Prevalence and Impact of Musculoskeletal Disorders of the Upper Limb in the General Population

Transcription

1 Arthritis & Rheumatism (Arthritis Care & Research) Vol. 51, No. 4, August 15, 2004, pp DOI /art , American College of Rheumatology ORIGINAL ARTICLE Prevalence and Impact of Musculoskeletal Disorders of the Upper Limb in the General Population KAREN WALKER-BONE, KEITH T. PALMER, ISABEL READING, DAVID COGGON, AND CYRUS COOPER Objective. To determine the prevalence, interrelation, and impact of musculoskeletal disorders of the upper limb in the general population. Methods. A total of 9,696 randomly selected adults of working age were surveyed in a 2-stage cross-sectional study involving a screening questionnaire and a standardized physical examination in symptomatic subjects. Age- and sex-specific prevalence rates were estimated for several musculoskeletal disorders and for nonspecific pain in the upper limbs. The overlap and impact on daily activities and healthcare utilization were explored. Results. Among 6,038 first-stage responders, 3,152 reported upper limb symptoms and 1,960 were subsequently examined. Of subjects with pain, 44.8% had 1 or more specific soft-tissue disorders. Site-specific prevalence rates were as follows: shoulder tendinitis 4.5% among men and 6.1% among women; adhesive capsulitis 8.2% among men and 10.1% among women; lateral epicondylitis 1.3% among men and 1.1% among women; de Quervain s disease 0.5% among men and 1.3% among women; other tenosynovitis of the hand or wrist, 1.1% among men and 2.2% among women. Specific disorders tended to cluster (P < 0.001) in individuals, with particular overlap at the shoulder. Compared with subjects with nonspecific pain, those with specific disorders more often reported inability to perform everyday tasks (P < 0.05), consultation with a doctor (P < 0.05), and use of prescribed medication (P < 0.05). Conclusion. Upper limb pain is common in the general population and is often associated with physical signs suggestive of specific upper-limb disorders. These disorders have a substantial impact on physical function and use of health care. KEY WORDS. Epidemiology; Upper limb disorders; Soft-tissue rheumatism; Prevalence; Impact. INTRODUCTION Pain and sensory disturbance in the upper limb are common symptoms with reported point prevalence rates ranging from 4% to 35% (1 7). Although they are not always associated with limitation of activities, they contribute to work absence. For example, during 1995, 3.8 million working days were lost in Britain because of upper limb Supported by a grant from the Health and Safety Executive and project grant PO552 from the Arthritis Research Campaign (ARC). Dr. Walker-Bone was supported by an ARC Clinical Research Fellowship and Ms Reading by a grant from the Colt Foundation. Karen Walker-Bone, BM, MRCP, PhD, Keith T. Palmer, MA, DM, FFOM, Isabel Reading, BSc, MSc, David Coggon, OBE, MA, PhD, DM, FRCP, FFOM, F Med Sci, Cyrus Cooper, MA, DM, FRCP, F Med Sci: Southampton General Hospital, Southampton, United Kingdom. Address correspondence to Cyrus Cooper, MRC Environmental Epidemiology Unit, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK. cc@mrc.soton.ac.uk. Submitted for publication July 8, 2003; accepted in revised form November 10, disorders (8). The resulting economic burden is substantial and rising (9). Little is known currently about the relative contributions of specific disorders and nonspecific arm pain to the overall burden of neck and upper limb symptoms in the general population. One reason for this is that, until recently, there was no agreed system of diagnostic classification for epidemiologic research in this area. However, in , the UK Health and Safety Executive convened a multidisciplinary panel that derived consensus diagnostic criteria for 8 specific soft-tissue disorders of the upper limb (rotator cuff tendinitis, adhesive capsulitis, bicipital tendinitis, lateral and medial epicondylitis, tenosynovitis of the wrist, de Quervain s tenosynovitis, and carpal tunnel syndrome (10) (Appendix A). To these we later added criteria for subacromial bursitis, acromioclavicular joint dysfunction, and painful osteoarthritis of the distal interphalangeal (DIP) joints and the thumb base, based upon the findings of a comprehensive literature review (11). To enable these case definitions to be applied efficiently in epidemiologic surveys, we developed a standardized examination protocol that includes inspection and palpation of the neck and upper limbs, standard provocation 642

2 Prevalence of Upper Limb Musculoskeletal Disorders 643 maneuvers, and measurement of active and passive ranges of motion. The protocol was taught to research nurses, performed reliably within and between observers (12), and had face validity when assessed against physicians clinical diagnoses (13). We used this tool to investigate the prevalence and health impact of specific disorders and of nonspecific pain in the upper limb among adults of working age in the general population. SUBJECTS AND METHODS The study population (n 9,696) comprised all men and women aged years who were 1) registered with either of 2 selected general practices in Southampton, 2) still living at the most recent address listed in the practice s records, and 3) not suffering from illness or recent bereavement that made it inadvisable for them to be approached or impossible for them to answer a self-administered questionnaire (Figure 1). The 2 practices were chosen from different geographic locations in the city to encompass a diverse socioeconomic profile (neither overtly deprived nor affluent) and range of occupational groups. In the UK, virtually everybody is registered with a general practitioner, so that primary care registers have been shown to provide a reliable and representative sample of the local population that they serve (14). Between June 1998 and August 2000, each member of the study population was sent a validated questionnaire (15,16) asking about demographic variables; lifestyle; employment; and recent symptoms of pain, numbness, or tingling in the neck, shoulder, elbow, hand, or wrist. Nonresponders were sent a single reminder after 4 weeks. All responders who reported symptoms in the previous week were invited to undergo interview and physical examination. At interview, 1 of 5 trained research nurses used a structured questionnaire to collect supplementary and updated information about the distribution and impact of symptoms in the upper limb and examined the subject according to the Southampton examination protocol (12,13). Those who failed to attend the interview were invited to another appointment after 3 4 weeks. An algorithm was applied to the findings from the interview and physical examination to classify participants according to whether they had any of the 12 specific disorders that it defined. Subjects who reported arm pain that was not attributable to 1 of these 12 disorders were deemed to have nonspecific arm pain at the anatomic site(s) concerned. The prevalence of each specific disorder and each category of nonspecific pain was then estimated for the study population, under the assumption that responders to the initial postal questionnaire were representative of the study population overall, and that those who underwent interview and examination were representative of all who were invited to attend. Pairwise associations between different disorders in the same arm or person were summarized by odds ratios (ORs), adjusted for age (in 10-year strata) and sex. The extent to which diagnoses clustered within individuals was assessed by comparing the numbers of participants with 0, 1, 2, etc. disorders with the numbers that would have been expected if, within each age and sex stratum, the occurrence of any 1 diagnosis was statistically independent of all others. We also examined the prevalence of disability and use of medical services in subjects with various groupings of specific diagnoses as compared with nonspecific pain. RESULTS Data on the number of subjects who responded to the postal questionnaire, the number invited, and the number who attended the interview are shown in Figure 1. Overall, 6,038 (62%) of the contacted individuals completed and returned the postal questionnaire. Response rates were similar in both practice samples (62.4% in practice 1 and 62.2% in practice 2). The mean age on the date the questionnaire was completed was 45.6 years (range years); 3,342 (55%) were women. Most (95%) were white and 77% were in paid employment (83% of men and 71% of women). Comparison of the demography of the respondents with that of the 1991 British census (17) showed no major differences (55% women versus 50% and 95% white versus 94%). The proportion of respondents in paid employment (77%) was almost identical to the national average (74.6%) and regional employment rates for the southeast of England (79.8%) (18). In total, 2.6% reported themselves to be diabetic. When answering the postal questionnaire, 3,152 subjects (52%) reported symptoms of pain (lasting 1 day or longer) or dysesthesia (lasting at least 3 minutes) in the past 7 days in the upper limb or neck. Allowing for overlap of symptoms, this corresponded to a 1-week prevalence of 24.1% for neck pain, 36.2% for upper limb pain, and 26.9% for sensory symptoms. Altogether, 1,960 symptomatic individuals (62%) attended the interview and examination. Those who attended did not differ importantly by age, sex, prevalence of diabetes mellitus (3.0% versus 2.6%), or pattern of symptoms (neck pain 55% versus 57%; shoulder pain 48% versus 43%; elbow pain 24% versus 24%; wrist or hand pain 47% versus 50%) from those who were invited but did not come forward. Table 1 summarizes the estimated prevalence rates of specific soft-tissue musculoskeletal disorders and regional nonspecific pain in the neck and upper limbs among men and women from the general population. The most prevalent specific disorders according to the diagnostic schedule were adhesive capsulitis (an estimated 8.2% of men and 10.1% of women) and rotator cuff tendinitis (4.5% of men and 6.1% of women). In contrast, the estimated prevalence rates for osteoarthritis in the digits were all 5%, and the prevalence rates for carpal tunnel syndrome, medial epicondylitis, and de Quervain s tenosynovitis were all 1.5%. The estimated age- and sex-specific prevalence rates for upper limb disorders in the general population are illustrated in Figure 2. Among men, the prevalence of nonspecific pain at each regional site tended to increase with age. In contrast, the prevalence of nonspecific shoulder and elbow pain among women peaked in the year age stratum. Although there was a general tendency for specific disorders to become more common with advancing

3 644 Walker-Bone et al Figure 1. An algorithm of the study design and response rates. age, the prevalence of lateral epicondylitis peaked during midlife (aged years). Furthermore, lateral epicondylitis was the only specific disorder that was more prevalent among men than women. The pairwise association between specific diagnoses within shoulders is shown in Table 2. We observed considerable overlap: for example, 205 of the 410 shoulders that fulfilled the criteria for adhesive capsulitis also met the criteria for rotator cuff tendinitis; and among 28 shoulders in which bicipital tendinitis was diagnosed, 23 also fulfilled diagnostic criteria for adhesive capsulitis and 16 for rotator cuff tendinitis. Because of this substantial overlap of specific shoulder disorders as defined by our criteria, in subsequent analyses we grouped them into a single diagnostic category. Thus, a total of 365 individuals had 1 or more specific shoulder disorder.

