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Occupational Medicine Advance Access originally published online on August 11, 2006
Occupational Medicine 2007 57(1):4-17; doi:10.1093/occmed/kql084
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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

Conservative treatment of work-related upper limb disorders—a review

Joanne O. Crawford and Elpiniki Laiou

The University of Birmingham, Institute of Occupational and Environmental Medicine, School of Medicine, Birmingham B15 2TT, UK

Correspondence to: Joanne O. Crawford, The University of Birmingham, Institute of Occupational and Environmental Medicine, School of Medicine, Birmingham B15 2TT, UK. Tel: +44 1214143623; fax: +44 1214146217; e-mail: J.O.Crawford{at}bham.ac.uk


   Abstract
Top
 Abstract
Introduction
 Method
 Results
 Discussion
 Conflicts of interest
 References
 
Aim The literature review was carried out to identify and summarize the evidence-base for conservative clinical management of upper limb disorders (ULDs) including specific disorders and non-specific ULDs.

Method Keywords were identified through a scoping study and guidance from the project sponsor. A number of databases were searched including Web of Knowledge, Pub Med, Medline, Ergonomics Online, the Cochrane Library and BMJ Clinical Evidence for the years 1993–2004. Abstracts were obtained for papers identified in the search and full papers were obtained for literature, which included diagnostic methods, conservative treatments, new data or results or systematic reviews.

Results The review identified that there is evidence for the efficacy of conservative treatments for the management of carpal tunnel syndrome, epicondylitis, rotator cuff tendonitis and bicipital tendonitis and tension neck syndrome. There was no evidence found to support or refute conservative treatment of tenosynovitis, tendonitis, de Quervain's disease or diffuse non-specific ULDs.

Conclusion The evidence reviewed was not always of good quality and data gaps including methodological design issues need to be addressed by future research.

Keywords      Evidence-base; musculoskeletal; treatment


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion
 Conflicts of interest
 References
 
The following review was carried out to identify and summarize the evidence-base for conservative clinical management of upper limb disorders (ULDs). This was the initial stage of a study to examine conservative clinical management of ULDs and how health professionals can be more effective. The literature review was carried out to identify what current evidence there is in musculoskeletal medicine nationally and internationally for the conservative management of musculoskeletal disorders and ULDs in order to find best practice in the treatment of ULDs.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion
 Conflicts of interest
 References
 
Relevant literature was obtained via the following research strategy, which was based on the methodology developed by the Centre for Reviews and Dissemination at the University of York [1]. Keywords were identified after a scoping study and guidance from the sponsor. The keywords were then cross-searched with general terms including musculoskeletal disorders, ULDs and specific disorders including tendonitis, tenosynovitis, rotator cuff tendonitis, bicipital tendonitis, carpal tunnel syndrome (CTS), de Quervain's disease, shoulder capsulitis, medial and lateral epicondylitis, diffuse, non-specific ULDs, tension neck and impingement syndrome. Hand–arm vibration syndrome (HAVS) was deemed beyond the scope of the study and was not included in the search.

To identify published research, the following databases were searched using the time frame of 1993–2004. The databases included Web of Knowledge (including the Science Citation Index and the Social Science Citation Index), Pub Med and Medline, Ergonomics Online, The Cochrane Library and BMJ Clinical Evidence. The time period was specified as it was thought that research in the last 10 years would be more relevant to the review.

The first sweep of the databases identified 408 references and the researchers reviewed the abstracts. Full papers were obtained for papers based on the criteria that they included conservative treatments for the specific disorders described, new data or results and systematic reviews. One of the initial drawbacks immediately identified was that many of the papers due to their time of publication did not use the criteria developed by Harrington et al. [2] or Sluiter et al. [3]. A decision was made to include all papers and where described in the study, report the criteria used in the diagnosis of participants. Where criteria for conservative treatments, new data or results were not reached, the paper was excluded from the review. In total, 352 papers were excluded from the review as they did not include conservative treatments or new data.

The information from each paper was evaluated and summarized. The information extracted from each paper included sample size, interventions undertaken, outcome measures and outcomes. The papers were assessed on the basis of no evidence, limited evidence for efficacy of treatment and good evidence for efficacy of treatment. The researchers in conjunction with the sponsors developed the quality criteria.


