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Occupational Medicine Advance Access originally published online on February 1, 2006
Occupational Medicine 2006 56(2):137-143; doi:10.1093/occmed/kqj024
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© The Author 2006. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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

Claire Ryall1, David Coggon1, Robert Peveler2, Isabel Reading1 and Keith T. Palmer1

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

Correspondence to: Keith T. Palmer, MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. Tel: +44 23 8077 7624; fax: +44 23 8070 4021; e-mail: ktp{at}mrc.soton.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
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.

Keywords      Arm pain; functional syndromes; mental health; somatizing


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Chronic upper limb pain often occurs in the absence of obvious tissue pathology. It has been suggested that in such cases psychosocial, psychiatric or iatrogenic factors matter more than physical exposures and activities [1,2]. Thus, epidemics of non-specific arm pain attributed to work have arisen in various countries and at various times without any abrupt corresponding changes in occupational physical workload [3–5]. At the same time, however, it seems possible that specific clinical disorders such as tenosynovitis, for which there is evidence of local pathology in the arm, could have a predominantly mechanical basis.

Evidence on this is limited, but if correct, patterns of comorbidity could differ in patients with non-specific as compared with specific complaints. Wessely et al. [6] and others [7,8] have suggested that medically unexplained or ‘functional’ syndromes, which are common across all specialties, could be artefacts of medical specialization, created by patients who tend to report distress from somatic symptoms and specialists who focus only on symptoms in their own field of interest. In support of this, excesses of chronic fatigue syndrome (CFS), migraine and irritable bowel syndrome have been found in patients with fibromyalgia [9–11]. The overlap between arm pain and somatic functional syndromes has only been examined rarely, but Helfenstein and Feldman [12] found that many patients labelled as having ‘repetitive strain injury’ fulfilled the American College of Rheumatology (ACR) criteria for fibromyalgia.

If Wessely is correct, patients complaining of non-specific arm pain might have a greater tendency to somatize or an excess of functional somatic disorders, whereas for those with discrete clinically verifiable diseases, exposure to mechanical factors might be more apparent. Information on this could inform prevention and the management of patients, and direct future research. For example, psychosocial interventions might be appropriate for those with non-specific pain and targeted ergonomic controls for those with discrete clinical disorders, and in analysing intervention studies in the workplace and other settings, it would be necessary to stratify outcome by presenting diagnosis, to allow unbiased comparisons of efficacy.

To investigate these issues we conducted a case–control study, nested within a prospective investigation of arm pain in primary care. We aimed to determine (i) if certain functional syndromes were more common among those presenting with arm pain than in other patients registered with the same general practices; (ii) whether such presentations were linked with poorer mental health or with a tendency to somatize; (iii) whether they were linked with physical occupational activities and occupational psychosocial factors, after allowing for any differences in individual mental health, and (iv) whether associations with risk factors differed according to the presenting diagnosis (specific disorder versus non-specific pain).


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
Approval for the study was obtained from Southampton and South West Hampshire and Salisbury Local Research Ethics Committees. The study population comprised all men and women aged 16–65 years who were registered with eight general practices in Wessex (an estimated population of 45 979 subjects). Patients who presented to these services over a 2-year period with an incident episode of pain in the upper limb as the main reason for consultation were invited to participate. The arm was defined as a shaded area on a diagram (Figure 1). A ‘new’ episode was defined as one for which there has been no consultation over the past 12 months. Eligible patients were given an information leaflet by their family doctor and a reply slip to return to the research team.


Figure 1
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  		Figure 1. The upper limb, as defined in the study.

 
Group-matched controls were recruited from other patients registered with the same general practices. To achieve this, initially four individuals of the same age and sex were identified for each case from practice age–sex registers; the person closest in age was approached first, continuing with the next closest in age until a questionnaire was returned. Respondents who had consulted about upper limb pain in the past 12 months were excluded and a replacement control sought.

