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Rheumatology Advance Access originally published online on September 14, 2006
Rheumatology 2007 46(3):508-515; doi:10.1093/rheumatology/kel320
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

A prospective cohort study of arm pain in primary care and physiotherapy—prognostic determinants

C. Ryall, D. Coggon, R. Peveler1, J. Poole and K. T. Palmer

MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD and 1Department of Mental Health, Royal South Hants Hospital, Southampton, UK.

Correspondence to: Dr Keith Palmer, MRC Epidemiology Resource Centre, Southampton General, Hospital, Tremona Road, Southampton SO16 6YD, UK. E-mail: ktp{at}mrc.soton.ac.uk


   Abstract
Top
 Abstract
Introduction
 Method
 Results
 Discussion
 Acknowledgements
 References
 
Objective. To investigate outcome and prognostic determinants for arm pain presenting to primary care and physiotherapy services.

Methods. Patients with arm pain were recruited as they presented to primary care and physiotherapy services, and were followed for 12 months. At baseline, they were classified by diagnosis using a validated examination schedule. Depression, somatizing tendency, health anxiety, fear-avoidance beliefs and chronic pain outside the arm were ascertained using standard definitions. Three outcomes were considered: same-site pain during the final month of follow-up (continuing pain); pain present on most days of that month; and pain present without a break of 7 days over follow-up (‘unremitting’ pain). Associations were explored in multi-level logistic regression models and summarized as odds ratios (ORs) with 95% confidence intervals (95% CIs).

Results. Altogether, 313 (83%) of 375 subjects completed follow-up, including 53% with ‘continuing’ and 24% with ‘unremitting’ pain. ‘Continuing’ pain was predicted most strongly by male sex (OR 1.9, 95% CI 1.2–3.2) (this association was restricted largely to the elbow), higher frequency of pain in the past month at baseline (OR 2.5, 95% CI 1.1–5.6), chronic pain at sites outside the arm (ORs 1.6–2.4 for different sites) and current smoking (OR 3.3, 95% CI 1.6–6.6). There were also indications that mental health and fear-avoidance beliefs influenced prognosis. Predictors for the other two adverse outcomes were similar.

Conclusion. Arm pain often persists in patients who consult medical services. Predictors of persistence include male sex (elbow only), frequency of pain at baseline, chronic pain at other sites and smoking.

KEY WORDS: Upper limb pain, Natural history, Epidemiology, Prognosis


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion
 Acknowledgements
 References
 
Musculoskeletal disorders are the second most frequent reason for adult consultations with general practitioners in the UK, and arm pain is often the primary complaint [1]. Disorders of the upper limb are also a major cause of incapacity for work. Data from the UK Labour Force Survey indicate a self-reported annual incidence of 91 per 1000 adults for work-related illnesses of the upper limb and neck, with an estimated loss of 4.1 million working days per year [2]. However, despite this economic importance, the best way of managing upper limb disorders is presently unclear. In particular, there are uncertainties about the relevance of diagnostic labels [3] and about the clinical features on which general practitioners and physiotherapists should base prognosis and choice of treatment.

Upper limb disorders include various discrete clinical entities (e.g. tenosynovitis, epicondylitis, rotator cuff tendonitis) and also ‘non-specific upper limb pain’ (pain for which no clear underlying pathology can be identified). Different disorders may demand different management strategies. In some, specific treatments such as injections, drugs or physical therapy may be warranted [4–7], but the benefits from other approaches to the management of arm pain have yet to be established. It is unclear, for example, whether simple advice to rest the arm is beneficial or whether it is better to remain active; whether occupational activities should be avoided and under which circumstances, and whether psychological factors, including health beliefs, represent a useful therapeutic target for some subcategories of arm pain. A contrast can be drawn with non-specific low-back pain, for which management has improved following appreciation of the role played in its chronicity by psychological factors and by fear-avoidance beliefs and behaviour [8].

Ultimately, randomized trials will be needed to identify the best care options for patients with upper limb disorders, but before this can happen, more information is required on their clinical course and on factors that influence or predict outcome.

