Download Effective management of upper limb disorders by general practitioners and

HSE
Health & Safety
Executive
Effective management of upper limb
disorders by general practitioners and
trainee occupational physicians
Prepared by the Institute of Occupational and
Environmental Medicine
for the Health and Safety Executive 2005
RESEARCH REPORT 380
HSE
Health & Safety
Executive
Effective management of upper limb
disorders by general practitioners and
trainee occupational physicians
Joanne O Crawford PhD M Erg S
Elpiniki Laiou BSc MSc
Insitute of Occupational and Environmental Medicine
Division of Primary Care, Public and Occupational Health
School of Medicine
The University of Birmingham
Edgbaston
Birmingham
B15 2TT
The Institute of Occupational and Environmental Medicine were commissioned to carry out research to
identify how health professionals could become more effective in the clinical management of cases of
work related upper limb disorders, to identify their training needs and to investigate discrepancies
between current and best practice.
The objectives of the study were to:
�
Identify current best practice in the clinical management of work related upper limb disorders by
reviewing the literature and contacting relevant institutions and associations.
�
To determine the nature of teaching on this subject in the training of Occupational Physicians and GPs.
�
To gather information via focus groups and questionnaire survey to identify perceived difficulties
in the management of upper limb disorders and identify training needs.
�
To review key findings from the previous steps and to report results and recommendations.
The study found that there was a lack of good quality of research for specific disorders but some
evidence was identified. Education on this topic in the UK was reviewed. The focus groups were used to
develop the questionnaire. The questionnaire response rate was not high but results were summarised.
The recommendations from this study include improving teaching of this topic at undergraduate level,
ensuring access to professional groups by practitioners, improving the evidence base by better quality
research, producing guidelines for best practice, ensuring that training is more accessible and
examining other media that can be used in
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its
contents, including any opinions and/or conclusions expressed, are those of the authors alone and do
not necessarily reflect HSE policy.
HSE BOOKS
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First published 2005
ISBN 0 7176 6158 X
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ii
Acknowledgements
The authors would like to acknowledge the participants who took part in this research. Without
their involvement in the focus groups and questionnaire survey, this research would not have
happened.
iii
iv CONTENTS
Index of Tables............................................................................................................................ vii
Index of Figures ........................................................................................................................... ix
Executive Summary ......................................................................................................................xi
1 Introduction ................................................................................................................................ 1
1.1 Our Approach……………………………………………………………………………....1
2 Literature review ........................................................................................................................ 2
2.1 Introduction ......................................................................................................................... 2
2.2 Search Strategy.................................................................................................................... 2
2.3 Musculoskeletal Education ................................................................................................. 3
2.4 Diagnosis of ULDs.............................................................................................................. 6
2.5 General Management of Work Related Musculoskeletal Disorders ................................... 6
2.6 Carpal Tunnel Syndrome .................................................................................................... 9
2.7 Epicondylitis Medial and Lateral ...................................................................................... 12
2.8 Rotator Cuff Tendonitis and Bicipital Tendonitis ............................................................. 18
2.9 Shoulder Capsulitis ........................................................................................................... 19
2.10 Impingement Syndrome .................................................................................................. 20
2.11 Tenosynovitis and Flexor-extensor Peritendonitis of the Hand and Forearm ................. 21
2.12 Tendonitis of the Wrist and Forearm .............................................................................. 22
2.13 De Quervain’s Disease .................................................................................................... 22
2.14 Cervical Spondylosis....................................................................................................... 23 2.15 Diffuse Non-Specific Upper Limb Disorders ................................................................. 24
2.16 Tension Neck .................................................................................................................. 25
2.17 Summary of Conservative Treatments for Upper Limb Disorders ................................. 26
3. Current Education in UK Medical Schools and Postgraduate Deaneries................................ 40
3.1 Undergraduate Teaching in Universities ........................................................................... 40
3.2 Postgraduate Deaneries ..................................................................................................... 42
3.3 Training for Occupational Physicians in the UK .............................................................. 43
3.4 Other Training opportunities ............................................................................................. 43
4. Focus Group Analysis and Findings ....................................................................................... 44
4.1 Reasons for the Qualitative Enquiry ................................................................................. 44
4.2 Method ............................................................................................................................. 44
4.3. Focus Group Results ....................................................................................................... 46 4.4. Discussion ....................................................................................................................... 68
5. Questionnaire Survey .............................................................................................................. 77
5.1 Introduction ....................................................................................................................... 77
5.2 Methodology ..................................................................................................................... 77
5.3 Results ............................................................................................................................... 77
5.4 Discussion ....................................................................................................................... 110
6. Recommendations ................................................................................................................. 114
6.1 Training ........................................................................................................................... 114
6.2 Clinical management....................................................................................................... 115
6.3 Perceived difficulties in managing upper limb disorders ................................................ 115
6.4 Training needs ................................................................................................................. 115
v
Appendix 1 Focus Group Content Analysis.............................................................................. 117
Appendix 2. Questionnaires Used in Questionnaire Survey ..................................................... 136
Appendix 3 Questionnaire Data ................................................................................................ 165
References ................................................................................................................................. 181
vi INDEX OF TABLES
Table 1 Diagnostic and surveillance criteria for carpal tunnel syndrome ..................................... 9
Table 2 Diagnostic and surveillance criteria for medial and lateral epicondylitis ...................... 13
Table 3 Diagnostic and surveillance criteria for rotator cuff syndrome...................................... 18
and bicipital tendonitis ................................................................................................................ 18
Table 4 Diagnostic and surveillance criteria for shoulder capsulitis........................................... 19
Table 5 Diagnostic and surveillance criteria for tenosynovitis ................................................... 21
Table 6 Diagnostic and surveillance criteria for de Quervain’s disease ..................................... 23
Table 7 Diagnostic and surveillance criteria for diffuse non-specific upper limb disorders....... 24
Table 8 Summary of evidence..................................................................................................... 27 Table 9 Formal training in musculoskeletal disorders ................................................................ 42
Table 10 Informal (on-the-job) training in musculoskeletal disorders........................................ 43
Table 11 Training in musculoskeletal disorders.......................................................................... 78
Table 12 Sources of vocational upper limb musculoskeletal disorders training ......................... 78
Table 13 Treatment options for tenosynovitis............................................................................. 80
Table 14 Treatment options for tendonitis .................................................................................. 80
Table 15. Treatment options for carpal tunnel syndrome ........................................................... 81
Table 16 Treatment options for de Quervain’s disease ............................................................... 81
Table 17 Treatment options for epicondylitis ............................................................................. 82
Table 18 Treatment options for rotator cuff syndrome and bicipital tendonitis.......................... 82
Table 19 Treatment options for shoulder capsulitis .................................................................... 82
Table 20 Treatment options for cervical spondylosis ................................................................. 83
Table 21 Treatment options for impingement syndrome ............................................................ 83
Table 22 Treatment options for tension neck .............................................................................. 84
Table 23 Treatment options for diffuse non-specific upper limb disorders ................................ 84
Table 24 Contact with occupational physician............................................................................ 85
Table 25 Referrals for musculoskeletal problems ....................................................................... 85
Table 26 Barriers when referring patients ................................................................................... 89
Table 27 Training in musculoskeletal disorders.......................................................................... 93
Table 28 Sources of vocational upper limb musculoskeletal disorders training ......................... 93
Table 29 Courses undertaken in relation to upper limb disorders............................................... 94
Table 30 Previous job.................................................................................................................. 95
Table 31 Treatment options for tenosynovitis............................................................................. 96
Table 32 Treatment options for hand/forearm tendonitis............................................................ 96
Table 33 Treatment options for carpal tunnel syndrome ............................................................ 97
Table 34 Treatment options for de Quervain’s disease ............................................................... 97
Table 35 Treatment options for epicondylitis ............................................................................. 98
Table 36 Treatment options for rotator cuff syndrome and bicipital tendonitis.......................... 98
Table 37 Treatment options for shoulder capsulitis .................................................................... 99
Table 38 Treatment options for cervical spondylosis ................................................................. 99
Table 39 Treatment options for impingement syndrome .......................................................... 100
Table 40 Treatment options for tension neck ............................................................................ 100
Table 41 Treatment options for diffuse non-specific upper limb disorders .............................. 101
Table 42 Do you initiate contact with patient’s GP .................................................................. 101
Table 43 Referrals for musculoskeletal problems ..................................................................... 102
Table 44. Barriers when referring patients ................................................................................ 107
vii
Table A1.1 Content analysis of the ‘ULD management’ dimension based on the Occupational Physicians’ quotes. .................................................................................................................... 118 Table A1.2. Content analysis of the ‘ULD management’ dimension based on the TOPs’ quotes.
................................................................................................................................................... 119
Table A1.3 Content analysis of the ‘ULD management’ dimension based on the GPs’ quotes.
................................................................................................................................................... 121
Table A1.4 Content analysis of the ‘best practice’ dimension based on the Occupational Physicians’ quotes. .................................................................................................................... 122
Table A1.5 Content analysis of the ‘best practice’ dimension based on the TOPs’ quotes. .... 123
Table A1. 6. Content analysis of the ‘best practice’ dimension based on the GPs’ quotes...... 123
Table A1.7. Content analysis of the ‘training’ dimension based on the Occupational Physicians’
quotes. ....................................................................................................................................... 124
Table A1.8 Content analysis of the ‘training’ dimension based on the TOPs’ quotes.............. 125
Table A1.9 Content analysis of the ‘training’ dimension based on the GPs’ quotes. ............... 126
Table A1.10 Content analysis of the ‘informal learning’ dimension based on the Occupational Physicians’ quotes. .................................................................................................................... 127
Table A1.11 Content analysis of the ‘informal learning’ dimension based on the TOPs’ quotes.
................................................................................................................................................... 127
Table A1.12 Content analysis of the ‘informal learning’ dimension based on the GPs’ quotes.
................................................................................................................................................... 128
Table A1.13 Content analysis of the ‘evidence base’ dimension based on the Occupational Physicians’ quotes. .................................................................................................................... 129
Table A1.14 Content analysis of the ‘evidence base’ dimension based on the TOPs’ quotes. . 129
Table A1.15. Content analysis of the ‘evidence base’ dimension based on the GPs’ quotes. . 130
Table A1.16 Content analysis of the ‘perceived difficulties’ dimension based on the Occupational Physicians’ quotes. .............................................................................................. 131
Table A1.17 Content analysis of the ‘perceived difficulties’ dimension based on the TOPs’
quotes. ....................................................................................................................................... 132
Table A1.18 Content analysis of the ‘perceived difficulties’ dimension based on the GPs’
quotes. ....................................................................................................................................... 133
Table A1.19 Content analysis of the ‘training needs’ dimension based on the Occupational Physicians’ quotes. .................................................................................................................... 133
Table A1.20 Content analysis of the ‘training needs’ dimension based on the TOPs’ quotes.. 134
Table A1.21 Content analysis of the ‘training needs’ dimension based on the GPs’ quotes. ... 135
Table A3.1 GP training in upper limb musculoskeletal disorders............................................. 165
Table A3.2 GP training in work related upper limb musculoskeletal disorders ....................... 166
Table A3.3 GP sources of information in professional development ...................................... 167
Table A3.4 GP level of confidence with different aspects of upper limb management............ 168
Table A3.5 GP evidence base in the choice of treatment of musculoskeletal disorders ........... 169
Table A3.6 GP perceived difficulties in establishing a diagnosis ............................................. 170
Table A3.7 GP difficulties in managing upper limb disorders.................................................. 171
Table A3.8 GP level of interest in continuing medical education topics .................................. 172
Table A3.9 TOP training in upper limb musculoskeletal disorders .......................................... 173
Table A3.10 TOP training in work related upper limb musculoskeletal disorders ................... 174
Table A3.11 TOP sources of information in professional development ................................... 175
Table A3.12 TOP level of confidence with different aspects of upper limb management ....... 176
Table A3.13 TOP evidence base in the choice of treatment of musculoskeletal disorders....... 177
Table A3.14 TOP perceived difficulties in establishing a diagnosis......................................... 178
Table A3.15 TOP difficulties in managing upper limb disorders ............................................. 179
Table A3.16 TOP level of interest in continuing medical education topics.............................. 180
viii
INDEX OF FIGURES Figure 1. Teaching Functioning Musculoskeletal System ......................................................... 40
Figure 2. Teaching Musculoskeletal Abnormalities................................................................... 41
Figure 3. Teaching of WRMDs .................................................................................................. 41
Figure 4. Sources of Information Used in Professional Development ....................................... 79
Figure 5. Level of Confidence with Different Aspects of Upper Limb Management................ 86
Figure 6. Evidence Base in your Choice of Treatment of Musculoskeletal Disorders............... 87
Figure 7. Perceived Difficulties in Establishing a Diagnosis ..................................................... 88
Figure 8. Difficulties in Managing Upper Limb Disorders ........................................................ 89
Figure 9. Level of interest in Continuing Medical Education Topics ........................................ 91
Figure 10. Sources of Information Used in Professional Development ..................................... 94
Figure 11. Level of Confidence with Different Aspects of Upper Limb Management............ 103
Figure 12. Evidence Base in the Choice of Treatment of Upper Limb Disorders.................... 104
Figure 13. Perceived Difficulties in Establishing a Diagnosis ................................................. 105
Figure 14. Difficulties in Managing Upper Limb Disorders .................................................... 106
Figure 15. Level of Interest in Continuing Medical Education Topics .................................... 109
ix
x
EXECUTIVE SUMMARY The Institute of Occupational and Environmental Medicine were commissioned to carry out
research to identify how health professionals could become more effective in the clinical
management of cases of work related upper limb disorders.
The objectives of the study were to:
Identify best practice in the clinical management of work related upper limb disorders by
reviewing the literature and contacting relevant institutions and associations
To determine the nature of teaching on this subject in the training of Occupational Physicians
and GPs
To gather information via focus groups and questionnaire survey to identify perceived
difficulties in the management of upper limb disorders and identify training needs.
To review key findings from the previous steps and to report results and recommendations.
The study comprised of three main parts:
Reviewing available literature on the conservative management of specific and non specific
upper limb disorders
Contacting UK universities and postgraduate training centres to identify when and where in the
curriculum musculoskeletal disorders are covered
Convening three focus groups and developing a questionnaire survey for GPs and Trainee
Occupational Physicians to identify training received, management of upper limb disorders, the
evidence base used, perceived difficulties and training needs.
The literature review identified that there is evidence for the efficacy of conservative treatments
in the management of carpal tunnel syndrome (the use of steroids and steroid injection, range of
motion exercises), epicondylitis (topical NSAIDs and steroid injection), rotator cuff tendonitis
and bicipital tendonitis (NSAIDs and steroid injection), impingement syndrome (home exercise
programmes and manual therapy) and tension neck (workplace intervention). There was no
evidence to support the use of conservative treatments for tenosynovitis, tendonitis, de
Quervain’s disease, cervical spondylosis or diffuse non-specific upper limb disorders. The
evidence reviewed was not always found to be high quality and there are serious methodological
issues with much of the research reviewed.
With regard to education, the majority of universities who responded, covered musculoskeletal
issues, however, not every course could identify what they covered for work related
musculoskeletal disorders. For postgraduate training, a number of opportunities were identified
for GPs and Occupational Physicians. It was highlighted that during GP training, further
training could be obtained if it was identified as a learner-centred need.
To develop a questionnaire, three focus groups were convened including experienced
Occupational Physicians, General Practitioners and a group of trainee Occupational Physicians.
The focus groups and questionnaire aimed to address the following areas: Training and training sources in musculoskeletal disorders
Management of upper limb disorders
The evidence base used in the management of upper limb disorders
Perceived difficulties in managing upper limb disorders
Training needs
The response rate for the focus groups was 90% for the experienced physicians, 40% for the
General Practitioners and 40% for the trainee Occupational Physicians. The response rate to the
questionnaire survey was 10.6% for the GPs and 8.2% for the trainee Occupational Physicians.
It is recognised that the findings of the present study are limited by the small sample size. In
xi
view of this, some caution must be exercised when generalising the findings. This highlights
the difficulty in obtaining specific groups including physicians for research projects.
The focus groups and questionnaire identified that the majority of training in musculoskeletal
disorders was during the registrar years by Continuous Medical Education. For vocational
training, orthopaedics and rheumatology were the main sources used. Contact with other
professionals was also identified as important and this appeared easier for those in occupational
health. Sources identified as important for professional development included books, journals
and contact with other medical specialists.
With regard to management of upper limb disorders, there was some consistency in the results
from both groups. When comparing management with the evidence reviewed, good practice
was identified in a number of disorders but this was not always consistent. Respondents were
also asked to identify their level of confidence in particular aspects of upper limb management;
levels of confidence reflected training in specific aspects of management.
The evidence base used in the management of upper limb disorders included previous clinical
experience, previous training, Continuous Medical Education, textbooks and the patient’s
positive feedback.
The questionnaire survey also asked respondents about the perceived difficulties in managing
specific aspects of upper limb disorders. With regard to diagnosis, diffuse non-specific upper
limb disorders were as an issue. The areas identified as being problematic in managing were
psychosocial factors, recurrent symptoms, chronicity and the patient’s high expectations
compared to other issues. Barriers to treatment identified were not barriers to accessing
services, rather the long waiting for other specialists e.g., physiotherapy or rheumatology.
Respondents were asked to identify their interest in training needs of various topics. Both
groups were consistent in identifying training needs but differences were found in that joint
injections were rated more highly for GPs and psychosocial factors, and work relatedness for
trainee Occupational Physicians. The trainee Occupational Physicians also most often rated
solid evidence-based guidelines as being important. The main barriers to training identified
were time and financial constraints.
Recommendations from the study include: For current training and resources, improving teaching of this topic at undergraduate level and
ensuring opportunities are created to allow meetings with other healthcare professionals
(Section 6.1).
For clinical management of upper limb disorders there is a need to improve the evidence base
by high quality research and to produce guidelines for practitioners similar to those for back
pain and HAVS (Section 6.2).
With regard to perceived difficulties, there is a need to ensure that the patient is as well
informed as possible about the possible duration of symptoms. Further research is vital with
regard to psychosocial issues and their impact on musculoskeletal disorders as is improving the
time taken to see other specialists. (Section 6.3).
Where training is concerned, this needs to be accessible hands-on training but investigation
should also be made of the usefulness of electronic media including CD-ROMs and accredited
websites. (Section 6.4).
xii
1 INTRODUCTION The Institute of Occupational and Environmental Medicine was commissioned to carry out
research to identify how health professionals – in this case GPs and trainee Occupational
Physicians can become more effective in the clinical management of upper limb disorders
(ULDs); to identify their training needs and investigate discrepancies between current and best
practice in clinical management.
The objectives of the project were to:
• Identify current best practice in the clinical management of ULDs by literature review
and other data sources
• Determine the nature of teaching in this subject area in the training of Occupational
Physicians and GPs
• To gather information via focus groups and questionnaire survey to identify perceived
difficulties and training needs in the management of ULDs
• To present recommendations and conclusions.
1.1 Our Approach
The study comprised of 4 main parts.
Reviewing available literature
Contacting Universities and Postgraduate Deaneries
Carrying out Focus Groups with experienced Occupational Physicians, GPs and trainee
Occupational Physicians (TOPs)
Conducting a questionnaire survey with GPs and TOPs
The literature review was carried out to identify what current evidence there is in
musculoskeletal medicine nationally and internationally for the management of musculoskeletal
disorders and ULDs. The review also identified evidence on diagnosis and conservative clinical
management of ULDs to find best practice in the diagnosis and management of ULDs.
Due to the nature of the research, the study had to undergo ethical clearance. The London
Multicentre Research Ethics Committee reviewed the protocol and data collection tools. The
study obtained ethical clearance for all elements involving participants.
The second stage of the research was communication with those involved in the education of
physicians, GPs and Occupational Physicians. Further research aimed to identify other sources
of education and training for physicians with regard to ULDs.
The focus groups were convened as this was deemed as the most appropriate method for the
development of a questionnaire survey that would aim to explore physicians’ perceptions of the
difficulties of managing ULDs.
The final part of the study was a questionnaire survey to 650 physicians to identify sources of
training, resources used in their current practice, perceptions of difficulties in managing ULDs
and their training needs.
1
2 LITERATURE REVIEW
2.1 INTRODUCTION
The following literature review aims to examine current available evidence on musculoskeletal
education in medicine both internationally and nationally and on diagnosis and conservative
clinical management of ULDs by physicians. The review is presented by firstly focusing on
education at undergraduate and postgraduate level in the area of musculoskeletal medicine.
Sections follow this on diagnosis of ULDs, general management of ULDs and finally specific
disorders, their diagnosis and management.
After each section a summary of the findings is provided in order to give a brief overview of
current knowledge. There are however, situations where there has not been enough research
carried out to indicate the efficacy of specific treatments. This highlights areas where more
research is required to identify the efficacy of treatments.
2.2 SEARCH STRATEGY
The relevant literature was obtained via the following research strategy. Keywords were
identified including the following:
•
•
•
•
•
•
•
•
Musculoskeletal
Diagnosis
Treatment
Medical Management
General Practitioner
Occupational Physician
Education
Training
These were then cross-searched with the following disorders that were identified by the
sponsors.
•
•
•
•
•
•
•
•
•
•
•
•
•
Musculoskeletal Disorders
Upper Limb Disorders
Tendonitis (fingers, hand or forearm)
Tenosynovitis (hand/forearm)
Rotator Cuff Tendonitis and Bicipital Tendonitis
Carpal Tunnel Syndrome
De Quervain’s Disease
Shoulder Capsulitis
Epicondylitis Medial and Lateral
Cervical Spondylosis
Diffuse Non-Specific Upper Limb Disorders
Tension Neck
Impingement Syndrome
The following databases were searched using these terms within the time frame of 1993 to
2004.
2
• Web of Knowledge databases (Science Citation Index and the Social Science Citation
Index)
• Medline and Pub Med
• Ergonomics Online
• The Cochrane Library
• BMJ Clinical Evidence (http://www.clinicalevidence.com)
Systematic Reviews were identified via the Cochrane library and included in the current review.
The first sweep of the databases identified 408 references. The researchers reviewed the
abstracts for the references. This allowed relevant publications to be identified from the
abstracts. Full papers that included diagnostic methods, conservative treatments, new data,
systematic reviews and musculoskeletal education were then obtained.
2.3 MUSCULOSKELETAL EDUCATION
2.3.1 The international perspective
From an international viewpoint, the World Health Organisation (WHO) has dedicated the years
2000 – 2010 as Bone and Joint Decade. This has been highlighted by Akesson et al (2003), in
the Bulletin of the WHO. This paper emphasises some of the issues with regard to general
musculoskeletal problems in that it suggests that individuals with musculoskeletal problems
often have their health problems underestimated by doctors; it is suggested that this is due to a
lack of knowledge and education by physicians (1). In treating patients with musculoskeletal
problems, a number of different medical specialities are often involved - this can result in poor
treatment outcomes and a lack of cohesion in approach (1).
A number of research papers have found that general education in musculoskeletal medicine is
essential for all physicians but is lacking in some medical school curricula (1), (2). There has been
a suggestion that subjects such as Rheumatology and musculoskeletal system examination are
perceived as not important by some clinicians (3), (4). This is despite the fact that in Canada, the
main reason for visits to primary care physicians is musculoskeletal problems. In the U.S.A.,
Saywell et al (4) report that musculoskeletal and orthopaedic complaints are the second most
common complaint dealt with by primary care physicians after upper respiratory tract
infections. Akesson et al (1), report that everyone at some time will suffer from a problem
relating to the musculoskeletal system. This is compounded by the fact that the increasing older
population is likely to increase the burden of musculoskeletal disease and disorders in this area
(5)
.
Akesson et al (1), highlight the problems at both undergraduate and postgraduate level. At
undergraduate (pre-clinical) level, less than 3% of the curriculum time is spent in teaching
musculoskeletal diseases and injuries. At clinical teaching level, there is little teaching of this
subject and any elective programmes are often geared to surgery rather than conservative
treatments.
Saywell et al (4) and Freedman and Bernstein (5), report that although
musculoskeletal health problems account for more than 20% of primary care and emergency
visits, only 3% of pre-clinical training is devoted to this area. In addition, this study found that
mandatory teaching of clinical musculoskeletal medicine occurs in only 12% of U.S. Medical
Schools. This is reiterated by Pinney and Regan (6) in a survey of Canadian Medical Schools.
In terms of teaching hours, a survey of 32 countries and different medical specialities found that
the median teaching time for Rheumatology was 26 hours, Orthopaedics; 30 hours contact time,
Surgery for Trauma 21 hours and Physical Medicine Rehabilitation 20 hours (1). This appears to
3
be unusually short in comparison to the length of medical education and the number of
consultations made about musculoskeletal problems.
For postgraduate training, Akesson et al (1) suggest that many family doctors or primary care
physicians do not have adequate training. This statement is justified by the study of Craton and
Matheson (7) where only 3.5% of interns choose Orthopaedic Surgery and less than 1% had
training in combined subjects such as Rheumatology, Sports Medicine and Physical Medicine.
Matheny et al (8) report that family practice interns were found to have lower confidence in
physical examination and the diagnosis and treatment of musculoskeletal problems in
comparison with medical management of other health problems. In examining musculoskeletal
problems, Saywell et al (4), found that students in family medicine clerkships in year 3 of their
studies were significantly less confident in treating musculoskeletal problems. This paper does
imply that this may be due to the timing of orthopaedic education that does not happen until the
fourth year in this medical school.
Glazier et al (9), also highlight the need for mandatory exposure to musculoskeletal problems
during training and some innovative approaches to Continuous Medical Education (CME) are
suggested. In their questionnaire survey of 798 Ontario family physicians, participants were
asked how they would approach three scenario-based cases from a previously agreed list of
treatments. The results found that management of musculoskeletal problems was in line with
best practice agreed in the study. However, the results did identify unnecessary use of
diagnostic tests and Non-Steroidal Anti Inflammatory Drugs (NSAIDs). Few respondents to the
survey would use more conservative and patient centred treatments such as exercise
programmes; the authors found this disappointing.
The international perspective on musculoskeletal medical training has highlighted that there are
concerns with medical education in this area especially with regard to changing demographics
and thus health problems among society as a whole. However, much of the literature obtained
in this area describes general musculoskeletal medicine – no specific information was found on
work related musculoskeletal problems and training at an international level.
2.3.2 Undergraduate medical education in the United Kingdom
Kay et al (2), surveyed medical schools in the UK about Rheumatology teaching. The study was
a comparison study of data previously collected in 1990. The results found that all medical
schools taught Rheumatology but only 18 medical schools taught Clinical Rheumatology. The
study also found that only 3 medical schools taught Rheumatology as a stand-alone subject; 18
of the schools surveyed taught Orthopaedics and Rheumatology, 10 taught Rheumatology with
General Medicine and 6 taught Rheumatology with Rehabilitation Medicine. Although the
majority of schools surveyed did teach Clinical Rheumatology, it was found that this was not a
mandatory subject in 5 of the participant schools. Although the survey has found changes in
medical school curricula, which are in line with national recommendations, there is concern that
there has been little emphasis on linking Rheumatology teaching to Primary Care.
Basu et al (10), compared competence in Musculoskeletal Medicine, Cardiovascular Medicine
and Neurology in undergraduate medical students in one medical school. The study was carried
out due to a concern that new graduates in Medicine were lacking appropriate knowledge in
Musculoskeletal Medicine. This was due to the curriculum design where there was more time
spent on Cardiology and Neurology training versus Musculoskeletal Medicine. The study
evaluated a computer-based assessment for Musculoskeletal Medicine, Cardiology and
Neurology. The results found that there were no significant differences between the subject
areas when tested. However, the authors do state that the results cannot be generalised to other
4
medical schools. Another issue highlighted by the authors is that although an adequate
knowledge base has been identified in the students tested, future work needs to identify if that
can be translated into effective clinical practice. The authors of this paper also ask for a refining
of guidelines from specialist bodies to design undergraduate musculoskeletal medical education.
The picture for occupationally related musculoskeletal disorders in undergraduate medicine has
been investigated by Wynn et al (11), in a survey of U.K. Medical Schools. The aim of the
survey was to examine any changes in commitment to teaching Occupational Medicine at
undergraduate level. A postal survey was sent to the 24 academic leads responsible for health
and safety/occupational health or public health training in U.K. universities. A response rate of
19 institutions (79%) was achieved. This study, although it concentrated on Occupational
Medicine, found that only 12 (63%) of the medical schools surveyed covered work related
musculoskeletal disorders.
2.3.3 Postgraduate medical education in the United Kingdom
At Postgraduate level, Akesson et al (1) report that in 1990 in the UK, only 10% of vocational
training schemes for primary care physicians included Orthopaedics. It is not clear whether this
situation is still the same at a national level within the UK.
Dubey et al (12), surveyed specialist registrars (N=198) to assess perceptions of quality for
training in Rheumatology and to identify training strategies that trainees’ felt improved their
learning. The results found that training in patient care, injections and musculoskeletal
examination were rated positively by respondents. However, training in Primary Care
Rheumatology, Paediatric Rheumatology, Sports Medicine and Epidemiology received a
negative rating. The main factor highlighted in influencing training was workload due to the
reduction in junior doctor hours leaving less time for training. Other issues raised were a lack
of central structure to training and a lack of IT access to apply evidence-based medicine. The
authors recommend that curricula for Primary Care Musculoskeletal Medicine, Sports Medicine
and Paediatric Rheumatology need to be re-examined. Training innovations suggested by the
participants included focussed training workshops, discussions after outpatient clinics and
increased consultation time.
Roberts et al (13) carried out a survey of 446 GPs in Sheffield and Barnsley in 1999. With a
response rate of 54%, the survey examined a number of factors about treatment of
musculoskeletal disorders. These included patterns of referral, practitioner’s perceived
workload and the usefulness of relevant educational interventions. This study found that
musculoskeletal disorders made up 18% of the GPs workload. It also identified that GPs were
on the whole happy to manage common musculoskeletal conditions such as gout, back pain,
osteoarthritis and sporting injuries. The referral pattern found that rheumatoid arthritis and
osteoporosis were normally referred on to a consultant. The GPs surveyed in the study did
highlight the lack of resources in support of services of this type.
Duckett and Casserley (14) published a paper in 2003 about the development of an orthopaedic
GP fellowship. This paper reports on 9 GPs who attended the fellowship programme, which
covered history taking, examination, diagnosis, investigation of orthopaedic problems and intraarticular injection techniques. The study found that referral rates to local hospitals increased by
2.7%. There was also an increase in the number of referrals to physiotherapy services and an
increase in the number of intra-articular injections carried out (from 4 to 11). This is a very
small study but it suggested that the orthopaedic GP fellowship did improve the medical
management of patients.
5
As in the previous section, there are a number of papers on postgraduate education in the field
of musculoskeletal medicine. However, all of the papers obtained were on general
musculoskeletal health and not occupationally related.
2.3.4 The future for musculoskeletal medical education
The papers reviewed in this section highlighted that there are a number of issues with regard to
the quality of musculoskeletal education at both an international level and within the UK. There
has been agreement by authors about what is required for future education. There is a need to
agree on a core curriculum and on musculoskeletal examination requirements (1). At
postgraduate level, Akesson et al (1) suggest that with better educated students at undergraduate
level, future training programmes at postgraduate level can be developed to include training
within specialities such as Rheumatology, Orthopaedics and Rehabilitation Medicine within
family practice.
It would be hoped that this change in musculoskeletal medical education would also influence
diagnosis and treatment of work related musculoskeletal disorders. However, Melhorn (15), in a
position paper suggests that orthopaedic specialists in this century will need to understand workrelated injuries and their management including non-medical issues such as early return to
work, prevention via ergonomics and intervention studies.
2.4 DIAGNOSIS OF ULDS
Although a large amount of research has been carried out in the field of ULDs, much of the
research has been beset by a number of problems that include a lack of consistency in diagnosis
of specific disorders.
Harrington et al (16), using the Delphi technique and a 3-stage process examined nine different
disorders using a core group of 29 UK experts. The experts involved in the study were cross
disciplinary and representative of Rheumatology, Surgery, Occupational Health, Epidemiology,
Physiotherapy, General Practice, Psychiatry, Psychology and Pain Physiology. Agreement for
case-definition for Carpal Tunnel Syndrome, Tenosynovitis of the wrist, de Quervain’s Disease
of the wrist, Epicondylitis, Shoulder Capsulitis and Shoulder Tendonitis was reached using this
methodology.
The Health and Safety Executive in 2002 (17) published up-dated guidance on the management
of ULDs including up-dated information on diagnostic criteria for common upper limb
disorders. This was based on the work of Harrington et al (16) but has shown a level of
consensus for the common work related upper limb disorders.
Sluiter et al (18) in their report presented case definitions for 11 ULDs including Radiating Neck
Complaints, Rotator Cuff Syndrome, Epicondylitis (lateral and medial), Cubital Tunnel
Syndrome, Radial Tunnel Syndrome, Tenosynovitis of the forearm and wrist region, de
Quervain’s Disease, Carpal Tunnel Syndrome, Guyon Canal Syndrome, Raynaud’s phenomena,
Osteoarthrosis of the distal upper-extremity joints and Non-Specific Upper-Extremity
Musculoskeletal Disorders. These definitions will be returned to within the review.
2.5 GENERAL MANAGEMENT OF WORK RELATED MUSCULOSKELETAL
DISORDERS
As part of the review, papers were identified that related to particular musculoskeletal disorders,
but 21 papers covered general management of musculoskeletal problems. All twenty-one
papers were obtained but after reading, only 2 were found to be relevant to the study. The 19
papers rejected were not applicable as they related to Rheumatoid Arthritis and Arthritis and did
not bring new data to the research.
6
In terms of general management of work related musculoskeletal disorders, two papers were
found to cover this area. O’Neil et al (19), published an evidence-based review of Repetitive
Strain Injuries (RSI) including common disorders such as Carpal Tunnel Syndrome,
Epicondylitis and Rotator Cuff Tendonitis. The study found that for prognosis and treatment of
musculoskeletal disorders, the prognosis is less good for those individuals who have a longer
duration of symptoms (19).
The treatment for chronic tendon injuries is similar to that of acute tendon injuries. The use of
rest, ice, compression and elevation (RICE) for the first 48 hours, recommendations of light
duties and ergonomic adjustments to the workplace were recommended. O’Neil et al’s (19)
review also investigated limb immobilisation as a treatment but they suggested caution as this
may lead to muscle atrophy and limb stiffness. Instead, early eccentric exercising with drugs
such as NSAIDs and analgesics may be a preferred option. With regard to particular disorders,
the recommended treatment for Epicondylitis was steroid injections for short-term relief, while
research indicated that topical NSAIDs and bands on the forearm could also relieve symptoms,
but shock wave therapy was not found to help. The treatment of Rotator Cuff Tendonitis
included the use of RICE and NSAIDs, and steroid injections for the short-term relief of pain,
while steroid-lidocaine injections were indicated for the treatment of de Quervain’s Disease.
For Carpal Tunnel Syndrome, recommendations for treatment included ergonomic adjustments
to the workstation and steroid injections to reduce pain, whereas it was pointed out that specific
nerve gliding exercises were found to improve prognosis better than splinting. The paper by
O’Neil et al does stress that surgery should only be carried out when symptoms continue after
all conservative treatment routes have been considered.
The paper by Hagberg (20) is an educational publication in the British Medical Journal. As such,
the paper reviews management of work related disorders of the neck and arm. A number of
treatment options are suggested including NSAIDs, which can reduce both pain and
inflammation; acupuncture which the author suggests can reduce pain; corticosteroid injection
which can cure Shoulder Tendonitis with a single subacromial injection and treatment of Lateral
Epicondylitis and Carpal Tunnel Syndrome by corticosteroid injection by specialists only. With
regards to surgery, surgical division of the carpal ligament is the first choice of treatment for
Carpal Tunnel Syndrome, whereas surgery for chronic severe Shoulder Tendonitis has been
found to improve pain at night. The author agrees that the use of splints in the treatment of
Carpal Tunnel Syndrome and Tendonitis is not proven.
Hagberg (20) also suggests a number of modifications to the workplace including job analysis,
job design and technique training. These are suggested as means of identifying whether
symptoms are work related, whether risky job factors can be reduced and whether working
technique can also be changed to reduce the risk of injury or trauma. This paper does
summarise the available information, however, it is an educational report and not a review of
current knowledge. It may however, guide readers of the journal to further areas of reading.
The lack of papers about general medical management of work related musculoskeletal
disorders is not surprising as each of the individual disorders has its own aetiology and pattern
of diagnosis. It is therefore unlikely that a generalised approach to all disorders would help
clinical management.
2.5.1 The effects of pain management programmes
Three papers were identified in this field relating to musculoskeletal problems. Johansson et al
(21)
, reported on a cognitive-behavioural programme which included education, goal setting,
graded activity training, exercise, pacing of activities, relaxation, cognitive techniques, social
7
skills training, drug reduction methods, contingency management of pain behaviours and the
planning of return to work. The programme was evaluated in two studies presented in this
paper. The first one was a randomised controlled outcome study of the pain management
programme at 1 month after treatment. The participants involved in the study were individuals
who had chronic musculoskeletal pain that significantly disrupted their lives and no further
treatment options were open to them. The paper was unclear about specific pain sites.
In total, 42 individuals were invited to take part in two groups, the treatment group and the
waiting list control group. However, the attrition rate during the study was 14% leaving 36
participants. The outcome measures in the study included occupational activity measured by
sickness absence and hours of occupational training per day. At one-month follow-up,
occupational activity was significantly increased from 1.2 hours per day to 2.8 hours per day
(F(1, 33)=11.24, p<0.001) in the treatment group with no significant change in the control
group. The level of sickness absence was not changed between treatment and control group at
the one-month stage.
The Johansson et al (21) paper included a second stage to the study at one year after treatment.
This was not controlled and 85 patients took part in the study. At one year follow up; there
were significant reductions in pain intensity, pain severity, interference, and life control
measures. In terms of occupational activity, sickness absence had decreased from 63.8% pretreatment to 29.8% at one year (F(2, 154)=32.6, p<0.001).
Marhold et al (22) examined the effects of the same cognitive behavioural therapy on return to
work for individuals with chronic back pain, neck pain and shoulder pain. This study had a
randomised cross over 2 x 2 design where individuals were assigned between those with longterm sickness absence, short-term sickness absence, treatment and control. All sickness absence
was certified. There were 72 female participants in the study and their inclusion was based upon
diagnosed musculoskeletal pain, age range of 25 to 60 years, no psychotic illnesses and being
employed. The participants were randomly assigned to treatment and control groups with 18
participants in each group. The outcome measures of the study were sickness absence pretreatment, 2 months post-treatment; four months post treatment and 6 months post-treatment.
The results found that there was a significant decrease in sickness absence for the short-term
absence group from a mean of 57.4 days pre-treatment, a mean of 38.9 days at 2 months, a mean
of 25.4 days at 4 months and a mean of 21 days at 6 months (F(3,99)=2.78, p<0.05). No
significant differences were found for the long-term sickness absence group.
Both studies have identified that there is some evidence that the use of cognitive behavioural
therapies for the treatment of chronic musculoskeletal pain can improve occupational outcomes.
Johansson et al (21) found an increase in occupational activity at 1-month post treatment. This
study also found a significant decrease in sickness absence at one year. Marhold et al’s (22)
study found that cognitive behavioural therapy decreased sickness absence but only in
individuals who had short-term sickness absence. Although each of the studies has limitations
in terms of numbers and design, they do indicate that this type of therapy may enable some
individuals with chronic pain to return to work. The Marhold et al study also emphasised the
importance of early intervention with individuals on short-term sickness absence to aid their
return to work.
Karjalainen et al (23) carried out a review of the effectiveness of biopsychosocial rehabilitation
on repetitive strain injuries. In this review only two studies were included but were considered
low quality in their results. The interventions made in the first study of 48 participants included
EMG biofeedback, relaxation with progressive muscular relaxation and imagery methods versus
EMG biofeedback and relaxation versus relaxation only. No significant differences were found
between the groups at either 8 weeks of follow-up or 6 months follow-up. The second study
8
reviewed 32 patients who were involved in treatment including medication and physiotherapy
referral. The intervention included hypnosis with biofeedback and autogenics once a week for 6
weeks. The outcome of this study found that pain intensity measured on a visual analogue scale
was significantly lower in the intervention group.
The studies indicate limited evidence for the use of hypnosis and autogenics in pain reduction
. However, both studies reviewed were affected by poor design and as such; decisions cannot
be made from them. Further research is required in this area to support or refute the use of
biopsychosocial rehabilitation.
(23)
2.6 CARPAL TUNNEL SYNDROME
2.6.1 Diagnostic criteria
Carpal tunnel syndrome (CTS) is the most commonly diagnosed neuropathy (24), (25) with a
prevalence rate of clinically and electrophysiologically diagnosed CTS of 2.7% (25). Gerritsen et
al (26), report that in the Netherlands CTS has an electrophysiologically diagnosed prevalence
rate among adults in the general population of 0.6% in men and 9.2 % in women. With regard to
diagnosis, Table 1 shows the criteria developed by Harrington et al (16) and Sluiter et al (18). The
use of both Phalen’s Tests and Tinel’s tests in the diagnosis of CTS is essential. However,
Feuerstein et al (27) and Herbert et al (28), report that the “gold standard” in CTS diagnosis is the
use of electrodiagnostic testing and physical examination. What must be appreciated is that
chronic and more serious cases will result in surgical intervention.
Table 1 Diagnostic and surveillance criteria for carpal tunnel syndrome
Author
Harrington et al
Sluiter et al (18)
(16)
Symptoms
Surveillance Criteria
A clinical syndrome
caused by compression
of the median nerve as
it passes through the
carpal tunnel
Pain, or paraesthesia, or
sensory loss in the median
nerve distribution and one of:
Tinel’s test positive, Phalen’s
test
positive,
nocturnal
exacerbation of symptoms,
motor loss with wasting of
abductor pollicis brevis, and
abnormal nerve conduction
times
Intermittent
paraesthesia or pain in
at least 2 digits, I, II or
III; either may be
present at night as well
(allowing pain in the
palm, wrist or radiation
proximal to the wrist)
At least one of the following
tests positive: Flexion compression test
Carpal compression test
Tinel’s sign
Phalen’s test
Two-point discrimination test
Resisted thumb abduction or
motor loss with wasting of
abductor
pollicis
brevis
muscle
Time Rule
Symptoms now or
on at least 4 days
during the last 7
2.6.2 Conservative treatment for Carpal Tunnel Syndrome
Sixteen papers were obtained which examined conservative treatment methods for CTS. The
papers were reviewed and 8 were rejected as being generalised review papers or bringing no
new data. The types of conservative treatment for CTS in the literature include NSAIDs to
physical therapies. Each of these will be discussed in this section. Three reviews, Giele et al
9
(29)
, Gerritsen et al (25) and Wilson and Sevier (30), recommend that conservative treatment options
should be considered before surgical treatment of CTS.
