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Objectives: To explore the association of sickness absence ascribed to pain at specific anatomical sites with wider propensity to musculoskeletal pain., Methods: As part of the CUPID (Cultural and Psychosocial Influences on Disability) study, potential risk factors for sickness absence from musculoskeletal pain were determined for 11 922 participants from 45 occupational groups in 18 countries. After approximately 14 months, 9119 (78%) provided follow-up information about sickness in the past month because of musculoskeletal pain, including 8610 who were still in the same job. Associations with absence for pain at specific anatomical sites were assessed by logistic regression and summarised by ORs with 95% CIs., Results: 861 participants (10%) reported absence from work because of musculoskeletal pain during the month before follow-up. After allowance for potential confounders, risk of absence ascribed entirely to low back pain (n=235) increased with the number of anatomical sites other than low back that had been reported as painful in the year before baseline (ORs 1.6 to 1.7 for ≥4 vs 0 painful sites). Similarly, associations with wider propensity to pain were observed for absence attributed entirely to pain in the neck (ORs up to 2.0) and shoulders (ORs up to 3.4)., Conclusions: Sickness absence for pain at specific anatomical sites is importantly associated with wider propensity to pain, the determinants of which extend beyond established risk factors such as somatising tendency and low mood. Better understanding of why some individuals are generally more prone to musculoskeletal pain might point to useful opportunities for prevention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Arm pain is common, costly to health services and society. Physiotherapy referral is standard management, and while awaiting treatment, advice is often given to rest, but the evidence base is weak., Objective: To assess the cost-effectiveness of advice to remain active (AA) versus advice to rest (AR); and immediate physiotherapy (IP) versus usual care (waiting list) physiotherapy (UCP)., Methods: Twenty-six-week within-trial economic evaluation (538 participants aged ≥18 years randomized to usual care, i.e. AA (n = 178), AR (n = 182) or IP (n = 178). Regression analysis estimated differences in mean costs and Quality-Adjusted Life Years (QALYs). Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves were generated. Primary analysis comprised the 193 patients with complete resource use (UK NHS perspective) and EQ-5D data. Sensitivity analysis investigated uncertainty., Results: Baseline-adjusted cost differences were £88 [95% confidence interval (CI): -14, 201) AA versus AR; -£14 (95% CI: -87, 66) IP versus UCP. Baseline-adjusted QALY differences were 0.0095 (95% CI: -0.0140, 0.0344) AA versus AR; 0.0143 (95% CI: -0.0077, 0.0354) IP versus UCP. There was a 71 and 89% probability that AA (versus AR) and IP (versus UCP) were the most cost-effective option using a threshold of £20,000 per additional QALY.  The results were robust in the sensitivity analysis., Conclusion: The difference in mean costs and mean QALYs between the competing strategies was small and not statistically significant. However, decision-makers may judge that IP was not shown to be any more effective than delayed treatment, and was no more costly than delayed physiotherapy. AA is preferable to one that encourages AR, as it is more effective and more likely to be cost-effective than AR., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Only few longitudinal studies have explored separately predictors of pain incidence and persistence., Objective: To investigate whether biological, lifestyle, occupational and psychological risk factors for the development of new episodes of upper limb pain (ULP) differ from those for its persistence., Methods: Spanish nurses and office workers (1105) were asked at baseline about biological, lifestyle, occupational and psychological risk factors and pain in the past month at six anatomical sites in the upper limb (left and right shoulder, elbow and wrist/hand). At follow up, 12 months later, pain in the past month was again ascertained. Analysis was based on anatomical sites clustered by person. Associations were assessed by multilevel logistic regression models., Results: Nine hundred and seventy-one participants (87.9%) completed follow-up. Job dissatisfaction and older age carried higher risk of new ULP. Somatising tendency (OR 2.2, 95% CI 1.6-3.1) was the strongest predictor of new ULP, with a risk estimate which differed significantly from that for the same exposure and persistence of ULP. Having adverse beliefs about the work-relatedness of ULP carried a significantly reduced risk for persistence of ULP., Conclusion: Our study provides only limited evidence that risk factors predicting new ULP differ from those predicting its persistence.

