Occupational Medicine 2009;59:44–52

Published online 10 December 2008 doi:10.1093/occmed/kqn151

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

...................................................................................................................................................................................

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

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 in-
formation was synthesized into high-level evidence statements, which were ordered into themes cov-
ering classification/diagnosis, epidemiology, associations/risks and management/treatment, focusing
on return to work or work retention and taking account of distinctions between non-specific com-
plaints 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 mes-
sages can contribute to the needed cultural shift.
...................................................................................................................................................................................

Key words Biopsychosocial; interventions; return to work; upper limb disorders; work relevant.
...................................................................................................................................................................................

Introduction manifesting at work can be prevented [2], there is a need

to determine effective approaches for managing those
This paper reports on a literature review commissioned
cases that do occur.
by the UK Health & Safety Executive. The present article
ULDs are characterized by symptoms (usually pain)
is an abridged version of the original report entitled ‘Man-
which have inconsistent associations with work loss and
agement of upper limb disorders and the biopsychosocial
disability. While there is evidence that MSDs in general,
model’ [1].
Acknowledging that musculoskeletal disorders like other common health problems, have a strong asso-
(MSDs) are responsible for a considerable proportion ciation with psychosocial factors [3], it is uncertain to
of work loss and that not all upper limb disorders (ULDs) what extent that holds true specifically for ULDs.
This review aimed to establish the extent to which the
1
Centre for Health and Social Care Research, University of Huddersfield, UK.
scientific evidence supports management of ULDs accord-
2
ing to the biopsychosocial model. In particular, the objec-
Health Services Consultancy, Surbiton, UK.
3
tive was to draw conclusions on the question of whether
Humane Technology Limited, Rothley, UK.
4
there is evidence that the biopsychosocial model can be
Institute of Occupational Medicine, Edinburgh, UK.
successfully applied to the management of ULDs and to
5
Pulvertaft Hand Centre, Derbyshire Royal Infirmary, Derby, UK.
provide evidence-based, high-level messages about what
Correspondence to: A. Kim Burton, Centre for Health and Social Care Research,
University of Huddersfield, 30 Queen Street, Huddersfield HD1 2SP, UK. Tel:
should be done to help people with ULDs recover quickly
144 1484 535200; fax: 144 1484 435744; e-mail: [email protected] and achieve sustained return to work.

The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: [email protected]
 A. K. BURTON ET AL.: MANAGEMENT OF WORK-RELEVANT UPPER LIMB DISORDERS 45

Methods Table 1. Evidence grading system used to rate the strength of the
scientific evidence underlying the evidence statements (adapted
The overall methodology should be viewed as a ‘best evi- from [5])
dence synthesis’, summarizing the available literature and
drawing conclusions about the balance of evidence, based Evidence grade Definition
on its quality, quantity and consistency [4]. This approach
offers the flexibility needed to handle complex topics, but *** Strong Generally, consistent findings provided
by (systematic reviews of) multiple
at the same time takes a rigorous approach when it came scientific studies.
to assessing the strength of the scientific evidence. A more ** Moderate Generally consistent findings provided
detailed description is in the original report [1]. by (reviews of) fewer and/or lower
An electronic search of the major electronic databases quality scientific studies.
was conducted in June 2007, limited to articles published * Weak Based on a single scientific study,

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

general consensus and guidance
from 1996 onwards. It included search strings with all rel- or inconsistent findings provided
evant keywords that might include the wide range of terms by (reviews of) multiple scientific
used to describe upper limb conditions in working-age studies.
adults. The main search was supplemented with citation
tracking and hand searching to identify non-indexed ma-
terial and relevant grey literature (grey literature includes The first set of statements concern the extent to which
conference proceedings, dissertations, theses, clinical trials ULDs can be classified and recognized; exploration of de-
registries and other reports). To maintain focus on occu- tailed diagnostic criteria was beyond the scope of the re-
pationally relevant disorders, some conditions and topics, view (Box 1).
such as rheumatic and systemic diseases, fractures and dis- Nosological inconsistencies have led to debate and un-
orders of peripheral circulation were excluded. certainty over issues from pathology to causation [12]. It is
Systematic reviews and extensive narrative reviews likely that misdiagnoses will be common both in the clinic
were the primary focus, but individual studies were se- and in the workplace [8], frequently manifested as patients
lected where they provided additional or more detailed receiving multiple and conflicting explanations and diag-
information. Once a potential pool of articles and studies nostic labels from the various clinicians they encounter.
was identified, the titles and abstracts were circulated While it is possible to achieve expert consensus on cri-
among three reviewers (K.B., N.A.S.K., B.G.P.), who de- teria for case definitions suitable for occupational surveil-
cided by consensus which full articles to select for possible lance systems, the clinical validity of the classifications is
inclusion in the review. Copies of some 200 relevant uncertain [20,21], and it is unknown if they lead to im-
articles were obtained, circulated, analysed and archived. proved clinical management.
Summary data from included articles were entered in- A considerable number of the articles retrieved for the
to detailed evidence tables, which accompany the original present review take a ‘lumping’ approach whereby studies
report [1]. Themes in the data were identified and orga- will include a variety of different disorders under labels
nized to cover three main categories: epidemiology/risk such as ‘work-related upper limb disorder’ or simply
factors, intervention/classification and concepts/guidance. ‘musculoskeletal disorders’. However, that is not a univer-
The information was synthesized into high-level evidence sal view, and some researchers point to the possibility of
statements, each linked to the supporting evidence, with specific neuropathic pathologies underlying what is often
the final wording of the evidence statements developed termed non-specific arm pain, ‘cumulative trauma disor-
through an iterative process involving all five reviewers. Fi- ders’ or ‘repetitive strain injuries’ [22]. An alternative util-
nally, the information contained within the evidence state- itarian approach is that the optimal definition for
ments was distilled into a number of key messages related a disorder may vary according to the circumstances in
to evidence-based management of work-relevant ULDs. which it is applied [23].
The strength of the scientific evidence supporting the The epidemiology of ULDs is essential to understand-
statements was graded using the system in Table 1. The ing how they arise, in whom, and to inform on their nat-
strength of the evidence should be distinguished from the ural history (Box 2). There is a cascade in the way they are
size of the effect: there may be strong evidence about experienced and expressed, which is similar to that noted
a particular association, yet the effect size may be small. for other musculoskeletal problems such as back pain:
a clear distinction should be made between the presence
Results of symptoms, the reporting of symptoms, attributing
symptoms to work, seeking health care, loss of time from
The findings of the review are presented in the form of high- work and long-term damage, which may all have rather
level ‘evidence statements’ as a convenient way of summariz- different determinants [24].
ing knowledge across complex themes, with each statement The issue of risk factors for ULDs is clearly highly rel-
being linked to the main supportive sources of evidence. evant to the concept of preventing onset of symptoms or
46 OCCUPATIONAL MEDICINE