NSAIDs and Analgesics
The use of NSAIDs and other analgesics has been researched as a treatment option by a number
of authors. Wilson and Sevier (30) found them to be a common treatment approach and were
used frequently and cited as an example, the most common prescription being 800 mg of
Ibuprofen 2/3 times a day for 7 –10 days. Feuerstein et al (27) identified that the most common
primary treatments used for CTS were splinting and using NSAIDs. In an evidence-based
review of treatment of CTS by Giele (29), one of the studies reviewed identified that in a
randomised controlled trial of NSAIDs versus diuretics, versus oral steroids, versus a placebo;
only the steroids reduced symptoms. Gerritsen et al (25) carried out a systematic review of
randomised control trials for conservative treatments for CTS. The systematic review agreed
with Giele (29) that there is no current evidence that the use of NSAIDs is more effective than
placebos in the treatment of CTS.
Steroids (Oral and Injection)
The use of oral steroids has been found to be more effective on symptoms of CTS than
NSAIDs, placebo or diuretics in the short term (29), (25). Additional treatment options using
steroids include steroid injection and steroid infusion into the carpal tunnel. Gerritsen et al have
systematically reviewed the evidence for the efficacy of steroid injection (25). The review found
two high quality studies and one low quality study for inclusion. The high quality studies found
that local injection significantly improved symptoms compared to control or muscular steroid
injection after a one-month period. No long-term follow-ups were carried out in this study.
There is some evidence that in the short-term, steroid injections can reduce the symptoms of
CTS.
Physical Therapies
A number of physical therapies have been examined in the treatment of CTS. These include a
study reviewed by Gerritsen et al (25), where chiropracty including manipulation, wrist support
and ultrasound were compared with the use of NSAIDs and wrist supports. However, Gerritsen
et al (25), report that no outcome measures for symptoms were included in this paper. On
reviewing this research paper by Davis et al (31), the outcome measures were self-reported
mental and physical distress, objective measures including nerve conduction and finger
sensation. There were no significant differences found in the study between the two treatment
methods.
Splinting of the wrists of CTS patients has also been researched. Gerritsen et al (26), carried out
a randomised control trial of 176 patients, clinically diagnosed and randomly assigned to
nocturnal wrist splinting for 6 weeks (N=89) or open carpal tunnel release (N=87). The study
followed the patients over an 18-month period and 84% of the original patients completed the
final follow up session. During the study, patients were examined by a physiotherapist and
completed a questionnaire at 3 months, 6 months and 12 months. From the questionnaire data,
patients were considered improved if they reported being “completely recovered” or “much
improved”. The study was confounded by a number of problems within the splint group, where
58% had additional treatment options including pain medication, occupational therapy etc. The
results showed that in the short term, at one month follow up; the splint patients had improved
significantly more than the surgery patients. However, on examination at 18 months, the
outcomes for the surgery patients were significantly better than the splint patients. The study
therefore shows that the surgical intervention results in better long-term outcomes than
splinting. However, the evidence for this is confounded by the lack of the control on the
splinting participants.
10 Exercise and stretching has also been suggested as a treatment methodology for CTS.
Feuerstein et al (27), found that range of motion exercises versus splinting, significantly
improved pain reporting and numbness at 1 month. Progressive resistive exercise was also
reviewed versus no exercise. A significant improvement in wrist extension was found only after
a 3-week intervention period.
Yoga has also been researched as a means of intervention with CTS. Garfinkel et al (32), used a
randomised controlled trial to examine the effectiveness of a yoga regime of 11 yoga postures
and relaxation exercises given twice weekly for an 8 week period. The patients in the control
group were supplied with a wrist splint to go alongside current treatment. The outcome
measures included number of hours of disturbed sleep, pain intensity, Phalen’s sign, Tinel’s
sign, grip strength and latency of the median nerve; at the start of treatment and at 8 weeks. The
results from 22 individuals in the yoga treatment group and 20 in the control group found that
grip strength was significantly increased and pain intensity was significantly reduced in the
yoga group. Both groups were found to have improved nerve motor conduction but this was not
statistically significant. The study does show some improvements but there were few control
measures in the group wearing splints or any mention made of the other treatments they were
receiving. Gerritsen et al (25), go as far to say that this study made false claims about comparing
yoga, splinting and no intervention. There is however, only limited evidence that yoga has an
impact on pain and is more effective than other treatments.
The papers reviewed highlight a number of methodological difficulties in research in this area
including lack of control over treatment and different outcome measures.
Ultrasound
Ebenbichler et al (33) have evaluated the use of ultrasound as a treatment for CTS in a
randomised “sham” controlled trial. The study included 34 patients who received 20, 15-minute
ultrasound sessions applied to the area over the carpal tunnel of one wrist. The sham treatment
was the same but was blind in that one individual would set ultrasound equipment, not the
individuals giving treatment. The outcome measures were subjective symptoms of complaints
and sensory loss, nerve conductivity and physical functioning; these were measured at week 2,
week 7 and at 6 months follow-up. The study found that where active treatment was concerned,
significant improvement was found in both subjective symptoms and nerve conductivity. The
author’s themselves state that further work is needed and comparison made with other
treatments to find out if this is a viable treatment methodology. There is limited evidence that
ultrasound has an impact on the symptoms of CTS.
Laser Acupuncture
Gerritsen et al (25), have reviewed low-level laser acupuncture as a treatment modality. Their
conclusions were that there was limited evidence that soft laser acupuncture is more effective
than a placebo in the treatment of CTS.
Workplace Interventions
Although workplace interventions are mentioned by a number of authors, there is little good
evidence in support of those interventions. Giele et al (29), suggest that modification of activity,
i.e. job change, increasing rest periods and better ergonomics may be effective in reducing
symptoms. This is reiterated by Herbert et al (28), who recommend a programme involving
health surveillance, job evaluation to identify risks, risk reduction through job redesign, training
and medical management. There is however little evidence that these factors will impact on
CTS. This is mainly due to a lack of good research in the area of workplace interventions to
find out if any of the methods are effective.
11 Treatment of CTS in Primary Care and Occupational Health
Miller et al (34) identified one paper regarding treatment of CTS in primary care in Canada. This
study involved 254 primary care physicians and 824 patients who reported symptoms of CTS.
Out of those 552 patients agreed to take part in the study. The study asked primary care
physicians to include patients in the research if they suspected CTS and they met at least one of
three symptoms, Phalen’s sign or Tinel’s sign. Physicians documented evidence at the first visit
including the diagnostic criteria, patient’s occupational, activity level and pregnancy status.
Patients were also asked to complete a questionnaire about the onset of symptoms, specific
occupational tasks and movements required and interference with activity. The study found that
patients with new onset of CTS were mostly female (73.5%) between the ages of 30 – 49 years.
Treatment of patients was most commonly splints (56.3%), NSAIDs (50.8%), surgery (2.9%),
referral (7.6%) and local injection (1.6%). However, most patients were treated with more than
one type of treatment. The four-month follow-up of patients found that 10% had complete
relief of symptoms, 45% had some improvement, 28% had no change in symptoms and 17%
had worsening symptoms. In terms of occupation, 50.6% reported no impact on their
performance at work, 39.1 % had modified their activities at work, 4.2% of the sample had
changed jobs, 5.3% were unable to work and 0.8% reported losing their jobs.
The study found that 55% of the participants did get some relief from symptoms with treatment
remaining in primary care. Conversely, the authors do acknowledge weaknesses in the study
such as biased reporting and incomplete information from both physicians and patients. It does
however; identify the important role of the primary care physician in the diagnosis and
treatment of CTS.
Herbert et al (28), in a review paper, examines the role of the physician in work related CTS.
The paper underlines the importance of the occupational history including exposure to present
ergonomic risk factors - including repetition, force, work tasks, rest breaks, workplace design
and layout. The paper also recommends examining the family history for neurological disease
or connective tissue diseases. Obtaining a social history including smoking, exposure to
vibration and non-work activities is also vital to exclude other health issues or sources of risk
(28)
.
2.7 EPICONDYLITIS MEDIAL AND LATERAL
2.7.1 Diagnostic Criteria
According to a clinical review by Piligian et al (35), the highest incidence of epicondylitis
appears to occur in manually intensive occupations involving high work demands in dynamic
environments, e.g. in mechanics, wallboard installation, roofing, masonry, foundries, building
construction, furniture/casket manufacturing, wood frame building construction, paper products
manufacturing, meat dealers and concrete construction. With regard to diagnosis, Table 2.,
shows the criteria developed by Harrington et al (16) and Sluiter et al (18).
12
Table 2 Diagnostic and surveillance criteria for medial and lateral epicondylitis
Author
Symptoms
Surveillance Criteria
Harrington et al (16)
A lesion at the common
extensor origin of the
lateral epicondyle of the
humerus causing the
effects in the section
below
Lateral epicondylar pain and
epicondylar tenderness and
pain on resisted extension of
the wrist.
Similar criteria
apply to medial epicondylitis
and with pain on resisted
flexion of the wrist
Sluiter et al (18)
At
least
intermittent
activity-dependent pain
directly located around
the lateral or medial
epicondyle
Local pain on resisted wrist
extension (lateral) or on
resisted wrist flexion (medial)
Time Rule
Symptoms present
now or on at least
4 days during the
last 7 days
2.7.2 Conservative treatment for Medial and Lateral Epicondylitis
According to Piligian et al (35), management options for lateral epicondylitis (tennis elbow)
include worksite modification, compression straps, NSAIDS, physical therapy modalities
(manual modalities, iontophoresis), acupuncture and steroid injections if above fails. Medical
management of medial epicondylitis (golfer’s elbow) is similar with some exceptions e.g.
compression straps and surgery are less frequently advised and steroid injection is not
recommended.
NSAIDS
Burnham et al (36), evaluated the effectiveness of topical 2% diclofenac as a treatment for
chronic lateral epicondylitis in a ‘convenience sample’ of 14 patients, using a double blind,
randomised, within-subject crossover study design. Patients used a pluronic lecithin liposome
organo-gel (PLO) for one week, followed by a 1-week washout period during which no PLO
was used, and then used a PLO for another week. However, only one of the PLOs used
contained diclofenac. On average, topical diclofenac ‘reduced pain and wrist extensor strength
was improved by approximately one third during the period of diclofenac use’. However, this
effect was short termed, lasting mainly during the diclofenac use period, as marked by the return
of the pre-treatment pain by the end of the washout 1-week period.
According to a large pragmatic randomised controlled trial in primary care by Hay et al (37),
discussed below, a two-week course of a standard NSAID (naproxen) ‘was no better than
placebo’. Green et al (38), carried out a Cochrane review on the use of NSAIDs for treating
lateral elbow pain. The review, which included fourteen trials, found some support for the use
of topical NSAIDs in the short-term relief of lateral elbow pain, while the evidence regarding
the use of oral NSAIDs was deemed insufficient.
Steroid Injection
Hay et al (37) compared the clinical effectiveness of local steroid injection and a standard NSAID
(naproxen) in the treatment of lateral epicondylitis in primary care. The study design was that
of a multicentre pragmatic randomised, placebo-controlled trial involving the participation of
164 patients in 23 general practices over 2 years. At four weeks, 92% of the injection group
were completely better or improved compared with 57% in the naproxen group and 50% in the
placebo group. Nevertheless, there was no significant difference found among the pain scores
of the three groups at 12 months.
13 Thus, it was concluded that ‘corticosteroid injections are the initial treatment of choice for
lateral epicondylitis in primary care if the objective of treatment is to obtain optimal relief of
symptoms during the early weeks’. However, the study population ‘consisted mainly of patients
with relatively short duration of symptoms’, a usual phenomenon in primary care which does
not necessarily apply to hospital based studies. Furthermore, these results were related only to
the specific injection and NSAID regimens used.
In agreement, Smidt et al’s (39) results of a randomised controlled trial comparing steroid
injections to physiotherapy and a wait-and-see policy suggest that ‘corticosteroid injections are
the best treatment option in the short-term for patients with lateral epicondylitis’. However,
there was a high recurrence rate reported in the injection group.
A tendency to recurrence was also reported by Solveborn et al (40) who studied the effectiveness
of cortisone injection with anaesthetic additives for tennis elbow in 109 patients participating in
a prospective, randomised, double- blind study. In this study, lidocaine and bupivacaine as
additives to corticosteroid injection showed no difference in effects for the patients. Following
a typical pattern, at a 2-week follow-up examination the symptom improvement was impressive
for the entire patient group; however, symptoms recurred at 3 months. Moreover, the authors
reported that patients who had not been treated previously in any way or were acute cases had a
more favourable prognosis.
Thus, it appears that there may be some advantage in steroid injection in the short-term relief of
lateral epicondylitis symptoms, but this is not sustained in the longer term.
Physiotherapy Treatment
Smidt et al (39), compared the efficacy of physiotherapy (pulsed ultrasound, deep friction
massage and an exercise programme), corticosteroid injections and a wait- and- see policy for
lateral epicondylitis through a randomised controlled trial involving 185 patients. All outcomes
were assessed in 3, 6, 12, 26 and 52 weeks. While corticosteroid injections were significantly
better (92% success rate compared with 47% for physiotherapy and 32% for a wait-and – see
policy) at 6 weeks, long-term differences between injections and physiotherapy were
significantly in favour of physiotherapy (91% success rate compared with 69% for injections
and 83% for a wait-and-see policy) at 52 weeks.
Thus, they suggested that physiotherapy might be the best option in the long-term followed by a
wait-and-see policy. However, differences between physiotherapy and a wait-and-see policy
were not significant. Physiotherapy was associated with the highest probability of recovery
after 6 months, but whether this extra value is worth the additional resources was deemed
questionable.
Concerning manipulative therapy for the treatment of lateral epicondylitis, there are no reviews
to be found according to Vicenzino (41). However, in a randomised, double blind, placebo
controlled, repeated measures study of 15 patients suffering from lateral epicondylalgia,
Vicenzino et al (42), reported that cervical spine manipulative physiotherapy is capable of
producing rapid pain improvements. The lateral glide technique used was reported to
significantly improve neurodynamics, pain-free grip strength and mechanical hyperalgesia in
patients in the 24 h period immediately following its application. Although this is a small study,
which will require reproducing, it does give some evidence of an area of further research.
Iontophoresis
Regarding iontophoresis, two randomised controlled trials were found. In the first, by Nirschl et
al (43), 199 patients suffering from elbow epicondylitis participated in a multicentre, randomised,
14 double-blinded, placebo-controlled study investigating the effectiveness of the iontophoretic
administration of Dexamethasone Sodium Phosphate. Six iontophoresis treatments of 40 mAminutes of dexamethasone were applied. Statistically significant differences were found in
visual analogue scale (VAS) scores in favour of the dexamethasone group. Dexamethasone
iontophoresis was found effective in reducing epicondylitis symptoms, particularly if treatments
were completed in 10 days or less. However, side effects were often also reported regarding
mild drug electrode reactions and, less frequently, disperse site reactions.
In another randomised controlled study, Baskurt et al (44) compared the effectiveness of
naproxen applied by topical iontophoresis or by phonophoresis in the treatment of lateral
epicondylitis in 61 patients. Pain severity decreased in both groups after treatment, while no
significant difference was found between the two groups. During the study, both groups were
also treated by other standard physiotherapy methods (cold pack, progressive strengthening and
stretching exercises) so the improvement of grip strength, functional levels and pain cannot be
attributed to any single of the applications used.
Radiation therapy (RT)
Ionising Radiation Therapy is usually only used as last resort for refractory epicondylopathia
humery (EPH) and no established treatment parameters exist leading to empirical use of RT
doses. Seegenschmiedt and Keilholz, (45) who treated 85 EPH patients using two RT series of
six fractions of 0.5-0.7 Gy doses and a mean follow-up of 4 years, concluded that RT is
effective for the eradication or alleviation of refractory EPH pain with a lower success rate in
cases with long symptom duration, many prior therapies and long-term immobilization.
However, they recommended that RT be applied only after conventional measures have been
judged ineffective and following interdisciplinary counselling (45).
In contrast, in a randomised, controlled clinical trial, Basford et al (46) found low intensity laser
irradiation ineffective in the treatment of lateral epicondylitis in 52 patients participating. This
conclusion was restricted to the specific parameters used in the study, however, the protocol
chosen mimicked clinical practice in terms of treatment sessions and wavelength. Thus, the
authors concluded that they could not support the use of laser therapy in the treatment of lateral
epicondylitis based on their findings.
Shock wave therapy
Shock Wave Therapy is among the conservative treatments for lateral epicondylitis for which
scientific evidence is considered deficient (47). Despite its extensive use, there are no established
treatment parameters (47). Thus, the efficacy of shock wave therapy in the treatment of lateral
epicondylitis remains controversial.
In a controlled, prospective study, Rompe et al (48) treated 100 patients for tennis elbow using
Extracorporeal Shock Wave Therapy (ESWT), half randomly assigned to 3000 pulses of 0.08
mJ/mm2 and half to only 30 pulses of 0.08 mJ/mm2. They reported a significant alleviation of
pain and improvement of function in the first group with a good or excellent outcome in 48%
and an acceptable outcome in 42% at the final review after 24 weeks, compared with 6% and
24%, respectively, in the second group. However, patients were not blinded and nor was the
effectiveness of randomisation reported.
In a later study, Rompe et al (49) compared the effects of a combination of ESWT with 1000
pulses of 0.16 mJ/mm2 and manual therapy of the cervical spine with ESWT alone in treating 60
patients suffering from chronic tennis elbow. The 12 months outcome of the therapy was
excellent or good in 56% of the first group and 60% of the second group so they concluded that
ESWT might be an effective conservative treatment for chronic tennis elbow. Yet, this study,
15 being focussed on the possible additive effects of cervical manual therapy, did not include a
control for ESWT. In addition, the patients undergoing both procedures were not randomised,
allowing for selection and information bias.
In contrast, Haake et al (47) found no benefit in comparing ESWT in combination with local
anaesthesia to placebo therapy combined with local anaesthesia. They evaluated the
effectiveness of a 2000 pulses of 0,07 to 0.09 mj/mm2 ESWT for the treatment of lateral
epicondylitis in 246 patients participating in a prospective, randomised, placebo-controlled trial.
Patients and observers were both blinded to treatment allocation. The authors found ‘nearly no
differences between the success rates of the ESWT and the placebo’ and also reported that there
were more side effects in the ESWT group. Thus, they attributed positive findings of previous
comparative clinical trials to placebo effects resulting from the absence of patient blinding.
In agreement, Melikyan et al (50) in their randomised double-blind placebo-controlled study of
74 patients found no evidence that ESWT for tennis elbow was better than placebo. Treatment
sessions started at a low energy level and the intensity gradually increased finally amounting to
1000 mj/mm2, while no shockwave energy was applied to the placebo group patients. No
significant difference between the groups was found at any point in the parameters measured.
The patients’ symptoms improved steadily over the one-year follow-up regardless of which
group they belonged.
Acupuncture
When classical conservative treatment has been unsuccessful, several patients consider the
possibility of complementary medicine in the form of acupuncture, as there has been some
evidence that acupuncture may help alleviate the pain and improve the functioning of the arm.
In an attempt to evaluate the clinical efficacy of acupuncture in the treatment of chronic lateral
epicondylitis, Fink et al (51), treated 23 patients with real acupuncture and 22 patients with sham
acupuncture. This randomised, investigator- and patient- blinded, controlled clinical study
concluded that acupuncture with correct location and stimulation according to the traditional
Chinese recommendations might be a useful alternative to classical conservative treatments in
chronic epicondylitis.
However, the treatment effects were less evident at the 2-month follow-up. In addition, there
was no control group receiving no treatment at all, which would have served to compare the
treatment effect to the natural course of the disease. Finally, the small number of the patients
and a possible bias in their selection due to their being recruited through press advertisement
imposed further limitations in the evaluation of this study’s results.
Green et al (52), carried out a Cochrane review on the use of acupuncture for treating lateral
elbow pain. The review, which included four small randomised controlled trials, found some
support for the use of needle acupuncture in the short-term relief of lateral elbow pain but no
benefit lasting more than 24 hours following treatment. The reviewers concluded that there was
insufficient evidence to recommend or discourage the use of needle or laser acupuncture in the
treatment of lateral elbow pain.
Wait-and-see policy
According to the clinical guidelines of the Dutch College of General Practitioners a wait-and see
policy, including ergonomic advice and prescription of pain medication if necessary is
recommended for lateral epicondylitis. This recommendation was supported by the results of
the randomised controlled trial of Smidt et al (39). Furthermore, it was supported by the
pragmatic randomised controlled trial of Hay et al (37) who concluded that there is a high
probability that lateral epicondylitis patients will get better in the long-term regardless of their
16 treatment. Haake et al (47) further support this conclusion by reporting that nearly two thirds of
their patients with chronic lateral epicondylitis ‘had improvement after one year regardless of
the initial treatment’.
In addition, Haahr and Andersen (53) were not able to find an advantage in treating 266
consecutive new cases of lateral epicondylitis diagnosed in general practice by using minimal
intervention by occupational specialists involving information about epicondylitis,
encouragement to stay active and instruction in graded self-performed exercises. In this
randomised controlled study with a one-year follow-up, minimal occupational intervention was
compared to treatment usually given in general practice. It was found that the minimal
occupational intervention did not seem to have any lasting positive effect on global or pain
improvement. Although the intervention group received less treatment during follow-up, the
intervention was not followed by fewer visits to a GP or to physiotherapists than in the control
group. Conversely, no relation was found between the type of medical treatment received and
prognosis. The findings supported further the adoption of a wait-and- see policy, along with the
encouragement of patients to stay active.
However, the authors reported that the power of the study was reduced by exercise being
encouraged by GPs in the control group as well, and by low compliance in the intervention
group. Due to the study design, no blinding treatment could be done either.
17 This section has collated information about treatment of a number of shoulder musculoskeletal
problems. The information has been collated as the research papers obtained often assemble
data in this format. Where possible, individual disorders have been separated out but in some
cases, there is little information available.
2.8 ROTATOR CUFF TENDONITIS AND BICIPITAL TENDONITIS
2.8.1 Diagnostic Criteria
Diagnoses of the two disorders of rotator cuff tendonitis and bicipital tendonitis have been
agreed by both Harrington et al (16) and Sluiter et al (18).
Table 3 Diagnostic and surveillance criteria for rotator cuff syndrome
and bicipital tendonitis
Author
Harrington et al
Sluiter et al (18)
(16)
Symptoms
Surveillance Criteria
Symptomatic
inflammation
or
degeneration of the
rotator cuff or biceps
Rotator cuff: history of pain in the
deltoid region and pain on one or
more resisted active movements
(abduction of the supraspinatus;
external
rotation
of
the
infraspinatus, teres minor; internal
rotation of the subscapularis)
Biceps: history of anterior
shoulder pain and pain on resisted
active flexion of elbow or
supination of forearm
At least intermittent
pain in the shoulder
region
without
paraesthesia;
pain
worsened by active
elevation movement
of the upper arm as in
scratching
of
the
upper back
At least one of the following tests
positive: Resisted shoulder abduction,
external rotation, or internal
rotation
Resisted elbow flexion
Painful arc on active upper arm
elevation
Time Rule
Symptoms now or
on at least 4 days
during the last 7
2.8.2 Conservative Treatment of Rotator Cuff Syndrome and Bicipital Tendonitis
Four papers were identified that covered medical management of rotator cuff syndrome
(including supraspinatus) and bicipital tendonitis. Two of the papers were clinical practice
papers by Price (54), and Woodward and Best (55). Price (54) and Woodward and Best (55) both
recommend a number of treatments including NSAIDs which may only give partial relief,
analgesics which can control pain at night, ice packs and slings which may temporarily reduce
symptoms, and gentle mobilisation exercises and steroid injections. Both authors point out that
for cases resistant to treatment, surgery is an option. The two papers are however clinical
practice papers and not evidence based reviews.
Bartolozzi et al (56), carried out a study of 136 patients with impingement syndrome and rotator
cuff syndrome. Conservative treatments were used including physical therapy, local steroid
injection and NSAIDs. The patients received a combination of those treatments. The outcome
measures included 14 clinical outcome variables including functional impairment, instability,
and cuff pathology. The results found that at 6 months post-treatment, 46% of patients obtained
an excellent or good result. At 18 months follow-up, 47 of the 68 patients followed-up at 18
months had a diagnosis of chronic impingement syndrome. This research suggests that patients
18 should undergo 18 months of conservative treatment including NSAIDs, physical therapy and
steroid injection before surgery is considered. It recommends that surgical intervention should
be carried out when symptoms have been evident for 12 or more months, there is severe
functional impairment or a rotator cuff tear of more than 1 cm. However, the paper itself is
confusing in how patients were allocated to treatment. It gives some evidence but indicates the
need for further research.
Green et al (57), carried out a Cochrane review for interventions for shoulder pain. The review
found that NSAIDs and subacromial steroid injection might improve range of movement in
rotator cuff syndrome more than a placebo.
The evidence for conservative treatment of rotator cuff syndrome and bicipital tendonitis is
unclear. This is mainly due to lack of agreement on diagnostic criteria in previous research,
lack of clarity in treatment methodologies and poor methodological quality of research in this
area.
2.9 SHOULDER CAPSULITIS
2.9.1 Diagnostic Criteria
The case and surveillance definitions of shoulder capsulitis reached consensus with the
Harrington et al (16) study. Woodward and Best (55), also described symptoms including a slow
in onset shoulder pain and discomfort in the deltoid region. However, Nicholson (58) reports that
the diagnostic criteria and classification of this disorder is still under investigation and
discussion.
Table 4 Diagnostic and surveillance criteria for shoulder capsulitis
Author
Harrington et al
(16)
Symptoms
Surveillance Criteria
A condition characterised by
current or past pain in the
upper arm, with global
restriction of glenohumeral
movement in a capsular
pattern
History of unilateral pain in
the deltoid area and equal
restriction of active and
passive
glenohumeral
movement in a capsular
pattern (external rotation >
abduction>internal rotation)
2.9.2 Conservative Treatment of Shoulder Capsulitis
Eleven papers were obtained dealing with conservative medical management of shoulder
capsulitis. After reviewing the papers, seven were rejected due to either being one case or
surgical outcomes.
Gam et al (59) report on a randomised controlled trial for treatment of frozen shoulder via
distension and glucorticoid versus treatment with glucorticoid alone. The study was small in
that only 20 patients who fulfilled the strict criteria for taking part completed it. Outcome
measures included severity of pain, functional movement, pain at rest, daily use of analgesics
and the type and number of side effects. An impartial physician examined the participants at
weeks 3, 6 and 12 of the trial period. At the start of the study there were no significant
differences found in any of the outcome measures. On completion of the study, the results
indicated that there was significant improvement in functional movement and decrease of
19 analgesic use in the group treated with shoulder distension and glucorticoid alone.
however is a small study and needs to be further researched to confirm this outcome.
This
De Jong et al (60), carried out a randomised clinical trial to identify the optimum dosage of
acetonide injection for shoulder capsulitis. The study included 32 patients who were given a
dose of 10 mg of triamcinolone acetonide and 25 patients who received a 40 mg dose. The
outcome measures of the study included pain measures; sleep disturbance, functional
impairment and movement restriction at 6 weeks. The results found that between the two doses,
there was a significant reduction in pain, functional impairment and movement restrictions in
the high dose group. The authors do comment that 40 mg may not be the optimal dosage but
this paper does give evidence that this treatment is more effective than injecting 10 mg of
triamcinolone acetonide.
Nicholson (58), in a paper on arthroscopic capsular release does comment that home therapy,
formal physiotherapy and steroid injections do show success in patients with this disorder.
However, little further information is available on evidence for the success of conservative
treatments.
Green et al (57), in the Cochrane review again conclude that there is little evidence to either
support or disprove the efficacy of conservative treatment for shoulder capsulitis.
2.10 IMPINGEMENT SYNDROME
2.10.1 Diagnostic Criteria
There has been no consensus agreement made about diagnostic criteria for impingement
syndrome however, Ludewig and Borstad (61), Ludewig and Cook (62) and Bigliani (63) all refer to
a 1983 paper by Neer in describing the definition for impingement syndrome. It is defined as
the “compression and irritation of the rotator cuff as they pass beneath the coracoacromial arch
during arm elevation” (61). Symptoms include pain in the anterosuperior part of the shoulder (63)
2.10. 2 Conservative Treatment of Impingement Syndrome
Treatment of impingement syndrome has included conservative options. Bigliani and Levine
(63)
, report that most patients will eventually recover using conservative treatment options.
These include modification of activity, NSAIDs and subacromial steroid injection. Morrison
(64)
, carried out a retrospective study of 616 patients who were conservatively managed via
supervised physical therapy, which included isotonic and muscle strengthening exercises and
NSAIDs. The study found that at follow-up appointments 67% of patients had a satisfactory
outcome, 28% had an unsatisfactory outcome and were recommended for surgical intervention
and 5% had an unsatisfactory outcome but turned down surgical intervention. The study,
although finding positive results, was not consistent in following up patients as the range of
follow-up appointments was 6 months to 81 months.
Ludewig and Borstad (61), reported on a home exercise programme for construction workers.
The participants were 67 male construction workers who were screened for shoulder pain and
impingement syndrome. The participants were randomly allocated into a treatment intervention
group (N=34), a control group (N=33) and an asymptomatic control group (N=25). The
outcome measures for the study were the shoulder rating questionnaire and the Shoulder Pain
and Disability Index. The treatment for the intervention group was two stretches for 30 seconds
five times per day and progressive resistance strengthening exercises 3 times per week. The
results of the study found a significant improvement in the shoulder-rating questionnaire
between pre and post-test for the treatment group at between 8 and 12 weeks. Improvements
were also found for pain reporting and satisfaction score but these were not significant. This
20 study gives some evidence for the use of home exercises programmes in reducing symptoms of
impingement syndrome.
Blair et al (65), report on a randomised blind controlled trial for the short-term efficacy of
subacromial steroid injection. This was a study of 40 patients, 19 who received corticosteroid
injection and 21 who were randomised into the control group. Outcome measures included pain
scores, physical examination and functional status. The results found that at the most recent
follow-up appointment; the mean pain score was significantly reduced for the treatment group.
The physical examination found a significant increase in movement compared to controls but no
differences were found between the two groups with regard to performance of daily living
activities. The study does indicate that subacromial steroid injection does improve symptoms
and functional movement. This however again is a small study and there was no consistent
follow-up time for each of the participants; the follow-up time ranged from 12 to 55 weeks. In
addition, all participants in this study were receiving physical therapy that may have
confounded the results.
Desmeules et al (66) systematically reviewed randomised controlled trials examining therapeutic
exercise and orthopaedic manual therapy for the treatment of impingement syndrome. In their
review of 7 randomised controlled trials that had acceptable criteria, they found that there was
some evidence for the use of therapeutic exercise and manual therapy in treating shoulder
impingement syndrome. However, the authors are concerned about the methodological quality
in the research reviewed and agree on a need for further research to obtain good evidence.
2.11 TENOSYNOVITIS AND FLEXOR-EXTENSOR PERITENDONITIS OF THE
HAND AND FOREARM
2.11.1 Case Definitions
The case definitions for tenosynovitis of the hand and forearm was agreed by both Harrington et
al (16) and Sluiter et al (18)
Table 5 Diagnostic and surveillance criteria for tenosynovitis
Author
Harrington et al
Sluiter et al (18)
(16)
Symptoms
Surveillance Criteria
Painful swelling of the
first
extensor
compartment
containing
extensor
pollicis brevis and
adductor
pollicis
longus
Pain which is centred over the
radial styloid and tender
swelling of the first extensor
compartment and either pain
reproduced by resisted thumb
extension
or
positive
Finkelstein’s test
Intermittent pain-ache
in the ventral or dorsal
forearm
or
wrist
region
Provocation of symptoms
during resisted movement(s)
of the muscles under the
symptom area.
and
Reproduction of pain during
palpation of the affected
tendons or palpable crepitus
under the symptom area or
visible swelling of the dorsum
wrist-forearm
21
Time Rule
Symptoms now or on
at least 4 days during
the last 7
Sluiter also includes flexor-extensor peritendonitis in this area. However, it must be made clear
that tendonitis is the inflammation of the tendons and of tendon-muscle attachments.
Tenosynovitis is an inflammatory reaction around the vagina synovialis of the tendon sheaths
and produces crepitus as a sign (18).
2.11.2 Conservative Treatment of Tenosynovitis
Only two papers were identified for the medical management of tenosynovitis. The first was a
review paper from 1993 (67). Within it, four recommendations were made including removal
from current job, rest, arm support including slings, hand supports and casts for short periods,
NSAIDs and physiotherapy. There was no evidence given for the efficacy of any of the
treatments suggested.
Piligian et al (35), recommend a number of interventions including workplace modifications, rest,
NSAIDs or analgesics and physical or hand therapy. This paper does state that the efficacy of
conservative treatments has not been fully assessed at present. It can therefore be concluded
that there is no evidence to either support or refute conservative treatments of tenosynovitis.
2.12 TENDONITIS OF THE WRIST AND FOREARM
2.12.1 Case Definitions
In the previous section tendonitis was mentioned. Although no agreed criteria is evident for
occupationally related tendonitis, from sports medicine it is defined as an inflammation of the
tendon and tendon-muscle attachments (18), (68), (35). The symptoms include pain in the affected
tendon, and for extensor tendonitis, pain worsened by finger extension against resistance; for
flexor tendonitis pain associated with wrist flexion and ulnar deviation especially against
resistance (35).
2.12.2 Conservative Treatment of Tendonitis
Piligian et al (35), report that conservative treatments are used generally for tendonitis. For mild
cases it is recommended that a workplace risk assessment and workplace modifications be made
to reduce exposure to high-risk movements. It is also important to examine opportunities for
rest during the working day. Piligian et al (35) also report that NSAIDs can be used to reduce
inflammation. Other therapies that can be used are physical and occupational therapy, the use
of ice and heat, deep friction massage, ultrasound, transcutaneous electrical nerve stimulation
(TENS), ultrasound and stretching and lengthening exercises (35), (68). Piligian et al do point out
that none of these treatments have been assessed as to their effectiveness in treating tendonitis.
For more chronic non-responsive tendonitis, further options are steroid injection and surgery (35),
(68)
2.13 DE QUERVAIN’S DISEASE
2.13.1 Diagnostic Criteria
According to Piligian et al (35), the incidence and prevalence of de Quervain’s disease are not
well established. They report that limited studies point to women being affected more
frequently than men, while high risk occupations and activities include knitting, switchboard
operation, typing, piano playing, golfing, fly casting, and initiating unaccustomed repetitive
tasks or resuming repetitive work after a vacation. With regard to diagnosis, Table 6., shows
the criteria developed by Harrington et al (16) and Sluiter et al (18).
22 Table 6 Diagnostic and surveillance criteria for De Quervain’s disease
Author
Symptoms
Surveillance Criteria
Harrington et al (16)
Painful swelling of
the first extensor
compartment
containing extensor
pollicis brevis and
adductor
pollicis
longus
Pain which is centred over the
radial styloid and tender
swelling of the first extensor
compartment and either pain
reproduced by resisted thumb
extension
or
positive
Finkelstein’s test
Sluiter et al (18)
Intermittent pain or
tenderness localised
over the radial side
of the wrist: either
may
radiate
proximally to the
forearm or distally
to the thumb
At least one of the following
tests positive: Finkelstein’s test
Resisted thumb extension
Resisted thumb abduction
Time Rule
Symptoms now or on
at least 4 days during
the last 7
2.13.2 Conservative Treatment for De Quervain’s Disease
According to Piligian et al (35), management options for de Quervain’s disease include worksite
modification, rest from inciting/ aggravating movements, anti-inflammatory and/or pain
medication, neutral wrist splinting with thumb spica, physical or hand therapy with
iontophoresis and cortisone injection. On reviewing the literature of the last 10 years regarding
the conservative treatment of de Quervain’s disease, 35 review papers were found. However,
no high quality studies were found.
In agreeing with Moore (69), it appears that ‘the majority of the published studies on this subject
are case series related to the surgical treatment of the condition’ and most of the results are
descriptive in nature. Richie et al (70) conducted a pooled qualitative literature evaluation to
review the studies on treatment of De Quervain’s disease in English and to determine the
various reported rates. They found only 35 articles on de Quervain’s tenosynovitis and selected
7 studies that allowed comparison among potential treatments: Across the selected studies (459
wrists) the most effective (83% cure rate) and most frequently used treatment was steroid
injection alone. They also reported that the combination of injection and splinting in fact
resulted in greater treatment failure (39%) than injection alone (17%). However, these results
should be viewed critically as they are based on descriptive studies, where there was no
comparison to a specified control group.
2.14 CERVICAL SPONDYLOSIS
2.14.1 Diagnostic Criteria
Cervical spondylosis is a degenerative disease of the cervical spine (71), (72), and is the most
common spinal cord disorder for individuals of 55 years and older (71). Emery, describes it as a
“nearly universal process of degeneration of the disks and joints of the cervical spine”.
However, the process is a combination of compression (both dynamic and anatomical), vascular
factors and myelopathy of the cervical area (71), (72), (73).
2.14.2 Conservative Treatment of Cervical Spondylosis
One paper was found that reviewed conservative treatments for cervical spondylosis. Levy (74),
in a discussion article suggests conservative treatments including rest, immobilisation, and ice
for up to 2 days. Other treatment methods including massage and ultrasound can be included
for the first two weeks of treatment. The use of passive treatments including rest, soft collars
23 and exercise are often used but there is no conclusive evidence that the outcome is affected by
any of the above treatments. One paper by Emery (72) recommended observation of patients
who did not have myelopathy before taking a surgical route. Sypert, in a letter to the journal
Surgical Neurology, stated that, “medical therapies did not alter the natural history of cervical
myelopathies” (75). There is also no consensus on which surgical strategies give the best results.
It can be concluded that there is no evidence to either support or refute the use of conservative
treatments for cervical spondylosis.
2.15 DIFFUSE NON-SPECIFIC UPPER LIMB DISORDERS
2.15.1 Diagnostic Criteria
Both Harrington et al (16) and Sluiter et al (18) agreed on diagnostic criteria for non-specific upper
limb disorders. However, Palmer et al (76) also added other symptoms to the surveillance
criteria. The symptoms and surveillance criteria are presented below in Table 7.
Table 7 Diagnostic and surveillance criteria for diffuse non-specific upper limb
disorders
Author
Harrington et al
(16)
Symptoms
Surveillance Criteria
Pain in the forearm in
the absence of a
specific diagnosis or
pathology
Pain in the forearm and
failure to meet the diagnostic
criteria for other specific
diagnoses
and
diseases
(sometimes includes loss of
function, weakness, cramp,
muscle tenderness, allodynia,
slowing of fine movements
(76)
Sluiter et al
(18)
Pain
in
muscles,
tendons, nerves or
joints
(other
sensations may be
present)
without
evidence of a specific
combination
of
symptoms and signs
of a specified disorder
2.15.2 Conservative Treatment of Non-Specific Upper Limb Disorders
Only one paper was identified for rehabilitation of patients with non-specific musculoskeletal
pain (77). The randomised controlled study included 158 patients in the rehabilitation group and
a control group of 226 patients. The rehabilitation used in the research was a multi-disciplinary
approach including a physician, nurse, psychotherapist, social worker and occupational
therapist. Interventions included patient evaluation by a physician including interview, a review
of previous investigations and if necessary physical examination. Goal setting for each patient
was carried out at team conference meetings and programme planning with the patient was
agreed with regular patient meetings. The patients were considered rehabilitated when they
either returned to work, seek work, become unfit for work or did not comply with the
24 programme. The results of the study did not find a significant difference between the
rehabilitation group and the control group in terms of return to work or sickness absence.
There is no evidence available currently about conservative treatments of non-specific upper
limb disorders.
2.16 TENSION NECK
2.16.1 Diagnostic criteria
A number of authors have contributed to the definition of tension neck. Helliwell (78) describes
the definition used by Viikari-Juntura (1987), which is “a feeling of fatigue or stiffness in the
neck, neck pain or headache radiating from the neck”. Helliwell (78) also describes signs of two
tender spots or palpable hardenings. Mekhora et al (79), also summarised the disorder and
describe it as a type of occupational cervicobrachial syndrome that can be work-related.
However, Mekhora et al point out that tension neck syndrome must be differentiated from other
neck problems that are joint or neurologically based. The symptoms include constant muscle
fatigue and stiffness in the neck and shoulder areas and palpation of these areas may identify
two tender spots or trigger points.
2.16.2 Conservative Treatments for Tension Neck
Two studies were found for interventions in the management of tension neck. Mekhora et al (79)
examined the long-term effects of ergonomic interventions in computer users. The study was a
randomised controlled pre and post-test study. The participants were 470 individuals who were
selected via questionnaire and interview and were between 18 and 60 years old, worked with
computers for 4 hours or more a day, no history of neck trauma, neurological or spinal disease,
no other medical treatment, no symptom improvement in the last 3 months and with discomfort
or pain which alleviated overnight. The outcomes measures of the study were the Nordic
Musculoskeletal Questionnaire, a visual analogue discomfort scale, workload and work duration
measurement. Workplace interventions included the use of computer software that made
recommendations for configuration of the workstations and simple interventions such as
footstools, document holders and wooden boards to raise keyboards. Outcome measures were
applied for a period of 6 months after the intervention was introduced. The results found that
discomfort levels in 8 body areas were significantly reduced after interventions were made.
This did include the neck (0.64 cm) area but greatest reductions in discomfort were found for
the lower back (0.85 cm), eyes (0.75 cm), upper back (0.73 cm) and right shoulder (0.65 cm).
The study does highlight that ergonomics intervention can reduce discomfort in office workers.