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion
 Conflicts of interest
 References
 
Carpal tunnel syndrome
CTS is the most commonly diagnosed neuropathy with prevalence rates of clinically and electrophysically diagnosed CTS of 2.7% [4,5]. Within the UK, estimated prevalence rates for men are 1.2% and for women 0.9% [6]. Harrington et al. [2] and Sluiter et al. [3] have agreed upon diagnostic and surveillance criteria and the use of Phalen's tests and Tinel's test is essential in this process. However, Feuerstein and Herbert suggest that the ‘gold standard’ in CTS diagnosis is the use of electrodiagnostic testing and physical examination [7,8]. Sluiter et al. [3] also suggest a time rule in that symptoms are evident currently or on at least 4 days of the last 7.

The papers reviewed are presented in Table 1. The review has identified that in the short-term, effective treatments include local steroid injection, exercise and stretching and limited evidence for the use of ultrasound. There is currently no evidence that non-steroidal anti-inflammatory drugs (NSAIDs) are an effective treatment for CTS versus diuretics, oral steroids or a placebo [9]. The review also identified that there was little evidence to support workplace intervention strategies but this was mainly due to a lack of high quality research [8,9]. Although there is some evidence to support steroid injection as a treatment for CTS, what is appreciated is that chronic and more serious cases will result in surgical intervention.


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  		Table 1 Summary of conservative treatments for CTS

 
Epicondylitis (medial and lateral)
According to a clinical review by Piligian et al. [10], the highest incidence of epicondylitis appears to occur in manually intensive occupations involving high work demands, for example, mechanics, wall board installation, roofing, masonry, foundries. Although there is evidence available to link forceful work and combinations of risk factors including force/repetition and force/posture, there is still minimal evidence to link epicondylitis and occupation [10,11]. In a study of 1757 workers by Descatha et al. [12], the prevalence of medial epicondylitis was 3.8% with an annual incidence calculated >3 years of 1.5%. Estimated prevalence rates within the UK for medial epicondylitis are 0.6% for men and 1.1% for women [6]. Estimated prevalence rates for lateral epicondylitis are 1.3% for men and 1.1% for women [6].

Harrington et al. [2] and Sluiter et al. [3] have developed diagnostic and surveillance criteria for this disorder including local pain on resisted wrist extension (lateral) or on resisted wrist flexion (medial) with the addition of the time rule by Sluiter et al. of symptoms present now or on at least 4 days out of the last 7.

With regard to conservative treatment of epicondylitis, the data reviewed are presented in Table 2. In the short-term, local steroid injection significantly improved symptoms; however, there is no current evidence to support the use of oral NSAIDs in treating epicondylitis [13,14]. Green et al. [14] did identify that topical NSAIDs gave some relief in the short-term. However, at the follow-up at 1 year, physiotherapy resulted in the main reduction in symptoms followed by a wait-and-see policy [15].


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  		Table 2 Epicondylitis (medial and lateral)

 
Other treatments that have been researched include iontophoresis, however, results are currently unclear for this treatment [16,17]. Again the research was affected by low numbers and confounding of results. However, the authors do report side-effects using this treatment [16]. Similar results were also found for radiation/laser therapy but this should be viewed as a last resort treatment after trying other conventional measures [18].

Shock wave therapy (also known as extracorporeal shock wave therapy, ESWT) is a treatment involving high-pressure sound waves. In the research reviewed, it was not found to be an effective treatment for epicondylitis [19–22]. Small numbers affected much of the research on this topic, however, those studies rated as good did not show shock wave therapy as effective.

Two studies were found that examined acupuncture as a treatment for elbow pain. In a study of acupuncture versus sham acupuncture, significant pain reduction and arm mobility and strength was found at 2 weeks, however, only arm function was improved at 2 months [23]. This study was rated as limited evidence due to the small numbers and the lack of a control group. Green et al. [24] in a systematic review of acupuncture for lateral elbow pain reviewed four randomized controlled studies. The review found that although there was some evidence to support the use of needle acupuncture 24-h post-treatment, there was insufficient evidence to support the use of laser or needle acupuncture in the treatment of elbow pain [24].

Disorders of the shoulder
Rotator cuff syndrome and bicipital tendonitis
In a Finnish survey of a nationally representative sample of persons aged ≥30 years, the prevalence of chronic rotator cuff tendonitis and non-specific shoulder pain were 2.0% (78 of 3909 subjects) and 12% (410 of 3525 subjects), respectively [30]. Within the UK, the prevalence estimates for rotator cuff syndrome have been calculated at 4.5% among men and 6.1% among women with prevalence estimates for bicipital tendonitis at 0.7% (in both sexes) [6].