Box 1. Classification and diagnosis Box 3. Associations and risks

*** Classification and diagnosis of ULDs is particu- ** Large-scale influential reviews published
larly problematic; there is a lack of agreement on around the turn of the millennium (which in-
diagnostic criteria, even for the more common cluded much cross-sectional data) concluded
specific diagnoses (e.g. tenosynovitis, epicondyli- that there were strong associations between bio-
tis and rotator cuff syndrome). Inconsistent ap- mechanical occupational stressors (e.g. repeti-
plication, both in the clinic and in the tion, force) and ULDs: backed by plausible
workplace, leads to misdiagnosis, incorrect label- mechanisms from the biomechanics literature,
ling and difficulties in interpretation of research the association was generally considered to be
findings [6–12]. causative, particularly for prolonged or multiple

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

** The scientific basis for descriptive classification exposures (though a dose–response relationship
terms implying a uniform aetiology, such as re- generally was not evident) [38–40].
petitive strain injuries and cumulative trauma *** More recent epidemiological studies involving
disorders, is weak or absent and they are incon- longitudinal designs also suggest an association
sistently applied/understood; there is an argu- between physical exposures and development of
ment that such terms should be avoided [13–19]. ULDs, but they report the effect size to be
rather modest and largely confined to intense
exposures. The predominant outcome investi-
gated (primary causation, symptom expression
Box 2. Epidemiology or symptom modification) is inconsistent across
studies and remains a subject of debate. This is
*** There is a very high background prevalence of true for regional complaints and (with few ex-
upper limb pain and neck symptoms in the gen- ceptions [41]) most of the specific diagnoses
eral population: the 1-week prevalence in general [26,28,36,41–47].
population can be as high as 50%. Estimates of * The evidence that cumulative exposure to typ-
the prevalence rates of specific diagnoses are less ical (modern) work is the cause of most reported
precise, but are considerably lower than for non- upper limb injury is limited and inconsistent
specific complaints. Rates vary depending on re- [19,38,48,49].
gion, population, country, case definition and on *** Workplace psychosocial factors (beliefs, percep-
the question asked [6,25–33]. tions and work organization) have consistently
** Upper limb pain is often recurrent and frequently been found to be associated with various aspects
experienced in more than one region at the same of ULDs, including symptom expression, care
time (both bilaterally and at anatomically adja- seeking, sickness absence and disability
cent sites) [19,29–31]. [19,26,38,40,42,50–55].
*** ULDs often lead to difficulty with normal activ- *** Individual psychological factors (such as anxi-
ities and to sickness absence, yet most workers ety, distress and depression) have consistently
with ULDs can and do remain at work been found to be associated with various aspects
[29,31,34,35]. of ULDs, including symptom expression, care
seeking, sickness absence and disability
[40,48,56–59].
injury, but the subject is poorly understood and inconsis-
tently documented (Box 3). Many factors, both occupa-
tional and personal, are purported to be ‘risk factors’, but specific diseases [41], yet these diseases account for a rela-
the nature of those risks and their potential outcomes are tively small proportion of all ULDs. Many non-specific up-
readily misunderstood. This is evident in the high levels of per limb symptoms are likely to result from some physical
growth in disability and work loss associated with muscu- stress across joints and in soft tissues, but work is not the
loskeletal pain over the very period when industrialized exclusive (or necessarily most important) source of such
countries have implemented occupational safety and stress. There is emerging evidence that a combination of
health legislation and developed inspectorates for compli- exposure to physical and psychosocial factors at work
ance and enforcement [36,37]. Thus, further consider- has a stronger association than either type of factor alone
ation of the evidence on risk factors is needed to [55,60]. By and large, the duration of exposure has been
permit robust conclusions. inconsistently reported across the epidemiological litera-
There is no doubt that certain jobs can legitimately be ture, so attributing upper limb complaints to cumulative ex-
considered to entail hazards that are, on the balance of posure is by no means fully justified. Of interest in this
probabilities, risk factors for the development of certain respect is that one of the strongest predictors of incident
 A. K. BURTON ET AL.: MANAGEMENT OF WORK-RELEVANT UPPER LIMB DISORDERS 47

