Elaine Thomas

Occupational risk factors for shoulder pain: a systematic review

OBJECTIVES To systematically evaluate the available evidence on occupational risk factors of shoulder pain. METHODS Relevant reports were identified by a systematic search of Medline, Embase, Psychlit, Cinahl, and Current Contents. The quality of the methods of all selected publications was assessed by two independent reviewers using a standardised checklist. Details were extracted on the study population, exposures (physical load and psychosocial work environment), and results for the association between exposure variables and shoulder pain. RESULTS 29 Studies were included in the review; three case-control studies and 26 cross sectional designs. The median method score was 60% of the maximum attainable score. Potential risk factors related to physical load and included heavy work load, awkward postures, repetitive movements, vibration, and duration of employment. Consistent findings were found for repetitive movements, vibration, and duration of employment (odds ratio (OR) 1.4–46 in studies with method scores ⩾ 60%). Nearly all studies that assessed psychosocial risk factors reported at least one positive association with shoulder pain, but the results were not consistent across studies for either high psychological demands, poor control at work, poor social support, or job dissatisfaction. Studies with a method score ⩾60% reported ORs between 1.3 and 4.0. Substantial heterogeneity across studies for methods used for exposure assessment and data analysis impeded statistical pooling of results. CONCLUSIONS It seems likely that shoulder pain is the result of many factors, including physical load and the psychosocial work environment. The available evidence was not consistent across studies, however, and the associations were generally not strong. Future longitudinal research should evaluate the relative importance of each individual risk factor and the role of potential confounding variables—such as exposure during leisure time—to set priorities for the prevention of shoulder pain in occupational settings.

Predicting who develops chronic low back pain in primary care: a prospective study.

Abstract Objectives: To quantify the relative contribution of premorbid and episode specific factors in determining the long term persistence of disabling symptoms of low back pain. Design:Prospective cohort study. Setting: Two general practices in the south Manchester area. Participants: 180 patients, who previously participated in a cross sectional population survey, who consulted because of low back pain during the study period. They were followed at 1 week and 3 and 12 months after consultation. Main outcome measure: Persistent disabling low back pain in the 12 months after the consultation. Results: Disabling low back pain persisted in one third of participants after consultation and was more common with increasing age, among those with a history of low back pain, and in women. Persistence of symptoms was associated with “premorbid” factors (high levels of psychological distress (odds ratio 3.3; 95% confidence interval 1.5 to 7.2), poor self rated health (3.6; 1.9 to 6.8), low levels of physical activity (2.8; 1.4 to 5.6), smoking (2.1; 1.0 to 4.3), dissatisfaction with employment (2.4; 1.3 to 4.5)) and factors related to the episode of low back pain (duration of symptoms, pain radiating to the leg (2.6; 1.3 to 5.1), widespread pain (6.4; 2.7 to 15), and restriction in spinal mobility). A multivariate model based on six factors identified groups whose likelihood of persistent symptoms ranged from 6% to 70%. Conclusions: The presence of persistent low back pain is determined not only by clinical factors associated with pain but also by the premorbid state

Risk factors for neck pain: a longitudinal study in the general population

&NA; The objective of the study was to examine the 1‐year cumulative incidence of episodic neck pain and to explore its associations with individual risk factors, including a history of previous neck injury. A baseline cross‐sectional survey of an adult general population sample made up of all 7669 adults aged 18–75 years, registered with two family practices in South Manchester, United Kingdom, identified the study population of adults with no current neck pain. This study population was surveyed again 12 months later to identify all those who had experienced neck pain during the follow‐up period. At follow‐up, cumulative 1‐year episode incidence of neck pain was estimated at 17.9% (95% confidence interval 16.0–19.7%). Incidence was independent of age, but was more common in women. A history of previous neck injury at baseline was a significant risk factor for subsequent neck pain in the follow‐up year (risk ratio 1.7, 95% confidence interval 1.2–2.5), independent of gender and psychological status. Other independent baseline risk factors for subsequent neck pain included number of children, poor self‐assessed health, poor psychological status and a past history of low back pain. We have carried out a prospective study in a general population sample and demonstrated that established risk factors for chronic pain predict future episodes of neck pain, and shown that in addition a history of neck injury is an independent and distinct risk factor. This finding may have major public health and medicolegal implications.

