HSEHealth & 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

HSEHealth & 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

© Crown copyright 2005

First published 2005

ISBN 0 7176 6158 X

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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.

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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 ......................................................................................................................... 22.2 Search Strategy.................................................................................................................... 22.3 Musculoskeletal Education ................................................................................................. 32.4 Diagnosis of ULDs.............................................................................................................. 62.5 General Management of Work Related Musculoskeletal Disorders ................................... 62.6 Carpal Tunnel Syndrome .................................................................................................... 92.7 Epicondylitis Medial and Lateral ...................................................................................... 122.8 Rotator Cuff Tendonitis and Bicipital Tendonitis ............................................................. 182.9 Shoulder Capsulitis ........................................................................................................... 192.10 Impingement Syndrome .................................................................................................. 202.11 Tenosynovitis and Flexor-extensor Peritendonitis of the Hand and Forearm ................. 212.12 Tendonitis of the Wrist and Forearm .............................................................................. 222.13 De Quervain’s Disease .................................................................................................... 222.14 Cervical Spondylosis....................................................................................................... 23 2.15 Diffuse Non-Specific Upper Limb Disorders ................................................................. 242.16 Tension Neck .................................................................................................................. 252.17 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 ........................................................................... 403.2 Postgraduate Deaneries ..................................................................................................... 423.3 Training for Occupational Physicians in the UK .............................................................. 433.4 Other Training opportunities ............................................................................................. 43

4. Focus Group Analysis and Findings ....................................................................................... 44

4.1 Reasons for the Qualitative Enquiry ................................................................................. 444.2 Method ............................................................................................................................. 444.3. Focus Group Results ....................................................................................................... 46 4.4. Discussion ....................................................................................................................... 68

5. Questionnaire Survey .............................................................................................................. 77

5.1 Introduction ....................................................................................................................... 775.2 Methodology ..................................................................................................................... 775.3 Results ............................................................................................................................... 775.4 Discussion ....................................................................................................................... 110

6. Recommendations ................................................................................................................. 114

6.1 Training ........................................................................................................................... 1146.2 Clinical management....................................................................................................... 1156.3 Perceived difficulties in managing upper limb disorders ................................................ 1156.4 Training needs ................................................................................................................. 115

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Appendix 1 Focus Group Content Analysis.............................................................................. 117

Appendix 2. Questionnaires Used in Questionnaire Survey ..................................................... 136

Appendix 3 Questionnaire Data ................................................................................................ 165

References ................................................................................................................................. 181

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INDEX OF TABLESTable 1 Diagnostic and surveillance criteria for carpal tunnel syndrome ..................................... 9Table 2 Diagnostic and surveillance criteria for medial and lateral epicondylitis ...................... 13Table 3 Diagnostic and surveillance criteria for rotator cuff syndrome...................................... 18and bicipital tendonitis ................................................................................................................ 18Table 4 Diagnostic and surveillance criteria for shoulder capsulitis........................................... 19Table 5 Diagnostic and surveillance criteria for tenosynovitis ................................................... 21Table 6 Diagnostic and surveillance criteria for de Quervain’s disease ..................................... 23Table 7 Diagnostic and surveillance criteria for diffuse non-specific upper limb disorders....... 24Table 8 Summary of evidence..................................................................................................... 27 Table 9 Formal training in musculoskeletal disorders ................................................................ 42Table 10 Informal (on-the-job) training in musculoskeletal disorders........................................ 43Table 11 Training in musculoskeletal disorders.......................................................................... 78Table 12 Sources of vocational upper limb musculoskeletal disorders training ......................... 78Table 13 Treatment options for tenosynovitis............................................................................. 80Table 14 Treatment options for tendonitis .................................................................................. 80Table 15. Treatment options for carpal tunnel syndrome ........................................................... 81Table 16 Treatment options for de Quervain’s disease ............................................................... 81Table 17 Treatment options for epicondylitis ............................................................................. 82Table 18 Treatment options for rotator cuff syndrome and bicipital tendonitis.......................... 82Table 19 Treatment options for shoulder capsulitis .................................................................... 82Table 20 Treatment options for cervical spondylosis ................................................................. 83Table 21 Treatment options for impingement syndrome ............................................................ 83Table 22 Treatment options for tension neck .............................................................................. 84Table 23 Treatment options for diffuse non-specific upper limb disorders ................................ 84Table 24 Contact with occupational physician............................................................................ 85Table 25 Referrals for musculoskeletal problems ....................................................................... 85Table 26 Barriers when referring patients ................................................................................... 89Table 27 Training in musculoskeletal disorders.......................................................................... 93Table 28 Sources of vocational upper limb musculoskeletal disorders training ......................... 93Table 29 Courses undertaken in relation to upper limb disorders............................................... 94Table 30 Previous job.................................................................................................................. 95Table 31 Treatment options for tenosynovitis............................................................................. 96Table 32 Treatment options for hand/forearm tendonitis............................................................ 96Table 33 Treatment options for carpal tunnel syndrome ............................................................ 97Table 34 Treatment options for de Quervain’s disease ............................................................... 97Table 35 Treatment options for epicondylitis ............................................................................. 98Table 36 Treatment options for rotator cuff syndrome and bicipital tendonitis.......................... 98Table 37 Treatment options for shoulder capsulitis .................................................................... 99Table 38 Treatment options for cervical spondylosis ................................................................. 99Table 39 Treatment options for impingement syndrome .......................................................... 100Table 40 Treatment options for tension neck ............................................................................ 100Table 41 Treatment options for diffuse non-specific upper limb disorders .............................. 101Table 42 Do you initiate contact with patient’s GP .................................................................. 101Table 43 Referrals for musculoskeletal problems ..................................................................... 102Table 44. Barriers when referring patients ................................................................................ 107

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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.................................................................................................................................................... 119Table A1.3 Content analysis of the ‘ULD management’ dimension based on the GPs’ quotes.