To investigate prognostic determinants for arm pain and thereby inform the design of future intervention studies, we enrolled symptomatic patients from general practice and physiotherapy services prospectively, and followed them over a 12-month interval. We focused on various potential risk factors for the persistence of pain during follow-up, including diagnosis, severity of pain at baseline, mental health, distress associated with multiple somatic symptoms (somatizing tendency), health beliefs about arm pain, smoking habits, and co-morbidity from chronic pain outside the arm and from chronic fatigue.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion
 Acknowledgements
 References
 
Participants were recruited from three sources in the Southampton area: (i) patients who attended for primary care at any of the eight general practices during 2001–03 with new arm pain as the reason for consultation; (ii) a consecutive series of patients referred to local physiotherapy services with new arm pain during 2002–03; and (iii) people with arm pain who were seen over a 6-month period in 2003 at a clinic to which patients from primary care were referred for orthopaedic assessment and triage. In the assessment of patients’ eligibility for inclusion, the upper limb was defined by means of a shaded area on a line diagram. For recruits from primary care and physiotherapy, a ‘new’ episode was one for which there had been no consultation with that service in the preceding 12 months. The triage patients mostly comprised people contacting the service for the first time, but included a few who had consulted previously.

All who agreed to take part in the study (response rate = 43.4%) were asked to complete a baseline self-administered questionnaire and to attend a clinical assessment.

The questionnaire covered age, sex, smoking habits, occupation, mental health, health beliefs and aspects of co-morbidity. Items on mental health were drawn from the Hospital Anxiety Depression Scale (HADS) [9], the Whiteley Index (health anxiety) [10] and elements of the Brief Symptom Inventory (BSI) (tendency to report distress from somatic symptoms) [11]. A priori cut-points were chosen for the HADS and Whiteley index, according to previously published recommendations [9, 10]; and somatizing tendency was scored according to the number of somatic symptoms moderately, quite a lot or extremely distressing during the past 7 days. The questions on health beliefs were adapted from the fear-avoidance beliefs questionnaire on low-back pain [12], and scored (out of four) according to the number of positively expressed beliefs regarding the need to rest the painful arm and avoid physical activity. Several of these scales have been validated [13–15]. With regard to other co-morbidity, questions were posed to identify: chronic fatigue syndrome (CFS), based on the criteria of the Center for Diseases Control [16]; chronic widespread pain (CWP), based on the American College of Rheumatology (ACR) criteria [17]; abdominal pain lasting at least 12 weeks in the past year, and chronic headache (present on an average ≥15 days per month during the previous 6 months). Questions on smoking history and occupation were included in view of suspected associations with chronic pain including arm pain [18, 19].

At the clinical assessment, one of the four trained research staff (three nurses and a physiotherapist) conducted an interview and clinical examination according to a standardized and validated protocol (the Southampton Examination Schedule for Upper Limb Disorders) [19–22]. Clinical assessments were carried out at a median interval of 2 weeks from initial consultation, generally at the patient's home, and were used to classify subjects according to whether or not they fulfilled criteria for each of five diagnostic groups:

  1. shoulder pain;
  2. specific disorders of the elbow (lateral epicondylitis, medial epicondylitis or olecranon bursitis);
  3. non-specific elbow pain (elbow pain in the absence of a specific elbow disorder);
  4. specific disorders of the forearm, wrist or hand (carpal tunnel syndrome, tenosynovitis, de Quervain's disease of the wrist, or osteoarthritis of thumb base or distal interphalangeal joint);
  5. non-specific pain of the forearm or wrist-hand (pain in forearm or wrist-hand in the absence of any of the specific disorders listed in (iv) above).

Shoulder pain was not sub-classified as we had previously found substantial overlap of diagnoses at this site [23]. As part of the interview, information was collected also about the frequency of arm pain in the previous 4 weeks, and whether it had made it difficult to carry out any of a specified list of everyday activities. Pain was classed as disabling if it had made all three of sleeping, dressing and carrying bags difficult or impossible during the 4 weeks preceding the assessment. The location of pain was established using standardized pre-shaded line drawings.

Following this baseline assessment, participants were contacted by telephone by a research nurse or physiotherapist at four times over the next 12 months (1, 3, 6 and 12 months after entry to the study). On each occasion they were asked: whether they still had pain at the same anatomical site(s); whether they had been free from pain at any time since their last response for as long as seven consecutive days; whether their symptoms had made it difficult or impossible to sleep, dress, or carry bags in the previous 4 weeks; whether, if working, they had lost work time or changed their work activity or environment because of symptoms since they had last been contacted, and whether they had received various forms of medical treatment because of their arm problem since last contacted.

Analysis focused on three main outcomes:

  1. same-site pain during the last 4 weeks of follow-up, i.e. at 11–12 months from baseline (defined as ‘continuing pain’);
  2. same-site pain on most days (≥14) during those four weeks (‘frequent continuing’ pain); and
  3. same-site pain from which the subject had never been free for as long as seven consecutive days at any stage during the entire follow-up period (‘unremitting’ pain). This was determined from the answers given at each successive follow-up.

