Pain in the forearm, wrist and hand

Article Outline

• Abstract
• 1. Clinical aspects
  • 1.1. Tenosynovitis and tendinitis
  • 1.2. Carpal tunnel syndrome
  • 1.3. Arthritis
  • 1.4. Chronic upper limb pain
  • 1.5. Other soft-tissue rheumatic disorders
• 2. State-compensated and reportable disorders in workers
• 3. Case definitions in epidemiology and research
• 4. The frequency of hand–wrist pain and hand–wrist disorders in the general population
  • 4.1. Hand–wrist pain
  • 4.2. Tenosynovitis and tendinitis
  • 4.3. Carpal tunnel syndrome
  • 4.4. Arthritis affecting the hand
  • 4.5. Chronic upper limb pain
• 5. Risk factors for hand–wrist pain and hand–wrist disorders
  • 5.1. Physical risk factors
  • 5.2. Psychosocial risk factors
• 6. Pathogenesis of hand–wrist pain and hand–wrist disorders
• 7. Prevention and management of hand–wrist disorders
• 8. Conclusions and future research needs
• References
• Copyright

Abstract 

Pain in the forearm, wrist or hand may arise from one of several discrete rheumatic disorders of soft tissues, such as tenosynovitis, or from a non-specific regional pain syndrome. Symptoms are prevalent in the general population and both patterns of illness are well represented. Many epidemiological investigations of prevalence, incidence, causal risk factors, management and prevention exist, although surveys have used a wide variety of case definitions, hampering comparisons. Improved standardized approaches to classification are in prospect and these are described. A synthesis is also attempted of the main findings of existing surveys. A growing body of evidence now links distal arm pain with physical risk factors in the workplace (e.g. repetition, force, duration, short cycle time and awkwardness of posture); some possible ergonomic solutions to occupational arm pain are discussed. But occupational and psychosocial factors are also linked with symptom reporting and disability, and their role in pathogenesis may be important in primary prevention and the management of recalcitrant cases. Some key research questions are proposed aimed at preventing chronicity and disablement from arm pain.

Keywords:  arm pain, epidemiology, occupation, psychosocial risk factors, stress, pathogenesis, prevention

Clinically relevant pain in the wrist, forearm or hand may have one of several causes. Two broad divisions of disorder exist: specific rheumatic disorders, of the kind classically recognized in textbooks¹, and non-specific pain syndromes (Table 1). The relative contribution of each to the burden of disability arising from chronic upper limb pain is a matter of current research interest, as is the correct approach to case management in each circumstance.² Perhaps most common in the general population is diffuse non-specific pain in isolation, or pain as a component of a regional or general pain syndrome. Less commonly in the community, but quite often in rheumatological practice, symptoms arise from a discrete disorder such as a tenosynovitis. Wrist pain may also occur as a consequence of previous injury and arthritic change, while referred pain may arise from nerve entrapment in the carpal tunnel, cubital tunnel, or at the level of the cervical roots.

Table 1. Some disorders which cause forearm, wrist and hand pain

This chapter focuses initially on the clinical features of some common sources of rheumatic forearm, wrist and hand pain (tenosynovitis, De Quervain's disease, carpal tunnel syndrome (CTS), chronic non-specific arm pain, and soft-tissue disorders that are recognized for disability benefit in the UK), and then on their classification for research purposes. A review is provided of their descriptive epidemiology (the data on which are influenced by case definition), and the evidence on their causation, management and prevention. Finally, some new research observations are described, and a view is given on the major issues surrounding disorders of the distal upper limb and the direction future research should take.

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1. Clinical aspects 

1.1. Tenosynovitis and tendinitis 

In a pathoanatomical sense, tendinitis is defined as inflammation of one or more tendons, and tenosynovitis as inflammation of the synovial sheath of one or more tendons. Some authors also draw a distinction between these and inflammation of the paratendon at the muscle–tendon junction further up the arm (peritendinitis). But histological evidence of inflammatory change is rarely obtained in the diagnosis of soft-tissue disorders, and so these terms, which rely on clinical findings suggestive of inflammation (pain, warmth, redness and swelling over the site of one or more tendons), have often been lumped together in field surveys and research.

The radial extensors of the wrist and the long abductor and short extensor of the thumb are most frequently involved, and less commonly the flexor tendons. In a typical account of tenosynovitis, symptoms develop on returning to work after a long lay off, or when a person's job changes to require new, unfamiliar rapid movements of the wrist, hand and fingers.³ To begin with, a dull aching is experienced, becoming more severe with continuation of the work. Classically, a tender sausage-shaped swelling is present on the radial side of the lower dorsal forearm, proximal to the radial styloid process. Local redness and warmth may occur, and crepitus is often palpable and audible, sometimes extending up the forearm.

