Background/Purpose:

Pain in the distal upper limb (elbow, forearm, wrist or hand) is common, yet the best approach to management is unclear.  While the etiological and prognostic factors are similar to other pain conditions, such as low back pain, management approaches differ greatly.  Bed rest is no longer advocated for back pain, although patients with arm pain are often advised to rest and to avoid ‘harmful’ activities, while awaiting physiotherapy.  This advice is without an evidence base.

We hypothesized a) that advice to remain active and maintain usual activities while awaiting physiotherapy, would be superior to advice to rest the arm; and b) that fast-track physiotherapy would be superior to normal (waiting list) physiotherapy.

Methods:

Multi-center randomized controlled trial (ISRCTN79085082).  Patients with distal upper limb pain were identified from 14 out-patient physiotherapy departments across the UK.  A telephone screening and pre-trial physical assessment confirmed eligibility and collected baseline information.  Participants were randomized to either:

 * Advice to remain active, or

 * Advice to rest the arm

while awaiting physiotherapy, or

 * Immediate physiotherapy,

using a mixed randomization/minimization algorithm to maintain treatment balance in terms of treatment center, gender, laterality (dominant, non-dominant, or bilateral problem), a broad categorization of diagnosis (elbow versus wrist/hand problem), and baseline arm function.  Outcome was measured at 26 weeks using the modified DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire which asks people to rate difficulty in performing eleven pre-specified activities over the past week, because of pain in their distal upper limb.  This was scored as 0 (no disability) versus >=1 (some disability).  Results , from an intention-to-treat analysis, are presented as odds ratios (95% confidence intervals) for the probability of recovery.

Results:

539 patients were randomized evenly between the three groups (179, 182 and 178, respectively).  Participants had a mean age of 49yrs (SD 13.6); 54.5% were female; and 87.6% were right handed.  Approximately an equal number of patients reported pain in their elbow, wrist/hand, or both; and pain was most common in the dominant side (45.5%), or bilateral (24.7%).  435 participants (81%) provided follow-up data at 26 weeks.

32.1% of patients who received advice to rest were free of disability at 26 weeks, compared to 45.2% of those who received advice to remain active.  Thus, advice to rest was associated with a decrease in the likelihood of recovery (odds ratio: 0.54; 95%CI: 0.32-0.90).  There was no difference in recovery between those receiving immediate physiotherapy (35.8%) versus delayed (38.6%).

Conclusion:

We have shown, among patients referred to physiotherapy with distal upper limb pain, that advice to remain active is associated with a superior long-term outcome, compared with advice to rest the arm, but our results do not support the provision of ‘fast-track’ physiotherapy for such patients.  These findings call into question current advice and provide evidence that the no-bed-rest management approaches now common in back pain perhaps have parallels in other regional musculoskeletal pain conditions.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/advice-to-remain-active-while-awaiting-physiotherapy-is-associated-with-superior-long-term-outcome-among-patients-with-distal-arm-pain-results-from-a-randomised-controlled-trial/