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Occupational Medicine Advance Access originally published online on December 10, 2008
Occupational Medicine 2009 59(1):44-52; doi:10.1093/occmed/kqn151
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Management of work-relevant upper limb disorders: a review

A. Kim Burton1, Nicholas A. S. Kendall2, Brian G. Pearce3, Lisa N. Birrell4 and L. Christopher Bainbridge5

1 Centre for Health and Social Care Research, University of Huddersfield, UK
2 Health Services Consultancy, Surbiton, UK
3 Humane Technology Limited, Rothley, UK
4 Institute of Occupational Medicine, Edinburgh, UK
5 Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK

Correspondence to: A. Kim Burton, Centre for Health and Social Care Research, University of Huddersfield, 30 Queen Street, Huddersfield HD1 2SP, UK. Tel: +44 1484 535200; fax: +44 1484 435744; e-mail: kim{at}spineresearch.org.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 
Background Upper limb disorders (ULDs) are clinically challenging and responsible for considerable work loss. There is a need to determine effective approaches for their management.

Aim To determine evidence-based management strategies for work-relevant ULDs and explore whether a biopsychosocial approach is appropriate.

Methods Literature review using a best evidence synthesis. Data from articles identified through systematic searching of electronic databases and citation tracking were extracted into evidence tables. The information was synthesized into high-level evidence statements, which were ordered into themes covering classification/diagnosis, epidemiology, associations/risks and management/treatment, focusing on return to work or work retention and taking account of distinctions between non-specific complaints and specific diagnoses.

Results Neither biomedical treatment nor ergonomic workplace interventions alone offer an optimal solution; rather, multimodal interventions show considerable promise, particularly for occupational outcomes. Early return to work, or work retention, is an important goal for most cases and may be facilitated, where necessary, by transitional work arrangements. The emergent evidence indicates that successful management strategies require all the players to be onside and acting in a coordinated fashion; this requires engaging employers and workers to participate.

Conclusions The biopsychosocial model applies: biological considerations should not be ignored, but psychosocial factors are more influential for occupational outcomes. Implementation of interventions that address the full range of psychosocial issues will require a cultural shift in the way the relationship between upper limb complaints and work is conceived and handled. Dissemination of evidence-based messages can contribute to the needed cultural shift.

Keywords      Biopsychosocial; interventions; return to work; upper limb disorders; work relevant


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Funding
 Conflicts of interest
 References
 
This paper reports on a literature review commissioned by the UK Health & Safety Executive. The present article is an abridged version of the original report entitled ‘Management of upper limb disorders and the biopsychosocial model’ [1].

Acknowledging that musculoskeletal disorders (MSDs) are responsible for a considerable proportion of work loss and that not all upper limb disorders (ULDs) manifesting at work can be prevented [2], there is a need to determine effective approaches for managing those cases that do occur.

ULDs are characterized by symptoms (usually pain) which have inconsistent associations with work loss and disability. While there is evidence that MSDs in general, like other common health problems, have a strong association with psychosocial factors [3], it is uncertain to what extent that holds true specifically for ULDs.

This review aimed to establish the extent to which the scientific evidence supports management of ULDs according to the biopsychosocial model. In particular, the objective was to draw conclusions on the question of whether there is evidence that the biopsychosocial model can be successfully applied to the management of ULDs and to provide evidence-based, high-level messages about what should be done to help people with ULDs recover quickly and achieve sustained return to work.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Funding
 Conflicts of interest
 References
 
The overall methodology should be viewed as a ‘best evidence synthesis’, summarizing the available literature and drawing conclusions about the balance of evidence, based on its quality, quantity and consistency [4]. This approach offers the flexibility needed to handle complex topics, but at the same time takes a rigorous approach when it came to assessing the strength of the scientific evidence. A more detailed description is in the original report [1].

An electronic search of the major electronic databases was conducted in June 2007, limited to articles published from 1996 onwards. It included search strings with all relevant keywords that might include the wide range of terms used to describe upper limb conditions in working-age adults. The main search was supplemented with citation tracking and hand searching to identify non-indexed material and relevant grey literature (grey literature includes conference proceedings, dissertations, theses, clinical trials registries and other reports). To maintain focus on occupationally relevant disorders, some conditions and topics, such as rheumatic and systemic diseases, fractures and disorders of peripheral circulation were excluded.

Systematic reviews and extensive narrative reviews were the primary focus, but individual studies were selected where they provided additional or more detailed information. Once a potential pool of articles and studies was identified, the titles and abstracts were circulated among three reviewers (K.B., N.A.S.K., B.G.P.), who decided by consensus which full articles to select for possible inclusion in the review. Copies of some 200 relevant articles were obtained, circulated, analysed and archived.

Summary data from included articles were entered into detailed evidence tables, which accompany the original report [1]. Themes in the data were identified and organized to cover three main categories: epidemiology/risk factors, intervention/classification and concepts/guidance. The information was synthesized into high-level evidence statements, each linked to the supporting evidence, with the final wording of the evidence statements developed through an iterative process involving all five reviewers. Finally, the information contained within the evidence statements was distilled into a number of key messages related to evidence-based management of work-relevant ULDs.

The strength of the scientific evidence supporting the statements was graded using the system in Table 1. The strength of the evidence should be distinguished from the size of the effect: there may be strong evidence about a particular association, yet the effect size may be small.