Using STATA (version 8.2 SE) software, we examined the relation of these outcomes to factors at entry to follow-up by random effects multi-level logistic regression. Multi-level modelling was employed to allow for possible within-individual correlations in 38 subjects who presented initially with pain at more than one site in the arm (shoulder, elbow and forearm/wrist/hand). This method estimates variances and CI after allowing for the non-independence of correlated observations. Risk estimates were summarized by prevalence odds ratios (ORs) with associated 95% CI. All regression models were constrained to include a set of risk factors that were deemed a priori to be relevant and potential confounders of other associations (sex, age, diagnostic group, whether the pain at baseline was unilateral or bilateral, frequency of pain in the month before entry to follow-up and whether the pain was associated with disability at baseline). Other risk factors were analysed separately from each other, but with allowance for these potential confounders. Finally, all of the risk factors were entered into backward stepwise regression models, in which independent variables that had not been designated as relevant a priori were removed if their statistical significance was >0.2.

Approval for the study was obtained from Southampton and South West Hampshire and Salisbury Local Research Ethics Committees.


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion
 Acknowledgements
 References
 
A total of 375 patients were recruited at baseline—128 from primary care, 213 from physiotherapy services and 34 from the triage clinic. Within this cohort, 313 individuals (83.5%) completed the 12-month follow-up questionnaire and thus were eligible for analysis. There was little difference in baseline characteristics (sex, age, site and severity of arm pain, mental health score and health beliefs) between those analysed and those lost to follow-up. Most of the patients included in the analysis (267, 85.3%) had also responded to all of the intermediate follow-up questionnaires (at 1, 3 and 6 months).

Table 1 shows the prevalence of pain outcomes, and of various treatment modalities during follow-up, according to diagnostic group at baseline. Many subjects (41–68% depending on diagnostic group) had continuing pain in the final month of follow-up, including 15–27% with frequent continuing pain and 12–27% who had unremitting pain. Patients recruited through physiotherapy and triage services were more likely to have these outcomes than those recruited through general practice, but differences by source of recruitment were fairly minor. Altogether, 44 people (14%) had ‘disabling’ pain during the last 4 weeks of follow-up (defined as pain making it difficult or impossible to sleep and dress and carry bags). Among those for whom the relevant information was available (i.e. the 283 who completed the 6-month follow-up), 14% were still seeing a general practitioner for arm pain 6–12 months after entry to the study and 9% a physiotherapist. Patients with specific disorders were more likely to have an injection or operation during follow-up than those with non-specific pain, but the differences were not statistically significant.


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  		TABLE 1. Prevalence of continuing arm pain at 12 months and of treatments received during follow-up by diagnostic group

 
Among those who supplied complete follow-up data and held a job at the entry to the study (182 of 267 subjects), 42 (23% of those in work) took time off work because of arm pain over the 12 months of follow-up, while 120 (66%) reported having to reduce or change their activities at work, or make modifications to their work environment because of their arm pain.

Table 2 presents the associations of sex, age and pain characteristics at baseline with same-site pain at follow-up. Risk estimates were mutually adjusted (i.e. derived from a single regression model for each pain outcome) as well as being adjusted for the source of recruitment (primary care, physiotherapy services or triage clinic). The odds of pain at follow-up were higher in men than in women, but tended to be lower at age ≥45 years than in younger patients. Bilateral arm pain at baseline was associated with a higher risk of continuing symptoms a year later, but differences by diagnostic group were relatively minor. Nor was there any clear difference in prognosis according to the frequency of pain at baseline, or the presence of associated disability. Nevertheless, all of these variables were carried forward to subsequent analyses as a priori factors of adjustment.


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  		TABLE 2. Prevalence of continuing same site pain at 12 month follow-up according to sex, age and characteristics of pain at baseline

 
Table 3 shows associations of continuing arm pain, with various psychological characteristics and health beliefs that were assessed at baseline. The risk of continuing pain was significantly elevated in patients with a Whitley hypochondriasis score of 5+, and non-significantly in those with high HAD scores for anxiety and depression. There was also some indication of worse outcome in patients who at baseline reported being troubled by common somatic symptoms, but with no clear trend in relation to the extent of somatizing tendency. Beliefs about prognosis and the adverse impact of physical activity were not consistently associated with continuing pain.


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  		TABLE 3. Prevalence of continuing same site pain at 12 months follow-up according to psychological characteristics at baseline

 
Long-lived pain at sites outside the arm was a strong predictor of poorer outcome (Table 4). Baseline reports of CWP, chronic abdominal pain and chronic headache were all significantly associated with continuing arm pain, with ORs of 2.2–5.2. In contrast, CFS showed little relation to continuing pain.