upper limb symptoms among workers can be a prior history The bulk of the literature reporting on the manage-
of symptoms, as opposed to work exposures such as repet- ment of ULDs has either concentrated on regional symp-
itiveness, work pace or forceful awkward postures [61]. toms (termed disorders by some investigators) or taken an
In view of the widespread experience of upper limb even wider perspective and combined regional symptoms
symptoms in the community, the patchy nature of asso- (including the upper limb) under generic labels such as
ciations between work characteristics and ULDs (both work-related musculoskeletal disorder. While there seems
non-specific and specific), and the difficulty of establish- to be good reason to separate (some) specific diagnoses
ing cogent occupational causation [62], the often used when making clinical decisions about treatment, there
collective term ‘work related’, seems not altogether accu- is little evidence that the distinction is helpful when con-
rate and potentially misleading. Instead, it seems more sidering vocational outcomes and rehabilitation. It can be
reasonable to refer to ULDs among workers as ‘work rel- argued that returning a hurting worker to their job relies
evant’, which avoids undue occupational attribution and on achieving an acceptable balance between ‘capacity’

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

the notion of permanent impairment yet acknowledges and ‘tolerance’, and this concept is largely independent
that work can be troublesome for people experiencing up- of whether the individual has a specific diagnosis or re-
per limb symptoms, irrespective of cause. gional complaint [85,95].
The retrieved articles on management and treatment Overall, the evidence indicates that effective interven-
covered a wide range of outcomes, clinical presentations tions for work-relevant ULDs require a multimodal ap-
and interventions. The effectiveness of biomedical treat- proach: specific treatment (when needed, using a stepped
ments was outside the scope of the review, but a simple approach) coupled with workplace accommodation (when
‘review of reviews’ indicates that many common treat- needed, on a temporary basis). While lumping and splitting
ments for ULDs are less effective than might be expected. approaches may be helpful under differing circumstances
While some are effective for specific diagnoses (exercise [23], achieving a balance in terminology is likely to be
for rotator cuff tendonitis; oral steroids for shoulder pain
such as impingement syndrome or capsulitis and cortico-
steroid injections for tenosynovitis), effect sizes tend to be
Box 5. Interventions specifically in
small and are limited to clinical outcomes [1].
The retrieved material on management approaches for
respect of ULDs
ULDs tended to reflect a view that there is a commonality ** Pain management programmes using cognitive-
to MSD that justifies considering their management in behavioural principles and multidisciplinary occu-
a generic sense (Box 4). pational rehabilitation for people with ULDs can
In addition to the information concerning MSDs in improve occupational outcomes in the short term
general, the search retrieved studies concerning interven- and significantly reduce sickness absence in the
tions specifically on people with ULDs; specific diagnoses longer term. Earlier intervention appears to yield
were generally included along with non-specific com- better results [71,72].
plaints (Boxes 5–7). * 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].
Box 4. Interventions for MSDs in
** Ergonomic work redesign directed at equipment
general or organization has not been shown to have a sig-
* General management principles are to provide nificant effect on incidence and prevalence rates of
advice that promotes self-management, such as ULDs. Ergonomic interventions can improve
staying active and engaging in productive activity worker comfort (which is valuable) which can in
(with appropriate modifications). Pain modula- principle contribute positively to multimodal in-
tion and control should be directed towards al- terventions [13,15,48,77–80].
lowing appropriate levels of activity [63,64]. * There is limited evidence that ergonomic adjust-
*** Programmes using cognitive–behavioural ap- ments (mouse/keyboard design) can reduce upper
proaches are effective and cost-effective at reduc- limb pain in display screen workers but insufficient
ing pain and increasing productive activity in evidence for equipment interventions among
both the earlier and the later phases [65–67]. manufacturing workers [78,81,82].
* Multimodal integrated interventions that address * In general resting injured upper limbs delays re-
both biomechanical and psychosocial aspects at covery; early activity improves pain and stiffness
the same time should be useful for managing and can speed return to work yet does not increase
musculoskeletal problems in the workplace complications or residual symptoms and may lead
[3,40,68–70]. to less treatment consumption [83–87].
48 OCCUPATIONAL MEDICINE

while some consensus seems possible, diagnostic criteria

Box 6. Return to work remain unreliable—many cases will be mislabelled
* There is wide consensus that early return to work (whether colloquially or by a health care professional).
is an important goal which should be facilitated For many people, their symptoms will be work rele-
by multimodal interventions including provision vant: their work may be painful or difficult irrespective
of accurate information pain relief and encour- of the origin of the symptoms. However, even when work
agement of activity. An integrative approach by is related to the expression of symptoms, that does not
all the players (notably employer worker and mean work was necessarily the underlying cause: it is ap-
health professional) is conceptually a fundamen- parent that work is not the predominant cause of most
tal requirement [14,34,64,66,73,76,85,87–89]. ULD episodes.
** Although the components of return to work in- Many people with ULDs cope without recourse to
health care or need for sick leave, yet a small number