Objective: Musculoskeletal pain is associated with occupational physical activities and psychosocial risk factors. We evaluated the relative importance of work-related and psychological determinants of the number of -anatomical sites affected by musculoskeletal pain in a cross-sectional survey., Methods: The survey focused on musculoskeletal pain in six body regions (low-back, neck, shoulder, elbow, wrist-hand, and knee) among 224 nurses, 200 office workers and 140 postal clerks in Crete, Greece (response rate 95%). Information was collected about demographic characteristics, occupational physical load, psycho-social aspects of work, perceptions about the causes of pain, mental health, somatization, and experience of pain in the past 12 months. We used Poisson regression to assess associations of risk factors with the number of painful anatomical sites and explored interactions using classification and regression trees (CART)., Results: Two-thirds of the study sample reported pain in >or=2 body sites during the past 12 months, and in 23%, >3 sites were affected. The number of painful anatomical sites was strongly related to both physical load at work and somatization (with relative risks increased 5-fold or more for frequent and disabling multisite pain) and was also significantly associated with work-related psychosocial factors and beliefs about work causation. The CART analysis suggested that somatization was the leading determinant of the number of painful body sites., Conclusion: In the population studied, pain at multiple anatomical sites was common and strongly associated with somatization, which may have a more important influence on multisite pain than pain that is limited to a single anatomical site.

Objectives: To establish whether review articles provide consistent conclusions on associations between workplace psychosocial factors and musculoskeletal pain and, if differences exist, to explore whether this is related to the methods used., Methods: Reviews, reported up to February 2007, that included consideration of workplace psychosocial factors and upper limb, back or knee pain were identified through searches of multiple databases. The specific work-related psychosocial factors considered were job demands, support, job autonomy and job satisfaction. The conclusions of each review on one or more of the psychosocial/musculoskeletal pain associations were extracted., Results: 15 review articles were identified that considered one or more of the regional pain syndromes included in the study. For back pain, the most consistent conclusions (four reviews positive out of six) were with high job demands and low job satisfaction. The studies of upper limb pain were exclusively related to shoulder and/or neck pain, and the most consistent positive conclusions were with high and low job demands (four reviews positive out of six and two reviews positive out of three, respectively). For knee pain, only a single review was identified. For individual reviews of back and upper limb pain, there were marked differences in the number of associations concluded to be positive between reviews., Conclusions: The reasons for reviews coming to different conclusions included that they were often evaluating different bodies of evidence (according to their search criteria, the year when the review was conducted, the role that quality assessment played in whether studies contributed to evidence, and the combination of risk factors addressed in individual studies), but more important was whether the review specified explicit criteria for making conclusions on strength of evidence. These conclusions emphasise the importance of developing standardised methods for conducting such evaluations of existing evidence and the importance of new longitudinal studies for clarifying the temporal relationship between psychosocial factors and musculoskeletal pain in the workplace.

Objective: Statistics from Labour Force Surveys are widely quoted as evidence for the scale of occupational illness in Europe. However, occupational attribution depends on whether participants believe their health problem is caused or aggravated by work, and personal beliefs may be unreliable. The authors assessed the potential for error for work-associated arm pain., Methods: A questionnaire was mailed [corrected] to working-aged adults, randomly chosen from five British general practices. They were asked about: occupational activities; mental health; self-rated health; arm pain; and beliefs about its causation. Those in work (n = 1769) were asked about activities likely to cause arm pain, from which the authors derived a variable for exposure to any "arm-straining" occupational activity. The authors estimated the relative risk (RR) from arm-straining activity, using a modified Cox model, and derived the population attributable fraction (PAF). They compared the proportion of arm pain cases reporting their symptom as caused or made worse by work with the calculated PAF, overall and for subsets defined by demographic and other characteristics., Results: Arm pain in the past year was more common in the 1143 subjects who reported exposure to arm-straining occupational activity (RR 1.2, 95% CI 1.1 to 1.5). In the study sample as a whole, 53.9% of 817 cases reported their arm pain as work-associated, whereas the PAF for arm-straining occupational activity was only 13.9%. The ratio of cases reported as work-related to the calculated attributable number was substantially higher below 50 years (5.4) than at older ages (3.0) and higher in those with worse self-rated and mental health., Conclusions: Counting people with arm pain which they believe to be work-related can overestimate the number of cases attributable to work substantially. This casts doubt on the validity of a major source of information used by European governments to evaluate their occupational health strategies.