4 Prevalence of Upper Limb Musculoskeletal Disorders 645 Table 1. Upper limb diagnoses in those examined and estimated prevalence of these diagnoses in the general population* Men (n 2,696) Women (n 3,342) Diagnosis No. of cases in sample (n 777) Prevalence (%) in general population No. of cases in sample (n 1,183) Prevalence (%) in general population Shoulder Adhesive capsulitis Rotator cuff tendinitis Bicipital tendinitis Subacromial bursitis AC joint dysfunction Any of these specific shoulder disorders Nonspecific shoulder pain Elbow Lateral epicondylitis Medial epicondylitis Any epicondylitis Nonspecific elbow pain Wrist de Quervain s disease Tenosynovitis of the wrist Carpal tunnel syndrome Any of these specific wrist/hand disorders Nonspecific wrist/hand pain Painful osteoarthritis, DIP joint Painful osteoarthritis, thumb base *AC acromioclavicular; DIP distal interphalangeal. A person was classed as a case if the diagnoses was made in one or both arms. Assuming that those who responded to the questionnaire and attended for examination were representative (see text). Table 3 shows the pairwise association between specific diagnoses at different anatomic sites of the upper limb within the same individual. The risk of medial epicondylitis was much higher in the presence of lateral epicondylitis (OR 30.8, 95% confidence interval [95% CI] ) and tenosynovitis of the wrist overlapped strongly with de Quervain s disease (OR 40.1, 95% CI ). Moreover, individuals with painful osteoarthritis of the thumb base carried an increased risk of painful osteoarthritis of the DIP joints (OR 9.7, 95% CI ). Table 4 compares the observed and expected prevalence of multiple diagnoses within the same individuals. The occurrence of an isolated specific disorder was less common than expected given the underlying prevalence rates of each disorder (observed:expected [O:E] ratio 0.89). In contrast, more subjects than expected had multiple diagnoses. Thus, the O:E ratio for 3 diagnoses occurring in the same individual was 5.0. Because the diagnostic criteria for many of the specific disorders included pain and tenderness, we hypothesized that the observed clustering of specific diagnoses might be explained, at least partly, by comorbidity with fibromyalgia syndrome. In total, 37 subjects (1.9% of interviewees) had tenderness at 11 of 18 of the fibromyalgia tender spots proposed by the American College of Rheumatology (19). The diagnostic classification of the 37 subjects was as follows: 15 of them were among the 1,467 who had no specific diagnosis; 10 were among the 427 with 1 specific diagnosis; 10 were among the 60 with 2 diagnoses; and the remaining 2 were among the 6 subjects who fulfilled criteria for 3 diagnoses. Table 5 sets out the proportion of subjects whose symptoms impaired physical function or led them to seek health care, according to anatomic site and diagnosis. Specific disorders were more commonly reported to be disabling than nonspecific pain at all of the upper limb sites. For example, 11.5% of individuals with specific shoulder disorders found it impossible to carry shopping bags, as compared with 6.1% of those with nonspecific shoulder pain; and 28.3% of those with wrist or de Quervain s tenosynovitis reported difficulty with undoing lids, as compared with only 16.3% of those with nonspecific wrist pain. Individuals classified as having specific upper limb disorders were significantly more likely than those with nonspecific pain to have seen a physician, received an injection, or been prescribed medication. In contrast, there were no significant differences between the 2 groups in the use of self-prescribed medication. DISCUSSION This study supports other investigations in finding that upper limb pain is common among adults in the general population (20 25). Furthermore, when a predefined diagnostic algorithm was applied to data from a structured physical examination, the prevalence of specific disorders (44.8%) relative to nonspecific regional arm pain (24.7%) was high. Site-specific prevalence rates were as follows: shoulder tendinitis 4.5% among men and 6.1% among women; adhesive capsulitis 8.2% among men and 10.1% among women; lateral epicondylitis 1.3% among men and 1.1% among women; de Quervain s disease 0.5% among men and 1.3% among women; other tenosynovitis of the

5 646 Walker-Bone et al Figure 2. The estimated prevalence in the general population of specific disorders and nonspecific pain by age and sex at the shoulder, elbow, and wrist or hand. hand or wrist 1.1% among men and 2.2% among women. Specific disorders tended to cluster within individuals more often than would be expected by chance, and they were associated with greater disability and more use of health services than was nonspecific pain. The criteria by which we classified upper limb disorders in this study evolved from a consensus that was established at a specially convened multidisciplinary workshop (10), and they had demonstrable face validity when tested against diagnoses made by clinicians (13). However, ex-