Agreed diagnostic and surveillance criteria have been suggested by Harrington et al. [2] and Sluiter et al. [3] with symptoms including inflammation or degeneration of the rotator cuff or biceps and pain in the shoulder region worsened by elevation movement such as scratching of the upper back. Sluiter et al. also consider the time rule of symptoms now or on at least 4 days of the last 7 [3].

Two papers were identified that examined conservative treatments of rotator cuff syndrome and bicipital tendonitis and are presented in Table 3. The first study examined the impact of physical therapy, local steroid injection and NSAIDs by measuring 14 clinical outcomes at 6 and 18 months [31]. The authors suggest that patients should undergo 18 months of conservative treatment before surgery is considered. However, the evidence is limited due to the questionable study design and the small numbers. Green et al. [32] carried out a Cochrane Review for interventions on shoulder pain. The evidence identified in the review was that NSAIDs and subacromial steroid injection might improve the range of movement in the rotator cuff more than a placebo. This paper highlights the lack of good quality research in this area.


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  		Table 3 Summary of conservative treatments for disorders of the shoulder

 
The evidence for conservative treatment of rotator cuff syndrome and bicipital tendonitis is unclear. This is the result of a lack of agreement in diagnostic criteria in previous research and a lack of clarity in treatment methodologies and low quality research.

Shoulder capsulitis
A prevalence of 2–3% has been quoted as the population rate for shoulder capsulitis in textbooks but Walker-Bone et al. [33] found no recent population-based data in their review. Harrington et al. [2] have suggested diagnostic and surveillance criteria for shoulder capsulitis, with symptoms including current or past pain in the upper arm with restriction of glenohumeral movement in a capsular pattern. Nicholson [34] suggests that the criteria and classification of this disorder is still under investigation.

Gam et al. [35] found in a randomized controlled trial (RCT) comparing steroid injection versus steroid injection and distension that functional movement improved and analgesic use decreased in a small study. In 32 patients, de Jong et al. [36] found that when assessing injected dosage of triamcinolone acetonide, the higher dose of 40 versus 25 mg resulted in a significant reduction in pain, sleep disturbance and increased functional movement. However, both these studies only give limited evidence on the efficacy of the treatments assessed due to the small numbers of participants. In a Cochrane Review by Green et al. [32], there was little evidence found to support or refute the use of conservative treatments for shoulder capsulitis.

Impingement syndrome
No data were found on prevalence rates for the general population for impingement syndrome. However, one study calculated the prevalence ratio for shoulder impingement syndrome at 5.27 (95% CI 2.09–12.26) among currently working and 7.90 (95% CI 2.94–21.18) among former slaughterhouse workers [37].

There has been no consensus agreement made with regard to diagnostic criteria for impingement syndrome. However, Ludewig and Borstad [38], Ludewig and Cook [39] and Bigliani [40] all refer to a 1983 paper by Neer which gives a definition of impingement syndrome as ‘the compression and irritation of the rotator cuff as they pass beneath the coracoacromial arch during arm elevation’. Symptoms include pain in the anterosuperior part of the shoulder [40].

Four research studies were identified that examined conservative treatment of impingement syndrome and are summarized in Table 3. The use of physical therapy and NSAIDs was assessed by Morrison [41]. The study found that using the treatments, 67% of the sample had a satisfactory outcome and 28% were recommended for surgery. However, the evidence is rated as poor as the follow-up for participants ranged from 6 to 81 months. The same issue affected a second study which examined the short-term efficacy of subacromial steroid injection [42]. The study was a RCT with small numbers and the outcome measures included pain scores, physical examination and functional movement. At the most recent follow-up, pain scores had been significantly reduced and movement had increased. Again this was rated as limited evidence due to inconsistent follow-up times.

One further intervention was a home exercise programme for construction workers [38]. This was a RCT that used a shoulder-rating questionnaire pre- and post-treatment. The study found a significant improvement in the intervention group versus the control group but was rated as limited evidence due to the small numbers studied.

Desmeules et al. [43] carried out a systematic review of RCTs for therapeutic exercise and manual therapy. The review identified that there was limited evidence for the use of these treatments. The study also highlighted that there are issues of methodological quality in this research that results in an inability to decide on the efficacy of conservative treatments.