Tenosynovitis of the wrist (De Quervain's disease), also known as ‘washerwoman's wrist’, is defined as stenosing tenosynovitis (tenovaginitis) of the first dorsal compartment.⁴ It is characterized by pain on the radial side of the wrist and thumb base, impairment of thumb function, and thickening of the ligamentous structure covering the tendons in the first dorsal compartment of the wrist. The movements liable to cause pain are pinching or grasping while the wrist is deviated.⁵ This is the basis of the clinical provocation test, Finkelstein's manoeuvre, in which the wrist is firmly placed in ulnar deviation with the thumb adducted across the palm.⁴ The test is positive if pain is elicited at the first dorsal compartment.

Trigger finger results from tenosynovitis affecting the flexor tendons of the finger or thumb. The consequent fibrosis and constriction interfere with normal tendon gliding at the first annular pulley, which overlies the metacarpophalangeal joint and cause the characteristic intermittent, troublesome locking of the digit in flexion (triggering effect).

1.2. Carpal tunnel syndrome 

This syndrome, which is caused by compression of the median nerve as it passes through the carpal tunnel into the wrist, classically comprises sensory and motor features in the median nerve distribution of the hand and evidence of delayed nerve conduction. In the carpal tunnel the median nerve lies immediately beneath the palmaris longus tendon and anterior to the flexor tendons. Conditions that decrease the size of the tunnel, or swell the structures contained within it, compress the median nerve against the transverse ligament which bounds the tunnel's roof. Such circumstances can arise traumatically, congenitally, or due to systemic or inflammatory effects (e.g. diabetes mellitus, rheumatoid arthritis, acromegaly, hypothyroidism, pregnancy and tenosynovitis).

The history in CTS is normally one of gradual onset of numbness and tingling in the median nerve distribution of the hand. Pain is also reported. Strenuous use of the hand tends to aggravate symptoms, although this may not become apparent until several hours after the activity. Night-time pain disturbs sleep, and patients often hang the affected hand over the side of the bed in an attempt to gain relief. Many sufferers also complain of progressive weakness and clumsiness in their hands.

Tinel's test (percussion over the flexor retinaculum) and Phalen's test (sustained complete flexion of the wrist for a minute or so) may provoke paraesthesiae over the median nerve distribution, but these signs have a variable sensitivity (10–88%) and specificity (47–100%) in comparison with the gold standard of delayed nerve conduction on electrophysiological testing.^6., ^7., ^8.

Electro-diagnostic standards for CTS vary widely, but in general distal motor latencies of more than 4.5ms and distal sensory latencies of more than 3.5ms are considered abnormal. Asymmetry of conduction between the two hands (of more than 1ms for motor conduction or 0.5ms for sensory conduction) is also considered abnormal.

In the treatment of CTS, conservative measures may suffice. Interventions which are considered to be of benefit include splinting, local corticosteroid injection and prescription of anti-inflammatory drugs. Steroid injections offer transient relief in the majority of patients, but in some series only one-fifth of subjects are symptom-free at 12 months, the better outcome being in those whose symptoms have been present for less than a year and who have no muscle wasting.⁹ If untreated, however, CTS may progress and cause wasting of the thenar eminence and loss of hand function. A progressive increase in distal motor latency can be used to identify the need for surgery. Surgical release of the transverse carpal ligament is indicated in the presence of progressive weakness or persisting neurological changes, and may also be helpful if a source of obstruction in the carpal tunnel is identified. Surgery relieves symptoms in 90% of carefully chosen patients, the prognosis being less good if symptoms have been present for more than 5 years beforehand.¹⁰

1.3. Arthritis 

Pain in the hand or wrist may be caused by osteoarthritic changes at the carpometacarpal (CMC) joints, the distal interphalangeal (DIP) joints, or, less commonly (after trauma), at the wrist.

Nodal generalized osteoarthritis (OA) appears to be a distinct subset of the disease characterized by polyarticular finger interphalangeal involvement, Heberden's and Bouchard's nodes, female preponderance, onset around the menopause, increased risk of OA at the hips, knees and neck, and a good functional outcome for the hands. Less commonly, hand interphalangeal joint involvement is accompanied by florid inflammation, radiographic subchondral erosions, and tendency to interphalangeal joint ankylosis (erosive OA). The prognosis for hand function is less good under these circumstances.