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

terventions vary there is emerging evidence that
integrative approaches can be effective for MSDs of people with ULDs will progress to persistent pain
in general and probably also for ULDs. Case and/or long-term disability, irrespective of severity or di-
management shows promise for getting all the agnosis. This pattern is typical of a wide range of common
players onside. Facilitation of return to work health problems, in which personal and cultural factors
through temporary transitional work arrange- are a predominant feature, notably the psychological
ments (modified work) seems to be an important and social variables that influence beliefs and behaviours
component [64,68–70,89–93]. [3]. Although the evidence is limited for ULDs, knowl-
edge from the literature on other musculoskeletal prob-
lems strongly implicates psychosocial factors as drivers
for symptom reporting, work loss and disability
Box 7. Non-specific complaints and [97,98]. Since there is no particular reason to expect that
complaints and disorders related to the musculoskeletal
specific diagnoses
apparatus of the upper limb and neck are fundamentally
* There is insufficient robust evidence to identify re- different from the musculoskeletal apparatus of the lower
liable prognostic indicators that are applicable back, it is logical and reasonable to surmise that there will
across the ULD spectrum (specific diagnoses be shared influences. Indeed, what evidence there is sup-
and regional complaints) [8,14,27,38,94]. ports psychosocial factors as being important in under-
* There is inconsistent and conflicting evidence on standing and managing ULDs.
whether and to what extent certain specific diagno- Biomedical management of ULDs is seemingly less ef-
ses and regional complaints should be conceived fective than might be expected, perhaps reflecting the dif-
differently in terms of overall management targeted ficulties around classification and diagnosis, together with
at vocational outcomes [48,85,95,96]. uncertainties over the optimal timing of treatment deliv-
ery (longer duration of symptoms having a negative im-
pact on outcomes [56]). Nevertheless, in principle,
particularly important: if wrongly applied, diagnostic la- there is likely to be benefit from biomedical interventions
bels can alarm and harm, whereas unemotive complaint- aimed at controlling symptoms (and/or targeting any
based labels can help ‘normalize’ the experience and ease identifiable pathology) while offering support and
the path to participation in productive activity. encouragement for early return to normal activities (in-
cluding work). However, in order to impact on work out-
Discussion comes, intervention requires more than biomedical
treatment. There is a need to address the range of psycho-
This review used a best evidence synthesis to summarize social factors (obstacles to recovery/return to work) at
the balance of the wide range of retrieved evidence [4], both the individual and workplace levels, and those efforts
which has been synthesized in high-level terms to provide need to be coordinated and integrated among the relevant
a set of messages to guide the management of work- players, including the individual worker.
relevant ULDs. Some patients will have a recognized pathology requir-
The epidemiological evidence is quite clear: musculo- ing medical or surgical intervention (which may involve
skeletal symptoms affecting the upper limb and neck are short-term rest), and there is some concern that applying
a common experience among the general population, tend- the principles of an active approach together with early
ing to be a recurrent complaint. A specific pathology cannot return to work will be inappropriate for some conditions
reliably be established for the majority of people with upper such as ‘tenosynovitis’, where anecdotally rest is the pre-
limb symptoms, indicating they might best be viewed as ferred option [34]. Although limited, the evidence on
having a regional complaint. There is considerable debate work-relevant ULDs (both specific and regional) is con-
over the classification of the various specific diagnoses and, sistent with the principle of the active approach promoted
 A. K. BURTON ET AL.: MANAGEMENT OF WORK-RELEVANT UPPER LIMB DISORDERS 49

and implemented for MSDs in general [84]: importantly, If the need for cultural change is accepted, then there is
there is no robust contradictory evidence. The notion of also a need for policymakers to rethink the priorities of
‘rest’ as a sole treatment is likely to be unhelpful: even if certain underlying concepts (e.g. primary prevention ver-
specific aggravating activities need to be modified or sus management: work caused versus work relevant) and
avoided short term that does not preclude other activities develop means to disseminate evidence-based informa-
and exercises being undertaken as part of therapy [99]. So tion to the various players (employers, workers, health
far as post-surgical management is concerned, there has care providers, unions and trade/professional organiza-
been an increasing recognition of the benefits of early acti- tions, lawyers, legislators and decision makers). Media
vation following most surgical procedures, and restrictions campaigns are increasingly seen as a suitable vehicle to
may be more a matter of the surgeon’s idiosyncratic advice contribute to public health and cultural change in respect
than any absolute need [100]. of health behaviours, supplemented by guidance material

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

Although early work return is seen as advantageous, and patient education; this strategy has been recommen-
simply sending someone directly back to a job they find ded specifically in respect of ULDs [34].
painful is counterintuitive and inappropriate. There is While the overall message may be clear—biopsychoso-
a strong case for using transitional work arrangements cial factors are influential in the phenomenon of upper
as the facilitator, which takes account of both biological limb complaints and need to be addressed—there are
and psychosocial obstacles to return to work. There is gaps in the evidence. Observational studies will help to
considerable evidence for the use of temporary modifica- better understand the natural history of non-specific com-
tion of activities to support people with regional pain plaints and the specific diagnoses, and controlled trials are
states on their return to normal activity, and there is needed to determine the most appropriate means for
no clear evidence that the principle cannot or should implementing both clinical and workplace care. Innova-
not be applied to the specific diagnoses. tive multimodal interventions seem promising, yet the op-
Just because the epidemiological pattern of most ULDs timal content, timing and method of delivery needs
does not favour ergonomic interventions as a significant further clarification.
primary preventive measure, this does not mean that there A number of salient messages emerge from the evidence,
is no merit in making work ergonomically acceptable; jobs, which may contribute to the needed cultural shift. They ap-
naturally, should be within the reasonable capabilities of the ply to the whole range of players involved (population/
workers. Unfortunately, portions of the ergonomics litera- workers, employers, health professionals, unions, lawyers,
ture and official guidance give the erroneous impression media, policymakers and enforcers), so they will need to be
that work is intrinsically the major cause of ULDs and that carefully constructed for each target group, tailored to their
by applying an ‘ergonomics approach’ they will be elimi- needs and comprehensively disseminated. The main mes-
nated. The evidence reviewed here indicates that they will sages are reflected here in the key points and are available in
expanded form in the original report [1].
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 en-
courage undue reporting of symptoms, inappropriate work
loss and development of disability [36]. Nevertheless, an
ergonomics approach, correctly applied, should improve Key points
comfort and efficiency, thus assisting in accommodating • ULDs can be triggered by everyday activities and
those with work-relevant complaints or disorders. overattribution to work can be detrimental to recov-
Viewed overall, the evidence on the management of ery: overmedicalization and negative diagnostic
ULDs favours neither biomedical nor workplace inter- labels are unhelpful.
ventions alone, either for regional complaints or specific • Many cases settle with self-management—this
diagnoses. Rather, what is needed is a biopsychosocial ap- should be encouraged—though some need treat-
proach, which necessitates multimodal interventions with ment: intervention should take a stepped care ap-
all the players onside and acting in unison. While the ev- proach, based on a biopsychosocial principles.
idence base supporting the principle of addressing the • Early return to work is important, though some
beliefs and behaviours of all the relevant players is as work may be difficult or impossible to perform
yet limited, the concept is central to overcoming biopsy- for a short while: work should be comfortable
chosocial obstacles [3]. Achieving all that will require and accommodating.
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 tai-
Funding
lored to the relevant target audience [101]. UK Health & Safety Executive. Contract No. 6325.
50 OCCUPATIONAL MEDICINE

