuickDASH, NULI questionnaires, and the SAMP test are promising measures, but they require further robust evaluation.

Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study

OBJECTIVE

The purpose of this preliminary study was to assess whether the dual somatosensory evoked potential (SEP) technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck or upper extremity pain and, if so, whether changes are associated with changes in pain scores.

METHODS

The dual peripheral nerve stimulation SEP ratio technique was used for 6 subjects with a history of chronic neck or upper limb pain. SEPs were recorded after left or right median and ulnar nerve stimulation at the wrist. SEP ratios were calculated for the N9, N13, P14-18, N20-P25, and P22-N30 peak complexes from SEP amplitudes obtained from simultaneous median and ulnar stimulation divided by the arithmetic sum of SEPs obtained from individual stimulation of the median and ulnar nerves. Outcome measures of SEP ratios and subjects' visual analog scale rating of pains were recorded at baseline, after a 2-week usual care control period, and after 12 weeks of multimodal chiropractic care (chiropractic spinal manipulation and 1 or more of the following: exercises, peripheral joint adjustments/manipulation, soft tissue therapy, and pain education).

RESULTS

A significant decrease in the median and ulnar to median plus ulnar ratio and the median and ulnar amplitude for the cortical P22-N30 SEP component was observed after 12 weeks of chiropractic care, with no changes after the control period. There was a significant decrease in visual analog scale scores (both for current pain and for pain last week).

CONCLUSION

The dual SEP ratio technique appears to be sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck pain. The observations in 6 subjects revealed that 12 weeks of chiropractic care improved suppression of SEPs evoked by dual upper limb nerve stimulation at the level of the motor cortex, premotor areas, and/or subcortical areas such as basal ganglia and/or thalamus. It is possible that these findings explain one of the mechanisms by which chiropractic care improves function and reduces pain for chronic pain patients.

Prevalence of musculoskeletal disorders and rheumatic disease in the Warao, Kari'ña, and Chaima indigenous populations of Monagas State, Venezuela

This study aimed to estimate the prevalence of musculoskeletal disorders and rheumatic diseases in the Warao, Kari’ña, and Chaima indigenous populations of Monagas State, Venezuela. A cross-sectional, analytical, community-based study was conducted in 1537 indigenous subjects ≥18 years old (38.6 % male, mean age 41.4 ± 17.5 years). The cross-culturally validated Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) diagnostic questionnaire was applied. Subjects with a positive COPCORD diagnosis (either historic or current pain) were evaluated by primary care physicians and rheumatologists. A descriptive analysis was performed and comparisons made using analysis of variance and the chi-square test. Pain in the last 7 days was reported by 32.9 %, with pain intensity, according to a Likert-type scale [no pain, 195 (38.5 %); minimal pain, 231 (45.6 %); strong pain, 68 (13.4 %); intense pain, 5 (0.9 %)], 38.0 % reported historical pain, and 641 (41.7 %) had either historic or current pain. Of the COPCORD-positive subjects, pain most frequently occurred in the knee, back, and hands. Musculoskeletal and rheumatic diseases included osteoarthritis (14.1 %), back pain (12.4 %), rheumatic regional pain syndromes (RRPS) (9.7 %), undifferentiated arthritis (1.5 %), rheumatoid arthritis (1.1 %), and fibromyalgia (0.5 %). Chaima (18.3 %) and Kari’ña (15.6 %) subjects had a high prevalence of osteoarthritis, and Warao subjects had a high prevalence of low back pain (13.8 %). The prevalence of RRPS was high in all three ethnic groups. The Chaima group had the highest prevalence of rheumatic diseases, with 2.0 % having rheumatoid arthritis. This study provides useful information for health care policy-making in indigenous communities.

Prevalence of rheumatic regional pain syndromes in Latin-American indigenous groups: a census study based on COPCORD methodology and syndrome-specific diagnostic criteria

This study assessed the overall and specific prevalence of the main rheumatic regional pain syndromes (RRPS) in four Latin-American indigenous groups. A Community Oriented Program for Control of Rheumatic Diseases (COPCORD) methodology-based census study was performed in 4240 adults (participation rate: 78.88 %) in four indigenous groups: Chontal (Oaxaca, Mexico, n = 124), Mixteco (Oaxaca, Mexico; n = 937), Maya-Yucateco (Yucatán, Mexico; n = 1523), and Qom (Rosario, Argentina; n = 1656). Subjects with musculoskeletal pain were identified using a cross-cultural, validated COPCORD questionnaire administered by bilingual personnel, and reviewed by general practitioners or rheumatologists using standardized case definitions for the 12 most frequent RRPS. The overall prevalence of RRPS was confirmed in 239 cases (5.64 %, 95 % CI: 4.98–6.37). The prevalence in each group was Chontal n = 19 (15.32 %, 95 % CI: 10.03–22.69); Maya-Yucateco n = 165 (10.83 %, 95 % CI: 9.37–12.49); Qom n = 48 (2.90 %, 95 % CI: 2.19–3.82); and Mixteco n = 7 (0.75 %, 95 % CI: 0.36–1.53). In the whole sample, the syndrome-specific prevalence was rotator cuff tendinopathy: 1.98 % (95 % CI: 1.60–2.45); lateral epicondylalgia: 0.83 % (95 % CI: 0.59–1.15); medial epicondylalgia: 0.73 % (95 % CI: 0.52–1.04); biceps tendinopathy: 0.71 % (95 % CI: 0.50–1.01); anserine syndrome: 0.64 % (95 % CI: 0.44–0.92); inferior heel pain: 0.61 % (95 % CI: 0.42–0.90); trochanteric syndrome: 0.49 % (95 % CI: 0.25–0.64); de Quervain’s tendinopathy: 0.45 % (95 % CI: 0.29–0.70); trigger finger: 0.42 % (95 % CI: 0.27–0.67); carpal tunnel syndrome: 0.28 % (95 % CI: 0.16–0.49); Achilles tendinopathy (insertional): 0.12 % (95 % CI: 0.05–0.28); and Achilles tendinopathy (non-insertional): 0.07 % (95 % CI: 0.02–0.21). Leaving aside the comparison between Maya-Yucateco and Chontal groups (p = 0.18), we found significant differences (p < 0.001) in overall RRPS prevalence between the remaining pairs of indigenous groups. Syndrome-specific prevalences were also different between groups. Our findings support the hypothesis that overall RRPS prevalence and syndrome-specific prevalences are modulated by population-specific factors.