View this table:
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  		Table 1. Evidence grading system used to rate the strength of the scientific evidence underlying the evidence statements (adapted from [5])

 

   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Funding
 Conflicts of interest
 References
 
The findings of the review are presented in the form of high-level ‘evidence statements’ as a convenient way of summarizing knowledge across complex themes, with each statement being linked to the main supportive sources of evidence.

The first set of statements concern the extent to which ULDs can be classified and recognized; exploration of detailed diagnostic criteria was beyond the scope of the review (Box 1).


Box 1. Classification and diagnosis
***Classification and diagnosis of ULDs is particularly problematic; there is a lack of agreement on diagnostic criteria, even for the more common specific diagnoses (e.g. tenosynovitis, epicondylitis and rotator cuff syndrome). Inconsistent application, both in the clinic and in the workplace, leads to misdiagnosis, incorrect labelling and difficulties in interpretation of research findings [6–12].
**The scientific basis for descriptive classification terms implying a uniform aetiology, such as repetitive strain injuries and cumulative trauma disorders, is weak or absent and they are inconsistently applied/understood; there is an argument that such terms should be avoided [13–19].

 

Nosological inconsistencies have led to debate and uncertainty over issues from pathology to causation [12]. It is likely that misdiagnoses will be common both in the clinic and in the workplace [8], frequently manifested as patients receiving multiple and conflicting explanations and diagnostic labels from the various clinicians they encounter.

While it is possible to achieve expert consensus on criteria for case definitions suitable for occupational surveillance systems, the clinical validity of the classifications is uncertain [20,21], and it is unknown if they lead to improved clinical management.

A considerable number of the articles retrieved for the present review take a ‘lumping’ approach whereby studies will include a variety of different disorders under labels such as ‘work-related upper limb disorder’ or simply ‘musculoskeletal disorders’. However, that is not a universal view, and some researchers point to the possibility of specific neuropathic pathologies underlying what is often termed non-specific arm pain, ‘cumulative trauma disorders’ or ‘repetitive strain injuries’ [22]. An alternative utilitarian approach is that the optimal definition for a disorder may vary according to the circumstances in which it is applied [23].

The epidemiology of ULDs is essential to understanding how they arise, in whom, and to inform on their natural history (Box 2). There is a cascade in the way they are experienced and expressed, which is similar to that noted for other musculoskeletal problems such as back pain: a clear distinction should be made between the presence of symptoms, the reporting of symptoms, attributing symptoms to work, seeking health care, loss of time from work and long-term damage, which may all have rather different determinants [24].


Box 2. Epidemiology
***There is a very high background prevalence of upper limb pain and neck symptoms in the general population: the 1-week prevalence in general population can be as high as 50%. Estimates of the prevalence rates of specific diagnoses are less precise, but are considerably lower than for non-specific complaints. Rates vary depending on region, population, country, case definition and on the question asked [6,25–33].

**Upper limb pain is often recurrent and frequently experienced in more than one region at the same time (both bilaterally and at anatomically adjacent sites) [19,29–31].

***ULDs often lead to difficulty with normal activities and to sickness absence, yet most workers with ULDs can and do remain at work [29,31,34,35].

 

The issue of risk factors for ULDs is clearly highly relevant to the concept of preventing onset of symptoms or injury, but the subject is poorly understood and inconsistently documented (Box 3). Many factors, both occupational and personal, are purported to be ‘risk factors’, but the nature of those risks and their potential outcomes are readily misunderstood. This is evident in the high levels of growth in disability and work loss associated with musculoskeletal pain over the very period when industrialized countries have implemented occupational safety and health legislation and developed inspectorates for compliance and enforcement [36,37]. Thus, further consideration of the evidence on risk factors is needed to permit robust conclusions.


Box 3. Associations and risks
**Large-scale influential reviews published around the turn of the millennium (which included much cross-sectional data) concluded that there were strong associations between biomechanical occupational stressors (e.g. repetition, force) and ULDs: backed by plausible mechanisms from the biomechanics literature, the association was generally considered to be causative, particularly for prolonged or multiple exposures (though a dose–response relationship generally was not evident) [38–40].
***More recent epidemiological studies involving longitudinal designs also suggest an association between physical exposures and development of ULDs, but they report the effect size to be rather modest and largely confined to intense exposures. The predominant outcome investigated (primary causation, symptom expression or symptom modification) is inconsistent across studies and remains a subject of debate. This is true for regional complaints and (with few exceptions [41]) most of the specific diagnoses [26,28,36,41–47].
*The evidence that cumulative exposure to typical (modern) work is the cause of most reported upper limb injury is limited and inconsistent [19,38,48,49].
***Workplace psychosocial factors (beliefs, perceptions and work organization) have consistently been found to be associated with various aspects of ULDs, including symptom expression, care seeking, sickness absence and disability [19,26,38,40,42,50–55].
***Individual psychological factors (such as anxiety, distress and depression) have consistently been found to be associated with various aspects of ULDs, including symptom expression, care seeking, sickness absence and disability [40,48,56–59].

 

There is no doubt that certain jobs can legitimately be considered to entail hazards that are, on the balance of probabilities, risk factors for the development of certain specific diseases [41], yet these diseases account for a relatively small proportion of all ULDs. Many non-specific upper limb symptoms are likely to result from some physical stress across joints and in soft tissues, but work is not the exclusive (or necessarily most important) source of such stress. There is emerging evidence that a combination of exposure to physical and psychosocial factors at work has a stronger association than either type of factor alone [55,60]. By and large, the duration of exposure has been inconsistently reported across the epidemiological literature, so attributing upper limb complaints to cumulative exposure is by no means fully justified. Of interest in this respect is that one of the strongest predictors of incident upper limb symptoms among workers can be a prior history of symptoms, as opposed to work exposures such as repetitiveness, work pace or forceful awkward postures [61].