The one confounding factor in this study was different workloads among the population.
However, this study does give some evidence for this type of intervention to reduce neck
symptoms.
Klemetti et al (80), report on an evaluation of a physical training course in bank workers and its
impact on tension neck. In the study a group of participants with diagnosed tension neck
received physical training (N=74) were compared with a control group of workers with
diagnosed tension neck who did not receive any physical training (N=77). The intervention in
the study was a physical training course consisting of 2 meetings a week for 4 weeks; the aim of
the course was to emphasise the participants’ activities and take a self-care approach.
Participants were taught relaxation and stretching exercises; with individual exercise
programmes and planned physical treatment for the tension neck symptoms. The outcome
measure for the study was a postal questionnaire 6 months after the training course which
measured symptoms including headache, fatigue and anxiety; pain and disability in the neck and
shoulder in the past 6 months; changes in and frequency of exercise in the last 6 months,
frequency of using relaxation and stretching exercises and evaluation of the physical training
25 course. The results found that there were no significant differences in pain in the neck and
shoulder region between the experimental and control group at 6 months. Although the study is
a negative result for the management of tension neck, the authors’ highlight that psychosocial
factors should also be included in rehabilitation programmes although there is no evidence for
this.
In summary, there has been little research done for the conservative management of tension
neck. There is some evidence for the impact of ergonomic workplace intervention but no
evidence supporting physical training interventions for this disorder. It can be concluded that
more research is required to evaluate other treatment options.
2.17 SUMMARY OF CONSERVATIVE TREATMENTS FOR UPPER LIMB
DISORDERS
The evidence for conservative treatment options of upper limb disorders ranges from good to no
current evidence as to the efficacy for some medical treatments. For general management of
upper limb disorders two papers were found that did not give evidence of positive treatment
outcomes, as one was a summary paper and one an educational paper. Pain management
programmes did give limited evidence for impact in the short-term on reducing sickness
absence.
When examining specific disorders, effective treatment of carpal tunnel syndrome includes the
use of steroids, and steroid injection in the short term. There was no current evidence to support
the use of NSAIDs; there was no current evidence to support the use of chiropracty, wrist
supports or yoga but there was some evidence to support exercise and range of motion exercises
in the short term. Further papers found limited evidence to the use of ultrasound treatment, laser
acupuncture and workplace interventions.
For epicondylitis, no evidence was found to support the use of NSAIDs but some support was
found for the use of topical NSAIDs. In the short-term, steroid injections were found to be an
effective treatment for epicondylitis; little evidence was found to support the use of
iontophoresis and radiation/laser therapy should only be used after other conventional measures
fail. No evidence was found to support the use of shockwave therapy and only limited evidence
was found to support the use of needle or laser acupuncture.
For shoulder disorders, limited evidence was found to support the use of NSAIDs and steroid
injection to treat rotator cuff tendonitis and bicipital tendonitis; little evidence was found to
support conservative treatments for shoulder capsulitis. For the treatment of impingement
syndrome, limited evidence was found to support home exercise programmes and manual
therapy.
No evidence of the efficacy of conservative treatments was found for tenosynovitis, tendonitis
of the wrist or forearm, de Quervain’s Disease, Cervical Spondylosis or Diffuse Non-specific
Upper Limb Disorders. For the treatment of tension neck, there is limited evidence that
ergonomic intervention can reduce symptoms.
Much of the research reviewed was lacking in a number of areas including poor experimental
design, small populations, a lack of control measures and inconsistent follow-up. This suggests
that future research must address methodological design issues to carry out research that can be
used to give a stronger evidence-base for the treatment of upper limb disorders.
26 27
Table 8 Summary of evidence
General Management of WRULDs
Author
Treatment
O’Neil et al (19)
Prognosis less good with
longer duration of
symptoms
Hagberg (20)
NSAIDs
Acupuncture
Steroid Injection
Workplace Modification
Job Changes
Technique Training
Treatment of Chronic Tendon Injuries
O’Neil et al (19)
RICE (rest, ice,
compression and elevation)
Pain Management Programmes
Johansson et al (21)
Cognitive Behavioural
Programme
N=85
Randomised Controlled
Outcome Study
Occupational Activity
increased No difference
at one month.
Significant reduction in
pain intensity and
severity, interference.
And life control
measures. Sickness
absence decreased
significantly
Occupational Activity
Follow-up at one year
Sickness Absence
No evidence given
No evidence given
Educational Paper
Summary Paper
Evidence
No evidence given
Outcome Measures
Summary Paper
Limited evidence but
small numbers
Not applicable
Not applicable
Quality of Evidence
Not applicable
28
Karjalainen et al (23)
Marhold et al (22)
Hypnosis with biofeedback
and autogenics
N=32
Review Paper including two
papers.
EMG Biofeedback
Relaxation
Imagery
Vs
EMGbiofeedback and
relaxation
Vs
Relaxation
N=48
Treatment
Cognitive Behavioural
Therapy for individuals with
chronic back, neck and
shoulder pain
N=72
Randomised Cross Over 2x2
design
Author
Outcome Measures
Pain intensity on VAS scale
Pain intensity measures
Sickness absence Pre-treatment
2 months post treatment
4 months post treatment
6 months post treatment
Pain intensity
significantly lowered in
the intervention group
No significant differences
No significant
differences in long term
sickness absence
Significant decrease in
short-term sickness
absence.
Evidence
Quality of Evidence
Limited evidence and
issue of poor study
design
Limited evidence but
issue of poor study
design
Some Evidence for
impact in short-term
sickness absence
29
Carpal Tunnel Syndrome
Gerritsen (26)
Physical Therapies
Gerritsen et al (25)
Davis et al (31)
Splinting vs Open Carpal
Tunnel release
RCT N=176
Chiropracty, wrist support
and ultrasound vs NSAIDs
and wrist supports
Steroids (Oral and Injection)
Treatment
NSAIDs and analgesics
Gerritsen et al (25)
Gerritsen et al (25)
Author
Giele (29)
Follow-up 18 months
Physiotherapy examination, questionnaire at 3, 6
and 12 months
Self-reported mental and physical distress, nerve
conduction and finger sensation
At 18 months surgery had
a better long term
outcomes than splinting
No significant difference
found
Good but confounders
in the splinting group
None
Good but no long-term
follow-up
Good
No current evidence that
NSAIDs more effective
than placebos
Local injection
significantly improved
symptoms at one-month
Systematic Review
Systematic Review
Quality of Evidence
Good
Evidence
RCT of NSAIDs vs
Diuretics vs oral steroids
vs placebo: only steroid
reduced symptoms
Outcome Measures
Systematic Review
30
Laser Acupuncture
Workplace Interventions
Including job change,
increased rest periods, better
ergonomics
Giele et al(29)
Herbert et al (28)
Randomised “sham”
controlled trial
N=34
Gerritsen et al(25)
Ebenbichler et al
Yoga regime vs wrist splint
and current treatment
RCT N=42
Garfinkel et al (32)
Ultrasound
Summary of Research
Paper
Exercise and Stretching
Range of motion exercises
vs splinting
N=50
Feuerstein et al (27)
(33)
Treatment
Physical Therapies (cont)
Carpal Tunnel Syndrome (Continued)
Author
Literature review
Subjective complaints, sensory loss, nerve
conductivity and physical functioning
2 weeks, 7 weeks and 6 months
Disturbed sleep, pain intensity, Phalen’s sign,
Tinel’s sign, grip strength and nerve conduction
Follow-up at one month Movement
Outcome Measures
Improved nerve
conduction and subjective
symptoms
Improved nerve
conduction but not
statistically significant
Wrist extension
significantly improved
after 3 weeks
Evidence
Little evidence due to
lack of good research
Limited evidence that
soft laser acupuncture is
more effective than
placebo
Limited Evidence –
more work required
Poor - Small study and
no control measures in
the group wearing
splints.
Good but short-term
results
Quality of Evidence
31
Hey et al (37)
Green et al (38)
Hey et al (37)
N=164 new episode patients
Pragmatic randomised
control trial of steroid
injection vs NSAIDs and
simple analgesics
Steroid Injection
Cochrane Review
N=164 new episode patients
Pragmatic randomised
control trial of steroid
injection vs NSAIDs and
simple analgesics
Epicondylitis (Medial and Lateral)
Author
Treatment
NSAIDs
Measured at 4 weeks and 12 months
Global assessment by participants, pain severity,
pain free grip strength (Likert scales)
The use of NSAIDs for treating lateral elbow
pain
Global assessment by participants, pain severity,
pain free grip strength (Likert scales)
Measured at 4 weeks and 12 months
Outcome Measures
Steroid injection was
significantly better than
NSAIDs or placebo at 4
weeks
No significant differences
at one year
Some support for the use
of topical NSAIDs in the
short-term relief of lateral
elbow pain. Insufficient
evidence to support the
use of oral NSAIDs
A two week course of
NSAIDs is no better than
placebo
Evidence
Good
Good
Good
Quality of Evidence
32
Basford et al (46)
Seegenshmiedt and
Keilholz (45)
Baskurt et al (44)
Nirsch et al (43)
Smidt et al (39)
Low level laser irradiation
vs placebo
RCT, N=52
Ionising Radiation Therapy
Case Reports
N=85
Radiation/Laser Therapy
Naproxen by topical
iontophoresis
RCT, N=61
Iontophoresis
Acute symptoms
Dexamethasone Sodium
Phosphate by Iontophoresis
vs placebo
RCT, N=199
Physiotherapy vs steroid
injection vs wait-and-see
policy
RCT, N=185
Epicondylitis (Medial and Lateral) continued
Author
Treatment
Physiotherapy
Pain in last 24 hours, benefit by patient
Pain Symptoms
1 year follow-up
Pain severity
VAS Score
Severity of main complaint, pain during the day,
inconvenience
Severity of elbow complaints and elbow
disability.
Outcome measures made at 6, 12, 26 and 52
weeks
Outcome Measures
Treatment Effective
Significant improvement
in pain symptoms in 74%
of cases
No significant differences
found
Found significant results
in favour of iontophoresis
but side effects reported
Steroid injections were
best treatment in the short
term
At long–term follow up,
physiotherapy was the
best treatment followed
by wait-and –see policy
Evidence
Good but small sample
Good but treatment
should only be used
after conventional
measures fail
Poor - Other treatment
methods also used
including physiotherapy
so results confounded
Good
Good
Quality of Evidence
33
Melikyan et al
ESWT and local anaesthesia
vs placebo and anaesthesia
Prospective randomised
placebo controlled trial
N=246
Haake et al (47)
Randomised double-blind
placebo-controlled study
N=74
ESWT vs placebo
ESWT and manual therapy
of the cervical spine vs
ESWT in chronic cases
Prospective single-blind
controlled
N=127
Rompe et al (49)
(50)
ESWT, 3000 pulses vs 30
pulses
Controlled Prospective
Study, N=100
Rompe et al (48)
Epicondylitis (Medial and Lateral) continued
Author
Treatment
Shockwave Therapy
Disabilities Questionnaire, grip strength, pain,
analgesic usage and rate of progression to
surgery
Pain measures: the Roles and Maudsley at 12
weeks and 12 month follow-up
Pain measures: The Roles and Maudsley
outcome score at 12 months
Grip strength, Pain severity, palpation, chair test,
resisted finger extension at 3, 6 and 24 weeks
Outcome Measures
No significant
differences between
groups
No significant differences
between the groups and
improvement observed in
two thirds of patients at
12 months
No significant difference
between groups – both
showed a significant
improvement
Reduced pain and
improved function in the
higher pulsed group
Evidence
Good, no evidence that
ESWT is better than a
placebo
Good, ESWT
ineffective
Poor, lack of control on
ESWT and cervical
manipulation. Patients
not randomised
Poor, confounded by
patients not blinded nor
randomisation effect
reported
Quality of Evidence
34
Acupuncture vs sham
acupuncture
RCT investigator and
patient blinded
N=55
Cochrane Review
Acupuncture for treating
lateral elbow pain
Fink et al(51)
Green et al (52)
Epicondylitis (Medial and Lateral) continued
Author
Treatment
Acupuncture
Systematic Review
Maximal strength, pain intensity and disability
scale at 2 weeks and 2 months post-treatment
Outcome Measures
Four RCTs reviewed.
Some evidence to support
needle acupuncture in the
short-term – 24 hours
At 2 weeks, significantly
reduced pain intensity and
increased arm function
and strength
At 2 months, only the arm
function was significantly
improved
Evidence
Insufficient evidence to
support or refute the use
of needle or laser
acupuncture
Limited evidence –
no control group and
small numbers
Quality of Evidence
35
Green et al (57)
Bartolozzi et al (56)
Cochrane Review
Systematic review for
interventions on shoulder
pain
Combined treatments
included physical therapy,
local steroid injection and
NSAIDs
N=136
Rotator Cuff Tendonitis and Bicipital Tendonitis
Author
Treatment
NSAIDS
Systematic Review
14 clinical outcome measures at 6 months
and 18 months
Outcome Measures
NSAIDs and
Subacromial steroid
injection may improve
range of movement in
rotator cuff syndrome
more than a placebo
Suggests patients
should undergo 18
months of conservative
treatment. Paper
unclear on how patients
were allocated -
At 6 months, 46% of
patients had excellent
or good results; at 18
months, 47/68 patients
diagnosed with chronic
impingement syndrome
Evidence
Limited evidence –
more good quality
research needed
Limited as design
questionable and
numbers small
Quality of Evidence
36
Green et al (57)
De Jong et al (60)
Shoulder Capsulitis
Author
Gam et al (59)
Cochrane Review
Systematic Review for
interventions on shoulder
pain
32 patients 10mg of
triamcinolone acetonide
injection vs 25 patients with
40 mg triamcinolone
acetonide injection
Treatment
Steroid Injection
Distension and glucorticoid
vs glucorticoid alone
N=20
Systematic Review
Pain, sleep disturbance, functional
movement
Outcome Measures
Functional movement, pain, daily use of
analgesics at 3, 6 and 12 weeks
Higher does level more
effective but this may not
be the optimum dosage
Significant reduction in
pain and functional
impairment in the high
does group
Evidence
Improvement in
functional movement and
decrease in analgesic use
with shoulder distension
and glucorticoid
Little evidence to
support or refute
efficacy of conservative
treatments for shoulder
capsulitis
Limited evidence –
numbers small
Small sample – more
research required
Quality of Evidence
37
Systematic Review of RCT
examining therapeutic
exercise and manual therapy
Desmeules (66)
Blair et al (65)
Home exercise
programme for construction
workers. Participants
randomly allocated
Treatment group N=35
Control group N=33
Asymptomatic Group N=25
Short term efficacy of
subacromial steroid
injection
RCT, N=40, Treatment
group = 19, Control group =
21
Treatment
Retrospective study of 616
patients conservatively
managed via physical
therapy and NSAIDs
Ludewig and Borstad (61)
Impingement Syndrome
Author
Morrison (64)
Pain scores, physical examination and
functional status
Shoulder-Rating Questionnaire pre and post
treatment between 8 and 12 weeks
Shoulder-Rating Scale of the University of
California at Los Angeles
Outcome Measures
At most recent followup appointment, pain
score significantly
reduced and a
significant increase in
movement
Significant
improvement in
treatment group vs
control group
Evidence
At follow-up
appointments 67% of
patients had a satisfactory
outcome and 28% were
recommended for surgery
Limited evidence for
the use of therapeutic
exercise and manual
therapy, however
methodological issues
in research reviewed
and needs further
research
Limited evidence but
no consistency in
follow-up as time
ranged between 12 – 55
weeks
Limited evidence but
small numbers involved
in the study
Poor - Inconsistent in
follow-up times as
they ranged from 681 months
Quality of Evidence
38
Richie (70)
Pooled qualitative literature
review
Tendonitis of the wrist and forearm
Piligian (35)
Suggested interventions,
workplace risk assessment
and work modification, rest,
NSAIDs
De Quervain’s Disease
Piligian (35)
Suggested interventions
include worksite
modification, rest, NSAIDs,
analgesics, wrist splinting
Moore (69)
Review
Tenosynovitis and Flexor-Extensor Peritendonitis
Author
Treatment
Payling (67)
Review Paper
recommending various
options including removal
from current job, rest, arm
support, casts and
physiotherapy
Piligian (35)
Suggested interventions
including workplace
modification, rest, NSAIDs,
analgesics and physical
therapy
Outcome Measures
Most effective
treatment steroid
injection
Evidence
Majority of researches
are case series relating
to surgery rather than
RCTs
Poor evidence as based
on descriptive studies
not RCTs
No evidence given to
support or refute
conservative treatment
No evidence given to
support or refute
conservative treatment
No evidence given to
support or refute
conservative treatment
Quality of Evidence
No evidence given to
support or refute
conservative treatment
39
Treatment
Discussion article
suggesting rest,
immobilisation and ice
Klemmeti et al (80)
Tension Neck
Mekhora (79)
Ergonomic Interventions for
computer users
RCT, pre and post study
with delayed intervention
for the second group N=80
Physical training in bank
workers
Treatment group diagnosed
with tension neck N=74 vs
control group diagnosed
with tension neck but no
intervention
Diffuse Non-specific Upper Limb Disorders
Lindh et al (77)
Multidisciplinary
Rehabilitation
RCT, Treatment Group,
N=158, control group
N=226
Cervical Spondylosis
Author
Levy (74)
Postal questionnaire 6 months after
intervention
Discomfort measures
Return to work, contact with the Work
Evaluation Unit or medical incapacity
Outcome Measures
No significant
differences between
groups at 6 months
follow-up
Significant reduction in
discomfort measures
post intervention
No significant
differences between
treatment and control
group
Evidence
Some evidence that
ergonomic intervention
can reduce discomfort
for tension neck
sufferers
No evidence that
physical training has an
impact on tension neck
– more research
required
Currently, no evidence
available to support or
refute conservative
treatment of nonspecific upper limb
disorders
Quality of Evidence
Poor – no current
evidence on the
efficacy of conservative
treatments
3. CURRENT EDUCATION IN UK MEDICAL SCHOOLS AND
POSTGRADUATE DEANERIES
3.1 UNDERGRADUATE TEACHING IN UNIVERSITIES
All universities in the United Kingdom running undergraduate medical degrees were contacted
by either telephone or email. Twenty-three universities responded to the request for information
giving a response rate of 83%. One of the respondents was a new degree course and did not feel
it could contribute at this time. Thus information on current undergraduate teaching has been
collated on twenty-two (73%) of UK universities.
The first question was about normal functioning of the musculoskeletal system and when
undergraduates are taught this. One respondent could not break this down as the course was
problem-based learning from year one. Figure 1. presents the information year by year for
undergraduate teaching of normal function. However, some universities tackled the subject in
more than one year as follows; 10 (45%) of respondents taught about normal function in year 1
only, 2 (9%) taught in year two only, five (23%) taught normal functioning in years one and
two, one (5%) taught in year 4, one (5%) taught in years 1, 4 and 5; one (5%) taught in years 1,
2, 4 and 5 and one (5%) taught normal functioning in years 1 to 5.
20
16
Number
12
8
4
0
Year 1
Year 2
Year 3
Year 4
Year 5
Year of Undergraduate Study
Figure 1. Teaching Functioning Musculoskeletal System
The second question asked when undergraduates were taught about abnormal or dysfunction in
the musculoskeletal system. There were a variety of responses to this question and the year-byyear data is presented in Figure 2. Sixteen (73%) of the respondents reported tackling the
subject in more than one year.
40 20
Number
16
12
8
4
0
1
2
3
4
5
Year of Undergraduate Study
Figure 2. Teaching Musculoskeletal Abnormalities
The participants were asked to report on whether they taught particular topics including
rheumatic disorders, arthritis, back pain and work related musculoskeletal disorders (WRMDs).
Twenty-one (96%) reported that they taught about rheumatic disorders and arthritis. However,
the information was missing for one respondent. With regard to back pain, all 22 respondents
reported teaching about back pain. The picture for WRMDs was not so clear and the results are
shown in Figure 3. Sixteen (73%) of respondents did tackle this subject.
20
Number
16
12
8
4
0
Yes
No
Don't know
Not specifically
Response
Figure 3. Teaching of WRMDs
Respondents to the survey were asked to break down the types and amount of teaching carried
out with regard to rheumatology, arthritis, back pain and WRMDs. Respondents were clear
about rheumatology and arthritis teaching with 18 responding to the question. Fourteen (64%)
41
reported using lectures and this ranged from 4 hours to 22 hours. Six universities (27%)
reported using problem based learning and four (18%) carried out seminars. One of the
respondents described their use of combined teaching of rheumatics, orthopaedics and trauma.
There was a comment from one respondent that “WRMDs may be underrepresented”.
With regard to back pain, there were seven responses to this question. Two respondents
identified lectures ranging from 1.25 hours to 3 hours. There was one report of PBL for 3
weeks and one report of a one-week back pain scenario.
There were 6 responses to teaching of WRMDs. With regard to lectures and seminars, one
respondent (4%) mentioned a lecture of 1.25 hours and a seminar of 1.25 hours. PBL, clinical
teaching and tutorials were the method used by another respondent. One respondent mentioned
symposia and clinical teaching in a six-week block in year 4. One days teaching (method not
specified) in primary care was mentioned by one respondent and one respondent covered the
epidemiology of WRMDs.
3.2 POSTGRADUATE DEANERIES
All 28 Directors of Postgraduate GP Education were contacted via email to obtain information
about the training practitioners within their region. Twenty-one (75%) responded to the request
for information; however, two respondents (7%) were unwilling to give any information and
two respondents (7%) were unable to give information within the time available.
Off the respondents, 16 (76%) reported that they did cover musculoskeletal disorders in
training. Respondents were asked to identify the content and duration of the courses that were
available to GPs. The responses are shown in Tables 9. and 10.
The responses were split into formal training courses and informal or on-the-job training. The
formal training available encompasses both diplomas and lecture sessions.
Table 9 Formal training in musculoskeletal disorders
Training Type
Four week residential course and distance learning
Diploma in Sports and Training Injuries
Four day course British Association of Sports Medicine
Joint injection course 1 day
Hand problem lecture 1.5 hours
The knee and shoulder lecture
One afternoon dedicated to rheumatology
One afternoon dedicated to occupational health
Four sessions a year on musculoskeletal medicine
Orthopaedic up-dates
Half a day on musculoskeletal disease
Half a day on chronic pain management
Episodic Sports Medicine and Rheumatology Courses
Two to three afternoons with Rheumatologists
Physiotherapists
Day release
42
and
Number of responses
2
2
1
3
1
2
2
2
1
1
1
1
1
4
1
For informal training, the most common response was that the topic was tackled if it was raised
as a learner-centred need. This was followed by the comment that training was largely
opportunistic and dependent on what was available.
Table 10 Informal (on-the-job) training in musculoskeletal disorders
Training Type
Only if raised as a learner-centred need
Largely opportunistic
Informal tutorials
Case presentations
During hospital component of vocational training
During GP registration exposed to significant musculoskeletal load
Specific on-the-job training
Vocational training on back pain
All common conditions covered
Number of Responses
9
2
1
1
1
1
1
1
1
3.3 TRAINING FOR OCCUPATIONAL PHYSICIANS IN THE UK
There are a number of routes for training for Occupational Medicine in the UK.
Occupational Medicine is available from 8 centres within the UK. This is
course for those with an interest in Occupational Medicine and equips the
generalist in occupational medicine. The core syllabus for the diploma
musculoskeletal system, epidemiology and ergonomics.
The Diploma in
an introductory
individual as a
does cover the
The other area for training in Occupational Medicine is the Associateship of the Faculty of
Occupational Medicine (AFOM) examination. This examination is aimed at physicians who
wish to have a career in Occupational Medicine and demonstrates a sound understanding of core
knowledge and practice in this field. There are currently two courses running in the UK to
equip trainees in Occupational Medicine. The syllabus for the AFOM examination covers areas
including the impact of work on health, aetiological processes, differential diagnosis and
ergonomics; all of which can be related to the aetiology and management of ULDs.
3.4 OTHER TRAINING OPPORTUNITIES
Other training opportunities available to physicians include the MSc in Sport and Exercise
Medicine at Bath University. This course covers anatomy, biomechanics, exercise physiology,
sports injuries and rehabilitation. The university also provides a diploma in Sports and Training
Injuries for those working in military environments.
The British Institute of Musculoskeletal Medicine provides a modular course in musculoskeletal
medicine aimed at physicians. The course aims to give core knowledge of musculoskeletal
science to be able to take a comprehensive approach to the diagnosis and management of
musculoskeletal disorders. The course consists of 8 modules accredited by the Royal College of
Physicians and the Royal College of General Practitioners.
43 4. FOCUS GROUP ANALYSIS AND FINDINGS
4.1 REASONS FOR THE QUALITATIVE ENQUIRY
In the present study, qualitative data was collected using three focus groups of General
Practitioners, Occupational Physicians and trainee Occupational Physicians respectively. This
qualitative approach via focus groups was deemed as the most appropriate for the development
of a questionnaire survey that would aim to explore physicians’ perceptions of the difficulties of
managing ULDs. Qualitative methods can serve to ground quantitative data with regard to
defining the research questions for occupational health research. Qualitative approaches use
purposive sampling and rely on key persons singly or collectively to provide rich descriptions of
the situation as they perceive and experience it. These key informants or focus groups can serve
in helping to define the research problem. Thus, combining qualitative with quantitative
methods in a complementary manner can lead to better understanding of work environments and
labour situations and a means for developing appropriate strategies for preventive intervention
(81)
.
4.2 METHOD
The focus groups were developed to inform the questionnaire design. The purpose of the focus
group interviews was to use the dynamics and interactions of the groups to obtain rich and
diverse information regarding the research questions of the project i.e. the management of
ULDs, best practice, the physicians’ training, their evidence base, their perceived difficulties
and perceived training needs. The use of focus groups was chosen as it allows for reflection and
comment, incorporating a wide range of experience from group members, which are often
triggered to recall and discuss experiences that may not emerge in individual interview (82).
4.2.1. Participants
As part of the Survey Development and Questionnaire Design phase, thirty individuals were
contacted and invited to take part in one of three focus groups. Senior Occupational Physicians
with experience in the field of ULDs composed the first focus group. The second group
consisted of General Practitioners, and the final group consisted of trainee Occupational
Physicians.
Focus groups were convened in the Institute of Occupational and Environmental Medicine
(IOEM). The first focus group (N=9) involved the senior Occupational Physicians and an
attendance rate of 90% was achieved. The other targeted groups, however, consisted of GPs
and trainee Occupational Physicians, proved elusive. After convening three focus groups, 4
GPs consented to participate, who took part in two sessions. Similar efforts produced one
additional focus group session consisted of 4 trainee Occupational Physicians, while further
efforts were hindered by the project’s timescale.
4.2.2. Interview Schedule
An interview format with open-ended questions was selected as the most appropriate means of
using the dynamics and interactions of the groups to obtain rich and diverse information
regarding the management of ULDs, best practice, and the physicians’ training, evidence base,
perceived difficulties and training needs. The content and design of the interview schedule for
the focus groups were devised based upon review of the literature, on the aforementioned
theoretical framework, which entails the research questions of the present project, and on
relevant methodology sources on qualitative interviewing (83,84).
44
A standardized format was used for the focus group interview schedule. Each focus group was
presented with the same questions in the same manner, except from follow-up probes that were
utilized in order to elaborate and clarify some responses. Thus, while the focus groups sessions
were structured and standardized, there was flexibility in relating the questions to the
participants and the way they presented their experiences. This allowed greater depth of
information as well as the building of rapport.
The focus group interview schedule consisted of three parts. Part 1 included introductions and
general information about the scope of the study, the terms of confidentiality and the focus
group procedure. In the second major part of the focus group session, 6 open-ended questions
were asked regarding the different aspects of managing ULDs:
1. How do [Occupational physicians/ GPs] manage upper limb disorders regarding diagnosis and treatment? 2. What is considered ‘best practice’ in the management of upper limb disorders?
3. What training do [Occupational physicians/ GPs] receive with regard to upper limb
disorders?
4. What is your evidence base regarding the management of upper limb disorders?
5. What difficulties do you perceive in the management of upper limb disorders?
o Probe: How do you deal with them?
6. What training needs do [Occupational physicians/ GPs] have regarding the management of upper limb disorders? o Probe: What training would you suggest?
Interview techniques were employed to enhance the likelihood of a positive interaction between
the interviewer and the focus group participants, and to obtain coherent, in-depth responses to
each question. These included using effective communication techniques such as paraphrasing,
and probing for clarification and elaboration.
The concluding portion of the interview schedule allowed the participants the opportunity to
make additional comments and clarifications about the content of the focus group session, as
well as ask questions to the facilitator. At the completion of the session, the participants were
reminded of the confidentiality of the discussion and were thanked for providing their input.
4.2.3. Interview Procedure
The study had the approval of the London Multicentre Research Ethics Committee (REC
reference no: 03/2/107). The principal investigator facilitated all focus groups, while the
research associate of the project took notes throughout the session so as to maintain a written
record of each discussion. A two-page sheet was generated, detailing preparation and
guidelines for interviewing and was reviewed by the researchers prior to each session. Focus
groups sessions lasted between 60-90 minutes.
The focus groups were held in a conference room without distractions. Seats were configured
around a conference table so that all participants could see each other. A portable video camera
with a built-in microphone was used in addition to note taking. All interviews were audiotaped
using the audio recording feature of the camera. However, the visual feature was deliberately
obscured to protect the anonymity of the participants. Upon arrival at the IOEM, participants
were briefed on the focus group process and were given a consent form to sign. They were
reminded that their responses were confidential and that they could terminate their participation
at any time.
45 Upon completion of these preliminary procedures (part 1), the camera was turned on and
participants were introduced to part 2 of the interview schedule. Throughout the session,
follow-up, detail-oriented (i.e., when, what, how and what questions) elaboration (i.e., ‘could
you say some more about that?’) and clarification (i.e., ‘what do you mean by that?’) probes
were used where deemed appropriate.
The focus group interviews were transcribed verbatim by the research associate and checked by
the principal investigator subsequent to each session. The participants’ anonymity was assured,
as the tapes were only accessible to the researchers.
4.2.4. Data Analysis
Content analysis, using the NVivo 2.0 software and a constant comparative approach, was
employed to analyse the focus group interview transcripts. Content analysis entails coding large
amounts of interview data into blocks that represent a common theme to organise transcribed
material (85). In this project, both ways of conducting content analysis – inductively and
deductively- were used. With inductive analysis, new themes and categories emerge from the
participants’ comments, while deductive analysis entails the use of a pre-existing set of
categories to organize the quotes (86).
In the present project, deductive analysis was performed originally through coding quotes based
on the theoretical framework mentioned in section 4.2.2. The analysis then continued
inductively by combining the remaining quotes along with some of the quotes that had been
previously grouped deductively, into new themes and dimensions. The combination of
inductive and deductive content analysis has been suggested by qualitative methodologists as
the most pragmatic way of conducting content analysis (86).
Firstly, the researchers read the 23 single-spaced pages of the transcribed interviews until they
became very familiar with the transcripts. At all stages of analysis, the researchers worked
independently and then came together to reach consensus prior to advancing to the next stage of
analysis. Raw data extracts with similar meaning were combined into groups. These groups
were labelled lower order themes and represented the basic unit of analysis. Then, the grouping
process was repeated with the lower order themes so that a greater degree of abstraction was
attained. Thus, the lower order themes with similar meaning were combined into higher order
themes. Finally, higher order themes were categorized into dimensions, which represent the
highest level of abstraction as no further meaningful grouping could be formed.
All the data
relevant to each dimension were further examined using a process of constant comparison, in
which each theme was checked or compared with the rest of the data across and between focus
groups.
Additionally, in an effort to cross-validate the inductive process, the research associate’s ULD
management dimensions, higher order themes and lower order themes were given to the
principal investigator in a random order. The principal investigator was then asked to assign the
groups of higher order themes to their respective dimensions and the groups of lower order
themes to their respective higher order themes. The principal investigator’s groupings yielded a
percentage of agreement of 80%.
4.3. FOCUS GROUP RESULTS
The content analysis of the focus group responses regarding the medical management of ULDs
yielded 7 dimensions, 47 higher order themes and 158 lower order themes for the Occupational
Physicians (OPs), 7dimensions, 36 higher order themes and 126 lower order themes for the
trainee Occupational Physicians (TOPs) and 7 dimensions, 37 higher order themes and 103
46 lower order themes for the GPs. Tables A1.1-A1.21 show the general categories (i.e.
dimensions) and their specific themes (i.e. higher order and lower order themes). The
dimensions that emerged from the focus groups were labelled ULD management, best practice,
evidence base, training, informal learning, perceived difficulties and training needs. All seven
dimensions were reflected in the responses of all the participants, while several of the higher
order themes of the three groups also coincided. However, the content analysis of the responses
yielded a number of differences as well, particularly in the lower order theme level.
4.3.1. Occupational physician focus group: key findings
ULD management
The dimension of ULD management is defined as the various routes that OPs adopt towards
managing ULDs. Higher order themes from the OPs’ transcripts included a) patient’s history,
b) examination, c) investigation, d) diagnosis, e) interventions, f) treatment, g) referral and h)
time spent with the patient. These higher order themes were derived from lower order themes
and raw data quotations, presented in Table A1.1.
With regards to the management of ULDs, OPs quoted patient’s history, investigation and
examination as routes they use towards diagnosing and making appropriate interventions.
Finding occupational causes through occupational history and investigation of the workplace
was regarded as a prominent feature in their approach as well as one of the unique elements
provided by the OP specialty concerning ULDs management. Means used towards this
included risk assessments, ergonomic assessments, and specialised questionnaires, seeing more
people from the same workplace and workplace visits.
We ask about the job they are doing, understand their job. Has it caused the problem? We ask
about factors outside work. Does it improve when away from work?
We have access to resources that GPs do not have; risk assessments and ergonomic
assessments available.
We pick up work relatedness quicker than the GPs. We use specific questionnaires and see
more people from one place.
We sneak up on them with or without a camera!
In terms of diagnosis, we often go looking not at a single person but a group of people, which
might identify a work activity, which is going to affect other people and exhibit symptoms. So
we have a secondary prevention effect, which GPs usually are not in a position to do unless they
are in an area with a particular industry where activities occur that cause this sort of symptoms.
On the subject of treating ULDs, the OP approach tends to be based on interventions rather than
on treatment in its strict clinical sense. Tackling aggravating occupational factors through
advising modifications in the workplace and in the patients’ duties and addressing the
psychosocial side of ULDs appeared to be a main concern in the OPs’ active management of
ULDs. Conservative treatment was quoted as the preferred course of action.
The treatment is according to undergraduate and postgraduate training and experience. It’s a
combination. The treatment is trying to identify the cause and then removing it or modify it.
Us OPs are much less likely to do things to people like sticking needles…We try to deal with,
reduce aggravating factors.
47 We would modify, change the job if necessary, if it is contributing to the problem.
In the case of carpal tunnel syndrome, by moving somebody from one job to another the
problem goes away. Due to psychological elements changing maybe; less pressure from the
Management...Most others would give pills, injections or operations….
Regarding carpal tunnel syndrome, we try a variety of conventional and less conventional
treatments before surgery. We try to move around away from costly, towards conservative
treatment, on their own or with a physio before they go onto surgery. OPs use rehabilitation,
gradual return to work.
We can treat the psychosocial side, showing to people that with changes in the work
environment, they can go back to work, [and] make changes in the work environment so they
can go back to work.
Communication and cooperation with the workplace Management was also regarded as
prominent features in the OPs’ approach towards managing ULDs.
Some employers are very ‘switched on’, willing to pay in order to address the problem and
change the process if told by the OP that it is causing the problem; epicondylitis for example.
We can be more specific than the GPs and our opinions are taken aboard by the Management.
With regards to referrals, availability and past experience seemed to influence the OPs’ choices.
Obviously, specialist referral is available sometimes but it can be regretted. People can be
waiting a long time for a diagnosis.
Regarding tennis elbow, ultrasound never works! My experience has shown that but it’s a
standard referral…We refer by experience.
Additional remarks focused on the time length of the consultation with the patient. It was felt
that the doctor - patient consultation needed to be extensive in order to address the multifactorial
nature of ULDs.
We spend longer time with our patients than the GPs. At least 30 minutes. It’s difficult to
assess in less time. We get to assess presenting complaints and do psychiatric assessment and
assess their job.
It’s difficult to get through in much less than 40 minutes.
Best practice
The dimension of best practice is defined as the perceptions of OPs of what constitutes best
practice in managing ULDs. Higher order themes from the OPs’ transcripts included a) keeping
the persons at work, b) providing evidence-based management, c) having the patients’ ability to
function retained, d) avoiding iatrogenic disease, e) seeking input from the employer, f) seeking
multidisciplinary communication and collaboration g) encouraging the employer to be proactive
h) having easy access to treatments and i) avoiding ‘labels’ regarding conditions. These higher
order themes were derived from lower order themes and raw data quotations, presented in table
A1.4.
48 With regards to what constitutes best practice, OPs quotes identified employing all available
means to keep the person at work and providing evidence based management as main aspects.
Encouraging the patients to maintain their ability to function in order for them to be able to
return back to work and avoiding medical management practices that can create disease were
also pointed out as important aims.
Best practice is to keep the person in their job or at work; move the individual to another job if
it causes the problem or change the individual’s approach to the job.
Best practice is evidence based. It comes back to the diagnosis; you’ve got some areas that are
better known; a lot of evidence available in the literature, in terms of diagnosis, like carpal
tunnel syndrome and epicondylitis. If the diagnosis is unknown, then it is difficult to identify
best practice.
…Functionally best practice is to maintain activity; encourage the person to return back to
work…and have the ability to function retained.
Avoiding iatrogenic diseases is important. Not undertaking treatments if you are not sure of the
pathology as it can create disease…If there are medically unexplained symptoms, one should
not undertake interventions that may have an adverse effect.
Seeking input from the employers with regards to the employees’ health history and employing
their help in monitoring the patients’ progress were regarded as steps towards best practice.
Furthermore, best practice was related to a multidisciplinary approach. Communication and
collaboration with different specialties such as orthopaedics, and GPs were identified by the
OPs as desirable features towards attaining best practice. However, OPs’ quotes reflected
dissatisfaction with the present state of multidisciplinary communication.
There is detailed input to be acquired by the employers as to who is off sick or has a specific
disease, which is a way to know if our treatment is working or not. For example, some
employers are very switched on regarding epicondylitis.
Best practice is multidisciplinary, which we are not terribly good at; working with orthopaedics
and surgeons. It’s the communication, which is missing.
[Best practice is] involving the GP in the loop of the problem and being proactive with an aim
to keep the persons well in their work.
Additional remarks on the subject of best practice addressed the need for having easy access to
treatments, such as physiotherapy, and for avoiding labelling one’s condition with terms like
‘for life’ so as not to predispose the patient negatively towards rehabilitation.
Best practice is get the patient back to action as soon as possible and having easy access to
physio.
[Best practice is] not giving generic labels like ‘you are going to have this for life’.
Training and Informal learning
The training dimension is defined as the formal training that OPs receive on the subject of
managing ULDs. The content analysis of the OPs’ transcripts led to two higher order themes,
which were a) undergraduate training and b) postgraduate training. These higher order themes
were derived from lower order themes and raw data quotations, presented in table A1.7. In
49 addition, the content analysis of the OPs’ transcripts with regards to their training in relation to
ULDs yielded a supplementary dimension; the dimension of informal learning. Thus, training
and informal learning constitute the route that OPs take on towards learning to manage ULDs.
With regards to ULDs, OPs quotes on formal training reflected the absence of a standardised
curriculum. With the exception of dissection, training experiences varied among individuals
according to availability of courses and training opportunities in their place of study, training
trends at the time and individual interest. Learning from other doctors, and under the influence
of senior doctors, appeared as prominent features in their training process, while studying for
the AFOM was quoted as having a positive contribution to their ULD learning. Sports medicine
courses were also cited as a useful source of learning about ULDs.
We learn from dissection…
We learn mainly from other doctors as undergraduates and postgraduates rather than from
books.
As a student I used to go to Birmingham rehabilitation centre, which provided me with realistic
and relevant teaching.
It’s all very individual. We learn during relevant house jobs; orthopaedics; registrar jobs. [We
learn] from picking up undergraduate courses that were fashionable at the time; some
questionable as people might be throwing in their own view.
We become very focused during the AFOM. That crystallised my understanding.
Attending a course in sports medicine leads to learning about upper limb disorders; doing a
Masters.
We learn a lot when we go back to education because WE want to do it!
‘Medical bosses’ or senior doctors can be very influential in terms of development; especially to
junior staff, which most of the time is good.
The dimension of informal learning is defined as all the informal routes to learning, in addition
to formal training, that OPs adopt towards managing ULDs. Higher order themes from the OPs’
transcripts included a) web based learning, b) clinical experience, c) reading publications, d)
videos, e) scientific meetings, f) learning from other physicians and g) other practitioners.
These higher order themes were derived from lower order themes and raw data quotations,
presented in table A1.10.
OP quotes on informal learning reflected the use of a variety of resources. Web based learning
and clinical experience acquired through everyday medical practice and observations of the
ULD management of other professionals were identified as prominent features, along with
reading publications. Another element cited was the existence of individual learning plans.
We get our knowledge from web based learning; the BMJ learning website can provide a good
retest of what you should learn. Most of us learn from clinical experience –trial and error,
publications from societies, publications which give useful tips...The Nottingham hand surgeons
society meeting every two years attracts many occupational physicians…
Internet sites are quite useful. Some have alerts on new papers for people with a learning plan.
50
We pick up bits along the way.
We learn from witnessing slightly different approaches in examining; physios, rheumatologists.
We learn from practitioners who we perceive as effective or not in what they are doing, or
doing something in a particular way, like physios or nurses. By watching them we tend to
learn.
Evidence base
The dimension of evidence base is defined as the sources of evidence that OPs use as the basis
for their management of ULDs. Higher order themes from the OPs’ transcripts included a)
personal experience, b) colleagues, c) journals, d) web sites, e) textbooks and f) available
guidelines. These higher order themes were derived from lower order themes and raw data
quotations, presented in table A1.13.
With regards to management of ULDs, OPs identified previous personal and colleagues’ clinical
experience as a significant source of their evidence base. Publications in journals were quoted
as important while accredited websites featuring evidence-based medicine related topics were
also referred to as a source of their evidence. Additional sources identified were textbooks and
standardised approaches, where available.
