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

Posterior glenohumeral joint capsule contracture

Glenohumeral joint posterior capsule contracture may cause shoulder pain by altering normal joint mechanics. Contracture is commonly noted in throwing athletes but can also be present in nonthrowers. The cause of contracture in throwing athletes is assumed to be a response to the high amount of repetitive tensile force placed on the tissue, whereas the mechanism of contracture in nonthrowers is unknown. It is likely that mechanical and cellular processes interact to increase the stiffness and decrease the compliance of the capsule, although the exact processes that cause a contracture have not been confirmed. Cadaver models have been used to study the effect of posterior capsule contracture on joint mechanics and demonstrate alterations in range of motion and in humeral head kinematics. Imaging has been used to assess posterior capsule contracture, although standard techniques and quantification methods are lacking. Clinically, contracture manifests as a reduction in glenohumeral internal rotation and/or cross body adduction range of motion. Stretching and manual techniques are used to improve range of motion and often decrease symptoms in painful shoulders.

Perceived exertion, comfort and working technique in professional computer users and associations with the incidence of neck and upper extremity symptoms

Background

The aim of this study was to investigate whether perceived exertion, perceived comfort and working technique is associated with the incidence of neck and upper extremity symptoms among professional computer users.

Methods

At baseline a self-administered questionnaire was distributed to 853 participants from 46 different work sites (382 men and 471 women) who, at baseline, had been free from neck and upper extremity symptoms during the preceding month. Work-related exposures, individual factors, and symptoms from the neck and upper extremities were assessed. Observations of working technique were performed by ergonomists using an ergonomic checklist. Incidence data were collected by means of 10 monthly questionnaires, asking for information on the occurrence of neck, shoulder and arm/hand symptoms. Perceived exertion was rated on a modified Borg RPE scale ranging from 0 (very, very light) to 14 (very, very strenuous). Perceived comfort was rated on a 9-point scale ranging from -4 (very, very poor) to +4 (very, very good) in relation to the chair, computer screen, keyboard, and computer mouse.

Results

The median follow up time was 10.3 months. The incidence of symptoms from the neck, shoulders and arm/hands were 50, 24 and 34 cases per 100 person years, respectively.

Higher perceived exertion in the neck, shoulder or arm/hands was associated with an increased risk of developing symptoms in the corresponding body region. Moreover, a dose-response relationship between the level of exertion and the risk of developing symptoms was recorded for all three regions. There was an association between low comfort and an increased risk for neck symptoms, but not for shoulder and arm/hand symptoms, although a trend towards such an association (not statistically significant) could be seen. Working technique was, in this study, not associated with the risk of developing symptoms in any of the investigated body regions.

Conclusion

There was a strong association between high perceived exertion and the development of neck, shoulder, and arm/hand symptoms. Moreover, there was an association between poor perceived comfort and neck pain. Surveillance of computer users may include perceived exertion and comfort to target individuals at risk for neck and upper extremity symptoms.

Frozen shoulder

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.

Musculoskeletal disorders among spine surgeons: results of a survey of the Scoliosis Research Society membership

STUDY DESIGN

Survey of surgeon members of the Scoliosis Research Society.

OBJECTIVE

To assess the prevalence of musculoskeletal disorders (MSDs) among spine surgeons.

SUMMARY OF BACKGROUND DATA

Spinal deformity surgery is characterized by long duration and repetitive, forceful tasks. The purpose of this study is to describe the type and prevalence of MSDs among orthopedic spine surgeons.

METHODS

A modified version of the physical discomfort survey was sent to surgeon members of the Scoliosis Research Society via standard mail and e-mail. A total of 3 attempts to contact potential respondents were made, with 62% (561/904 × 100) responding. Mean respondent age was 54 years. Mean annual total caseload was 147, of which 62 were of spinal deformity. A total of 84% of the respondents had an active surgical practice.

RESULTS

The most common self-reported diagnoses included neck pain/strain/spasm (38%, 215/561), lumbar disc herniation/radiculopathy (31%, 172/561), cervical disc herniation/radiculopathy (28%, 155/561), rotator cuff disease (24%, 134/561), varicose veins or peripheral edema (20%, 112/561), and lateral epicondylitis (18%, 99/561). For lumbar disc disease, 7.1% (40/561 × 100) and for cervical disc disease, 4.6% (26/561 × 100) of spine surgeons underwent surgery. Among active spine surgeons, multiple linear regression analysis revealed that total caseload correlated with neck pain (P = 0.01) and lower extremity edema (P = 0.03), while the number of deformity cases correlated with wrist pain (P = 0.003) and hand pain (P = 0.03). Age was correlated with shoulder (P = 0.03), elbow (P = 0.04), and hand pain (P = 0.02). Number of years in practice did not correlate with MSDs.

CONCLUSION

Compared with disease estimates in the general population, spine surgeons have a higher prevalence of MSDs. Our cohort underwent surgical intervention for lumbar (7.1%) and cervical (4.6%) disc disease at rates far exceeding disease estimates in the general population. Increased awareness among spine surgeons may lead to earlier treatment and, ultimately, enhanced preventive measures.

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.

Hand pain other than carpal tunnel syndrome (CTS): the role of occupational factors

Some occupational factors have been implicated in the development of disorders manifested as hand pain. The associations seem to be well documented in processes such as hand-arm vibration syndrome (HAVS) or writer's cramp. There are contradictory data in the literature about the relationships of trigger finger, De Quervain's tenosynovitis (DQT) and tenosynovitis of the wrist with occupational factors. In this article, we review current knowledge about clinical manifestations, case definition, implicated occupational factors, diagnosis and treatment of the most relevant hand pain disorders that have been associated with occupational factors, excluding carpal tunnel syndrome (CTS).