In view of the widespread experience of upper limb symptoms in the community, the patchy nature of associations between work characteristics and ULDs (both non-specific and specific), and the difficulty of establishing cogent occupational causation [62], the often used collective term ‘work related’, seems not altogether accurate and potentially misleading. Instead, it seems more reasonable to refer to ULDs among workers as ‘work relevant’, which avoids undue occupational attribution and the notion of permanent impairment yet acknowledges that work can be troublesome for people experiencing upper limb symptoms, irrespective of cause.

The retrieved articles on management and treatment covered a wide range of outcomes, clinical presentations and interventions. The effectiveness of biomedical treatments was outside the scope of the review, but a simple ‘review of reviews’ indicates that many common treatments for ULDs are less effective than might be expected. While some are effective for specific diagnoses (exercise for rotator cuff tendonitis; oral steroids for shoulder pain such as impingement syndrome or capsulitis and corticosteroid injections for tenosynovitis), effect sizes tend to be small and are limited to clinical outcomes [1].

The retrieved material on management approaches for ULDs tended to reflect a view that there is a commonality to MSD that justifies considering their management in a generic sense (Box 4).


Box 4. Interventions for MSDs in general
*General management principles are to provide advice that promotes self-management, such as staying active and engaging in productive activity (with appropriate modifications). Pain modulation and control should be directed towards allowing appropriate levels of activity [63,64].
***Programmes using cognitive–behavioural approaches are effective and cost-effective at reducing pain and increasing productive activity in both the earlier and the later phases [65–67].
*Multimodal integrated interventions that address both biomechanical and psychosocial aspects at the same time should be useful for managing musculoskeletal problems in the workplace [3,40,68–70].

 

In addition to the information concerning MSDs in general, the search retrieved studies concerning interventions specifically on people with ULDs; specific diagnoses were generally included along with non-specific complaints (Boxes 5–7).


Box 5. Interventions specifically in respect of ULDs
**Pain management programmes using cognitive-behavioural principles and multidisciplinary occupational rehabilitation for people with ULDs can improve occupational outcomes in the short term and significantly reduce sickness absence in the longer term. Earlier intervention appears to yield better results [71,72].
*There is a conceptual case that rehabilitation should be started early and that long periods of rest or sick leave are generally counterproductive [14,73–76].
**Ergonomic work redesign directed at equipment or organization has not been shown to have a significant effect on incidence and prevalence rates of ULDs. Ergonomic interventions can improve worker comfort (which is valuable) which can in principle contribute positively to multimodal interventions [13,15,48,77–80].
*There is limited evidence that ergonomic adjustments (mouse/keyboard design) can reduce upper limb pain in display screen workers but insufficient evidence for equipment interventions among manufacturing workers [78,81,82].
*In general resting injured upper limbs delays recovery; early activity improves pain and stiffness and can speed return to work yet does not increase complications or residual symptoms and may lead to less treatment consumption [83–87].

 


Box 6. Return to work
*There is wide consensus that early return to work is an important goal which should be facilitated by multimodal interventions including provision of accurate information pain relief and encouragement of activity. An integrative approach by all the players (notably employer worker and health professional) is conceptually a fundamental requirement [14,34,64,66,73,76,85,87–89].
**Although the components of return to work interventions vary there is emerging evidence that integrative approaches can be effective for MSDs in general and probably also for ULDs. Case management shows promise for getting all the players onside. Facilitation of return to work through temporary transitional work arrangements (modified work) seems to be an important component [64,68–70,89–93].

 


Box 7. Non-specific complaints and specific diagnoses
*There is insufficient robust evidence to identify reliable prognostic indicators that are applicable across the ULD spectrum (specific diagnoses and regional complaints) [8,14,27,38,94].
*There is inconsistent and conflicting evidence on whether and to what extent certain specific diagnoses and regional complaints should be conceived differently in terms of overall management targeted at vocational outcomes [48,85,95,96].

 

The bulk of the literature reporting on the management of ULDs has either concentrated on regional symptoms (termed disorders by some investigators) or taken an even wider perspective and combined regional symptoms (including the upper limb) under generic labels such as work-related musculoskeletal disorder. While there seems to be good reason to separate (some) specific diagnoses when making clinical decisions about treatment, there is little evidence that the distinction is helpful when considering vocational outcomes and rehabilitation. It can be argued that returning a hurting worker to their job relies on achieving an acceptable balance between ‘capacity’ and ‘tolerance’, and this concept is largely independent of whether the individual has a specific diagnosis or regional complaint [85,95].

Overall, the evidence indicates that effective interventions for work-relevant ULDs require a multimodal approach: specific treatment (when needed, using a stepped approach) coupled with workplace accommodation (when needed, on a temporary basis). While lumping and splitting approaches may be helpful under differing circumstances [23], achieving a balance in terminology is likely to be particularly important: if wrongly applied, diagnostic labels can alarm and harm, whereas unemotive complaint-based labels can help ‘normalize’ the experience and ease the path to participation in productive activity.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Funding
 Conflicts of interest
 References
 
This review used a best evidence synthesis to summarize the balance of the wide range of retrieved evidence [4], which has been synthesized in high-level terms to provide a set of messages to guide the management of work-relevant ULDs.