Tension neck
Although there is no consensus agreement for the diagnosis or surveillance criteria for tension neck, a number of authors have used this term. Helliwell [45] describes a definition used by Viikari-Juntura (1987), which is ‘a feeling of fatigue or stiffness in the neck, neck pain or headache radiating from the neck’. Helliwell also describes signs of two tender spots or palpable hardenings. Mekhora et al. [46] have summarized the disorder and describe it as a type of occupational cervicobrachial syndrome that can be work related. However, Mekhora et al. also point out that tension neck syndrome must be differentiated from joint or neurologically based neck problems; symptoms include constant muscle fatigue, stiffness in the neck and shoulder areas and agreeing with Helliwell, two tender spots or trigger points. This syndrome is not related to whiplash injuries.

Very little data are available on the prevalence or incidence of tension neck syndrome. In a study among frequent computer users, the prevalence rate ratio for tension neck syndrome was 3.5 (95% CI 1.0–12) for 25–29 h/week of mouse use and increased to 4.7 (95% CI 1.2–18) for >30 h/week of mouse use [47].

Two studies were identified for conservative treatment of tension neck and are presented in Table 4. The first was a randomised controlled pre- and post-test study of computer users and ergonomics intervention [46]. The outcome measures included the validated Nordic Musculoskeletal Questionnaire, a discomfort scale and measurement of workload. From the data, discomfort measures were significantly reduced post-intervention. The data were confounded by a lack of measurement of the different workloads within the sample but it does offer limited evidence that ergonomic interventions may reduce discomfort. The second study reviewed was an evaluation of a physical training course in bank workers [48]. The research was a controlled intervention with a 4-week physical training given to the first group with diagnosed tension neck. The results found no significant differences between the treatment and the control group that indicates physical training does not have an impact on tension neck. However, further research on a larger sample, including psychosocial factors, would be helpful.


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  		Table 4 Summary of conservative treatment of tension neck

 
Disorders with no current effective conservative treatment
Table 5 is a summary table for those disorders where there is currently no evidence to support conservative treatments. With regards to tenosynovitis and flexor-extensor peritendonitis, diagnostic and surveillance criteria have been agreed by both Harrington et al. [2] and Sluiter et al. [3]. Prevalence rates of tenosynovitis of the wrist within the UK population have been estimated at 1.1% for men and 2.2% for women [6].


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  		Table 5 Disorders with no evidence of effective conservative treatment

 
Two papers were identified which examined medical management of tenosynovitis [10,49]. Recommendations included removal from current job, rest, arm supports including slings, hand supports, NSAIDs, physiotherapy or hand therapy and workplace modifications. However, neither of the papers reviewed identified any evidence to support or refute conservative treatment of tenosynovitis.

Neither diagnostic criteria nor surveillance criteria have been agreed upon for tendonitis of the wrist or forearm. However, from Sports Medicine it has been defined as an inflammation of the tendon and tendon-muscle attachments [3,10,50]. Prevalence or incidence rates of hand/wrist tendonitis have been found to range from 4 to 56% in groups subjected to workplace exposures and from 0 to 14% in unexposed groups, probably due to variability in diagnostic criteria and workplace exposures [11]. Symptoms include pain in the affected tendon and for extensor tendonitis, pain worsened by finger extension against resistance; for flexor tendonitis, pain associated with wrist flexion and ulnar deviation especially against resistance [10]. Only one paper was identified that examined conservative treatments for tendonitis [10]. However, the paper was a summary paper and gave no evidence to support the use of conservative treatments for tendonitis of the wrist or forearm.

With regard to de Quervain's disease, diagnostic and surveillance criteria have again been agreed upon by Harrington et al. [2] and Sluiter et al. [3] including pain or tenderness over the radial side of the wrist and pain reproduced by resisted thumb extension or abduction or a Finkelstein's test. Sluiter et al. [3] also suggest a time rule of current symptoms or on at least 4 days out of the last 7 days. Estimated prevalence data from the UK suggest that within the general population, de Quervain's disease exists at a rate of 0.5% among men and 1.3% among women [6].

Two papers were identified that researched conservative treatment of de Quervain's disease. However, no evidence was provided by Piligian et al. [10] to support the use of conservative treatments. Richie et al. [51] carried out a pooled qualitative literature evaluation of seven studies (n = 459 wrists), where they found that the most effective treatment was a steroid injection (83% cured). The combination of splinting and injection resulted in greater treatment failure (39%) than injection alone (17%). However, the results must be viewed cautiously as they are based on descriptive studies with no control on possible confounding variables.