Inflammatory arthropathies are less common in the general population, but important because some are serious sources of pain and enduring disability. In rheumatoid arthritis, involvement of the small joints of the hands with symmetry and sparing of the proximal interphalangeal joints is the most common presentation. The total number of affected joints increases over the first few years of illness – the main sites in the distal limb being the wrists, metacarpophalangeal and proximal interphalangeal finger joints.

1.4. Chronic upper limb pain 

Troublesome and persistent pain in the distal arm is quite often found in the absence of clear-cut pathology. Such cases have been described as ‘repetitive strain disorders (RSI)’ or ‘cumulative trauma disorders’, although this terminology is unsatisfactory in several respects. In particular, it presupposes both an injury and a mechanism; and its intended coverage is unclear: some physicians use these terms to describe the collective range of recognized and ill-defined disorders arising (or appearing to arise) from frequent, forceful overuse of the upper limb at work, but others regard RSI as diagnosis of exclusion (chronic upper limb pain ascribed to over-use at work and for which no clinical diagnosis can be made). Surveillance and research data are often presented with similar ambiguity – blurring the distinction between discrete and non-specific disorders, and so failing to distinguish between potentially dissimilar clinical end-points.²

The confusion that ensues can be illustrated by reference to some cases that have attracted publicity in Britain. In 1981 an enquiry over upper limb complaints in an Inland Revenue office concluded that complaints such as tenosynovitis could sometimes arise from work with a visual display unit (VDU). In 1991, the High Court found that two telecom keyboard operators had RSI (diagnosed as tenosynovitis and epicondylitis) induced by frequent keying in adverse ergonomic conditions; and in 1994 a legal secretary received an award for tenosynovitis provoked by periods of intense typing. But by contrast, in 1993 the complaints of a journalist were dismissed by a judge who concluded that RSI did not exist (perhaps meaning that the link between disabling but undiagnosed upper limb pain and work was unproven). To avoid such confusion in this account, the term RSI refers to chronic upper arm pain for which no diagnosis is made and which has been ascribed to occupational over-use.

Miller and Topliss¹¹ have described a series of 200 consecutive patients referred for specialist opinion with suspected RSI, defined in this way. In three-quarters the onset of pain was gradual, beginning as localized distal pain but more diffusely spread by the time they were seen. The dominant hand was more commonly affected, but bilateral disease was also common. Nearly all the patients described paraesthesiae and most described subjective swelling of the limb. Anxiety, mood change, fatigue and sleep disturbance were usually present. Clinical signs were generally absent although a majority described tenderness at multiple sites. In this respect RSI shares some similarities with fibromyalgia, in which sufferers also tend to complain of fatigue, sleep disturbance, stiffness and paraesthesiae. The clinical similarity between the two conditions has led some commentators to suggest that RSI is a variant of fibromyalgia.^11., ^12.

1.5. Other soft-tissue rheumatic disorders 

Beat hand is a subcutaneous cellulitis of the hand, and is associated with pain, tenderness, redness and swelling of the palm. It is found especially in miners, quarrymen and labourers, and is ascribed to the repeated use of picks, shovels and hand tools.

Writer's cramp (telegraphist's cramp, twister's cramp or craft palsy) occurs in jobs that require a great deal of handwriting, typing, or other repetitive hand–arm movement. It is a less clear-cut entity, but includes symptoms of spasm, tremor and pain in the hand or forearm in the absence of physical signs or detectable abnormalities on investigation. In common with beat hand, it is recognized under some circumstances for state compensation (see below) and it has become described in this context.

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2. State-compensated and reportable disorders in workers 

In many countries upper limb disorders (ULDs) are compensated by state welfare benefit for insured workers who develop illness because of their occupation. In Britain, for example, provisions have existed to cover occupational accidents since 1897 and occupationally related diseases since 1906. Tenosynovitis, CTS (in users of vibratory tools), beat hand and cramp arm are compensatable; and trends, although affected by rule changes, can be monitored over time (Figure 1).¹³ However, only willing, knowledgeable and insured workers (employees rather than the self-employed) can lodge a claim, and benefit is paid only under qualifying conditions of occupation and severity. Altogether, the Department of Works and Pensions confirms only about 1600 cases per year from these causes, but this most probably represents the tip of a morbidity iceberg. Similar constraints limit the usefulness of international data on compensation of work-related ULDs (WRULDs).

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• Figure 1. 