Shoulder disorders and occupation

Shoulder pain is very common, and it causes substantial morbidity. Standardised classification systems based upon presumed patho-anatomical origins have proved poorly reproducible and hampered epidemiological research. Despite this, there is evidence that exposure to combinations of physical workplace strains such as overhead working, heavy lifting and forceful work as well as working in an awkward posture increases the risk of shoulder disorders. Psychosocial risk factors are also associated. There is currently little evidence to suggest that either primary prevention or treatment strategies in the workplace are very effective, and more research is required, particularly around the cost-effectiveness of different strategies.

Measures of upper limb function for people with neck pain: a systematic review of measurement and practical properties (protocol)

BACKGROUND

Upper limb disability is a common musculoskeletal condition frequently associated with neck pain. Recent literature has reported the need to utilise validated upper limb outcome measures in the assessment and management of patients with neck pain. However, there is a lack of clear guidance about the suitability of available measures, which may impede utilisation. This review will identify all available measures of upper limb function developed for use in neck pain patients and evaluate their measurement and practical properties in order to identify those measures that are most appropriate for use in clinical practice and research.

METHODS/DESIGN

This review will be performed in two phases. Phase one will identify all measures used to assess upper limb function for patients with neck pain. Phase two will identify all available studies of the measurement and practical properties of identified instrument. The COnsensus-based Standards for selection of health Measurement INstrument (COSMIN) will be used to evaluate the methodological quality of the included studies. To ensure methodological rigour, the findings of this review will be reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline.

DISCUSSION

Optimal management of patients with neck pain should incorporate upper limb rehabilitation. The findings of this study will assist clinicians who seek to utilise suitable and accurate measures to assess upper limb function for a patient with neck pain. In addition, the findings of this study may suggest new research directions to support the development of upper limb outcome measures for patients with neck pain.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015016624.

Health surveillance under adverse ergonomics conditions--validity of a screening method adapted for the occupational health service

A new health surveillance protocol for work-related upper-extremity musculoskeletal disorders has been validated by comparing the results with a reference protocol. The studied protocol, Health Surveillance in Adverse Ergonomics Conditions (HECO), is a new version of the reference protocol modified for application in the Occupational Health Service (OHS). The HECO protocol contains both a screening part and a diagnosing part. Sixty-three employees were examined. The screening in HECO did not miss any diagnosis found when using the reference protocol, but in comparison to the reference protocol considerable time savings could be achieved. Fair to good agreement between the protocols was obtained for one or more diagnoses in neck/shoulders (86%, k = 0.62) and elbow/hands (84%, k = 0.49). Therefore, the results obtained using the HECO protocol can be compared with a reference material collected with the reference protocol, and thus provide information of the magnitude of disorders in an examined work group. Practitioner Summary: The HECO protocol is a relatively simple physical examination protocol for identification of musculoskeletal disorders in the neck and upper extremities. The protocol is a reliable and cost-effective tool for the OHS to use for occupational health surveillance in order to detect workplaces at high risk for developing musculoskeletal disorders.

Natural course of rotator cuff syndrome in a French working population

BACKGROUND

The aim was to assess the persistence of rotator cuff syndrome (RCS) in workers and to study associations with personal and work-related factors, job change, exposure change and treatment.

METHODS

At baseline, 274 workers suffered from RCS, of whom 150 were followed up. Three groups were constituted: (1) a RCS recovery group, (2) a shoulder pain without RCS group, and (3) a RCS without recovery group. We studied the differences between groups (1) and (3) because of the low number of workers in group (2).

RESULTS

Recovery occurred in 61.5% of men and 51.4% of women. Factors related to work were associated with persistence of RCS in men whereas upper limb pain and absence of job rotation were associated with persistence of RCS in women.

CONCLUSION

This descriptive study showed that a high percentage of workers recovered and several personal and work-related factors were associated with persistent RCS. Larger prospective studies are needed to confirm these results.

Shoulder diagnoses in secondary care, a one year cohort

BACKGROUND

Shoulder pain is common in the general population. Reports on specific diagnoses in general populations are scarce and only from primary care. The diagnostic distribution of shoulder disorders in secondary care is not reported. Most of the clinical research in the shoulder field is done in hospital settings. The aim of this study was to identify the diagnoses in a 1-year cohort in a hospital-based outpatient clinic using standardized diagnostic criteria and to compare the results with previous studies.

METHODS

A diagnostic routine was conducted among patients referred to our physical medicine outpatient clinic at Oslo University Hospital. Diagnostic criteria were derived from the literature and supplemented with research criteria.