Table A1.4 Content analysis of the ‘best practice’ dimension based on the Occupational

Table A1.7. Content analysis of the ‘training’ dimension based on the Occupational Physicians’

Table A1.10 Content analysis of the ‘informal learning’ dimension based on the Occupational

Table A1.11 Content analysis of the ‘informal learning’ dimension based on the TOPs’ quotes.

Table A1.12 Content analysis of the ‘informal learning’ dimension based on the GPs’ quotes.

Table A1.13 Content analysis of the ‘evidence base’ dimension based on the Occupational

Table A1.16 Content analysis of the ‘perceived difficulties’ dimension based on the

Table A1.17 Content analysis of the ‘perceived difficulties’ dimension based on the TOPs’

Table A1.18 Content analysis of the ‘perceived difficulties’ dimension based on the GPs’

Table A1.19 Content analysis of the ‘training needs’ dimension based on the Occupational

................................................................................................................................................... 121

Physicians’ quotes. .................................................................................................................... 122Table A1.5 Content analysis of the ‘best practice’ dimension based on the TOPs’ quotes. .... 123Table A1. 6. Content analysis of the ‘best practice’ dimension based on the GPs’ quotes...... 123

quotes. ....................................................................................................................................... 124Table A1.8 Content analysis of the ‘training’ dimension based on the TOPs’ quotes.............. 125Table A1.9 Content analysis of the ‘training’ dimension based on the GPs’ quotes. ............... 126

Physicians’ quotes. .................................................................................................................... 127

................................................................................................................................................... 127

................................................................................................................................................... 128

Physicians’ quotes. .................................................................................................................... 129Table A1.14 Content analysis of the ‘evidence base’ dimension based on the TOPs’ quotes. . 129Table A1.15. Content analysis of the ‘evidence base’ dimension based on the GPs’ quotes. . 130

Occupational Physicians’ quotes. .............................................................................................. 131

quotes. ....................................................................................................................................... 132

quotes. ....................................................................................................................................... 133

Physicians’ quotes. .................................................................................................................... 133Table A1.20 Content analysis of the ‘training needs’ dimension based on the TOPs’ quotes.. 134Table A1.21 Content analysis of the ‘training needs’ dimension based on the GPs’ quotes. ... 135Table A3.1 GP training in upper limb musculoskeletal disorders............................................. 165Table A3.2 GP training in work related upper limb musculoskeletal disorders ....................... 166Table A3.3 GP sources of information in professional development ...................................... 167Table A3.4 GP level of confidence with different aspects of upper limb management............ 168Table A3.5 GP evidence base in the choice of treatment of musculoskeletal disorders ........... 169Table A3.6 GP perceived difficulties in establishing a diagnosis ............................................. 170Table A3.7 GP difficulties in managing upper limb disorders.................................................. 171Table A3.8 GP level of interest in continuing medical education topics .................................. 172Table A3.9 TOP training in upper limb musculoskeletal disorders .......................................... 173Table A3.10 TOP training in work related upper limb musculoskeletal disorders ................... 174Table A3.11 TOP sources of information in professional development ................................... 175Table A3.12 TOP level of confidence with different aspects of upper limb management ....... 176Table A3.13 TOP evidence base in the choice of treatment of musculoskeletal disorders....... 177Table A3.14 TOP perceived difficulties in establishing a diagnosis......................................... 178Table A3.15 TOP difficulties in managing upper limb disorders ............................................. 179Table A3.16 TOP level of interest in continuing medical education topics.............................. 180

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INDEX OF FIGURES Figure 1. Teaching Functioning Musculoskeletal System ......................................................... 40Figure 2. Teaching Musculoskeletal Abnormalities................................................................... 41Figure 3. Teaching of WRMDs .................................................................................................. 41Figure 4. Sources of Information Used in Professional Development ....................................... 79Figure 5. Level of Confidence with Different Aspects of Upper Limb Management................ 86Figure 6. Evidence Base in your Choice of Treatment of Musculoskeletal Disorders............... 87Figure 7. Perceived Difficulties in Establishing a Diagnosis ..................................................... 88Figure 8. Difficulties in Managing Upper Limb Disorders ........................................................ 89Figure 9. Level of interest in Continuing Medical Education Topics ........................................ 91Figure 10. Sources of Information Used in Professional Development ..................................... 94Figure 11. Level of Confidence with Different Aspects of Upper Limb Management............ 103Figure 12. Evidence Base in the Choice of Treatment of Upper Limb Disorders.................... 104Figure 13. Perceived Difficulties in Establishing a Diagnosis ................................................. 105Figure 14. Difficulties in Managing Upper Limb Disorders .................................................... 106Figure 15. Level of Interest in Continuing Medical Education Topics .................................... 109

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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

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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).

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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.

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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.

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• 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

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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

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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 intra-articular 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.

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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 work-related 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.

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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

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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 long-term 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

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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 (23). 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.

2.6 CARPAL TUNNEL SYNDROME

2.6.1 Diagnostic criteria

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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

(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 Symptoms Surveillance Criteria Time Rule

Harrington et al (16) A clinical syndrome Pain, or paraesthesia, or caused by compression sensory loss in the median of the median nerve as nerve distribution and one of: it passes through the Tinel’s test positive, Phalen’s carpal tunnel test positive, nocturnal

exacerbation of symptoms, motor loss with wasting of abductor pollicis brevis, and abnormal nerve conduction times

Sluiter et al (18) Intermittent At least one of the following Symptoms now or paraesthesia or pain in tests positive: - on at least 4 days at least 2 digits, I, II or Flexion compression test during the last 7 III; either may be Carpal compression test present at night as well Tinel’s sign (allowing pain in the Phalen’s test palm, wrist or radiation Two-point discrimination test proximal to the wrist) Resisted thumb abduction or

motor loss with wasting of abductor pollicis brevis muscle

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

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(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.