A Consensus Approach Toward the Standardization of Back Pain Definitions for Use in Prevalence Studies

Study Design. A modified Delphi study conducted with 28 experts in back pain research from 12 countries. Objective. To identify standardized definitions of low back pain that could be consistently used by investigators in prevalence studies to provide comparable data. Summary of Background Data. Differences in the definition of back pain prevalence in population studies lead to heterogeneity in study findings, and limitations or impossibilities in comparing or summarizing prevalence figures from different studies. Methods. Back pain definitions were identified from 51 articles reporting population-based prevalence studies, and dissected into 77 items documenting 7 elements. These items were submitted to a panel of experts for rating and reduction, in 3 rounds (participation: 76%). Preliminary results were presented and discussed during the Amsterdam Forum VIII for Primary Care Research on Low Back Pain, compared with scientific evidence and confirmed and fine-tuned by the panel in a fourth round and the preparation of the current article. Results. Two definitions were agreed on a minimal definition (with 1 question covering site of low back pain, symptoms observed, and time frame of the measure, and a second question on severity of low back pain) and an optimal definition that is made from the minimal definition and add-ons (covering frequency and duration of symptoms, an additional measure of severity, sciatica, and exclusions) that can be adapted to different needs. Conclusion. These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Risk of malignancy among patients with rheumatic conditions

Previous studies have described an increased risk of malignancy in subjects diagnosed with rheumatic conditions, most notably rheumatoid arthritis (RA). Our aim was to quantify and compare risks for site‐specific malignancy among hospitalized patients with RA, osteoarthritis (OA) and other rheumatic conditions in a nationwide, population‐based cohort. Subjects were identified from Scottish hospital in‐patient records from 1981 to 1996 and followed up by computer linkage of the Scottish Cancer Registry and the national registry of deaths. Expected cancer incidence was calculated from national cancer rates and related to the observed incidence by the standardized incidence ratio (SIR). Among RA patients, there was an increased risk for hematopoietic [males SIR= 2.13, 95% confidence interval (CI) 1.7–2.7; females SIR = 1.76, 95% CI 1.5–2.1], lung (males SIR = 1.32, 95% CI 1.2–1.5; females SIR = 1.44, 95% CI 1.3–1.6) and prostate (SIR = 1.26, 95% CI 1.0–1.6) cancers. Reduced risk were seen for colorectal cancer (males SIR = 0.87, 95% CI 0.7–1.1; females SIR = 0.71, 95% CI 0.6–0.9) and, among females, stomach cancer (SIR = 0.70, 95% CI 0.5–1.0). The excess risk for hematopoietic cancer and the reduced risk for colorectal and stomach cancers were sustained over 10 years of follow‐up. An overall decreased risk of cancer was observed for patients with OA; the greatest reductions were observed for colorectal (males SIR = 0.88, 95% CI 0.8–1.0; females SIR = 0.84, 95% CI 0.8–0.9), stomach (males SIR = 0.79, 95% CI 0.7–0.9; females SIR = 0.66, 95% CI 0.6–0.8) and lung (males SIR = 0.72, 95% CI 0.7–0.8; females SIR = 0.84, 95% CI 0.8–0.9) malignancies, with decreased risks generally still evident at 10 years of follow‐up. Our results support several previous findings regarding the incidence of hematopoietic and colorectal malignancies in RA patients. In addition, we have shown a large decrease in stomach cancer among patients with OA and females with RA that warrants further investigation since it may provide clues to possible prevention strategies. To further our knowledge about the underlying mechanisms of altered risk in cancer patients with rheumatic conditions, population studies requiring primary data collection are required. Int. J. Cancer 88:497–502, 2000.

Psychologic distress and low back pain. Evidence from a prospective study in the general population.

Study Design The present is a prospective population-based cohort study. Objectives To determine whether psychologic distress in patients free of low back pain predicts future new episodes of such pain. Summary of Background Data An association between symptoms of depression and anxiety and low back pain has been described in cross-sectional studies. It is unclear whether this represents cause or effect or whether it is found only in chronic pain sufferers attending specialist clinics. There is a need to investigate this prospectively in the general population. Methods The study population was 4501 adults aged 18–75 years who responded to a questionnaire survey mailed to all those registered with two family practices in the United Kingdom. The survey inquired about low back pain during the previous month and included the 12-item General Health Questionnaire, a validated schedule for measuring psychologic distress in the general population. New episodes of low back pain during the 12 months after the survey were identified by two methods-continuous monitoring of all primary care consulters and a second postal survey at the end of the 12-month period to determine occurrences for which consultation had not been sought. Results Among 1638 subjects free of current low back pain in the baseline survey, the likelihood of developing a new episode of nonconsulting low back pain was higher among those with General Health Questionnaire scores in the upper third of the range compared with the lower third (adjusted odds ratio, 1.8[1.4, 2.4]). This could not be explained either by age and gender differences or by general physical health. The increased risk persisted when analysis was restricted to those who at baseline could not recall ever having had low back pain in the past and to those with full-time employment. Conclusion Symptoms of psychologic distress in individuals without back pain predict the subsequent onset of new episodes of low back pain. We calculate from these data that the proportion of new episodes of low back pain that might be attributable to such psychologic factors in the general population is 16%.

Illness perceptions of low back pain patients in primary care: What are they, do they change and are they associated with outcome?