Acknowledgements 15. Szabo RM, King KJ. Repetitive stress injury: diagnosis or
self-fulfilling prophecy? J Bone Joint Surg 2000;82-
We are grateful to the following colleagues, from a variety of dis- A:1314–1322.
ciplines, who kindly offered helpful ideas and comments: Frank 16. Lucire Y. Constructing RSI: Belief and Desire. Sydney: Uni-
Burke, David Coggon, Serena McCluskey, Margaret Hanson, versity of New South Wales Press, 2003.
Trang Nguyen, David Randolph and Mary Wyatt. We thank 17. European Agency for Safety and Health at Work. Repetitive
Debbie McStrafick for her administrative assistance and for re- Strain Injuries in the Member States of the European Union: The
trieving and carefully archiving the selected articles. Results of an Information Request. Luxembourg: Office for Of-
ficial Publications of the European Communities, 2000.
18. Bonde JP, Mikkelsen S, Andersen JH et al. Prognosis of
Conflicts of interest shoulder tendonitis in repetitive work: a follow up study
None declared. in a cohort of Danish industrial and service workers. Occup
Environ Med 2003;60:e8.

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

19. Macfarlane GJ, Hunt IM, Silman AJ. Role of mechanical
References and psychosocial factors in the onset of forearm pain: pro-
spective population based study. Br Med J 2000;321:1–5.
1. Burton AK, Kendall NAS, Pearce BG, Birrell LN, 20. Harrington JM, Carter JT, Birrell L, Gompertz D. Surveil-
Bainbridge LC. Management of Upper Limb Disorders and lance case definitions for work related upper limb pain syn-
the Biopsychosocial Model. London: HSE Books, 2008. dromes. Occup Environ Med 1998;55:264–271.
2. HSE. Upper Limb Disorders in the Workplace (HSG60(rev)). 21. Huisstede BMA, Miedema HS, Verhagen AP, Koes BW,
London: Health & Safety Executive, 2002. Verhaar JAN. Multidisciplinary consensus on the termi-
3. Waddell G, Burton AK. Concepts of Rehabilitation for the nology and classification of complaints of the arm, neck
Management of Common Health Problems. Norwich: The and/or shoulder. Occup Environ Med 2007;64:313–319.
Stationery Office, 2004. 22. Greening J, Lynn B, Leary R. Sensory and autonomic
4. Slavin R. Best evidence synthesis: an intelligent alternative function in the hands of patients with non-specific arm
to met-analysis. J Clin Epidemiol 1995;48:9–18. pain (NSAP) and asymptomatic office workers. Pain
5. Waddell G, Burton AK. Is Work Good for Your Health and 2003;104:275–281.
Well-being? London: TSO, 2006. 23. Coggon D, Martyn C, Palmer KT, Evanofff B. Assessing
6. Huisstede BMA, Bierma-Zeinstra SMA, Koes BW, case definitions in the absence of a diagnostic gold stan-
Verhaar JAN. Incidence and prevalence of upper-extremity dard. Int J Epidemiol 2005;34:949–952.
musculoskeletal disorders. A systematic appraisal of the 24. Waddell G, Burton AK. Occupational health guidelines for
literature. BMC Musculoskelet Disord 2006;7. the management of low back pain at work: evidence review.
7. Helliwell PS. A Review of Diagnostic Criteria for Work-related Occup Med (Lond) 2001;51:124–135.
Upper Limb Disorders. Leeds: Rheumatism Research Unit, 25. Walker-Bone KE, Palmer KT, Reading I, Cooper C. Soft-
University of Leeds, 1996. tissue rheumatic disorders of the neck and upper limb:
8. Nørregaard J, Jacobsen S, Kristensen JH. A narrative re- prevalence and risk factors. Semin Arthritis Rheum
view on classification of pain conditions of the upper ex- 2003;33:185–203.
tremities. Scand J Rehabil Med 1999;31:153–164. 26. Walker-Bone K, Cooper C. Hard work never hurt anyone:
9. Piligian G, Herbert R, Hearns M, Dropkin J, or did it? A review of occupational associations with soft
Landsbergis P, Cherniack M. Evaluation and management tissue musculoskeletal disorders of the neck and upper
of chronic work-related musculoskeletal disorders of the limb. Ann Rheum Dis 2005;64:1391–1396.
distal upper extremity. Am J Ind Med 2000;37:75–93. 27. Kuijpers T, van der Windt DAWM, van der Heijden GJMG,
10. Van Eerd D, Beaton D, Cole D, Lucas J, Hogg-Johnson S, Bouter LM. Systematic review of prognostic cohort studies
Bombardier C. Classification systems for upper-limb mus- on shoulder disorders. Pain 2004;109:420–431.
culoskeletal disorders in workers: a review of the literature. 28. Palmer KT, Smedley J. Work relatedness of chronic neck
J Clin Epidemiol 2003;56:925–936. pain with physical findings. Scand J Work Environ Health
11. Walker-Bone KE, Palmer KT, Reading I, Cooper C. Cri- 2007;33:165–191.
teria for assessing pain and nonarticular soft-tissue rheu- 29. Walker-Bone K, Reading I, Coggon D, Cooper C,
matic disorders of the neck and upper limb. Semin Palmer KT. The anatomical pattern and determinants of
Arthritis Rheum 2003;33:168–184. pain in the neck and upper limbs: an epidemiologic study.
12. Beaton DE, Bombardier C, Cole DC, Hogg-Johnson S, Pain 2004;109:45–51.
Van Eerd D. A pattern recognition approach to the devel- 30. Walker-Bone K, Palmer KT, Reading I, Coggon D,
opment of a classification system for upper-limb musculo- Cooper C. Prevalence and impact of musculoskeletal dis-
skeletal disorders of workers. Scand J Work Environ Health orders of the upper limb in the general population. Arthritis
2007;33:131–139. Rheum 2004;51:642–651.
13. Szabo RM. Determining causation of work-related upper 31. Silverstein BA, Viikari-Juntura E, Fan ZJ, Bonauto DK,
extremity disorders. Clin Occup Environ Med 2006;5: Bao S, Smith C. Natural course of nontraumatic rotator
225–234. cuff tendinitis and shoulder symptoms in a working pop-
14. Hagberg M. Clinical assessment, prognosis and return to ulation. Scand J Work Environ Health 2006;32:99–108.
work with reference to work related neck and upper limb 32. Eltayeb S, Staal B, Kennes J, Lamberts PHG, de Bie RA.
disorders. G Ital Med Lav Ergon 2005;27:51–57. Prevalence of complaints of arm, neck and shoulder among
 A. K. BURTON ET AL.: MANAGEMENT OF WORK-RELEVANT UPPER LIMB DISORDERS 51