Diffuse non-specific ULDs have been the topic of much discussion but different groups have agreed on diagnostic criteria for them. The symptoms include pain in the forearm, muscles, tendons, nerves or joints without a specific pathology [2,3]. However, Palmer et al. [52], have suggested additional symptoms including loss of function, weakness, cramp, muscle tenderness, allodynia and slowing of fine movements. One randomised controlled study was identified for rehabilitation of individuals with non-specific musculoskeletal pain [53]. The study included 158 patients with a control group of 226 patients. A multidisciplinary rehabilitation approach was used including, patient evaluation by a physician, including an interview, a review of previous investigations and physical examination where necessary. No significant differences were found between the treatment and control group indicating that multidisciplinary rehabilitation is not effective in the management of non-specific ULDs. No further research studies were identified to support or refute conservative treatment of this particular disorder.

General management of work-related musculoskeletal disorders
Two papers were identified relating to general management of musculoskeletal disorders. The paper by O'Neil suggests treatments or chronic tendon injuries including rest, ice, compression and elevation but there is no evidence to support these suggestions [54]. The second paper was an educational paper and does summarize information available at the time, however, again there is no evidence to support the suggested treatments [55]. The lack of papers with regard to general clinical management of ULDs is not surprising as each disorder has its own diagnosis and aetiology and it would be unlikely that a generalized approach would help clinical management. O'Neil et al. [54] did identify that the prognosis is less good for those individuals with a longer duration of symptoms.

Pain management programmes
Three papers were identified in this field relating to musculoskeletal problem and are presented in Table 6. The studies included in the review were two randomized crossover design studies where the intervention included a cognitive behavioural programme [56,57]. The studies identified an increase in occupational activity, reduction in pain intensity and severity and a significant decrease in sickness absence at 1-year follow-up [56]. However, this was not replicated in the study of Marhold et al. [57] where there was a significant decrease in short-term sickness absence only, not in those individuals with long-term sickness absence. In a review of the effectiveness of biopsychosocial rehabilitation on repetitive strain injuries, Karjalainen et al. [58] reviewed two studies. The first study did not find significant differences in pain intensity measures for electromyography (EMG) biofeedback, relaxation and imagery. The second paper did find pain intensity significantly reduced using hypnosis with biofeedback and autogenics. However, poor study design and low numbers affected both papers reviewed.


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  		Table 6 Summary of pain management programmes for treatment of ULDs

 
These studies highlight that cognitive behavioural therapies can improve occupational outcomes in the short-term and result in a significant decrease in sickness absence at 1 year but where there is earlier intervention, the outcome is better.


   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
Conflicts of interest
 References
 
The evidence for conservative treatment options for ULDs ranged from good to no current evidence to support specific treatments. This was either due to a lack of research on the topic or the quality of the research projects carried out. What also impacts on the collation of information on conservative treatment of ULDs is the lack of cohesion in the use of diagnostic criteria. It would be hoped that future research ensures consistency in diagnosis of specific disorders.

For specific disorders, a number of effective treatments were identified including steroids and steroid injection for CTS in the short-term. However, there was no evidence found to support the use of NSAIDs, chiropracty, wrist supports or yoga; there was some evidence found to support the use of range of motion exercises in the short-term and limited evidence for the use of ultrasound treatment, laser acupuncture and workplace interventions.

The review identified no evidence on whether withdrawal from hand guided vibratory tool use or exclusion of aggravating postures leads to CTS symptom resolution. There is evidence supporting an association between exposure to vibration and CTS but the evidence to demonstrate that awkward postures alone are associated with CTS is insufficient [11]. Furthermore, it has been suggested that CTS symptoms in a worker who has worked with vibrating tools for many years pose a diagnostic challenge as a diagnosis of HAVS or co-diagnosis of HAVS should also be considered [59].

For epicondylitis, again no evidence was found to support the use of NSAIDs but one study identified that the use of topical NSAIDs could improve symptoms. In the short-term, steroid injections were found to be an effective treatment for epicondylitis but little evidence was found to support iontophoresis. Radiation therapy has also been assessed and is recommended only after other conventional measures fail. The review did not find support for the use of shock wave therapy and only limited evidence for the use of needle or laser acupuncture.

For treatment of different shoulder disorders, the review found limited evidence for the effectiveness of NSAIDs and steroid injection to treat rotator cuff tendonitis and bicipital tendonitis. Limited to no evidence was found to support conservative treatments of shoulder capsulitis. Where impingement syndrome was evaluated, again limited evidence was found to support home exercise programmes and manual therapy.