The epidemiological evidence is quite clear: musculoskeletal symptoms affecting the upper limb and neck are a common experience among the general population, tending to be a recurrent complaint. A specific pathology cannot reliably be established for the majority of people with upper limb symptoms, indicating they might best be viewed as having a regional complaint. There is considerable debate over the classification of the various specific diagnoses and, while some consensus seems possible, diagnostic criteria remain unreliable—many cases will be mislabelled (whether colloquially or by a health care professional).

For many people, their symptoms will be work relevant: their work may be painful or difficult irrespective of the origin of the symptoms. However, even when work is related to the expression of symptoms, that does not mean work was necessarily the underlying cause: it is apparent that work is not the predominant cause of most ULD episodes.

Many people with ULDs cope without recourse to health care or need for sick leave, yet a small number of people with ULDs will progress to persistent pain and/or long-term disability, irrespective of severity or diagnosis. This pattern is typical of a wide range of common health problems, in which personal and cultural factors are a predominant feature, notably the psychological and social variables that influence beliefs and behaviours [3]. Although the evidence is limited for ULDs, knowledge from the literature on other musculoskeletal problems strongly implicates psychosocial factors as drivers for symptom reporting, work loss and disability [97,98]. Since there is no particular reason to expect that complaints and disorders related to the musculoskeletal apparatus of the upper limb and neck are fundamentally different from the musculoskeletal apparatus of the lower back, it is logical and reasonable to surmise that there will be shared influences. Indeed, what evidence there is supports psychosocial factors as being important in understanding and managing ULDs.

Biomedical management of ULDs is seemingly less effective than might be expected, perhaps reflecting the difficulties around classification and diagnosis, together with uncertainties over the optimal timing of treatment delivery (longer duration of symptoms having a negative impact on outcomes [56]). Nevertheless, in principle, there is likely to be benefit from biomedical interventions aimed at controlling symptoms (and/or targeting any identifiable pathology) while offering support and encouragement for early return to normal activities (including work). However, in order to impact on work outcomes, intervention requires more than biomedical treatment. There is a need to address the range of psychosocial factors (obstacles to recovery/return to work) at both the individual and workplace levels, and those efforts need to be coordinated and integrated among the relevant players, including the individual worker.

Some patients will have a recognized pathology requiring medical or surgical intervention (which may involve short-term rest), and there is some concern that applying the principles of an active approach together with early return to work will be inappropriate for some conditions such as ‘tenosynovitis’, where anecdotally rest is the preferred option [34]. Although limited, the evidence on work-relevant ULDs (both specific and regional) is consistent with the principle of the active approach promoted and implemented for MSDs in general [84]: importantly, there is no robust contradictory evidence. The notion of ‘rest’ as a sole treatment is likely to be unhelpful: even if specific aggravating activities need to be modified or avoided short term that does not preclude other activities and exercises being undertaken as part of therapy [99]. So far as post-surgical management is concerned, there has been an increasing recognition of the benefits of early activation following most surgical procedures, and restrictions may be more a matter of the surgeon’s idiosyncratic advice than any absolute need [100].

Although early work return is seen as advantageous, simply sending someone directly back to a job they find painful is counterintuitive and inappropriate. There is a strong case for using transitional work arrangements as the facilitator, which takes account of both biological and psychosocial obstacles to return to work. There is considerable evidence for the use of temporary modification of activities to support people with regional pain states on their return to normal activity, and there is no clear evidence that the principle cannot or should not be applied to the specific diagnoses.

Just because the epidemiological pattern of most ULDs does not favour ergonomic interventions as a significant primary preventive measure, this does not mean that there is no merit in making work ergonomically acceptable; jobs, naturally, should be within the reasonable capabilities of the workers. Unfortunately, portions of the ergonomics literature and official guidance give the erroneous impression that work is intrinsically the major cause of ULDs and that by applying an ‘ergonomics approach’ they will be eliminated. The evidence reviewed here indicates that they will not. Furthermore, a possible problem with ergonomic interventions is that they can reinforce workers’ beliefs that they are exposed to a significant hazard, and thereby encourage undue reporting of symptoms, inappropriate work loss and development of disability [36]. Nevertheless, an ergonomics approach, correctly applied, should improve comfort and efficiency, thus assisting in accommodating those with work-relevant complaints or disorders.

Viewed overall, the evidence on the management of ULDs favours neither biomedical nor workplace interventions alone, either for regional complaints or specific diagnoses. Rather, what is needed is a biopsychosocial approach, which necessitates multimodal interventions with all the players onside and acting in unison. While the evidence base supporting the principle of addressing the beliefs and behaviours of all the relevant players is as yet limited, the concept is central to overcoming biopsychosocial obstacles [3]. Achieving all that will require a cultural shift in the way the relationship between upper limb complaints and work is conceived and handled. Educational strategies are likely to be a useful tool in that respect, but will need to be carefully developed and tailored to the relevant target audience [101].

If the need for cultural change is accepted, then there is also a need for policymakers to rethink the priorities of certain underlying concepts (e.g. primary prevention versus management: work caused versus work relevant) and develop means to disseminate evidence-based information to the various players (employers, workers, health care providers, unions and trade/professional organizations, lawyers, legislators and decision makers). Media campaigns are increasingly seen as a suitable vehicle to contribute to public health and cultural change in respect of health behaviours, supplemented by guidance material and patient education; this strategy has been recommended specifically in respect of ULDs [34].