  Wrist and forearm disorders prescribed (PD) and reported (RD) in England, Wales and Scotland. (Adapted from Health and Safety Commission.¹³)

In many countries there is also a legal obligation to report a scheduled list of work-related illnesses to health and safety enforcement agencies. In Britain, for example, most of the illnesses which are compensatable by the State in insured workers (including tenosynovitis, CTS and cramp arm) must be notified to the Health and Safety Executive or to local Environmental Health Officers for workers in general. But the onus falls on informed employers to submit a return, and under-reporting is recognized to be a wide-spread and substantial problem, as it is for compensated illness. Information is collected only for workers whose illnesses are attributed to work activity, and relatively few cases are reported (Figure 1).¹³

A more comprehensive view of the burden of ULDs requires targeted information from representative community samples, and this in turn needs an epidemiological approach to case definition.

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3. Case definitions in epidemiology and research 

Epidemiological research focuses on large groups of people rather than on individuals. So the case definitions employed in epidemiological surveys are necessarily cruder than those used in clinical practice, or to assess patients seeking compensation. Frequently the determination of ‘caseness’ is based solely on self-report of pain, but the definition may be refined by reference to an anatomical site, time period, duration, severity, or impact on daily activities. Many surveys have employed the Nordic Questionnaire¹⁴, a simple self-completed questionnaire, to collect standardized data on the 1-week and 1-year period prevalence of limb and neck complaint, including pain that interferes with everyday activities (e.g. work, hobbies and housework). This convenient tool enables the frequency of pain reports to be assessed on a large scale (e.g. in representative community samples or occupational cohorts), but does not allow an exact clinical diagnosis to be made.

To provide more detail, some field surveys have employed supplementary assessments by physicians, nurses or physiotherapists, but often without standardization and sometimes without specification.¹⁵ The wide variety of case definitions used hampers interpretation.²

More recently structured diagnostic schedules have been devised to address this concern. A systematic review by Buchbinder et al¹⁵ identified four physical examination systems – two from Finland^16., ^17. and two from North America^18., ^19. – intended for this purpose. But these schemes were criticized because of their failure to demonstrate satisfactory construct validity and repeatability. They were also thought to require elaborate training and special skills, and did not cater for patients whose pattern of symptoms and signs fell outwith the specified diagnosed categories.

Buchbinder et al¹⁵ recommended that future work should be directed toward improving systems of classification and adopting new approaches that fulfilled basic measurement criteria. Since their review, two new schemes, one from Britain²⁰ and one from The Netherlands²¹, have been developed, building on these recommendations. Both schemes have grown out of criteria proposed by expert workshops^21., ^22. (Table 2), and so benefit from face validity and consensus backing. Moreover, the British scheme has been tested and found to be repeatable in hospital and community settings with useful validity relative to specialist opinion^20., ^23.; and it has proved feasible to use it in large-scale field surveys, heralding the way for wider application.

Table 2. Diagnostic criteria for upper limb disorders proposed by a British Delphi consensus workshop

Adapted from Harrington JM et al (1998, Occupational and Environmental Medicine 55: 264–271) with permission.²²

These standardized systems represent a useful advance on the status quo. But current information on the frequency, impact, and associations of arm pain comes from earlier surveys, with their piecemeal approach to classification. The next few sections summarize the principal observations.

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4. The frequency of hand–wrist pain and hand–wrist disorders in the general population 

4.1. Hand–wrist pain 

The estimated prevalence of distal upper limb pain varies, depending on the time period, severity, and the duration of symptoms for which enquiry is made (Table 3)^24., ^25., ^26., ^27., ^28., ^29.; but by any measure, such symptoms are common. For example, persistent pain in the hand or wrist had a prevalence of 3–7% in a large American population survey²⁴ and 9–17% in one rural area of Sweden.²⁹ More recently, two British surveys^26., ^28. have found a prevalence of hand or wrist pain preventing normal activity of 5–10% in working-age adults sampled from the age-sex registers of general practitioners. Such pains are more commonly reported at older ages, as evidenced by data from a population survey in Southampton (Figure 2) and findings from Manchester.²⁸

Table 3. Surveys of hand, wrist and forearm pain in the general population

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• Figure 2. 

  Prevalence of wrist and hand pain in a community sample from Southampton, England.

4.2. Tenosynovitis and tendinitis 

Although there have been several informative surveys of arm pain, less is known about the frequency of discrete ULDs in the general population. In a study from primary care in Britain, the incidence of tenosynovitis, tendinitis, synovitis and bursitis combined was 10.9/1000 persons per year.³⁰ But no pre-defined criteria were used to standardize diagnosis, and the proportion of complaints arising solely from tendinitis was not separately identified. In the US National Health Interview, 20 adults per 1000 reported that a doctor had told them they had ‘tendinitis’.²⁴ The incidence was more common in women than men at all ages, and peaked in middle age.