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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.

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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).

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Table 2 Diagnostic and surveillance criteria for medial and lateral epicondylitis Author Symptoms Surveillance Criteria Time Rule

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)

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.

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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

al Regarding iontophoresis, two randomised controlled trials were found. In the first, by Nirschl et

(43), 199 patients suffering from elbow epicondylitis participated in a multicentre, randomised,

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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

2mJ/mm2 and half to only 30 pulses of 0.08 mJ/mm . 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,

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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

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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

(18)agreed by both Harrington et al (16) and Sluiter et al .

Table 3 Diagnostic and surveillance criteria for rotator cuff syndrome and bicipital tendonitis

Author Symptoms Surveillance Criteria Time Rule

Harrington et al (16) Symptomatic Rotator cuff: history of pain in the inflammation or deltoid region and pain on one or degeneration of the more resisted active movements rotator cuff or biceps (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

Sluiter et al (18) At least intermittent At least one of the following tests Symptoms now or pain in the shoulder positive: - on at least 4 days region without Resisted shoulder abduction, during the last 7 paraesthesia; pain external rotation, or internal worsened by active rotation elevation movement Resisted elbow flexion of the upper arm as in Painful arc on active upper arm scratching of the elevation upper back

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 Symptoms Surveillance Criteria

Harrington et al (16) A condition characterised by History of unilateral pain in current or past pain in the the deltoid area and equal upper arm, with global restriction of active and restriction of glenohumeral passive glenohumeral movement in a capsular movement in a capsular pattern 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. This however is a small study and needs to be further researched to confirm this outcome.

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

al The case definitions for tenosynovitis of the hand and forearm was agreed by both Harrington et

(16) and Sluiter et al (18)

Table 5 Diagnostic and surveillance criteria for tenosynovitis Author Symptoms Surveillance Criteria Time Rule

Harrington et al (16) Painful swelling of the Pain which is centred over the first extensor radial styloid and tender compartment swelling of the first extensor containing extensor compartment and either pain pollicis brevis and reproduced by resisted thumb adductor pollicis extension or positive longus Finkelstein’s test

Sluiter et al (18) Intermittent pain-ache Provocation of symptoms Symptoms now or on in the ventral or dorsal during resisted movement(s) at least 4 days during forearm or wrist of the muscles under the the last 7 region 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

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 Time Rule

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

At least one of the following tests positive: - Finkelstein’s test

of the wrist: either Resisted thumb extension may radiate proximally to the forearm or distally to the thumb

Resisted thumb abduction

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

(72), (73)factors and myelopathy of the cervical area (71), .

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 Symptoms Surveillance Criteria

Harrington et al (16) Pain in the forearm in Pain in the forearm and the absence of a failure to meet the diagnostic specific diagnosis or criteria for other specific pathology diagnoses and diseases

(sometimes includes loss of function, weakness, cramp, muscle tenderness, allodynia, slowing of fine (76)

movements

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

Tabl

e 8

Sum

mar

y of

evi

denc

eG

ener

al M

anag

emen

t of W

RU

LD

s A

utho

r Tr

eatm

ent

Out

com

e M

easu

res

Evi

denc

e Q

ualit

y of

Evi

denc

e O

’Nei

l et a

l (19)

Pr

ogno

sis l

ess g

ood

with

lo

nger

dur

atio

n of

sy

mpt

oms

Sum

mar

y Pa

per

No

evid

ence

giv

en

Not

app

licab

le

Hag

berg

(20)

N

SAID

s A

cupu

nctu

re

Ster

oid

Inje

ctio

n W

orkp

lace

Mod

ifica

tion

Job

Cha

nges

Te

chni

que

Trai

ning

Educ

atio

nal P

aper

N

o ev

iden

ce g

iven

N

ot a

pplic

able

Tre

atm

ent o

f Chr

onic

Ten

don

Inju

ries

O

’Nei

l et a

l (19)

R

ICE

(res

t, ic

e,co

mpr

essi

on a

nd e

leva

tion)

Su

mm

ary

Pape

r N

o ev

iden

ce g

iven

N

ot a

pplic

able

Pain

Man

agem

ent P

rogr

amm

es

Joha

nsso

n et

al (2

1)

Cog

nitiv

e B

ehav

iour

al

Prog

ram

me

N

=85

Ran

dom

ised

Con

trolle

d O

utco

me

Stud

y

Occ

upat

iona

l Act

ivity

Sick

ness

Abs

ence

Follo

w-u

p at

one

yea

r

Occ

upat

iona

l Act

ivity

incr

ease

d N

o di

ffer

ence

at

one

mon

th.

Sign

ifica

nt re

duct

ion

in

pain

inte

nsity

and

se

verit

y, in

terf

eren

ce.

And

life

con

trol

mea

sure

s. Si

ckne

ss

abse

nce

decr

ease

d si

gnifi

cant

ly

Lim

ited

evid

ence

but

sm

all n

umbe

rs

27

Aut

hor

Trea

tmen

t O

utco

me

Mea

sure

s E

vide

nce

Qua

lity

of E

vide

nce

Mar

hold

et a

l (22)

C

ogni

tive

Beh

avio

ural

Th

erap

y fo

r ind

ivid

uals

with

ch

roni

c ba

ck, n

eck

and

shou

lder

pai

n N

=72

Ran

dom

ised

Cro

ss O

ver 2

x2

desi

gn

Sick

ness

abs

ence

Pre

-trea

tmen

t 2

mon

ths p

ost t

reat

men

t 4

mon

ths p

ost t

reat

men

t 6

mon

ths p

ost t

reat

men

t

Sign

ifica

nt d

ecre

ase

in

shor

t-ter

m si

ckne

ss

abse

nce.