While the overall message may be clear—biopsychosocial factors are influential in the phenomenon of upper limb complaints and need to be addressed—there are gaps in the evidence. Observational studies will help to better understand the natural history of non-specific complaints and the specific diagnoses, and controlled trials are needed to determine the most appropriate means for implementing both clinical and workplace care. Innovative multimodal interventions seem promising, yet the optimal content, timing and method of delivery needs further clarification.

A number of salient messages emerge from the evidence, which may contribute to the needed cultural shift. They apply to the whole range of players involved (population/workers, employers, health professionals, unions, lawyers, media, policymakers and enforcers), so they will need to be carefully constructed for each target group, tailored to their needs and comprehensively disseminated. The main messages are reflected here in the key points and are available in expanded form in the original report [1].


Key points
  • ULDs can be triggered by everyday activities and overattribution to work can be detrimental to recovery: overmedicalization and negative diagnostic labels are unhelpful.
  • Many cases settle with self-management—this should be encouraged—though some need treatment: intervention should take a stepped care approach, based on a biopsychosocial principles.
  • Early return to work is important, though some work may be difficult or impossible to perform for a short while: work should be comfortable and accommodating.

 


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
Conflicts of interest
 References
 
UK Health & Safety Executive. Contract No. 6325.


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


   Acknowledgements
 
We are grateful to the following colleagues, from a variety of disciplines, who kindly offered helpful ideas and comments: Frank Burke, David Coggon, Serena McCluskey, Margaret Hanson, Trang Nguyen, David Randolph and Mary Wyatt. We thank Debbie McStrafick for her administrative assistance and for retrieving and carefully archiving the selected articles.


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

  1. Burton AK, Kendall NAS, Pearce BG, Birrell LN, Bainbridge LC. Management of Upper Limb Disorders and the Biopsychosocial Model (2008) London: HSE Books.

  2. HSE. Upper Limb Disorders in the Workplace (HSG60(rev)) (2002) London: Health & Safety Executive.

  3. Waddell G, Burton AK. Concepts of Rehabilitation for the Management of Common Health Problems (2004) Norwich: The Stationery Office.

  4. Slavin R. Best evidence synthesis: an intelligent alternative to met-analysis. J Clin Epidemiol (1995) 48:9–18.[CrossRef][Web of Science][Medline]

  5. Waddell G, Burton AK. Is Work Good for Your Health and Well-being? (2006) London: TSO.

  6. Huisstede BMA, Bierma-Zeinstra SMA, Koes BW, Verhaar JAN. Incidence and prevalence of upper-extremity musculoskeletal disorders. A systematic appraisal of the literature. BMC Musculoskelet Disord (2006) 7.

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

  8. Nørregaard J, Jacobsen S, Kristensen JH. A narrative review on classification of pain conditions of the upper extremities. Scand J Rehabil Med (1999) 31:153–164.[CrossRef][Web of Science][Medline]

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

  10. Van Eerd D, Beaton D, Cole D, Lucas J, Hogg-Johnson S, Bombardier C. Classification systems for upper-limb musculoskeletal disorders in workers: a review of the literature. J Clin Epidemiol (2003) 56:925–936.[CrossRef][Web of Science][Medline]

  11. Walker-Bone KE, Palmer KT, Reading I, Cooper C. Criteria for assessing pain and nonarticular soft-tissue rheumatic disorders of the neck and upper limb. Semin Arthritis Rheum (2003) 33:168–184.[CrossRef][Web of Science][Medline]

  12. Beaton DE, Bombardier C, Cole DC, Hogg-Johnson S, Van Eerd D. A pattern recognition approach to the development of a classification system for upper-limb musculoskeletal disorders of workers. Scand J Work Environ Health (2007) 33:131–139.[Web of Science][Medline]

  13. Szabo RM. Determining causation of work-related upper extremity disorders. Clin Occup Environ Med (2006) 5:225–234.[Medline]

  14. Hagberg M. Clinical assessment, prognosis and return to work with reference to work related neck and upper limb disorders. G Ital Med Lav Ergon (2005) 27:51–57.[Medline]

  15. Szabo RM, King KJ. Repetitive stress injury: diagnosis or self-fulfilling prophecy? J Bone Joint Surg (2000) 82-A:1314–1322.[Free Full Text]

  16. Lucire Y. Constructing RSI: Belief and Desire (2003) Sydney: University of New South Wales Press.

  17. European Agency for Safety and Health at Work. Repetitive Strain Injuries in the Member States of the European Union: The Results of an Information Request (2000) Luxembourg: Office for Official Publications of the European Communities.