The intra- and inter-rater reliability of manual muscle testing and a hand-held dynamometer for measuring wrist strength in symptomatic and asymptomatic subjects

Objective

The objective of this study was to assess the intra- and inter-rater reliability of manual muscle testing (MMT) and hand-held dynamometer (HHD) in the measurement of isometric wrist strength in asymptomatic and symptomatic (distal radius fractures [DRF] and non-specific wrist pain [NSWP]) populations.

Method

Thirty-nine adults participated in an intra session, repeat measure, crossover study design. MMT and HHD isometric wrist strength was tested in six standardized test positions by two raters.

Results

Poor-to-excellent intra- and inter-rater reliability with MMT was found in all patient populations (ICC = 0.04–1.00). Excellent intra-rater reliability with HHD in the DRF (ICC = 0.86–0.95) and NSWP (ICC = 0.92–0.97) populations and excellent inter-rater reliability in the asymptomatic (ICC = 0.77–0.93) and DRF (ICC = 0.82–0.95) populations. Fair to excellent intra-rater reliability with HHD was seen in the asymptomatic population (ICC = 0.71–0.94) and fair to excellent inter-rater reliability in the NSWP population (ICC = 0.59–0.90).

Conclusion

MMT is shown to have variable reliability when assessing isometric wrist strength and is insensitive to small strength changes. HHD has been shown to be an objective and reliable measure of isometric wrist strength in specific positions in asymptomatic, DRF and NSWP populations. Further studies are required to ensure adequate dynamometry stabilization and obtain an optimal testing procedure for these populations.

Associations of cardiovascular risk factors, carotid intima-media thickness and manifest atherosclerotic vascular disease with carpal tunnel syndrome

BACKGROUND

The role of atherosclerosis in carpal tunnel syndrome (CTS) has not previously been addressed in population studies. The aim of this study was to investigate the associations of cardiovascular risk factors, carotid artery intima-media thickness (IMT), and clinical atherosclerotic diseases with CTS.

METHODS

In this cross sectional study, the target population consisted of subjects aged 30 or over who had participated in the national Finnish Health Survey in 2000-2001. Of the 7977 eligible subjects, 6254 (78.4%) were included in our study. Carotid IMT was measured in a sub-sample of subjects aged 45 to 74 (N=1353).

RESULTS

Obesity (adjusted odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1-5.4), high LDL cholesterol (OR 3.8, 95% CI 1.6-9.1 for >190 vs. <129 mg/dL), high triglycerides (OR 2.7, 95% CI 1.2-6.1 for >200 vs. <150 mg/dL), hypertension (OR 3.4, 95% CI 1.6-7.4) and cardiac arrhythmia (OR 10.2, 95% CI 2.7-38.4) were associated with CTS in subjects aged 30-44. In the age group of 60 years or over, coronary artery disease (OR 1.9, 95% CI 1.1-3.5), valvular heart disease (OR 2.3, 95% CI 1.0-5.0) and carotid IMT (1.4, 95% CI 0.9-2.1 for each 0.23 mm increase) were associated with CTS. Carotid IMT was associated with CTS only in subjects with hypertension or clinical atherosclerotic vascular disease, or in those who were exposed to physical workload factors.

CONCLUSIONS

Our findings suggest an association between CTS and cardiovascular risk factors in young people, and carotid IMT and clinical atherosclerotic vascular disease in older people. CTS may either be a manifestation of atherosclerosis, or both conditions may share similar risk factors.

Psychosocial factors predicted nonrecovery in both specific and nonspecific diagnoses at arm, neck, and shoulder

OBJECTIVES

To evaluate the differences in predictors of nonrecovery between patients with a specific diagnosis at arm, neck, and/or shoulder, vs. patients with a nonspecific diagnosis in general practice at 6 months after the first consultation.

STUDY DESIGN AND SETTING

New consulters with nontraumatic arm, neck, or shoulder complaints entered the cohort. Patient, complaint, and physical, psychosocial, and work characteristics were evaluated as possible predictors. Logistic regression analyses were conducted for the specific and nonspecific groups separately.

RESULTS

At 6 months, 38% (n=298) of the specific-group members and 49% (n=249) of the nonspecific-group members reported nonrecovery. Univariately, similar variables were related in both groups, although their strength sometimes differed. Multivariately, duration of complaints was predictive of nonrecovery in both groups. Other predictors in the specific group were as follows: more somatization, low social support, older age, high body mass index, and unemployment. In the nonspecific group, the predictors were as follows: musculoskeletal comorbidity, recurrent complaint, poor perceived general health, multiple-region complaints, and high level of kinesiophobia.

CONCLUSION

At 6 months, nonrecovery was reported more frequently in the group of patients with a nonspecific diagnosis. The predictive value of psychosocial factors on nonrecovery is at least of equal importance in patients with a specific diagnosis compared with patients with a nonspecific diagnosis.

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.

Workplace management of upper limb disorders: a systematic review

BACKGROUND

Upper limb pain is common among working-aged adults and a frequent cause of absenteeism.

AIMS

To systematically review the evidence for workplace interventions in four common upper limb disorders.

METHODS

Systematic review of English articles using Medline, Embase, Cinahl, AMED, Physiotherapy Evidence Database PEDro (carpal tunnel syndrome and non-specific arm pain only) and Cochrane Library. Study inclusion criteria were randomized controlled trials, cohort studies or systematic reviews employing any workplace intervention for workers with carpal tunnel syndrome, non-specific arm pain, extensor tenosynovitis or lateral epicondylitis. Papers were selected by a single reviewer and appraised by two reviewers independently using methods based on Scottish Intercollegiate Guidelines Network (SIGN) methodology.

