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Abstract Number: 2218

Do Some Patients with Distal Upper Limb Pain Benefit More Than Others from Advice to Remain Active?

Daniel Whibley1,2,3, Kathryn Remmes Martin1,2,3, Karina Lovell4, Gary J. Macfarlane1,2,3, Keith Palmer5,6, David Coggon5,6, Karen Walker-Bone5,6, Kim Burton7, Peter Heine8, Candida McCabe9,10, Paul McNamee11, Alex McConnachie12 and Gareth T. Jones1,2,3, 1Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom, 2Arthritis Research UK / MRC Centre for Musculoskeletal Health and Work, University of Aberdeen, Aberdeen, United Kingdom, 3Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom, 4School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, United Kingdom, 5MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom, 6University of Southampton, Arthritis Research UK / MRC Centre for Musculoskeletal Health and Work, Southampton, United Kingdom, 7Centre for Health and Social Care Research, University of Huddersfield, Huddersfield, United Kingdom, 8Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom, 9University of West of England, Bristol, Bristol, United Kingdom, 10Royal United Hospitals NHS Foundation Trust, Bath, United Kingdom, 11Health Economics Research Unit, University of Aberdeen, Aberdeen, United Kingdom, 12Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom

Meeting: 2016 ACR/ARHP Annual Meeting

Date of first publication: September 28, 2016

Keywords: Disability, pain, patient outcomes and physical therapy

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Session Information

Date: Tuesday, November 15, 2016

Title: Fibromyalgia, Soft Tissue Disorders, Regional and Specific Clinical Pain Syndromes - Poster II: Clinical Focus

Session Type: ACR Poster Session C

Session Time: 9:00AM-11:00AM

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.


Disclosure: D. Whibley, None; K. R. Martin, None; K. Lovell, None; G. J. Macfarlane, None; K. Palmer, None; D. Coggon, None; K. Walker-Bone, None; K. Burton, None; P. Heine, None; C. McCabe, None; P. McNamee, None; A. McConnachie, None; G. T. Jones, None.

To cite this abstract in AMA style:

Whibley D, Martin KR, Lovell K, Macfarlane GJ, Palmer K, Coggon D, Walker-Bone K, Burton K, Heine P, McCabe C, McNamee P, McConnachie A, Jones GT. Do Some Patients with Distal Upper Limb Pain Benefit More Than Others from Advice to Remain Active? [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/do-some-patients-with-distal-upper-limb-pain-benefit-more-than-others-from-advice-to-remain-active/. Accessed .
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