Cases and controls self-completed a common questionnaire, which asked about demographic characteristics (age, sex, smoking habits, social class), work history and physical activities during a typical working day, mental and psychosocial well-being and comorbidity. Specific items on mental health were drawn from the Hospital Anxiety Depression Scale (depressive subscale, HADS-D) [13], the Brief Symptom Inventory (somatizing tendency) [14] and the Whiteley Index (health anxiety) [15]. A priori cut-points were chosen for HADS-D and the Whiteley Index, according to previously published recommendations [13], and somatizing tendency was categorized according to the number of somatic symptoms moderately or extremely distressing during the past 7 days (<3 versus ≥3). Additionally, questions were posed to identify CFS, based on the criteria of the Center for Diseases Control [16], and chronic widespread pain (CWP), based on the ACR criteria [17]. Subjects were also asked about certain potential confounders, including diabetes, rheumatoid arthritis, whiplash neck injury and fractures affecting the upper limb (but occurrences proved to be too few to warrant analysis). Finally, for those who held a job, questions were posed on three psychosocial work stressors (control, support and demand in the job), based upon the Karasek model [18], and four physical activities in a typical working day—using a computer keyboard (>1 versus ≤1 h), repeated wrist/finger movements (>1 versus ≤1 h), repeated elbow bending and straightening (>1 versus ≤1 h) and carrying weights (on one shoulder or lifting or carrying weights of ≥5 kg in one hand). Many of the questionnaire items have been used by others, and have been shown to have adequate reliability and validity [19–23].

Additionally, cases underwent a standardized physical examination, conducted by one of four research staff (three nurses and a physiotherapist). Examinations generally took place at home at a median interval of 2 weeks from the initial general physician's consultation. Cases were subclassified by previously defined and validated criteria [24–26] into one of several mutually exclusive diagnostic categories:

(i) shoulder pain in the absence of distal symptoms;
(ii) one or more specific disorders of the distal limb—namely, lateral epicondylitis, medial epicondylitis, olecranon bursitis, carpal tunnel syndrome, tenosynovitis, De Quervain's disease of the wrist or osteoarthritis of the thumb base or distal interphalangeal joint;
(iii) distal arm pain, affecting (one or more of) the elbow, forearm, wrist or hand, that did not fulfil any of the pre-specified criteria for a distal specific disorder [as defined in (ii)] or
(iv) mixed distal pathology—a distal specific disorder [as defined in (ii)], together with non-specific pain at a different distal site [as defined in (iii)].
Shoulder symptoms were aggregated, as there was considerable overlap of diagnoses at this site [27] and the classification schedule was considered potentially less discriminating.

All statistical analyses were conducted in STATA version 8.0. Associations of work exposures, comorbidity and mental health with consulting about arm pain were explored using unconditional logistic regression, and summarized as odds ratios (ORs) with 95% confidence intervals (95% CIs). Adjustment was made for age, sex and general practice throughout. In addition, adjustments for personal mental health were explored in analyses of workplace factors. The latter analyses were confined to those who held a job when the questionnaire was completed.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
Invitations were issued to some 270 patients with arm pain. Of these, 157 (58%) agreed to participate and 132 proved to be eligible. (Twenty-five respondents were excluded because they had consulted with arm pain in the previous 12 months.) On average, three questionnaires were sent out in order to recruit a control of similar age and gender to each case, and eventually 127 controls were enrolled.

As expected from the design, cases and controls were very closely matched on age (both median 50 years, interquartile range 42–57 versus 41–58 years, respectively) and practice, and contained similar proportions by sex (45% male in both groups), work status (28% versus 22% unemployed) and smoking habits (20% versus 22% currently smoking).

Table 1 shows the relations between comorbid illness, mental health and consulting with different patterns of arm pain. There were many significant associations, but differences by diagnostic subcategory (specific versus non-specific) were not clear-cut. Thus, strong associations were found with CFS, irrespective of the site of arm pain or diagnosis (ORs 3.3–7.6). Similarly, the odds of arm pain, overall and for all categories other than shoulder pain, were substantially increased among those reporting ≥3 versus <3 somatic symptoms as distressing (ORs 1.6–8.6). There were also significant associations between a high HADS-D score and consulting with arm pain. Associations with health anxiety score and CWP were less consistent.


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  		Table 1. Associations between mental health, comorbid illness and consulting with arm pain

 
When the three mental health scores were entered into the same model with adjustment for age, sex and general practice, the association of arm pain with somatizing tendency was essentially unchanged (OR 3.9, 95% CI 1.7–9.0), that for HADS-D was reduced but still elevated (OR 2.1, 95% CI 0.8–5.3) and that for health anxiety score was eliminated (OR 0.8, 95% CI 0.4–1.8). Thus, subsequent analyses adjusted for somatization and HADS-D, as well as for the three demographic variables.