More recently, the prevalence of discrete wrist and hand disorders was estimated to be 4.7% in men and 7.9% in women from one general practice in Southampton, following a two-stage sampling process in which some 1800 subjects were clinically examined according to a standardized diagnostic schedule (Walker-Bone et al, unpublished data).

The impact of tenosynovitis on work capacity has been little studied, although case series indicate that about 10–30 days of work tend to be lost per illness episode.^3., ^31.

4.3. Carpal tunnel syndrome 

Estimates of the prevalence and incidence of CTS are critically affected by the adopted case definition. The characteristic pattern of symptoms, signs and nerve conduction abnormalities can arise separately or in combination, allowing for several choices. Also, a range of plausible cut-points exists for defining electrophysiological abnormality, but these generate markedly different estimates of prevalence.³²

In a large Dutch population survey that took as its definition sensory disturbance in the median nerve distribution occurring at least twice a week, generally awakening the patient from sleep, and associated with nerve conduction abnormalities, the point prevalence was estimated at 0.6% in men and 8% in women.³³ But surveys which have defined cases solely on the distribution of symptoms generate higher estimates of prevalence (14–19% in some investigations).^34., ^35.

Ferry et al have developed an instrument to assess the disability from CTS, which incorporates domains such as sleep disturbance, clumsiness, dependence and difficulty with writing, dressing and driving.³⁶ The researchers explored case definitions based on symptoms and nerve conduction and found consistently higher levels of self-reported disability in those with electrophysiological abnormalities.

Estimates of prevalence and incidence also depend on the setting in which inquiries are made. The crude incidence rate is reported to be one per 1000 person years in hospital-diagnosed patients^37., ^38. and about two per 1000 person years in British primary care.³⁰ In selected working populations, CTS has been found to be somewhat more common (about 1–2%), using less strict clinically based diagnostic criteria.^18., ^19.

The age-adjusted incidence rate of CTS may be increasing in the general population^37., ^39., but exact comparisons between surveys are difficult as case definitions have changed over time (notably since the introduction of electrophysiological testing).

4.4. Arthritis affecting the hand 

OA is defined as focal loss of articular cartilage with variable subchondral bone reaction. There is incomplete concordance between these pathological changes and radiographic or clinical features of the disorder, and so in epidemiological studies the radiological and clinical characteristics of OA are widely used in case definition. Severity is conventionally described for the commonly affected joint sites (including the hand) using standardized rating scales that score joint space narrowing, abnormalities of bony contour, and formation of osteophytes, subchondral sclerosis and cysts.

Two large population surveys, the US National Health Survey and the Dutch Zoetermeer survey provide helpful estimates of the prevalence of radiographic OA in the hand. Lawrence et al⁴⁰ reported an overall prevalence of 3.8% among adults aged 25–74 from the U.S.A, but with a strong age-dependent trend. Mild changes (grades 1 and 2) were found in 2–5% of those aged 25–34 years, and only 0.1% for severe changes (grades 3 or 4); but in those aged 65–74 years severe changes were described in 22% of men and 37% of women. A similar pattern was apparent In the Dutch data⁴¹: grade 3–4 disease was not found at the DIP and CMC1 joints in those 25–34 years of age, but in those 65–74 years of age the DIP joints were affected to this extent in 10–22% of subjects and the CMC1 joint in 5–14% (women more often than men).

The estimated point prevalence of rheumatoid arthritis is about 0.5–1% according to surveys from England, The Netherlands, Sweden, the U.S.A, Japan and South Africa.⁴² The reported annual incidence of rheumatoid arthritis varies more widely, but figures from a prospective population-based registry of new cases in Norfolk, UK indicate an annual incidence of 3.4 per 10 000 among women and 1.4 per 10 000 in men.⁴³

4.5. Chronic upper limb pain 

Non-specific arm pain has seldom been studied as a separate entity in field epidemiology. There is a need therefore to regress to routinely collected statistics, with their attendant limitations, to gain a profile of the problem.