Most evidence comes from personal and other peoples experiences. Did it work? Not a clever
way of practising but we all know what doesn’t work.
Conditions and treatments published in journals. Epicondylitis and carpal tunnel syndrome are
well covered. Journals are important to us; what has been published.
Doctors.net and BMJ.com provide modules linked to evidence base and scoring of the evidence.
If there are no randomised controlled trials available, we have to rely on textbooks and
colleagues.
We have standardised approaches.
Perceived difficulties
The perceived difficulties dimension is defined as the difficulties that OPs perceive in their
management of ULDs. Higher order themes from the OPs’ transcripts included a) difficulties
related to the disease b) difficulties related to the patient c) difficulties related to the employer d)
difficulties related to the resources available e) adversarial effects of previous medical
management f) difficulties ensuing from the use of ‘labels’ g) adversarial influence of other
parties and h) difficulties ensuing from medico-legal factors. These higher order themes were
derived from lower order themes and raw data quotations, presented in table A1.16.
A number of difficulties affecting the OP management of ULDs were identified. The long
natural course of a number of ULDs was stated as a disruptive factor, which prolongs the
therapeutic process, leading to patient dissatisfaction. Chronic problems were also stated as a
source of difficulty leading to a pain – injury cycle, which hinders patient cooperation.
Some upper limb disorders have a fairly long history so eight to ten weeks may pass after
whatever intervention with no result seen. So the patient becomes disillusioned.
51 The more chronic [the disease] the more difficult to manage.
Breaking the pain-injury cycle [is difficult]. The patient perceives that anything that causes
pain is going to cause injury.
Difficulties identified in relation to the employer included problems resulting from the work
organisation e.g. lack of appropriate breaks and complaints with the workplace Management
resulting in a manifestation of physical complaints. Uncooperative managers were an additional
source of difficulty cited from the OPs, hindering their management of ULDs, while another
difficulty identified was the employer pressuring the physician for results.
Sometimes the diagnosis may lie outside the patient parameter. The problem may be due to
very strict supervisory style; no breaks allowed at appropriate times and the solution lies in
changing the management style or the work organisation.
Sometimes there may be a grievance festering away having to do with the Management. They
[the patients] may convert emotional complain to physical complain to withdraw their labour
leading to long term sickness and it is easier to complain about something physical rather than
having an emotional complain like unhappiness with the organization. The patient feels safer
and this can be conscious or unconscious.
Getting the managers to make the alterations, allow the patient to stay and do the job
differently; negative response by the managers. Employers want a guarantee they [the patients]
will be back to work, they tend to want rid of it; cynical view of the Management.
There is pressure to send the case home happy. GPs have no pressure by the employer like the
Occupational Physicians. The employer is the one who is paying for it.
With regards to available resources, OPs identified long waiting times for specialist and
treatment referrals and delay in getting to see the individual as factors hindering the
management of ULDs.
…Most have to wait up to 6 months if it's up to NHS to deliver physio. And small contracts have
difficulty in accessing physio.
Carpal tunnel syndrome is one of the easiest to manage. Biggest problem is waiting to be seen
by a specialist and then for treatment.
Sometimes weeks pass before we get to see the patient. By then the patient may have already
been conditioned that he won't get better or is afraid of further injury.
Previous medical management was also stated as a potential source of difficulties in the form of
conflicting diagnoses by different physicians and previous discouraging diagnoses having
caused demoralisation of the patient.
The commonest is difficulty on getting the diagnosis. This happens if the person is being seen
by many people and has been given several different diagnoses; three or four different
diagnoses.
Medicine can also be adversarial. Some doctors come up with extraordinary diagnoses!
52 …diagnoses saying ‘you cannot do this work ever again’, which are difficult to undo. That can
be damaging and takes a lot of time to undo.
The use of labels for the disease was also identified as a potential source of difficulties in the
management of ULDs. OPs stated that labels such as ‘upper limb disorders’ tended to
predispose negatively the patients with regard to their condition. Conversely, it was cited that
patients tended to require a label given to their problem in order to feel confident towards the
medical management adopted by the physician.
The term 'upper limb disorders' implies lack of function and a problem as opposed to ‘upper
limb symptoms’. It’ s too much of a label.
One should try to talk through with the patient and not give a name if he is not sure of the
condition… orthopaedic surgeons and rheumatologists don't do that. And patients require
from the doctor a label for their problem saying 'How can you treat it if you do not know what it
is?'
Other difficulties identified, were related to the adversarial influence of parties such as the
labour unions, family members and legal advisors. Medico-legal factors in particular were
stated by the OPs as a major source of problems with regards to managing ULDs, as
compensation issues seemed to be linked to increased sickness absence, reduced patient
cooperation and subsequent decreased rehabilitation.
The Unions and the family can get in the way of the [medical] management.
Employers' liability is very adversarial by nature. It starts a process that prevents the
management of ULDs. It is very difficult to engage somebody in active treatment and get better
if they assume that that will lower the amount of their claim.
The compensation issue has a major impact.
The lawyers contradict the doctors'
recommendation for return to work and the patient in that situation always does what the
lawyer says.
Temporary injury allowance can stimulate increased absence from work because of the money
reward attached, prolongs things and decreases rehabilitation, as they do not realise the
functional reward attached in terms of better capability in the future. Some people never return,
get better due to medico legal factors or personal gain of some sort. I suspect this is a very high
figure.
Training needs
The dimension of training needs is defined as the various needs that OPs perceive regarding
training to advance the quality of their ULD management. Higher order themes from the OPs’
transcripts included a) communication skills, b) managing the psychosocial aspect of ULDs, c)
updates, d) opportunities to learn from other physicians, e) access to knowledge f) individual
learning plans and g) general medicine experience. These higher order themes were derived
from lower order themes and raw data quotations, presented in table A1.19.
With regards to their training needs in relation to ULDS, OPs identified a gap in dealing with
the psychosocial side of these conditions and asked for communications skills training towards
liasing with the workplace management in order to bring about changes in the workplace.
53 How to deal with, influence the management structure. How do you change the workplace?
Who do you speak or write to? We need communication skills, influencing skills to achieve that.
How to use our knowledge to bring about change in a worker.
We deal with the physiological side but there is a training gap in dealing with the psychosocial
aspect of conditions.
In a more general note, OPs mentioned that they need opportunities to learn from each other and
other specialists through the process of continuous professional development (CPD). Access to
training programmes to accommodate individual training needs was also mentioned while, in a
final note, it was stated that general medicine experience should be acquired by physicians prior
to joining the occupational medicine sector.
Occupational physicians can be isolated. They need opportunities created to learn from each
other in the CPD arena and GPs need the same. We need to discuss with other specialists.
Every OH practice does not cover everything but a proportion of the new learning involved so
apart from ‘brushing up’, new learning is needed.
Individual training programmes for physicians. We differ; we have very different things coming
up from day to day, which are not so clear. Access to knowledge is needed.
One should not be too ‘green’ when coming to Occupational Health. Having general medicine
experience before coming to occupational medicine would be wise.
4.3.2 Trainee occupational physician focus group: key findings
ULD management
The dimension of ULD management is defined as the various routes that TOPs adopt towards
managing ULDs. Higher order themes from the TOPs’ transcripts were a) patient’s history, b)
examination, c) investigation, d) diagnosis, e) interventions, f) treatment, g) referral and h) time
spent with the patient. These higher order themes were derived from lower order themes and
raw data quotations, presented in table A1.2.
With regards to the management of ULDs, TOPs quoted a detailed patient’s history, physical
examination and workplace investigation as the steps they use towards diagnosing.
We go all the way back. By management you mean diagnosis as well. The diagnosis would be
based on…full medical history. Where is the pain, what makes it better, what makes it worse,
when it starts, can you think of any precipitating factors for it, which brings you to the
occupational history as well.
‘Has there been an ergonomic assessment? Has there been a recent change in your work? Has
somebody gone off?’ So trying to find some precipitating factors. They may be able to identify
but they may not. So you get a detailed history first of all. Exactly what we are try to look at
and the back to their thumb with the physical tests…
However, on the subject of diagnosis TOPs’ experiences were varied. There were cases where
patients would visit the TOP with their diagnosis already established by some other party, which
influenced subsequent management, while the opposite was also reported, where the TOP was
the one to establish the diagnosis primarily.
54 I have rarely diagnosed someone with something. They usually come with the diagnosis, like
carpal tunnel syndrome...When they come to the City Hospital they have a district order…You
find the management is completely different. They know what they want with the treatment.
…During my occupational health experience employees often, especially in the NHS, come to
the Occupational Health as a first port of call. Probably, their managers just sort of push them,
saying ‘To get that sorted out quickly, go to your Occupational Health. And I’ve had two
patients who said ‘Doc I ’ vet got this problem and find it difficult to work. I ’ vet been to the
GP but can you examine?’ Self-referral. And one was a frozen shoulder and one was a tennis
elbow, which I diagnosed and then I wrote to the GP.
Finding occupational causes through investigation of the workplace was regarded as one of the
distinguishing elements provided by the OP specialty concerning ULDs management.
One thing that Occupational Physicians do that other doctors don’t do is actually going to the
workplace; actually watch what these people do and say ‘there is a problem here and that is
contributing to this symptom’.
On the subject of treating ULDs, the OP approach was reported as being intervention based
rather than being based on treatment in its strict clinical sense, the latter being regarded more as
the GPs’ job. Advising modifications in the workplace and in the patients’ duties and
addressing the psychosocial side of ULDs appeared to be main concerns in the OPs’ active
management of ULDs, while conservative treatment was quoted as the preferred course of
action. Confidence and training were also quoted as factors influencing the physician’s choice
of treatment.
As occupational physicians in these problems, this group of diseases, we have to get involved
when it has a direct effect on work or work is causing it because we do not actually manage it
primarily because that is the GP’s job. I don’t think any Occupational Physician manages
these disorders actively by giving injections or treatment…Well, some physicians may refer to
specialists.
But if we feel something is missing, we bring it back to the GP with the patient’s permission.
We actively manage it by ergonomic assessments, that their work station is correct, that they
are following their break every hour etc and then adjusting their hours if we feel that’s
appropriate or providing ergonomic keyboards or whatever. That’s our part of management as
opposed to the clinical of the GP.
You find the part that is preventing them from going back to work. Half of my time goes if you
have dealt with the physical side, the rest goes to the psychosocial side and what is really going
on. Everybody has some other problem; managerial etc. And sometimes there are confounding
factors. For the physical side I try referring them to the orthopaedicians or the physiotherapist
and on the managerial issues I spend more time. And that is the difference in our practice: you
can actually give proper advice on what to do about that particular case.
Tennis Elbow; again surgery is the last resort; ultrasound, injections quite popular; things like
that. So it's very very relieve basic conservative management; that's how we approach it.
I do very simple things. I think it depends on the individual; in their confidence and in their
training.
55 The time length of the patient – OP consultations was denoted as another distinguishing element
of the OP specialty with regards to ULD management. It was felt that having more time with
the patient enhanced doctor – patient communication and allowed the OPs to adopt a more
comprehensive approach to managing ULDs.
I think it’s a reasonable place of the OPs, particularly compared to the GPs. We have got 45
minutes to half an hour and I’ m sure a lot of us find that patients say ‘My GP did not tell me
that’ which has to do with the fact we’ve got 45 minutes to half an hour. We can speak to them
and ask their fears and say ‘this may not be 100%, these are the facts’, because we sit down
with them, draw diagrams and everything else. I think that’s actually part of our job.
Best practice
The dimension of best practice is defined as the perceptions of TOPs of what constitutes best
practice in managing ULDs. Higher order themes from the TOPs’ transcripts were a) keeping
the persons at work, b) following guidelines, c) avoiding iatrogenic disease, d) visiting the
workplace, e) conservative management, and f) having access to ergonomic advice. These
higher order themes were derived from lower order themes and raw data quotations, presented
in table A1.5.
On the subject of best practice, keeping the persons at work and avoiding imposing unnecessary
restrictions in their activities was felt to constitute best practice. Following Faculty guidelines
was viewed as a route to achieving best practice, while avoiding medical management practices
that can create disease was also pointed out as an important feature.
…The teaching by the orthopaedicians in Nottingham is that there should be no restrictions in
activities. They should continue the normal manual activities.
About best practice and management, I think best practice is that if you have a moderate or
mild pain, it will not make any big harm if you continue working, or reasonable adjustments if
necessary and if it is really bad then try to impose some restrictions.
Following the guidelines from some Faculties; the guidelines from NICE [National Institute of
Clinical Excellence].
…I think the general ‘Do no harm’. For example, you should not cause harm to this patient. I
mean even if supposedly you do not intervene, if that is going to harm the patient that’s also
[bad].
Other elements of best practice identified included the OP visiting the workplace to observe
what the workers do and conservative management in the form of workplace modifications,
conservative treatments such as RICE, NSAIDs, physiotherapy and cognitive behavioural
therapy (CBT), and adopting ergonomic advice.
What’s considered best practice in the management of the patient; I think the first thing as an
OP is to go and see the workplace. Best practice personally; go and see what they do and if you
can identify what may be causing the problem.
Best practice I suppose is conservative management. First that the workplace is better and then
going to management; Rest, Splint, RICE, anti-inflammatories, physio and ultimately those that
have a definite disorder to operate upon but most surgeons would not stick a knife in…They
need CBT, not a surgeon going to their shoulder.
56 [Best practice is] I think the services of an ergonomist; especially in office staff and even
factory workers; would be useful. I think a lot of hospitals have that access.
Training and informal learning
The training dimension is defined as the formal training that TOPs receive on the subject of
managing ULDs. The content analysis of the TOPs’ transcripts led to two higher order themes,
which were a) undergraduate training and b) postgraduate training. These higher order themes
were derived from lower order themes and raw data quotations, presented in table A1.8. In
addition, the content analysis of the TOPs’ transcripts with regards to their training in relation to
ULDs yielded a supplementary dimension; the dimension of informal learning. Thus, training
and informal learning constitute the route that TOPs take on towards learning to manage ULDs.
On the subject of learning about ULDs, TOPs cited general orthopaedic training in hospitals
during their undergraduate and postgraduate years as a prominent source.
As part of the general orthopaedic training or syllabus, ULDs are covered. I think I got pretty
good orthopaedic training. OK, it was in isolation from the workplace. So how to examine a
shoulder, an elbow, other bits and pieces, a bit of diagnosis. But I think it was as an
undergraduate and after getting through house jobs, surgical jobs and staff off the road of
general practice. It was very traditional teaching, teaching in hospitals, which was teaching by
humiliation. If you got it wrong they would bury you in front of the patients and your
colleagues.
With regards to their postgraduate training prior to entering the occupational health field, it was
stated that ULD training was variable among the vocational training schemes (VTS) and with
little emphasis given on the occupational causes of ULDs. The physician’s medical background
prior to becoming an OP was viewed as an important indication of the amount of exposure they
have had to managing ULDs. The influence of senior doctors was also identified as another
prominent factor. Orthopaedics, Orthopaedic Surgery and Accidents and Emergencies (A and
E) training were seen as sources of ULD training.
We didn't have to. We may do; as I did basket surgery and neurology. So I didn't do any
orthopaedics in the houseman stage.
And housemen do get to inject patients and tennis elbows with supervision. There is exposure to
upper limb disorders but there is very little emphasis on the occupational causes of upper limb
disorders. It's just taken as a diagnosis; as a treatable condition and just get the patient better
but there is no explanation or in depth information about the occupational causative factors.
It's Variable. It depends on the physician’s background. Because I came from a surgical
background, so my story is different. I vet treated upper limb disorders, I vet done carpal
tunnel operations day in day out and injected all sorts of joints, so that's different exposure
really. But I think that the majority of OPs come from a GP medical, general medicine
background, which there they don't.
…unless you have one of the 'Gipsies' GP with a special interest in your practice who does joint
injections etc, it's his interest, and if you are his trainee […] you will obviously go through it.
Some GP VTS schemes do have orthopaedics; 3 months orthopaedics, 3 months A and E. But
when I was working in orthopaedics some of my colleagues were GP trainees, doing 3 months
and to be honest, they never got involved in depth at all. They just did the ward work and they
57 were just happy watching cases, doing a bit...That's my experience; I think the examination of
the upper limb was poor among the GP trainees.
It depends […]. If you go to orthopaedics, general surgery or general medicine. It depends on
personal allegiance. When someone comes from medicine or a subject different suddenly to
OH; then they are going to struggle.
Individual interest was also mentioned as a factor influencing the amount of physicians’
exposure to ULD training.
During the GP vocational training there was none as of three months in orthopaedics or
something like that. I attended the course and the lectures…So it probably has to do with if you
wish [to do] upper limb disorders.
On the subject of ULD training during the trainee OP stage, TOPs once again reported
variability as a main feature. The trainees’ assigned place of work was regarded as influencing
the amount and variety of their training. Trainees working for the NHS Plus scheme, and thus
visiting multiple worksites, were regarded as being in a favourable position.
The training is very variable. Some trainees get a lot of experience in certain areas, some
trainees don't at all. I think there is an advantage in the NHS because of the NHS Plus scheme
where they contract factories and private companies. And of course the benefit goes to the
trainees who work in that trust and can use that scheme to go out to all these factories. Whereas
Jaguar and other big companies who have got SPRs [Specialist Registrars], I don't think they
send their trainees to other factories so it's very variable training; In that little area they
become expert, but not all around.
However, it was also felt that orthopaedics might be one of the areas overlooked with regard to
SPRs’ training in ULDs.
Basically us trainees have to ask our superior, our consultant advisor and I don't think as
routine SPRs attend orthopaedic clinics. I think SPRs are not sort of in touch with
orthopaedics. They've got sessions with respiratory and skin physicians, ophthalmology but I
don't think occupational health registrars do get management [of ULDs].
The dimension of informal learning is defined as all the informal routes to learning, in addition
to formal training, that TOPs adopt towards managing ULDs. Higher order themes from the
TOPs’ transcripts included a) reading publications, b) clinical experience, c) learning from other
physicians. These higher order themes were derived from lower order themes and raw data
quotations, presented in table A1.11.
With regards to informal learning, TOPs cited reading books and acquiring clinical experience
through everyday medical practice as some of the routes adopted. A third source of their
informal learning cited by the TOPs was consulting with other physicians including partners in
the same practice for those coming from a GP background.
Sometimes you identify the training needs while you are doing things to your patient, while
doing the examination, and you go and read the books.
When coming from medicine background and seeing some cases we are reviewing them more or
asking for opinions.
58 In general practice, if one of the other partners has an interest in it; that will give you a sort of
semiformal training.
Evidence base
The dimension of evidence base is defined as the sources of evidence that TOPs use as the basis
for their management of ULDs. Higher order themes from the TOPs’ transcripts included a)
previous clinical experience, b) continuing medical education, c) journals, d) clinical evidence
and e) available guidelines. These higher order themes were derived from lower order themes
and raw data quotations, presented in table A1.14.
With regards to management of ULDs, TOPs identified previous clinical experience as a source
of their evidence base. Continuing medical education through attending orthopaedic lectures
was quoted as another significant source, while HSE publications and publications in
occupational health and ergonomic journals were also identified for being used as evidence.
If 40 hours caused you tremendous pain and limited activities, let’s try cutting it down to 30. If
it’s better, let’s keep it at 30 -this is assuming all the ergonomic assessments have been doneand then increase it. But is there a strong evidence? I don’t know.
I had had experience in treatment but from the occupational health point, the HSE documents
and the journals [comprise my evidence base].
My evidence base is going to lectures of orthopaedicians and getting knowledge from them.
…and anything I can read, so I read journals but not orthopaedic journals. I tend to read
review articles on the occupational journals; or the ergonomic journals.
Existing clinical evidence with regard to the pathology of specific diseases such as carpal tunnel
syndrome and lateral epicondylitis was regarded as a significant source to be used as evidence
base. However, the lack of pathology evidence with regards to less clearly defined diagnoses
such as RSI was mentioned as a limiting factor. Furthermore, it was felt that available
guidelines, such as HSE guidelines, could comprise a valuable source of evidence.
Evidence base comes with carpal tunnel syndrome and tennis elbow. For these, that’s fairly
reasonable. They are not changing too much. But we all get hung up on what’s the evidence
for RSI…
All these other conditions [carpal tunnel syndrome, tennis elbow, De Quervain’s] have got
pathologies proof. They’ve done histopathology studies and they’ve actually proved what’s
going on. Whereas, for RSI they haven’t found anything; no specific symptoms and signs, just
generalised pain in the wrist. Ache.
I think for occupational physicians the best evidence base should be keeping in touch with the
HSE guidelines. We should be aware of the new guidelines published.
Perceived difficulties
The perceived difficulties dimension is defined as the difficulties that TOPs perceived in their
management of ULDs. Higher order themes from the TOPs’ transcripts included a) difficulties
related to the disease b) difficulties related to the patient c) difficulties related to the resources
available d) difficulties related to physician’s knowledge being limited, e) difficulties ensuing
from the use of ‘labels’. These higher order themes were derived from lower order themes and
raw data quotations, presented in table A1.17.
59 TOPs identified a number of difficulties related to managing symptoms that did not match a
recognised clinical entity. Conditions of unknown pathology such as RSI were cited as an
important problem in terms of providing appropriate advice on work modifications.
Furthermore, symptoms of such conditions appeared to be affected by multiple psychosocial
factors rendering the ULD management complicated.
So conditions that are not tenosynovitis, carpal tunnel syndrome, frozen shoulder, what do you
call them? Non-specific pain. But the thing is that I have difficulty managing that.
We know what to do in carpal tunnel syndrome and tennis elbow; we know the pathology. But
RSI [Repetitive Strain Injury] is the main problem. What advice do we give? What has to be
modified? We can even visit the workplace or the office and watch him working for an hour.
But how do we know that the amount of typing, the way they are working is repetitive enough to
cause the problem?
…In all philosophy it’s psychosocial. It’s expectation, it’s belief, it’s myth, it’s economics, it’s
Unions, it’s Management. I think it’s more of that than actually the subject. It’s physical
nevertheless; they still got the pain and we’ve got to try to address that.
Difficulties identified in relation to the patient were another issue raised as patients tended to be
sceptical towards recommendations to carry on with their occupation or go back to it and
maintain unrestricted activity in the presence of symptoms. Furthermore, it was suggested that
some patients tended to adopt an illness behaviour matching their perception of the diagnosis
given to them.
Even in milder or moderate cases the teaching by the orthopaedicians in Nottingham is that
there should be no restrictions in activities. They should continue the normal manual activities
and even if you wait for the operation for 6 months, it is not going to cause any harm. But
selling that idea to the client is extremely difficult.
The problem is to make the patient understand that some symptoms are not going to harm them
if they carry on with their occupation.
We try to educate the patient as much as we can. The difficulty is in saying ‘you can work’;
convincing the patient that he can go back.
Say for tennis elbow: It’s a very common disorder. It’s the perception. I think some patients
take that diagnosis to their mind and have that illness behaviour.
Further difficulties TOPs mentioned related to limitations of the resources available for
managing ULDs. It was pointed out that the size of the organisation where the problem
occurred could be a limiting factor in applying OH advice such as job rotation. Furthermore,
infrequent access to the workplace in some cases was seen as restrictive to acquiring a clear
picture of the events leading to ULDs.
Some of the problems we cannot anticipate. Just from the nature of the organisation, the size of
the organisation. Small size organizations have different problems as opposed to the big sized
just because the small size will not be able to rotate patients or something like that and if you
are sitting in the hospital at the OH department your advice to rotate them is difficult.
60 Other problem is lack of monitoring on the occupation itself. What sort of situation of the upper
limbs is there. One should go and relate with the patient and do an assessment of their illness
situation but it’s difficult…you go there once.
Additional comments related to the tests used towards diagnosing ULDs. Concern was
expressed with regards to the sensitivity of physical tests such as Tinnel’s, while the benefit of
nerve conduction studies was also challenged.
Some of the [physical] tests are inaccurate. They may not be as evidence based as they might
be.
Ultimately, we go towards nerve conduction studies. Even then, how sensitive and specific that
is?
TOPs also agreed on the existence of difficulties related to limitations imposed on the
physician’s knowledge. Several of them cited lack of confidence in making workplace
assessments resulting from lack of knowledge of the workplace. This seemed to result from
their having limited practice experience, being still on the OP trainee stage. However, lack of
knowledge of the workplace was also an issue arising when TOPs were called to manage
external contracts i.e. patients working in an organisation different to the one employing them.
It was denoted that the nature of the organisation that employed the TOP influenced the type of
clinical practice experiences they gained and subsequently the nature of knowledge they
acquired. This could lead to significant expertise in certain OH areas but also to limiting their
variety.
My problem is how to identify what is wrong in the workplace.
I have little experience of the workplace; how it should be.
I perceive a difficulty is in working in NHS or non-NHS. If I am working in NHS: I started 26
months ago as an OH registrar [coming] from general practice experience and I didn't know
about various occupations. Fortunately in the hospital setting my trainer…put me on visits on
the first 2 weeks to all the major departments and things like those. Also I went there without
any knowledge of what was happening and how I should I assess the risk and hazards and all
that. But just looking at what they have been doing it was quite enough experience for me and I
started relating with them… But if I was in another institute it became difficult; or getting any
external contracts at agencies sending their patients; I haven’t got any knowledge.
Similarly, if you are working for an automotive manufacturer or another industry and you are
the occupational physician there. You are used to seeing the same kind of patients all the time
and you are going to be expert to that and you try to increase your knowledge because you can't
do without that.
The difficulty for me with occupational diagnosis [of ULDs] is that the last surgical house I got
was my last experience… and after that I got no experience at all.
A further difficulty was identified in relation to advising appropriate activity levels during
recovery. Giving a timescale with regards to workers’ activity levels during recovery was
regarded as difficult in the absence of guidelines similar to those established for low back pain.
The other important aspect is, if a person comes to you on the first visit with an ULD with a
severe restriction a severe pain, how long? You say ‘this is a problem and you should not be
working at this point in time’ but how long do you say that? When can this person get back?
61 For back pain the guidelines are there. You should be getting back within a couple weeks time
with physical activity. If it's not getting better after 6 weeks then it has to be treated by a
specialist. But for ULDs you cannot say that to employers. I've actually had difficulty in giving a
timescale.
In a final note, there were comments made on the use of ‘labels’ such as RSI. It was felt that the
use of ‘RSI’ as a ULD diagnosis was problematic as it led patients to preconceived conclusions
about their condition while it did not provide any helpful indications on what the course of
management should be.
I’ve got a problem with diagnosing and accepting the diagnosis of ‘RSI’. Because there is a lot
of controversy about it anyway.
I think the myths like RSI. It’s so stuck in people’s mind. Whatever they have been doing, they
come and say ‘I have that’; they have the diagnosis!
Training needs
The dimension of training needs is defined as the various needs that TOPs perceive regarding
training to advance the quality of their ULD management. Higher order themes from the TOPs’
transcripts included a) specific ULD training, b) emphasis on the occupational causes of ULDs,
c) solid evidence base, d) advice on activity level during recovery e) opportunities to learn from
other physicians and g) ergonomics teaching. These higher order themes were derived from
lower order themes and raw data quotations, presented in table A1.20.
With regards to their training, TOPs stated a need for more emphasis to be given to ULDs and
their occupational causes. It was felt that the evidence base they were presently provided with
could be improved on, especially, in terms of consistency. A need was indicated for the
establishment of guidelines similar to those existing for low back pain. This would render the
OP management of ULDs more consistent and would assist them with difficult issues, such as
advising appropriate activity levels during recovery.
There should be separate part of training to deal with upper limb disorders.
There is exposure to ULDs but there is very little emphasis on the occupational causes of ULDs.
We need training on how the occupation is affecting the disease. How much harm will happen
and when to tell them to stop working.
We need a good evidence base to direct our training and ensure that we ask the correct
questions and undertake the right examinations. This will also allow us to inform patients
accurately and ensure we all sing from the same hymn sheet. In many ways, we need a
consensus opinion similar to that that was produced by Professor Waddel about LBP and then
GPs and OPs will give consistent evidence based advice.
…But again If you are asking for medication and the person is driving, it’s complicated. Shall I
advise them to continue driving? For that you need to have some in depth knowledge about
how severely disabling this condition can be…Knowledge about the disability of these
conditions is needed.
In addition, TOPs mentioned that they needed opportunities to learn from other specialists. In
that aspect, hand surgeon specialists were highly regarded as a source of ULD knowledge, while
62 ergonomics teaching was also identified as useful. With regards to the forms of delivering
training, clinical presentations and ‘hands on’ teaching were cited as the most helpful.
We need specialist upper limb surgeons-hand surgeon specialists- to give lectures. They’ vet
got the in depth knowledge, guidelines. And we need ergonomics teaching.
Watching; Clinical presentations are the most helpful. And small group workshops. Hands on
experience or at least demonstration.
4.3.3. GP focus group: key findings
ULD management
The dimension of ULD management is defined as the various routes that GPs adopt towards
managing ULDs. Higher order themes from the GPs’ transcripts included a) patient’s history
b) examination, c) diagnosis, d) review, e) interventions, f) treatment, g) referral and h) time
spent with the patient. These higher order themes were derived from lower order themes and
raw data quotations, presented in table A1.3.
With regards to the management of ULDs, GPs quoted patient’s history and physical
examination as the primary steps they use towards diagnosing.
We start with the diagnosis: Physical examination is the key and history
ULD treatment was described as a longitudinal process involving several patient-GP ten minute
consultations and changing over the course of time. NSAIDs and corticosteroid injections were
among the means cited as regularly used in the treatment of ULDs.
Depends on exposures you’ vet had: If it is the first time you see the patient you start obviously
with NSAIDs. After three months time you may move to injections. One sees patients again and
again in General Practice.
We aim at spending ten minutes with each patient but not everything is discussed in one visit.
Conservative treatment, including analgesia, exercise and advice, was quoted as the GP’s first
choice regarding medical treatment of ULDs. However, the more invasive technique of joint
injections was also mentioned as being frequently used, particularly in relation to recurrent
symptoms.
[GPs manage ULDs] conservatively, anecdotally
Obviously you start at the easiest and simplest. Change whatever activities precipitate it,
analgesia and exercise.
People do inject a lot but there is very little evidence whether injections are actually better than
conservative treatment like physiotherapy, advice, medications.
Recurrent symptoms…I don’t inject but others do.
GPs also reported offering different options to the patient, thus, involving them in the decisionmaking with regards to the management of their ULD.
63 Regarding treatment I give management options to the patient ‘1.2.3…physio, injections,
surgery…'
Accordingly [to the patient’s history], we give them different options; medications or exercise.
On the subject of the communication between the GP and the patients’ workplace, GPs reported
that the contact occurring tended to be indirect through the patient, unless there was sickness
absence or referral involved. Patients were encouraged to talk to any available occupational
health professionals in their workplace if they thought that their problem was work-related.
However, reluctance was also reported regarding direct GP- OP communication, due to
confidentiality issues involved.
There is no contact with the OP, unless indirectly through the patient. No contact directly. One
may tell the patient to consult with the OP if the patient comes up with a work related complain.
There is not a lot of contact with the Employer.
If the problem is work related and there is sickness absence involved then we communicate with
the workplace.
It’s the GP who has to do the referral so usually it’s the OP who contacts us requesting for a
referral. I have had OPs asking me for patient information but then I wonder whether they are
trying to pull a fast one on me. I have had a patient working in a canteen, complaining about
arm pain, and they phoned me up asking for information. Afterwards they didn’t want to take
her back to work.
Best practice
The dimension of best practice is defined as the perceptions of GPs of what constitutes best
practice in managing ULDs. Higher order themes from the GPs’ transcripts included a) aiming
for the easiest and simplest options b) providing patient-centred management for the ULD, c)
avoiding iatrogenic disease, d) providing evidence-based management and e) consulting with a
specialist. These higher order themes were derived from lower order themes and raw data
quotations, presented in table A1.6.
With regards to what constitutes best practice, GPs quotes identified opting primarily for easy
and simple options of ULD management and providing patient –centred management aiming to
patient satisfaction as main aspects. Avoiding medical management practices that could lead to
iatrogenic disease and using available evidence and specialist advice were also pointed out as
important features.
Start at the easiest and the simplest; change whatever activities precipitate it, analgesia and
exercise.
Best practice for me is that they think that I have done the job properly.
Best practice is patient centred.
Without doing damage, harm to them. Not inject and inject and inject. Best practice is the
simple things.
What the patient wants combined with your experience and the evidence and resources.
64 To find best practice we refer to textbooks; examination by a specialist who shows us…There is
no particular guidance or document.
Training and informal learning
The training dimension is defined as the formal training that GPs receive on the subject of
managing ULDs. The content analysis of the GPs’ transcripts led to two higher order themes,
which were a) undergraduate training and b) postgraduate training. These higher order themes
were derived from lower order themes and raw data quotations, presented in table A1.9.
Moreover, the content analysis of the GPs’ transcripts with regards to their training in relation to
ULDs yielded a supplementary dimension; the dimension of informal learning. Thus, training
and informal learning constitute the route that GPs take on towards learning to manage ULDs.
With regards to their formal training in ULDs, GPs quotes reflected the absence of a
standardised curriculum. Training experiences in ULDs varied considerably among individuals
according to training opportunities made available in their place of training and individual
interest. Learning from other doctors during clinical practice, and under the influence of senior
doctors appeared as prominent features in their training process. In terms of training in ULDs,
orthopaedic surgery guidance was regarded as highly favourable.
Training [was] divided in med school, house office jobs, registrar jobs.
It’s chance. One is very lucky if he gets orthopaedic surgery guidance.
As much as one seeks. Depends on one’s perception of their own skill; whether they are
confident or they feel they need more.
From other GPs is the most useful training I’ve had.
You gain your training from working with other individuals. That’s the biggest way; by doing
the job!
One of the problems is that if you have a particular consultant that may treat ULDs in a
particular way and that particular person may guide your practice and education, so you learn
only that particular way.
Listening to speakers…GPs get called to different speakers.
The dimension of informal learning is defined as all the informal routes to learning, in addition
to formal training, that GPs adopt towards managing ULDs. Higher order themes from the GPs’
transcripts included a) reading publications b) learning from other physicians, c) clinical
experience, d) practice meetings, e) use of teaching materials and f) web based learning. These
higher order themes were derived from lower order themes and raw data quotations, presented
in table A1.12.
GP quotes on informal learning revealed the use of a variety of sources. These included
textbooks, colleagues, learning acquired through everyday clinical practice, GP practice
meetings, CD ROMS and e-learning. Individual interest and perceived weaknesses were
identified as important factors with regard to the content of the knowledge sought.
You can seek further training. You can always go back, use books.
65
It’s what you seek. Just reading, or asking a colleague or attending a course. It’s actually
opportunistic. Depends on when you realise that you need it, your areas of weakness.
The information for the diagnosis comes from med school training, textbooks, CME courses,
literature, e-learning, talking to a friend.
Evidence base
The dimension of evidence base is defined as the sources of evidence that GPs use as the basis
for their management of ULDs. Higher order themes from the GPs’ transcripts included a)
colleagues b) journals, c) web sites, d) guidelines, e) text books, f) patients’ input and g)
previous training. These higher order themes were derived from lower order themes and raw
data quotations, presented in table A1.15.
With regards to their evidence base for managing ULDs, GPs identified journals, web sites
featuring evidence based medicine, textbooks, previous training and available guidelines as their
sources. However, it was also felt that a significant part of it was anecdotal, comprising of
consulting with colleagues and taking into consideration patients’ input.
[It is] anecdotal.
When you are a registrar, you are always asking other doctors and talking in a group.
During meetings as a practice, various things, areas, journals are covered and discussed from
month to month, from week to week, depending on what you see.
Journals; BMJ puts on every year evidence based medicine.
Bandolier gives an idea [NHS publication covering evidence-based medicine, also available
version]. Textbooks; surgical orthopaedic, rheumatology or for general practice…
in internet
We follow guidelines.
I do it because the patient says it works. Patients swear that joint injections are fantastic so I
do it.
I recently undertook the MRCGP exam so my evidence base is proper peer reviewed evidence
based medicine.
Perceived difficulties
The perceived difficulties dimension is defined as the difficulties that GPs perceive in their
management of ULDs. Higher order themes from the GPs’ transcripts included a) difficulties
related to the disease b) difficulties related to the patient and c) difficulties related to the
resources available. These higher order themes were derived from lower order themes and raw
data quotations, presented in table A1.18.
A number of difficulties affecting the GP management of ULDs were identified. With regards
to the disease, recurrent symptoms were identified as a difficulty frequently encountered. In
addition, shoulder problems were cited as difficult in terms of diagnosis.
66 Recurrence occurring in 3 months time; Then you ask people around what to do and they
suggest injections. I refer to orthopaedic or rheumatology clinic, using previous knowledge to
decide where.
Recurrent symptoms. How do I deal with them? I speak to my partner; what he thinks. If
acute, I refer to orthopaedics.
Shoulder diagnosis is really difficult to localise.
Patient dissatisfaction was another main GP concern with regards to ULD management. The
long natural course of a number of ULDs, that causes delays in the therapeutic process, led to
disillusionment of patients’ expectations.
If the patient is not happy.
Patient expectations are a difficulty. If the cure is not working or is not happening quickly.
In a final note, GPs identified ULD management difficulties in relation to physiotherapy access.
Long waiting times and lack of facilities were cited as problems encountered.
There are management problems regarding physiotherapy.
facilities for physio.
Long waiting time or lack of
Training needs
The dimension of training needs is defined as the various needs that GPs perceived regarding
training to advance the quality of their ULD management. Higher order themes from the GPs’
transcripts included a) individual learning plans b) ‘hands on’ practice, c) access to knowledge,
d) opportunities to learn from other physicians, e) right timing, f) use of technology and g)
specific training. These higher order themes were derived from lower order themes and raw
data quotations, presented in table A1.21.
On the subject of ULD training, GPs identified a need for training that accommodates personal
development plans and, subsequently, individual training needs. The timing of training was
also denoted as an important feature so as for the training to be relevant to the current GP needs.
According to a personal development plan. Listening to speakers…GPs get called to different
speakers and meetings.
It’s important that you get the timing right. If you have to practice something that you were
taught two years ago then you nay not remember it or it may not be relevant any more.
With regards to the forms of delivering training, ‘hands on’ teaching was cited as the most
helpful while interactive teaching materials such as CD ROMs were deemed useful.
In some courses they teach you how to inject on a mannequin…I think that those courses are far
moved from reality; it’s of minimal value. You need to do it on the patient.
CD ROMs are used for training. There are CD ROMS on injecting joints. Any technology that
is there…Interactive things are easier to use.
67 In addition, GPs mentioned that they needed opportunities to learn from ULD experts.
Specialists were highly regarded as a source of ULD knowledge.
Basically we learn from others who are more experienced. The practical bits we learn from
others.
An expert reintroducing a subject. Just talking can make you think as you can get stuck doing
specific treatments. Specialists are very useful.
Furthermore, the need was stated for ULDs and their occupational dimension to be given
additional attention during medical training years and CME.
There is no training specifically done for upper limb disorders…Training should be provided
for the new doctors; undergraduate, postgraduate, CME [Continuous Medical Education].
More occupational health training in med school would be useful.
4.4. DISCUSSION
The main points from the focus groups are listed according to each topic covered. This study
has focused on the different routes and aspects of the medical management of ULDs. The focus
group sessions conducted offered insight into the perceptions of Occupational Physicians,
trainee Occupational Physicians and GPs regarding their management of ULDs, their ULD
knowledge foundations, the related difficulties and their arising training needs. Overall, seven
dimensions of medical management of ULDs were identified: ULD management, best practice,
evidence base, training, informal learning, perceived difficulties and training needs.
It is recognized that the findings of the present study are limited by the comparatively small
sample of views. In view of the small sample size, specific context and methodological
decisions in this study, some caution must be exercised when generalizing the findings.
Qualitative research data are directly affected by the context in which they are collected, and are
affected by the methodology of data collection and analysis. However, the elimination of bias is
not necessarily an appropriate concept in qualitative research (87,88).
4.4.1 ULD management
In comparing the content analysis results of the three focus groups, several of the higher order
themes, such as patient history and physical examination, appear to be common, which denotes
the universal framework of the medical approach to managing disease. However, upon closer
investigation, the routes described towards managing ULDs also presented differences, which
reflect the different angles of treatment adopted by different specialities treating the same
patients (1).
Thus, several OP and TOP quotes revolved around work-relatedness. Finding occupational
causes through occupational history and investigation of the workplace was regarded as a
prominent feature in the OP approach as well as one of the distinguishing elements provided by
the OP specialty concerning ULDs management. Means used towards this included using risk
assessments, ergonomic assessments, and specialised questionnaires, seeing many people from
the same workplace and visiting the workplace.
With regards to ULD treatment, the OP approach was reported as being intervention based
rather than being based on treatment in its strict clinical sense, the latter being regarded more as
the GPs’ job. Advising modifications in the workplace and in the patients’ duties and
68 addressing the psychosocial side of ULDs appeared to be main concerns in the OPs’ active
management of ULDs. Return to work recommendations, workplace guides or work
restrictions have been previously cited as a requirement for the OP treating the patient with a
work-related musculoskeletal disorder (15). Communication and cooperation with the workplace
Management were also identified as prominent features in the OPs’ approach towards managing
ULDs.
Conservative treatment was quoted as the preferred course of action by all three focus groups in
relation to ULDs. However, the more invasive technique of joint injections was also mentioned
by the GP focus group as being frequently used, particularly in relation to recurrent symptoms.
NSAIDs and corticosteroid injections were among the means cited by GPs as regularly used in
the treatment of ULDs. These quotes agreed with a previous study where the highest level of
confidence was observed for using non-steroidal anti-inflammatory drugs (NSAIDs) (1).
Furthermore, in previous qualitative research there has been mention of NSAIDs being given to
gain time with the hope that the musculoskeletal disorder will settle down by each self with time
and rest (90). GPs also reported offering different treatment options to the patient, thus,
involving them in the decision-making with regards to the management of their ULD.
The time length of the patient – OP consultations, ranging between half an hour and 45 minutes,
was denoted as another distinguishing element of the OP specialty with regards to ULD
management. It was felt that having more time with the patient enhanced doctor – patient
communication and allowed the OPs to adopt a more comprehensive approach to managing
ULDs. In contrast, ULD treatment was described as a longitudinal process involving several
patient-GP ten minute consultations and changing over the course of time.