No

sign

ifica

ntdi

ffer

ence

s in

long

term

si

ckne

ss a

bsen

ce

Som

e Ev

iden

ce fo

r im

pact

in sh

ort-t

erm

si

ckne

ss a

bsen

ce

Kar

jala

inen

et a

l (23)

Rev

iew

Pap

er in

clud

ing

two

pape

rs.

EMG

Bio

feed

back

Rel

axat

ion

Imag

ery

Vs

EMG

biof

eedb

ack

and

rela

xatio

n V

sR

elax

atio

n N

=48

Hyp

nosi

s with

bio

feed

back

an

d au

toge

nics

N

=32

Pain

inte

nsity

mea

sure

s

Pain

inte

nsity

on

VA

S sc

ale

No

sign

ifica

nt d

iffer

ence

s

Pain

inte

nsity

si

gnifi

cant

ly lo

wer

ed in

th

e in

terv

entio

n gr

oup

Lim

ited

evid

ence

but

is

sue

of p

oor s

tudy

de

sign

Lim

ited

evid

ence

and

is

sue

of p

oor s

tudy

de

sign

28

Car

pal T

unne

l Syn

drom

eA

utho

r Tr

eatm

ent

Out

com

e M

easu

res

Evi

denc

e Q

ualit

y of

Evi

denc

e G

iele

(29)

Ger

ritse

n et

al (2

5)

NSA

IDs a

nd a

nalg

esic

s Sy

stem

atic

Rev

iew

Syst

emat

ic R

evie

w

RC

T of

NSA

IDs v

s D

iure

tics v

s ora

l ste

roid

s vs

pla

cebo

: onl

y st

eroi

d re

duce

d sy

mpt

oms

No

curr

ent e

vide

nce

that

N

SAID

s mor

e ef

fect

ive

than

pla

cebo

s

Goo

d

Goo

d

Ger

ritse

n et

al (2

5)

Ster

oids

(Ora

l and

Inje

ctio

n)

Syst

emat

ic R

evie

w

Loca

l inj

ectio

nsi

gnifi

cant

ly im

prov

ed

sym

ptom

s at o

ne-m

onth

Goo

d bu

t no

long

-term

fo

llow

-up

Ger

ritse

n et

al (2

5)

Dav

is e

t al (3

1)

Ger

ritse

n (26)

Phys

ical

The

rapi

es

Chi

ropr

acty

, wris

t sup

port

and

ultra

soun

d vs

NSA

IDs

and

wris

t sup

ports

Splin

ting

vs O

pen

Car

pal

Tunn

el re

leas

e R

CT

N=1

76

Self-

repo

rted

men

tal a

nd p

hysi

cal d

istre

ss, n

erve

co

nduc

tion

and

finge

r sen

satio

n

Follo

w-u

p 18

mon

ths

Phys

ioth

erap

y ex

amin

atio

n, q

uest

ionn

aire

at 3

, 6

and

12 m

onth

s

No

sign

ifica

nt d

iffer

ence

fo

und

At 1

8 m

onth

s sur

gery

had

a

bette

r lon

g te

rm

outc

omes

than

splin

ting

Non

e

Goo

d bu

t con

foun

ders

in

the

splin

ting

grou

p

29

Car

pal T

unne

l Syn

drom

e (C

ontin

ued)

Auth

or

Trea

tmen

t O

utco

me

Mea

sure

s Ev

iden

ce

Qua

lity

of E

vide

nce

Feue

rste

in e

t al (

27)

Gar

finke

l et a

l (32)

Phys

ical

The

rapi

es (c

ont)

Sum

mar

y o

f Res

earc

h Pa

per

Exer

cise

and

Stre

tchi

ng

Ran

ge o

f mot

ion

exer

cise

s vs

splin

ting

N=5

0

Yog

a re

gim

e vs

wris

t spl

int

and

curr

ent t

reat

men

t R

CT

N=4

2

Follo

w-u

p at

one

mon

th M

ovem

ent

Dis

turb

ed sl

eep,

pai

n in

tens

ity, P

hale

n’s s

ign,

Ti

nel’s

sign

, grip

stre

ngth

and

ner

ve c

ondu

ctio

n

Wris

t ext

ensi

on

sign

ifica

ntly

impr

oved

af

ter 3

wee

ks

Impr

oved

ner

ve

cond

uctio

n bu

t not

st

atis

tical

ly si

gnifi

cant

Goo

d bu

t sho

rt-te

rm

resu

lts

Poor

- S

mal

l stu

dy a

nd

no c

ontro

l mea

sure

s in

the

grou

p w

earin

g sp

lints

.