Two papers were identified that examined intervention studies for tension neck syndrome. The papers identified that there is limited evidence to support the use of ergonomics intervention for tension neck syndrome but physical training programmes were not found to improve symptoms.

For the disorders of tenosynovitis, tendonitis of the wrist or forearm, de Quervain's disease or diffuse non-specific ULDs, no research was identified to support or refute the use of conservative treatments. Furthermore, it has been suggested that ‘tendinopathy’ rather than ‘tendinitis’ may be a more appropriate term to describe common painful overuse tendon conditions as light microscopy of patients operated on for tendon pain has commonly revealed tendinosis, a degenerative rather than an inflammatory disorder [50–61]. Accordingly, the effects of anti-inflammatory medication treatment for these conditions require further research.

Pain management programmes did give limited evidence in the short-term for reducing sickness absence and highlighted the need for intervention earlier in ULDs rather than later.

The review has identified a large data gap in conservative treatments for ULDs. This is possibly as a result of the only recent agreement on diagnostic and surveillance criteria that can then be used in research projects. Future research must address the methodological design issues found in many studies to develop a stronger evidence-base for the treatment of these disorders.


Key points
  • There is evidence of the efficacy of conservative treatments for CTS, epicondylitis, rotator cuff tendonitis, bicipital tendonitis and tension neck syndrome.
  • No evidence was found to support or refute conservative treatment of tenosynovitis, tendonitis, de Quervain's disease or diffuse non-specific ULDs.
  • To obtain further evidence, future research needs to address issues including poor methodological design, small numbers and lack of controls.

 


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


   Acknowledgements
 
The authors would like to thank the Health & Safety Executive for funding this research.


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Conflicts of interest
 References
 

  1. The University of York, NHS centre for reviews and dissemination. (1996) Undertaking Systematic Reviews of Research on Effectiveness(York Publishing Services, CRD Report 4. York).

  2. Harrington JM, Carter JT, Birrell L, et al. (1998) Surveillance case definitions for work related upper limb pain syndromes. Occup Environ Med 55:264–271.[Abstract/Free Full Text]

  3. Sluiter JK, Rest KM, Frings-Dresen MHW. (2001) Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. Scand J Work Environ Health 27:1–102.[Web of Science][Medline]

  4. Sen D, Chhaya S, Morris VH. (2002) Carpal tunnel syndrome. Hosp Med 63:392–395.[Web of Science][Medline]

  5. Gerritsen AA, de Krom MC, Struijs MA, et al. (2002) Conservative treatment options for carpal tunnel syndrome: a systematic review of randomised controlled trials. J Neurol 249:272–280.[CrossRef][Web of Science][Medline]

  6. Walker-Bone K, Palmer KT, Reading I, et al. (2004) Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum 51:642–651.[CrossRef][Web of Science][Medline]

  7. Feuerstein M, Burrell LM, Miller VI, et al. (1999) Clinical management of carpal tunnel syndrome: a 12-year review of outcomes. Am J Ind Med 35:232–245.[CrossRef][Web of Science][Medline]

  8. Herbert R, Gerr F, Dropkin J. (2000) Clinical evaluation and management of work-related carpal tunnel syndrome. Am J Ind Med 37:62–74.[CrossRef][Web of Science][Medline]

  9. Giele H. (2001) Evidence-based treatment of carpal tunnel syndrome. Curr Orthop 15:249–255.[CrossRef][Web of Science]

  10. Piligian G, Herbert R, Hearns M, et al. (2000) Evaluation and management of chronic work-related musculoskeletal disorders of the distal upper extremity. Am J Ind Med 37:75–93.[CrossRef][Web of Science][Medline]

  11. NIOSH Musculoskeletal disorders and workplace factors. A critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Cincinnati, OH, DHHS (NIOSH), 1997; Publication No. 97-141.