On the subject of the communication between the GP and the patients’ workplace, GPs reported
that the contact occurring tended to be indirect through the patient, unless there was sickness
absence or referral involved. This was found to agree with previous qualitative research related
to occupational health in primary care (89). GPs’ gatekeeper role with regards to referral has also
been previously identified(87).
With regards to referrals, availability and past experience seemed to influence the OPs’
recommendations with regards to physiotherapy treatments. This has been previously stated for
GPs, whose past experience of physiotherapy was described as significantly affecting GPs’ use
of physiotherapy referral (87).
4.4.2. Best practice
With regards to what constitutes best practice, all three focus groups quoted avoiding medical
management practices that could lead to iatrogenic disease. Furthermore, best practice was
related to a multidisciplinary approach. Communication and collaboration with different
specialties such as orthopaedics, and GPs were identified by the OPs as desirable features
towards attaining best practice, which was in agreement with the GPs response about seeking
specialist advice. However, OPs’ quotes reflected dissatisfaction with the present state of
multidisciplinary communication.
This was in agreement with Akesson who has previously stated that multispecialty focus is
often lacking in treating patients with musculoskeletal complaints (1). The same author has
called for a more holistic multiprofessional approach stating that it is important that experts of
various specialties work more closely together and look for commonality of approach, as they
often treat the same patients but from different angles. There is therefore a need for more
69 interaction and overlap and better understanding of what each specialty has to offer (1). OPs and
GPs also agreed on best practice being linked to evidence based medicine.
GPs quotes identified best practice in opting primarily for easy and simple options of ULD
management. This was in agreement with TOPs response about conservative management in the
form of workplace modifications and conservative treatments. A further aspect in relation to
what constitutes best practice, which came up in the GP focus group, was providing patient–
centred management aiming to patient satisfaction.
OPs and TOPs agreed on best practice being employing all available means to keep the person
at work. This included quotes on avoiding imposing unnecessary restrictions in patient
activities and encouraging them to maintain their ability to function in order for them to be able
to return back to work. Early return to work has been shown to be in the patient’s best interest
(15)
, as the duration of time already out of work is an independent risk factor for the employee to
fail to return to work (90).
Additional OP remarks on the subject of best practice addressed the need for having easy access
to treatments, such as physiotherapy, engaging the employer in the ULD management and
avoiding labelling one’s condition with terms like ‘for life’ so as not to predispose the patient
negatively towards rehabilitation. TOPs on their part, viewed following Faculty guidelines and
observing what workers do in the workplace as further elements leading towards best practice.
4.4.3. Training
Medical training starts with the medical studentship, which is typically five years, leading to a
period of supervised apprenticeship in a hospital, usually consisting of one junior and two senior
‘house officer’ years. This is followed by a more focused in depth specialist ‘registrar’ training,
which is four years for most medical specialties, before independent existence as a qualified
doctor with specified accreditation (GP, doctor, surgeon with a specialty interest, etc) (93).
With regards to their formal training, quotes by all three groups reflected the absence of a
standard curriculum. Training experiences varied among individuals according to availability of
courses and training opportunities in their place of training, training trends at the time and
individual interest. Several of the GPs lower order themes seem to be in agreement with the
results of a recent survey that showed that musculoskeletal teaching represents just under 4% of
the undergraduate curriculum and indicated an increasing discrepancy between the amount of
time spent on orthopaedic teaching and the number of GP musculoskeletal consultations, not
made up during VTS placements (90). It has been suggested that the problem appears to be poor
availability of organised musculoskeletal teaching (93).
The variability in undergraduate and postgraduate musculoskeletal training was also evident in
the replies received by UK Universities and Postgraduate Deaneries contacted by the research
team for the purposes of the current study. Undergraduate medical students spend few hours on
the musculoskeletal system, both in basic science and in clinical training (1) and there is a lack of
consistency in what they are taught(82).
On the subject of learning about ULDs, TOPs cited general orthopaedic training in hospitals
during their undergraduate and postgraduate years as a prominent source. Orthopaedics,
orthopaedic surgery and Accidents and Emergencies VTS placements were also seen as useful
sources, while orthopaedic surgery guidance was regarded as highly favourable among GPs.
However, training in orthopaedics and rheumatology are rarely mandatory in systems with
70 rotating internships or in family practice training programmes
and GPs quotes.
(1)
, which was reflected on TOPs
With regards to their postgraduate training prior to entering the occupational health field, TOPs
stated that ULD training was variable among the VTS and with little emphasis given on the
occupational causes of ULDs. Furthermore, the physician’s medical background prior to
becoming an OP was viewed as an important indication of the amount of exposure they have
had to managing ULDs.
On the topic of ULD training during the trainee OP stage, TOPs once again reported variability
as a main feature. The trainees’ assigned place of work was regarded as influencing the amount
and variety of their training with trainees working for the NHS Plus scheme and thus visiting
multiple worksites, regarded as being in a favourable position. However, it was also felt that
orthopaedics might be one of the areas overlooked with regard to SPRs’ training in ULDs.
Learning from other doctors and under the influence of senior doctors in the course of clinical
practice were cited by all three groups as prominent features in OPs and GPs training process.
Experience gained in clinical practice appears to be more important than formal training (87). As
stated by Akesson, clinical skills are best learnt in the real-life situations of outpatient clinics,
and emergency services of primary care (1).
In an additional note, studying for qualifications such as the AFOM and the MRCGP were
quoted as having a positive contribution to the OP and GP ULD learning respectively.
Furthermore, sports medicine courses were among the courses cited by OPs as a useful source
of learning about ULDs. This is in agreement with previous observations in the literature stating
that similarities exist between sports medicine and occupational medicine (15).
4.4.4. Informal learning
OP quotes on informal learning reflected the use of a variety of resources. Clinical experience
acquired through everyday medical practice and observations of the ULD management of other
professionals, reading publications and web-based learning were identified as prominent
features. Another element cited was the existence of individual learning plans. Education and
contact with other healthcare professionals have been previously identified as important factors
in changing doctor behaviour (94). In turn, TOPs cited reading books and acquiring clinical
experience through everyday medical practice as some of their sources of informal learning. A
third source cited by TOPs was consulting with other physicians including partners in the same
practice for those coming from a GP background.
GP quotes on informal learning revealed an equal variety of resources used. These included
textbooks, colleagues, learning acquired through everyday clinical practice, GP practice
meetings, CD ROMS and e-learning. Interactive CD ROMs provide education on various
topics and give instant feedback to the participant. Along with accredited websites, are among
the information technology educational recourses available to help GPs individually (95).
Practice based meetings and personal learning plans have been used as ways that GPs can gain
Post Graduate Education Allowance points (95). These can lead to standard (and significant)
event audits, which have been shown to be effective strategies for behaviour change when they
include targeted feedback. Significant event audits, peer review, group based learning, and
reminders by computer have all been shown to be effective educational strategies for general
practice (96). Peer review and group learning interventions have been proposed as particularly
relevant in general practice settings and have been shown to be feasible (96). Learning linked to
71 clinical practice and interactive educational meetings are among the most effective CME
methods identified, maintaining and improving clinical performance (96).
With regards to informal learning, focus group participants consistently referred to clinical
experience, contact with professionals (discussion with consultants, observation of their
practice, discussion with a partner, observation of their practice, practice meetings) and nonmedical professionals, education (reading medical journals, attending organised educational
events) and patient centred reasons. All these have been previously quoted as reasons for
change in GP and consultant clinical practice (94).
In addition, individual interest and perceived weaknesses were identified among GPs as
important factors with regard to the content of the knowledge sought. Physicians’ levels of
confidence in managing MSDs have been significantly associated with interest in CME in a
previous study (97), with CME being any and all the ways by which doctors learn after formal
completion of their training (96). The physicians who report the lowest level of confidence have
been shown to express the highest level of interest (97). However, confidence related to
perceived self efficacy does not automatically translate into clinical competence (98). There is
little published evidence linking perceived competence with actual performance in primary care
(13)
. Thus, relying entirely on individual doctors’ self-assessments of their learning needs may
be problematic. Needs assessment should not be based entirely on self assessment as according
to one study, the correlation between doctor’s self assessment of their knowledge and their
subsequent performance in objective tests of their knowledge can be poor (96).
4.4.5. Evidence base
With regards to ULDs management, OPs identified previous personal and colleagues’ clinical
experience as a significant source of their evidence base. Publications in journals were quoted
as important while accredited websites featuring evidence-based medicine related topics were
also referred to as a source of their evidence. Additional sources identified were textbooks and
standardised approaches, where available. Attending orthopaedic lectures was quoted by TOPs
as another significant source, while HSE publications and publications in occupational health
and ergonomic journals were also identified for providing useful evidence.
Existing clinical evidence with regard to the pathology of specific diseases, such as carpal
tunnel syndrome and lateral epicondylitis, was regarded by TOPs as significant source of
evidence. However, the lack of pathology evidence with regards to less clearly defined
diagnoses such as RSI was mentioned as a limiting factor. Furthermore, it was felt that
available guidelines, such as HSE guidelines, could comprise another valuable source of
evidence.
With regards to their evidence base for managing ULDs, GPs identified journals, web sites
featuring evidence based medicine, textbooks, previous training and available guidelines as their
sources. According to Hosie, most GPs use a computer in their daily practice and have ready
access during their working day to guidelines. Familiarity with the internet gives access to
evidence-based clinical guidelines, databases, scientific papers, and review articles from well
accredited sites (95).
However, it was also felt that a significant part of the evidence base was anecdotal, comprising
of consulting with colleagues and taking into consideration patients’ input. Patient satisfaction
has been previously cited in qualitative research as part of outcome measurement in the delivery
of community-based musculoskeletal services (99).
72 4.4.6. Perceived difficulties
OP perceived difficulties
A number of difficulties affecting the OP management of ULDs were identified. The long
natural course of a number of ULDs was stated as a disruptive factor, which prolonged the
therapeutic process, leading to patient dissatisfaction. Chronicity of the problem was also
addressed as a source of difficulty leading to a pain – injury cycle, which hinders patient
cooperation.
Difficulties identified in relation to the employer included problems resulting from the work
organisation e.g. lack of appropriate breaks and complaints against the workplace Management
resulting in a manifestation of physical complaints. It has been stated that tension between the
worker and the employer greatly impacts the worker’s chance of injury reporting and
promptness to return to work (92). Uncooperative managers were an additional source of
difficulty cited by the OPs, hindering their management of ULDs. As previously reported by
Foye, return to work can sometimes be delayed by administrative factors at the worksite, such
as an employer who is unable or unwilling to provide modified duty or workplace
accommodations (90).
With regards to available resources, OPs identified long waiting times for specialist and
treatment referrals and delay in getting to see the individual as factors hindering the
management of ULDs. Previous medical management was also stated as a potential source of
difficulties in the form of conflicting diagnoses by different physicians and previous
discouraging diagnoses having damaged the morale of the patient.
The use of labels for the disease was also identified as a potential source of difficulties in the
management of ULDs. OPs stated that labels such as ‘upper limb disorders’ tended to
predispose negatively the patients with regard to their condition. It has been suggested that
giving an unjustified and all-embracing medical diagnostic label is of no practical utility, and
runs the risk of reinforcing illness beliefs, disability and handicap (100). According to Buckle, the
extent to which a worker is labelled as patient, chronic or acute, disabled etc may be associated
with behaviour and subsequent long-term outcome (101). Giving an unfounded and allembracing medical diagnostic label is of no practical value, and runs the risk of reinforcing
illness beliefs, disability and handicap (100). Conversely, OPs cited that patients tended to
require a label given to their problem in order to feel confident towards the medical
management adopted by the physician.
Other difficulties identified, were related to the adversarial influence of parties such as the
labour unions, family members and legal advisors. Medico-legal factors in particular were
stated by the OPs as a major source of problems with regards to managing ULDs, as
compensation issues seemed to be linked to increased sickness absence, reduced patient
cooperation and subsequent decreased rehabilitation. The complication of physicians’ treatment
efforts and negative shift in outcome due to workers’ compensation have been previously
accounted in the literature (15,92).
Disease has legal dimensions and being paid a temporary injury allowance while out of work
along with the potential for monetary gain through legal settlement have been described as
important barriers to work return. Worker’s compensation discourages return to work as the
employee can collect part of his/her usual salary without having to work. This salary
apportionment can be particularly strong factor if return to work is disagreeable because of other
factors such as job dissatisfaction. In addition, injured workers seeking financial gain from
litigation related to their occupational injury have little motivation to return to work because
73 doing so would weaken their legal argument that they have become incapacitated by the injuries
.
(92)
TOPs perceived difficulties
TOPs identified a number of difficulties in relation to managing symptoms that do not match a
recognised clinical entity. Conditions of unknown pathology such as RSI were cited as an
important problem in terms of providing appropriate advice on work modifications.
Furthermore, symptoms of such conditions appeared to be affected by multiple psychosocial
factors rendering the ULD management complicated.
Difficulties identified in relation to the patient were another issue raised as patients tended to be
sceptical towards recommendations to carry on with their occupation or go back to it and
maintain unrestricted activity in the presence of symptoms. Once more, it was suggested that
some patients tended to adopt an illness behaviour matching their perception of the diagnosis
given to them.
Further difficulties TOPs mentioned related to limitations of the resources available for
managing ULDs. It was pointed out that the size of the organisation where the problem
occurred could be a limiting factor in applying OH advice such as job rotation. Furthermore,
infrequent access of the OP to the workplace in some cases was seen as restrictive to acquiring a
clear picture of the events leading to ULDs. Additional limitations were related to the tests
used towards diagnosing ULDs. Concern was expressed with regards to the sensitivity of
physical tests such as Tinnel’s, while the benefit of nerve conduction studies was also
challenged.
TOPs also agreed on the existence of difficulties related to limitations imposed on the
physician’s knowledge. A number of them cited lack of confidence in making workplace
assessments resulting from lack of knowledge of the workplace. This seemed to result from
their having limited practice experience, being still on the OP trainee stage. However, lack of
knowledge of the workplace was also an issue arising when TOPs were called to manage
external contracts i.e. patients working in an organisation different to the one employing them.
It was denoted that the nature of the organisation that employed the TOP influenced the type of
clinical practice experiences they gained and subsequently the nature of knowledge they
acquired. This could lead TOPs to significant expertise in certain OH areas but also to limiting
the variety of knowledge.
A further significant difficulty was identified in relation to advising appropriate activity levels
during recovery. Giving a timescale with regards to workers’ activity levels during recovery
was reported as difficult in the absence of guidelines similar to those established for low back
pain.
In a final note, there were more comments made on the use of ‘labels’, this time in relation to
RSI. It was felt that the use of ‘RSI’ as a ULD diagnosis was problematic as it led patients to
preconceived conclusions about their condition while it did not provide any helpful indications
on what the course of management should be. The notion of RSI being a label rather than a
disease has been previously expressed by Helliwell (102). It has been suggested that RSI implies
a universal aetiological relationship with work which is not justified, i.e. that repetitive
mechanical forces cause pain and tissue damage, which is unproven (100).
74
GP perceived difficulties
A number of difficulties affecting the GP management of ULDs were identified. With regards
to the disease, recurrent symptoms were identified as a significant difficulty that GPs encounter
regularly. Additionally, shoulder problems were cited as difficult in terms of diagnosis.
Patient dissatisfaction was another main GP concern with regards to ULD management. A
number of ULDs, having a long natural course that causes delays in the therapeutic process,
lead to the disillusionment of patients’ expectations. Patients with chronic painful disease, in
particular, may become disillusioned with their care in general practice and feel that nothing is
being done for them (95).
In a final note, GPs identified ULD management difficulties in relation to physiotherapy access.
Long waiting times and lack of facilities were cited as problems encountered.
In a previous
questionnaire survey, GPs reported that their physiotherapy list was too long along with lack of
resources in supporting services (13). Moreover, GP referral rates have been reported to be
significantly affected by resource-related issues (103), while according to a recent qualitative
survey, community-based musculoskeletal services provided by primary care organizations
within the UK are not available in all local practices (99).
4.4.7. Training needs
OPs identified a need for opportunities to learn from each other and other specialists through the
process of continuous professional development (CPD). This need was confirmed by TOPs and
GPs, who also stated that they needed opportunities to learn from other specialists, with hand
surgeon specialists being a highly regarded source of ULD knowledge among TOPs. It is
important that CME activity is multidisciplinary, with combined case discussions and
educational meetings as increased interaction during training has been deemed likely to improve
the combined care of the patient (1).
Access to training programmes to accommodate individual training needs was an additional
needed element stated by the OPs. GPs also identified a need for ULD training that
accommodates personal development plans and, subsequently, individual training needs.
Training that supports individual learning needs along with multidisciplinary rolling training
based on primary care and training with specialty consultants have been previously cited in
qualitative research as good approaches to training for musculoskeletal service deliverers (99).
Maintenance of professional competence through continuing medical education (CME) with a
focus on the physician’s personal and professional development and individual needs, that is,
CPD, has been previously characterised as essential (1).
With regard to learning needs, GPs quotes appeared to be in agreement with a previous study
looking into the quality of care of musculoskeletal conditions in primary care, where GPs placed
emphasis on education being multidisciplinary and interactive. They preferred taught
interactive musculoskeletal courses, done as part of a personal learning plan and including
refreshing of clinical skills. GPs need access to a range of learning materials that accommodate
their personal learning style and preferred format and consider consultant colleagues to be an
important resource of meeting their learning needs (13).
The timing of the training was also denoted as an important feature for the training to be
relevant to the current GP needs. Relating new skills and knowledge to the learner’s day-to-day
work is a factor needed to ensure change in medical behaviour, which has previously stated in
literature. CME for GPs should be largely based on the work that they do and the importance of
relating educational activity to the work that doctors do has been highlighted by other authors
(96)
.
75 In another note, TOPs stated a need for more emphasis to be given to ULDs and their
occupational causes. It was felt that the evidence base they were presently provided with could
be improved on, especially, in terms of consistency. Correspondingly, GPs stated a need for
ULDs and their occupational dimension to be given additional attention during medical training
years and CME. A unified educational strategy based on self directed, practice based,
multiprofessional programmes has already been proposed by Calman (96).
With regards to forms of delivering training, clinical presentations, small group workshops and
‘hands on’ teaching were cited by TOPs as the most helpful. Small group teaching has been
cited among the preferred methods of rheumatology teaching by GP trainees in a previous
national study (93) . GPs agreed on ‘hands on’ teaching being the most desirable form. In
agreement with Gormley et al , GPs preferred to train on ‘real patients’ rather than on
‘mannequin models’ (98). Hands on small group practice has also been found to produce the
highest levels of initial mastery and long term retention of physical examination skills in
undergraduate students compared to written or videotape instruction (104).
Interactive teaching materials such as CD ROMs on injecting joints were also deemed useful by
one GP. CD ROMs have also been suggested by lead rheumatology teachers for providing
assistance to medical schools for musculoskeletal teaching (2). The increase in the use of CD
ROMs designed particularly as aids to teaching medical students has previously been deemed
useful (82).
With regards to their training needs in relation to ULDS, OPs identified a gap in dealing with
the psychosocial side of these conditions and asked for communication skills training towards
liasing with the workplace Management in order to bring about changes in the workplace.
Learning how to improve the workplace and to manage biosocial issues are OPs’ training needs
that have been previously identified in the literature (15).
Furthermore, TOPs identified a need for establishment of guidelines similar to those existing for
low back pain. It was felt that this would render the OP management of ULDs more consistent
and would assist them with difficult issues, such as advising appropriate activity levels during
recovery.
76 5. QUESTIONNAIRE SURVEY
5.1 INTRODUCTION
After conclusion of the focus groups, a questionnaire was developed from both the literature
review and the focus group analysis. The aim of the questionnaire was to address the following
•
•
•
•
•
Training and training sources in musculoskeletal disorders
Management of upper limb musculoskeletal disorders
The evidence base used in the management of upper limb musculoskeletal disorders
Perceived difficulties in managing upper limb musculoskeletal disorders
Training needs.
5.2 METHODOLOGY
As a result of the focus groups, two questionnaires were developed, one for GPs and one for
trainee Occupational Physicians (TOPs). The questionnaire development was based on the
literature review and focus group data. The researchers also contacted Dr Glazier to obtain
further information on how his research on primary care physicians had been carried out and the
questionnaire that he used in the two studies (97,9).
The questionnaires were piloted on 20 GPs and 20 TOPs. Few changes were required as a result
of the pilot survey and the two questionnaires were then sent for a final review with the London
Multi-centre Research Ethics Committee. The finalised questionnaires can be seen in Appendix
A.2.
After receiving ethical clearance, the questionnaires were distributed to 300 GPs and 350 TOPs.
The GP questionnaires were sent to a random sample of individual physicians across the UK.
The TOPs questionnaire was sent to course centres for distribution both through the postal
system and electronically via Portable Document Format.
The response rate from the initial survey was approximately 10%. A further 100 questionnaires
were distributed to GPs in the West Midlands area to improve the response rate. The Faculty of
Occupational Medicine were also approached to contact the Specialists Registrars in
Occupational Medicine across the UK. However, no further completed questionnaires were
returned to the researchers
5.3 RESULTS
The response rate for the initial sweep of questionnaires for GPs was 32 (10.6%) for the first
survey, and 29 (8.2%) for the TOPs. Four additional questionnaires were returned by GPs
declining to participate. No further questionnaires were returned from the follow-up surveys.
5.3.1 General Practitioner Results
Description of sample
The GP sample had an age range of 32-63 years and included 4 (12.5%) females and 28 (87.5%)
males. The sample had graduated from medical school between the years of 1966 and 1997.
Within the group only one individual had graduated outside the U.K. Twenty-nine (90.6%)
worked full-time, with the majority, 26 (81.3%) working in the NHS.
77 Upper Limb Musculoskeletal Training
The first section of the questionnaire asked for information on training received in
musculoskeletal disorders and work related musculoskeletal disorders. Table 11 describes how
much training the respondents obtained in both upper limb musculoskeletal disorders and work
related musculoskeletal disorders. It is apparent that more training was received during
continuing medical education than previously.
Table 11 Training in musculoskeletal disorders
Musculoskeletal training during medical
school
During House Officer years
During Registrar years
Continuing Medical Education
Upper limb musculoskeletal
disorders
Mean S.D.
Min
Max
2.81
1.302
1
6
2.56
1.523
1
2.79
1.612
1
4.41
1.500
1
Range on questionnaire 1-7
Work Related Upper limb
musculoskeletal disorders
Mean S.D.
Min Max
1.81 1.281
1
6
6
6
7
1.72
1.86
3.66
1.276
1.281
1.945
1
1
1
6
7
7
Respondents were asked to identify sources of vocational training. The most common
responses in Table 12 were to Orthopaedics, Rheumatology, Occupational Health and Sports
Medicine. Off the six responses in the other category, two reported Accident and Emergency as
a source, one reported Orthopaedic Medicine, one on GP attachment as a source, one working
with Primary Care and one reading journals
Table 12 Sources of vocational upper limb musculoskeletal disorders training
Sources of Vocational Training
Orthopaedics
Rheumatology
Sports Medicine
Rehabilitation Medicine
Occupational Health
None
Other
N
20
14
9
2
10
0
6
%
62.5
43.8
28.1
6.3
31.3
0
18.6
Other courses identified by the respondents included courses in Occupational Health, Joint
Injections, Sports Medicine and individual organisation of sessions with Rheumatology
specialists.
The participants were asked to identify which sources they used in their professional
development. The question was rated one to seven with one being never or not applicable and
seven being always. Figure 4., presents the mean data obtained for the GP Participants. These
data indicate that the most common sources used are medical journals, contact with GP partners,
contact with medical specialists and conferences/seminars. The sources least used include CDROMs and other Professional Groups.
78 7
Mean
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Figure 4. Sources of Information Used in Professional Development
GPs comments with regard to training included the following.
Mainly learned through experience of patients and through working with
physiotherapists/occupational therapists. I look after a lot of musicians who have ULD
problems
Actually had very little training
I recognised a gap years ago and have tried to fill it myself, but very little specific training
appears available
Mostly non-existent
No
Non-existent until Occ Health Training started
Poor and almost all because I have sought it out. I feel confident with most shoulder and neck
problems and epicondylitis but lack training in other area.
Has been self-driven/motivated
Very limited - ad hoc
Very limited - Would Like more
79 ULD Management
Respondents were asked to give first and second management approaches they would use with
regard to different musculoskeletal disorders. Tables 13 to 23 present the treatment options
reported by participants for specific disorders.
Table 13 Treatment options for tenosynovitis
First Treatment Option
NSAIDs
Rest, NSAIDs
Rest
Rest, NSAIDs and Splinting
Splinting and NSAIDs
RICE, NSAIDs
Rest, Time
Remove cause, RICE, NSAIDs
Rest, Strapping
Physiotherapy, NSAIDs
Rest then rehabilitation Exercises
Physiotherapy
N
10
6
3
3
2
1
1
1
1
1
1
1
%
31.3
18.8
9.4
9.4
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Second Treatment Option
Physiotherapy
NSAIDs
Steroid Injection
Steroid Injection, Physiotherapy
Steroid Injection, Splinting
Stronger NSAIDs, more rest
Splint
Referral to Rheumatology
PCM/NSAIDs
Rest
Referral
Physiotherapy, Strapping
N
11
6
4
2
1
1
1
1
1
1
1
1
%
34.4
18.8
12.5
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Table 14 Treatment options for tendonitis
First Treatment Option
NSAIDs
Rest, NSAIDs
Rest, NSAIDs and Splinting
NSAIDs and Splint
Rest then rehabilitation Exercises
Rest, Time
RICE, NSAIDs
Rest, avoidance of precipitating factors
Physiotherapy
Rest
Remove cause, RICE and NSAIDs
Rest, Strapping
N
11
6
3
2
1
1
1
1
1
1
1
1
80
%
34.4
18.8
9.4
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Second Treatment Option
Physiotherapy
NSAIDs
Referral
Steroid Injection
NSAIDs, paracetomal
Steroid
Stronger NSAIDs, more rest
N
19
4
3
2
%
59.4
12.5
9.4
6.3
1
1
1
3.1
3.1
3.1
Table 15. Treatment options for carpal tunnel syndrome
First Treatment Option
NSAIDs
Splint
Steroid Injection
Referral
NSAIDs, Splinting
Rest, NSAIDs and Splinting
Nerve conduction studies for
confirmation
Rest
NSAIDs and Cortisone
Night Splint, Analgesia
Splinting, Physiotherapy
Check Thyroid Function
Rest, time, blood testing
Advice, NSAIDs, blood testing
Surgical Decompression
Remove Cause
Referral to Hand Surgeon
N
8
2
2
2
2
2
1
%
25.0
6.3
6.3
6.3
6.3
6.3
3.1
1
1
1
1
1
1
1
1
1
1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Second Treatment Option
Steroid Injection
Referral
Refer Orthopaedics
Refer for nerve conduction studies
Splinting
Injection, surgical release
Physiotherapy and nerve conduction
Physiotherapy
N
13
3
3
2
2
1
1
%
40.6
9.4
9.4
6.3
6.3
3.1
3.1
1
3.1
N
12
4
3
3
2
2
1
1
1
%
37.5
12.5
9.4
9.4
6.3
6.3
3.1
3.1
3.1
Table 16 Treatment options for De Quervain’s disease
First Treatment Option
NSAIDs
NSAIDs, Rest
Rest then structured rehabilitation
Splinting
Physiotherapy
Rest, NSAIDs and Splinting
Remove cause, RICE, NSAIDs
Physiotherapy, NSAIDs
Steroid Injection
Rest
Rest, Analgesia
Rest, time
Refer Orthopaedics
NSAIDs, Splinting
Refer for injection
N
12
6
1
1
1
1
1
1
1
1
1
1
1
1
1
%
37.5
18.8
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
81
Second Treatment Option
Steroid Injection
Physiotherapy
Splinting
Referral
Injection in Tendon Sheath
NSAIDs
Refer Orthopaedics
Refer Rheumatology
Injection or surgical release
Table 17 Treatment options for epicondylitis
First Treatment Option
NSAIDs
Rest
Rest, NSAIDs
Physiotherapy, NSAIDs
Avoidance, Paracetomal, NSAIDs
NSAIDs, Injection
NSAIDs gel
Rest, analgesia
NSAIDs, oral and topical
Remove cause, RICE and NSAIDs
Steroid Injection
Advice
Splinting
Rest, NSAIDs, Splinting
Rest, time
N
13
3
3
1
1
1
1
1
1
1
1
1
1
1
1
%
40.6
9.4
9.4
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Second Treatment Option
Steroid Injection
Steroid injection or physiotherapy
Injection (if patients choice)
Physiotherapy, steroid injection
Referral
NSAIDs and referral
Physiotherapy
Physiotherapy and refer to GP colleague
Forearm clasp, NSAIDs
Steroid/local anaesthetic injection
N
20
4
1
1
1
1
1
1
1
1
%
62.5
12.5
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Table 18 Treatment options for rotator cuff syndrome and bicipital tendonitis
First Treatment Option
NSAIDs
NSAIDs, Rest
Physiotherapy
NSAIDs, injection
Advice
NSAIDs and Analgesia
NSAIDs and Physiotherapy
Rest, Physiotherapy
Physiotherapy, Steroid Injection
Rest, time, analgesia
Exercise, analgesia
NSAIDs, rest, splinting
N
13
5
4
1
1
1
1
1
1
1
1
1
%
40.6
15.6
12.5
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Second Treatment Option
Steroid Injection
Physiotherapy
NSAIDs
Referral to physiotherapy or rheumatology
Rheumatology advice
Specialist Referral
Refer to GP Colleague
Steroid Injection or physiotherapy
Steroid Injection, ultrasound
Cortisone Injection, physiotherapy
Refer Rheumatology
Injection and lidocaine
N
12
6
2
1
1
1
1
1
1
1
1
1
%
37.5
18.8
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Table 19 Treatment options for shoulder capsulitis
First Treatment Option
NSAIDs
Physiotherapy
Rest, NSAIDs
Rest
Steroid Injection
NSAIDs and advice
NSAIDs and analgesia
Rest, time
NSAIDs, Exercise
NSAIDs, Injection
Analgesia and Injection x 3
Rest, NSAIDs, Splinting
N
13
5
4
1
1
1
1
1
1
1
1
1
%
40.6
15.6
12.5
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
82
Second Treatment Option
Steroid Injection
Physiotherapy
Steroid Injection, Physiotherapy
NSAIDs
Referral to Shoulder Surgeon
REF Manipulation under general anaesthetic
Rheumatology Referral
Injection and lidocaine
Local Steroid
Refer to GP Colleague
Physiotherapy, Refer Orthopaedics
Injection (if patient’s choice)
N
13
4
3
2
1
1
1
1
1
1
1
1
%
40.6
12.5
9.4
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Table 20 Treatment options for cervical spondylosis
First Treatment Option
NSAIDs
Analgesia
Physiotherapy
Education, exercise
Analgesia, muscle relaxants
Analgesia, keeping mobile
Advice, simple analgesics
NSAIDs, McKenzie Exercises
Paracetomal
Exercise Regime
NSAIDs and Physiotherapy
Rest, Advice, Orthopaedic Pillow
N
11
6
4
1
1
1
1
1
1
1
1
1
%
34.4
18.8
12.5
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Second Treatment Option
Physiotherapy
NSAIDs
Rheumatology Referral
Simple Analgesia
Nil
Refer Orthopaedics
NSAIDs, dependent on age
Soft Collar
Osteopathy
Referral
Physiotherapy, collar
?
N
16
4
2
1
1
1
1
1
1
1
1
%
50.0
12.5
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
N
5
3
3
3
3
2
2
1
1
1
1
%
18.8
9.4
9.4
9.4
9.4
6.3
6.3
3.1
3.1
3.1
3.1
Table 21 Treatment options for impingement syndrome
First Treatment Option
NSAIDs
Physiotherapy
Steroid Injection
Analgesia
What is this?
Exercise, NSAIDs
Rest, time, analgesia
NJAIO
Collar, X-ray
Rest, analgesia
NSAIDs and Physiotherapy
Injection
N
7
7
3
2
1
1
1
1
1
1
1
1
%
21.9
21.9
9.4
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
83
Second Treatment Option
Physiotherapy
NSAIDs
Referral
Refer Orthopaedics
Steroid Injection
Rheumatology Referral
Steroid Injection, Physiotherapy
Specialist Referral
Soft Collar, Physiotherapy
Refer Orthopaedics and Physiotherapy
Refer to GP Colleague
Table 22 Treatment options for tension neck
First Treatment Option
NSAIDs
Analgesia
Physiotherapy
Exercise
?
Relaxation Techniques
Ergonomic Advice
NSAIDs, Physiotherapy
Rest
Rest, time
Manage
Advice on neck care, self-help
Analgesia, muscle relaxants
Muscle Relaxants
Antidepressants, analgesia
Rest, analgesia and relaxation
Exercise, education, analgesia
N
6
4
3
2
2
2
1
1
1
1
1
1
1
1
1
1
1
%
18.8
12.5
9.4
6.3
6.3
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Second Treatment Option
Physiotherapy
Antidepressants
Analgesia
Alexander Technique Exercises
Exercise
Physiotherapy and antidepressants
Osteopathy
Exercise, relaxation
Muscle Relaxants
Stress Management
Nil
Analgesia, massage
Stronger analgesic
N
12
2
1
1
1
1
1
1
1
1
1
1
1
%
37.5
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
N
10
3
3
2
2
1
1
1
1
1
1
1
1
%
31.3
9.4
9.4
6.3
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Table 23 Treatment options for diffuse non-specific upper limb disorders
First Treatment Option
NSAIDs
Analgesia
Physiotherapy
NSAIDs, rest
Exercise
What is this?
Investigation, analgesia
Relaxation therapy
Exercise, yoga
Rest
Reassurance, analgesia
Exercise, review
Rest, analgesia
NSAIDs, analgesia
Assess case, analgesia
N
7
6
3
2
1
1
1
1
1
1
1
1
1
1
1
%
21.9
18.8
9.4
6.3
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
84
Second Treatment Option
Physiotherapy
Referral
NSAIDs
Analgesia
Antidepressants
Muscle relaxants
?
Nil
Psychotherapy
Psychology
Rheumatology Referral
NSAIDs, focal exercises
Stronger Refer Orthopaedics
GPs were then asked if they would contact a patient’s occupational physician (assuming one
was available) with regard to musculoskeletal problems. The results presented in Table 24
identified that most respondents would make this contact.
Table 24 Contact with occupational physician
Contact
Yes sometimes
Yes rarely
No
Yes always
Not applicable
Advise Patient to attend
N
11
8
4
4
3
1
%
34.4
25.0
12.5
12.5
9.4
3.1
Question nine of the questionnaire asked respondents to identify which department they would
refer patients to. Table 25., highlights the departments referred to are mainly Orthopaedics,
Rheumatology and Physiotherapy. Three other departments were mentioned by respondents
and included referral to a Musculoskeletal Physician, Neurology for nerve conduction studies
and Autogenic Training/Hypnotherapy.
Table 25 Referrals for musculoskeletal problems
Departments referred to
Orthopaedics
Rheumatology
Physiotherapy
Occupational Therapy
Counselling
Rehabilitation
Cognitive Behavioural Therapy
Employment Service
N
29
23
32
5
4
3
3
3
%
90.6
71.9
100.0
15.6
12.5
9.4
9.4
9.4
Respondents were asked to rate their level of confidence with nine different aspects of upper
limb management. Figure 5. presents the mean data obtained on a seven-point scale with 1
being not at all confident and 7 denoting extreme confidence. The results indicate that the mean
value for all aspects assessed was high, however, some respondents did rate themselves as
having little confidence in joint injection and corticosteroids usage.
85 Mean
7
5
3
Es
ta
bl
ish
Re
in
fe
g
rra
w
A
ls
or
dv
k
ic
re
eo
la
n
te
dn
ap
pr
es
op
s
r ia
te
ac
tiv
ity
os
te
ro
id
s
s
or
tic
of
c
U
se
se
of
N
SA
ID
io
n
ec
t
is
ia
gn
os
D
Jo
in
ti
nj
U
Ph
ys
ic
al
e
xa
m
in
at
io
n
1
Figure 5. Level of Confidence with Different Aspects of Upper Limb Management
Respondents were asked for any further comments with regard to their management of ULDs.
The responses are shown below.
I feel I could manage it better. If courses were readily available I would attend
Difficult to generalise- wide range of possible disorders
It can be frustrating and commonly has led to individuals being forced to give up work.
Employers can be very unsympathetic
Knowledge is a wonderful thing, skills are good too, awareness is better
Much of the management is patient led, which makes a nonsense of this 'rational approach'. If a
patient wants local acupuncture then I refer. If they want physio, then I will refer, as long as
there is no harm to the patient. .They are involved in management decisions
No
Often governed by what managers want to do
There is scope for better GP Awareness and Training
Tenosynovitis - A single approach is unlikely to be effective! You need to treat symptoms and
cause together. De Quervains-Patient choice is also important. Epicondylitis - Physiotherapy
usually helpful as can be neck component as well
Treatment Preceded by Ergonomic Assessment
We have a physio...He is a member of the team+ invaluable. PCT maybe looks to remove him,
which would be a disaster. Management of medical problems is easier if you have a 'team' you
can rely on. Physio reduces referrals to hospital + the prescription of antinflammatories. With
the correct investments in general practice reductions in 2nd referral would follow.
Would like to feel more confident
Identifying the cause and remove /alter applies to all
Epicondylitis treatment depends on patient preference
Occupational therapy service overwhelmed with other diseases. CBT virtually not existent
Main problem...people who complain of ULDs but in fact are wanting off work – similar to LBP
The patient tends to have ideas about the different treatment modalities and options. Need to
acknowledge that treatment is often more than one solution at a time
86 Evidence Base
The questionnaire asked respondents how often they used particular sources as an evidence base
to aid their management of ULDs. The responses were based on a seven-point scale with one
being never and seven denoting always. Figure 6., presents the information.
Mean
7
5
3
Pr
ev
io
us
cl
in
ic
Co
al
ns
ex
u
P
pe
Co lta
re
ns tio vio rien
ns
ul
us
c
ta
w
tra e
t
i
i
Co
th
o
i
ot nin
nt n w
g
h
in
ui ith m er G
ng
m edic .P.s
ed
al
i
A cal sp..
cc
re edu .
di
ca
te
tio
d
n
w
eb
sit
e
Jo s
ur
n
M
RC Tex als
tb
G
oo
P
G
ui ks
de
lin
es
Cl
in
ic
al
ev
id
en
ce
1
Figure 6. Evidence Base in your Choice of Treatment of Musculoskeletal Disorders
Respondents were invited to offer any additional comments with regard to their evidence base
for managing ULDs. One participant responded with a comment about a Diploma in Sports
Medicine. Additional comments were:
A lot of traditional management e.g. injection/physio has no/poor evidence base in literature.
As with other areas of medicine the fact that Rx varies with several avenues available suggests
that NONE work very well. It is difficult to get evidence and to say which if any are better than
others
Is there a real evidence base if the diagnosis is rarely concrete and often coloured by people's
emotional and social state?
It's very personal
It is often difficult to separate evidence from the more anecdotal experience of individual
patient
Evidence base seems poor for most known interventions
Perceived Difficulties
The next section of the questionnaire asked participants about difficulties in establishing a
diagnosis for particular disorders. Respondents were asked to respond on a seven-point scale
with one being never and seven being always. The mean data is presented in Figure 7. Those
87 disorders which respondents find more difficult to diagnose include Impingement Syndrome
and Diffuse Non-specific Upper Limb Disorders.
Mean
7
5
3
te
ou
l
Sh
Sh
ou
l
de
r
Ep
i
co
nd
y
lit
i
nd s
o
ni
Ce der
tis
rv
c
a
i
p
D
c
I
m
su
al
iff
pi
us
ng Spo litis
en
em
n
on
en dylo
-s
tS
s
pe
yn is
ci
fic
Te dro
up
m
e
pe nsio
rl
n
N
im
e
b
di ck
so
rd
er
s
H
an
d/
fo
re
ar
m
H
an
d/ teno
f
sy
Ca ore
no
ar
rp
vi
m
al
tis
te
Tu
n
d
nn
on
el
Sy itis
nd
ro
m
e
1
Figure 7. Perceived Difficulties in Establishing a Diagnosis
The question on difficulty in diagnosis was followed by a question that asked individuals to rate
how difficult certain aspects of management of ULDs are. Figure 8., presents the mean data for
the responses to the question. The questions were rated on a one to seven scale with one being
never/not applicable and seven being always.
88 7
Mean
5
3
Sy
m
pt
o
m
s/S
ig
ns
do
no
tm
at
ch
ar
ec
og
n
A
bs E ised
l
e
D No nc usi cli
el
ay res e of ve d nic.
ed po c ia .
re ns lini gn
sp e ca os
on to l s is
Re se t trea ign
cu o t tm s
rre rea en
Th
nt tm ts
sy en
ep
m ts
O
at
pt
ie pp
C
nt os
hr om
is in
on s
re g p
ic
Ps
ce re
ity
D
yc
i
iff
A vin vio
h
os
cc g u s
ic
oc
ul
es tem m
ty
ia
s
lf
in A to po edic
ac
ad cc spe rar al
to
vi es ci y i m
rs
sin s t al nj an
i
o
u
a
st ry g
g
p
ap h se a em
p r y s i r v llo e
op ot ic w nt
ria he es an
te rap is d ce
ac y if
tiv is fic
ity dif ul
le ficu t
ve l
ls. t
..
1
Figure 8. Difficulties in Managing Upper Limb Disorders
Respondents were also asked to identify any barriers when obtaining referrals for patients. The
data are presented in Table 26. The data illustrates that most respondents find no barrier to
accessing Physiotherapy, Rheumatology, Orthopaedics and Occupational Therapy, there are
long waiting times for specific specialists.