Compensation data generally tend either to neglect non-specific arm pain or to employ umbrella classifications which obscure the distinction between regional pain and regional pathology. But in Australia the Bureau of Statistics separately codes compensation awards for injuries without explicit diagnosis ascribed to repetitive movement. RSI as defined in this fashion is more common in blue-collar than in white-collar workers.⁴⁴ For men, the highest rates have occurred in the manufacture of textiles, clothing and footwear, food and beverages, while in women, very high incidence rates occurred in parts of the manufacturing sector (Table 4). This relative ranking may reflect awareness and willingness within occupations to pursue redress. But the Australian data are of most significance not because of their absolute rates but because of the big changes that have occurred in sequential time periods. Between 1980 and 1985, for example, the number of successful claims among women increased fivefold and that in men by 50%.⁴⁴ Similar transient epidemics have been seen in other countries, in other time periods, and in selected workforces, often with abatement after a rapid increase in incidence.^45., ^46., ^47., ^48. These outbreaks cannot be explained readily by time-varying exposures to putative causal factors. They suggest rather that psychosocial variables influence importantly the recognition and presentation of non-specific arm pain ascribed to work, if not its actual development.^49., ^50.

Table 4. Incidence rates of compensated RSI by industry in Australia, 1985–1986.^a

The role of occupational and mental health factors in the presentation of hand–wrist conditions is considered more fully below.

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5. Risk factors for hand–wrist pain and hand–wrist disorders 

5.1. Physical risk factors 

Many investigations of hand–wrist complaints have been conducted in the occupational setting, as it is assumed that symptoms and disorders in the region are most often caused or aggravated by physical activities at work.

To investigate, researchers have generally compared the prevalence of pain (Table 5) or tendinitis (Table 6) in cross-sectional surveys of workers whose jobs entail contrasting degrees of repetitiveness, force, awkwardness and duration.^51., ^52., ^53., ^54., ^55., ^56., ^57., ^58., ^59., ^60. In some cases this general approach has been supplemented with more quantitative assessment of exposure, based either on self-reports or expert assessment or videotape analysis.

Table 5. Cross-sectional surveys of hand or wrist pain in selected occupations

	Exposed		Outcome/case	Prevalence (%)
Study	workers	Referents	definition	Exposed	Referent	RR (OR, PR)	95% CI
Roto and Kivi (1984)52	Meat cutters (n=90)	Construction foremen (n=72)	Symptoms of local pain and finger weakness	30	10	3.1	(1.4–6.7)
Andersen and Gaardboe (1993)53	Female sewing machine operators (n=424)	Unexposed women from the general population (n=781)	Pain on >30 days or daily in the past year in:forearm or wrist hand or finger	7.310.1	2.74.9	2.72.1	(1.6–4.7)(1.4–3.2)
Chiang et al (1993)54	Fish process workers with (a) medium or (b) highly repetitive jobs	Fish processors in jobs that were not repetitive	Wrist pain (last 30 days)Hand pain (last 30 days)	17.8 (a) 25.0 (b)21.2 (a) 32.1 (b)	8.2		P for trend=0.031P for trend=0.037
Punnett et al (1985)55	Female garment workers (n=162)	Female hospital workers (n=73)	Pain for most days over ≥1 months in past year in:
			hand	27.3	10.3	2.7	(1.3–5.2)
			wrist	16.8	4.3	3.9	(1.4–10.9)
			Persistent hand pain and sensory symptoms in median nerve distribution	18.0	6.0	3.0	(1.2–7.6)

Table 6. Cross-sectional surveys of hand–wrist tendinitis in selected occupations

Understanding is limited because the putative hazards are complex, time-varying and frequently present jointly rather than separately; but a number of useful points do emerge (Table 5, Table 6). First, whether the end-point is pain or clinically verified tendinitis, rates of complaint have been consistently higher in those classed as adversely exposed. Second, although case definitions of hand–wrist pain have varied, and the groups compared have been selected in an arbitrary (albeit purposive) way, the estimates of relative risk have been surprisingly close to one another (raised about two to fourfold – see Table 5). Third, rather higher risks have been found for tendinitis (Table 6) than for hand–wrist pain (Table 5). Finally, and perhaps most informatively, in surveys that have considered the joint actions of high force and high repetition, it seems that both exposures confer risks but that their combined effect is particularly injurious (see Armstrong et al, in Table 6).