  12. Descatha A, Leclerc A, Chastang JF, et al. (2003) Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors. J Occup Environ Med 45:993–1001.[Web of Science][Medline]

  13. Hay EM, Paterson SM, Lewis M, et al. (1999) Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. Br Med J 319:964–968.[Abstract/Free Full Text]

  14. Green S, Buchbinder R, Barnsley L, et al. (2002) Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev 2:CD003686.

  15. Smidt N, van der Windt DAWM, Assendelft WJJ, et al. (2002) Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 359:657–662.[CrossRef][Web of Science][Medline]

  16. Nirschl RP, Rodin DM, Ochiai DH, et al. (2003) Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis: a randomized, double-blinded, placebo-controlled study. Am J Sports Med 31:189–195.[Abstract/Free Full Text]

  17. Baskurt F, Ozcan A, Algun C. (2003) Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis. Clin Rehabil 17:96–100.[Abstract/Free Full Text]

  18. Seegenschmiedt MH and Keilholz L. (1998) Epicondylopathia humeri (eph) and peritendinitis humeroscapularis (phs): evaluation of radiation therapy long-term results and literature review. Radiother Oncol 47:17–28.[CrossRef][Web of Science][Medline]

  19. Rompe JD, Hope C, Kullmer K, et al. (1996) Analgesic effect of extracorporeal shock-wave therapy on chronic tennis elbow. J Bone Joint Surg Br 78:233–237.

  20. Rompe JD, Riedel C, Betz U, et al. (2001) Chronic lateral epicondylitis of the elbow: a prospective study of low-energy shockwave therapy and low-energy shockwave therapy plus manual therapy of the cervical spine. Arch Phys Med Rehabil 82:578–582.[CrossRef][Web of Science][Medline]

  21. Haake M, Konig IR, Decker T, et al. (2002) Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. J Bone Joint Surg Am 84-A:1982–1991.[Abstract/Free Full Text]

  22. Melikyan EY, Shahin E, Miles J, et al. (2003) Extracorporeal shock-wave treatment for tennis elbow. A randomised double-blind study. J Bone Joint Surg Br 85:852–855.

  23. Fink M, Wolkenstein E, Luennemann M, et al. (2002) Chronic epicondylitis: effects of real and sham acupuncture treatment: a randomised controlled patient- and examiner-blinded long-term trial. Forsch Komplementarmed Klass Naturheilkd 9:210–215.[CrossRef][Medline]

  24. Green S, Buchbinder R, Barnsley L, et al. (2002) Acupuncture for lateral elbow pain. Cochrane Database Syst Rev 1:CD003527.

  25. Gerritsen AA, de Vet HC, Scholten RJ, et al. (2002) Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. J Am Med Assoc 288:1245–1251.[Abstract/Free Full Text]

  26. Davis PT, Hulbert JR, Kassak KM, et al. (1998) Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trail. J Manipulative Physiol Ther 21:317–326.[Web of Science][Medline]

  27. Garfinkel MS, Singhal A, Katz WA, et al. (1998) Yoga-based intervention for carpal tunnel syndrome: a randomized trial. J Am Med Assoc 280:1601–1603.[Abstract/Free Full Text]

  28. Ebenbichler GR, Resch KL, Nicolakis P, et al. (1998) Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial. Br Med J 316:731–735.[Abstract/Free Full Text]

  29. Basford JR, Sheffield CG, Cieslak KR. (2000) Laser therapy: a randomized, controlled trial of the effects of low intensity nd:yag laser irradiation on lateral epicondylitis. Arch Phys Med Rehabil 81:1504–1510.[CrossRef][Web of Science][Medline]

  30. Miranda H, Viikari-Juntura E, Heistaro S, et al. (2005) A population study on differences in the determinants of a specific shoulder disorder versus nonspecific shoulder pain without clinical findings. Am J Epidemiol 161:847–855.[Abstract/Free Full Text]

  31. Bartolozzi A, Andreychik D, Ahmad S. (1994) Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop 308:90–97.

  32. Green S, Buchbinder R, Glazier R, et al. (2005) Interventions for shoulder pain. Cochrane Database Syst Rev 2:CD001156.

  33. Walker-Bone KE, Palmer KT, Reading I, et al. (2003) Soft-tissue rheumatic disorders of the neck and upper limb: prevalence and risk factors. Semin Arthritis Rheum 33:185–203.[CrossRef][Web of Science][Medline]

  34. Nicholson GP. (2003) Arthroscopic capsular release for stiff shoulders: effect of etiology on outcomes. Arthroscopy 19:40–49.[Web of Science][Medline]

  35. Gam AN, Schydlowsky P, Rossel I, et al. (1998) Treatment of ‘frozen shoulder’ with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial. Scand J Rheumatol 27:425–430.[CrossRef][Web of Science][Medline]

  36. de Jong BA, Dahmen R, Hogeweg JA, et al. (1998) Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Clin Rehabil 12:211–215.[Abstract/Free Full Text]

  37. Frost P and Andersen JH. (1999) Shoulder impingement syndrome in relation to shoulder intensive work. Occup Environ Med 56:494–498.[Abstract/Free Full Text]