  18. Bonde JP, Mikkelsen S, Andersen JH, et al. Prognosis of shoulder tendonitis in repetitive work: a follow up study in a cohort of Danish industrial and service workers. Occup Environ Med (2003) 60:e8.[Abstract/Free Full Text]

  19. Macfarlane GJ, Hunt IM, Silman AJ. Role of mechanical and psychosocial factors in the onset of forearm pain: prospective population based study. Br Med J (2000) 321:1–5.[Abstract/Free Full Text]

  20. 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]

  21. Huisstede BMA, Miedema HS, Verhagen AP, Koes BW, Verhaar JAN. Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder. Occup Environ Med (2007) 64:313–319.[Abstract/Free Full Text]

  22. Greening J, Lynn B, Leary R. Sensory and autonomic function in the hands of patients with non-specific arm pain (NSAP) and asymptomatic office workers. Pain (2003) 104:275–281.[CrossRef][Web of Science][Medline]

  23. Coggon D, Martyn C, Palmer KT, Evanofff B. Assessing case definitions in the absence of a diagnostic gold standard. Int J Epidemiol (2005) 34:949–952.[Abstract/Free Full Text]

  24. Waddell G, Burton AK. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med (Lond) (2001) 51:124–135.[CrossRef][Medline]

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

  26. Walker-Bone K, Cooper C. Hard work never hurt anyone: or did it? A review of occupational associations with soft tissue musculoskeletal disorders of the neck and upper limb. Ann Rheum Dis (2005) 64:1391–1396.[Abstract/Free Full Text]

  27. Kuijpers T, van der Windt DAWM, van der Heijden GJMG, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain (2004) 109:420–431.[CrossRef][Web of Science][Medline]

  28. Palmer KT, Smedley J. Work relatedness of chronic neck pain with physical findings. Scand J Work Environ Health (2007) 33:165–191.[Web of Science][Medline]

  29. Walker-Bone K, Reading I, Coggon D, Cooper C, Palmer KT. The anatomical pattern and determinants of pain in the neck and upper limbs: an epidemiologic study. Pain (2004) 109:45–51.[CrossRef][Web of Science][Medline]

  30. 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]

  31. Silverstein BA, Viikari-Juntura E, Fan ZJ, Bonauto DK, Bao S, Smith C. Natural course of nontraumatic rotator cuff tendinitis and shoulder symptoms in a working population. Scand J Work Environ Health (2006) 32:99–108.[Web of Science][Medline]

  32. Eltayeb S, Staal B, Kennes J, Lamberts PHG, de Bie RA. Prevalence of complaints of arm, neck and shoulder among computer office workers and psychometric evaluation of a risk factor questionnaire. BMC Musculoskelet Disord (2007) 8.

  33. Roquelaure Y, Ha C, Leclerc A, et al. Epidemiologic surveillance of upper-extremity musculoskeletal disorders in the working population. Arthritis Rheum (2006) 55:765–778.[CrossRef][Web of Science][Medline]

  34. Lee R, Higgins G. Report on the Proceedings of HSE's Musculoskeletal Disorder and Return to Work Workshop (WPS/06/02) (2006) Buxton: Health & Safety Laboratory.

  35. Baldwin ML, Butler RJ. Upper extremity disorders in the workplace: costs and outcomes beyond the first return to work. J Occup Rehabil (2006) 16:303–323.[Web of Science][Medline]

  36. Coggon D, Palmer KT, Walker-Bone K. Occupation and upper limb disorders. Rheumatology (2000) 39:1057–1059.[Free Full Text]

  37. Burton AK. Back injury and work loss: biomechanical and psychosocial influences. Spine (1997) 22:2575–2580.[CrossRef][Web of Science][Medline]

  38. 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 (1997) Cincinnati, OH: National Institute for Occupational Safety and Health.

  39. National Research Council. Work-related Musculoskeletal Disorders: Report, Workshop Summary and Workshop Papers (1999) Washington, DC: National Academy Press.

  40. National Research Council. Musculoskeletal Disorders and the Workplace (2001) Washington, DC: National Academy Press.

  41. Industrial Injuries Advisory Council. Prescribed Diseases. Industrial Injuries Advisory Council. www.iiac.org.uk/about/index.asp (11 February 2006, date last accessed).

  42. Bongers P, Ijmker S, den Heuvel Sv, Blatter B. Epidemiology of work related neck and upper limb problems: psychosocial and personal risk factors (Part I) and effective interventions from a bio behavioural perspective (Part II). J Occup Rehabil (2006) 16:272–295.[CrossRef]

  43. Palmer KT, Harris EC, Coggon D. Compensating occupationally related tenosynovitis and epicondylitis: a literature review. Occup Med (Lond) (2007) 57:67–74.[Medline]

  44. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol (2004) 14:13–23.[CrossRef][Web of Science][Medline]

  45. Ijmker S, Huysmans MA, Blatter BM, van der Beek AJ, van Mechelen W, Bongers PM. Should office workers spend fewer hours at their computer? A systematic review of the literature. Occup Environ Med (2007) 64:211–222.[Abstract/Free Full Text]

  46. Thomsen JF, Mikkelsen S, Andersen JH, et al. Risk factors for hand-wrist disorders in repetitive work. Occup Environ Med (2007) 64:527–533.[Abstract/Free Full Text]

  47. van den Heuvel SG, van der Beek AJ, Blatter BM, Bongers PM. Do work-related physical factors predict neck and upper limb symptoms in office workers? Int Arch Occup Environ Health (2006) 79:585–592.[CrossRef][Web of Science][Medline]

  48. Hadler NM. Occupational Musculoskeletal Disorders (2005) 3rd edn. Philadelphia, PA: Lippincott Williams & Wilkins.

  49. Dembe AE. Occupation and Disease. How Social Factors Affect the Conception of Work-related Disorders (1996) New Haven, CT: Yale University.

  50. Woods V. Work-related musculoskeletal health and social support. Occup Med (Lond) (2005) 55:177–189.[CrossRef][Medline]

  51. Woods V, Buckle P. Work, Inequality and Musculoskeletal Health (Contract Research Report 421) (2002) London: Health and Safety Executive.