6 Prevalence of Upper Limb Musculoskeletal Disorders 647 Table 2. Pairwise overlap of specific shoulder diagnoses for the 3,920 shoulders that were examined among the 1,960 interviewees* Adhesive capsulitis (n 410) Rotator cuff tendinitis (n 228) Bicipital tendinitis (n 28) Subacromial bursitis (n 42) Rotator cuff tendinitis (n 228) 205 (232.9) Bicipital tendinitis (n 28) 23 (69.1) 16 (23.1) Subacromial bursitis (n 42) 35 (65.1) 20 (17.6) 2 (7.8) Acromioclavicular joint disorder (n 43) 40 (188.6) 28 (34.2) 1 (3.4) 1 (2.3) * The figures in the body of the table indicate the number of shoulders in which both of a pair of diagnoses was made. Age- and sex-adjusted odds ratios for the pairwise association between diagnoses are given in parentheses. pert opinion, although a useful starting point for systems of diagnosis, cannot necessarily be regarded as a gold standard, and ultimately the validity of a diagnostic classification depends on its practical utility in the prevention and management of illness. We intend to address this issue further in future articles that will compare diagnostic categories according to their associations with risk factors (do they distinguish groups of patients whose illness differs in its causation?) and prognosis (differences that might indicate a need for different clinical management). Meanwhile, however, the current analysis shows the frequency and interrelation of disorders when classified in a way that accords broadly with current clinical practice in the UK. An important consideration when interpreting our observations is the potential for bias from incomplete participation of subjects who were eligible for study. The 62% response rate at each of the 2 sampling stages was comparable to that in other recent community-based surveys in the UK (23). Furthermore, the subjects who attended interview and examination had a similar profile of symptoms to those who were invited but declined (26). The population samples were derived from the complete general practice listings of working-aged adults registered with 2 practices in Southampton. The practices were selected so as to represent diverse socioeconomic backgrounds (blue collar and white collar), but were not specifically chosen to sample any particular occupational activities. The demographic characteristics of respondents to both stages of the survey closely resembled those of the British population (17,18). Our estimates of prevalence for the specific disorders are generally similar to those available from limited international literature. For example, the point prevalence of epicondylitis was 2 5% in year olds from the general population of Stockholm (1), and 2% in aeroengineers from the US (27) similar to our estimate of % in a population of working age people. A point prevalence of tenosynovitis of 3.5% has been estimated in male American textile workers aged years (28), as compared with our estimates of % for tenosynovitis of the wrist and % for de Quervain s disease. In community surveys from the Netherlands (29) and Sweden (30), the prevalence of carpal tunnel syndrome in men age years was % as compared with our estimate of %. In keeping with the survey from Stockholm (1) and other observations (31,32), we found that the prevalence of specific disorders tended to rise with age. Our estimate for the prevalence of adhesive capsulitis is higher than quoted in some textbooks (33). There are rather few community-based data on discrete shoulder disorders with which to compare, but in 1 survey of older subjects from Cambridge UK, a prevalence of 15% was reported for Table 3. Pairwise overlap of specific diagnoses among the 1,960 interviewees* Any shoulder diagnosis (n 365) Lateral epicondylitis (n 45) Medial epicondylitis (n 34) de Quervain s disease (n 39) Tenosynovitis (n 69) Painful OA DIP joints (n 85) Painful OA thumb base (n 151) Carpal tunnel syndrome (n 38) Lateral epicondylitis 14 (3.6) Medial epicondylitis 10 (3.3) 9 (30.8) de Quervain s 18 (6.8) 6 (14.3) 3 (8.3) disease Tenosynovitis of the 25 (4.6) 9 (12.9) 5 (8.4) 16 (40.1) wrist Painful osteoarthritis 21 (2.6) 2 (1.7) 6 (8.2) 8 (10.2) 8 (5.1) of the DIP joints Painful osteoarthritis 44 (3.4) 11 (6.9) 11 (10.2) 25 (42.3) 35 (26.3) 25 (9.7) of the thumb base Carpal tunnel syndrome 8 (2.1) 0 1 (2.5) 1 (2.2) 0 1 (1.0) 5 (3.1) * The figures in the body of the table indicate the number of individuals in whom both of a pair of diagnoses was made. Age- and sex-adjusted odds ratios for the pairwise association between diagnoses are given in parentheses. OA osteoarthritis; DIP distal interphalangeal.