RESULTS

Of 766 patients diagnosed, 55% were women and the mean age was 49 years (range 19-93, SD ± 14). The most common diagnoses were subacromial pain (36%), myalgia (17%) and adhesive capsulitis (11%). Subacromial pain and adhesive capsulitis were most frequent in persons aged 40-60 years. Shoulder myalgia was most frequent in age groups under 40. Labral tears and instability problems (8%) were most frequent in young patients and not present after age 50. Full-thickness rotator cuff tears (8%) and glenohumeral osteoarthritis (4%) were more prevalent after the age of 60. Few differences were observed between sexes. We identified three studies reporting shoulder diagnoses in primary care.

CONCLUSION

Subacromial pain syndrome, myalgia and adhesive capsulitis were the most prevalent diagnoses in our study. However, large differences in prevalence between different studies were found, most likely arising from different use of diagnostic criteria and a difference in populations between primary and secondary care. Of the diagnoses in our cohort, 20% were not reported by the studies from primary care (glenohumeral osteoarthritis, full thickness rotator cuff tears, labral tears and instabilities).

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).

Evaluation of a musculoskeletal training package for occupational health practitioners

BACKGROUND

Musculoskeletal disorders (MSDs) are a common cause of disability in the workplace. Despite this, there is known to be a wide variation in the assessment of MSDs by UK occupational health (OH) professionals. Therefore we developed a workshop, supported by a bespoke, on-line video, focussing on the assessment and management of MSDs.

AIMS

To assess the impact of the training package on the knowledge, confidence and reported behaviour of attendees.

METHODS

Workshops were held in two regional centres in England. Delegates completed a questionnaire on arrival to establish their baseline knowledge and confidence and again at the end of the training. A third questionnaire, with one reminder, was e-mailed to delegates 4 months following the workshops.

RESULTS

Ninety-two OH professionals (77 nurses, 10 doctors and 5 'others') attended and more than 80% reported that they had no previous training in examining the upper or lower limb or in distinguishing specific from non-specific MSDs. Confidence among delegates in examination, diagnosis and management of MSDs improved after the workshop and these changes were sustained and remained statistically significant from baseline 4 months afterwards. Following the training, 79% (50) of delegates reported that they had shared the knowledge and skills acquired with their colleagues and 71% reported that they had used the examination techniques in their day-to-day practice.

CONCLUSIONS

We have developed a training package which resulted in improved knowledge among attendees and gave them confidence to use their skills in practice.

Evidence-based soft tissue rheumatology: epicondylitis and hand stenosing tendinopathy

Lateral and medial epicondylitis represent overuse tendinopathies of wrist extensor and wrist flexor muscles, respectively. In lateral epicondylitis, a short-term therapeutic efficacy of glucocorticoid injection and limited evidence on the efficacy of acupuncture has been shown. De Quervain tendinopathy is caused by tendinous impingement by a thickened retinaculum. There is limited evidence on the efficacy of glucocorticoid injection in this condition.Trigger finger usually results from tendon entrapment beneath a thickened A1 flexor pulley. An association with hand tool use and diabetes has been shown in this condition, and there is evidence on the therapeutic efficacy of glucocorticoid injection. No other therapeutic modality has shown efficacy or has been assessed in a placebo-controlled clinical trial in these conditions.It can be concluded that epicondylitis and stenosing tendinopathy are readily diagnosed, and most patients recover with current therapies. However, still unsolved issues preclude a purely evidence-based approach to these entities.

A survey of the McKenzie Classification System in the Extremities: prevalence of mechanical syndromes and preferred loading strategies

BACKGROUND

Classification of patients with extremity problems is commonly based on patho-anatomical diagnoses, but problems exist regarding reliability and validity of the tests and diagnostic criteria used. Alternatively, a classification system based on patient response to repeated loading strategies can be used to classify and direct management.

OBJECTIVE

The purpose of this study was to investigate the prevalence of McKenzie's classification categories among patients with extremity problems and the loading strategies used in their management.

DESIGN

This was a prospective, observational study.

METHODS

Thirty therapists among 138 invited (response rate=22%) with a Diploma in Mechanical Diagnosis and Therapy (MDT) were identified from the McKenzie Institute International registry and recruited worldwide to complete an e-mailed questionnaire. They provided data about their age, years qualified, years since gaining a diploma, and practice, and prospectively provided data on anatomical site and categorization for 15 consecutive patients with extremity problems.

RESULTS

Data were gathered on 388 patients; classification categories were as follows: derangement (37%); contractile dysfunction (17%); articular dysfunction (10%); and "other" (36%), of which 20% were postsurgery or posttrauma. Exercise management strategies and syndrome application varied considerably among anatomical sites. Classification categories remained consistent in 85.8% of patients over the treatment episode.

LIMITATIONS

These findings are not generalizable to therapists who are not experienced with use of MDT in the extremities.

CONCLUSIONS

This study demonstrates that trained clinicians can classify patients with extremity problems into MDT classifications and that these classifications remain stable during the treatment episode. Further work is needed to test the efficacy of this system compared with other approaches, but if derangements are as common as this survey suggests, the findings have important prognostic implications because this syndrome is defined by its rapid response to repeated movements.

Occupation and epicondylitis: a population-based study

OBJECTIVE

To explore the relationship between occupational exposures and lateral and medial epicondylitis, and the effect of epicondylitis on sickness absence in a population sample of working-aged adults.

METHODS

This was a cross-sectional study of 9696 randomly selected adults aged 25-64 years involving a screening questionnaire and standardized physical examination. Age- and sex-specific prevalence rates of epicondylitis were estimated and associations with occupational risk factors explored.