Eben

bich

ler e

t al (3

3)

Ultr

asou

ndR

ando

mis

ed “

sham

” co

ntro

lled

trial

N

=34

Subj

ectiv

e co

mpl

aint

s, se

nsor

y lo

ss, n

erve

co

nduc

tivity

and

phy

sica

l fun

ctio

ning

2

wee

ks, 7

wee

ks a

nd 6

mon

ths

Impr

oved

ner

ve

cond

uctio

n an

d su

bjec

tive

sym

ptom

s

Lim

ited

Evid

ence

–

mor

e w

ork

requ

ired

Ger

ritse

n et

al(2

5)

Lase

r Acu

punc

ture

Li

tera

ture

revi

ew

Lim

ited

evid

ence

that

so

ft la

ser a

cupu

nctu

re is

m

ore

effe

ctiv

e th

an

plac

ebo

Gie

le e

t al(2

9)

Her

bert

et a

l (28)

W

orkp

lace

Inte

rven

tions

In

clud

ing

job

chan

ge,

incr

ease

d re

st p

erio

ds, b

ette

r er

gono

mic

s

Littl

e ev

iden

ce d

ue to

la

ck o

f goo

d re

sear

ch

30

Epi

cond

yliti

s (M

edia

l and

Lat

eral

) A

utho

r Tr

eatm

ent

Out

com

e M

easu

res

Evi

denc

e Q

ualit

y of

Evi

denc

e

Hey

et a

l (37)

Gre

en e

t al (3

8)

NSA

IDs

Prag

mat

ic ra

ndom

ised

co

ntro

l tria

l of s

tero

id

inje

ctio

n vs

NSA

IDs a

nd

sim

ple

anal

gesi

cs

N=1

64 n

ew e

piso

de p

atie

nts

Coc

hran

e R

evie

w

Glo

bal a

sses

smen

t by

parti

cipa

nts,

pain

seve

rity,

pa

in fr

ee g

rip st

reng

th (L

iker

t sca

les)

M

easu

red

at 4

wee

ks a

nd 1

2 m

onth

s

The

use

of N

SAID

s for

trea

ting

late

ral e

lbow

pa

in

A tw

o w

eek

cour

se o

f N

SAID

s is n

o be

tter t

han

plac

ebo

Som

e su

ppor

t for

the

use

of to

pica

l NSA

IDs i

n th

e sh

ort-t

erm

relie

f of l

ater

al

elbo

w p

ain.

Ins

uffic

ient

ev

iden

ce to

supp

ort t

he

use

of o

ral N

SAID

s

Goo

d

Goo

d

Hey

et a

l (37)

Ster

oid

Inje

ctio

n

Prag

mat

ic ra

ndom

ised

co

ntro

l tria

l of s

tero

id

inje

ctio

n vs

NSA

IDs a

nd

sim

ple

anal

gesi

cs

N=1

64 n

ew e

piso

de p

atie

nts

Glo

bal a

sses

smen

t by

parti

cipa

nts,

pain

seve

rity,

pa

in fr

ee g

rip st

reng

th (L

iker

t sca

les)

Mea

sure

d at

4 w

eeks

and

12

mon

ths

Ster

oid

inje

ctio

n w

as

sign

ifica

ntly

bet

ter t

han

NSA

IDs o

r pla

cebo

at 4

w

eeks

No

sign

ifica

nt d

iffer

ence

s at

one

yea

r

Goo

d

31

Epi

cond

yliti

s (M

edia

l and

Lat

eral

) con

tinue

d A

utho

r Tr

eatm

ent

Out

com

e M

easu

res

Evi

denc

e Q

ualit

y of

Evi

denc

e

Smid

t et a

l (39)

Phys

ioth

erap

y

Phys

ioth

erap

y vs

ster

oid

inje

ctio

n vs

wai

t-and

-see

po

licy

RC

T, N

=185

Seve

rity

of m

ain

com

plai

nt, p

ain

durin

g th

e da

y,

inco

nven

ienc

e Se

verit

y of

elb

ow c

ompl

aint

s and

elb

ow

disa

bilit

y.

Out

com

e m

easu

res m

ade

at 6

, 12,

26

and

52

wee

ks

Ster

oid

inje

ctio

ns w

ere

best

trea

tmen

t in

the

shor

t te

rmA

t lon

g–te

rm fo

llow

up,

ph

ysio

ther

apy

was

the

best

trea

tmen

t fol

low

ed

by w

ait-a

nd –

see

polic

y

Goo

d

Nirs

ch e

t al (4

3)

Bas

kurt

et a

l (44)

Iont

opho

resi

s A

cute

sym

ptom

s D

exam

etha

sone

Sod

ium

Ph

osph

ate

by Io

ntop

hore

sis

vs p

lace

boR

CT,

N=1

99

Nap

roxe

n by

topi

cal

iont

opho

resi

s R

CT,

N=6

1

VA

S Sc

ore

Pain

seve

rity

Foun

d si

gnifi

cant

resu

lts

in fa

vour

of i

onto

phor

esis

bu

t sid

e ef

fect

s rep

orte

d

No

sign

ifica

nt d

iffer

ence

s fo

und

Goo

d

Poor

- O

ther

trea

tmen

t m

etho

ds a

lso

used

in

clud

ing

phys

ioth

erap

y so

resu

lts c

onfo

unde

d

Seeg

ensh

mie

dt a

nd

Kei

lhol

z (4

5)

Bas

ford

et a

l (46)

Rad

iatio

n/La

ser T

hera

py

Ioni

sing

Rad

iatio

n Th

erap

y C

ase

Rep

orts

N

=85

Low

leve

l las

er ir

radi

atio

n vs

pla

cebo

RC

T, N

=52

Pain

Sym

ptom

s 1

year

follo

w-u

p

Pain

in la

st 2

4 ho

urs,

bene

fit b

y pa

tient

Sign

ifica

nt im

prov

emen

t in

pai

n sy

mpt

oms i

n 74

%

of c

ases

Trea

tmen

t Eff

ectiv

e

Goo

d bu

t tre

atm

ent

shou

ld o

nly

be u

sed

afte

r con

vent

iona

l m

easu

res f

ail

Goo

d bu

t sm

all s

ampl

e

32

Epi

cond

yliti

s (M

edia

l and

Lat

eral

) con

tinue

d A

utho

r Tr

eatm

ent

Out

com

e M

easu

res

Evi

denc

e Q

ualit

y of

Evi

denc

e

Rom

pe e

t al (4

8)

Rom

pe e

t al (4

9)

Haa

ke e

t al (4

7)