RESULTS

1532 abstracts were identified, 28 papers critically appraised and four papers met the minimum quality standard (SIGN grading + or ++) for inclusion. There was limited evidence that computer keyboards with altered force displacement characteristics or altered geometry were effective in reducing carpal tunnel syndrome symptoms. There was limited, but high quality, evidence that multi-disciplinary rehabilitation for non-specific musculoskeletal arm pain was beneficial for those workers absent from work for at least four weeks. In adults with tenosynovitis there was limited evidence that modified computer keyboards were effective in reducing symptoms. There was a lack of high quality evidence to inform workplace management of lateral epicondylitis.

CONCLUSIONS

Further research is needed focusing on occupational management of upper limb disorders. Where evidence exists, workplace outcomes (e.g. successful return to pre-morbid employment; lost working days) are rarely addressed.

Chronic shoulder pain of myofascial origin: a randomized clinical trial using ischemic compression therapy

OBJECTIVE

The aim of this clinical trial was to evaluate the effect of 15 myofascial therapy treatments using ischemic compression on shoulder trigger points in patients with chronic shoulder pain.

METHODS

Forty-one patients received 15 experimental treatments, which consisted of ischemic compressions on trigger points located in the supraspinatus muscle, the infraspinatus muscle, the deltoid muscle, and the biceps tendon. Eighteen patients received the control treatment involving 15 ischemic compression treatments of trigger points located in cervical and upper thoracic areas. Of the 18 patients forming the control group, 16 went on to receive 15 experimental treatments after having received their initial control treatments. Outcome measures included a validated 13-question questionnaire measuring shoulder pain and functional impairment. A second questionnaire was used to assess patients' perceived amelioration, using a scale from 0% to 100%. Outcome measure evaluation was completed for both groups at baseline after 15 treatments, 30 days after the last treatment, and finally for the experimental group only, 6 months later.

RESULTS

A significant group x time interval interaction was observed after the first 15 treatments, indicating that the experimental group had a significant reduction in their Shoulder Pain and Disability Index (SPADI) score compared with the control group (62% vs 18% amelioration). Moreover, the patients perceived percentages of amelioration were higher in the experimental group after 15 treatments (75% vs 29%). Finally, the control group subjects significantly reduced their SPADI scores after crossover (55%).

CONCLUSION

The results of this study suggest that myofascial therapy using ischemic compression on shoulder trigger points may reduce the symptoms of patients experiencing chronic shoulder pain.

Specific mechanical pain hypersensitivity over peripheral nerve trunks in women with either unilateral epicondylalgia or carpal tunnel syndrome

STUDY DESIGN

Case-control study with blinded examiner.

OBJECTIVE

To investigate if pressure pain sensitivity is related to specific nerve trunks in the upper extremity of patients with either unilateral lateral epicondylalgia (LE) or carpal tunnel syndrome (CTS).

BACKGROUND

In the clinical setting, patients with LE tend to exhibit radial nerve trunk tenderness, whereas patients with CTS exhibit median nerve tenderness. No studies have investigated if specific nerve pressure pain hypersensitivity exists in patients with either LE or CTS.

METHODS

Sixteen women with unilateral LE (mean±SD age, 43±7 years), 17 women with unilateral CTS (43±6 years), and 17 healthy women (43±6 years) were included in this study. Pressure pain thresholds (PPT) were bilaterally assessed over the median, ulnar, and radial nerve trunks, as well as over the C5-6 zygapophyseal joints, by an examiner blinded to the subjectsí condition. A mixed-model analysis of variance was used to evaluate differences in PPT among groups (LE, CTS, or controls) and between sides (affected/nonaffected or dominant/nondominant).

RESULTS

The individuals in both the LE and CTS groups demonstrated lower PPT bilaterally over the median (group, P<.001; side, P=.437), radial (group, P<.001; side, P=.556), and ulnar (group, P<.001; side, P=.938) nerve trunks as compared to controls. Additionally, radial (P<.001) and ulnar (P=.005) nerves were more sensitive bilaterally in patients with LE than in patients with CTS. The median nerve was more sensitive bilaterally in patients with CTS than patients with LE (P=.002). Lower PPT over the cervical spine (group, P<.001; side, P=.233) were found bilaterally in both the LE and CTS groups. Further, patients with CTS exhibited lower cervical PPT than patients with LE (P<.001). PPT was negatively correlated with both pain intensity and duration of symptoms in both the LE and CTS groups (P<.001).

CONCLUSIONS

Bilateral mechanical nerve pain hypersensitivity is related to specific and particular nerve trunks in women with either unilateral LE or CTS. Our results suggest the presence of central and peripheral sensitization mechanisms in individuals with either LE or CTS.

Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy

The aim of the current study was to identify whether hyperexcitability of the central nervous system is a prognostic factor for individuals with carpal tunnel syndrome (CTS) likely to experience rapid and clinical self-reported improvement following a physical therapy program including soft tissue mobilization and nerve slider neurodynamic interventions. Women presenting with clinical and electrophysiological findings of CTS were involved in a prospective single-arm trial. Participants underwent a standardized examination and then a physical therapy session. The physical therapy sessions included both soft tissue mobilization directed at the anatomical sites of potential median nerve entrapment and a passive nerve slider neurodynamic technique targeted to the median nerve. Pressure pain thresholds (PPT) over the median, radial and ulnar nerves, C5-C6 zygapophyseal joint, carpal tunnel and tibialis anterior muscle were assessed bilaterally. Additionally, thermal detection and pain thresholds were measured over the carpal tunnel and thenar eminence bilaterally to evaluate central nervous system excitability. Subjects were classified as responders (having achieved a successful outcome) or non-responders based on self-perceived recovery. Variables were entered into a stepwise logistic regression model to determine the most accurate variables for determining prognosis. Data from 72 women were included in the analysis, of which 35 experienced a successful outcome (48.6%). Three variables including PPT over the C5-C6 joint affected side <137 kPa, HPT carpal tunnel affected side <39.6º and general health >66 points were identified. If 2 out of 3 variables were present (LR + 14.8), the likelihood of success increased from 48.6 to 93.3%. We identified 3 factors that may be associated with a rapid clinical response to both soft tissue mobilization and nerve slider neurodynamic techniques targeted to the median nerve in women presenting with CTS. Our results support that widespread central sensitization may not be present in women with CTS who are likely to achieve a successful outcome with physical therapy. Future studies are now necessary to validate these findings.

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.

Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability

BACKGROUND

Lateral elbow tendinopathy is a common condition often diagnosed by ultrasound. Debate exists regarding which ultrasound findings correlate with disease severity and prognosis.

HYPOTHESIS

Sonographic predictors for tendon healing in patients with lateral elbow tendinopathy can be found by correlating initial ultrasound findings with subsequent changes in pain and functional disability scores after a period of nonoperative management.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

Sixty-two elbows (34 right, 28 left) in 62 patients (30 male, 32 female) with a clinical diagnosis of lateral elbow tendinopathy underwent sonographic evaluation of the common extensor origin after assessment with a validated outcome measure, the Patient-Rated Tennis Elbow Evaluation (PRTEE). After 6 months of nonoperative standardized treatment (physiotherapy with eccentric loading), the PRTEE questionnaire was repeated.

RESULTS

The mean pretreatment PRTEE was 78 (range, 51-97) and posttreatment score was 29 (range, 0-91). This difference in means was found to be significant (P < .0001). A positive correlation was identified between the presence of a lateral collateral ligament tear (P < .0001) and the size of the largest intrasubstance tear (P < .0001) and poor outcome. A negative correlation was identified with amount of hypoechogenicity (P = .0009). No correlation was found with age, sex, side, duration of symptoms, thickness of tendon, or amount of neovascularity.

CONCLUSION

The size of intrasubstance tears and presence of a lateral collateral ligament tear on ultrasound can be used to assess lateral elbow tendinopathy severity, indicate those who may not respond to nonoperative therapy, and potentially guide more invasive treatment. Those patients with a large intrasubstance tear or tears identified on ultrasound are less likely to respond to nonoperative treatment. Presence of neovascularity has little correlation with change in pain severity or functional disability and may be a poor predictor of prognosis.

Diagnosis and management of patients with hand and wrist problems in general practice

OBJECTIVES

1) To describe diagnoses made by general practitioners (GPs) in patients with hand or wrist problems, 2) to describe management, and 3) to determine the association between diagnostic information and two outcomes: persistent symptoms and specialist referral.

METHODS

GPs recruited patients with hand or wrist problems and completed a standardized form recording information about patient history, observations, palpation, and physical tests. Patients were sent a questionnaire at baseline, 3, and 12 months, containing questions on characteristics and symptom severity. Logistic regression analyses were used to determine the association between diagnostic information and the odds of persistent symptoms or specialist referral.

RESULTS

The three most frequently recorded diagnoses were osteoarthritis (17%), tenosynovitis (16%), and nerve entrapment (13%). "Wait and see" (30%) and painkillers (24%) were most often advised. Higher probability of persistent symptoms at both 3 and 12 months was associated with being female, higher age, long baseline symptom duration, and higher baseline pain intensity score; positive DeQuervain test was associated with lower probability of persistent symptoms. Having a recurrent problem was associated with higher odds of specialist referral.

CONCLUSION

In primary care, physical tests and information about physical signs are of importance in diagnosing patients with hand or wrist problems, but provide limited prognostic information.

Randomised controlled trial of local corticosteroid injections for de Quervain's tenosynovitis in general practice

Background

De Quervain's tenosynovitis is a stenosing tenosynovitis of the first dorsal compartment of the wrist and leads to wrist pain and to impaired function of the wrist and hand. It can be treated by splinting, local corticosteroid injection and operation. In this study effectiveness of local corticosteroid injections for de Quervain's tenosynovitis provided by general practitioners was assessed.

Methods

Participants with de Quervain's tenosynovitis were recruited by general practitioners. Short-term outcomes (one week after injections) were assessed in a randomised, placebo-controlled trial. Long-term effectiveness was evaluated in an open prospective cohort-study of steroid responders during a follow-up period of 12 months. Participants were randomised to one or two local injections of 1 ml of triamcinolonacetonide (TCA) or 1 ml of NaCl 0.9% (placebo). Non-responders to NaCl were treated with additional TCA injections. Main outcomes were immediate treatment response, severity of pain, improvement as perceived by participant and functional disability using sub items hand and finger function of the Dutch Arthritis Impact Measurement Scale (Dutch AIMS-2-HFF).

Results

11 general practitioners included 21 wrists in 21 patients. The TCA-group had better results for short-term outcomes treatment response (78% vs. 25%; p = 0.015), perceived improvement (78% vs. 33%; p = 0.047) and severity of pain (4.27 vs. 1.33; p = 0.031) but not for the Dutch-AIMS-HFF (2.71 vs. 1.92; p = 0.112). Absolute risk reduction for the main outcome short-term treatment response was 0.55 (95% CI: 0.34, 0.76) with a number needed to treat of 2 (95% CI: 1, 3). In the cohort of steroid responders (n = 12) the beneficial effects of steroid injections were sustained during the follow-up of 12 months regarding severity of pain (p = 0.67) and scores of Dutch AIMS-2-HFF (p = 0.36), but not for patient perceived improvement (p = 0.02). No adverse events were observed during the 12 months of follow-up.