7 648 Walker-Bone et al Table 4. Observed and expected numbers of interviewees according to the number of specific diagnoses made Number of specific diagnoses* Observed count Expected count Ratio of observed: expected 0 1,467 1, * Out of a total of 4 possible diagnostic categories: any specific shoulder disorder, epicondylitis, de Quervain s disease or tenosynovitis, and carpal tunnel syndrome. The method of deriving expected counts is described in the text. pain in the shoulder accompanied by pain on resisted abduction, external rotation, or internal rotation (2). We based the diagnosis of carpal tunnel syndrome on clinical features rather than neurophysiologic testing. Such a case definition may lead to a higher estimate of prevalence than the stricter criteria often employed in case management; but it is in keeping with the case definitions based on symptoms and signs that are often used in field epidemiology (4,5,32). With the case definitions that we employed, we found a high degree of overlap between specific disorders of the shoulder. Other investigators have also encountered difficulty in identifying clinical findings that differentiate pathology of one structure in the shoulder from another (33 35). This could be because different pathologies often coexist at this anatomic site, either as a consequence of shared causes, or because the presence of one disorder predisposes to another. Indeed, in the original (1934) description of adhesive capsulitis, Codman (36) proposed that the initiating lesion was almost always a localized supraspinatus tendinitis, although this view has since been disputed (37) and other hypotheses advanced (38). In one arthroscopic study, there was wide variation in the histologic findings among 150 individuals who had been assigned a diagnosis of adhesive capsulitis (39). However, it is also possible that our clinical assessment was not sufficiently discriminatory. We think it unlikely that this would have occurred through poor execution of the examination protocol. The nurses who conducted the examinations were subject to rigorous periodic checks, and the reliability of their performance was acceptable when formally tested (12,13). Furthermore, the face validity of the nurse examinations was excellent when compared with the diagnoses of hospital physicians (e.g., for a diagnosis of adhesive capsulitis, sensitivity was 87% and specificity 90% and for rotator cuff tendinitis, sensitivity was 58% but specificity was 84%) (13). Even after allowance for the problems in classification of shoulder complaints, we observed marked clustering of specific upper limb disorders within individuals. Exam- Table 5. Relative impact on daily activities and health-seeking behavior of specific disorders and nonspecific pain at the corresponding anatomic site* Shoulder Elbow Wrist/hand Any specific disorder (n 365) Nonspecific pain (n 82) Epicondylitis (n 70) Nonspecific pain (n 179) De Quervain s or wrist tenosypovitis (n 92) Carpal tunnel syndrome (n 38) Nonspecific pain (n 270) Impossible to Sleep Drive Carry bags Dress Open doors Get things down from shelf Fasten clothes Do heavy jobs Write Undo lids on bottles/jars Fasten/unfasten zippers Consulted Doctor Other health care professional Had injection Took Prescribed drugs Self-prescribed drugs * The figures in the body of the table represent the proportion (%) of subjects in each diagnostic group who reported the disability, consulted, or took medication because of pain at the relevant anatomic site during the post 12 months. If data is missing, the question was not asked. P 0.05 in comparison with nonspecific pain at the same anatomic site. Physiotherapist, chiropractor, or osteopath.