RESULTS

Among 6038 respondents, 636 (11%) reported elbow pain in the last week. Of those surveyed, 0.7% were diagnosed with lateral epicondylitis and 0.6% with medial epicondylitis. Lateral epicondylitis was associated with manual work [odds ratio (OR) 4.0, 95% CI 1.9, 8.4]. In multivariate analyses, repetitive bending/straightening elbow >1 h day was independently associated with lateral (OR 2.5, 95% CI 1.2, 5.5) and medial epicondylitis (OR 5.1, 95% CI 1.8, 14.3). Five per cent of adults with epicondylitis took sickness absence because of their elbow symptoms in the past 12 months (median 29 days).

CONCLUSION

Repetitive exposure to bending/straightening the elbow was a significant risk factor for medial and lateral epicondylitis. Epicondylitis is associated with prolonged sickness absence in 5% of affected working-aged adults.

Carpal tunnel syndrome: the role of occupational factors

Carpal tunnel syndrome (CTS) is a fairly common condition in working-aged people, sometimes caused by physical occupational activities, such as repeated and forceful movements of the hand and wrist or use of hand-held, powered, vibratory tools. Symptoms may be prevented or alleviated by primary control measures at work, and some cases of disease are compensable. Following a general description of the disorder, its epidemiology and some of the difficulties surrounding diagnosis, this review focusses on the role of occupational factors in causation of CTS and factors that can mitigate risk. Areas of uncertainty, debate and research interest are emphasised where relevant.

Inter-rater reliability of physical examinations in a prospective study of upper extremity musculoskeletal disorders

OBJECTIVE

To test the inter-rater reliability of physical examinations for upper extremity musculoskeletal disorders.

METHODS

A total of 111 subjects were examined by both an occupational medicine physician and a physical therapist, who were blinded to each others' tests results and subjects' current symptoms and health histories.

RESULTS

Inter-rater reliability was moderate to excellent (0.52 to 0.88) for shoulder tests but required the inclusion of symptoms for increased inter-rater reliability of fair to excellent (0.27 to 0.57) for the elbow and hand/wrist tests.

CONCLUSIONS

With the lack of "gold standard" tests, it is important that epidemiologic field studies conduct and report inter-rater reliability testing results between study examiners. It is important for researchers to report the results of inter-rater reliability, so that practitioners can weigh the results of study findings to improve both their diagnosis and treatment of these costly injuries.

Hand assessment in older adults with musculoskeletal hand problems: a reliability study

BACKGROUND

Musculoskeletal hand pain is common in the general population. This study aims to investigate the inter- and intra-observer reliability of two trained observers conducting a simple clinical interview and physical examination for hand problems in older adults. The reliability of applying the American College of Rheumatology (ACR) criteria for hand osteoarthritis to community-dwelling older adults will also be investigated.

METHODS

Fifty-five participants aged 50 years and over with a current self-reported hand problem and registered with one general practice were recruited from a previous health questionnaire study. Participants underwent a standardised, structured clinical interview and physical examination by two independent trained observers and again by one of these observers a month later. Agreement beyond chance was summarised using Kappa statistics and intra-class correlation coefficients.

RESULTS

Median values for inter- and intra-observer reliability for clinical interview questions were found to be "substantial" and "moderate" respectively [median agreement beyond chance (Kappa) was 0.75 (range: -0.03, 0.93) for inter-observer ratings and 0.57 (range: -0.02, 1.00) for intra-observer ratings]. Inter- and intra-observer reliability for physical examination items was variable, with good reliability observed for some items, such as grip and pinch strength, and poor reliability observed for others, notably assessment of altered sensation, pain on resisted movement and judgements based on observation and palpation of individual features at single joints, such as bony enlargement, nodes and swelling. Moderate agreement was observed both between and within observers when applying the ACR criteria for hand osteoarthritis.

CONCLUSION

Standardised, structured clinical interview is reliable for taking a history in community-dwelling older adults with self reported hand problems. Agreement between and within observers for physical examination items is variable. Low Kappa values may have resulted, in part, from a low prevalence of clinical signs and symptoms in the study participants. The decision to use clinical interview and hand assessment variables in clinical practice or further research in primary care should include consideration of clinical applicability and training alongside reliability. Further investigation is required to determine the relationship between these clinical questions and assessments and the clinical course of hand pain and hand problems in community-dwelling older adults.

What are the important components of the clinical assessment of hand problems in older adults in primary care? Results of a Delphi study

BACKGROUND

To identify clinical questions and assessments regarded by health care practitioners as important when assessing undifferentiated hand pain or problems in adults aged 50 years and over presenting to primary care.

METHODS

A purposively selected panel of 26 UK-based Health Care Practitioners comprising occupational therapists, physiotherapists, rheumatologists and general practitioners, were invited to take part in a consensus study involving three postal rounds of a Delphi questionnaire with accompanying case scenarios. Participants were asked to generate questions and assessments (round 1), rate their importance (round 2), and vote on which items were most important (round 3).

RESULTS

Sixteen Health Care Practitioners agreed to participate with 11 completing all three rounds. The first round of the Delphi study generated 156 questions and 143 assessments. After three rounds agreement was reached on the importance of 25 questions and 19 assessments. Questions were weighted towards current symptoms, but also included the history of previous hand problems, self-reported hand function, co-morbidity and general health. Observation and palpation of features predominated in the choice of assessment, but specific tests, grip strength, evaluation of sensation and hand function were also included.