Conclusion

One or two local injections of 1 ml triamcinolonacetonide 10 mg/ml provided by general practitioners leads to improvement in the short term in participants with de Quervain's tenosynovitis when compared to placebo. The short-term beneficial effects of steroid injections for symptoms were maintained during the follow-up after 12 months.

Trial registration

Current Controlled Trials ISRCTN53171398

Management decisions in nontraumatic complaints of arm, neck, and shoulder in general practice

OBJECTIVE We wanted to evaluate associations between diagnosis and characteristics of the patient, complaint, and general practitioner (GP), as well as 6 common management decisions, in patients with nontraumatic arm, neck, and shoulder complaints at the time of the first consultation with their physician.

METHODS

We undertook an observational cohort study set in 21 Dutch general practices, including 682 patients with nontraumatic complaints of arm, neck, and shoulder. The outcome measure was application (yes/no) of a specific management option: watchful waiting, additional diagnostic tests, prescription of medication, corticosteroid injection, referral for physiotherapy, and referral for medical specialist care.

RESULTS

Separate multilevel analyses showed that overall, the diagnostic category, having long duration of complaints, and reporting many functional limitations were most frequently associated with the choice of a management option. For watchful waiting, only complaint variables played a role (long duration of complaints, high complaint severity, many functional limitations, recurrent complaint). All these variables were negatively associated with watchful waiting. When opting for 1 of the 5 other management options, several physician characteristics played a role as well. Less clinical experience was associated with additional diagnostic tests and referral to a medical specialist. GPs working in a solo practice more frequently referred to a medical specialist. GPs working in a rural area more frequently referred for physiotherapy. Female GPs prescribed medication less frequently. Physicians with special interest in musculoskeletal complaints gave corticosteroid injections more frequently.

CONCLUSIONS

Diagnostic category, long duration of complaints, and high functional limitations were key variables in management decisions with these complaints. In addition, several physician characteristics played a role as well.

Corticosteroid injection for de Quervain's tenosynovitis

BACKGROUND

De Quervain's tenosynovitis is a disorder characterised by pain on the radial (thumb) side of the wrist and functional disability of the hand. It can be treated by corticosteroid injection, splinting and surgery.

OBJECTIVES

To summarise evidence on the efficacy and safety of corticosteroid injections for de Quervain's tenosynovitis.

SEARCH STRATEGY

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to April 2009), EMBASE (1956 to April 2009), CINAHL (1982 to April 2009), AMED (1985 to April 2009), DARE, Dissertation Abstracts and PEDro (physiotherapy evidence database).

SELECTION CRITERIA

Randomised and controlled clinical trials evaluating the efficacy and safety of corticosteroid injections for de Quervain's tenosynovitis.

DATA COLLECTION AND ANALYSIS

After screening abstracts of studies identified by the search we obtained full text articles of studies which fulfilled the selection criteria. We extracted data using a predefined electronic form. We assessed the methodological quality of included trials by using the checklist developed by Jadad and the Delphi list. We extracted data on the primary outcome measures: treatment success; severity of pain or tenderness at the radial styloid; functional impairment of the wrist or hand; and outcome of Finkelstein's test, and the secondary outcome measures: proportion of patients with side effects; type of side effects and patient satisfaction with injection treatment.

MAIN RESULTS

We found one controlled clinical trial of 18 participants (all pregnant or lactating women) that compared one steroid injection with methylprednisolone and bupivacaine to splinting with a thumb spica. All patients in the steroid injection group (9/9) achieved complete relief of pain whereas none of the patients in the thumb spica group (0/9) had complete relief of pain, one to six days after intervention (number needed to treat to benefit (NNTB) = 1, 95% confidence interval (CI) 0.8 to 1.2). No side effects or local complications of steroid injection were noted.

AUTHORS' CONCLUSIONS

The efficacy of corticosteroid injections for de Quervain's tenosynovitis has been studied in only one small controlled clinical trial, which found steroid injections to be superior to thumb spica splinting. However, the applicability of our findings to daily clinical practice is limited, as they are based on only one trial with a small number of included participants, the methodological quality was poor and only pregnant and lactating women participated in the study. No adverse effects were observed.

Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: a protocol for a randomised control trial with placebo comparison

Background

Corticosteroid injection and physiotherapy are two commonly prescribed interventions for management of lateral epicondylalgia. Corticosteroid injections are the most clinically efficacious in the short term but are associated with high recurrence rates and delayed recovery, while physiotherapy is similar to injections at 6 weeks but with significantly lower recurrence rates. Whilst practitioners frequently recommend combining physiotherapy and injection to overcome harmful effects and improve outcomes, study of the benefits of this combination of treatments is lacking. Clinicians are also faced with the paradox that the powerful anti-inflammatory corticosteroid injections work well, albeit in the short term, for a non-inflammatory condition like lateral epicondylalgia. Surprisingly, these injections have not been rigorously tested against placebo injections. This study primarily addresses both of these issues.