  38. Ludewig PM and Borstad JD. (2003) Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occup Environ Med 60:841–849.[Abstract/Free Full Text]

  39. Ludewig PM and Cook TM. (2000) Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 80:276–291.[Abstract/Free Full Text]

  40. Bigliani LU and Levine WN. (1997) Subacromial impingement syndrome. J Bone Joint Surg Am 79A:1854–1868.[Free Full Text]

  41. Morrison DS, Frogameni AD, Woodworth P. (1997) Non-operative treatment of subacromial impingement syndrome. J Bone Joint Surg Am 79:732–737.[Abstract/Free Full Text]

  42. Blair B, Rokito AS, Cuomo F, et al. (1996) Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 78:1685–1689.[Abstract/Free Full Text]

  43. Desmeules F, Cote CH, Fremont P. (2003) Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Clin J Sport Med 13:176–182.[CrossRef][Web of Science][Medline]

  44. Ludewig PM and Borstad JD. (2003) Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occup Environ Med 60:841–849.[Abstract/Free Full Text]

  45. Helliwell PS. (1996) A Review of Diagnostic Criteria for Work-related Upper Limb Disorders(Rheumatism Research Unit, University of Leeds, Leeds).

  46. Mekhora K, Liston CB, Nanthavanij S, et al. (2000) The effect of ergonomic intervention on discomfort in computer users with tension neck syndrome. Int J Ind Ergon 26:367–379.[CrossRef][Web of Science]

  47. Brandt LPA, Andersen JH, Lassen CF, et al. (2004) Neck and shoulder symptoms and disorders among Danish computer workers. Scand J Work Environ Health 30:399–409.[Web of Science][Medline]

  48. Klemetti M, Santavirta N, Sarvimaki A, et al. (1997) Tension neck and evaluation of a physical training course among office workers in a bank corporation. J Adv Nurs 26:962–967.[CrossRef][Web of Science][Medline]

  49. Payling KJ. (1993) Take the strain out of repetitive movement. Management of tenosynovitis and upper limb disorders. Prof Nurse 9:64–67.[CrossRef][Medline]

  50. Almekinders LC and Temple JD. (1998) Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 30:1183–1190.

  51. Richie CA and Briner WW. (2003) Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract 16:102–106.

  52. Palmer K, Coggon D, Cooper C, et al. (1998) Work related upper limb disorders: getting down to specifics. Ann Rheum Dis 57:445–446.[Free Full Text]

  53. Lindh M, Lurie M, Sanne H. (1997) A randomized prospective study of vocational outcome in rehabilitation of patients with non-specific musculoskeletal pain: a multidisciplinary approach to patients identified after 90 days of sick-leave. Scand J Rehabil Med 29:103–112.[Web of Science][Medline]

  54. O'Neil BA, Forsythe ME, Stanish WD. (2001) Chronic occupational repetitive strain injury. Can Fam Physician 47:311–316.[Abstract/Free Full Text]

  55. Hagberg M. (1996) ABC of work related disorders: neck and arm disorders. Br Med J 313:419–422.[Free Full Text]

  56. Johansson C, Dahl J, Jannert M, et al. (1998) Effects of a cognitive-behavioral pain-management program. Behav Res Ther 36:915–930.[CrossRef][Web of Science][Medline]

  57. Marhold C, Linton SJ, Melin L. (2001) A cognitive-behavioral return-to-work program: effects on pain patients with a history of long-term versus short-term sick leave. Pain 91:155–163.[CrossRef][Web of Science][Medline]

  58. Karjalainen KA, Malmivaara AO, van Tulder MW, et al. (2000) Biopsychosocial rehabilitation for repetitive-strain injuries among working-age adults. Scand J Work Environ Health 26:373–381.[Web of Science][Medline]

  59. Falkiner S. (2003) Diagnosis and treatment of hand-arm vibration syndrome and its relationship to carpal tunnel syndrome. Aust Fam Physician 32:530–534.[Medline]

  60. Khan KM, Cook JL, Kannus P, et al. (2002) Time to abandon the ‘tendinitis’ myth—painful, overuse tendon conditions have a non-inflammatory pathology. Br Med J 324:626–627.[Free Full Text]

  61. Khan KM, Cook JL, Bonar F, et al. (1999) histopathology of common tendinopathies—update and implications for clinical management. Sports Med 27:393–408.[CrossRef][Web of Science][Medline]


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