&NA; We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire (IPQ‐R). Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ) and patients’ global rating of change. Associations between patients, perceptions and poor outcome were analysed using unadjusted and adjusted risk ratios (RR) and 95% confidence intervals. 1591 completed questionnaires were received at baseline and 810 at 6 months. Patients had a mean age of 44 years and 59% were women. Mean (SD) RMDQ score at baseline was 8.6 (6.0) and 6.2 (6.1) at 6 months. 52% and 41% of patients had a poor clinical outcome at 6 months using RMDQ and global rating scores, respectively. There were strong, statistically significant, associations (RRs of 1.4 and over) between IPQ‐R baseline consequences, timeline acute/chronic, personal control and treatment control scores and poor outcome. Patients who expected their back problem to last a long time, who perceived serious consequences, and who held weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes 6 months after they consulted their doctor. These results have implications for the management of patients, and support the need to assess and address patients’ cognitions about their back problems.

Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care

&NA; Many psychological factors have been suggested to be important obstacles to recovery from low back pain, yet most studies focus on a limited number of factors. We compared a more comprehensive range of 20 factors in predicting outcome in primary care. Consecutive patients consulting 8 general practices were eligible to take part in a prospective cohort study; 1591 provided data at baseline and 810 at 6 months. Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ). The relative strength of the baseline psychological measures to predict outcome was investigated using adjusted multiple linear regression techniques. The sample was similar to other primary care cohorts (mean age 44 years, 59% women, mean baseline RMDQ 8.6). The 20 factors each accounted for between 0.04% and 33.3% of the variance in baseline RMDQ score. A multivariate model including all 11 scales that were associated with outcome in the univariate analysis accounted for 47.7% of the variance in 6 months RMDQ score; rising to 55.8% following adjustment. Four scales remained significantly associated with outcome in the multivariate model explaining 56.6% of the variance: perceptions of personal control, acute/chronic timeline, illness identify and pain self‐efficacy. When all independent factors were included, depression, catastrophising and fear avoidance were no longer significant. Thus, a small number of psychological factors are strongly predictive of outcome in primary care low back pain patients. There is clear redundancy in the measurement of psychological factors. These findings should help to focus targeted interventions for back pain in the future.

Weak association between subjective symptoms of and objective testing for dry eyes and dry mouth: results from a population based study

OBJECTIVES To determine associations between symptoms of dry eyes and dry mouth and objective evidence of lacrimal and salivary gland dysfunction in a population based sample. To determine associations between these elements and the presence of autoantibodies. METHODS A cross sectional population based survey. Subjects were interviewed and examined (Schirmer-1 test and unstimulated salivary flow) for the presence of dry eyes and mouth. Antibodies (anti-Ro [SS-A], anti-La [SS-B], rheumatoid factor, antinuclear antibody) were measured. RESULTS 341 subjects were examined. Twenty four per cent had dry eye symptoms, 29% dry mouth symptoms, and 14% both. There was only a weak association between the presence of oral or ocular symptoms and their respective test results. Associations were strongest between dry mouth symptoms and positive test results, and in subjects under 55 years of age. There was no association between the presence of autoantibodies and either symptoms or signs of dry eyes or dry mouth. CONCLUSION Only weak associations were found between self reported symptoms of dry eyes and dry mouth and objective measures said to define Sjögrens syndrome in the general population. The clinical significance of these symptoms in the community needs reappraisal.

Psychosocial factors in the workplace--do they predict new episodes of low back pain? Evidence from the South Manchester Back Pain Study.

Study Design. A prospective, population‐based cohort study of working adults. Objectives. To determine whether work‐related psychosocial factors and social status predict the occurrence of new episodes of low back pain and influence consultation behavior. Summary and Background Data. Dissatisfaction with work and social status has been associated with low back pain in several studies; few of these studies have been prospective or population based. Methods. An initial postal survey was returned by 4,501 (59%) adults (18‐75 years old) registered with two primary care practices. From this, a cohort of 1,412 people currently in employment and free of low back pain was identified, and baseline information on work‐related psychosocial factors and psychologic distress was obtained. Social class was derived from current occupation using a standardized classification. New episodes of low back pain occurring in the next 12 months were identified by continuous monitoring of primary care consulters and by mailing a second questionnaire a year later to identify occurrences of low back pain for which no consultation was sought. Results. The baseline cross‐sectional survey showed modest but significant associations between low back pain and perceived inadequacy of income (risk ratio 1.3), dissatisfaction with work (risk ratio 1.4) and social class IV/V (risk ratio 1.2). In the follow‐up year, the risk of reporting low back pain for which no consultation was sought doubled in those dissatisfied with their work. Both perceived inadequacy of income (odds ratio 3.6) and social class IV/V (odds ratio 4.8) were strongly associated with consulting with a new episode of low back pain during the follow‐up year, an association more marked in women. The associations with work dissatisfaction and perceived adequacy of income were not explained by general psychologic distress or social status. Conclusion. People dissatisfied with work are more likely to report low back pain for which they do not consult a physician, whereas lower social status and perceived inadequacy of income are independent risks for working people to seek consultation because of low back pain.