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

From: Ann Fam Med. 2009 Sep-Oct;7(5):446-54

Complaints of arm, neck, and shoulder pain are very common in Western societies. In the Netherlands the estimated 12-month prevalence in the general population was 31% for neck pain, 30% for shoulder pain, 11% for elbow pain, and 18% for wrist or hand pain. Studies have reported that of the respondents with noninflammatory musculoskeletal pain, about 30% to 45% contacted their general practitioner. In Dutch general practice, incidence data for patients with nontraumatic arm, neck, or shoulder complaints show 97 consultations per 1,000 registered persons annually.

Common management options for patients with nontraumatic arm, neck, and shoulder complaints are watchful waiting, additional diagnostic tests, prescription of medication, referral for physiotherapy, a corticosteroid injection, and referral for medical specialist care. Use of these 6 management options shows wide variation, however, both between and within diagnostic groups. Until now, no studies have evaluated the determinants that contribute to variation in the management of these complaints. Part of this variation may be explained by the diagnosis, which, because of its natural course and available treatment, usually guides management. Also, patient and complaint characteristics may influence management. In the Netherlands guidelines issued by the Dutch College of General Practitioners are available for epicondylitis and shoulder complaints; in both guidelines, management advice is partly based on differences in the levels of hindrance (pain severity and functional limitations). In other study populations, patient and complaint characteristics reported to be associated with management options are distress, poor perceived health, age, and sex. Additionally, indicators of poor prognosis can play a role in management decisions. In our earlier study in this population, indicators of poor prognosis were long duration of the complaints at baseline, having musculoskeletal comorbidity, recurrent complaint, low social support, and a high somatization level.

The authors wanted to evaluate associations between diagnosis and characteristics of the patient, complaint, and general practitioner, 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. They 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. 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. General practitioners working in a solo practice more frequently referred to a medical specialist. General practitioners working in a rural area more frequently referred for physiotherapy. Female General practitioners prescribed medication less frequently. Physicians with special interest in musculoskeletal complaints gave corticosteroid injections more frequently.

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

Prevalence of Self Reported Neck, Shoulder, Arm Pain and Concurrent Low Back Pain or Psychological Distress: Time-Trends in a General Population, 1990-2006

From: Spine: 2009 Aug 1;34(17): 1863-8

Nonspecific neck, shoulder, arm pain is a very common symptom in the general population. It causes suffering for individuals as well as high societal costs in form of sick leave, disability pensions, health care utilization, and loss of productivity. Reviews have reported that the 12-month prevalence of neck pain range from 14% up to 78% and that the 12-month prevalence of shoulder pain range from 5% to 47%. It is important to understand whether the magnitude of different pain conditions are changing in order to plan and provide appropriate health care as well as preventive measures. However, differences in case definitions and study methodologies are considerable, making it difficult to establish time trends for neck, shoulder and arm pain. The authors are not aware of any published studies that have attempted to investigate time trends by repeatedly following the prevalence in a given geographical area.

Neck, shoulder, arm pain is more common among females. A summary of data from epidemiological studies in the general population found a median ratio between females and males of 1.4 for neck pain and 1.3 for shoulder pain. Treaster and Burr concluded that females do have higher prevalence than males for many types of upper extremity musculoskeletal disorders, even after controlling for the type of data source self reporting, plant/worker compensation records or physical examinations and confounders such as age. The reasons behind the prevalence differences are poorly understood, and it is still unclear whether this gender gap has been constant over time, or is increasing or decreasing.

Several studies have reported that both comorbid low back pain and comorbid psychological distress are common. Both a national study and a cross national study have shown that about two-third of individuals with musculoskeletal pain reported pain in at least 2 regions. The link between symptoms in different bodily regions may involve shared pathology, common mechanical risk factors, or some aspects of psychological distress. To the authors knowledge, no studies have reported whether the prevalence of neck, shoulder, arm pain with concurrent low back pain or psychological distress has changed over time.

This article presents data on the prevalence of neck, shoulder, arm pain, neck, shoulder, arm pain with concurrent low back pain, and neck, shoulder, arm pain with concurrent psychological distress, from the Stockholm Public Health Surveys that have been carried out every 4 years since 1990.

It has been hypothesized that the prevalence of musculoskeletal pain is increasing, but the evidence has been both sparse and equivocal. In contrast to an earlier study that found a 2 to 4 fold increase of pain in 2 surveys conducted 40 years apart, the results in the present article indicated a slight rise in the prevalence of neck, shoulder, arm pain, which may indicate a similar but weaker time trend.

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Four-year incidence of sick leave because of neck and shoulder pain and its association with work and lifestyle

From: Spine. 2009 Feb 15;34(4):413-8

Musculoskeletal disorders are one of the important health problems in the world. With the exception of back pain, neck and shoulder pain is one of the prevalent disorders in workplaces and a common reason for abseentism, job change, and disability pension.