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  		TABLE 4. Prevalence of continuing same site pain at 12 months follow-up according to comorbidity at baseline

 
Smoking habits were another important prognostic indicator, ORs for the three indices of continuing pain in current smokers ranging from 2.7 to 5.0 (Table 5). However, there were no major differences in outcome between manual and non-manual workers.


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  		TABLE 5. Prevalence of continuing same site pain at 12 months follow-up according to smoking habits and occupation

 
Table 6 shows results from the stepwise regression analyses of risk factors for continuing pain. As described earlier, all three models were constrained to include the independent variables examined in Table 2. Other variables were retained if they were statistically significant at a 20% level. From this analysis, it appeared that apart from bilaterality of pain at baseline, the most important and consistent predictors of continuing pain at follow-up were male sex, presence of pain for 14+ days in the past month at baseline, chronic pain at sites outside the arm and current smoking.


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  		TABLE 6. Stepwise regression analyses of risk factors for continuing pain

 
We repeated the analyses for Table 6 after exclusion of the 62 subjects who received injections or operations during follow-up, and found that, in general, associations were little changed, although those with health anxiety, somatizing tendency and smoking history tended, if anything, to become stronger. Thus, for example, in those with a Whitely score of 5+ vs <5 at baseline, the OR for unremitting pain at follow-up was 4.7 (95% CI 1.6–13.6).

We also carried out the analyses for Tables 2–6GoGoGoGo separately for the five diagnostic groupings of arm pain. Numbers were small, but there were no indications that associations with mental health, pain outside the arm and smoking were limited by anatomical site or to non-specific as compared with specific categories of disorder. The associations of male sex with persistence were largely confined to elbow complaints, and at the elbow there were clear associations with blue-collar employment and with unemployment (data available on request).


   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
Acknowledgements
 References
 
In this study, arm pain presenting to primary care and physiotherapy services often continued to be troublesome for a year or longer. Baseline characteristics that were associated with worse outcome included male sex, higher frequency of pain in the past month, chronic pain at sites outside the arm and current smoking. In addition, there were indications of psychological influences on prognosis. No clear differences in outcome were apparent by diagnostic group, although shoulder pain tended to be more persistent than pain at other sites.

Among the study's strengths were its longitudinal design and consistently high response rate throughout follow-up. Those finally analysed were similar to those lost to analysis in their baseline characteristics, and any bias from attritional losses is unlikely to have had much impact on the associations observed.

Another strength was our application of a validated standardized examination at baseline to distinguish specific disorders of the elbow, wrist and hand from non-specific pain. Underlying disorders may differ importantly in their causes and clinical course, and understanding has been hampered by a common failure to classify cases according to validated assessment procedures. Only recently have consensus-driven diagnostic criteria been developed [20, 24], tested for their agreement with specialist opinion and reproducibility in clinical and community settings [21, 22], and incorporated into structured assessment schedules in field epidemiology [23]. The congruence of the diagnostic classification with clinical practice is further supported by our observation that specific disorders tended to be treated more frequently by injection or surgery than non-specific pain at the same sites.

Our study also had several limitations. In addition to documented refusals, routinely recorded data from two of the participating general practices suggest that a number of eligible patients were never invited to take part. We have no reason to believe that general practitioners consciously selected patients for invitation on the basis of diagnosis or other personal characteristics, but to the extent that recruitment was selective, our findings on the prevalence of continuing pain may not be fully representative. Possible differences in case-mix are an indication for caution also in extrapolation to other communities and clinical settings, although we found no major differences in outcome frequency by source of recruitment.

Findings on associations with prognostic indicators are probably less sensitive to the constitution of the study sample than those on the absolute prevalence of adverse outcomes. Thus, apart from the higher rate of persistence in men, which was restricted largely to elbow complaints, we found no indication that associations differed importantly by anatomical site or by our categorization into specific disorders vs non-specific pain. However, the diagnostic groups that we defined were relatively broad (e.g. a number of distinct specific disorders of the wrist were considered together), and it is possible that important differences at this level were missed. Unfortunately, statistical power to conduct sub-analyses by more detailed diagnostic category was lacking, and this again limits the conclusions that can be drawn.

Notwithstanding these weaknesses, our study is broadly consistent with other research, and points to several important predictors of non-recovery from upper limb pain.