8 Prevalence of Upper Limb Musculoskeletal Disorders 649 ples of such clustering have been reported before (40 45). One explanation for this observation is that some individuals have a generally lower threshold for reporting pain and tenderness on examination. In support of this, subjects with 2 or more specific diagnoses were more likely to satisfy diagnostic criteria for fibromyalgia (12 of 66 as compared with 25 of 1,894). However, such cases constituted a minority (18%) of those with multiple specific diagnoses, and accounted for only a small part of the clustering. Another possibility is that some people have an increased predisposition to soft-tissue rheumatism at multiple sites. This might occur, for example, because of a constitutional diathesis, because some physical activities impose hazardous mechanical stresses at several sites in the arm, or because the presence of one disorder can disturb the mechanical function of the upper limb in a way that promotes the development of others. In keeping with the findings of others (46), we found upper limb disorders to be disabling. Subjects in whom we diagnosed specific disorders reported greater interference with everyday activities, and had more commonly sought and received treatment for their symptoms. Thus, 48% of subjects with tenosynovitis of the wrist had consulted their primary care physician over the previous 12 months, as compared with 31% of those with nonspecific wrist or hand pain. No patients with nonspecific shoulder pain had received intraarticular injections, but 9% of those with specific disorders had required such treatment. Twenty percent of individuals with epicondylitis reported difficulty with carrying bags, as compared with 5.6% of those with nonspecific elbow pain. Taken together, these results suggest a considerable burden of functional disability and healthcare utilization among working-age adults. In conclusion, our data show that 36% of men and women report upper limb pain in any given week and that 45% of these have evidence of a specific soft-tissue disorder, according to criteria of the type that are currently applied in clinical practice in the UK. These disorders are associated with considerable morbidity in the general population and have a substantial social impact in terms of consumption of health care resources (47) and lost time from work (8), highlighting the importance of appropriate evaluation and treatment. ACKNOWLEDGMENTS We are grateful to Dr. Cathy Linaker, Mrs. Trish Byng, Mrs. Angie Shipp, Mrs. Claire Ryall, and Mrs. Karen Collins who helped conduct the interviews and examinations; to Vanessa Cox and Ken Cox for computer support; and to the staff at the MRC Unit, Southampton who assisted in data handling and the typing of this report. REFERENCES 1. Allander E. Prevalence, incidence and remission rates of some rheumatic diseases and syndromes. Scand J Rheumatol 1974; 3: Chard MD, Hazelman R, Hazelman BL, King RH, Reiss BB. Shoulder disorders in the elderly: a community survey. Arthritis Rheum 1991;34: Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and their associated disability. Am J Public Health 1984;74: Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in the general population. JAMA 1999;282: De Krom M, Knipschild PG, Kester ADM, Thus CT, Boekkooi PF, Spaans F. Carpal tunnel syndrome: prevalence in the general population. J Clin Epidemiol 1992;45: Ferry S, Silman A, Pritchard T, Keenan J, Croft P. The association between different patterns of hand symptoms and objective evidence of median nerve compression. Arthritis Rheum 1998;41: Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic neck pain in a geographically defined general population: studies of differences in age, gender, social class and pain localisation. Clin J Pain 1993;9: Jones JR, Hodgson JT, Clegg TA. Self-reported work-related illness in Norwich (UK): HMSO; Bernard BP, editor. Musculoskeletal disorders (MSDs) and workplace factors. Cincinnati (OH): US Department of Health and Human Services; Harrington JM, Carter JT, Birrell L, Gompertz D. Surveillance case definitions for work related upper limb pain syndromes. Occup Environ Med 1998;55: Walker-Bone K, Palmer K, Reading I, Cooper C. Criteria for assessing pain and non-articular soft tissue rheumatic disorders of the neck and upper limb. Semin Arthritis Rheum 2003;33: Walker-Bone K, Byng P, Linaker C, Reading I, Coggon D, Palmer KT, et al. Reliability of the Southampton examination schedule for the diagnosis of upper limb disorders in the general population. Ann Rheum Dis 2002;61: Palmer KT, Walker-Bone K, Linaker C, Reading I, Kellingray S, Coggon D, et al. The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the neck and upper limb. Ann Rheum Dis 2000;59: Pope D, Croft P. Surveys using general practice registers: who are the non-responders? J Public Health Med 1996;18: Kuorinka I, Jonsson BG, Kilbom A, Vinterberg H, Biering- Sorensen F, Andersson G, et al. Standardised Nordic questionnaire for the analysis of musculoskeletal symptoms. Appl Ergon 1987;18: Palmer KT, Smith G, Kellingray S, Cooper C. Repeatability and validity of the upper limb and neck discomfort questionnaire: the utility of the standardised Nordic questionnaire. Occup Med 1999;49: Office of National Population Statistics British national census data. London: HMSO; 18. Office of National Population Statistics. National labour force survey. London: HMSO; Wolfe F, Smythe H, Yunus M, Bennett R, Bombardier C, Goldenberg D. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum 1990;33: Lawrence JS. Disc degeneration: its frequency and relationship to symptoms. Ann Rheum Dis 1969;28: Takala J, Sievers K, Klaukka T. Rheumatic symptoms in the middle-aged population in south-western Finland. Scand J Rheumatol 1982;47 Suppl: Jacobsson L, Lindgarde F, Manthorpe R. The commonest rheumatic complaints of over six weeks duration in a twelvemonth period in a defined Swedish population. Scan J Rheumatol 1989;18: Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites. Ann Rheum Dis 1998;57: Bergenudd H, Lindgarde F, Nilsson B, Petersson CJ. Shoulder pain in middle age. Clin Orthop 1988;231: Pope D, Croft P, Pritchard CM, Silman A. Prevalence of shoulder pain in the community: the influence of case definition. Ann Rheum Dis 1997;56: Walker-Bone K. Prevalence of and risk factors for musculoskeletal disorders of the neck and upper limb [Thesis]. Southampton, UK: Southampton Univ.; Dimberg L. The prevalence and causation of tennis elbow

9 650 Walker-Bone et al (lateral humeral epicondylitis) in a population of workers in an engineering industry. Ergonomics 1987;30: McCormack RR, Inman RD, Wells A, Berntsen C, Imbus HR. Prevalence of tendinitis and related disorders of the upper extremity in a manufactering workforce. J Rheumatol 1990;17: Hamilton PG. The prevalence of humeral epicondylitis: a survey in general practice. J Royal Coll Gen Pract 1986;36: Moore JS. De Quervain s tenosynovitis. J Occup Environ Med 1997;39: Lundberg BJ. The frozen shoulder. Acta Orthop Scand 1969; 119: Rempel D, Evanoff B, Amadio PC, de Krom M, Franklin G, Franzblau A, et al. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. Am J Public Health 1998;88: Sobel JS, Winters JC, Arendzen JH, Groenier KH, Meyboom-de Jong D. Schouderklachten in de huisartspraktijk [Shoulder complaints in general practice]. Huisarts Wet 1995;38: Winters JC, Groenier KH, Sobel JS, Arendzen JH, Meyboom-de Jong D. Classification of shoulder complaints in general practice by means of cluster analysis. Arch Phys Med Rehabil 1997;78: Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoulder: can consultants agree? Br J Rheumatol 1996;35: Codman EA. The shoulder. Boston: Todd; Cyriax JH. Diagnosis of soft tissue lesions. In: Textbook of orthopaedic medicine. London: Bailliere Tindall; Bunker TD. Frozen shoulder: unravelling the enigma. Ann R Coll Surg Engl 1997;79: Wiley AM. Arthroscopic appearance of frozen shoulder. Arthroscopy 1993;7: Lipscomb PR. Tenosynovitis of the hand and wrist: carpal tunnel syndrome, de Quervain s disease, trigger digit. Clin Orthop 1959;13: Conklin JE, White WL. Stenosing tenosynovitis and its possible relation to carpal tunnel syndrome. Surg Clin North Am 1960;40: Griggs SE, Weiss APC, Lane LB, Schwenker C, Akelman E, Sachar K. Treatment of trigger finger in patients with diabetes mellitus. J Hand Surg 1995;20-A: Gray RG, Gottlieb NL. Rheumatic disorders associated with diabetes mellitus: literature review. Semin Arthritis Rheum 1976;6: Gudmundsson KG, Arngrimsson R, Sigfusson N, Bjornsson A JT. Epidemiology of Dupuytren s disease: clinical, serological and social assessment: the Reykjavik Study. J Clin Epidemiol 2000;53: Noble J, Heathcote JG, Cohen H. Diabetes mellitus in the aetiology of Dupuytren s disease. J Bone Joint Surg Br 1984; 66: Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. BMJ 1996;313: Van der Windt D, Koes B/W, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics and management. Ann Rheum Dis 1995;54: APPENDIX A: DIAGNOSTIC CRITERIA FOR THE SOUTHAMPTON EXAMINATION PROTOCOL* Soft tissue upper limb disorder Adhesive capsulitis Rotator cuff tendinitis Bicipital tendinitis Lateral epicondylitis Medial epicondylitis Tenosynovitis of the hand/wrist Diagnostic criteria proposed by the HSE consensus group (ref. 10) History of pain in the deltoid area and equal restriction of active and passive glenohumeral movement with capsular pattern (external rotation abduction internal rotation) History of pain in the deltoid region and pain on resisted active movement (abduction - supraspinatus; external rotation - infraspinatus; internal rotation - subscapularis) History of anterior shoulder pain and pain on resisted active flexion or supination of the forearm Epicondylar pain and epicondylar tenderness and pain on resisted extension of the wrist Epicondylar pain and epicondylar tenderness and pain on