Mel

ikya

n et

al (5

0)

Shoc

kwav

e Th

erap

y

ESW

T, 3

000

puls

es v

s 30

puls

esC

ontro

lled

Pros

pect

ive

Stud

y, N

=100

ESW

T an

d m

anua

l the

rapy

of

the

cerv

ical

spin

e vs

ES

WT

in c

hron

ic c

ases

Pr

ospe

ctiv

e si

ngle

-blin

d co

ntro

lled

N=1

27

ESW

T an

d lo

cal a

naes

thes

iavs

pla

cebo

and

ana

esth

esia

Pr

ospe

ctiv

e ra

ndom

ised

pl

aceb

o co

ntro

lled

trial

N

=246

ESW

T vs

pla

cebo

Ran

dom

ised

dou

ble-

blin

d pl

aceb

o-co

ntro

lled

stud

y N

=74

Grip

stre

ngth

, Pai

n se

verit

y, p

alpa

tion,

cha

ir te

st,

resi

sted

fing

er e

xten

sion

at 3

, 6 a

nd 2

4 w

eeks

Pain

mea

sure

s: T

he R

oles

and

Mau

dsle

y ou

tcom

e sc

ore

at 1

2 m

onth

s

Pain

mea

sure

s: th

e R

oles

and

Mau

dsle

y at

12

wee

ks a

nd 1

2 m

onth

follo

w-u

p

Dis

abili

ties Q

uest

ionn

aire

, grip

stre

ngth

, pai

n,

anal

gesi

c us

age

and

rate

of p

rogr

essi

on to

su

rger

y

Red

uced

pai

n an

d im

prov

ed fu

nctio

n in

the

high

er p

ulse

d gr

oup

No

sign

ifica

nt d

iffer

ence

be

twee

n gr

oups

– b

oth

show

ed a

sign

ifica

nt

impr

ovem

ent

No

sign

ifica

nt d

iffer

ence

s be

twee

n th

e gr

oups

and

im

prov

emen

t obs

erve

d in

tw

o th

irds o

f pat

ient

s at

12 m

onth

s

No

sign

ifica

ntdi

ffer

ence

s bet

wee

n gr

oups

Poor

, con

foun

ded

by

patie

nts n

ot b

linde

d no

r ra

ndom

isat

ion

effe

ct

repo

rted

Poor

, lac

k of

con

trol o

n ES

WT

and

cerv

ical

m

anip

ulat

ion.

Pat

ient

s no

t ran

dom

ised

Goo

d, E

SWT

inef

fect

ive

Goo

d, n

o ev

iden

ce th

at

ESW

T is

bet

ter t

han

a pl

aceb

o

33

Epi

cond

yliti

s (M

edia

l and

Lat

eral

) con

tinue

d A

utho

r Tr

eatm

ent

Out

com

e M

easu

res

Evi

denc

e Q

ualit

y of

Evi

denc

e

Fink

et a

l (51)

Gre

en e

t al (5

2)

Acu

punc

ture

Acu

punc

ture

vs s

ham

ac

upun

ctur

eR

CT

inve

stig

ator

and

pa

tient

blin

ded

N=5

5

Coc

hran

e R

evie

w

Acu

punc

ture

for t

reat

ing

late

ral e

lbow

pai

n

Max

imal

stre

ngth

, pai

n in

tens

ity a

nd d

isab

ility

sc

ale

at 2

wee

ks a

nd 2

mon

ths p

ost-t

reat

men

t

Syst

emat

ic R

evie

w

At 2

wee

ks, s

igni

fican

tly

redu

ced

pain

inte

nsity

and

in

crea

sed

arm

func

tion

and

stre

ngth

A

t 2 m

onth

s, on

ly th

e ar

m

func

tion

was

sign

ifica

ntly

im

prov

ed

Four

RC

Ts re

view

ed.

Som

e ev

iden

ce to

supp

ort

need

le a

cupu

nctu

re in

the

shor

t-ter

m –

24

hour

s

Lim

ited

evid

ence

–

no c

ontro

l gro

up a

nd

smal

l num

bers

Insu

ffic

ient

evi

denc

e to

su

ppor

t or r

efut

e th

e us

e of

nee

dle

or la

ser

acup

unct

ure

34

Rot

ator

Cuf

f Ten

doni

tis a

nd B

icip

ital T

endo

nitis

A

utho

r Tr

eatm

ent

Out

com

e M

easu

res

Evi

denc

e Q

ualit

y of

Evi

denc

e

Bar

tolo

zzi e

t al (5

6)

NSA

IDS

Com

bine

d tre

atm

ents

in

clud

ed p

hysi

cal t

hera

py,

loca

l ste

roid

inje

ctio

n an

d N

SAID

s N

=136

14 c

linic

al o

utco

me

mea

sure

s at 6

mon

ths

and

18 m

onth

s A

t 6 m

onth

s, 46

% o

f pa

tient

s had

exc

elle

ntor

goo

d re

sults

; at 1

8 m

onth

s, 47

/68

patie

nts

diag

nose

d w

ith c

hron

ic

impi

ngem

ent s

yndr

ome

Sugg

ests

pat

ient

ssh

ould

und

ergo

18

mon

ths o

f con

serv

ativ

e tre

atm

ent.