CONCLUSIONS

A pool of clinical questions and assessments were generated by Health Care Practitioners, and those considered most important for assessing older adults presenting with undifferentiated hand pain and hand problems in primary care were identified. Further evaluation is required to establish the reliability and feasibility of using these questions and assessments in primary care. In particular, the relative contribution of these questions and assessments in evaluating the nature and severity of hand problems, assisting diagnosis, indicating appropriate management, and predicting future course requires further investigation.

Differential diagnosis and physical therapy management of a patient with radial wrist pain of 6 months' duration: a case

STUDY DESIGN

Case report.

BACKGROUND

Differential diagnosis for patients with radial wrist pain requires consideration of systemic disease, referred pain to the radial aspect of the wrist, and local dysfunction. The list of possible local dysfunctions should include De Quervain syndrome, as well as entrapment neuropathy of the superficial radial nerve.

CASE DESCRIPTION

The patient was a 57-year-old man with right radial wrist pain of 6 months' duration. The referral diagnosis was De Quervain syndrome, but a previous course of electrophysical agents-based physical therapy management had been unsuccessful. The physical examination ruled out the cervical, shoulder, elbow, and wrist joints as possible sources of pain. In this case, the diagnosis of entrapment neuropathy of the superficial radial nerve, rather than De Quervain syndrome, was primarily based on the symptom provocation resulting from a modified radial bias upper limb nerve tension test. Based on this diagnosis, treatment consisted of active and passive exercises using neurodynamic techniques.

OUTCOMES

After 1 treatment session, the patient noted changes with regard to current pain intensity and function that exceeded the minimal clinically important difference and the minimal detectable change, respectively. After only 2 treatment sessions, the patient reported a complete resolution of symptoms and a full return to work.

DISCUSSION

This case report critically evaluates the diagnostic process for patients with radial wrist pain and suggests neuropathy of the superficial sensory branch of the radial nerve as a differential diagnostic option.

LEVEL OF EVIDENCE

Therapy, level 4.J Orthop Sports Phys Ther 2010;40(6):361-368, Epub 22 April 2010. doi:10.2519/jospt.2010.3210.

Diagnostic strategies using physical examination are minimally useful in defining carpal tunnel syndrome in population-based research studies

OBJECTIVE

We evaluated the utility of physical examination manoeuvres in the prediction of carpal tunnel syndrome (CTS) in a population-based research study.

METHODS

We studied a cohort of 1108 newly employed workers in several industries. Each worker completed a symptom questionnaire, a structured physical examination and nerve conduction study. For each hand, our CTS case definition required both median nerve conduction abnormality and symptoms classified as "classic" or "probable" on a hand diagram. We calculated the positive predictive values and likelihood ratios for physical examination manoeuvres in subjects with and without symptoms.

RESULTS

The prevalence of CTS in our cohort was 1.2% for the right hand and 1.0% for the left hand. The likelihood ratios of a positive test for physical provocative tests ranged from 2.0 to 3.3, and those of a negative test from 0.3 to 0.9. The post-test probability of positive testing was <50% for all strategies tested.

CONCLUSION

Our study found that physical examination, alone or in combination with symptoms, was not predictive of CTS in a working population. We suggest using specific symptoms as a first-level screening tool, and nerve conduction study as a confirmatory test, as a case definition strategy in research settings.

Expert therapists use specific clinical reasoning processes in the assessment and management of patients with shoulder pain: a qualitative study

QUESTION

What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the assessment and management of patients with shoulder pain?

DESIGN

Qualitative study using a three-round Delphi procedure.

PARTICIPANTS

Twenty-six experts in the UK consented to be involved and were contactable, of whom 20 contributed, with 12, 15, and 15 contributing to the different rounds.

RESULTS

Clinical reasoning was mostly about diagnostic reasoning, but also involved narrative reasoning. Diagnostic reasoning involved both pattern recognition and hypothetico-deductive reasoning. Diagnostic reasoning emphasised general history items, a constellation of signs and symptoms to identify specific diagnostic categories, and standard physical examination procedures. Narrative reasoning was highlighted by the communication involved in expert history taking, seeing patients in their functional and psychological context, and collaborative reasoning with the patient regarding management.

CONCLUSIONS

These expert clinicians demonstrated the use of diagnostic pattern recognition, and hypothetico-deductive and narrative clinical reasoning processes. The emphasis was on the history and basic physical examination procedures to make clinical decisions.

Diagnosing soft tissue rheumatic disorders of the upper limb in epidemiological studies of vibration-exposed populations

OBJECTIVES

To investigate approaches adopted to diagnose soft tissue rheumatic disorders of the upper limb (ULDs) in vibration-exposed populations and in other settings, and to compare their methodological qualities.

METHODS

Systematic searches were made of the Medline, Embase, and CINAHL electronic bibliographic databases, and of various supplementary sources (textbooks, reviews, conference and workshop proceedings, personal files). For vibration-exposed populations, qualifying papers were scored in terms of the provenance of their measuring instruments (adequacy of documentation, standardisation, reliability, criterion-related and content validity). Similar criteria were applied to general proposals for whole diagnostic schemes, and evidence was collated on the test-retest reliability of symptom histories and clinical signs.

RESULTS

In total, 23 relevant reports were identified concerning vibration-exposed populations--21 involving symptoms and 9 involving examination/diagnosis. Most of the instruments employed scored poorly in terms of methodological quality. The search also identified, from the wider literature, more than a dozen schemes directed at classifying ULDs, and 18 studies of test-retest reliability of symptoms and physical signs in the upper limb. Findings support the use of the standardised Nordic questionnaire for symptom inquiry and suggest that a range of physical signs can be elicited with reasonable between-observer agreement. Four classification schemes rated well in terms of content validity. One of these had excellent documentation, and one had been tested for repeatability, agreement with an external reference standard, and utility in distinguishing groups that differed in disability, prognosis and associated risk factors.