To investigate whether somatising tendency, low mood and poor self-rated health (SRH) predict incident arm pain, and whether these factors and beliefs about causation and prognosis predict symptom persistence, we conducted an 18-month postal follow-up in 1798 working-aged subjects, sampled from the registers of five British general practices. At baseline questions were asked about pain in the arm (lasting >or=1day in the prior 12months), mental health (Short-Form 36 (SF-36MH)), somatising tendency (the Brief Symptom Inventory (BSI)), SRH, and beliefs about causation and prognosis. At follow-up we asked about arm pain in the last four weeks, and whether it had been present on >or=14days. Associations with incidence and persistence were explored using logistic regression. The 1256 participants (70% response) comprised 613 free of, and 643 with, arm pain initially. Among the former, 21% reported new pain at follow-up, while 53% of the latter reported symptom persistence. The odds of both incident and persistent arm pain were significantly raised (1.7- to 4-fold) in the least vs. most favourable bands of SF-36MH, BSI and SRH. Even stronger associations were found for arm pain on >or=14days. Persistent pain was significantly more common among those who attributed their pain to work or stress, and in those who expected symptoms still to be a problem in 12months. Thus, SRH and mental health indices were strong predictors of incident and persistent arm pain in adults from the community, while persistence was also predicted by beliefs about causation and prognosis.

Objectives: To investigate whether knee pain in the community behaves like a regional pain syndrome, determined by its association with mental health, self-rated health (SRH) and beliefs about prognosis., Methods: An 18-month postal follow-up was conducted in 1798 working-aged subjects, sampled from the community. At baseline questions were asked about pain in the knee lasting > or =1 day in the previous 12 months, mental health (Short-Form 36), somatising tendency (elements of the Brief Symptom Inventory), SRH and concern about 12-month prognosis. At follow-up we asked about knee pain during the last 4 weeks, and whether it had been present for > or =14 days or prescription-treated. Associations with incidence and persistence were explored using logistic regression., Results: The 1256 participants (70% response) comprised 468 with knee pain at baseline and 788 without. Among the former, 49% had persistent knee pain at follow-up, while among the latter, 15% reported new symptoms. Incident prescription-treated knee pain was strongly associated with all of the mental health variables and with SRH. The odds of knee pain persisting were significantly raised in the least versus most favourable bands of somatising tendency and SRH, and persistence was also significantly more common among those who at baseline were concerned that they would still have a problem in 12 months., Conclusions: Our observations support the hypothesis that knee pain in the community shares risk factors in common with other non-specific regional pain syndromes.

Background: Arm pain is a common cause of incapacity for work and is often attributed to occupational activities, but in many cases the pathogenesis is unclear., Objective: To investigate whether arm pain in the absence of identifiable underlying pathology is associated with reduced tolerance of painful sensory stimuli., Methods: 133 incident cases of arm pain, recruited from primary care and physiotherapy services, were classified according to a validated diagnostic algorithm. Pain tolerance was measured at three sites in each arm in response to electrocutaneous stimulation. Associations with pain tolerance (the geometric mean of the six measurements at 5 Hz) were assessed by linear regression, and findings were summarised as proportional changes in pain tolerance., Results: Pain tolerance was generally lower than in an earlier community survey. Women had a lower tolerance than men. After allowance for sex, age, use of analgesics and anatomical extent of pain, there was no indication of reduced tolerance in patients with non-specific pain relative to those with specific local pathology., Conclusions: Pain tolerance may be generally reduced in patients presenting to medical services with arm pain, but those with non-specific pain do not seem to have lower tolerance than those with identifiable local pathology.