  52. Bongers PM, Kremer AM, ter Laak J. Are psychosocial factors, risk factors for symptoms and signs of the shoulder, elbow, or hand/wrist?: a review of the epidemiological literature. Am J Ind Med (2002) 41:315–342.[CrossRef][Web of Science][Medline]

  53. Burton AK, Bartys S, Wright IA, Main CJ. Obstacles to Recovery from Musculoskeletal Disorders in Industry (Research Report 323). London: HSE Books www.hse.gov.uk/research/rrhtm, 2005.

  54. van den Heuvel SG, van der Beek AJ, Blatter BM, Hoogendoorn WE, Bongers PM. Psychosocial work characteristics in relation to neck and upper limb symptoms. Pain (2005) 114:47–53.[CrossRef][Web of Science][Medline]

  55. Devereux J, Rydstedt L, Kelly V, Weston P, Buckle P. The Role of Work Stress and Psychological Factors in the Development of Musculoskeletal Disorders (RR 273) (2004) London: Health and Safety Executive.

  56. Mallen CD, Peat G, Thomas E, Dunn KM, Croft PR. Prognostic factors for musculoskeletal pain in primary care: a systematic review. Br J Gen Pract (2007) 57:655–661.[Web of Science][Medline]

  57. Alizadehkhaiyat O, Fisher AC, Kemp GJ, Frostick SP. Pain, functional disability, and psychologic status in tennis elbow. Clin J Pain (2007) 23:482–489.[CrossRef][Web of Science][Medline]

  58. Coutu M-F, Durand M-J, Loisel P, Goulet C, Gauthier N. Level of distress among workers undergoing work rehabilitation for musculoskeletal disorders. J Occup Rehabil (2007) 17:289–303.[CrossRef][Web of Science][Medline]

  59. Henderson M, Kidd BL, Pearson RM, White PD. Chronic upper limb pain: an exploration of the biopsychosocial model. J Rheumatol (2005) 32:118–122.[Abstract/Free Full Text]

  60. Warren N, Dillon C, Morse T, Hall C, Warren A. Biomechanical, psychosocial, and organizational risk factors for WRMSD: population-based estimates from the Connecticut Upper-extremity Surveillance Project (CUSP). J Occup Health Psychol (2000) 5:164–181.[CrossRef][Medline]

  61. Descatha A, Roquelaure Y, Evanoff B, Mariel J, Leclerc A. Predictive factors for incident musculoskeletal disorders in an in-plant surveillance program. Ann Occup Hyg (2007) 51:337–344.[Abstract/Free Full Text]

  62. Hadler NM. The semiotics of ‘upper limb musculoskeletal disorders in workers’. J Clin Epidemiol (2003) 56:937–939.[CrossRef][Web of Science][Medline]

  63. ARMA. Standards for People with Regional Musculoskeletal Pain (2007) London: Arthritis and Musculoskeletal Alliance.

  64. Breen A, Langworthy J, Baghust J. Improved Early Pain Management for Musculoskeletal Disorders: (RR 399) (2007) London: Health & Safety Executive.

  65. Hanson MA, Burton AK, Kendall NAS, Lancaster RJ, Pilkington A. The Costs and Benefits of Active Case Management and Rehabilitation for Musculoskeletal Disorders (RR 493) (2006) London: HSE Books.

  66. Meijer EM, Sluiter JK, Frings-Dresen MHW. Evaluation of effective return-to-work treatment programs for sick-listed patients with non-specific musculoskeletal complaints: a systematic review. Int Arch Occup Environ Health (2005) 78:523–532.[CrossRef][Web of Science][Medline]

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

  68. Cole DC, Van Eerd D, Bigelow P, Rivilis I. Integrative interventions for MSDs: nature, evidence, challenges & directions. J Occup Rehabil (2006) 16:359–374.[Web of Science][Medline]

  69. Selander J, Marnetoft S-U, Bergroth A, Ekholm J. Return to work following vocational rehabilitation for neck, back and shoulder problems: risk factors reviewed. Disabil Rehabil (2002) 24:704–712.[CrossRef][Web of Science][Medline]

  70. Feuerstein M, Huang GD, Ortiz JM, Shaw WS, Miller VI, Wood PM. Integrated case management for work-related upper-extremity disorders: impact of patient satisfaction on health and work status. J Occup Environ Med (2003) 45:803–812.[CrossRef][Web of Science][Medline]

  71. Crawford JO, Laiou E. Conservative treatment of work-related upper limb disorders—a review. Occup Med (Lond) (2007) 57:4–17.[Medline]

  72. Feuerstein M, Burrell LM, Miller VI, Lincoln A, Huang GD, Berger R. Clinical management of carpal tunnel syndrome: a 12-year review of outcomes. Am J Ind Med (1999) 35:232–245.[CrossRef][Web of Science][Medline]

  73. Helliwell PS, Taylor WJ. Repetitive strain injury. Postgrad Med J (2004) 80:438–443.[Abstract/Free Full Text]

  74. NHMRC. Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians (2004) Bowen Hills, Queensland: National Health and Medical Research Council, Australian Academic Press Pty Ltd.

  75. Franche R-L, Krause N. Readiness for return to work following injury or illness: conceptualizing the interpersonal impact of health care, workplace, and insurance factors. J Occup Rehabil (2002) 12:233–256.[CrossRef][Web of Science][Medline]

  76. Waddell G, Burton AK. Concepts of Rehabilitation for the Management of Common Health Problems (2004) London: The Stationery Office.