resisted flexion of the wrist Pain on movement localized to the tendon sheaths in the wrist and reproduction of pain by resisted active movement The Southampton examination protocol diagnostic criteria 1) Pain lasting one day or longer in the past 7 days in the shoulder region and 2) Restriction of active and passive movements for at least one of abduction, or external rotation, or internal rotation. (Cut points: 140 for abduction; 70 for external rotation, 90 for internal rotation) 1) Pain lasting one day or longer in the past 7 days in the shoulder region and 2) Pain induced by resisted active motion in at least one of external rotation, internal rotation, abduction or positive painful arc. 1) Pain lasting one day or longer in the past 7 days in the anterior region of the shoulder and 2) Pain occurring in the anterior shoulder region on performance of Speed s test or Yergason s test 1) Pain lasting one day or longer in the last 7 days in the lateral elbow region and 2) Tenderness over the lateral elbow region and 3) Pain occurring over the lateral elbow region during resisted active extension of the wrist 1) Pain lasting one day or longer in the last 7 days in the medial elbow region and 2) Tenderness over the medial elbow region and 3) Pain occurring over the medial elbow region during resisted active flexion of the wrist 1) Pain lasting one day or longer in the last 7 days over the dorsal aspect of the wrist plus pain occurring over the dorsal aspect of the wrist on resisted extension of the fingers 2) Pain lasting a day or longer in the last 7 days over the palmar aspect of the wrist plus pain occurring over the palmar aspect of the wrist on resisted flexion of the fingers (continued)

10 Prevalence of Upper Limb Musculoskeletal Disorders 651 APPENDIX A: DIAGNOSTIC CRITERIA FOR THE SOUTHAMPTON EXAMINATION PROTOCOL (Continued) Soft tissue upper limb disorder Diagnostic criteria proposed by the HSE consensus group (ref. 10) The Southampton examination protocol diagnostic criteria de Quervain s disease Carpal tunnel syndrome Nonspecific arm pain Acromioclavicular (AC) joint dysfunction Pain over the radial styloid and tender swelling of the first extensor compartment and either pain reproduced by resisted thumb extension or positive Finkelstein s test result Pain or paraesthesia or sensory loss in the median nerve distribution and one of. Tinel s test positive, Phalen s test positive, nocturnal exacerbation of symptoms, motor loss with wasting of abductor pollicis brevis, abnormal nerve conduction time Pain in the arm in the absence of a specific diagnosis or pathology (sometimes includes: loss of function, weakness, cramp, muscle tenderness, allodynia, slowing of fine movement) N/A 3) Pain lasting a day or longer during the last 7 days over the medial aspect of the wrist plus pain occurring over the medial aspect of the wrist during resisted medial movement of the wrist 4) Pain lasting a day or longer in the last 7 days over the radial aspect of the wrist plus pain occurring over the radial aspect during resisted radial movement of the wrist in the absence of a diagnosis of de Quervain s disease at the same wrist 1) Pain lasting a day or longer in the last 7 days over the radial aspect of the wrist and 2) Tenderness over the radial aspect of the wrist, and 3) Pain occurring over the radial aspect of the wrist during resisted extension of the thumb or a positive Finkelstein s test result 1) Sensory disturbance occurring in the hand for at least 3 minutes in the last 7 days in the median nerve distribution of a Katz hand diagram or sensory disturbance affecting light touch in the thumb or index finger, but not the little finger, plus 2) Either, Tinel s test positive, Phalen s test positive, motor loss (defined as wasting of the thenar eminence, weakness of thumb abduction or weakness of thumb opposition), or sleep disturbed by symptoms of sensory disturbance in the hand lasting at least 3 minutes during the last 7 days 1) Pain lasting a day or longer in the last 7 days at the shoulder, elbow or wrist/hand and 2) that does not fulfill criteria for any of the specific disorders at the appropriate anatomic site 1) Pain lasting a day or longer in the last 7 days over the AC joint region and 2) Tenderness over the AC joint region and 3) A positive AC stress test result Subacromial bursitis N/A 1) Pain lasting a day or longer in the last 7 days over the subacromial bursa and 2) Tenderness over the subacromial bursa Painful osteoarthritis of the DIP joints Painful osteoarthritis of the thumbbase Fibromyalgia syndrome N/A N/A N/A * HSE Health and Safety Executive; N/A not applicable; DIP distal interphalangeal. 1) Pain lasting a day or longer in the last 7 days in the fingers and 2) Clinical evidence of Heberden s nodes 1) Pain lasting a day or longer in the last 7 days localised to the thumb base and 2) Tenderness at the thumb base 1) More than 11 of 18 fibromyalgia tender spots touch positive.