Table 2 considers the associations between physical and psychosocial risk factors at work and consulting with arm pain, with analysis restricted to those who held a job. Although those reporting poor job support were more likely to consult, there were no significant associations at the 5% level with workplace factors of control, support or demand. Arm pain was more common in those whose work normally entailed repetitive wrist and finger movements (OR 1.9, 95% CI 1.0–3.5) and repeated elbow movements (OR 3.0, 95% CI 1.6–5.5). Adjustment for somatization and HADS-depression score made little difference to these risk estimates.


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  		Table 2. Associations between occupational risk factors and consulting with arm pain

 
There were, however, some differences by site and diagnosis (Table 3). Specifically, work involving repeated elbow movements was associated with both proximal (shoulder) and distal patterns of complaint. By contrast, work entailing repeated wrist and finger movements was associated only with distal disorders—notably in those receiving a specific diagnosis (OR 5.0 for distal specific and 15.1 for distal mixed disorders). Most associations were not significant, however, at the 5% level.


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  		Table 3. Association of physical occupational risk factors with presenting diagnoses

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
Our findings suggest that those who consult a doctor with arm pain are more likely than other similar practice-registered patients to have CFS, and a high score on scales of health anxiety, depression and somatization. As hypothesized, certain physical work activities that stressed the tissues locally (repeated wrist/finger movements and carrying weights) were more strongly associated with discrete disorders than with non-specific arm pain. But against our initial hypothesis, functional disorders and scores of mental ill-health did not associate more strongly with non-specific pain, being important to both patterns of complaint. Moreover, there was a stronger association with individual personal mental health (Table 1) than with psychosocial factors specific to the workplace (Table 3).

A particular strength of our study was the care taken to subclassify cases using a pre-defined and validated classification algorithm [24–26]. This reduced the potential for diagnostic misclassification (a particular problem in studies of upper limb disorder) and permitted an internal comparison by diagnostic category. Another strength was the suitable control group, with further adjustment in analysis for potential confounding by age, sex and general practice (which may be a proxy for likelihood of consulting and other social characteristics). The principal exposures (CFS, somatization, health anxiety, depression, occupational stressors) were assessed using well-tested measuring instruments. Also, almost everyone in Britain registers with a family doctor, and services for arm pain are free at the point of delivery, making the registers of general practices a valid attractive sampling frame for such inquiries.

Set against this we count the incomplete response, uncertainty about the direction of causation, given the case–control design, and the small sample size relative to the many diagnostic possibilities for upper limb pain—a particular challenge in this field of inquiry.

Incomplete response raises questions about representativeness and bias. Cases were chosen to give representative exposure information (work circumstances, prevalence of ill-mental health, functional syndromes) in patients with new onset arm pain seen by family doctors, and controls to give the same information in the population from which the cases derived. Bias from incomplete response could lead to misleading associations with consulting, but only if responders differed materially from non-responders in exposure to risk factors, and this pattern of difference varied by case–control status.

The study collected exposure information in retrospect, but the hypotheses concerning mental health were not familiar or widely discussed ones. To this extent, subjects were blinded and less likely to give a biased exposure history. Furthermore, subjects were examined and classified blind to exposure history. It seems unlikely that findings such as those on physical risk factors in relation to distal specific disorders could arise from reporting or information bias.

Of more concern is our capacity to examine associations by diagnostic subgroup, given a relatively small sample size. To preserve sufficient power we were forced to combine disorders into broad groupings such as ‘distal specific’ versus ‘distal non-specific’, with the potential for diagnostic heterogeneity. Even then, a number of associations were not significant at the 5% level, and limited power could account in part for our inability to demonstrate differential associations of mental health factors and functional syndromes by diagnostic subgroup. It is hard, however (particularly in the absence of a better gold standard), to imagine how the information could be improved upon, except by a larger study with similar measuring instruments.

Consulting with arm pain has two components—presence of symptoms and health-seeking behaviour. Our methods do not help us to distinguish which of these is influenced by mental health, functional comorbidity or physical occupational risk factors, although there is room to speculate. It seems unlikely, for example, that upper limb pain causes CFS to any important extent, but plausible that those with CFS find it hard to cope with arm pain and seek help more readily; conceivably, the tendency to feel concerned about physical symptoms promotes both the awareness of symptoms and the inclination to seek a doctor's opinion, and a growing body of evidence suggests that physical and psychosocial risk factors specific to work may be both a source [28–31] and an aggravation [31,32] of arm pain, and so could contribute both to occurrence and to consulting.