  77. Pransky G, Robertson MM, Moon SD. Stress and work-related upper extremity disorders: implications for prevention and management. Am J Ind Med (2002) 41:443–455.[CrossRef][Web of Science][Medline]

  78. Boocock MG, McNair PJ, Larmer PJ, et al. Interventions for the prevention and management of neck/upper extremity musculoskeletal conditions: a systematic review. Occup Environ Med (2007) 64:291–303.[Abstract/Free Full Text]

  79. Karsh B-T, Moro FBP, Smith MJ. The efficacy of workplace ergonomic interventions to control musculoskeletal disorders: a critical analysis of the peer-reviewed literature. Theor Issues Ergon Sci (2001) 2:23–96.[CrossRef]

  80. Christmansson M, Fridén J, Sollerman C. Task design, psycho-social work climate and upper extremity pain disorders—effects of an organisational redesign on manual repetitive assembly jobs. Appl Ergon (1999) 30:463–472.[CrossRef][Web of Science][Medline]

  81. Verhagen AP, Karels C, Bierma-Zeinstra SMA, et al. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. Cochrane Database Syst Rev (2006) Issue 3. Art. No.: CD003471. DOI: 10.1002/14651858.CD003471.pub3.

  82. Williams RM, Westmorland MG, Schmuck G, MacDermid JC. Effectiveness of workplace rehabilitation interventions in the treatment of work-related upper extremity disorders: a systematic review. J Hand Ther (2004) 17:267–273.[Medline]

  83. Nash CE, Mickan SM, Del Mar CB, Glasziou PP. Resting injured limbs delays recovery: a systematic review. J Fam Pract (2004) 53:706–712.[Web of Science][Medline]

  84. Buckwalter JA. Activity vs. rest in the treatment of bone, soft tissue and joint injuries. Iowa Orthop J (1995) 15:29–42.[Medline]

  85. Melhorn JM. Working with common upper extremity problems. In: A Physician's Guide to Return to Work—Talmage JB, Melhorn JM, eds. (2005) Chicago: AMA Press. 181–213.

  86. Haahr JP, Andersen JH. Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Rheumatology (2003) 42:1216–1225.[Abstract/Free Full Text]

  87. Cheng AS-K, Hung L-K. Randomised controlled trial of workplace-based rehablitation for work-related rotator cuff disorder. J Occup Rehabil (2007) 17:487–503.[CrossRef][Web of Science][Medline]

  88. Kupper A, Mackenzie S, Heasman T. The Challenge of Managing Upper Limb Disorders—How Can Health Professionals Become More Effective? (RR215) (2004) London: Health & Safety Executive.

  89. Franche RL, Cullen K, Clarke J, et al. Workplace-based return-to-work interventions: a systematic review of the quantitative literature. J Occup Rehabil (2005) 15:607–631.[CrossRef][Web of Science][Medline]

  90. Shaw WS, Feuerstein M, Huang GD. Secondary prevention and the workplace. In: New Avenues for the Prevention of Chronic Musculoskeletal Pain and Disability. Pain Research and Clinical Management—Linton SJ, ed. (2002) vol. 12. Amsterdam: Elsevier Science B.V. 215–235.

  91. Abásolo L, Blanco M, Bachiller J, et al. A health system program to reduce work disability related to musculoskeletal disorders. Ann Intern Med (2005) 143:404–414.[Abstract/Free Full Text]

  92. McCluskey S, Burton AK, Main CJ. The implementation of occupational health guidelines principles for reducing sickness absence due to musculoskeletal disorders. Occup Med (Lond) (2006) 56:237–242.[CrossRef][Medline]

  93. Shaw WS, Feuerstein M. Generating workplace accommodations: lessons learned from the integrated case management study. J Occup Rehabil (2004) 14:207–216.[CrossRef][Web of Science][Medline]

  94. Ryall C, Coggon D, Peveler R, Poole J, Palmer KT. A prospective cohort study of arm pain in primary care and physiotherapy—prognostic determinants. Rheumatology (2007) 46:508–515.[Abstract/Free Full Text]

  95. Derebery J, Kadan ML, Gonzalez R. Clinics in Occupational and Environmental Medicine (2006) vol. 5. New York: W B Saunders Company.

  96. Staal JB, de Bie RA, Hendriks EJM. Aetiology and management of work-related upper extremity disorders. Best Pract Res Clin Rheumatol (2007) 21:123–133.[CrossRef][Medline]

  97. Burton AK, Waddell G, Main CJ. Beliefs and obstacles in low back pain. In: The power of belief. Oxford: Oxford University Press—Halligan PW, Aylward M, eds. (2006) 161–176.

  98. Fordyce WE. Back Pain in the Workplace: Management of Disability in Nonspecific Conditions (1995) Seattle, WA: IASP Press.

  99. Jebson PJL, Steyers CM. Hand injuries in rock climbing: reaching the right treatment. Phys Sportsmed (1997) 25:54–63.

  100. Ratzon N, Schejter-Margalit T, Froom P. Time to return to work and surgeons’ recommendations after carpal tunnel release. Occup Med (Lond) (2006) 56:46–50.[CrossRef][Medline]

  101. Shaw K, Haslam C, Haslam R. A Staged Approach to Reducing Musculoskeletal Disorders (MSDs) in the Workplace—A Long Term Follow-up (2007) London: Health & Safety Executive.


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