CONCLUSIONS

Hitherto, most studies of ULDs in vibration-exposed populations have used custom-specified diagnostic methods, poorly documented, and non-stringent in terms of standardisation and supporting evidence of reliability and/or validity. The broader literature contains several question sets and procedures that improve upon this, and offer scope in vibration-exposed populations to diagnose ULDs more systematically.

Repetitive strain injury

Repetitive strain injury remains a controversial topic. The term repetitive strain injury includes specific disorders such as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of the wrist or hand. The diagnosis is usually made on the basis of history and clinical examination. Large high-quality studies using newer imaging techniques, such as MRI and ultrasonography are few. Consequently, the role of such imaging in diagnosis of upper limb disorders remains unclear. In many cases, no specific diagnosis can be established and complaints are labelled as non-specific. Little is known about the effectiveness of treatment options for upper limb disorders. Strong evidence for any intervention is scarce and the effect, if any, is mainly short-term pain relief. Exercise is beneficial for non-specific upper limb disorders. Immobilising hand braces and open carpal tunnel surgery release are beneficial for carpal tunnel syndrome, and topical and oral non-steroidal anti-inflammatory drugs, and corticosteroid injections are helpful for lateral epicondylitis. Exercise is probably beneficial for neck pain, as are corticosteroid injections and exercise for shoulder pain. Although upper limb disorders occur frequently in the working population, most trials have not exclusively included a working population or assessed effects on work-related outcomes. Further high-quality trials should aim to include sufficient sample sizes, working populations, and work-related outcomes.

The role of physical examinations in studies of musculoskeletal disorders of the elbow

OBJECTIVES

To present data on pain and physical findings from the elbow region, and to discuss the role of diagnostic criteria in epidemiological studies of epicondylitis.

METHODS

From a cohort of computer workers a subgroup of 1369 participants, who reported at least moderate pain in the neck and upper extremities, were invited to a standardised physical examination. Two independent physical examinations were performed-one blinded and one not blinded to the medical history. Information concerning musculoskeletal symptoms was obtained by a baseline questionnaire and a similar questionnaire completed on the day of examination.

RESULTS

349 participants met the authors' criteria for being an arm case and 249 were elbow cases. Among the 1369 participants the prevalence of at least mild palpation tenderness and indirect tenderness at the lateral epicondyle was 5.8%. The occurrence of physical findings increased markedly by level of pain score. Only about one half with physical findings fulfilled the authors' pain criteria for having lateral epicondylitis. A large part with physical findings reported no pain at all in the elbow in any of the two questionnaires, 28% and 22%, respectively. Inter-examiner reliability between blinded and not blinded examination was found to be low (kappa value (0.34-0.40)).

CONCLUSION

Very few with at least moderate pain in the elbow region met common specific criteria for lateral epicondylitis. The occurrence of physical findings increased markedly by level of pain score and the associations were strongest with pain intensity scores given just before the examination. Physical signs were commonly found in subjects with no pain complaints. No further impact was achieved if the physical examination was not blinded to the medical history. Furthermore, the authors propose that pain, clinical signs and disability are studied as separate outcomes, and that the diagnoses of lateral epicondylitis should be used only for cases with classical signs of inflammation reflected by severe pain, which for example conveys some disability.

Occupational disorders: non-specific forearm pain

Work-related upper limb disorder is a non-specific diagnosis for pain in the hand, wrist or, in particular, forearm once more discrete clinical conditions such as epicondylitis, tenosynovitis and carpal tunnel syndrome have been excluded. The pathophysiology of the condition is uncertain, although it is normally held to be related to an ergonomic incident. Ergonomic factors either at work or at home remain important and are discussed. Initial management is based on modification of ergonomics with appropriate periods of rest and job rotation. Treatment, however, remains somewhat unfocused and unsatisfactory. Much can be learnt from the ergonomic study of musicians, where the condition is perhaps at its most refined. Medico-legal aspects and recent thoughts on pathogenesis are also discussed.

Cervical spine magnetic resonance imaging in primary care consulters with shoulder pain: a case control study

OBJECTIVES

To investigate the association between shoulder region pain presenting in primary care and cervical spine magnetic resonance imaging (MRI) abnormalities.

METHODS

A matched case-control study of 48 pairs of participants. Patients had presented to primary care with a new episode of shoulder pain. Controls had no history of pain in the shoulder region and were individually matched with cases by age, gender and referring clinician. All participants underwent a structured clinical assessment and cervical spine MRI. Scans were scored by experienced musculoskeletal radiologists blinded to case-control status.

RESULTS

Median age of participants was 51 years (range 19-79) and 21 (44%) were female. "Neck pain in the past week" was reported by 25 (52%) cases and seven (15%) controls (odds ratio, OR, 10.0; 95% confidence interval, CI, 2.4, 88.2). Cervical spine MRI from C3/4 to C6/7 revealed: 18 (38%) of both cases and controls had disc height loss >/=50% at any level; 10 (21%) cases and eight (17%) controls had disc disease with neural compromise; 11 (23%) cases and 16 (33%) controls had foraminal stenosis; nine (19%) of both cases and controls had canal narrowing. At least one of the above findings was present in 24 (50%) cases and 23 (48%) controls (OR 1.1; 95% CI 0.4, 3.4).

CONCLUSIONS

Cervical spine MRI abnormalities were similar in both cases and controls, despite significantly more self-reported neck pain in cases with shoulder pain. Other possible mechanisms, such as muscular strain or postural problems, may explain the observed clinical association between shoulder region pain and neck associated symptoms.