There have been only a few studies of arm pain in community samples from primary care, mostly focusing on the shoulder. In a survey by Badcock et al. [33], patients with shoulder–neck pain were more likely to consult over 2-year follow-up if pain was severe, prolonged or psychologically distressing (as judged on the HADS) at baseline. None of these associations reached statistical significance. In a population-based case–control study from Sweden [34], low job control and work with powered vibratory tools were the main risk factors in men for consulting a primary care service with neck or shoulder pain [relative risks (RR) 1.5–1.6], whereas in women repetitive hand or finger movements (RR 1.6), constrained sitting (RR 1.6) and solitary work (RR 1.8) were of most importance. A case-referent study by Haahr and Andersen [35] found that consulting with epicondylitis was related to self-reported forceful, repetitive or precise activities at work and, in men, low social support.

More generally, a higher frequency of consulting may be expected in patients with anxiety–depression or somatizing tendency [36–38]. Our observations add to the sum of knowledge by demonstrating how important such mental health factors are among arm pain sufferers who present to medical services. They also highlight the overlap between arm pain and CFS (as hypothesized by Wessely), and suggest that psychological approaches to management and prevention may prove rewarding in some circumstances [39]. Notwithstanding this, physical–mechanical exposures at work are relevant, especially to disorders with specific underlying pathology. The preventive implications of this should not be overlooked, although achieving the expected benefits of ergonomic intervention in practice may prove challenging [40].


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
C.R. was funded by a Research Training Fellowship and project grant from the National Health Service Executive South East, and I.R. by a Colt Foundation Fellowship. 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 the manuscript.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. Ireland DCR. Psychological and physical aspects of occupational arm pain. J Hand Surg 1985;13B:5–10.

  2. Hadler N. Illness in the workplace: the challenge of musculoskeletal symptoms. J Hand Surg 1985;10A:451–456.

  3. Gun RT. The incidence and distribution of RSI in South Australia 1980–81 to 1986–87. Med J Aust 1990;153:376–380.[Web of Science][Medline]

  4. Hocking B. Epidemiological aspects of ‘repetition strain injury’ in Telecom Australia. Med J Aust 1987;147:218–222.[Web of Science][Medline]

  5. Great Britain and Ireland Post Office. Departmental Committee on Telegraphist's Cramp Report. London: HMSO, 1911.

  6. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999;354:936–939.[CrossRef][Web of Science][Medline]

  7. Hudson JI, Goldenberg DL, Pope HGJ, Keck PEJ, Schlesinger L. Comorbidity of fibromyalgia with medical and psychiatric disorders. Am J Med 1992;92:363–367.

  8. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999;130:910–921.[Abstract/Free Full Text]

  9. Norregaard J, Bulow PM, Prescott E, Jacobsen S, Danneskiold-Samsoe B. A four-year follow-up study in fibromyalgia. Relationship to chronic fatigue syndrome. Scand J Rheumatol 1993;22:35–38.[Web of Science][Medline]

  10. Sivri A, Cindas A, Dincer F, Sivri B. Bowel dysfunction and irritable bowel syndrome in fibromyalgia patients. Clin Rheumatol 1996;15:283–286.

  11. Barton A, Pal B, Whorwell PJ, Marshall D. Increased prevalence of sicca complex and fibromyalgia in patients with irritable bowel syndrome. Am J Gastroenterol 1999;94:1898–1901.[CrossRef][Web of Science][Medline]

  12. Helfenstein M Jr, Feldman D. Prevalence of fibromyalgia in patients with diagnosis of repetitive strain injury. Rev Bras Reumatol 1998;38:71–77.

  13. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361–370.[Web of Science][Medline]

  14. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report. Psychol Med 1983;13:595–605.[Web of Science][Medline]

  15. Pilowsky I. Dimensions of hypochondriasis. Br J Psychol 1967;113:89–93.[CrossRef]

  16. Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121:953–959.[Abstract/Free Full Text]

  17. Wolfe F, Smythe HA, Yunus MB et al. The American College of Rheumatology 1990. Criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–172.[Web of Science][Medline]

  18. Karasek RA. Job demands, job decision latitude, and mental strain: implications for job redesign. Adm Sci Q 1979;24:285–307.[CrossRef][Web of Science]

  19. Speckens AEM, Spinhoven PH, Sloekers PPA, Bolk JH, van Hemert AM. A validation study of the Whitely Index, the illness attitude scales, and the somatosensory amplification scale in general medical and general practice patients. J Psychosom Res 1996;40:95–104.[CrossRef][Web of Science][Medline]