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.

Background: Few community-based epidemiological investigations of upper limb disorders (ULDs) have classified cases by validated procedures involving a structured clinical examination., Aim: To compare risk factor profiles for different diagnostic categories of ULD using one such examination scheme., Methods: A questionnaire about upper limb pain and demographic, occupational and psychosocial risk factors was mailed to 10,264 adults from two English general practices, followed by standardized physical examination in those with arm or neck pain. Logistic regression was used to compare those with specific ULDs and non-specific arm pain with those who had no neck or arm symptoms., Results: There was a 59% response rate. A total of 1,197 subjects with arm or neck pain underwent standardized physical examination and were classified as having one or more of 11 specific ULDs or non-specific regional pain. Among these, 250 subjects with specific ULDs and 176 with only non-specific arm pain were compared with 2,248 subjects who had no neck or arm symptoms. Certain physical risk factors were more strongly associated with specific disorders than with non-specific pain. In comparison with pain-free subjects, the odds ratios (ORs) in keyboard users (>or=1 h versus <1 h/day) were 3.1 (95% CI 1.3, 7.8) for hand-wrist tendonitis but 1.3 (0.8, 2.1) for non-specific hand-wrist pain. Other differential associations were found with age, sex, manual versus non-manual employment and smoking. Unexpectedly, low vitality was similarly associated with both specific disorders and non-specific pain., Conclusion: These findings suggest that the schedule may usefully distinguish disorders that differ in their association with physical risk factors.

Objectives: To investigate the association of occupational activities, mental health and comorbidity with care seeking for arm pain, and to test the hypothesis that specific disorders arise from physical risk factors and non-specific pain from psychological ones., Methods: Patients with a new episode of arm pain and matched controls were recruited from eight general practices. A questionnaire about risk factors was completed and cases were classified using a validated examination schedule. Questions were asked about occupational activities and psychosocial stressors. Mental health was assessed using the Hospital Anxiety Depression Scale, elements of the Brief Symptom Inventory (somatizing tendency) and the Whiteley Index (health anxiety); comorbidity from chronic fatigue syndrome (CFS) and chronic widespread pain (CWP) was ascertained using standard definitions. Associations were explored using logistic regression and summarized as odds ratios (ORs) with 95% confidence intervals (95% CIs)., Results: Altogether, 132 cases and 127 controls were studied. Consulting with arm pain was strongly associated with all of the mental health variables and with CFS and CWP, irrespective of the site of arm pain or diagnosis. The OR in those with >3 versus <3 distressing somatic symptoms was 3.9 (95% CI 1.7-9.0). There were several significant associations with physical activity, but none with occupational psychosocial stressors. Repeated wrist/finger movements and carrying weights were more strongly associated with specific diagnoses than with non-specific pain., Conclusions: Somatizing tendency, health anxiety, low mood, CFS and CWP are more common in arm pain consulters. Certain mechanical activities are also overrepresented, particularly in those with specific pathology.