Epidemiological surveys of incident hand–wrist disease are few, but in one cohort study, the risk ratio for new-onset tendinitis was 24–36 in packers and sausage makers (exposed to strenuous work), as compared with office workers (unexposed).³¹ Moreover, in a population survey, subjects who used their arms repetitively at work ‘half to most of the time’ were found to have a relative risk of 2.9 (95% CI 1.2–7.3) for incident forearm pain in comparison with those who did not use their arms in this way at all.²⁸

The literature is more replete with case series, and in general these suggest the same risk factors as found in more formal investigations. Early case reports of hand–wrist tendinitis came from tea and tobacco packers, rubber industry workers, insurance workers, and car manufacturing workers³; while De Quervain's tenosynovitis has been reported in those whose with hobbies involve repetitive use of the thumb, (piano-playing, sewing, knitting, and weaving).⁵

The relation between CTS and work activities has also been closely studied. A review by Hagberg et al identified 21 studies (15 cross-sectional and six case-control) that met high-quality criteria for case ascertainment.⁶¹ Particularly high prevalences and odds ratios were reported in workers whose jobs entailed repetitive forceful gripping, such as grinders, frozen food factory workers and platers. High force and high frequency of repetition also emerged as a potent risk factor for CTS in the survey by Silverstein et al.⁵¹ Compared with low-force–low-repetition jobs, the combination resulted in an odds ratio of more than 15. The strongest associations in case-control studies have been with use of vibratory tools, and with activities that frequently flex or extend the wrist^33., ^62., ^63., ^64., and the link with vibration exposure – perhaps arising from direct injury or because of the way powered tools are gripped and used – is now accepted for State compensation purposes in Britain and many parts of Europe.

5.2. Psychosocial risk factors 

Psychosocial, as well as physical, risk factors may underlie the presentation and natural history of musculoskeletal disorders.⁶⁵ Occupational factors, such as high quantitative job demands (e.g. time-pressure and paced work, overtime, work overload and high peaks of work), high qualitative job demands (e.g. heavy responsibilities), monotonous work, low job control (e.g. lack of autonomy and flexibility), low social support from peers or supervisors, low job satisfaction, and perceived job stress have been most closely studied – especially the model of Karasek⁶⁶, which is based upon decision latitude and its relation to job demands. But personal and non-occupational risks for poor mental health may also be relevant. Huang et al⁶⁷ have reviewed alternative models of ‘stress’, including one based upon the balance of efforts, rewards, and coping skills (the Siegrist model)⁶⁸; one based on the human need to seek explanation for bodily sensations, health beliefs, and illness behaviour (Cioffi)⁶⁹; and a biopsychosocial model akin to that now used in the management of low-back pain.⁷⁰

A recent systematic review by Bongers et al⁷¹ identified 28 studies which explored the association between psychosocial factors and arm pain. All but two of the studies were cross-sectional in design, only 20 reported on forearm, wrist or hand pain, only 11 of these were rated of good quality, and only a handful included an examination to evaluate self-reported symptoms. Most studies employed the Karasek model of occupational stress, and no eligible investigations were discovered on illness behaviour, pain beliefs, coping, and personality. An attempted synthesis of the findings was complicated by the many ways in which psychosocial factors were defined. Many studies reported at least one positive association with hand–wrist problems, but there was only limited consistency in the risk factors implicated. Weak positive associations were found with high perceived job stress in all of four studies that considered this exposure; five of nine studies favoured an association with high quantitative job demands (with risk estimates ranging up to 2.2); eight of 10 studies found against low job control as a cause of forearm, wrist and hand complaints; and three studies all found no impact of home and family support on this outcome. Understandably, the reviewers reached guarded conclusions and emphasized that the main research challenges still lie ahead.

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6. Pathogenesis of hand–wrist pain and hand–wrist disorders 

Various models of causation for WRULD have been proposed. Generally speaking, the mechanical model of pathogenesis assumes a passage through the steps of activity, biomechanical stress, temporal loading (as some function of duration and repetitiveness), tissue strain, tissue response (injury and attempted repair), and pathology.⁷²

For some outcomes this model is supported by the finding of gross pathological changes in the tendons at necropsy or surgery, consistent with a process of wear and tear. Thus, in De Quervain's tenosynovitis the flexor retinaculum overlying the first dorsal compartment has been found to be densely fibrous, with three to four times its normal thickness.^4., ^73. Also, it has proved possible, using animal models, to induce fibrocartilaginous metaplasia and functional hypertrophy in the tendons by placing them under compressive and repeated tensile loading.⁷²

Direct mechanical pressure or tension around a nerve can cause nerve entrapment; while abnormal postures, positions, and movements may cause some muscles to be overused, others to be underused, and some muscles to shorten, tighten and become painful when stretched.⁷⁴ Novak and Mackinnon have suggested that the minor degrees of nerve compression, when accumulated at multiple sites, may explain non-specific arm pain with normal nerve conduction⁷⁵, and Greening et al have made a similar claim in respect of median nerve compression falling short of overt CTS.⁷⁶

However, the biomechanical model is unlikely to explain every case of WRULD – as demonstrated by the marked variation in incidence over time (p. 29–30) and a growing body of evidence on psychosocial aspects of the problem (p. 32–34). It is notable that WRULDs have come to prominence at a time when the physical demands of work have generally been decreasing. Although high rates have been reported in some manual occupations, large numbers of cases also occur in white-collar workers. This paradox might be explained if more forceful movements of the arm do not carry the highest risk, and it has been postulated that non-specific arm pain may arise in keyboard work from apparent incongruence between motor intention and proprioceptive feedback in a task where finger movements are of low amplitude and visual feedback is limited.⁷⁷ But alternatively the trend over time may reflect changes in culture and expectations.