  20. Bjelland I, Dahl AA, Tangen Haug T, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res 2002;52:69–77.[CrossRef][Web of Science][Medline]

  21. Preston NJ, Harrison TJ. The Brief Symptom Inventory and the Positive and Negative Syndrome Scale: discriminate validity between a self-reported and observational measure of psychopathology. Compr Psychiatry 2003;44:220–226.[CrossRef][Web of Science][Medline]

  22. Kawakami N, Fujigaki Y. Reliability and validity of the Japanese version of Job Content Questionnaire: replication and extension in computer company employees. Ind Health 1996;34:295–306.[Web of Science][Medline]

  23. Brisson C, Larocque B. Validity of occupational stress and decision latitude on health in the National Population Health Survey of 1994–95. Can J Public Health 2001;92:468–474.[Web of Science][Medline]

  24. Harrington JM, Carter JT, Birrell L, Gompertz D. Surveillance case definitions for work related upper limb pain syndromes. Occup Environ Med 1998;55:264–271.[Abstract/Free Full Text]

  25. Palmer K, Walker-Bone K, Linaker C et al. The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb. Ann Rheum Dis 2000;59:5–11.[Abstract/Free Full Text]

  26. Walker-Bone K, Byng T, Linaker C et al. Reliability of the Southampton examination schedule for the diagnosis of upper limb disorders in the general population. Ann Rheum Dis 2002;61:1103–1106.[Abstract/Free Full Text]

  27. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum 2004;51:642–651.[CrossRef][Web of Science][Medline]

  28. Harkness EF, Macfarlane GJ, Nahit ES, Silman AJ, McBeth J. Mechanical and psychosocial factors predict new onset shoulder pain: a prospective cohort study of newly employed workers. Occup Environ Med 2003;60:850–857.[Abstract/Free Full Text]

  29. Smedley J, Inskip H, Trevelyan F, Buckle P, Cooper C, Coggon D. Risk factors for incident neck and shoulder pain in hospital nurses. Occup Environ Med 2003;60:864–869.[Abstract/Free Full Text]

  30. Leclerc A, Chastang JF, Niedhammer I, Landre MF, Roquelaure Y. Incidence of shoulder pain in repetitive work. Occup Environ Med 2004;61:39–44.[Abstract/Free Full Text]

  31. Punnett L, Gold J, Katz JN, Gore R, Wegman DH. Ergonomic stressors and upper extremity musculoskeletal disorders in automobile manufacturing: a one-year follow up study. Occup Environ Med 2004;61:668–674.[Abstract/Free Full Text]

  32. Juul-Kristensen B, Jensen C. Self-reported workplace related ergonomic conditions as prognostic factors for musculoskeletal symptoms: the "BIT" follow up study on office workers. Occup Environ Med 2005;62:188–194.[Abstract/Free Full Text]

  33. Badcock LJ, Lewis M, Hay EM, Croft PR. Consultation and the outcome of shoulder-neck pain: a cohort study in the population. J Rheumatol 2003;30:2694–2699.[Abstract/Free Full Text]

  34. Tornqvist EW, Kilbom A, Vingard E et al. The influence on seeking care because of neck and shoulder disorders from work-related exposures. Epidemiology 2001;12:537–545.[CrossRef][Web of Science][Medline]

  35. Haahr JP, Andersen JH. Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study. Occup Environ Med 2003;60:322–329.[Abstract/Free Full Text]

  36. Hoeper EW, Nycz GR, Regeir DA, Goldberg ID, Jacobson A, Hankin J. Diagnosis of mental disorder in adults and increased use of health services in four outpatients settings. Am J Psychol 1980;145:1351–1357.

  37. Fink R, Shapiro S. Patterns of medical car related to mental illness. J Health Hum Behav 1977;7:98–105.

  38. Gill D, Sharpe M. Frequent consulters in general practice: a systematic review of studies of prevalence, associations and outcome. J Psychosom Res 1999;47:115–130.[CrossRef][Web of Science][Medline]

  39. Morris R, Gask L, Ronalds C et al. Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Fam Pract 1998;15:119–125.[Abstract/Free Full Text]

  40. Gerr F, Marcus M, Monteilh C, Hannan L, Ortiz D, Kleinbaum D. A randomised controlled trial of postural interventions for prevention of musculoskeletal symptoms among computer users. Occup Environ Med 2005;62:478–487.[Abstract/Free Full Text]


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