Table 26 Barriers when referring patients
No
barrier
Specialist
Rheumatology
Orthopaedics
Physiotherapy
Rehabilitation
Occupational Therapy
Employment Service
Cognitive
Behavioural
Therapy
N
8
8
21
2
8
4
1
%
25.0
25.0
65.6
6.3
25.0
12.5
3.1
Waiting time
unacceptably
long
N
%
24
75.0
24
75.0
11
34.4
13
40.6
11
34.4
2
6.3
16
50.0
Travel
distance
too far
N
%
*
*
*
*
*
*
*
*
*
*
*
*
1
3.1
Not
available
N
*
*
*
6
4
6
7
%
*
*
*
18.8
12.5
18.8
21.9
Not sure
if
available
N
%
*
*
*
*
*
*
10 31.3
8 25.0
16 49.9
5 15.6
Not
applicable
N
*
*
*
*
*
*
1
%
*
*
*
*
*
*
3.1
Respondents were invited to offer additional comments with regard to the difficulties they come
across in managing ULDs. One respondent offered comments that were they were uncertain of
89 the role of other physical therapies including Chiropracty and Osteopathy.
comments were:
Additional
Lack of signs - Elusive diagnosis. Element of compensationitis
I think employment service available but no idea what options they have or how effective they
are
Referral centres appear completely unaware of the disability attributed to these problems. If
they cannot reach a firm diagnosis then they tend to wash their hands of the patient
Unacceptably poor access to services
Recovery depends on whether occupational medicine available in workplace
Cinderella subject
Patients almost always have chronicity, recurrence and multiple symptomatology relating to
many symptoms. I am very pessimistic that there are any permanent solutions to the problem.
Maybe short term alleviation is possible although I suspect this has a lot to do with the natural
history of the problem rather than the therapeutic efficacy
Often patients are seen by occupational health workers who give them unreasonable and
unrealistic expectations of what NHS can do. Frequently they encourage multiple O.P.D.
referrals which are usually a dead end, with assessment in outpatient and quick discharge to
G.P
Training Needs
Participants in the questionnaire were asked to rate their level of interest in CME in specific
topics. The respondents were asked to rate their level of interest on a seven-point scale with 1
representing not at all interested and seven representing extremely interested. Figure 9. presents
the data.
90 7
Mean
5
3
Co
m
pr
eh
en
s
iv
e
m
us
cu
lo
sk
M
e
an
D leta
ag
i
f
fe l ex
in
re a
g
nt m
co
ia in
m
l a
m
Jo dia tio
on
n
i
m U U nt gn
Ps us se se inj osis
yc cu of of ec
M hos losk cor NS tion
ed oc e tic A
ic ia let os
ID
o l al te s
A
dv
Co lega aspe con roid
ic
eo
m l a c t di s
n Wo ple spe s of tion
ac rk m c U s
tiv r en ts L
ity ela tar of Ds
le ted y M UL
ve ne e D
l d ss di s
ur of cin
in U e
g L
re D
co s
ve
ry
1
Figure 9. Level of interest in continuing medical education topics
Respondents were asked to identify any barriers to training and responses included time
constraints, costs of courses, courses not readily available and the quality of some courses. The
responses are shown below.
Time + Resources
Not enough time in the day!
Nil
Time + Money
Find a good enough course. Time
Courses not readily available in my area
Appropriate courses + time
Time out!
Time
Only time to do it
Time to go to courses
Time!
Time - The workload is now 20 hrs/day
Time!
My own time constraints. Too many courses now have a commercial basis, i.e. you pay for the
course so they add a lot of padding or else it's to sell a product
Time!
Many competitive things in my time. Cost of some courses. Some courses very poor quality.
Time + Money. - Most of the educating sessions are during working day and … cost £400+ per
day
91 Being single handed
The participants were invited to make any additional comments with regard to their training
needs for managing ULDs. Six participants responded with the following comments
I would be keen to attend such training
No
Unlikely to be met
Very interested if you produce/promote any training packages/CD ROM
Yes,some reassurance that what we are doing is OK
Would welcome training regarding work/occupational health + ULD
92 5.3.2 Trainee Occupational Physician Results
Description of sample
The TOPs sample had an age range of 26-69 years and included 6 (20.7%) females and 23,
(79.3%) males. The sample had graduated from medical school between the years of 1960 and
200. Within the group only 5, (17.2%) had graduated outside the U.K. Twenty-four (82.8%)
worked full-time, with 13 (44.8%) working in the NHS.
Upper limb musculoskeletal training
The first section of the questionnaire asked for information on training received in
musculoskeletal disorders and work related musculoskeletal disorders. Table 27., describes
how much training respondents obtained in both. It is apparent from the data that more training
was received in occupational health training years and CME than previously during medical
education and training.
Table 27 Training in musculoskeletal disorders
Upper limb musculoskeletal
disorders
Mean S.D.
Min
Max
2.24
1.244
1
6
Musculoskeletal skeletal training during
medical school
During your House Officer years
2.00
0.926
1
During your Registrar years
2.68
1.244
1
During your Occupational Health trainee
4.11
1.553
1
years
Continuing Medical Education
4.43
1.399
2
Range on questionnaire 1-7
Work Related Upper limb
musculoskeletal disorders
Mean S.D.
Min Max
1.66 1.111
1
6
4
6
7
1.31
1.90
4.22
0.541
1.205
1.695
1
1
1
3
4
7
7
4.25
1.602
1
7
Respondents were invited to identify sources of vocational training. Table 28., identifies that
the most common sources are Occupational Health, Rheumatology and Orthopaedics. Those
who responded with other, identified other sources including General Practice, SOM meetings,
HAVS training, Disability Assessment Medicine and visiting colleagues in Orthopaedics.
Table 28 Sources of vocational upper limb musculoskeletal disorders training
Source
Orthopaedics
Rheumatology
Sports Medicine
Rehabilitation Medicine
Occupational Health
None
Other
N
12
15
7
5
23
1
9
%
41.4
51.7
24.4
17.2
79.3
3.4
30.6
The next question on the questionnaire asked participants to identify any courses taken in
relation to ULDs. Table 29. presents these data. The most common courses identified were
those of the Diploma and Advance Diploma in Occupational Medicine.
93
Table 29 Courses undertaken in relation to upper limb disorders
Course
Diploma, advance diploma in occupational medicine
None
Disability Assessment
MSc in Occupational Health
Society of Occupational Medicine Meetings
Sports Medicine
Only in rheumatology
HAVS course
Occupational Health SMASHER course
N
13
3
2
1
1
1
1
1
1
%
44.8
10.3
6.8
3.4
3.4
3.4
3.4
3.4
3.4
Other courses include acupuncture training (1, 3.4%), lectures and presentations (1, 3.4%),
Diploma in Sports Medicine (1, 3.4%), Military Sports Injury course (1, 3.4%), AFOM (1.
3.4%) and ANHOPs Seminars (1, 3.4%)
The participants were asked to identify which sources they used in their professional
development. The question was rated one to seven with one being never or not applicable and
seven being always. Figure 10., presents the mean data obtained for TOPs. These data indicate
that the most common sources are medical journals, text books and conferences and seminars;
the least used being videos and CD-ROMs.
7
Mean
5
3
M
ed
ic
al
Jo
Te urna
Co Co
FO xt B ls
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O
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er
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A nce rac
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w
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sit
e
V s
Pr
i
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es
s
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ro
up
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1
Figure 10. Sources of Information Used in Professional Development
94
The questionnaire then asked respondents about their medical background before training to
become and Occupational Physician. The data presented in Table 30., highlights that the
majority of respondents were in general practice.
Table 30 Previous job
Previous Job
Consultant Physician
GP
GP Military
GP Disability Analysis
GP Ophthalmology Assistant
GP Medical Manager
GP and Rheumatology
S.H.O. Orthopaedics
N
1
22
1
1
1
1
1
1
%
3.4
75.9
3.4
3.4
3.4
3.4
3.4
3.4
The questionnaire then asked respondents if they had any additional comments about ULD
training. This obtained the following open comments.
An area of unmet need and a learning objective
As a Disability Analyst I have to assess clients claiming Industrial Injury Disablement Benefit
for Prescribed Diseases associated with ULD
Dismal lately, well taught at medical school
Have learned most from role as Union Rep. Had dealings with eminent ergonomist + learned
a lot about the multifactorial nature of WRULD
I need to arrange a specific, focused training only on ULD
In house presentations and visiting orthopaedic counsultants. I work with two doctors with
sports medicine diplomas
Most of it picked up in practice
Needs More
Needs to be evidence based
No
Slowly gaining confidence but would welcome practical guidelines
Sparse until studying for Occ Health Diploma
Very poor until started OH. No structured WRULD training
There is a scarcity of information. However, I always use the information that is available
ULD Management
Respondents to the questionnaires were asked to give first and second management approaches
they would use with regard to different musculoskeletal disorders. Tables 31 to 41 present the
treatment options reported by participants.
95 Table 31 Treatment options for tenosynovitis
First Treatment Option
Rest, NSAIDs
Rest
Temporary removal from work
NSAIDs
Ice, NSAIDs
Load reduction at workstation
NSAIDs, avoid precipitant agent
Physiotherapy
Rest, physiotherapy, job rotation
NSAIDs, analgesia
Reduce usage, wrist support
Manual therapy
Work adjustment and
physiotherapy
Workplace
assessment/modification
NSAIDs, physiotherapy
Employment limitations
Avoid repetitive activity
Rotation of work
Rest, ergonomic assessment, advice
N
6
5
1
1
1
1
1
1
1
1
1
1
1
%
20.7
17.2
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
1
3.4
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
Second Treatment Option
Physiotherapy
Referral
Steroid Injection
NSAIDs
NSAIDs, Physiotherapy
Refer to rheumatology
Education and training
Refer to GP
Referral for injections
Medication
Ergonomic workplace assessment
Change of job, physiotherapy
N
13
2
2
2
1
1
1
1
1
1
1
1
%
44.8
6.9
6.9
6.9
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
N
13
3
2
1
1
%
44.8
10.3
6.9
3.4
3.4
Table 32 Treatment options for hand/forearm tendonitis
First Treatment Option
Rest
Rest, NSAIDs
NSAIDs
Work adjustment, physiotherapy
Workplace
assessment/modification
Light job, muscle strengthening
exercises
Employment limitations,
physiotherapy and rest
Load reduction
NSAIDs, avoid precipitating
factors
Rest, NSAIDs
Physiotherapy
Rest, physiotherapy, job rotation
Temporary removal from work
Ice, NSAIDs
Work assessment, redeployment
Rest, ergonomic assessment, advice
NSAIDs, analgesia, reduce usage,
wrist support
Manual Therapy
N
6
7
2
1
1
%
20.7
24.0
6.9
3.4
3.4
1
3.4
Refer to GP
1
3.4
1
3.4
Steroid Injection
1
3.4
1
1
3.4
3.4
Refer to GP, NSAIDs
Medication
1
1
3.4
3.4
1
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
Ergonomic workplace assessment
Change of job, physiotherapy
Refer to Rheumatology
1
1
1
3.4
3.4
3.4
1
3.4
96
Second Treatment Option
Physiotherapy
NSAIDs
Referral
Education and training
NSAIDs, Physiotherapy
Table 33 Treatment options for carpal tunnel syndrome
First Treatment Option
Rest
Splint
NSAIDs
Referral for surgery
Conservative treatment
Splint and rest
NSAIDs, analgesia
Nerve conduction study,
reassurance
NSAIDs, avoid precipitating
factors
Avoid repetitive wrist movements
Rest, physiotherapy, job rotation
Temporary removal from work
Work assessment, redeployment
Work adjustment, referral
Refer to orthopaedics
NSAIDs, splint
Steroid injection
NSAIDs, rest and employment
limitations
Medication
Wait and see, referral
Work restriction
Manual therapy
N
Nerve conduction studies
Refer for Surgery
Physiotherapy
Referral
Steroid injection
Workplace assessment
Diuretics, surgery
NSAIDs
N
3
3
2
2
2
2
1
1
%
10.3
10.3
6.9
6.9
6.9
6.9
3.4
3.4
4
2
2
1
1
1
1
1
%
13.8
6.9
6.9
3.4
3.4
3.4
3.4
3.4
1
3.4
Splint
1
3.4
1
1
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
Rest
Refer to GP, splint
Refer to GP
Diuretics, physiotherapy
Physiotherapy, splinting
Injection or decompression
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
1
1
1
1
3.4
3.4
3.4
3.4
Physiotherapy
Steroid injection
Refer to Orthopaedics
Referral
NSAIDs
Refer to Rheumatology
Alter work practices
NSAIDs, Physiotherapy
N
7
3
3
2
2
1
1
1
%
24.1
10.3
10.3
6.9
6.9
3.4
3.4
3.4
Splint
Refer to GP
Immobilisation
Refer for injection
Injection, splint
Ergonomic workplace assessment
Referral, workplace assessment
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
Second Treatment Option
Table 34 Treatment options for De Quervain’s disease
First Treatment Option
Rest
Rest, NSAIDs
NSAIDs
NSAIDs, review job
Work adjustment, physiotherapy
Avoid precipitating causes
NSAIDs, analgesia
NSAIDs, avoid precipitating
factors
Load reduction
Lighter job, physiotherapy
Rest, physiotherapy, job rotation
Temporary removal from work
Work assessment, redeployment
Workplace Assessment
Rest, ergonomic assessment, advice
Physiotherapy, eliminate cause
Medication
Referral for injection
Manual therapy
N
6
5
2
1
1
1
1
1
%
20.7
17.2
6.9
3.4
3.4
3.4
3.4
3.4
1
1
1
1
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
97
Second Treatment Option
Table 35 Treatment options for epicondylitis
First Treatment Option
Rest, NSAIDs
NSAIDs
Rest
Physiotherapy
NSAIDs, keep active, support
Work adjustment, physiotherapy
Forearm strap
N
NSAIDs, avoid precipitating
factors
Load reduction
Work rotation
NSAIDs, employment limitations,
rest
Workplace modification
Rest, physiotherapy, job rotation
Temporary removal from work
Avoid precipitating actions
Conservative treatments, NSAIDs
Steroid injection
Rest, ergonomic assessment, advice
Medication
Temporary lighter job,
physiotherapy
Manual therapy
N
6
5
3
2
1
1
1
%
20.7
17.2
10.3
6.9
3.4
3.4
3.4
1
3.4
6
5
3
2
1
1
1
%
20.7
17.2
10.3
6.9
3.4
3.4
3.4
1
3.4
Steroid injection
Physiotherapy
Referral
Refer to GP
Refer to Rheumatology
Alter work practices
Steroid injection, physiotherapy,
clamp
Refer to Orthopaedics
1
1
1
3.4
3.4
3.4
Change of job, steroid injection
Steroid injection, liase with GP
Ergonomic workplace assessment
1
1
1
3.4
3.4
3.4
1
1
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
Surgery
NSAIDs, physiotherapy, Injection
Ergonomic workplace assessment
Referral, workplace assessment
1
1
1
1
3.4
3.4
3.4
3.4
1
3.4
Steroid injection
Physiotherapy
Referral
NSAIDs.
N
8
4
4
2
%
27.6
13.8
13.8
6.9
Second Treatment Option
Table 36 Treatment options for rotator cuff syndrome and bicipital tendonitis
First Treatment Option
Physiotherapy
Rest
NSAIDs
NSAIDs, avoid precipitating
factors
NSAIDs, physiotherapy
Load reduction
Work adjustment, physiotherapy,
NSAIDs
Rest, NSAIDs
Explanation, advice
X-ray, NSAIDs, analgesia
Workplace assessment, duty
modification
I.A. Injection
Workplace assessment
Conservative treatments NSAIDs
Steroid injection
Rest, ergonomic assessment, advice
Temporary removal from work,
physiotherapy
Rest, NSAIDs, job rotation
Manual therapy
N
4
3
3
1
%
13.8
10.3
10.3
3.4
1
1
1
3.4
3.4
3.4
Refer to Rheumatology
NSAIDs, physiotherapy
Alter work practices
1
1
1
3.4
3.4
3.4
1
1
1
1
3.4
3.4
3.4
3.4
Refer to GP
I.A. Injection
Medication
Ergonomic workplace assessment
1
1
1
1
3.4
3.4
3.4
3.4
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
Lighter job, physiotherapy
NSAIDs, physiotherapy, Injection
Ergonomic workplace assessment
Referral, workplace assessment
1
1
1
1
3.4
3.4
3.4
3.4
1
1
3.4
3.4
98
Second Treatment Option
Table 37 Treatment options for shoulder capsulitis
First Treatment Option
Physiotherapy
NSAIDs
Rest
Referral
Work adjustment, physiotherapy
Physiotherapy, employment
limitations, rest
Work modification
NSAIDs, physiotherapy
NSAIDs, physiotherapy and work
adjustment
NSAIDs, avoid precipitating
factors
Load reduction
Rest, NSAIDs
Rotatory movements
Physiotherapy and advice
Workplace assessment and duty
modification
I.A. Injection
Physiotherapy and steroid injection
Steroid injection
Temporary removal from work,
physiotherapy
Rest, NSAIDs, job rotation
Manual therapy
N
Physiotherapy
Steroid injection
Referral
NSAIDs
Refer to GP
Medication
N
6
5
5
3
2
2
%
20.7
17.2
17.2
10.3
6.9
6.9
4
3
3
1
1
1
%
13.8
10.3
10.3
3.4
3.4
3.4
1
1
1
3.4
3.4
3.4
NSAIDs, physiotherapy, injection
Surgery
Ergonomic workplace assessment
1
1
1
3.4
3.4
3.4
1
3.4
Refer to Orthopaedics
1
3.4
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
Refer to Neurology
1
3.4
1
1
1
1
3.4
3.4
3.4
3.4
1
1
3.4
3.4
N
13
4
1
1
1
1
1
1
1
%
44.8
13.8
3.4
3.4
3.4
3.4
3.4
3.4
3.4
1
3.4
Second Treatment Option
Table 38 Treatment options for cervical spondylosis
First Treatment Option
NSAIDs
Physiotherapy
Workplace assessment
Rest
NSAIDs, avoid precipitating agent
Load reduction
Rest, NSAIDs, job rotation
Exercise
NSAIDs, physiotherapy and work
adjustment
Analgesia
Medication
Employment limitations, rest
Ergonomic assessment, advice
Work adjustment, physiotherapy
Analgesia, maintain mobility
Conservative, pain relief
Rest, NSAIDs
Manual Therapy
N
6
4
2
2
1
1
1
1
1
%
20.7
13.8
6.9
6.9
3.4
3.4
3.4
3.4
3.4
1
1
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
99
Second Treatment Option
Physiotherapy
Referral
Exercise, education
Surgical fixation
Refer to Neurology
Ergonomic workplace assessment
Refer to GP
Analgesia
Physiotherapy, collar
NSAIDs
Table 39 Treatment options for impingement syndrome
First Treatment Option
Physiotherapy
NSAIDs
Rest
Steroid injection
Employment limitations, rest
NSAIDs, physiotherapy and work
adjustment
NSAIDs, avoid precipitating
factors
Load reduction
Rest, NSAIDs, job rotation
Work adjustment, physiotherapy
Exercise
Injection
NSAIDs, physiotherapy
Ergonomic assessment, advice
Referral
Temporary removal from work
Workplace assessment
Redeployment, duty modification
Pain relief, physiotherapy
Manual therapy
N
Physiotherapy
Steroid injection
Referral
Refer to Orthopaedics
NSAIDs, Physiotherapy
Subacromial injection
N
8
3
3
2
1
1
%
27.6
10.3
10.3
6.9
3.4
3.4
5
3
2
2
1
1
%
17.2
10.3
6.9
6.9
3.4
3.4
1
3.4
Steroid injection, ultrasound
1
3.4
1
1
1
1
1
1
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
3.4
Surgery
Medication
Ergonomic workplace assessment
Refer to GP
Liase with GP
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
Second Treatment Option
Physiotherapy
NSAIDs
Referral
Medication
Psychological assessment
Refer to G.P
N
9
2
2
1
1
1
%
31.0
6.9
6.9
3.4
3.4
3.4
Second Treatment Option
Table 40 Treatment options for tension neck
First Treatment Option
NSAIDs
Physiotherapy
Analgesia
Workplace assessment
Identify psychological issues
NSAIDs, relaxation exercise
programme
Ergonomic assessment, advice
Rest
Rest, NSAIDs, workplace
assessment
Employment limitations,
physiotherapy, rest
Exercise and advice
Antidepressants
NSAIDs, physiotherapy, workplace
adjustments
Rest, NSAIDs, job rotation
Exercise
Analgesia, advice
Load reduction
Temporary removal from work
Manual therapy
NSAIDs, avoid precipitating
factors
N
4
4
3
2
1
1
%
13.8
13.8
10.3
6.9
3.4
3.4
1
1
1
3.4
3.4
3.4
Physiotherapy, antidepressants
Refer to Rheumatology
Education
1
1
1
3.4
3.4
3.4
1
3.4
Analgesia
1
3.4
1
1
1
3.4
3.4
3.4
Manipulation
Work adjustment, physiotherapy
Ergonomic workplace assessment
1
1
1
3.4
3.4
3.4
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
Counselling
1
3.4
100
Table 41 Treatment options for diffuse non-specific upper limb disorders
First Treatment Option
Physiotherapy
Rest
NSAIDs
Analgesia
Psychological assessment
Explanation, reassurance
Rest, NSAIDs, job rotation
Employment limitations,
physiotherapy, rest
NSAIDs, avoid precipitating agent
Rest, NSAIDs
General assessment
Ergonomics
Ergonomic assessment and advice
Temporary removal from work
NSAIDs, workplace assessment
Work adjustment
Manual therapy
NSAIDs, physiotherapy, work
adjustment
Load reduction
N
5
3
2
2
2
1
1
1
%
17.2
10.3
6.9
6.9
6.9
3.4
3.4
3.4
1
1
1
3.4
3.4
3.4
1
1
1
1
1
1
1
3.4
3.4
3.4
3.4
3.4
3.4
3.4
1
3.4
Second Treatment Option
Physiotherapy
Referral
NSAIDs
Ergonomic workplace assessment
Refer to GP
Workplace assessment
Relaxation
Antidepressants
Refer to Rheumatology
Review
Ongoing multidisciplinary pain
clinic
Refer to Neurology
Job modification
Counselling
N
8
3
1
1
1
1
1
1
%
27.6
10.3
3.4
3.4
3.4
3.4
3.4
3.4
1
1
1
3.4
3.4
3.4
1
1
1
3.4
3.4
3.4
TOPs were then asked if they initiate contact with their patient’s GPs. The responses are shown
in Table 42. The majority of respondents will contact the GP involved sometimes or always.
Table 42 Do you initiate contact with patient’s GP
Contact with GP
Yes sometimes
Yes always
Not applicable
Yes rarely
No
N
17
7
2
1
1
%
58.6
24.1
6.9
3.4
3.4
Question 10. of the questionnaire asked respondents to identify which specialists they would
refer patients to. Table 43 highlights the specialists as General Practice, Orthopaedics,
Physiotherapy, Rheumatology, Counselling and Cognitive Behaviour Therapy.
101 Table 43 Referrals for musculoskeletal problems
Referral to
General Practice
Orthopaedics
Rheumatology
Physiotherapy
Occupational Therapy
Counselling
Rehabilitation
Cognitive Behavioural Therapy
Employment Service
None/not applicable
N
11
14
10
23
4
10
5
12
6
2
%
37.9
48.3
34.5
79.3
13.8
34.5
17.2
41.4
20.7
6.9
Other comments to this question are cited below
Can only refer to physiotherapy
Refer to a chiropractor
Refer to an orthopaedic physician
Refer to a pain clinic
Might ask patient to discuss something more with their GPs
Respondents were asked to rate their level of confidence with nine different aspects of upper
limb management. Figure 11 presents the mean data obtained with one representing not at all
confident and seven representing extreme confidence. These data indicate that most confidence
is reported in taking the patient’s history, using NSAIDs, referring patients, establishing work
relatedness and making recommendations to employers.
102 7
Mean
5
3
Ph
ys
ic
al
ex
am
in
at
D ion
i
Jo agn
os
in
ti
nj is
U
e
s
U
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1
Figure 11. Level of Confidence with Different Aspects of Upper Limb Management
Respondents were also asked for any further comments with regard to their management of
ULDs. The responses were:
I have good facilities. If I did not I would refer/ contact GP more
Picture may not be clear from first appointment with patient, Phased RTW essential
Very variable. No single approach. Depends on likely cause and ability of patient to avoid/
reduce the precipitant agent. The advice provided has to be tailored to the individual worker.
There is no 'one size fits all'. Medical Rx is not the whole story. NSAIDs, steroids, physio etc
are part of the rehab package, not all of it
There are no real experts in managing these conditions. It is difficult to find specialist physio +
Rheumatologists
Confidence relating to evidence…. Evidence base approaches would help….Use of non
evidence based therapies due to lack of solid evidence
I do not treat people. I provide OH advice
Basic treatment system is to give temporary reduction in activity, then match workload to
symptom level
My role is providing advice to employer
Easy access to physio and rehab facilities bias my treatment approaches
Experience is small and variable in work related ULD
Management will usually vary with severity, opportunities to alter working conditions. In many
cases, the worker has consulted their GP before seeing me
103 Evidence Base
The questionnaire aimed to identify the evidence base used by respondents to aid their
management of ULDs. The responses were again based on a seven-point scale and are
presented in Figure 12. The most commonly reported evidence used is previous clinical
experience and previous training.
7
Mean
5
3
Co
Co
Pr
ev
io
us
cl
in
ic
ns ns
al
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ta
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ie
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cc l e lis
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eg
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.g
., boo
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M s
,..
Cl
.
in
ic
al
ev
id
en
ce
1
Figure 12. Evidence Base in the Choice of Treatment of Upper Limb Disorders
Question 14., asked respondents for any additional comments about the evidence base they use
in their management of ULDs. The comments are listed below:Badly designed
It seems much better for lower back pain than upper limbs
Changing face of ULDs and not effective treatment
CME for Disability Analysts provided by my company
Due to variability in presentations patient feedback is v. important.
Feel reasonably confident with recent AFOM training
Information tends to be scattered and difficult to find
More evidence would be helpful
No
Not all in one place
Use of Internet is essential in my practice as I work in an academically isolated location
104 Perceived Difficulties
Respondents were then asked about difficulties in managing upper limb musculoskeletal
disorders. Each participant was firstly asked to rate on a seven-point scale perceived difficulties
in managing specific disorders. The results are presented in Figure 13. The data identifies that
Diffuse Non-specific Upper Limb Disorders appears to have the most difficulty associated with
diagnosis.
7
Mean
5
3
H
H
an
d/
fo
re
a
an rm t
d
e
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yn i s
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up Ten dro
m
pe
s
r l ion e
im
N
e
b
di ck
so
rd
er
s
1
Figure 13. Perceived Difficulties in Establishing a Diagnosis
The question on difficulty of diagnosis was followed by a question that asked participants to
rate how difficult certain aspects of managing ULDs are. The questions were rated on a one to
seven scale with one being never or not applicable and seven denoting always. The most
common difficulty identified was psychosocial factors, however other areas were also
highlighted including recurrent symptoms, chronicity and patients high expectations.
105 106
1
3
5
7
Figure 14. Difficulties in Managing Upper Limb Disorders
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Mean
Participants were asked to identify any barriers when obtaining referrals for patients. The data
are presented in Table 44. These data indicate that there are few barriers to physiotherapy,
employment services, rheumatology, rehabilitation, occupational therapy and cognitive
behavioural therapy. However, there do appear to be long waiting times for some of these
specialists. A pertinent point would be that unless occupational physicians have direct access to
physiotherapy, referrals will be through the individual’s general practitioner. Other comments
with regard to referring patients included a comment about referring directly to the GP, a
comment about there being no barrier and a comment about referring to pain clinics.
Table 44. Barriers when referring patients
No
barrier
Rheumatology
Orthopaedics
Physiotherapy
Rehabilitation
Occupational Therapy
Employment Service
Cognitive Behavioural
Therapy
N
10
8
17
9
9
14
11
%
34.5
27.6
58.6
31.0
31.0
48.3
37.9
Waiting time
unacceptably
long
N
%
9
31.0
13
44.8
6
20.7
7
24.1
2
6.9
1
3.4
8
27.6
Travel
distance
too far
N
%
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Not
available
N
4
2
1
5
8
4
4
%
13.8
6.9
3.4
17.2
27.6
13.8
13.8
Not sure
if
available
N
%
*
*
*
*
*
*
3 10.3
3 10.3
1
3.4
1
3.4
Not
applicable
N
1
1
*
*
*
1
*
%
3.4
3.4
*
*
*
3.4
*
Respondents were invited to offer additional comments with regard to the difficulties they come
across in managing ULDs. This obtained the following comments.
Deciding where my role ends and GP role begins and vice versa. So far no complaints on what
I do
Often clinical findings are limited and I have to rely on what patient describes for me
We have no right of NHS referral. All Rx/Ix has to be negotiated via the GP. No budget for
private referral
It seems very difficult to get a clear management plan from Rheumatologists and Orthopaedic
specialists
Waiting time for referrals is unacceptably long unless private schemes are involved
Time consuming/ No satisfactory outcome
Main problems I face are: 1. Apparent comorbidity e.g. Impingement Syndrome but also
symptoms suggestive of cervical radiculopathy or tennis elbow with cervical radiculopathy. 2.
Difficulty giving a precise diagnosis of shoulder conditions. Access to MRI which I have helps
a great deal
As GP - no problem. As OP - not much experience, so unable to comment.
Referrals depend on the employer. -Will they fund? (I work in private industry)
Claims, inappropriate health beliefs by patient and healthcare professionals
All that can truly be said is:
There is a lack of quality research – Fact. There are diagnostic difficulties – Fact. Vague non
specific Sx. Non specific physical signs. Lack of diagnostic test. There is no current universal
'truth'. Practice will vary and will be patient centred NOT gudeline/Ix/Rx centred
107 Training Needs
Respondents to the questionnaire were asked to rate their level of interest in CME in particular
topics. The response was rated on a scale of one to seven with one denoting no interest and
seven representing extreme interest. The results are presented in Figure 15.
108 7
Mean
5
3
M
an
ag
in
Co
m
pr
e
he
ns
iv
e
m
us
cu
lo
sk
el
D eta
iff l e
er xa
en m
g
tia in
co
l d ati
m
J
m
o i iag o n
on U U nt no
m s s in s
Ps us e o e o jec is
yc cu f c f N tio
M hos losk orti SA n
A
ed oc el co ID
dv
ic ia eta ste s
ic
e o W o le l as l co roi
g pe n d
n
ac ork al a cts dit s
Co
tiv re sp of ...
m
ity la ect U
m
un
l e t ed s o L D
ve ne f U s
ic
l d ss L
at
i
ur of Ds
So o n
in U
lid sk
g L
i
re D
ev lls
id w Er cov s
en i t h g o er
Co ce m n y
m -ba an om
pl se ag ic
em d e s
en gu me
ta ide nt
ry li
m ne
ed s
ic
in
e
1
Figure 15. Level of Interest in Continuing Medical Education Topics
Participants were asked to identify any barriers to training and the responses below were
obtained.
Evidence is not solid -guidelines would be great -including evidence+ placebo+ for
complementary therapies
Lack of knowledge of available courses
Lack of time to go on courses
None
None except time management
Remoteness
As already identified, there is a scarcity of clear information. Any new source of information
will be looked at, weighed and accepted/rejected as appropriate
There have been no barriers. Courses are available and literature
Time
Training which can combine both clinical viewpoint of treating physician and work-related
factors is rare
Where and how to further training
Time. Facility
Time Constraints. Financing of courses
Time! Priorities!
Time. Suitable venue to get to
Time to attend courses. Funding of courses.
Knowledge of where and how to further my training
109 There don't seem to be any experts to go to who have lots of experience in work related upper
limb problems.
Respondents were invited to make any further comments with regard to their training needs; the
comments obtained are presented below:Easily available, affordable
FOM publications would be well respected and used e.g. like those used for back and HAVS.
Advise on how to consolidate ULD training for AFOM exam
Interest in CME varies with perceived level of confidence and exposure
Need to find appropriate courses
Require training in making specific diagnosis and specific management requirements of each
condition
No
Physios seem to have more in depth training in examining the body and making diagnoses. Most
Drs probably need an update on these because we may not see that many upper limb problems
in a month. Most of my work is mental health with occasional upper limb problems
5.3.3 Comparative statistics between GPs and TOPs
Although sample sizes were small and there were differences in specific questions on each
questionnaire, some comparative analysis between the groups was carried out. The data were
analysed using Chi-Square on the Statistical Package for the Social Sciences software, version
12.
With regard to upper limb training and education, no significant differences were found between
GPs and TOPs when asked about training in musculoskeletal disorders during medical school,
house officer years, registrar years or through CME. The same result was found for sources of
vocational training.
When managing upper limb musculoskeletal problems a comparison was made between
confidence levels in specific aspects of medical management. The Chi-square analysis
identified that GPs reported more confidence in join injections than TOPs χ2=14.16, p≤0.05.
No significant differences were found in any reported difficulties in diagnosis.
A further analysis of training needs identified that GPs had more of an interest in joint injections
χ2=13.01, p≤0.05. TOPs reported more of an interest in Psychosocial Factors (χ2=12.84,
p≤0.05), Medico-legal issues (χ2=25.82, p≤0.001) and Work relatedness (χ2=20.86, p≤0.001)
5.4 DISCUSSION
5.4.1 Samples
The GP sample was a random sample from across the UK. The TOP sample, was all current
Specialist Registrars in Occupational Medicine and those registered on training courses for the
AFOM or Diploma in Occupational Medicine. The TOP sample when examined more closely
identified that the majority had been GPs before training in Occupational Medicine. Therefore
lack of significant differences in training is not surprising, as the majority have gone through the
same training route before training in Occupational Medicine.
110 5.4.2 Response Rates
One of the major drawbacks with questionnaire survey work can be the poor response rate. A
response rate of 10% from the GP sample and 9% from the TOP sample leads to problems with
regard to the validity of the responses obtained. Follow-up and further surveys were carried out
but this did not increase the response rate. This is a major issue when carrying out research with
physicians in that obtaining their time to respond to research is becoming more difficult. One
option – suggested by a non-respondent – was to pay the participants in the study. However,
paying participants may make obtaining ethical clearance more difficult. A descriptive analysis
has been carried out on the responses to give a picture of the results obtained.
5.4.3 Training and training sources in musculoskeletal disorders
For both groups, the majority of training in musculoskeletal disorders and work related
musculoskeletal disorders was during registrar years and through CME. However, the data
obtained from UK universities did identify that all respondents taught about back pain but only
73% taught about work related musculoskeletal disorders. However, more recent curricula
changes have been identified at some universities where there is more emphasis on
occupationally related musculoskeletal disorders. Basu et al, identified that undergraduates in
one medical school had an adequate knowledge base, although this had not been tested
clinically (10). The TOPs did identify more training in musculoskeletal disorders during their
occupational health trainee years than previously.
For vocational training, both groups identified orthopaedics and rheumatology as their main
source of information. The TOPs also identified occupational health training as a major source
of vocational training. Access routes for information for both groups include Sports Medicine,
Joint Injection Courses, and sessions with rheumatology Specialists. Further sources of training
for TOPs include General Practice, SOM Meetings, HAVS training, Disability Assessment
Medicine, Association of NHS Occupational Physicians (ANHOPs) Seminars and the AFOM
courses. None of the GPs involved in the study mentioned any specific routes of contact.
While the authors are aware of the role of GPs with a special interest this was not highlighted by
this sample.
These data indicate that there are more training opportunities within Occupational Health with
regard to ULDs. This may however, relate more to the types of disorders that Occupational
Physicians are required to assess and treat compared to those in general practice.
The sources identified as being important for professional development included medical
journals, text books, contact with other GPs/TOPs, contact with other medical specialists and
conferences and seminars. The TOPs also highlighted the importance of professional groups
such as ANHOPs in professional development. The sources least used by both groups include
CD-ROMs and videos. This may reflect a lack of resources in this area. However, comments
obtained during the focus group suggested that “hands-on” training might be a better route in
the field of ULDs.
The GP respondents also made a number of comments including the issue that there is very little
training available in this field and it has to be self-motivated. The TOPs reiterated this, where
comments included that training was sparse until they started in occupational health and more is
needed.
111 5.4.4 Management of upper limb musculoskeletal disorders
Management of specific disorders
With regard to managing specific disorders, there was some level of consistency in the
treatment options suggested by both groups of participants. This is again not surprising due to
the similar training routes that both groups have gone through for general practice training. The
majority of the conservative treatments suggested include rest, NSAIDs and referral to
physiotherapy. The GPs suggested the use of steroid injections as a second treatment option in
several of the disorders listed including carpal tunnel syndrome, de Quervain’s disease,
epicondylitis, shoulder tendonitis and shoulder capsulitis. This may however relate to their
higher confidence levels in steroid injections compared to TOPs.
Management against best practice
One of the objectives of the study was to examine how physicians manage ULDs against best
practice. This can only be done where good treatment practice has been identified. Within the
literature review, evidence for treatment options was found for carpal tunnel syndrome,
epicondylitis, shoulder capsulitis, impingement syndrome and tension neck.
For carpal tunnel syndrome the review found that there was evidence that oral steroids and
steroid injections reduced symptoms in the short term. However, there is currently no evidence
that NSAIDs are more effective than steroids in the treatment of carpal tunnel syndrome. The
initial treatment options are for the use of rest, NSAIDs and splinting by both groups of
physicians. Two of the GP participants did suggest the use of steroid injections as a first
treatment option. There is currently no evidence to support or refute the use of rest or splints as
a treatment option but the use of NSAIDs may be questionable.
The evidence base for management of epicondylitis suggests that in the short term steroid
injection is better than NSAIDs or a placebo in the treatment of this disorder. However, longterm research found that physiotherapy followed by a wait-and-see policy was more effective.
The respondents to the questionnaire in both groups suggested the use of NSAIDs and rest as a
first treatment option with a second treatment option of steroid injection or physiotherapy.
Again the use of NSAIDs in the treatment of epicondylitis may be open to discussion as
currently there is only limited evidence to support the use of topical NSAIDs in the short-term
relief of lateral elbow pain and insufficient evidence to support or refute the use of oral
NSAIDs.
The treatment of rotator cuff syndrome and bicipital tendonitis has been the subject of a
Cochrane Review that found that using NSAIDs and subacromial injection may improve the
range of motion of patients. The treatment options suggested by participants include
physiotherapy, rest and NSAIDs in the first instance and steroid injection and physiotherapy as
a second treatment option. Therefore it can be seen that participants are applying best practice
in the use of NSAIDs and steroid injection but there is currently no evidence to support or refute
the use of physiotherapy in the treatment of shoulder tendonitis.
From the review, research has indicated that there is some evidence to support the use of
therapeutic exercise and manual therapy in the treatment of impingement syndrome.
Participants in the questionnaire indicated that physiotherapy and NSAIDs are the preferred first
and second treatment options. Again participants are using current evidence in their treatment
of this disorder but there is no evidence to support or refute the use of NSAIDs in the treatment
of impingement syndrome at this time.
112 Although there is currently no evidence to support specific treatment of tension neck by
physicians, one study examined a workplace intervention to reduce discomfort. From the
questionnaire suggestions to treat tension neck include NSAIDs, physiotherapy, analgesia and
antidepressants. There is currently no evidence to support or refute any treatment for this
disorder.
The questionnaire results do highlight the usage of NSAIDs as a treatment option when there
may not be current evidence to support this. However, more importantly, the literature review
does highlight the lack of good research on which to create an evidence base for the treatment of
upper limb disorders. It is clear more high quality research is needed in the conservative
treatment of ULDs to ensure best practice can be achieved.
GPs and TOPs were asked if they made contact with each other when managing patients. Most
of the GPs surveyed reported that they contacted the occupational physician sometimes or
always. TOPs reported that they sometimes or rarely contacted the GP. There is some contact
between the two groups when managing patients. However, it should be noted that if an
Occupational Physician wishes to refer to another medical specialist, the referral would go
through the GP in the first instance.
The majority of referrals made by TOPs are to general practice, orthopaedics, rheumatology and
physiotherapy. This is consistent with the results from the GPs surveyed. Some comments
obtained from the TOPS in this section were that they could only refer to physiotherapy and one
who might ask the patient to discuss issues with their GP.
Respondents were asked to rate their level of confidence with nine aspects of upper limb
management. The analysis of results indicates that GPs are confident in most aspects of upper
limb management and TOPS are more confident in taking the patient’s history, using NSAIDs,
patient referral, establishing work relatedness and making recommendations to employers. The
Chi-square analysis of this data found that GPs were more confident in joint injections than
TOPs. The results are not surprising based on the training that both groups have received. With
TOPs, aspects vital to their role are the patient history and examining the work relatedness of
health. In general, GPs also have more access to training for areas such as joint injection.
5.4.5 The evidence-base used in management of upper limb musculoskeletal
disorders
Sources used in the participant’s evidence base include previous clinical experience, previous
training, continuing medical education, textbooks and the patient’s positive feedback. The
results were analysed using Chi-square but no significant differences were found between the
two groups. The comments made by the participants also emphasise the lack of an evidence
base for the management of such disorders and participants would like more information.
5.4.6 Perceived difficulties in managing upper limb musculoskeletal disorders
The respondents were asked to identify any difficulties in the diagnosis of the listed ULDs.
Although there were difficulties suggested in the diagnosis of diffuse non-specific ULDs, there
were no significant differences between the two groups. This was highlighted with least
difficulty found in the diagnosis of epicondylitis and carpal tunnel syndrome and possibly
reflects the ULDs about which most is known.
Difficulties identified in managing ULDs included psychosocial factors, recurrent symptoms,
chronicity and the patients’ high expectations as more problematic than other issues. That
psychosocial factors are an area of little research at the moment indicates where more research
is needed to help in the management of such disorders.
113 Respondents were asked to comment on any barriers when referring patients. Both groups
highlighted that there were no barriers to rheumatology, orthopaedics or physiotherapy but the
waiting times were unacceptably long. This implicates issues beyond the remit of this project
but can highlight the issues when patients are referred.
5.4.7 Training needs
The main topics of interest in further training for respondents were identified in the study. In
analysing differences between the two groups, it was found that GPs were significantly more
interested in joint injections whereas TOPs reported more of an interest in psychosocial factors,
medico-legal issues and work relatedness. This perhaps relates to the field of expertise for the
respondents. Where GPs are not able to access the workplace, they may feel that their role is in
treating the symptoms; whereas the TOPs have access to the workplace and may be more likely
to be involved in medico-legal issues and how to assess work relatedness. It perhaps raises a
number of issues about the role of the two groups in the treatment of ULDs. It is unlikely GPs
will be able to make time for workplace visits but perhaps better linkage been GPs and
Occupational Physicians will create a better understanding and management of ULDs.