Methods

A randomised placebo-controlled clinical trial with a 2 × 2 factorial design will evaluate the clinical efficacy, cost-effectiveness and recurrence rates of adding physiotherapy to an injection. In addition, the clinical efficacy and adverse effects of corticosteroid injection beyond that of a placebo saline injection will be studied. 132 participants with a diagnosis of lateral epicondylalgia will be randomly assigned by concealed allocation to one of four treatment groups – corticosteroid injection, saline injection, corticosteroid injection with physiotherapy or saline injection with physiotherapy. Physiotherapy will comprise 8 sessions of elbow manipulation and exercise over an 8 week period. Blinded follow-up assessments will be conducted at baseline, 4, 8, 12, 26 and 52 weeks after randomisation. The primary outcome will be a participant rating of global improvement, from which measures of success and recurrence will be derived. Analyses will be conducted on an intention-to-treat basis using linear mixed and logistic regression models. Healthcare costs will be collected from a societal perspective, and along with willingness-to-pay and quality of life data will facilitate cost-effectiveness and cost-benefit analyses.

Conclusion

This trial will utilise high quality trial methodologies in accordance with CONSORT guidelines. Findings from this study will assist in the development of evidence based practice recommendations and potentially the optimisation of resource allocation for rehabilitating lateral epicondylalgia.

Trial registration

Australian New Zealand Clinical Trials Register ACTRN12609000051246

Quantitative exposure-response relations between physical workload and prevalence of lateral epicondylitis in a working population

BACKGROUND

Lateral epicondylitis is a common work-related musculoskeletal disorder. The objective of this study was to identify risk factors associated with lateral epicondylitis among active workers.

METHODS

Seven-hundred thirty-three workers in 12 Washington worksites participated in structured interviews, physical examinations, and individual exposure assessments of biomechanical and psychosocial factors. Multivariable logistic modeling was used.

RESULTS

Thirty-eight subjects (5.2%) had lateral epicondylitis. Age (36-50 years-old), being female, and low social support at work were significant risk factors. Frequency of forceful exertion (> or =5 vs. < 1 times/min (OR 5.17, 95%CI 1.78-15.02), and > or =1 to <5 vs. <1 (OR 4.47, 95%CI 1.57-13.71)) and forearm supination at > or =45 degrees for > or =5% of the time with high lifting force (OR = 2.98, 95% CI 1.18-7.55) were significant physical load factors.

CONCLUSIONS

Frequency of forceful exertion or a combination of forearm supination and forceful lifting were significant physical factors and should be considered for prevention strategies.

What characterizes cleaners sustaining good musculoskeletal health after years with physically heavy work?

OBJECTIVES

The aim of this case-control study was to investigate characteristics of cleaners with good musculoskeletal health after years with physically heavy work.

METHODS

One hundred and 41 female seniority cleaners participated. Twenty-five reported no musculoskeletal symptoms, whereas 83 reported severe symptoms in the low back, neck shoulders or upper limbs. The groups were of matching age, height, body weight and seniority (19 years). Muscular strength was recorded by isometric maximal voluntary contractions on a day without pain. Exposure to physical risk factors at work, psychosocial work factors, and leisure time physical activity were assessed by a postal questionnaire.

RESULTS

Cleaners with good musculoskeletal health were not reporting different exposure to physical risk factors at work or leisure time physical activity, but had higher muscular strength and reported higher influence at work than cleaners with severe symptoms.

CONCLUSIONS

These findings suggest that muscular strength and influence at work are of relevance for sustaining good musculoskeletal health in workers with physically heavy work.

Bilateral thumb's active range of motion and strength in de Quervain's disease: comparison with a normal sample

The aims of the present study were to characterize the thumb active range of motion (AROM) and strength impairments resulting from unilateral de Quervain's disease; to verify the adequacy of standard clinical assessment tools to quantify impairments resulting from this pathology; and to validate the utilization of the asymptomatic thumb as a reference to quantify the symptomatic thumb's deficits by comparing the performances of asymptomatic to control thumbs. The thumb's AROM and strength were evaluated bilaterally in 31 participants with unilateral de Quervain's disease and 18 control participants using clinical assessments involving the flexors and adductors of the thumb and experimental assessment devices measuring strength and mobility in several directions of the thumb's movements. A comparison was made between the results obtained from the symptomatic, asymptomatic, and control thumbs. The AROM performance of symptomatic thumbs was found to be reduced when compared to the asymptomatic and control thumbs for maximal thumb flexion (p=0.008 and 0.003, respectively) and total circumduction displacement (p<0.001). The strength performance of the symptomatic thumb was also found to be reduced when compared to the asymptomatic and control thumbs for palmar pinch strength (p<0.001 and 0.002, respectively) and for maximal voluntary effort in all directions (p<0.001). Differences in performance were also found between the asymptomatic and control thumbs, reaching the significance level for some movement parameters of the thumb circumduction evaluations and when palmar pinch strength results are normalized (p<0.001 and 0.009, respectively). This study revealed bilateral impairments of thumb AROM and strength for participants with de Quervain's disease, the impairments being more pronounced on the symptomatic side. This finding may question the validity of using the asymptomatic thumb as a standard measure to identify the symptomatic thumb's impairments associated with de Quervain's disease. The study also demonstrated the validity of using clinical evaluations when assessing impairments associated with this disease.

Management of work-relevant upper limb disorders: a review

BACKGROUND

Upper limb disorders (ULDs) are clinically challenging and responsible for considerable work loss. There is a need to determine effective approaches for their management.

AIM

To determine evidence-based management strategies for work-relevant ULDs and explore whether a biopsychosocial approach is appropriate.

METHODS

Literature review using a best evidence synthesis. Data from articles identified through systematic searching of electronic databases and citation tracking were extracted into evidence tables. The information was synthesized into high-level evidence statements, which were ordered into themes covering classification/diagnosis, epidemiology, associations/risks and management/treatment, focusing on return to work or work retention and taking account of distinctions between non-specific complaints and specific diagnoses.