computer office workers and psychometric evaluation of a risk 52. Bongers PM, Kremer AM, ter Laak J. Are psychosocial
factor questionnaire. BMC Musculoskelet Disord 2007;8. factors, risk factors for symptoms and signs of the shoul-
33. Roquelaure Y, Ha C, Leclerc A et al. Epidemiologic surveil- der, elbow, or hand/wrist?: a review of the epidemiological
lance of upper-extremity musculoskeletal disorders in the literature. Am J Ind Med 2002;41:315–342.
working population. Arthritis Rheum 2006;55:765–778. 53. Burton AK, Bartys S, Wright IA, Main CJ. Obstacles to
34. Lee R, Higgins G. Report on the Proceedings of HSE’s Mus- Recovery from Musculoskeletal Disorders in Industry (Research
culoskeletal Disorder and Return to Work Workshop (WPS/06/ Report 323). London: HSE Books www.hse.gov.uk/
02). Buxton: Health & Safety Laboratory, 2006. research/rrhtm, 2005.
35. Baldwin ML, Butler RJ. Upper extremity disorders in the 54. van den Heuvel SG, van der Beek AJ, Blatter BM,
workplace: costs and outcomes beyond the first return to Hoogendoorn WE, Bongers PM. Psychosocial work char-
work. J Occup Rehabil 2006;16:303–323. acteristics in relation to neck and upper limb symptoms.
36. Coggon D, Palmer KT, Walker-Bone K. Occupation and Pain 2005;114:47–53.
upper limb disorders. Rheumatology 2000;39:1057–1059. 55. Devereux J, Rydstedt L, Kelly V, Weston P, Buckle P. The