Pape

run

clea

r on

how

pat

ient

s w

ere

allo

cate

d -

Lim

ited

as d

esig

n qu

estio

nabl

e an

dnu

mbe

rs sm

all

Gre

en e

t al (5

7)

Coc

hran

e R

evie

w

Syst

emat

ic re

view

for

inte

rven

tions

on

shou

lder

pa

in

Syst

emat

ic R

evie

w

NSA

IDs a

nd

Suba

crom

ial s

tero

id

inje

ctio

n m

ay im

prov

e ra

nge

of m

ovem

ent i

n ro

tato

r cuf

f syn

drom

e m

ore

than

a p

lace

bo

Lim

ited

evid

ence

–

mor

e go

od q

ualit

y re

sear

ch n

eede

d

35

Shou

lder

Cap

sulit

is

Aut

hor

Trea

tmen

t O

utco

me

Mea

sure

s E

vide

nce

Qua

lity

of E

vide

nce

Gam

et a

l (59)

St

eroi

d In

ject

ion

Dis

tens

ion

and

gluc

ortic

oid

vs g

luco

rtico

id a

lone

N

=20

Func

tiona

l mov

emen

t, pa

in, d

aily

use

of

anal

gesi

cs a

t 3, 6

and

12

wee

ks

Impr

ovem

ent i

n fu

nctio

nal m

ovem

ent a

nd

decr

ease

in a

nalg

esic

use

w

ith sh

ould

er d

iste

nsio

n an

d gl

ucor

ticoi

d

Smal

l sam

ple

– m

ore

rese

arch

requ

ired

De

Jong

et a

l (60)

32

pat

ient

s 10m

g of

tri

amci

nolo

ne a

ceto

nide

in

ject

ion

vs 2

5 pa

tient

s with

40

mg

triam

cino

lone

ac

eton

ide

inje

ctio

n

Pain

, sle

ep d

istu

rban

ce, f

unct

iona

lm

ovem

ent

Sign

ifica

nt re

duct

ion

in

pain

and

func

tiona

l im

pairm

ent i

n th

e hi

gh

does

gro

upH

ighe

r doe

s lev

el m

ore

effe

ctiv

e bu

t thi

s may

not

be

the

optim

um d

osag

e

Lim

ited

evid

ence

–

num

bers

smal

l

Gre

en e

t al (5

7)

Coc

hran

e R

evie

w

Syst

emat

ic R

evie

w fo

r in

terv

entio

ns o

n sh

ould

er

pain

Syst

emat

ic R

evie

w

Littl

e ev

iden

ce to

su

ppor

t or r

efut

e ef

ficac

y of

con

serv

ativ

etre

atm

ents

for s

houl

der

caps

uliti

s

36

Impi

ngem

ent S

yndr

ome

Aut

hor

Trea

tmen

t O

utco

me

Mea

sure

s E

vide

nce

Qua

lity

of E

vide

nce

Mor

rison

(64)

R

etro

spec

tive

stud

y of

616

pa

tient

s con

serv

ativ

ely

man

aged

via

phy

sica

l th

erap

y an

d N

SAID

s

Shou

lder

-Rat

ing

Scal

e of

the

Uni

vers

ity o

f C

alifo

rnia

at L

os A

ngel

es

At f

ollo

w-u

p ap

poin

tmen

ts 6

7% o

f pa

tient

s had

a sa

tisfa

ctor

y ou

tcom

e an

d 28

% w

ere

reco

mm

ende

d fo

r sur

gery

Poor

- In

cons

iste

nt in

fo

llow

-up

times

as

they

rang

ed fr

om 6

­81

mon

ths

Lude

wig

and

Bor

stad

(61)

H

ome

exer

cise

pr

ogra

mm

e fo

r con

stru

ctio

n w

orke

rs.

Parti

cipa

nts

rand

omly

allo

cate

d Tr

eatm

ent g

roup

N=3

5 C

ontro

l gro

up N

=33

Asy

mpt

omat

ic G

roup

N=2

5

Shou

lder

-Rat

ing

Que

stio

nnai

re p

re a

nd p

ost

treat

men

t bet

wee

n 8

and

12 w

eeks

Si

gnifi

cant

impr

ovem

ent i

n tre

atm

ent g

roup

vs

cont

rol g

roup

Lim

ited

evid

ence

but

sm

all n

umbe

rs in

volv

ed

in th

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39

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.

0

4

8

12

16

20

Num

ber

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-by-year data is presented in Figure 2. Sixteen (73%) of the respondents reported tackling the subject in more than one year.

40

20N

umbe

r

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.

0

4

8

12

16

20

Num

ber

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 Number of responses Four week residential course and distance learning 2 Diploma in Sports and Training Injuries 2 Four day course British Association of Sports Medicine 1 Joint injection course 1 day 3 Hand problem lecture 1.5 hours 1 The knee and shoulder lecture 2 One afternoon dedicated to rheumatology 2 One afternoon dedicated to occupational health 2 Four sessions a year on musculoskeletal medicine 1 Orthopaedic up-dates 1 Half a day on musculoskeletal disease 1 Half a day on chronic pain management 1 Episodic Sports Medicine and Rheumatology Courses 1 Two to three afternoons with Rheumatologists and 4 Physiotherapists Day release 1

42

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 Number of Responses Only if raised as a learner-centred need 9 Largely opportunistic 2 Informal tutorials 1 Case presentations 1 During hospital component of vocational training 1 During GP registration exposed to significant musculoskeletal load 1 Specific on-the-job training 1 Vocational training on back pain 1 All common conditions covered 1

3.3 TRAINING FOR OCCUPATIONAL PHYSICIANS IN THE UK There are a number of routes for training for Occupational Medicine in the UK. The Diploma in Occupational Medicine is available from 8 centres within the UK. This is an introductory course for those with an interest in Occupational Medicine and equips the individual as a generalist in occupational medicine. The core syllabus for the diploma does cover the musculoskeletal system, epidemiology and ergonomics.

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

(83,84).relevant methodology sources on qualitative interviewing

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

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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.

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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.

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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!

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…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.

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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.

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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.

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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.

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[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

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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.

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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 done- and 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.

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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.

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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?