RESULTS

Neither biomedical treatment nor ergonomic workplace interventions alone offer an optimal solution; rather, multimodal interventions show considerable promise, particularly for occupational outcomes. Early return to work, or work retention, is an important goal for most cases and may be facilitated, where necessary, by transitional work arrangements. The emergent evidence indicates that successful management strategies require all the players to be on side and acting in a coordinated fashion; this requires engaging employers and workers to participate.

CONCLUSIONS

The biopsychosocial model applies: biological considerations should not be ignored, but psychosocial factors are more influential for occupational outcomes. Implementation of interventions that address the full range of psychosocial issues will require a cultural shift in the way the relationship between upper limb complaints and work is conceived and handled. Dissemination of evidence-based messages can contribute to the needed cultural shift.

Predictors of upper extremity symptoms and functional impairment among workers employed for 6 months in a new job

BACKGROUND

We sought to identify personal and work-related predictors of upper extremity symptoms and related functional impairment among 1,108 workers employed for 6 months in a new job.

METHODS

We collected data at baseline and 6-month follow-up using self-administered questionnaires. Multivariate logistic regression models were created for each outcome variable. Predictors included personal risk factors, physical work exposures and psychosocial factors.

RESULTS

Independent predictors for upper extremity symptoms at 6-month follow-up were age, Caucasian race, female gender, baseline history of UE symptoms, and job tasks involving wrist bending or forceful gripping. Independent predictors for functional impairment were baseline history and severity of UE symptoms, wrist bending, and social support.

CONCLUSIONS

Both personal and work-related factors were independent predictors of upper extremity symptoms and functional impairment in this working population. We found different risk factors for symptoms than for functional impairment related to symptoms.

The de Quervain's screening tool: validity and reliability of a measure to support clinical diagnosis and management

BACKGROUND

Studies into the effectiveness of interventions for upper limb soft tissue disorders have been hampered by a lack of consistently used diagnostic criteria, meaning that comparison of research results is a problem. To aid homogeneous recruitment into a study of de Quervain's disease, a de Quervain's screening tool (DQST) was developed. This could also be used to facilitate clinical diagnosis and management in practice.

AIMS

To provide evidence for the content and construct validity and test-retest and inter-rater reliability of the DQST.

METHOD

The study was conducted in an acute care, outpatient hand unit in a district general hospital. Three convenience samples of: 59 people with de Quervain's disease; 18 with carpal tunnel syndrome (CTS) and 16 with osteoarthritis (OA) of the carpometacarpal (CMC) joint were recruited. The DQST diagnostic criteria were initially generated from a literature review. Content validity was then established by expert doctors with an interest in upper limb musculoskeletal disorders (n = 7) rating the relevance of the seven items included. The DQST was then tested in people either already diagnosed with, or reported as having some of the symptoms of, de Quervain's disease. Construct validity was tested with people with CTS or OA of the CMC joint.

RESULTS

The median DQST score was 5 (Interquartile range IQR = 4-6) out of a possible seven diagnostic criteria. Inter-rater reliability was excellent (Intra-class coefficient [ICC] = 0.85; 95% confidence interval [CI] = 0.75, 0.91). Test retest reliability was good (ICC = 0.64; 95% CI = 0.20, 0.87). Sensitivity (Se) and specificity (Sp) testing (Se = 1.00; Sp = 1.00) demonstrated that the DQST discriminated between people with de Quervain's disease, CTS or OA of the CMC joint.

CONCLUSIONS

The DQST is a valid, reliable tool which could be of assistance in aiding correct diagnosis for recruitment to clinical trials and in clinical practice. Future research is recommended to further examine retest reliability with a larger sample size and to identify the commonest diagnostic criteria required for inclusion.

Management in non-traumatic arm, neck and shoulder complaints: differences between diagnostic groups

Arm, neck and/or shoulder complaints are common in western societies. In the Netherlands, general practice guidelines are issued on shoulder pain and epicondylitis only. Little is known about actual management of the total range of diagnoses. The objectives of the study are: to determine management in patients consulting the GP with a new episode of non-traumatic arm neck and shoulder complaints up to 6 months after the first consultation. To evaluate differences in management between patients with specific diagnoses versus non-specific diagnoses and between specific diagnostic groups. In a prospective cohort study in general practice. We recruited 682 eligible patients. Data on diagnosis, management, patient- and complaint-characteristics were collected. Co-occurrence of treatment options was presented in scaled rectangles. After 6 months, additional diagnostic tests had been performed in 18% of the patients, mainly radiographic examination (14%). Further, 49% had been referred for physiotherapy and 12% to the medical specialist. Patients with specific diagnoses were more frequently referred for specialist treatment, and patients with non-specific diagnoses for physiotherapy. Corticosteroid injections (17%) were mainly applied specific diagnoses (e.g. impingement syndrome, frozen shoulder, carpal tunnel and M. Quervain). Frequencies of prescribed medication (51%) did not differ between specific and non-specific diagnoses. In 19% of the patients no referral, prescribed analgesics or injection was applied. Braces (4%) were mainly prescribed in epicondylitis. Overall, management most frequently consisted of prescribed analgesics and referral for physiotherapy. Specific and non-specific diagnostic subgroups differed in the frequency corticosteroid injections were applied, and referrals to physiotherapy and to a medical specialist.