However, where there is no occupational health service for the patient to attend, the GP still
needs to be aware of possible work relatedness and may be required to enter discussions with
employers.
A number of barriers to training were also identified by respondents. Possibly the main issues
were lack of time and finance to enable attendance at courses. A further issue included it being
difficult to identify appropriate courses. This emphasises the difficulty faced by those wanting
further knowledge of ULDs. The courses identified earlier in the research are longer-term
courses rather than short courses that may be easier for physicians to attend.
6. RECOMMENDATIONS
The following recommendations are made from the data obtained during the study. While it is
appreciated that the small numbers involved in the study may affect validity, the
recommendations are based on the data obtained during the literature review, the data collection
from universities and postgraduate deaneries, the focus groups and the questionnaire survey.
6.1 TRAINING
The research has highlighted a lack of training in ULDs at undergraduate level. One
recommendation would be to review this within medicine as to the importance of this topic in
the curriculum. The authors do appreciate that there are a large number of topics to cover in
undergraduate medicine however; this should be reviewed in terms of the high level of
musculoskeletal disorders within the population that future physicians will be treating. This
would be a natural process in all universities when curriculum review takes place.
Variability in exposure to ULDs during VTS training was highlighted within the postgraduate
deaneries survey and was presented by focus groups as a potential cause of gaps in physicians’
ULDs knowledge. Given that postgraduate deaneries respondents stated that ULDs in most
instances were a topic addressed only if raised as a learner-centred need, it may be advisable
that trainees are made aware by their trainers of the potential need of this topic.
Meeting with other professionals was highlighted within the focus groups and the survey as an
important route for information. These occur regularly within occupational health with
114 ANHOPs meetings and meetings of the Society of Occupational Medicine. More opportunities
could be made available for GPs to access these or similar groups.
6.2 CLINICAL MANAGEMENT
Currently, there is a lack of an evidence base for the clinical management of some ULDs. This
indicates the need for more research and the fact that the research needs to be high quality to
ensure that evidence based medicine can be practiced.
It would also be recommended that guidelines be produced similar to those for the treatment of
backpain (105) and HAVS (106). These could then be widely distributed among those involved in
the treatment of ULDs.
6.3 PERCEIVED DIFFICULTIES IN MANAGING UPPER LIMB DISORDERS
The difficulties perceived by respondents to the survey included issues of high patient
expectations and chronicity of symptoms. This is possibly due to the impact of other treatments
which may be much more short-term; whereas an ULD may take longer to treat, manage and
identify the causal factors. Perhaps a need arises to ensure the patient is as informed as possible
about the potential duration of particular disorders.
With regard to psychosocial issues, it has only been in recent studies that this has been accepted
as a factor in the aetiology of ULDs. Future research needs to identify which particular
psychosocial issues are implicated in the aetiology of such disorders to enable better
management in the future. However, given the lengthier time frame of occupational physicianpatient consultations, occupational physicians may be a group presented with better
opportunities to assess psychosocial issues compared to GPs. Therefore, they may constitute a
suitable candidate when seeking for a physician group to approach medically these issues.
The main barrier to referring patients to other medical specialists was an unacceptably long
waiting time. As stated previously, this issue is outside the remit of the current study; however,
the longer the wait the longer the treatment period for ULDs.
6.4 TRAINING NEEDS
With regard to training needs, the respondents identified the need for accessible hands-on small
group courses. It may be relevant for those involved in education of physicians to consider the
effectiveness of short courses for GPs and Occupational Physicians simultaneously. This would
result in a greater understanding of their respective roles in the management of patients with
ULDs.
As mentioned, different topics may be more relevant to either of the groups surveyed.
Identification of relevant courses was also mentioned as a problem. It would be recommended
that those involved in giving Continuous Professional Development accreditation review future
courses for their relevance to the management of ULDs, relating new skills and knowledge to
the learners’ day-to-day work.
The training and continuing education of GPs is on an individual need basis. It may be more
appropriate for them to find other routes to information. Although CD-ROMs and videos are
not used by either of the groups surveyed, this may be an area that should be further researched
to identify if this is because this media is not available or is it because it is difficult to educate
about upper ULDs through this route. If information can be developed through this type of
technology, it may relieve some of time constraints currently felt by physicians.
115 Furthermore, given the time, cost and access limitations to training mentioned consistently by
questionnaire respondents, along with the need to support individual learning plans arising form
the focus groups, the use of Internet may present another appropriate and flexible route to
knowledge. Well-accredited websites could provide physicians with specialised evidence-based
musculoskeletal modules, available clinical guidelines, databases, scientific papers and review
articles, including interactive features and alerts on updated ULD knowledge. They could also
provide physicians with a point of contact for different specialties and disciplines dealing with
ULDs. This might advance multidisciplinary communication with regard to ULDs and lead to a
better understanding of what each specialty has to offer.
116 APPENDIX 1 FOCUS GROUP CONTENT ANALYSIS
117 Table A1.1 Content analysis of the ‘ULD management’ dimension based on the Occupational
Physicians’ quotes.
DIMENSION
Higher order themes
Lower order themes
ULD MANAGEMENT*
a) Patient’s history
Use history
Ask about/understand the job they are doing
Ask whether the job caused the problem
Ask about factors outside work.
Ask whether the problem improves away from work
b) Examination
Perform physical examination
c) Investigation
Visit the workplace
Use specific questionnaires to pick up work-relatedness
See more people from the same workplace to pick up work-relatedness
Assess presenting complaints
Do psychiatric assessment
Assess their job
Access any available risk assessments and ergonomic assessments
d) Diagnosis
Identify the cause
Identify detrimental work activities by seeing not only a single person but a group of people from the
same workplace
The more specific the diagnosis, the easier to deal with the problem
Diagnoses based on nerve conduction studies
e) Interventions
Remove/ modify the identified cause
Eliminate or reduce aggravating factors
Make recommendations to the employer
to modify the job or
to change the job or
to move the person to another job
Collaborate with the patient to change his working technique
Treat the psychosocial side of the problem
By showing people that with changes in the work environment they can go back to work
By promoting changes in the work environment so that people can go back to work
Use rehabilitation
Use gradual return to work
Address the ergonomics of the problem
Give out related leaflets and websites
f) Treatment
According to undergraduate and postgraduate training
According to the physician’s experience
Depends on the diagnosis
Clinical management also done by the physiotherapists
Avoid invasive treatments
Try a variety of conventional and less conventional treatments before surgery
Avoid costly treatments
Recommend conservative treatments
Encourage activity
Use employers’ input to monitor the progress of the treatment
118 Use standardised approaches
g) Referral
Refer according to experience
Specialist referral available sometimes
There are standard referrals
h) Time spent with the patient
Spend at least 30 minutes with each patient
Difficult to assess the patient in much less than 40 minutes
*N=9
Table A1.2. Content analysis of the ‘ULD management’ dimension based on the
TOPs’ quotes.
DIMENSION
Higher order themes
Lower order themes
ULD MANAGEMENT*
a) Patient’s history
Get a detailed history first of all
Medical history
Where the pain is
What makes the pain better
What makes the pain worse
When the pain starts
Precipitating factors
Occupational history
Ergonomic assessments
Recent changes in their work
Colleagues going off work
Precipitating factors
Current post
Previous posts
b) Examination
Perform physical examination
Perform physical tests
Assess patients
c) Investigation
Visit the workplace
Watch the patients working
Accept information offered by the health and safety officer
Find the part preventing the patient from going back to work
Physical side
Psychosocial side
d) Diagnosis
Diagnosis based on full medical history Diagnosis already established prior to visiting the O.P. Diagnosis primarily established by the O.P.
e) Interventions
Modify the patients’ behaviour
Modify the patients’ working hours
Provide reassurance
Get involved when
The problem has a direct effect on work
Work is causing the problem
119 An occupational factor aggravates the condition
Contact the GP with the patient’s permission if deemed needed
Make ergonomic assessments
That their work station is correct
That they are following their break every hour
Make recommendations to the employer
To adjust their hours
To make ergonomic adjustments
To rotate individuals
To change the job
To change the shifts
Advise the employer on psychosocial/managerial issues
Many patients will get better without any intervention
Try interventions based on the balance of probability
Speak to the patients
Ask their fears
Explain the facts
Draw diagrams
Educate the patient
Depends on the physician
Physician’s confidence
Physician’s training
f) Treatment
Basic conservative treatment is preferred
Splints
Ultrasound
Some people give injections
Depends on the doctor
The doctor’s confidence
The doctor’s training
Surgical treatment is the last resort
O.P.s usually do not engage in active treatment e.g. injections
Primary/clinical management is considered as the GPs job
Treatment dictated by a district order
Patients wishes can influence non-conservative treatment
g) Referral
Some physicians may refer to specialists
Refer to physiotherapy
Refer chronic patients to Cognitive Behavioural Therapy
Alternative therapies are usually a patients’ self referral
h) Time spent with the patient
Spend 45 minutes to half an hour
*N=4
120
Table A1.3 Content analysis of the ‘ULD management’ dimension based on the GPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
ULD MANAGEMENT*
a) Patient’s history
History is a key aspect for diagnosis and management
The management depends on the history
Ask how long the problem has been there
Take into context work, other activities and previous self-treatment
b) Examination
Physical examination is a key aspect for diagnosis
c) Diagnosis
Diagnosis is the first goal of ULD management
Use history and physical examination to diagnose
No specific diagnostic tool used for ULDs
d) Review
If unsure ask the patient to come back to allow time to review
e) Interventions
Change whatever activities precipitate the problem
Contact with the workplace
Indirectly through the patient
No direct contact with the workplace unless ‘sickness absence’ is involved
f) Treatment
Depends on the doctor
Recommend conservative treatments
Start with the easiest and simplest treatments
Offer management options to the patient
Based on the evidence
Based on the proportion of treatment options
Depends on the physician’s exposure to the patient
Use standardized approaches
According to the physician’s experience
According to the patient’s input
By consulting a colleague or a specialist in the case of recurrent symptoms
Corticosteroid injections used by some GPs when symptoms persist
g) Referral
Referral to orthopaedics if acute
Specialist referral
Refer according to experience
Referrals done by the GP rather than the Occupational physician
h) Time spent with the patient
Spend 10 minutes with each patient
Spend 20 minutes with the patient when the visit involves corticosteroid injection
See the patient again and again
*N=4
121
Table A1.4 Content analysis of the ‘best practice’ dimension based on the
Occupational Physicians’ quotes.
DIMENSION
Higher order themes
Lower order themes
BEST PRACTICE*
a) Keep the persons at work
Keep the persons in their job and
address the ergonomics of the problem
change their approach to the job
make changes in the job
Move the persons to another job
b) Provide evidence-based management
Best practice is evidence based
Best practice relies on the evidence available for each diagnosis
Best practice lies in the interpretation of the available evidence
c) Have the patients’ ability to function retained
Encourage the persons to maintain activity
Encourage the persons to return back to work as soon as possible
d) Avoid iatrogenic disease
Not undertaking treatments if not sure of the pathology
Not undertaking interventions that may have an adverse effect
e) Seek input from the employer
Input regarding the employees’ health history and sickness absence
Use employer’s input to monitor treatment
f) Seek multidisciplinary communication and collaboration
Best practice is multidisciplinary
Working with other specialists
Communication between the Occupational physicians and the GPs
Involve the GP in the management of the ULD
g) Encourage the employer to be proactive
Encourage the employer to aim to keep the persons well in their work
h) Have easy access to treatments
Having easy access to physiotherapy
i) Avoid ‘labels’ regarding conditions
Not giving generic labels e.g. ‘for life’
*N=9
122
Table A1.5 Content analysis of the ‘best practice’ dimension based on the TOPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
BEST PRACTICE*
a) Keep the persons at work
There should be no restrictions in work activities
Make reasonable work adjustments if necessary
Impose some restrictions in the case of severe symptoms
b) Follow guidelines
Follow Faculty guidelines
Follow NICE guidelines
c) Avoid iatrogenic disease
Do no harm
By intervening
By not intervening
d) Visit the workplace
Go and see the workplace
Go and see what the patients do
e) Conservative management
Workplace adjustments
Rest, ice, compression, elevation
Splints
Anti-inflammatories
Physiotherapy
Cognitive behavioural therapy
f) Have access to ergonomic advice
Having access to the services of an ergonomist
*N=4
Table A1. 6. Content analysis of the ‘best practice’ dimension based on the GPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
BEST PRACTICE* a) Aim for the easiest and simplest options
Start with the easiest and simplest treatment
Change the activities that precipitate the disorder
Use conservative treatments first
b) Provide patient-centred management for the ULD
Best practice is patient-centred
The physician makes sure that the patient is satisfied
Combine the patient’s wishes with the physician’s experience, the evidence and the available resources
c) Avoid iatrogenic disease
Avoid doing damage/harm to the patient
Avoid abuse of corticoseroid injections
d) Provide evidence-based management
Refer to related literature
e) Consult with a specialist
Request guidance from a specialist
*N=4
123
Table A1.7. Content analysis of the ‘training’ dimension based on the Occupational
Physicians’ quotes.
DIMENSION
Higher order themes
Lower order themes
TRAINING*
a) Undergraduate training
From dissection
From other doctors rather than from books
Realistic and relevant teaching if attending in a rehabilitation centre
From picking up ‘fashionable’ courses
b) Postgraduate training
Variable
It’s all very individual
From other doctors rather than from books
While preparing for the AFOM
From attending a relevant course
From doing a distance learning course
From doing a related MSc
When going back to education voluntarily
During relevant house office jobs
During relevant registrar jobs
Under the influence of senior doctors
Very important in terms of the development of junior staff
Most of the time good
*N=9
124
Table A1.8 Content analysis of the ‘training’ dimension based on the TOPs’ quotes.
DIMENSION
Higher order themes Lower order themes
TRAINING*
a) Undergraduate training
As an undergraduate
b) Postgraduate training
Very variable
As part of the general orthopaedic training
In isolation from the workplace
Physical examination
Diagnosis
During house office jobs
Surgery
Orthopaedics
During general practice
During teaching in hospitals
Very little emphasis on the occupational causes of ULDs
Depends on the physician’s medical background
A surgical background can provide wide exposure to ULDs
A GP background provides limited exposure to ULDs
Under the influence of a senior doctor
Training with a GP who has a special interest in ULDs
From attending a relevant course
From attending orthopaedic lectures
Depends on individual interest
While preparing for the AFOM
Working in the NHS plus scheme
Specialist Registrars’ attendance to orthopaedic clinics is limited
By reading relevant HSE publications
*N=4
125
Table A1.9 Content analysis of the ‘training’ dimension based on the GPs’ quotes.
DIMENSION
Higher order themes Lower order themes
TRAINING*
a) Undergraduate training
A few things in medical school
b) Postgraduate training
Variable
It’s chance
As much as one seeks
Opportunistic
If receiving orthopaedic surgery guidance
During relevant house office jobs
During relevant registrar jobs
Not much training on ULDs during orthopaedics training
From attending a relevant course
Under the influence of a senior doctor
A particular consultant guiding one’s education towards a particular way
But then one learns only that particular way
When going back to education voluntarily
Depends on whether the physician feels that he/she needs more training
Depends on the perceived areas of weakness
From other doctors rather than from books
Listening to speakers
*N=4
126
Table A1.10 Content analysis of the ‘informal learning’ dimension based on the
Occupational Physicians’ quotes.
DIMENSION
Higher order themes
Lower order themes
INFORMAL LEARNING*
a) Web based learning
Web based modules promoted by the automotive industry Web based learning from scientific websites Scientific websites providing a good retest of what one should learn
Scientific websites providing modules linked to evidence-based medicine and scoring of the evidence
b) Clinical experience
Most people learn from clinical experience/trial and error Pick up bits along the way
c) Reading publications
Publications from societies Publications which give useful tips Conditions and treatments published in journals Journals/what has been published are important
Text books
d) Using teaching materials
Videos on how to examine
e) Scientific meetings
Scientific meetings of medical societies
f) From other physicians
Witnessing other physicians’ slightly different approaches in examining
g) From other practitioners
Working with staff physiotherapists
Witnessing other practitioners’ slightly different approaches in examining
Complementary medicine is interesting
Watching practitioners who are perceived as effective in what they are doing/in doing something in a
particular way.
*N=9
Table A1.11 Content analysis of the ‘informal learning’ dimension based on the TOPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
INFORMAL LEARNING*
a) Reading publications
Text books
b) Clinical experience
Seeing the same kind of patients all the time
Reviewing incoming cases
c) From other physicians
Working with other physicians
Asking for opinions
*N=4
127
Table A1.12 Content analysis of the ‘informal learning’ dimension based on the GPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
INFORMAL LEARNING*
a) Reading publications
Journals
Text books
b) From other physicians
From working with other individuals
Self taught after advice from peers
Learning from others who are more experienced
Learning the practical bits from others
From talking to a friend
Asking a colleague
Covering various things, areas, journals during meetings as a practice
Consulting a specialist
c) Clinical experience
By doing the job
By starting practicing
d) GP Practice meetings
Attending practice based meetings
e) Using teaching materials
CD ROMs
f) Web based learning
Using e-learning
Scientific websites providing evidence-based medicine
Web based learning from scientific sites
*N=4
128
Table A1.13 Content analysis of the ‘evidence base’ dimension based on the
Occupational Physicians’ quotes.
DIMENSION
Higher order themes
Lower order themes
EVIDENCE BASE*
a) Previous clinical experience
Previous experience of what has or has not worked
b) Colleagues
Other people’s experiences of what has or has not worked in the past
Reliance on colleagues in the absence of randomised controlled studies
c) Journals
What has been published
Conditions and treatments published in journals
Randomised controlled trials
d) Web sites
Web sites featuring evidence-based medicine
Web sites providing modules linked to evidence-based medicine
Web sites providing scoring of the evidence presented
e) Text books
Evidence found in text books
Reliance on text books in the absence of randomised controlled studies
f) Available guidelines
Standardised approaches
*N=9
Table A1.14 Content analysis of the ‘evidence base’ dimension based on the TOPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
EVIDENCE BASE*
a) Previous clinical experience
Previous experience of what has or has not worked
b) Continuing medical education
Teaching by professional groups
Orthopaedicians’ lectures
c) Journals
Review articles on occupational health journals
Review articles on ergonomic journals
d) Clinical evidence
Pathology evidence
Histopathology studies
e) Available guidelines
Published guidelines
HSE guidelines
*N=4
129
Table A1.15. Content analysis of the ‘evidence base’ dimension based on the GPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
EVIDENCE BASE* a) Colleagues
Asking other doctors and talking in a group
Covering and discussing various areas during practice meetings
Talking to a friend
b) Journals
Journals covered individually
Journals covered during practice meetings
Research papers
c) Web sites
Web sites featuring evidence-based medicine
d) Guidelines
Available guidelines
e) Text books
Evidence found in orthopaedic, rheumatology, surgical or general practice text books
f) Patients’ input
Patients’ positive input regarding the effects of the treatment
g) Previous training
During medical school
CME courses
While preparing for the MRCP (UK) examination
*N=4
130
Table A1.16 Content analysis of the ‘perceived difficulties’ dimension based on the
Occupational Physicians’ quotes.
DIMENSION
Higher order themes
Lower order themes
PERCEIVED DIFFICULTIES*
a) Difficulties related to the disease
Elusive diagnosis
No response to treatments
Long time needed for the results of the intervention to be seen
Chronicity
b) Difficulties related to the patient
Difficulty in establishing the patient’s wants
The patient becoming disillusioned when results delay
The patient having been conditioned that he won’t get better
The patient perceiving that anything that causes pain is going to cause further injury
The patient -consciously or unconsciously- converting emotional complain to physical
Changing the patient’s job is not always applicable
c) Difficulties related to the employer
The employer pressuring the physician
Getting the employer to make workplace alterations
The employer asking for guarantees
The employer wanting to rid of the employee
The diagnosis of the problem lying in the work organization
d) Difficulties related to the resources available
Waiting time for specialist referral unacceptably long
Othopaedic services variable even within trusts
Waiting time for physiotherapy in the NHS unacceptably long
Small contracts have difficulty in accessing physiotherapy
Limited access to the Occupational Physician
Nerve conduction studies can give unreliable results
e) Adversarial effects of previous medical management
Previous over-pessimistic diagnoses can be damaging / very difficult to undo
The patient may have already been conditioned that he won’t get better
Once treatment has been fixed, it is difficult to undo
Some doctors come up with extraordinary diagnoses
Several different diagnoses may have been given leading to no specific diagnosis
f) Difficulties ensuing from the use of ‘labels’
The term ‘Upper limb disorder’ implies lack of function
Patients requiring that the doctor ‘labels’ their problem in order to trust him
g) Adversarial influence of other parties
The Unions can create obstacles in the way of managing the ULD
The family of the patient can oppose the management of the ULD
h) Difficulties ensuing from medico-legal factors
Difficulty in engaging people in active treatment when compensation claims are involved
Lawyers contradicting the physician’s recommendations
Patients abide by the lawyers’ instructions
Temporary injury allowance financial gain stimulating absence / delays and decreases in
rehabilitation
Some people never return to work due to medico-legal factors
Legislation building unrealistic expectations
*N=9
131
Table A1.17 Content analysis of the ‘perceived difficulties’ dimension based on the
TOPs’ quotes.
DIMENSION
Higher order themes
Lower order themes
PERCEIVED DIFFICULTIES*
a) Difficulties related to the disease
Difficulty in managing non specific pain
Difficulty in giving advice about RSI
Insufficient evidence available with regard to RSI
Understanding the nature of the impact of the patients’ occupation on their disease
Difficulty in establishing the amount of disability to be attributed to the occupation
Symptoms affected by psychosocial factors
b) Difficulties related to the patient
Convincing the patient that no activity restriction is required
Difficulty in making the patients understand that some symptoms are not going to harm them if they
carry on with their occupation
Changing the beliefs of the patient about their disease
Patients adopting an illness behaviour
Managing post operative patients when
Their operation has failed
They fear of failure of their operation
Convince the patient to resume activity
c) Difficulties related to the resources available
Some workplaces do not have the means to rotate patients around different jobs
Limited access of the physician to the workplace
Having to diagnose without prior investigation of the workplace
Physical tests may not be accurate
Nerve conduction studies sensitivity and specificity being questioned
Lack of access to objective diagnostic tests
d) Difficulties related to physician’s knowledge being limited
Limited knowledge of how to identify what is wrong in the workplace
Little experience of how the workplace should be
Variable training experiences depending on whether one is working in NHS or not
Training in occupational diagnosis limited to surgical house office posts
Lack of guidelines with regard to advising appropriate activity levels during recovery
Vagueness surrounding RSI guidelines
e) Difficulties ensuing from the use of ‘labels’
Controversy surrounding the diagnosis of RSI
Patients coming up to the physician with a preconceived self -diagnosis of RSI
*N=4
132
Table A1.18 Content analysis of the ‘perceived difficulties’ dimension based on the
GPs’ quotes.
DIMENSION
Higher order themes
Lower order themes
PERCEIVED DIFFICULTIES*
a) Difficulties related to the disease
Recurrent symptoms
Elusive diagnosis
Chronicity
No response to treatments
Long time needed for the results of the intervention to be seen
b) Difficulties related to the patient
If the patient is not satisfied with the management of the ULD
The patient has high expectations
c) Difficulties related to the resources available
Waiting time for physiotherapy can be unacceptably long
There may be no facilities available regarding physiotherapy
*N=4
Table A1.19 Content analysis of the ‘training needs’ dimension based on the
Occupational Physicians’ quotes.
DIMENSION
Higher order themes
Lower order themes
TRAINING NEEDS*
a) Communication skills
Learn to deal with/influence the management structure of the workplace
Communication/influencing skills to achieve modifications/changes to the workplace
Learn to use OP knowledge to bring about change in a worker
b) Managing the psychosocial aspect of ULDs
Not much evidence exists on the psychosocial bit of the management of ULDs
Gap in dealing with the psychosocial aspect of ULDs
c) Updates
Updates of skills
‘Brushing up’
Cover all areas of new knowledge
Keeping ahead of patients
d) Opportunities to learn from other physicians
Semi clinical audits/discussions about particular cases/what each does
Opportunities to learn from each other in the CPD arena
Need to discuss with other specialists
e) Access to knowledge
Occupational physicians need opportunities created to learn as they can be isolated
Different things come up in each practice from day to day which are not so clear
Access to knowledge is needed
f) Individual learning plans
Need to have a learning plan
Individual training programmes for physicians
Training for the different things coming up from day to day
g) General medicine experience
Gaining experience in general medicine before entering the occupational medicine sector
*N=9
133
Table A1.20 Content analysis of the ‘training needs’ dimension based on the TOPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
TRAINING NEEDS*
a) Specific ULD training
A separate part of training to deal with ULDs
Learn about examination
Undergraduate ULD teaching
Clinical presentations
Small group workshops
Hands-on experience
Demonstrations
Visits
b) Emphasis on the occupational causes of ULDs
In depth information about the occupational causative factors
How the occupation is affecting the disease
c) Solid evidence base
Consistent management guidelines
Evidence on what affects the disease
Consistent evidence based advice
d) Advice on activity level during recovery
Knowledge about how severely disabling these conditions can be
When to tell the patients to stop working
e) Opportunities to learn from other physicians
Lectures by hand surgeon specialists
f) Ergonomics teaching
Ergonomics teaching
*N=4
134
Table A1.21 Content analysis of the ‘training needs’ dimension based on the GPs’
quotes.
DIMENSION
Higher order themes
Lower order themes
TRAINING NEEDS*
a) Individual learning plans
Support personal learning plans
b) Hands-on practice
Need to do it on the patient
c) Access to knowledge
GPs need opportunities created to learn as they tend to be isolated
d) Opportunities to learn from other physicians
Learn from others who are more experienced
Learn the practical bits from others
An expert reintroducing a subject
Specialists are very useful
e) Right timing
It’s important that one gets the timing right
If taught years ago
one may not remember what was taught
knowledge may not be relevant anymore
f) Use of technology
Use any technology that is there
Interactive things are easier to use
g) Specific ULD training
There is no training specifically done for ULDs
New doctors need undergraduate, postgraduate and CME training on ULDs
More Occupational Health basic training in medicine school would be useful
*N=4
135
APPENDIX 2. QUESTIONNAIRES USED IN QUESTIONNAIRE SURVEY 136 Questionnaire for Trainee Occupational Physicians
Institute of Occupational and
Environmental Medicine
MANAGEMENT OF UPPER LIMB DISORDERS
(ULDS)
QUESTIONNAIRE
Dear Physician,
Musculoskeletal disorders (MSDs) are the most common work related illness in Great
Britain with an estimated 1.1 million individuals being affected each year and an
estimated attached cost of £5.7 billion. Although a lot of research has been carried out on
MSDs and more specifically Work Related Upper Limb Disorders (WRULDs), there has
been little research in terms of proven treatments and clinical management of these
disorders. In an effort to promote best practice in the clinical management of WRULDs,
the Institute of Occupational and Environmental Medicine, The University of Birmingham
is carrying out a questionnaire survey of Occupational Physicians across the UK, funded
by the Health and Safety Executive.
The aim of this questionnaire survey is to better understand your management of common
musculoskeletal disorders. The following questionnaire has been developed to identify
how you treat and manage common musculoskeletal disorders; to ascertain your
perceived difficulties in the management of such disorders; to establish the evidence base
used by Occupational Physicians (O.P.s) and to determine the types of training received
and your training needs within this field. It takes approximately 10 minutes to complete,
and while the researchers do appreciate that your time is very important, your input is
considered invaluable to the detection of training considerations and the promotion of best
practice for the primary care clinical management of WRULDs. We believe the results
will enable better ways to be found to deal with some of the difficult cases you see.
On completion of the report, the results will be publicly available on the Health and Safety
Executive website. A similar study carried out with physiotherapists and occupational
health nurses is available at http://www.hse.gov.uk/research/rrhtm/rr215.htm.
We would be very grateful if you could answer the following questions and return them by
the 29th of October 2004. A freepost return envelope has been included with this letter. All
information collected will remain confidential and no links to participants will be made. All
137 data will be held securely in line with the Data Protection Act. Should you have any
further questions, please contact the researchers named at the back of the questionnaire. Kind Regards, Dr Joanne Crawford Principal Investigator Please return completed questionnaires to Dr Joanne Crawford, Institute of Occupational and
Environmental Medicine, The University of Birmingham, FREEPOST SERVICE
BM2843 B15 2BR
138 Musculoskeletal disorders, specifically, upper limb disorders; have been subject to a large
amount of research. With some disorders, there is little evidence of the efficacy of
treatments and clinical management of them. The aim of the questionnaire is to obtain
information about how you manage specific disorders including hand/forearm
tenosynovitis, hand/forearm tendonitis, carpal tunnel syndrome, de Quervain’s
tenosynovitis, epicondylitis, shoulder tendonitis, cervical spondylosis, impingement
syndrome, tension neck and diffuse non-specific upper limb disorders. The questionnaire
includes questions on the training you have received, how you treat specific disorders,
what you use as an evidence base for treatment, perceived difficulties in managing such
disorders and, finally, your perceived training needs. Please do not hesitate to contact the
researchers if you have any further questions or issues with the survey.
ULD Training
1. Please indicate how much training you have had with regard to upper limb
musculoskeletal disorders (Please circle the appropriate number):
None
1 2
3
4
5
6
A lot
7
During your ‘House Officer’ years
(HO/SHO)
1 2
3
4
5
6
7
During your ‘Registrar’ years
(Non O.P.)
1 2
3
4
5
6
7
During your ‘Occupational Health
Trainee’ years
1 2
3
4
5
6
7
Continuing Medical Education
1 2
3
4
5
6
7
During
medical
(undergraduate)
school
2. Please indicate how much training you have had with regard to work related upper
limb musculoskeletal disorders (Please circle the appropriate number):
None
1 2
3
4
5
6
A lot
7
During your ‘House Officer’ years
(HO/SHO)
1 2
3
4
5
6
7
During your ‘Registrar’ years
(Non O.P.)
1 2
3
4
5
6
7
During your ‘Occupational Health
Trainee’ years
1 2
3
4
5
6
7
Continuing Medical Education
1 2
3
4
5
6
7
During medical school
(undergraduate)
139
3. Please identify the sources of your vocational upper limb musculoskeletal disorders
training (Please tick all that apply):
Orthopaedics
Rheumatology
Sports Medicine
Rehabilitation Medicine
Occupational Health
None
Other (Please Specify)
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
4. Please identify any course(s) you have undertaken in relation to ULDs e.g. courses in
Occupational Health/Medicine, Sports Medicine, etc.
……………………………………………………………………………………………………
……………………………………………………………………………………………………
………………………………………………………………………………………………...…
5. Please indicate how often you use the following sources in your Continuous
Professional Development with regard to upper limb musculoskeletal disorders (Please
circle the appropriate number):
Never
/Not applicable
Always
Medical journals
1 2 3 4 5 6 7
Text books
1
2
3 4 5 6 7
FOM guidance
1
2
3 4 5 6 7
HSE guidance
1
2
3 4 5 6 7
Contact with other O.P.s
1
2
3 4 5 6 7
Contact with other medical specialists
1
2
3 4 5 6 7
Contact with other non-medical professionals
1
2
3 4 5 6 7
Observation of colleagues during practice
1
2
3 4 5 6 7
Conferences, seminars
1
2
3 4 5 6 7
Accredited websites
1
2
3 4 5 6 7
Videos
1
2
3 4 5 6 7
CD-ROMs
1
2
3 4 5 6 7
140
Professional groups e.g., Primary
Care Rheumatology Society, S.O.M
1
2
3 4 5 6 7
Other (Please Specify)
………………………………………………
1 2 3 4 5 6 7
………………………………………………
1 2 3 4 5 6 7
6. Please identify your medical background before becoming an Occupational Physician
(e.g. GP, surgeon etc).
……………………………………………………………………………………………………
7. Do you have any additional comments with regard to your ULD training?
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………………………………………………………….…………………….………..
ULD MANAGEMENT
8. Please identify the management approaches you use with regard to:
a) Hand/forearm tenosynovitis
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
b) Hand/forearm tendonitis
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
c) Carpal tunnel syndrome
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
d) De Quervain’s tenosynovitis
141
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
e) Lateral/medial epicondylitis
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
f)
Shoulder tendonitis
First type of intervntion/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
g) Shoulder capsulitis
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
h) Cervical spondylosis
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
i)
Impingement syndrome
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
…………………………………………………………………………….
j) Tension Neck
First type of intervention/treatment to try
…………………………………………………………………………….
If first intervention/treatment didn’t work, second type to try
142
…………………………………………………………………………….
k) Diffuse non-specific upper limb disorders
First type of intervention/treatment to try ……………………………………………………………………………. If first intervention/treatment didn’t work, second type to try
……………………………………………………………………………. 9. Do you initiate contact with your patients’ GP with regard to a work related upper limb
disorder? (Please tick the appropriate)
Yes, always
Yes, sometimes
Yes, rarely
No
10. What referrals do you make with regard to upper limb musculoskeletal disorders?
(Please tick all that apply):
None/not applicable General Practice Orthopaedics Rheumatology
Physiotherapy Occupational therapy
Rehabilitation Cognitive behavioural therapy
Counselling Employment Service Other (Please Specify) …………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
11. O.P.s have had variable training and experience in the management of ULDs. Please
rate your level of confidence with each of the following aspects of ULD management
(Please circle the appropriate number):
Patient’s history
Physical examination
143 Not at all
Confident
1
2
Extremely
Confident
3 4 5 6 7
1
2
3 4 5 6 7
11
Diagnosis
1
2
3 4 5 6 7
Joint injection
1
2
3 4 5 6 7
Use of NSAIDs
1
2
3 4 5 6 7
Use of corticosteroids
1
2
3 4 5 6 7
Referrals
1
2
3 4 5 6 7
Establishing work relatedness
1
2
3 4 5 6 7
Advice on appropriate activity
1
2
3 4 5 6 7
Workplace assessment
1
2
3 4 5 6 7
Addressing the ergonomic side
1
2
3 4 5 6 7
Making recommendations to the Employer
1
2
3 4 5 6 7
12. Do you have any additional comments with regard to your management of ULDs?
.…………………………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………..……………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Evidence base
13. Please indicate how often you use the following sources as your evidence base with
regard to your choice of treatment for upper limb musculoskeletal disorders (Please
circle the appropriate number):
Previous clinical experience
Never
1 2
3
4
5
6
Always
7
Previous training 1
2
3
4
5
6
7
Consultation with other O.P.s 1
2
3
4
5
6
7
Consultation with medical specialists
1
2
3
4
5
6
7
Continuing Medical Education 1
2
3
4
5
6
7
Accredited websites 1
2
3
4
5
6
7
144 Journals
1
2
3
4
5
6
7
Text books
1
2
3
4
5
6
7
Available guidelines e.g. FOM, HSE
1
2
3
4
5
6
7
Patient’s positive feedback
1
2
3
4
5
6
7
Clinical evidence e.g. BMJ website
1
2
3
4
5
6
7
Other (please specify)
……………………………………….
1
2
3
4
5
6
7
……………………………………….
1
2
3
4
5
6
7
……………………………………….
1
2
3
4
5
6
7
14. Do you have any additional comments with regard to your evidence base for managing
ULDs?
.…………………………………………………………………………………………………..
…………………………………………………………………………………………………....
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Perceived Difficulties
15. How often are you faced with difficulties in establishing a diagnosis with regard to
ULDs? (Please circle the appropriate number)
a) Hand/forearm tenosynovitis
Never
1
2
3
4
5
6
7
Always
5
6
7
Always
5
6
7
Always
b) Hand/forearm tendonitis
Never
1
2
3
4
c) Carpal tunnel syndrome
Never
1
2
3
4
145 d) De Quervain’s tenosynovitis
Never
Always
1
2
3
4
5
6
7
e) Lateral/Medial epicondylitis
Never
Always
1
2
3
4
5
6
7
4
5
6
7
4
5
6
7
4
5
6
7
4
5
6
7
f) Shoulder tendonitis
Never
Always
1
2
3
g) Shoulder capsulitis
Never
Always
1
2
3
h) Cervical spondylosis
Never
Always
1
i)
2
3
Impingement syndrome
Never
Always
1
2
3
j) Tension Neck
Never
Always
1
2
3
4
5
6
7
k) Diffuse non-specific upper limb disorders
Never
Always
1
2
3
4
5
6
7
16. O.P.s are faced with various aspects that render the management of ULDs difficult.
Please rate how often the following aspects affect your management of upper limb
musculoskeletal disorders (Please circle the appropriate number):
Never
/Not applicable
Always
Symptoms/Signs do not match a
recognised clinical entity
1
2
3 4 5 6 7
Elusive diagnosis
1
2
3 4 5 6 7
Absence of clinical signs
1
2
3 4 5 6 7
146
No response to treatments
1
2
3 4 5 6 7
Delayed response to treatments
1
2
3 4 5 6 7
Recurrent symptoms
1
2
3 4 5 6 7
Chronicity
1
2
3 4 5 6 7
Patient’s high expectations
1
2
3 4 5 6 7
Patient’s dissatisfaction
1
2
3 4 5 6 7
Uncooperative patients
1
2
3 4 5 6 7
Psychosocial factors
1
2
3 4 5 6 7
Patient’s involvement in litigation
1
2
3 4 5 6 7
Opposing previous medical management
1
2
3 4 5 6 7
The patient is receiving temporary
injury allowance
1
2
3 4 5 6 7
Access to specialist services is difficult
1
2
3 4 5 6 7
Access to physiotherapy is difficult
1
2
3 4 5 6 7
Difficulty in advising appropriate activity
levels during recovery
1
2
3 4 5 6 7
Limited access to the workplace
Uncooperative workplace Management
1
1
2
2
3 4 5 6 7
3 4 5 6 7
Uncooperative Unions
1
2
3 4 5 6 7
Limited knowledge of the workplace
1
2
3 4 5 6 7
Limited knowledge of the occupational causative
factors
1
2
3 4 5 6 7
Other (Please Specify)
……………………………………….
1
2
3 4 5 6 7
……………………………………….
1
2
3 4 5 6 7
……………………………………….
1
2
3 4 5 6 7
147 17. Are there any important barriers in your practice to obtaining the following referrals for
patients? (For each item, please tick all that apply)
No
barrier
Waiting time Travel time Not
unacceptably unacceptably available
long
long
Not sure Not
if
applicable
available
Rheumatology
Orthopaedics
Physiotherapy
Rehabilitation
Occupational
Therapy
Employment
Service
Cognitive
Behavioural
Therapy
Other
(Please specify)
………………
………………
………………
18. Do you have any additional comments with regard to the difficulties you come across in
managing ULDs?
.…………………………………………………………………………………………………...
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………………………………………………………………………..………………..
148 Training Needs
19. O.P.s have different learning needs. P
lease indicate your level of interest in Continuing
Medical Education for each of the following topics with regard to ULDs (Please circle
the appropriate number):
NOT AT ALL
EXTREMELY
INTERESTED
Comprehensive musculoskeletal examination 1 2
3
4
INTERESTED
5 6 7
Differential diagnosis
1
2
3
4
5
6
7
Joint injection
1
2
3
4
5
6
7
Use of NSAIDs
1
2
3
4
5
6
7
Use of corticosteroids
1
2
3
4
5
6
7
Managing
common
musculoskeletal 1
conditions (e.g., tendonitis, tenosynovitis,
epicondylitis)
2
3
4
5
6
7
Psychosocial aspects of ULDs
1
2
3
4
5
6
7
Medico legal aspects of ULDs
1
2
3
4
5
6
7
Work relatedness of ULDs
1
2
3
4
5
6
7
Advice on activity level during recovery
1
2
3
4
5
6
7
Ergonomics
1
2
3
4
5
6
7
Communication skills to deal with the
workplace Management
1
2
3
4
5
6
7
Solid evidence based guidelines
1
2
3
4
5
6
7
Complementary medicine
1
2
3
4
5
6
7
Other (Please Specify)
……………………………………….
1
2
3
4
5
6
7
……………………………………….
1
2
3
4
5
6
7
……………………………………….
1
2
3
4
5
6
7
20. Please identify any barriers you experience in receiving further training with regard to
ULDs management:
149 .…………………………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
21. Do you have any additional comments with regard to your training needs for managing
ULDs?
.…………………………………………………………………………………………………..
…………………………………………………………………………………………………....
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Personal Information
22. Year of birth 19……..
23. Year of graduation from medical school ……..
24. Place of graduation (UK or non UK)……..
25. Years of practice as an O.P. ……..
26. Are you (Please circle the appropriate gender):
Male
Female 27. We would like to know about your clinical practice and affiliations (For each set of
items, please tick all that apply):
Full-time (35 or more hours per
week)
Work Alone
Urban
NHS
150 Part-time (less than 35 hours per
week)
Work as part of an Organisation
Rural
Non NHS
Thank you for taking the time to fill the questionnaire.
any additional comments to make, please use this space:
If
you
have
Your assistance with this research project is greatly appreciated. Should you wish any
further information please contact the researchers below.
Dr Joanne Crawford,
Miss Niki Laiou
Institute of Occupational and
Institute of Occupational and
Environmental Medicine,
Environmental Medicine,
The University of Birmingham,
The University of Birmingham,
Edgbaston, Birmingham
Edgbaston, Birmingham
B15 2TT
B15 2TT
Tel 0121 414 3623
Tel 0121 414 6015
Email: [email protected]
Email: [email protected]
151 Questionnaire for General Practitioners
Institute of Occupational and
Environmental Medicine
MANAGEMENT OF UPPER LIMB DISORDERS
(ULDS)
QUESTIONNAIRE
Dear Physician,
Musculoskeletal disorders (MSDs) are the most common work related illness in Great Britain with
an estimated 1.1 million individuals being affected each year and an estimated attached cost of £5.7
billion. Although a lot of research has been carried out on MSDs and more specifically Work
Related Upper Limb Disorders (WRULDs), there has been little research in terms of proven
treatments and clinical management of these disorders. In an effort to promote best practice in the
clinical management of WRULDs, the Institute of Occupational and Environmental Medicine, The
University of Birmingham is carrying out a questionnaire survey of General Practitioners across
the UK, funded by the Health and Safety Executive.