Pain tolerance in patients presenting to primary care and physiotherapy services with upper limb disorders

BACKGROUND

Arm pain is a common cause of incapacity for work and is often attributed to occupational activities, but in many cases the pathogenesis is unclear.

OBJECTIVE

To investigate whether arm pain in the absence of identifiable underlying pathology is associated with reduced tolerance of painful sensory stimuli.

METHODS

133 incident cases of arm pain, recruited from primary care and physiotherapy services, were classified according to a validated diagnostic algorithm. Pain tolerance was measured at three sites in each arm in response to electrocutaneous stimulation. Associations with pain tolerance (the geometric mean of the six measurements at 5 Hz) were assessed by linear regression, and findings were summarised as proportional changes in pain tolerance.

RESULTS

Pain tolerance was generally lower than in an earlier community survey. Women had a lower tolerance than men. After allowance for sex, age, use of analgesics and anatomical extent of pain, there was no indication of reduced tolerance in patients with non-specific pain relative to those with specific local pathology.

CONCLUSIONS

Pain tolerance may be generally reduced in patients presenting to medical services with arm pain, but those with non-specific pain do not seem to have lower tolerance than those with identifiable local pathology.

Risk factors for specific upper limb disorders as compared with non-specific upper limb pain: assessing the utility of a structured examination schedule

BACKGROUND

Few community-based epidemiological investigations of upper limb disorders (ULDs) have classified cases by validated procedures involving a structured clinical examination.

AIM

To compare risk factor profiles for different diagnostic categories of ULD using one such examination scheme.

METHODS

A questionnaire about upper limb pain and demographic, occupational and psychosocial risk factors was mailed to 10,264 adults from two English general practices, followed by standardized physical examination in those with arm or neck pain. Logistic regression was used to compare those with specific ULDs and non-specific arm pain with those who had no neck or arm symptoms.

RESULTS

There was a 59% response rate. A total of 1,197 subjects with arm or neck pain underwent standardized physical examination and were classified as having one or more of 11 specific ULDs or non-specific regional pain. Among these, 250 subjects with specific ULDs and 176 with only non-specific arm pain were compared with 2,248 subjects who had no neck or arm symptoms. Certain physical risk factors were more strongly associated with specific disorders than with non-specific pain. In comparison with pain-free subjects, the odds ratios (ORs) in keyboard users (>or=1 h versus <1 h/day) were 3.1 (95% CI 1.3, 7.8) for hand-wrist tendonitis but 1.3 (0.8, 2.1) for non-specific hand-wrist pain. Other differential associations were found with age, sex, manual versus non-manual employment and smoking. Unexpectedly, low vitality was similarly associated with both specific disorders and non-specific pain.

CONCLUSION

These findings suggest that the schedule may usefully distinguish disorders that differ in their association with physical risk factors.

A case–control study of risk factors for arm pain presenting to primary care services

OBJECTIVES

To investigate the association of occupational activities, mental health and comorbidity with care seeking for arm pain, and to test the hypothesis that specific disorders arise from physical risk factors and non-specific pain from psychological ones.

METHODS

Patients with a new episode of arm pain and matched controls were recruited from eight general practices. A questionnaire about risk factors was completed and cases were classified using a validated examination schedule. Questions were asked about occupational activities and psychosocial stressors. Mental health was assessed using the Hospital Anxiety Depression Scale, elements of the Brief Symptom Inventory (somatizing tendency) and the Whiteley Index (health anxiety); comorbidity from chronic fatigue syndrome (CFS) and chronic widespread pain (CWP) was ascertained using standard definitions. Associations were explored using logistic regression and summarized as odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

Altogether, 132 cases and 127 controls were studied. Consulting with arm pain was strongly associated with all of the mental health variables and with CFS and CWP, irrespective of the site of arm pain or diagnosis. The OR in those with >3 versus <3 distressing somatic symptoms was 3.9 (95% CI 1.7-9.0). There were several significant associations with physical activity, but none with occupational psychosocial stressors. Repeated wrist/finger movements and carrying weights were more strongly associated with specific diagnoses than with non-specific pain.

CONCLUSIONS

Somatizing tendency, health anxiety, low mood, CFS and CWP are more common in arm pain consulters. Certain mechanical activities are also overrepresented, particularly in those with specific pathology.

Exploration of work and health disparities among black women employed in poultry processing in the rural south

We describe an ongoing collaboration that developed as academic investigators responded to a specific request from community members to document health effects on black women of employment in poultry-processing plants in rural North Carolina. Primary outcomes of interest are upper extremity musculoskeletal disorders and function as well as quality of life. Because of concerns of community women and the history of poor labor relations, we decided to conduct this longitudinal study in a manner that did not require involvement of the employer. To provide more detailed insights into the effects of this type of employment, the epidemiologic analyses are supplemented by ethnographic interviews. The resulting approach requires community collaboration. Community-based staff, as paid members of the research team, manage the local project office, recruit and retain participants, conduct interviews, coordinate physical assessments, and participate in outreach. Other community members assisted in the design of the data collection tools and the recruitment of longitudinal study participants and took part in the ethnographic component of the study. This presentation provides an example of one model through which academic researchers and community members can work together productively under challenging circumstances. Notable accomplishments include the recruitment and retention of a cohort of low-income rural black women, often considered hard to reach in research studies. This community-based project includes a number of elements associated with community-based participatory research.

Interrater reproducibility of clinical tests for rotator cuff lesions

BACKGROUND

Rotator cuff lesions are common in the community but reproducibility of tests for shoulder assessment has not been adequately appraised and there is no uniform approach to their use.