The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial

The aims of this study were to evaluate the effects of low-level laser therapy (LLLT) and to compare these with the effects of brace or ultrasound (US) treatment in tennis elbow. The study design used was a prospective and randomized, controlled, single-blind trial. Fifty-eight outpatients with lateral epicondylitis (9 men, 49 women) were included in the trial. The patients were divided into three groups: 1) brace group-brace plus exercise, 2) ultrasound group-US plus exercise, and 3) laser group-LLLT plus exercise. Patients in the brace group used a lateral counterforce brace for three weeks, US plus hot pack in the ultrasound group, and laser plus hot pack in the LLLT group. In addition, all patients were given progressive stretching and strengthening exercise programs. Grip strength and pain severity were evaluated with visual analog scale (VAS) at baseline, at the second week of treatment, and at the sixth week of treatment. VAS improved significantly in all groups after the treatment and in the ultrasound and laser groups at the sixth week (p<0.05). Grip strength of the affected hand increased only in the laser group after treatment, but was not changed at the sixth week. There were no significant differences between the groups on VAS and grip strength at baseline and at follow-up assessments. The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength.

Quantification of wrist joint laxity

PURPOSE

Laxity may be a trigger for chronic unidentified wrist pain. To determine whether this is the case, first an objective method to quantify wrist laxity needs to be defined. This study investigates different quantification methods (reference tests) from the literature and compares these with the judgment of 2 independent experienced clinicians (index test, or gold standard).

METHODS

Fifty healthy women (ages 19-43 y) without wrist complaints were included. For each subject, both clinicians were asked to give a laxity score for both wrists on a Likert scale of 1 to 5 (1 = very stiff, 5 = very lax). Subjects also had 3 reference tests: the Garcia-Elias method (passive range of motion), the Beighton method (general hypermobility), and the active range of motion method (specially designed measurement device).

RESULTS

There was no significant difference between the average laxity scores of clinicians 1 and 2. The intraclass correlation between clinician 1 and clinician 2 was significant but low. Correlation between the clinicians with the Garcia-Elias test as well as the Beighton method was significant but low (0.431 and 0.378). The correlation between reference tests was higher but still moderate.

CONCLUSIONS

This study showed that the index test used (clinical assessment) did not produce a satisfactory quantification of wrist laxity. Also, the reference tests are not suitable for quantification of laxity and seem to measure mobility rather than laxity. To quantify wrist laxity in a reliable and clinically relevant manner, it seems that consensus needs to be established between clinicians as to what elements of (abnormal) wrist motion define the wrist as "lax." In addition the development and testing of a measurement device that quantifies wrist translation might be needed for determining an objective score for wrist laxity.

Kinesiophobia in patients with non-traumatic arm, neck and shoulder complaints: a prospective cohort study in general practice

BACKGROUND

Complaints of arm, neck and shoulder are common in Western societies. Of those consulting a general practitioner (GP) with non-traumatic arm, neck or shoulder complaints, about 50% do not recover within 6 months. Kinesiophobia (also known as fear of movement/(re)injury) may also play a role in these complaints, as it may lead to avoidance behaviour resulting in hypervigilance to bodily sensations, followed by disability, disuse and depression. However, in relation to arm, neck and shoulder complaints little is known about kinesiophobia and its associated variables. Therefore this study aimed to: describe the degree of kinesiophobia in patients with non-traumatic complaints of arm, neck and shoulder in general practice; to determine whether mean scores of kinesiophobia change over time in non-recovered patients; and to evaluate variables associated with kinesiophobia at baseline.

METHODS

In this prospective cohort study set in general practice, consulters with a first or new episode of non-traumatic arm, neck or shoulder complaints (aged 18-64 years) entered the cohort. Baseline data were collected on kinesiophobia using the Tampa Scale for Kinesiophobia, the 13-item adjusted version: TSK-AV, and on patient-, complaint-, and psychosocial variables using self-administered questionnaires. The mean TSK-AV score was calculated. In non-recovered patients the follow-up TSK-AV scores at 6 and 12 months were analyzed with the general linear mixed model. Variables associated with kinesiophobia at baseline were evaluated using multivariate linear regression analyses.

RESULTS

The mean TSK-AV score at baseline was 24.8 [SD: 6.2]. Among non-recovered patients the mean TSK-AV score at baseline was 26.1 [SD: 6.6], which remained unchanged over 12- months follow-up period. The strongest associations with kinesiophobia were catastrophizing, disability, and comorbidity of musculoskeletal complaints. Additionally, having a shoulder complaint, low social support, high somatization and high distress contributed to the kinesiophobia score.

CONCLUSION

The mean TSK-AV score in our population seems comparable to those in other populations in primary care. In patients who did not recover during the 12- month follow-up, the degree of kinesiophobia remained unchanged during this time period. The variables associated with kinesiophobia at baseline appear to be in line with the fear-avoidance model.

Poorer elbow proprioception in patients with lateral epicondylitis than in healthy controls: a cross-sectional study

Two groups of women, 15 patients with lateral epicondylitis and 21 healthy controls, were studied to compare proprioception in the elbows and knees between the groups. Outcome measures were absolute error and variable error for joint position sense and for threshold to detection of a passive movement. Both absolute error and variable error of threshold to detection of a passive movement were greater in the lateral epicondylitis-diagnosed elbows than in the controls' elbows (lateral epicondylitis, 1.8 degrees vs controls 1.1 degrees, P = .026; lateral epicondylitis, 0.8 degrees vs controls 0.3 degrees, P = .015), and there was a tendency toward a greater absolute error of joint position sense compared with the control elbows (lateral epicondylitis, 8.2 degrees vs controls, 5.6 degrees; P = .078). Absolute error of joint position sense was greater in the elbows than in the knees of the lateral epicondylitis patients, but no group differences were found for knees. Proprioception seems, therefore, to be poorer in elbows with lateral epicondylitis elbows than in the controls' elbows. This needs to be taken into consideration in the management of lateral epicondylitis.