The aim of this questionnaire survey is to better understand your management of common
musculoskeletal disorders. The following questionnaire has been developed to identify how you
treat and manage common musculoskeletal disorders; to ascertain your perceived difficulties in the
management of such disorders; to establish the evidence base used by General Practitioners (GPs)
and to determine the types of training received and your training needs within this field. It takes
approximately 15 minutes to complete, and while the researchers do appreciate that your time is
very important, your input is considered invaluable to the detection of training considerations and
the promotion of best practice for the primary care clinical management of WRULDs. We believe
the results will enable better ways to be found to deal with some of the difficult cases you see.
On completion of the report, the results will be publicly available on the Health and Safety
Executive website. A similar study carried out with physiotherapists and occupational health
nurses is available at http://www.hse.gov.uk/research/rrhtm/rr215.htm.
We would be very grateful if you could answer the following questions and return them by the 14th
of January 2005. A freepost return envelope has been included with this letter. All information
collected will remain confidential and no links to participants will be made. All data will be held
securely in line with the Data Protection Act. Should you have any further questions, please
contact the researchers named at the back of the questionnaire.
Kind Regards,
Dr Joanne Crawford Principal Investigator
Please return completed questionnaires to Dr Joanne Crawford, Institute of Occupational and
Environmental Medicine, The University of Birmingham, FREEPOST SERVICE BM2843 B15 2BR
152 Musculoskeletal disorders, specifically, upper limb disorders; have been subject to a large
amount of research. With some disorders, there is little evidence of the efficacy of
treatments and clinical management of them. The aim of the questionnaire is to obtain
information about how you manage specific disorders including hand/forearm
tenosynovitis, hand/forearm tendonitis, carpal tunnel syndrome, de Quervain’s
tenosynovitis, epicondylitis, shoulder tendonitis, cervical spondylosis, impingement
syndrome, tension neck and diffuse non-specific upper limb disorders. The questionnaire
includes questions on the training you have received, how you treat specific disorders,
what you use as an evidence base for treatment, perceived difficulties in managing such
disorders and, finally, your perceived training needs. Please do not hesitate to contact the
researchers if you have any further questions or issues with the survey.
ULD Training
7. Please indicate how much training you have had with regard to upper limb
musculoskeletal disorders (Please circle the appropriate number):
A lot
None
1 2
3
4
5
6
7
During your ‘House Officer’ years
(HO/SHO)
1 2
3
4
5
6
7
During your ‘Registrar’ years
(Non-GP)
1 2
3
4
5
6
7
Continuing Medical Education
1 2
3
4
5
6
7
During
medical
(undergraduate)
school
8. Please indicate how much training you have had with regard to work related upper
limb musculoskeletal disorders (Please circle the appropriate number):
None
1 2
3
4
5
6
A lot
7
During your ‘House Officer’ years
(HO/SHO)
1 2
3
4
5
6
7
During your ‘Registrar’ years
(Non-GP)
1 2
3
4
5
6
7
Continuing Medical Education
1 2
3
4
5
6
7
During medical school
(undergraduate)
153
9. Please identify the sources of your vocational upper limb musculoskeletal disorders
training (Please tick all that apply):
Orthopaedics
Rheumatology
Sports Medicine
Rehabilitation Medicine
Occupational Health
None
Other (Please Specify)
…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
10. Please identify any course(s) you have undertaken in relation to ULDs e.g. courses in
Occupational Health/Medicine, Sports Medicine, etc.
……………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………………………………………………………………………………………...
5. Please indicate how often you use the following sources in your Continuous
Professional Development with regard to upper limb musculoskeletal disorders (Please
circle the appropriate number):
Never
/Not applicable
Always
Medical journals
1 2 3 4 5 6 7
Text books
1
2
3 4 5 6 7
MRCGP guidance
1
2
3 4 5 6 7
Contact with your GP partner(s)
1
2
3 4 5 6 7
Contact with other GPs
1
2
3 4 5 6 7
Contact with other medical specialists
1
2
3 4 5 6 7
Contact with other non-medical professionals
1
2
3 4 5 6 7
Observation of colleagues during practice
1
2
3 4 5 6 7
Practice meetings
1
2
3 4 5 6 7
Conferences, seminars
1
2
3 4 5 6 7
Accredited websites
1
2
3 4 5 6 7
CD-ROMs
1
2
3 4 5 6 7
Professional groups e.g., Primary
154 Care Rheumatology Society
1
2
3 4 5 6 7
Other (Please Specify)
………………………………………………
………………………………………………
1
1
2
2
3 4 5 6 7
3 4 5 6 7
10. Do you have any additional comments with regard to your ULD training?
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
ULD MANAGEMENT
11. Please identify the treatment options you offer your patients with regard to:
a) Hand/forearm tenosynovitis
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
b) Hand/forearm tendonitis
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
c) Carpal tunnel syndrome
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
d) De Quervain’s tenosynovitis
First type of treatment to try
…………………………………………………………………………….
155 If first treatment didn’t work, second type to try
……………………………………………………………………………
e) Lateral/medial epicondylitis
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
f) Shoulder tendonitis
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
g) Shoulder capsulitis
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
h) Cervical spondylosis
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
i)
Impingement syndrome
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
j) Tension Neck
First type of treatment to try
…………………………………………………………………………….
If first treatment didn’t work, second type to try
…………………………………………………………………………….
156 k) Diffuse non-specific upper limb disorders
First type of treatment to try
……………………………………………………………………………. If first treatment didn’t work, second type to try
……………………………………………………………………………. 12. If your patient’s workplace has an Occupational Physician, do you initiate contact with
him/her with regard to a work related ULD? (Please tick the appropriate)
Yes, always
Yes, sometimes
Yes, rarely
No
13. What referrals do you make with regard to upper limb musculoskeletal disorders?
(Please tick all that apply):
Orthopaedics
Rheumatology
Physiotherapy
Occupational therapy
Rehabilitation
Cognitive behavioural therapy
Counselling
Employment Service
Other (Please Specify)
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
14. GPs have had variable training and experience in the management of ULDs. Please rate
your level of confidence with each of the following aspects of ULD management
(Please circle the appropriate number):
Not at all
Confident
1
2
Extremely
Confident
3 4 5 6 7
Physical examination
1
2
3 4 5 6 7
Diagnosis
1
2
3 4 5 6 7
Patient’s history
157 Joint injection
1
2
3 4 5 6 7
Use of NSAIDs
1
2
3 4 5 6 7
Use of corticosteroids
1
2
3 4 5 6 7
Referrals
1
2
3 4 5 6 7
Establishing work relatedness
1
2
3 4 5 6 7
Advice on appropriate activity
1
2
3 4 5 6 7
15. Do you have any additional comments with regard to your management of ULDs?
.…………………………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………..……………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Evidence base
16. Please indicate how often you use the following sources as your evidence base with
regard to your choice of treatment for upper limb musculoskeletal disorders (Please
circle the appropriate number):
Never
Previous clinical experience
Always
1
2
3
4
5
6
7
Previous training 1
2
3
4
5
6
7
Consultation with other GPs 1
2
3
4
5
6
7
Consultation with medical specialists
1
2
3
4
5
6
7
Continuing Medical Education 1
2
3
4
5
6
7
Accredited websites 1
2
3
4
5
6
7
Journals 1
2
3
4
5
6
7
Text books 1
2
3
4
5
6
7
MRCGP guidelines 1
2
3
4
5
6
7
Patient’s positive feedback 1
2
3
4
5
6
7
158 Clinical evidence e.g. BMJ website
1
2
3
4
5
6
7
Other (please specify)
……………………………………….
1
2
3
4
5
6
7
……………………………………….
1
2
3
4
5
6
7
……………………………………….
1
2
3
4
5
6
7
17. Do you have any additional comments with regard to your evidence base for managing
ULDs?
.…………………………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Perceived Difficulties
18. How often are you faced with difficulties in establishing a diagnosis with regard to
ULDs? (Please circle the appropriate number)
l)
Hand/forearm tenosynovitis
Never
1
2
3
4
5
6
7
Always
5
6
7
Always
5
6
Always
7
5
6
7
Always
5
6
7
Always
m) Hand/forearm tendonitis
Never
1
2
3
4
n) Carpal tunnel syndrome
Never
1
2
3
4
o) De Quervain’s tenosynovitis
Never
1
2
3
4
p) Lateral/Medial epicondylitis
Never
1
2
3
4
q) Shoulder tendonitis
159
Never
Always
1
2
3
4
5
6
7
4
5
6
7
4
5
6
7
3
4
5
6
7
3
4
5
6
7
r) Shoulder capsulitis
Never
Always
1
2
3
s) Cervical spondylosis
Never
Always
1
2
3
t) Impingement syndrome
Never
Always
1
2
u) Tension Neck
Never
Always
1
2
v) Diffuse non-specific upper limb disorders
Never
1
2
3
4
5
6
Always
7
19. GPs are faced with various aspects that render the management of ULDs difficult.
Please rate how often the following aspects affect your management of upper limb
musculoskeletal disorders (Please circle the appropriate number):
Never
/Not applicable
Always
Symptoms/Signs do not match a
recognised clinical entity
1
2
3 4 5 6 7
Elusive diagnosis
1
2
3 4 5 6 7
Absence of clinical signs
1
2
3 4 5 6 7
No response to treatments
1
2
3 4 5 6 7
Delayed response to treatments
1
2
3 4 5 6 7
Recurrent symptoms
1
2
3 4 5 6 7
Chronicity
1
2
3 4 5 6 7
Patient’s high expectations
1
2
3 4 5 6 7
Patient’s dissatisfaction
1
2
3 4 5 6 7
160 Psychosocial factors
1
2
3 4 5 6 7
Patient’s involvement in litigation
1
2
3 4 5 6 7
Opposing previous medical management
1
2
3 4 5 6 7
The patient is receiving temporary
injury allowance
1
2
3 4 5 6 7
Access to specialist services is difficult
1
2
3 4 5 6 7
Access to physiotherapy is difficult
1
2
3 4 5 6 7
Difficulty in advising appropriate activity
levels during recovery
1
2
3 4 5 6 7
Other (Please Specify) ……………………………………….
1
2
3 4 5 6 7
……………………………………….
1
2
3 4 5 6 7
20. Are there any important barriers in your practice to obtaining the following referrals for
patients? (For each item, please tick all that apply)
No
barrier
Waiting time Travel time Not
unacceptably unacceptably available
long
long
Rheumatology
Orthopaedics
Physiotherapy
Rehabilitation
Occupational
Therapy
Employment
Service
Cognitive
Behavioural
Therapy
Other
(Please specify)
………………
161 Not sure Not
if
applicable
available
21. Do you have any additional comments with regard to the difficulties you come across in
managing ULDs?
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………..……………..
……………………………………………………………………………………………………
Training Needs
22. GPs have different learning needs. Please indicate your level of interest in Continuing
Medical Education for each of the following topics with regard to ULDs (Please circle
the appropriate number):
NOT AT ALL
EXTREMELY
INTERESTED
Comprehensive musculoskeletal examination 1 2
3
4
5
INTERESTED
6 7
Differential diagnosis
1
2
3
4
5
6
7
Joint injection
1
2
3
4
5
6
7
Use of NSAIDs
1
2
3
4
5
6
7
Use of corticosteroids
1
2
3
4
5
6
7
Managing
common
musculoskeletal 1
conditions (e.g., tendonitis, tenosynovitis,
epicondylitis)
2
3
4
5
6
7
Psychosocial aspects of ULDs
1
2
3
4
5
6
7
Medico legal aspects of ULDs
1
2
3
4
5
6
7
Complementary Medicine
1
2
3
4
5
6
7
Work relatedness of ULDs
1
2
3
4
5
6
7
Advice on activity level during recovery
1
2
3
4
5
6
7
162 Other (Please Specify) ……………………………………….
1
2
3
4
5
6
7
………………………………………. 1
2
3
4
5
6
7
………………………………………. 1
2
3
4
5
6
7
23. Please identify any barriers you experience in receiving further training with regard to
ULD management:
.…………………………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
24. Do you have any additional comments with regard to your training needs for managing
ULDs?
.…………………………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Personal Information
25. Year of birth 19……..
26. Year of graduation from medical school ……..
27. Place of graduation (UK or non UK) ……..
28. Years of practice as a GP ……..
29. Are you (Please circle the appropriate gender):
Male
Female 30. We would like to know about your clinical practice and affiliations (For each set of
items, please tick all that apply):
163 Full-time (35 or more hours per
week)
Work Alone
Urban
NHS
Part-time (less than 35 hours per
week)
In Group Practice
Rural
Private practice
Thank you for taking the time to fill the questionnaire.
any additional comments to make, please use this space:
If
you
have
Your assistance with this research project is greatly appreciated. Should you wish any
further information please contact the researchers below.
Dr Joanne Crawford, Institute of Occupational and Environmental Medicine, The University of Birmingham, Edgbaston, Birmingham
B15 2TT
Miss Niki Laiou
Institute of Occupational and
Environmental Medicine,
The University of Birmingham,
Edgbaston, Birmingham
B15 2TT
Tel 0121 414 3623
Email: [email protected]
Tel 0121 414 6015
Email:[email protected]
164 165
Musculoskeletal skeletal training during medical school
During your House Officer years
During your Registrar years
Continuing Medical Education
Mean
2.81
2.56
2.79
4.41
Table A3.1 GP training in upper limb musculoskeletal disorders
None
1
N
%
4 12.5
10 31.3
8 27.6
1
3.1
N
13
9
5
2
%
40.6
28.1
17.2
6.3
2
N
5
4
9
6
%
15.6
12.5
31.0
18.8
3
APPENDIX 3 QUESTIONNAIRE DATA
N
7
4
2
7
%
21.9
12.5
6.9
21.9
4
N
2
4
2
9
%
6.3
12.5
6.9
28.1
5
N
1
1
9
4
%
3.1
3.1
10.3
12.5
6
A Lot
7
N %
0
0
0
0
0
0
3 9.4
166
Musculoskeletal skeletal training during medical school
During your House Officer years
During your Registrar years
Continuing Medical Education
None
1
N
18
20
18
5
%
56.3
62.5
62.1
15.6
2
N
9
8
5
5
%
28.1
25.0
17.2
15.6
Table A3.2 GP training in work related upper limb musculoskeletal disorders
3
N
1
2
3
8
%
3.1
6.3
10.3
25.0
N
2
1
1
2
4
%
6.3
3.1
3.4
6.3
N
1
1
0
5
5
%
3.1
3.1
0
15.6
N
1
1
1
4
6
%
3.1
3.1
3.4
12.5
A Lot
7
N
%
0
0
0
0
1
3.4
3
9.4
167
Medical Journals
Text Books
MRCGP guidance
Contact with your GP partner(s)
Contact with other GPs
Contact with other medical specialists
Contact with other non-medical
professionals
Observation of colleagues during practice
Practice meetings
Conferences, seminars
Accredited websites
CD-ROMs
Professional groups
Sources
1.739
1.376
1.765
1.520
1.296
1.476
1.464
1.199
1.658
1.521
1.717
1.088
1.331
2.35
2.13
3.23
2.53
1.70
1.77
S.D.
3.90
3.32
2.48
3.61
2.90
3.61
3.00
Mean
1
1
1
1
1
1
1
1
1
1
1
1
1
Min
5
6
7
6
5
6
7
7
6
6
5
6
6
Max
9
13
4
14
19
20
3
4
13
3
6
3
5
29.0
43.3
12.9
46.7
63.3
66.7
9.7
12.9
44.8
9.7
20.0
9.7
17.2
Never/not
applicable
1
N
%
Table A3.3 GP sources of information in professional development
10
8
8
3
4
3
4
3
5
6
5
5
6
N
2
32.3
26.7
25.8
10.0
13.3
10.0
12.9
9.7
17.2
19.4
16.7
16.1
20.7
%
5
4
5
3
5
4
5
10
3
4
8
6
9
N
3
16.1
13.3
16.1
10.0
16.7
13.3
16.1
32.3
10.3
12.9
26.7
19.4
31.0
%
6
3
7
4
1
1
9
9
3
8
8
6
4
N
%
19.4
10.0
22.6
13.3
3.3
3.3
29.0
29.0
10.3
25.8
26.7
19.4
13.8
4
1
1
6
5
1
1
4
4
2
7
3
9
3
N
%
3.2
3.3
19.4
16.7
3.3
3.3
12.9
12.9
6.9
22.6
10.0
29.0
10.3
5
0
1
0
1
0
1
3
0
3
3
0
2
2
N
%
0
3.3
0
3.3
0
3.3
9.7
0
10.3
9.7
0
6.5
6.9
6
0
0
1
0
0
0
3
1
0
0
0
0
0
N
7
0
0
3.2
0
0
0
9.7
3.2
0
0
0
0
0
%
Always
168
Patient’s history
Physical examination
Diagnosis
Joint injection
Use of NSAIDs
Use of corticosteroids
Referrals
Establishing work relatedness
Advice on appropriate activity
Mean
5.41
5.09
4.97
4.72
5.81
4.58
5.19
4.53
4.59
S.D.
1.160
0.963
1.062
1.746
0.896
1.608
1.176
1.502
1.365
Min
3
3
3
1
4
1
2
2
2
Max
7
7
7
7
7
7
7
7
7
Not at all
confident
1
N
%
0
0
0
0
0
0
3
9.4
0
0
2
6.5
0
0
0
0
0
0
N
0
0
0
1
0
1
1
3
2
2
%
0
0
0
3.1
0
3.1
3.1
9.4
6.3
N
3
1
4
3
0
5
2
7
6
Table A3.4 GP level of confidence with different aspects of upper limb management
%
9.4
3.1
12.5
9.4
0
15.6
6.3
21.9
18.8
3
N
3
9
4
4
3
4
5
5
7
%
9.4
28.1
12.5
12.5
9.4
12.5
15.6
15.6
21.9
4
N
9
9
15
9
7
10
8
6
6
%
28.1
28.1
46.9
28.1
21.9
31.3
25.0
18.8
18.8
5
N
12
12
7
8
15
6
14
9
10
%
37.5
37.5
21.9
25.0
46.9
18.8
43.8
28.1
31.3
6
Extremely
confident
7
N
%
5 15.6
1
3.1
2
6.3
4 12.5
7 21.9
3
9.4
2
6.3
2
6.3
1
3.1
169
Previous clinical experience
Previous training
Consultations with other GPs
Consultation with medical
specialists
Continuing medical education
Accredited websites
Journals
Text books
MRCGP Guidelines
Patient’s positive feedback
Clinical Evidence
S.D.
1.085
1.469
1.470
1.204
1.256
1.435
1.635
1.416
1.507
1.494
1.832
Mean
5.72
4.69
3.33
3.87
4.31
2.44
3.84
3.16
2.27
4.66
2.77
2
1
1
1
1
1
1
Max
3
2
1
2
7
6
7
7
5
7
6
Min
7
7
6
6
0
11
2
4
14
1
12
0
34.4
6.5
12.9
46.7
3.1
40.0
Never
1
N
%
0
0
0
0
3 10.0
0
0
4
7
7
7
6
0
4
N
0
3
6
6
12.5
21.9
22.6
22.6
20.0
0
13.3
%
0
9.4
20.0
19.4
2
3
8
3
6
2
9
2
N
2
4
9
4
Table A3.5 GP evidence base in the choice of treatment of musculoskeletal disorders
9.4
25.0
9.7
19.4
6.7
28.1
6.7
%
6.3
12.5
30.0
12.9
3
9
2
7
10
4
3
7
N
2
7
5
11
28.1
6.3
22.6
32.3
13.3
9.4
23.3
%
6.3
21.9
16.7
35.5
4
12
3
7
3
4
7
1
N
6
7
4
8
37.5
9.4
22.6
9.7
13.3
21.9
3.3
%
18.8
21.9
12.5
25.8
5
3
1
4
0
0
10
4
N
15
8
3
2
9.4
3.1
12.9
0
0
31.3
13.3
%
46.9
25.0
9.4
6.5
6
1
0
1
1
0
2
0
3.1
0
3.2
3.2
0
6.3
0
Always
7
N
%
7 21.9
3
9.4
0
0
0
0
170
Disorder
Hand/forearm tenosynovitis
Hand/forearm tendonitis
Carpal Tunnel Syndrome
De Quervain’s
tenosynovitis
Epicondylitis
Shoulder tendonitis
Shoulder capsulitis
Cervical Spondylosis
Impingement Syndrome
Tension Neck
Diffuse non-specific upper
limb disorders
S.D.
1.276
1.181
1.073
1.027
0.984
1.121
1.282
1.298
1.558
1.172
1.600
Mean
3.28
3.34
2.59
2.91
2.00
2.97
3.03
2.84
3.68
2.93
4.19
1
2
1
1
2
1
2
Min
1
2
1
2
6
6
6
6
7
6
7
Max
6
6
6
6
8
0
1
2
0
2
0
25.0
0
3.1
6.3
0
6.7
0
Never
1
N
%
1
3.1
0
0
3
9.4
0
0
Table A3.6 GP perceived difficulties in establishing a diagnosis
20
14
13
14
10
10
7
N
10
9
15
14
62.5
43.8
40.6
43.8
32.3
33.3
22.6
%
31.3
28.1
46.9
43.8
2
2
9
9
9
5
10
2
N
7
10
8
10
6.3
28.1
28.1
28.1
16.1
33.3
6.5
%
21.9
31.3
25.0
31.3
3
1
7
4
4
7
5
11
N
9
8
5
6
3.1
21.9
12.5
12.5
22.6
16.7
35.5
%
28.1
25.0
15.6
18.8
4
0
0
3
0
5
2
2
N
3
3
0
1
%
9.4
9.4
0
3.1
0
0
9.4
0
16.1
6.7
6.5
5
1
2
2
3
2
1
7
N
2
2
1
1
%
6.3
6.3
3.1
3.1
3.1
6.3
6.3
9.4
6.5
3.3
22.6
6
0
0
0
0
2
0
2
0
0
0
0
6.5
0
6.5
Always
7
N %
0
0
0
0
0
0
0
0
171
Difficulties
Symptoms/Signs do not match a
recognised clinical entity
Elusive diagnosis
Absence of clinical signs
No response to treatments
Delayed response to treatments
Recurrent symptoms
Chronicity
Patient’s high expectations
Patient’s dissatisfaction
Psychosocial factors
Patient’s involvement in
litigation
Opposing previous medical
management
The
patient
is
receiving
temporary injury allowance
Access to specialist services is
difficult
Access to physiotherapy is
difficult
Difficulty in advising
appropriate activity levels during
recovery
S.D.
1.224
1.039
1.448
1.099
1.243
1.391
1.218
1.218
1.338
1.459
1.696
1.362
1.920
1.811
1.900
1.250
Mean
4.28
4.22
4.03
4.22
3.94
4.00
4.25
4.75
4.13
4.47
4.66
3.55
3.48
4.59
3.94
3.72
1
1
1
1
1
2
1
2
2
1
2
2
2
2
2
2
Min
Table A3.7 GP difficulties in managing upper limb disorders
6
7
7
7
6
6
7
6
6
6
6
7
7
7
7
7
Max
0
0
3.1
0
0
3.1
0
0
0
0
0
6.3
18.8
6.3
9.4
3.1
0
0
1
0
0
1
0
0
0
0
0
2
6
2
3
1
Never
1
N
%
4
8
3
4
4
1
4
2
5
4
4
2
4
4
6
3
N
2
%
12.5
25.0
9.4
12.5
12.9
3.1
12.5
6.3
15.6
12.5
12.5
6.3
12.5
12.5
18.8
9.4
10
2
5
6
10
9
6
8
7
8
4
2
6
5
2
5
N
3
%
31.3
6.3
15.6
18.8
32.3
28.1
18.8
25.0
21.9
25.0
12.5
6.3
18.8
15.6
6.3
15.6
7
5
3
4
9
6
9
5
8
4
8
9
11
5
5
9
N
4
%
21.9
15.6
9.4
12.5
29.0
18.8
28.1
15.6
25.0
12.5
25.0
28.1
34.4
15.6
15.6
28.1
N
8
5
6
2
2
14
8
15
9
11
12
9
5
10
8
11
5
%
25.0
15.6
18.8
6.3
6.5
43.8
25.0
46.9
28.1
34.4
37.5
28.1
15.6
31.3
25.0
34.4
2
7
9
6
4
2
2
2
3
4
4
9
5
6
6
3
N
6
%
6.3
21.9
28.1
18.8
12.9
6.3
6.3
6.3
9.4
12.5
12.5
28.1
15.6
18.8
18.8
9.4
0
2
4
1
0
0
2
0
0
0
0
1
1
2
5
1
0
6.3
12.5
3.1
0
0
6.3
0
0
0
0
3.1
3.1
6.3
15.6
3.1
Always
7
N
%
172
Education Topics
Comprehensive
musculoskeletal examination
Differential diagnosis
Joint injection
Use of NSAIDs
Use of corticosteroids
Managing
common
musculoskeletal conditions
Psychosocial aspects of ULDs
Medico legal aspects of ULDs
Complementary Medicine
Work relatedness of ULDs
Advice on activity level during
recovery
S.D.
1.883
1.510
1.680
1.523
1.773
1.564
1.687
1.794
1.762
1.712
1.563
Mean
4.44
4.91
4.62
3.44
3.87
4.61
3.84
3.59
3.16
4.19
4.59
1
1
1
1
1
2
2
1
1
2
Min
1
7
7
7
7
7
7
7
7
7
7
Max
7
2
4
5
2
2
0
0
2
1
0
6.3
12.5
15.6
6.3
6.3
0
0
6.3
3.1
0
Not at all
interested
1
N
%
2
6.3
Table A3.8 GP level of interest in continuing medical education topics
6
6
10
5
1
3
6
9
10
4
N
4
18.8
18.8
31.3
15.6
3.1
9.4
18.8
28.1
31.3
12.9
%
12.5
2
6
7
5
3
3
3
2
6
3
3
N
5
18.8
21.9
15.6
9.4
9.4
9.4
6.3
18.8
9.4
9.7
%
15.6
3
7
4
5
7
9
5
6
7
5
8
N
4
21.9
12.5
15.6
21.9
28.1
15.6
18.8
21.9
18.8
25.8
%
12.5
4
6
7
3
8
7
9
6
5
4
6
N
7
18.8
21.9
9.4
25.0
21.9
28.1
18.8
15.6
12.5
19.4
%
21.9
5
2
1
2
4
7
7
8
2
6
6
N
4
6.3
3.1
6.3
12.5
21.9
21.9
25.0
6.3
18.8
19.4
%
12.5
6
3
3
2
3
3
5
4
1
2
4
9.4
9.4
6.3
9.4
9.4
15.6
12.5
3.1
6.3
12.9
Extremely
Interested
7
N
%
6 18.8
173
Musculoskeletal
skeletal training
during medical school
During your House
Officer years
During your Registrar
years
During your
Occupational Health
trainee years
Continuing Medical
Education
7.4
2
0
25.0
7
0
11
34.5
10
4
1
7
N
10
None
1
N
%
9 31.0
2
14.3
3.7
25.0
37.9
%
34.5
Table A3.9 TOP training in upper limb musculoskeletal disorders
Occupational Physicians
3
7
6
6
N
7
10.7
25.9
21.4
20.7
%
24.1
3
5
5
5
2
N
1
6.9
%
3.4
17.9
18.5
17.2
4
10
8
2
0
N
1
6.9
0
%
3.4
35.7
29.6
5
5
2
1
0
N
1
6
17.9
7.4
3.4
0
%
3.4
1
2
0
0
3.6
7.4
0
0
A Lot
7
N %
0
0
174
Musculoskeletal
skeletal training during
medical school
During your House
Officer years
During your Registrar
years
Occupational Health
trainee years
Continuing Medical
Education
7
6
2
5
72.4
55.2
7.4
3.6
16
2
1
N
9
21
None
1
N
%
17 58.6
2
17.9
7.4
20.7
24.1
%
31.0
2
6
1
1
N
1
3
7.1
22.2
3.4
3.4
%
3.4
6
4
6
0
N
1
Table A3.10 TOP training in work related upper limb musculoskeletal disorders
4
21.4
14.8
20.7
0
%
3.4
7
6
0
0
N
0
5
25.0
22.2
0
0
%
0
6
5
0
0
N
1
6
21.4
18.5
0
0
%
3.4
1
2
0
0
3.6
7.4
0
0
A Lot
7
N %
0
0
175
Sources
Medical Journals
Text Books
FOM guidance
HSE guidance
Contact with other O.P.s
Contact with other medical specialists
Contact with other non-medical professionals
Observation of colleagues during practice
Conferences, seminars
Accredited websites
Videos
CD-ROMs
Professional groups
Mean
3.72
3.97
3.59
3.29
3.70
3.66
3.36
2.24
3.72
2.75
1.46
1.71
3.18
S.D
1.811
1.476
1.738
1.843
1.772
1.738
1.890
1.354
1.601
1.898
0.793
1.213
1.887
Min
1
1
1
1
1
1
1
1
1
1
1
1
1
Max
7
7
7
7
6
6
6
6
6
6
4
6
6
Table A3.11 TOP sources of information in professional development
Never/not
applicable
1
N
%
2
6.9
1
3.4
4 14.8
7 25.0
4 14.8
5 17.2
7 25.0
11 37.9
2
6.9
11 39.3
19 67.9
18 64.3
9 31.0
N
7
4
4
3
4
1
3
8
6
5
6
4
3
%
24.1
13.8
14.8
10.7
14.8
3.4
10.7
27.6
20.7
17.9
21.4
14.3
10.3
2
N
6
7
6
6
4
10
6
5
6
3
2
4
2
%
20.7
24.1
22.2
21.4
14.8
34.5
21.4
17.2
20.7
10.7
7.1
14.3
6.9
3
N
5
5
2
4
5
2
3
3
4
2
1
1
6
%
17.2
17.2
7.4
14.3
18.5
6.9
10.7
10.3
13.8
7.1
3.6
3.6
20.7
4
N
3
8
8
4
4
5
3
1
6
3
0
0
4
%
10.3
27.6
29.6
14.3
14.8
17.2
10.7
3.4
20.7
10.7
0
0
13.8
5
N
3
3
2
3
6
6
6
1
5
4
0
1
3
%
10.3
10.3
7.4
10.7
22.2
20.7
21.4
3.4
17.2
14.3
0
3.6
10.3
6
N
3
1
1
1
0
0
0
0
0
0
0
0
0
%
10.3
3.4
3.7
3.6
0
0
0
0
0
0
0
0
0
7
Always
176
Area
Patient’s history
Physical examination
Diagnosis
Joint injection
Use of NSAIDs
Use of corticosteroids
Referrals
Establishing work relatedness
Advice on appropriate activity
Workplace Assessment
Addressing the ergonomic side
Making recommendations to the
employer
Mean
5.34
4.83
4.59
2.97
5.43
3.50
5.37
4.93
4.96
4.62
4.24
4.90
S.D.
1.143
1.136
0.983
1.936
1.200
1.953
1.182
0.923
0.999
1.568
1.480
1.496
Min
3
3
3
1
1
1
3
3
3
1
1
1
Max
7
7
6
6
7
7
7
7
7
7
6
6
Not at all
confident
1
N
%
0
0
0
0
0
0
10 34.5
1
3.4
5 17.9
0
0
0
0
0
0
1
3.4
2
6.9
1
3.4
N
0
0
0
5
0
7
0
0
0
1
1
2
%
0
0
0
17.2
0
25.0
0
0
0
3.4
3.4
6.9
2
N
3
5
5
3
0
3
3
1
2
7
6
2
Table A3.12 TOP level of confidence with different aspects of upper limb management
%
10.3
17.2
17.2
10.3
0
10.7
11.1
3.4
7.1
24.1
20.7
6.9
3
N
3
5
7
3
4
2
2
9
7
3
6
5
%
10.3
17.2
24.1
10.3
14.3
7.1
7.4
31.0
25.0
10.3
20.7
17.2
4
N
7
10
12
3
5
5
8
11
10
6
7
3
%
24.1
34.5
41.4
10.3
17.2
17.9
29.6
37.9
35.7
20.7
24.1
10.3
5
N
13
8
5
5
16
5
10
7
8
9
7
16
%
44.8
27.6
17.2
17.2
55.2
17.9
37.0
24.1
28.6
31.0
24.1
55.2
6
Extremely
confident
7
N
%
3 10.3
1
3.4
0
0
0
0
2
7.1
1
3.6
4 14.8
1
3.4
1
3.6
2
6.9
0
0
0
0
177
Evidence Base
Previous clinical experience
Previous training
Consultations with other O.P.s
Consultation with medical specialists
Continuing medical education
Accredited websites
Journals
Text books
Available guidelines, e.g., FOM, HSE
Patient’s positive feedback
Clinical evidence
Mean
5.21
4.96
3.76
4.18
4.32
2.96
3.43
4.04
3.64
4.54
3.75
S.D.
1.197
1.347
1.562
1.307
1.188
1.774
1.451
1.503
1.747
1.138
1.669
Min
3
2
1
1
2
1
1
1
1
2
1
Max
7
7
6
6
6
6
6
7
6
6
6
Never
1
N
%
0
0
0
0
2
8.0
1
3.6
0
0
7 25.0
2
7.1
1
3.6
3 10.7
0
0
4 14.3
N
0
1
5
2
4
7
6
3
6
2
2
%
0
3.6
20.0
7.1
14.3
25.0
21.4
10.7
21.4
7.1
7.1
2
N
3
4
3
6
1
5
8
8
6
3
7
Table A3.13 TOP evidence base in the choice of treatment of musculoskeletal disorders
%
10.7
14.3
12.0
21.4
3.6
17.9
28.6
28.6
21.4
10.7
25.0
3
N
5
4
5
4
8
2
5
4
2
6
4
%
17.9
14.3
20.0
14.3
28.6
7.1
17.9
14.3
7.1
21.4
14.3
4
N
6
8
7
12
12
3
4
7
5
12
6
%
21.4
28.6
28.0
42.9
42.9
10.7
14.3
25.0
17.9
42.9
21.4
5
N
11
8
3
3
3
4
3
4
6
5
5
%
39.3
28.6
12.0
10.7
10.7
14.3
10.7
14.3
21.4
17.9
17.9
6
Always
7
N
%
3 10.7
3 10.7
0
0
0
0
0
0
0
0
0
0
1
3.6
0
0
0
0
0
0
178
Mean
3.46
3.64
2.86
3.11
2.25
3.48
3.50
2.86
3.46
3.39
4.39
Disorder
Hand/forearm tenosynovitis
Hand/forearm tendonitis
Carpal Tunnel Syndrome
De Quervain’s tenosynovitis
Epicondylitis
Shoulder tendonitis
Shoulder capsulitis
Cervical Spondylosis
Impingement Syndrome
Tension Neck
Diffuse non-specific upper limb disorders
1.374
1.311
1.239
1.286
.701
1.424
1.453
1.533
1.453
1.873
1.833
S.D.
2
2
1
1
1
1
1
1
1
1
1
Min
Ma
x
7
7
5
6
5
6
6
7
6
7
7
Table A3.14 TOP perceived difficulties in establishing a diagnosis
0
0
1
1
1
1
1
2
1
4
2
0
0
3.6
3.6
3.6
3.7
3.6
7.1
3.6
14.3
7.1
Never
1
N
%
7
4
15
10
21
7
8
15
7
7
4
N
%
25.0
14.3
53.6
35.7
75.0
25.9
28.6
53.6
25.0
25.0
14.3
2
11
13
4
9
5
7
6
4
9
5
2
N
%
39.3
46.4
14.3
32.1
17.9
25.9
21.4
14.3
32.1
17.9
7.1
3
4
4
3
2
0
5
5
3
4
6
6
N
%
14.3
14.3
10.7
7.1
0
18.5
17.9
10.7
14.3
21.4
21.4
4
3
4
5
5
1
4
5
1
3
1
4
N
%
10.7
14.3
17.9
17.9
3.6
14.8
17.9
3.6
10.7
3.6
14.3
5
2
2
0
1
0
3
3
2
4
2
7
N
%
7.1
7.1
0
3.6
0
11.1
10.7
7.1
14.3
7.1
25.0
6
1
1
0
0
0
0
0
1
0
3
3
3.6
3.6
0
0
0
0
0
3.6
0
10.7
10.7
Always
7
N
%
179
Difficulty
Symptoms/Signs do not match a rcognised clinical
entity
Elusive diagnosis
Absence of clinical signs
No response to treatments
Delayed response to treatments
Recurrent symptoms
Chronicity
Patient’s high expectations
Patient’s dissatisfaction
Uncooperative Patients
Psychosocial factors
Patient’s involvement in litigation
Opposing previous medical management
The patient is receiving temporary
Injury allowance
Access to specialist services is difficult
Access to physiotherapy is difficult
Difficulty in advising appropriate activity
Levels during recovery
Limited access to the workplace
Uncooperative workplace management
Uncooperative unions
Limited knowledge of the workplace
Limited knowledge of occupational causative factors
S.D.
1.197
1.279
1.210
1.090
.879
.882
.974
1.237
1.240
1.268
1.085
1.510
1.405
1.682
1.958
1.815
1.396
1.959
1.634
1.162
1.822
1.345
Mean
4.17
4.28
4.03
4.48
4.43
4.72
4.66
4.62
4.41
3.59
4.97
4.07
3.76
3.48
4.24
3.04
3.66
3.14
3.18
2.36
3.03
2.90
1
1
1
1
1
1
1
1
1
2
2
3
3
3
3
2
2
2
3
2
2
2
Min
Table A3.15 TOP difficulties in managing upper limb disorders
7
7
5
7
6
6
7
6
6
6
6
7
6
6
6
7
7
6
7
6
6
6
Max
6
4
5
6
4
3
7
1
0
0
0
0
0
0
0
0
0
0
0
0
3
20.7
14.3
17.9
20.7
13.8
10.3
25.0
3.4
0
0
0
0
0
0
0
0
0
0
0
0
10.3
Never
1
N
%
0
0
9
8
15
7
9
6
8
7
4
3
0
0
0
0
1
1
8
0
6
7
8
N
3
31.0
26.8
53.6
24.1
31.0
20.7
28.6
24.1
13.8
10.3
0
0
0
0
3.4
3.4
27.6
0
20.7
24.1
27.6
%
10.3
2
5
5
4
9
7
1
2
6
4
7
7
6
3
4
6
6
5
3
7
7
4
N
5
17.2
17.9
14.3
31.0
24.1
3.4
7.1
20.7
13.8
24.1
24.1
21.4
10.3
13.8
20.7
20.7
17.2
10.3
24.1
24.1
13.8
%
17.2
3
1
4
1
0
5
2
2
3
5
9
6
5
7
8
4
10
9
6
1
5
5
N
9
3.4
14.3
3.6
0
17.2
6.9
7.1
10.3
17.2
31.0
20.7
17.9
24.1
27.6
13.8
34.5
31.0
20.7
3.4
17.2
17.2
%
31.0
4
1
5
3
3
3
7
6
11
12
6
12
16
14
11
11
5
5
11
9
6
4
N
8
3.4
17.9
10.7
10.3
10.3
24.1
21.4
37.9
41.4
20.7
41.4
57.1
48.3
37.9
37.9
17.2
17.2
37.9
31.0
20.7
13.8
%
27.6
5
6
1
0
2
1
8
3
1
4
4
3
1
5
6
6
6
2
7
6
4
5
N
4
20.7
3.6
0
6.9
3.4
27.6
10.7
3.4
13.8
13.8
10.3
3.6
17.2
20.7
20.7
20.7
6.9
24.1
20.7
13.8
17.2
%
13.8
6
1
1
0
2
0
2
0
0
0
0
1
0
0
0
1
1
0
2
0
0
0
3.4
3.6
0
6.9
0
6.9
0
0
0
0
3.4
0
0
0
3.4
3.4
0
6.9
0
0
0
Always
7
N
%
0
0
180
Topics
Comprehensive musculoskeletal examination
Differential diagnosis
Joint injection
Use of NSAIDs
Use of corticosteroids
Managing common musculoskeletal conditions
Psychosocial aspects of ULDs
Medico legal aspects of ULDs
Work relatedness of ULDs
Advice on activity level during recovery
Ergonomics
Communication skills with management
Solid evidence-based guidelines
Complementary medicine
Mean
5.43
5.32
3.68
3.11
3.48
5.18
5.36
5.64
6.00
5.68
5.64
4.68
6.32
3.61
S.D.
1.620
1.492
2.127
1.641
1.602
1.517
1.569
1.339
1.122
1.249
1.224
1.867
.772
1.750
Min
2
2
1
1
1
2
2
2
3
3
2
2
5
1
Max
7
7
7
7
7
7
7
7
7
7
7
7
7
7
Not at all
interested
1
N
%
0
0
0
0
4 14.3
3 10.7
1
3.7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
7.1
Table A3.16 TOP level of interest in continuing medical education topics
N
3
2
7
8
8
2
2
1
0
0
1
5
0
8
%
10.7
7.1
25.0
28.6
29.6
7.1
7.1
3.6
0
0
3.4
17.9
0
28.6
2
N
1
1
4
9
6
0
1
0
1
1
0
3
0
4
%
3.6
3.6
14.3
32.1
22.2
0
3.6
0
3.6
3.6
0
10.7
0
14.3
3
N
2
4
5
5
7
9
6
6
3
5
3
6
0
5
%
7.1
14.3
17.9
17.9
25.9
32.1
21.4
21.4
10.7
17.9
10.7
21.4
0
17.9
4
N
6
8
0
0
1
5
4
3
2
6
8
4
5
6
%
21.4
28.6
0
0
3.7
17.9
14.3
10.7
7.1
21.4
28.6
14.3
17.9
21.4
5
N
7
5
3
0
2
4
6
9
11
6
8
2
9
0
%
25.0
17.9
10.7
0
7.4
14.3
21.4
32.1
39.3
21.4
28.6
7.1
32.1
0
6
Extremely
Interested
7
N
%
9 32.1
8 28.6
5 17.9
3 10.7
2
7.4
8 28.6
9 32.1
9 32.1
11 39.3
10 35.7
8 28.6
8 28.6
14 50.0
3 10.7
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Effective management of upper limb disorders by general practitioners and trainee occupational physicians
HSE BOOKS