Shoulder pain, the commonest presentation in our study, has been investigated most often. Following a systematic review of prognostic cohort studies, Kuijpers et al. [25] concluded that only a half of new episodes of shoulder disorders end in complete recovery within 6 months; a similar proportion of an occupational cohort with shoulder tendonitis at baseline had recovered by 10 months; [26] 54% of a population sample, recruited from British general practice, still had symptoms three years on [27]; and in a cohort from Dutch general practice, 41% were still affected after 12 months [28]. There is also some evidence that epicondylitis is often persistent [29], but for forearm pain, the frequency of persistence in consulters seems not to have been much documented.

Prognostic indicators for shoulder pain, arm pain and epicondylitis have also been studied. Duration and severity of pain and disability at baseline seem to be implicated in the persistence of shoulder pain [27, 30], while pain score at baseline has been linked with delayed recovery from epicondylitis in patients presenting to primary care [31]. And in one large follow-up survey of visual display unit users, generalized pain was associated with non-recovery from elbow, forearm and hand pain [32]. In keeping with these reports, we found a positive association with duration of pain in the past month and strong associations with chronic pain outside the arm. We also found a clear association with being a smoker that was independent of the other risk factors examined. Smoking has been linked with arm pain and pain at other sites in previous investigations [18, 19], and our study adds the new finding of a longitudinal association with continuing and unremitting pain. Possible explanations have been discussed elsewhere [19]. They include a pharmacological effect on pain perception, a socio-cultural difference in threshold for reporting symptoms and in illness behaviour, or injury to tissues (e.g. through vasoconstriction, hypoxia, defective fibrinolysis or other mechanisms that impair nutrition and structure).

There has been less emphasis in previous research on the prognostic influence of personal mental health, a point made in a systematic review by Bongers et al. [33]. However, in a small cohort of patients registered with British general practices [27] persistence of shoulder pain was predicted (although not significantly so at the 5% level) by mental distress, measured using the General Health Questionnaire; and Haahr and Anderson [31] found that distress at baseline, based upon a score of somatic symptoms, doubled the risk of persistent elbow pain at 12 months in cases of epicondylitis presenting to primary care. In contrast, van den Heuvel et al. [34] found no significant association between persistent neck-arm symptoms and various indices of mental health designed to assess burnout, poor coping skills and negative affectivity in an occupational cohort; and Estlander et al. [35] found little relation to somatizing tendency or depression, assessed by different measuring instruments from our own, in a cohort of forestry workers with a mixture of back, neck and shoulder pains at baseline. Beyond this there is little information, although in primary care attenders with low-back pain, poor mental health is a recognized risk factor for persistence. Thus, in data that appear similar to our own except in terms of anatomical site, Thomas et al. [36] found that persistent disabling low-back pain was predicted by high levels of distress (assessed by the General Health Questionnaire), and by duration of pain, presence of widespread pain and smoking habits at baseline, and Dionne et al. [37] found that somatization and depression at presentation were among the stronger predictors of two-year outcome.

We know of no studies that have examined the persistence of arm pain in relation to fear-avoidance beliefs at baseline, but associations have been reported with persistence of low-back pain and disability, including work limitations [38, 39]. Although we did not find a clear trend of increasing risk in relation to fear-avoidance beliefs (Table 6), our observations suggest that they may contribute to chronicity, and this merits further investigation.

Given the evidence that patients with non-specific low-back pain fare best if encouraged to remain active within the limits imposed by their symptoms [40, 41], and also the indications that psychological characteristics have a prognostic influence in arm pain, there is a need now for randomized controlled trials to assess the impact of continued activity as compared with resting the limb in patients with non-specific upper arm pain. Our study provides useful information for the planning of such trials, in particular on the frequency of potential outcome measures, and on important predictors of prognosis that might confound outcomes if not adequately balanced between treatment groups. The results may also be helpful to general practitioners and physiotherapists in assessing the prognosis of patients with arm pain.

Formula


   Acknowledgements
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Acknowledgements
References
 
The doctors and staff at Bitterne, Blackthorn, Chessel, Grove Road, Nightingale, Spitfire, Three Swans and West End general practices, and at Stoneham Centre, Moorgreen Hospital, Royal South Hants Hospital and Orthopaedic Choice, Southampton City Primary Care Trust assisted with patient recruitment, as did Trish Byng, Karen Collins and Cathy Linaker from the MRC. Ken Cox and Vanessa Cox prepared the data for analysis. Denise Gould typed this manuscript.

C.R. was funded by a Research Training Fellowship and project grant from the NHS Executive South East.

The authors have declared no conflict of interest.


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Acknowledgements
 References
 

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Submitted 27 April 2006; revised version accepted 3 August 2006.
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I. Madan, I. Reading, K. T Palmer, and D. Coggon
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Int. J. Epidemiol., May 29, 2008; (2008) dyn085v1.
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