Background: Somatization (a tendency to report distress from somatic symptoms) is a little studied, but potentially important, confounder and effect modifier in occupational studies of musculoskeletal disease., Aims: To assess the role of somatization as a risk factor for disabling regional pain., Methods: A questionnaire was mailed to 4998 subjects of working age. Questions were asked about chronic and disabling pain in the past 12 months affecting the arm, low back, knee or combinations of these sites. Distress from physical symptoms was assessed using elements of the Brief Symptom Inventory and mental well-being was assessed using the short-form 36 (SF-36). Associations were examined by modified Cox regression and expressed as hazard ratios (HRs) with 95% confidence intervals (CI)., Results: Among 2632 responders, 24% reported chronic pain and 25% disabling pain at one or several sites. Risk of chronic or disabling pain increased strongly according to the number of somatic symptoms reported as bothersome. For example, the HR for chronic upper limb pain in those distressed by > or =2 somatic symptoms in the past 7 days versus none was 3.9 (95% CI 2.9-5.3), and that of disabling upper limb pain was 5.8 (95% CI 4.1-8.3). Similar patterns were found for the low back and knee, and there was a gradient of increasing risk according to the number of sites with disabling pain. In comparison, associations with SF-36 mental well-being score were weaker., Conclusion: Somatizing tendency should be evaluated as a possible confounder or effect modifier in studies of occupational risk factors for musculoskeletal pain.

Objectives: To explore the relation between smoking habits and regional pain in the general population., Methods: A questionnaire was mailed to 21 201 adults, aged 16-64 years, selected at random from the registers of 34 British general practices, and to 993 members of the armed services, randomly selected from pay records. Questions were asked about pain in the low back, neck, and upper and lower limbs during the past 12 months; smoking habits; physical activities at work; headaches; and tiredness or stress. Associations were examined by logistic regression and expressed as prevalence ratios (PRs)., Results: Questionnaires were completed by 12 907 (58%) subjects, including 6513 who had smoked at some time, among whom 3184 were current smokers. Smoking habits were related to age, social class, report of headaches, tiredness or stress, and manual activities at work. After adjustment for potential confounders, current and ex-smokers had higher risks than lifetime non-smokers for pain at all of the sites considered. This was especially so for pain reported as preventing normal activities (with PRs up to 1.6 in current v never smokers). Similar associations were found in both sexes, and when analysis was restricted to non-manual workers., Conclusions: There is an association between smoking and report of regional pain, which is apparent even in ex-smokers. This could arise from a pharmacological effect of tobacco smoke (for example, on neurological processing of sensory information or nutrition of peripheral tissues); another possibility is that people with a low threshold for reporting pain and disability are more likely to take up and continue smoking.

Pain in the upper limb is a common complaint in adults, and is often attributed to or exacerbated by occupational activities. In many patients there is no demonstrable pathology in the neck or arm to account for the symptom, and this has prompted the hypothesis that such cases might arise through abnormal neural processing of sensory information with a lowering of pain thresholds. In this paper we review the evidence in support of this theory and suggest directions for future research.

Background: Epidemiological research in the field of soft tissue neck and upper limb disorders has been hampered by the lack of an agreed system of diagnostic classification. In 1997, a United Kingdom workshop agreed consensus definitions for nine of these conditions. From these criteria, an examination schedule was developed and validated in a hospital setting.Objective: To investigate the reliability of this schedule in the general population.Methods: Ninety seven adults of working age reporting recent neck or upper limb symptoms were invited to attend for clinical examination consisting of inspection and palpation of the upper limbs, measurement of active and passive ranges of motion, and clinical provocation tests. A doctor and a trained research nurse examined each patient separately, in random order and blinded to each other's findings.Results: Between observer repeatability of the schedule was generally good, with a median kappa coefficient of 0.66 (range 0.21 to 0.93) for each of the specific diagnoses considered.Conclusion: As expected, the repeatability of tests is poorer in the general population than in the hospital clinic, but the Southampton examination schedule is sufficiently reproducible for epidemiological research in the general population. [ABSTRACT FROM AUTHOR]