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

37. Burton AK. Back injury and work loss: biomechanical and Role of Work Stress and Psychological Factors in the Develop-
psychosocial influences. Spine 1997;22:2575–2580. ment of Musculoskeletal Disorders (RR 273). London: Health
38. NIOSH. Musculoskeletal Disorders and Workplace Factors: A and Safety Executive, 2004.
Critical Review of Epidemiologic Evidence for Work-related 56. Mallen CD, Peat G, Thomas E, Dunn KM, Croft PR.
Musculoskeletal Disorders of the Neck, Upper Extremity, Prognostic factors for musculoskeletal pain in primary
and Low Back. Cincinnati, OH: National Institute for Oc- care: a systematic review. Br J Gen Pract 2007;57:
cupational Safety and Health, 1997. 655–661.
39. National Research Council. Work-related Musculoskeletal 57. Alizadehkhaiyat O, Fisher AC, Kemp GJ, Frostick SP.
Disorders: Report, Workshop Summary and Workshop Papers. Pain, functional disability, and psychologic status in tennis
Washington, DC: National Academy Press, 1999. elbow. Clin J Pain 2007;23:482–489.
40. National Research Council. Musculoskeletal Disorders and 58. Coutu M-F, Durand M-J, Loisel P, Goulet C, Gauthier N.
the Workplace. Washington, DC: National Academy Press, Level of distress among workers undergoing work rehabil-
2001. itation for musculoskeletal disorders. J Occup Rehabil
41. Industrial Injuries Advisory Council. Prescribed Diseases. 2007;17:289–303.
Industrial Injuries Advisory Council. www.iiac.org.uk/ 59. Henderson M, Kidd BL, Pearson RM, White PD. Chronic
about/index.asp (11 February 2006, date last accessed). upper limb pain: an exploration of the biopsychosocial
42. Bongers P, Ijmker S, den Heuvel Sv, Blatter B. Epidemi- model. J Rheumatol 2005;32:118–122.
ology of work related neck and upper limb problems: psy- 60. Warren N, Dillon C, Morse T, Hall C, Warren A. Biome-
chosocial and personal risk factors (Part I) and effective chanical, psychosocial, and organizational risk factors for
interventions from a bio behavioural perspective (Part WRMSD: population-based estimates from the Connect-
II). J Occup Rehabil 2006;16:272–295. icut Upper-extremity Surveillance Project (CUSP). J Oc-
43. Palmer KT, Harris EC, Coggon D. Compensating occupa- cup Health Psychol 2000;5:164–181.
tionally related tenosynovitis and epicondylitis: a literature 61. Descatha A, Roquelaure Y, Evanoff B, Mariel J, Leclerc A.
review. Occup Med (Lond) 2007;57:67–74. Predictive factors for incident musculoskeletal disorders
44. Punnett L, Wegman DH. Work-related musculoskeletal in an in-plant surveillance program. Ann Occup Hyg
disorders: the epidemiologic evidence and the debate. J 2007;51:337–344.
Electromyogr Kinesiol 2004;14:13–23. 62. Hadler NM. The semiotics of ‘upper limb musculoskeletal
45. Ijmker S, Huysmans MA, Blatter BM, van der Beek AJ, disorders in workers’. J Clin Epidemiol 2003;56:
van Mechelen W, Bongers PM. Should office workers 937–939.
spend fewer hours at their computer? A systematic review 63. ARMA. Standards for People with Regional Musculoskeletal
of the literature. Occup Environ Med 2007;64:211–222. Pain. London: Arthritis and Musculoskeletal Alliance,
46. Thomsen JF, Mikkelsen S, Andersen JH et al. Risk factors 2007.
for hand-wrist disorders in repetitive work. Occup Environ 64. Breen A, Langworthy J, Baghust J. Improved Early Pain
Med 2007;64:527–533. Management for Musculoskeletal Disorders: (RR 399).
47. van den Heuvel SG, van der Beek AJ, Blatter BM, London: Health & Safety Executive, 2007.
Bongers PM. Do work-related physical factors predict 65. Hanson MA, Burton AK, Kendall NAS, Lancaster RJ,
neck and upper limb symptoms in office workers? Int Arch Pilkington A. The Costs and Benefits of Active Case Manage-
Occup Environ Health 2006;79:585–592. ment and Rehabilitation for Musculoskeletal Disorders (RR
48. Hadler NM. Occupational Musculoskeletal Disorders. 3rd edn. 493). London: HSE Books, 2006.
Philadelphia, PA: Lippincott Williams & Wilkins, 2005. 66. Meijer EM, Sluiter JK, Frings-Dresen MHW. Evaluation
49. Dembe AE. Occupation and Disease. How Social Factors Af- of effective return-to-work treatment programs for sick-
fect the Conception of Work-related Disorders. New Haven, listed patients with non-specific musculoskeletal com-
CT: Yale University, 1996. plaints: a systematic review. Int Arch Occup Environ Health
50. Woods V. Work-related musculoskeletal health and social 2005;78:523–532.
support. Occup Med (Lond) 2005;55:177–189. 67. Marhold C, Linton SJ, Melin L. A cognitive-behavioral
51. Woods V, Buckle P. Work, Inequality and Musculoskeletal return-to-work program: effects on pain patients with a
Health (Contract Research Report 421). London: Health history of long-term versus short-term sick leave. Pain
and Safety Executive, 2002. 2001;91:155–163.
52 OCCUPATIONAL MEDICINE

68. Cole DC, Van Eerd D, Bigelow P, Rivilis I. Integrative in- 84. Buckwalter JA. Activity vs. rest in the treatment of bone, soft
terventions for MSDs: nature, evidence, challenges & di- tissue and joint injuries. Iowa Orthop J 1995;15:29–42.
rections. J Occup Rehabil 2006;16:359–374. 85. Melhorn JM. Working with common upper extremity prob-
69. Selander J, Marnetoft S-U, Bergroth A, Ekholm J. Return lems. In: Talmage JB, Melhorn JM, eds. A Physician’s Guide
to work following vocational rehabilitation for neck, back to Return to Work. Chicago: AMA Press, 2005; 181–213.
and shoulder problems: risk factors reviewed. Disabil Re- 86. Haahr JP, Andersen JH. Prognostic factors in lateral epi-
habil 2002;24:704–712. condylitis: a randomized trial with one-year follow-up in
70. Feuerstein M, Huang GD, Ortiz JM, Shaw WS, Miller VI, 266 new cases treated with minimal occupational interven-
Wood PM. Integrated case management for work-related tion or the usual approach in general practice. Rheumatol-
upper-extremity disorders: impact of patient satisfaction ogy 2003;42:1216–1225.
on health and work status. J Occup Environ Med 87. Cheng AS-K, Hung L-K. Randomised controlled trial of
2003;45:803–812. workplace-based rehablitation for work-related rotator cuff
71. Crawford JO, Laiou E. Conservative treatment of work- disorder. J Occup Rehabil 2007;17:487–503.

