Background/Purpose: We have previously shown that, among patients awaiting physiotherapy for distal upper limb pain/disability, advice to remain active is associated with greater functional recovery compared to advice to rest. In low back pain, studies of stratified care have shown that matching patients to optimal interventions reduces costs of treatment, and can help individuals return to work. In contrast, few studies have examined whether patients benefit from a stratified approach to distal upper limb pain management. Thus, the aim of the current study was to investigate whether pre-specified patient characteristics (baseline pain intensity, pain duration, gender, employment status, pain history, and diagnostic category) modified the effect of advice, among patients referred for physiotherapy with distal upper limb pain.

Methods: This observational study used data from a UK multi-centre randomized controlled trial. Participants underwent a clinical examination and completed questionnaires before trial randomisation to either (a) advice to rest; or (b) advice to remain active, at the start of the six-to-seven week waiting time for physiotherapy. Follow-up questionnaires were mailed 6, 13 and 26 weeks later. Questionnaire items asked about pain intensity (11-point Numeric Rating Scale), employment status, pain duration and pain-related disability, using the modified Disabilities of the Arm, Shoulder and Hand questionnaire (mDASH). A difference of 1 unit on the mDASH equates to 1 additional functional limitation and was therefore interpreted as clinically meaningful change. The interaction between advice group and the 6 pre-defined factors on change in disability at 6, 13 and 26 weeks was quantified using linear regression, controlling for the level of disability at the time of referral.

Results: 282 participants with complete follow-up data were included in this analysis (57% female; mean age 50yrs, SD 14). There was a significant interaction between gender and treatment effect at 26 weeks (p=0.011). Males who received advice to remain active had greater functional improvement than males advised to rest, a difference that was both statistically significant and clinically meaningful (mDASH improvement 1.47, p=0.003). In contrast, among females, active advice was not associated with an improvement in outcome (mDASH improvement -0.17, p=0.68). This sex-treatment interaction was evident from 6-week follow-up (mDASH improvement in men, compared to women, among those advised to remain active: 1.11, p=0.05). No other factors were identified as effect modifiers.

Conclusion: Of six patient characteristics investigated as possible effect modifiers of advice for distal upper limb pain, only gender was identified to be of statistical significance and clinical importance. Active advice, previously found to be more effective overall, was particularly effective in males. It should be noted that the trial was not powered specifically to look at interactions and that this secondary data analysis was hypothesis-generating. The mechanisms driving the gender effect require further study before the introduction of stratified management approaches in distal upper limb pain can be supported.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/do-some-patients-with-distal-upper-limb-pain-benefit-more-than-others-from-advice-to-remain-active/