Many authors have suggested ways in which stress might contribute to the pathogenesis of musculoskeletal illness and lead to disability^65., ^67., ^69., ^70., ^78., ^79., ^80. (see Box 1 below). Some of these could operate through and mediate mechanical loading, whereas others, such as beliefs and coping skills, may bypass it or act downstream. Altered pain perception (perhaps as a consequence of functional changes in the central nervous system) is one interesting possibility, and limited evidence has accrued that patients with non-specific arm pain may have reduced pain tolerance⁸¹, akin to that in fibromyalgia.⁸² However, few of the psychological, psychophysiological, and behavioural mechanisms integral to current models of upper limb pain have been well tested and empirically substantiated so far.⁶⁷

Finally, it is apparent that physical activities and psyche explain only a part of the variation in risk for hand-wrist disorders. Other personal and medical risk factors appear to exist for some conditions such as CTS (e.g. obesity, hormonal status, and injury)⁸³, trigger finger (e.g. diabetes), and De Quervain's tenosynovitis (e.g. rheumatoid arthritis), through mechanisms that are largely thought to be mechanical or inflammatory.

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7. Prevention and management of hand–wrist disorders 

Preventive measures in the occupational setting, assuming a mechanical basis of occurrence, may include

The practice points aboveBox 2 summarize the basic principles of good ergonomic practice (see also Ref 84), some of which have been adopted beneficially to reduce self-reports of arm pain in a few uncontrolled interventions.⁸⁵ More research is needed to demonstrate their efficacy.

However, if psychosocial influences are as important as some observations suggest, the optimal approach to prevention may not lie simply in improved ergonomics. Indeed, by placing strong emphasis on ergonomics there may be a danger of creating a culture in which workers believe that they are at high risk, and that this perception of itself may generate disease.⁸⁶

Health beliefs may be of crucial importance in the natural history of ULD, especially for the patient with non-specific arm pain. Preventing disability and dependence are vital objectives, but the factors that cause the transition from acute to chronic handicapping arm pain are not well understood at present. In disabling back pain, negative thinking patterns, environmentally reinforced sick role behaviour, and maladaptive beliefs and coping mechanisms seem to play a significant part⁷⁰, and so by analogy these may be relevant in the management of the worker with arm pain. If so, there may be scope for interventions based on positive messages, reassurance and attempts to remain active in spite of short-term discomfort. In the secondary prevention of chronic back and neck pain, trials of cognitive behavioural therapy have shown early promise^87., ^88., and a rationale exists for trying them in selected patients with arm pain. The evaluation of such strategies represents an important area of future research inquiry.

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8. Conclusions and future research needs 

Pain in the distal upper limb is a common symptom in the general population. It often exists in the absence of discernible pathology, but sometimes arises from discrete upper limb rheumatic disorders such as tenosynovitis and CTS. A growing body of evidence, summarized in several large reviews^89., ^90., ^91., now links the symptom and its associated disorders with physical risk factors which may be avoidable if good ergonomic practices are followed. Control of mechanical risk factors in the workplace may also aid rehabilitation of the affected worker. But there are few longitudinal studies of risk and natural history at present, and little direct empirical evidence that the expected benefits of intervention will be realized. Priority should be given in new research to filling in these gaps.

Psychosocial risk factors are also associated with upper limb pain, as demonstrated by many cross-sectional and a few longitudinal studies. They may play a role in the pathogenesis of symptoms, or in their recognition, or translation into disability: there are several possibilities, and reaching a better understanding of the relationships is another important research need. Randomized controlled interventions may be required to provide reassurance that the present focus on physical solutions will not sow the seeds of illness by influencing health beliefs and illness behaviour. The scope for preventing ULDs through changes in work psychology and work organization also remains to be evaluated, and other individually centred approaches have received little attention so far. Much is known about the problem of arm pain but much still remains to be discovered (see Research agendaBox 3).

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