The incidence and prevalence of neck and shoulder pain have a broad range in different studies, depending on which data collection method is used (self-reported questionnaire, medical examination, sickness absence). Neck and shoulder pain is a dynamic entity that can change over time, but few longitudinal studies have been performed on workplace populations to address the above-mentioned issues.

The relation between neck and shoulder pain and physical as well as psychosocial factors at work have been studied and approved (with different consistency) in different surveys. Most of these studies are cross-sectional and related to high-income and industrialized countries. There is little information about neck and shoulder pain in the general population in developing and low-income countries. There are even fewer studies in working populations.

The main aim of this longitudinal investigation was to determine the incidence of sick leave because of neck and shoulder pain in a large population of Iranian workers, and to study its relation with physical and psychosocial factors at work, lifestyle, and previous pain. An additional aim was to compare risk factors for future sick leave versus risk factors for self-reported neck and shoulder pain in the cross-sectional baseline study.

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Effect of physical training on function of chronically painful muscles: A randomized controlled trial

From: J Appl Physiol. 2008 Oct 23; [Epub ahead of print]

Pain and tenderness of the upper trapezius muscle is frequent in several occupational groups. The objective of this study is to investigate the effect of three contrasting interventions on muscle function and pain in women with trapezius myalgia. A group of employed women (n=42) with a clinical diagnosis of trapezius myalgia participated in a 10 week randomized controlled intervention; specific strength training of the neck and shoulder muscles (SST), general fitness training performed as leg-bicycling (GFT), or a reference intervention without physical activity (REF). Torque and electromyography (EMG) were recorded during maximal shoulder abductions in an isokinetic dynamometer at -60, 60, 0 and 180 degrees. Further, a submaximal reference contraction with only the load of the arms was performed. Results: Significant changes were observed only in specific strength training. Pain decreased 42-49%. While EMG activity of the unaffected deltoid remained unchanged during the maximal contractions, an increase in EMG amplitude (42-86%) and median power frequency (19%) were observed for the painful trapezius muscle. Correspondingly, torque increased 18-53%. EMG during the reference contraction decreased significantly for both the trapezius and deltoid muscles.

In conclusion, specific strength training relieves pain and increases maximal activity specifically of the painful trapezius muscle, leading to increased shoulder abduction strength in women with trapezius myalgia. Further, decreased relative workload may indirectly augment pain reduction.

One-year randomized controlled trial with different physical activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers

From: Scand J Work Environ Health. 2008 Feb;34(1):55-65

This study evaluates the effect of two different worksite physical activity interventions on neck and shoulder symptoms, together with perceived work ability and sick leave among office workers. An examiner-blinded randomized controlled trial was conducted with 549 office workers allocated to one of three intervention groups: one with specific resistance training of the neck and shoulder region (N=180), one with all-round physical exercise (N=187), and one which acted as a reference group, which was informed about general health promoting activities but did not include a physical activity program (N=182). Questionnaires were filled out at baseline and after 1 year of training.

The duration and intensity of neck and shoulder symptoms was lower after the specified worksite physical-activity interventions than in the reference group. On an intervention group level, specific resistance training was not more effective than all-round physical exercise in reducing the duration and intensity of neck and shoulder symptoms. However, those asymptomatic at baseline had a significant lower prevalence of neck-shoulder symptoms at follow up when allocated to the specific resistance training group than placed in the all-round physical exercise group or reference group. At baseline the work ability index was close to 90% of the maximum score, and the mean sick leave was 5 days per year, both being unaffected by the interventions.

Different physical activity interventions were successful in reducing neck and shoulder symptoms, and specific resistance training was superior to all-round physical exercise in the primary prevention of such symptoms. The initially relatively high work ability index was the most probable reason for no further increase in work ability index. Likewise the mean sick leave the year before the intervention was very low, and it was probably not possible to reduce it further.

Incidence of shoulder and neck pain in a working population: effect modification between mechanical and psychosocial exposures at work? Results from a one year follow up of the Malmö shoulder and neck study cohort

From: J Epidemiol Community Health. 2005 Sep;59(9):721-8

Work related musculoskeletal disorders and complaints constitute an important health problem in many industrialised countries, as they account for a large number of working days lost and considerable workers compensation and disability payments. For a long time, low back pain has been the dominant problem. However, pain from the shoulder and neck region now seems to occur more frequently. The prevalence of shoulder and neck symptoms is highest in the 45–65 year age bracket, as well as among women, manual workers, and certain ethnic groups.

However, its aetiology is still incompletely understood. Mechanical exposure at work and psychosocial conditions within and without the workplace, in addition to lifestyle and individual variables (age, previous symptoms, etc) are frequently discussed as causal factors in the literature.

Shoulder and neck symptoms have been linked to jobs with highly repetitive work, static work, and work above shoulder level. However, mechanical exposure explains only part of these complaints. The role of psychosocial factors in the workplace has therefore received increasing attention. On the job pressure, monotonous work, and a high perceived workload have also been associated with musculoskeletal symptoms just as much as working situations characterised by high psychological demands, low decision latitude, and low social support.

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