OBJECTIVE

To study interrater reproducibility of standard tests for shoulder evaluation among a rheumatology specialist, rheumatology trainee, and research nurse.

METHODS

136 patients were reviewed over 12 months at a major teaching hospital. The three assessors examined each patient in random order and were unaware of each other's evaluation. Each shoulder was examined in a standard manner by recognised tests for specific lesions and a diagnostic algorithm was used. Between-observer agreement was determined by calculating Cohen's kappa coefficients (measuring agreement beyond that expected by chance).

RESULTS

Fair to substantial agreement was obtained for the observations of tenderness, painful arc, and external rotation. Tests for supraspinatus and subscapularis also showed at least fair agreement between observers. 40/55 (73%) kappa coefficient assessments were rated at >0.2, indicating at least fair concordance between observers; 21/55 (38%) were rated at >0.4, indicating at least moderate concordance between observers.

CONCLUSION

The reproducibility of certain tests, employed by observers of varying experience, in the assessment of the rotator cuff and general shoulder disease was determined. This has implications for delegation of shoulder assessment to nurse specialists, the development of a simplified evaluation schedule for general practitioners, and uniformity in epidemiological research studies.

Prevalence and impact of musculoskeletal disorders of the upper limb in the general population

OBJECTIVE

To determine the prevalence, interrelation, and impact of musculoskeletal disorders of the upper limb in the general population.

METHODS

A total of 9,696 randomly selected adults of working age were surveyed in a 2-stage cross-sectional study involving a screening questionnaire and a standardized physical examination in symptomatic subjects. Age- and sex-specific prevalence rates were estimated for several musculoskeletal disorders and for nonspecific pain in the upper limbs. The overlap and impact on daily activities and healthcare utilization were explored.

RESULTS

Among 6,038 first-stage responders, 3,152 reported upper limb symptoms and 1,960 were subsequently examined. Of subjects with pain, 44.8% had 1 or more specific soft-tissue disorders. Site-specific prevalence rates were as follows: shoulder tendinitis 4.5% among men and 6.1% among women; adhesive capsulitis 8.2% among men and 10.1% among women; lateral epicondylitis 1.3% among men and 1.1% among women; de Quervain's disease 0.5% among men and 1.3% among women; other tenosynovitis of the hand or wrist, 1.1% among men and 2.2% among women. Specific disorders tended to cluster (P < 0.001) in individuals, with particular overlap at the shoulder. Compared with subjects with nonspecific pain, those with specific disorders more often reported inability to perform everyday tasks (P < 0.05), consultation with a doctor (P < 0.05), and use of prescribed medication (P < 0.05).

CONCLUSION

Upper limb pain is common in the general population and is often associated with physical signs suggestive of specific upper-limb disorders. These disorders have a substantial impact on physical function and use of health care.

Criteria for assessing pain and nonarticular soft-tissue rheumatic disorders of the neck and upper limb

OBJECTIVE

To critically review the criteria used to diagnose nonarticular soft-tissue rheumatic disorders of the neck and upper limb.

METHODS

An extensive search of the literature, including a search of Medline and EMBASE, authoritative recent reviews, and relevant textbooks, was completed. The diagnostic criteria used in epidemiologic studies were compared and the reliability and validity of these criteria were assessed.

RESULTS

Altogether, the search identified 117 relevant research articles, among which 69 included a physical examination component, but few specified diagnostic criteria. Evidence supported respectable levels of between-observer repeatability regarding: symptom questionnaires (kappa, 0.52 to 0.79); measurement of shoulder range of motion with a goniometer (intraclass coefficients > 0.70); tests for carpal tunnel syndrome (Tinel's and Phalen's kappa, 0.53 to 0.80); and demonstration of neck tenderness (kappa = 0.43). The Katz hand diagram, and combinations of physical signs of carpal tunnel syndrome, show reasonable sensitivity and specificity for that diagnosis but only among patients referred to specialists with that putative diagnosis; no such validity has been shown among the general population. Only 1 diagnostic examination schedule has published data on both the reliability and the validity of its criteria and diagnoses. For the remaining soft-tissue upper-limb disorders, diagnostic criteria rely apparently on face and content validity and reliability data have not been published.

CONCLUSION

Classification of specific disorders of the neck and upper limb requires a back to basics approach. At present, the diagnosis of most of these conditions relies heavily on the clinical opinions of investigators and there are insufficient data to indicate that these criteria are repeatable, sensitive, or specific. Recent European initiatives offer scope to follow a more disciplined approach, but more work is urgently required.

Regional musculoskeletal conditions: pain in the forearm, wrist and hand

Pain in the forearm, wrist or hand may arise from one of several discrete rheumatic disorders of soft tissues, such as tenosynovitis, or from a non-specific regional pain syndrome. Symptoms are prevalent in the general population and both patterns of illness are well represented. Many epidemiological investigations of prevalence, incidence, causal risk factors, management and prevention exist, although surveys have used a wide variety of case definitions, hampering comparisons. Improved standardized approaches to classification are in prospect and these are described. A synthesis is also attempted of the main findings of existing surveys. A growing body of evidence now links distal arm pain with physical risk factors in the workplace (e.g. repetition, force, duration, short cycle time and awkwardness of posture); some possible ergonomic solutions to occupational arm pain are discussed. But occupational and psychosocial factors are also linked with symptom reporting and disability, and their role in pathogenesis may be important in primary prevention and the management of recalcitrant cases. Some key research questions are proposed aimed at preventing chronicity and disablement from arm pain.