Workers exposed to hand‐transmitted vibration (HTV) often experience aches and pains in the upper limbs, but there have been few studies of the pattern and severity of symptoms, or their relationship to the estimated dose of vibration. As part of a wider survey of vibration, we mailed a questionnaire about exposures to HTV and pain in the neck and upper limbs to a sample of men selected at random from the registration lists of 34 British general practices and the pay records of the armed services. Analysis was confined to the 1856 male respondents who had been employed in manual occupations for a year or more and who reported the last week as being representative of their job. Inquiry was made about pain in the neck, shoulder, elbow and wrist/hand over the past week and past year (including pains that limited normal activity). Subjects were classed according to their lifetime exposure to HTV and their estimated average daily vibration dose [A(8) r.m.s.] in the previous week. A total of 283 men had a minimum estimated A(8) greater than a proposed action level of 2.8 m/s2, and in this group symptoms were about twice as prevalent as in manual workers who had never used vibratory tools. The excess risk was somewhat higher for distal sites than for proximal ones (e.g. the prevalence ratio for hand/wrist pain in the past week was 2.7 versus 1.8 for neck pain). This accords with the pattern of transmission of HTV to the upper limb, although a confounding effect from other ergonomic risk factors cannot be discounted. [ABSTRACT FROM PUBLISHER]

Elbow pain is a common complaint and elbow hyperostosis a frequent radiological condition. However, little is known about the association between the clinical and radiological findings. To evaluate the relationship between spinal and extraspinal hyperostotic features and the clinical relevance of elbow hyperostosis we have performed the first controlled, double-blinded study of 85 hospitalized probands, 33 with and 52 without thoracospinal hyperostosis on lateral chest X-ray. Elbow and shoulder hyperostosis were graded on bilateral standard radiographs. Elbow pain was assessed by an interviewer using a standardized questionnaire and extraskeletal causes of elbow pain were recorded. The prevalence of elbow hyperostosis was increased in cases with thoracospinal hyperostosis compared to controls (82% versus 58%, X = 5.32, <0.025, = 85, odds ratio (OR) 3.30 (95% Cl 1.16–9.35)). Similarly, the prevalence of elbow hyperostosis was increased in cases with shoulder hyperostosis compared to controls (83% versus 60%, x = 4.51, <0.05, = 84, OR = 3.20 (95% CI 1.06–9.66)), emphasizing the multifocal nature of hyperostotic features. Elbow pain was only slightly more prevalent in cases with elbow hyperostosis compared to controls (21% versus l3%, x = 0.75, NS, OR = 1.84 (95% CI 0.46–7.44)). We conclude that elbow hyperostosis is a radiological finding of doubtful clinical relevance. [ABSTRACT FROM PUBLISHER]

Background: Recent findings indicate that wide international variation in the prevalence of disabling regional musculoskeletal pain among working populations is driven by unidentified factors predisposing to pain at multiple anatomical sites. As a step towards identification of those factors, it would be helpful to know whether the prevalence of multisite pain changes when people migrate between countries with differing rates of symptoms; and if so, whether the change is apparent in first generation migrants, and by what age it becomes manifest.Methods: To address these questions, we analysed data from an earlier interview-based cross-sectional survey, which assessed the prevalence of musculoskeletal pain and risk factors in six groups of workers distinguished by the nature of their work (non-manual or manual) and their country of residence and ethnicity (UK white, UK of Indian subcontinental origin and Indian in India). Prevalence odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression.Results: Among 814 participants (response rate 95.4%), 20.6% reported pain at ≥3 anatomical sites. This outcome was much less frequent in Indian manual workers than among white non-manual workers in the UK (adjusted OR 0.06, 95%CI 0.01-0.36), while rates in Indian non-manual workers were intermediate (OR 0.29, 95%CI 0.12-0.72). However, within the UK, there were only small differences between white non-manual workers and the other occupational groups, including those of Indian sub-continental origin. This applied even when analysis was restricted to participants aged 17 to 34 years, and when second and later generation migrants were excluded.Conclusions: The observed differences in the prevalence of multisite pain seem too large to be explained by healthy worker selection or errors in recall, and there was no indication of bias from differences in understanding of the term, pain. Our findings suggest that whatever drives the higher prevalence of musculoskeletal pain in the UK than India is environmental rather than genetic, affects multiple anatomical sites, begins to act by fairly early in adult life, and has impact soon after people move from India to the UK. [ABSTRACT FROM AUTHOR]