Downloaded from https://academic.oup.com/occmed/article-abstract/59/1/44/1419560 by guest on 01 October 2018

related upper limb disorders—a review. Occup Med (Lond) 88. Kupper A, Mackenzie S, Heasman T. The Challenge of
2007;57:4–17. Managing Upper Limb Disorders—How Can Health Profes-
72. Feuerstein M, Burrell LM, Miller VI, Lincoln A, sionals Become More Effective? (RR215). London: Health
Huang GD, Berger R. Clinical management of carpal tun- & Safety Executive, 2004.
nel syndrome: a 12-year review of outcomes. Am J Ind Med 89. Franche RL, Cullen K, Clarke J et al. Workplace-based
1999;35:232–245. return-to-work interventions: a systematic review of the
73. Helliwell PS, Taylor WJ. Repetitive strain injury. Postgrad quantitative literature. J Occup Rehabil 2005;15:607–631.
Med J 2004;80:438–443. 90. Shaw WS, Feuerstein M, Huang GD. Secondary preven-
74. NHMRC. Evidence-based Management of Acute Musculo- tion and the workplace. In: Linton SJ, ed. New Avenues for
skeletal Pain: A Guide for Clinicians. Bowen Hills, Queens- the Prevention of Chronic Musculoskeletal Pain and Disability.
land: National Health and Medical Research Council, Pain Research and Clinical Management, vol. 12. Amster-
Australian Academic Press Pty Ltd, 2004. dam: Elsevier Science B.V, 2002; 215–235.
75. Franche R-L, Krause N. Readiness for return to work fol- 91. Abásolo L, Blanco M, Bachiller J et al. A health system pro-
lowing injury or illness: conceptualizing the interpersonal gram to reduce work disability related to musculoskeletal
impact of health care, workplace, and insurance factors. J disorders. Ann Intern Med 2005;143:404–414.
Occup Rehabil 2002;12:233–256. 92. McCluskey S, Burton AK, Main CJ. The implementation
76. Waddell G, Burton AK. Concepts of Rehabilitation for the of occupational health guidelines principles for reducing
Management of Common Health Problems. London: The sickness absence due to musculoskeletal disorders. Occup
Stationery Office, 2004. Med (Lond) 2006;56:237–242.
77. Pransky G, Robertson MM, Moon SD. Stress and work- 93. Shaw WS, Feuerstein M. Generating workplace accom-
related upper extremity disorders: implications for preven- modations: lessons learned from the integrated case man-
tion and management. Am J Ind Med 2002;41:443–455. agement study. J Occup Rehabil 2004;14:207–216.
78. Boocock MG, McNair PJ, Larmer PJ et al. Interventions 94. Ryall C, Coggon D, Peveler R, Poole J, Palmer KT. A pro-
for the prevention and management of neck/upper extrem- spective cohort study of arm pain in primary care and
ity musculoskeletal conditions: a systematic review. Occup physiotherapy—prognostic determinants. Rheumatology
Environ Med 2007;64:291–303. 2007;46:508–515.
79. Karsh B-T, Moro FBP, Smith MJ. The efficacy of work- 95. Derebery J, Kadan ML, Gonzalez R. Clinics in Occupa-
place ergonomic interventions to control musculoskeletal tional and Environmental Medicine, vol. 5. New York: W
disorders: a critical analysis of the peer-reviewed literature. B Saunders Company, 2006.
Theor Issues Ergon Sci 2001;2:23–96. 96. Staal JB, de Bie RA, Hendriks EJM. Aetiology and man-
80. Christmansson M, Fridén J, Sollerman C. Task design, agement of work-related upper extremity disorders. Best
psycho-social work climate and upper extremity pain Pract Res Clin Rheumatol 2007;21:123–133.
disorders—effects of an organisational redesign on manual 97. Burton AK, Waddell G, Main CJ. Beliefs and obstacles in
repetitive assembly jobs. Appl Ergon 1999;30:463–472. low back pain. In: Halligan PW, Aylward M, eds. The power
81. Verhagen AP, Karels C, Bierma-Zeinstra SMA et al. of belief. Oxford: Oxford University Press, 2006; 161–176.
Ergonomic and physiotherapeutic interventions for treat- 98. Fordyce WE. Back Pain in the Workplace: Management of
ing work-related complaints of the arm, neck or shoul- Disability in Nonspecific Conditions. Seattle, WA: IASP
der in adults. Cochrane Database Syst Rev. 2006 Issue Press, 1995.
3. Art. No.: CD003471. DOI: 10.1002/14651858. 99. Jebson PJL, Steyers CM. Hand injuries in rock climbing:
CD003471.pub3. reaching the right treatment. Phys Sportsmed 1997;25:
82. Williams RM, Westmorland MG, Schmuck G, 54–63.
MacDermid JC. Effectiveness of workplace rehabilitation 100. Ratzon N, Schejter-Margalit T, Froom P. Time to return
interventions in the treatment of work-related upper ex- to work and surgeons’ recommendations after carpal tun-
tremity disorders: a systematic review. J Hand Ther nel release. Occup Med (Lond) 2006;56:46–50.
2004;17:267–273. 101. Shaw K, Haslam C, Haslam R. A Staged Approach to
83. Nash CE, Mickan SM, Del Mar CB, Glasziou PP. Resting Reducing Musculoskeletal Disorders (MSDs) in the
injured limbs delays recovery: a systematic review. J Fam Workplace—A Long Term Follow-up. London: Health &
Pract 2004;53:706–712. Safety Executive, 2007.