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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

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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 decision-making with regards to the management of their ULD.

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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.

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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.

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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 in internet

version]. Textbooks; surgical orthopaedic, rheumatology or for general practice…

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.

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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. Long waiting time or lack of facilities for physio.

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.

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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

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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

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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

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rotating internships or in family practice training programmes (1), which was reflected on TOPs and GPs quotes.

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

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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).

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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 all- embracing 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

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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 .

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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).

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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.

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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.

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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

Upper limb musculoskeletal Work Related Upper limb disorders musculoskeletal disorders Mean S.D. Min Max Mean S.D. Min Max

Musculoskeletal training during medical 2.81 1.302 1 6 1.81 1.281 1 6 school During House Officer years 2.56 1.523 1 6 1.72 1.276 1 6 During Registrar years 2.79 1.612 1 6 1.86 1.281 1 7 Continuing Medical Education 4.41 1.500 1 7 3.66 1.945 1 7

Range on questionnaire 1-7

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 N % Orthopaedics 20 62.5 Rheumatology 14 43.8 Sports Medicine 9 28.1 Rehabilitation Medicine 2 6.3 Occupational Health 10 31.3 None 0 0 Other 6 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 CD-ROMs and other Professional Groups.

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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

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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 N % Second Treatment Option N % NSAIDs 10 31.3 Physiotherapy 11 34.4 Rest, NSAIDs 6 18.8 NSAIDs 6 18.8 Rest 3 9.4 Steroid Injection 4 12.5 Rest, NSAIDs and Splinting 3 9.4 Steroid Injection, Physiotherapy 2 6.3 Splinting and NSAIDs 2 6.3 Steroid Injection, Splinting 1 3.1 RICE, NSAIDs 1 3.1 Stronger NSAIDs, more rest 1 3.1 Rest, Time 1 3.1 Splint 1 3.1 Remove cause, RICE, NSAIDs 1 3.1 Referral to Rheumatology 1 3.1 Rest, Strapping 1 3.1 PCM/NSAIDs 1 3.1 Physiotherapy, NSAIDs 1 3.1 Rest 1 3.1 Rest then rehabilitation Exercises 1 3.1 Referral 1 3.1 Physiotherapy 1 3.1 Physiotherapy, Strapping 1 3.1

Table 14 Treatment options for tendonitis

First Treatment Option N % Second Treatment Option N % NSAIDs 11 34.4 Physiotherapy 19 59.4 Rest, NSAIDs 6 18.8 NSAIDs 4 12.5 Rest, NSAIDs and Splinting 3 9.4 Referral 3 9.4 NSAIDs and Splint 2 6.3 Steroid Injection 2 6.3 Rest then rehabilitation Exercises 1 3.1 Rest, Time 1 3.1 NSAIDs, paracetomal 1 3.1 RICE, NSAIDs 1 3.1 Steroid 1 3.1 Rest, avoidance of precipitating factors 1 3.1 Stronger NSAIDs, more rest 1 3.1 Physiotherapy 1 3.1 Rest 1 3.1 Remove cause, RICE and NSAIDs 1 3.1 Rest, Strapping 1 3.1

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Table 15. Treatment options for carpal tunnel syndrome

First Treatment Option N % Second Treatment Option N % NSAIDs 8 25.0 Steroid Injection 13 40.6 Splint 2 6.3 Referral 3 9.4 Steroid Injection 2 6.3 Refer Orthopaedics 3 9.4 Referral 2 6.3 Refer for nerve conduction studies 2 6.3 NSAIDs, Splinting 2 6.3 Splinting 2 6.3 Rest, NSAIDs and Splinting 2 6.3 Injection, surgical release 1 3.1 Nerve conduction studies for 1 3.1 Physiotherapy and nerve conduction 1 3.1 confirmation Rest 1 3.1 Physiotherapy 1 3.1 NSAIDs and Cortisone 1 3.1 Night Splint, Analgesia 1 3.1 Splinting, Physiotherapy 1 3.1 Check Thyroid Function 1 3.1 Rest, time, blood testing 1 3.1 Advice, NSAIDs, blood testing 1 3.1 Surgical Decompression 1 3.1 Remove Cause 1 3.1 Referral to Hand Surgeon 1 3.1

Table 16 Treatment options for De Quervain’s disease

First Treatment Option N % Second Treatment Option N % NSAIDs 12 37.5 Steroid Injection 12 37.5 NSAIDs, Rest 6 18.8 Physiotherapy 4 12.5 Rest then structured rehabilitation 1 3.1 Splinting 3 9.4 Splinting 1 3.1 Referral 3 9.4 Physiotherapy 1 3.1 Injection in Tendon Sheath 2 6.3 Rest, NSAIDs and Splinting 1 3.1 NSAIDs 2 6.3 Remove cause, RICE, NSAIDs 1 3.1 Refer Orthopaedics 1 3.1 Physiotherapy, NSAIDs 1 3.1 Refer Rheumatology 1 3.1 Steroid Injection 1 3.1 Injection or surgical release 1 3.1 Rest 1 3.1 Rest, Analgesia 1 3.1 Rest, time 1 3.1 Refer Orthopaedics 1 3.1 NSAIDs, Splinting 1 3.1 Refer for injection 1 3.1

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Table 17 Treatment options for epicondylitis

First Treatment Option N % Second Treatment Option N % NSAIDs 13 40.6 Steroid Injection 20 62.5 Rest 3 9.4 Steroid injection or physiotherapy 4 12.5 Rest, NSAIDs 3 9.4 Injection (if patients choice) 1 3.1 Physiotherapy, NSAIDs 1 3.1 Physiotherapy, steroid injection 1 3.1 Avoidance, Paracetomal, NSAIDs 1 3.1 Referral 1 3.1 NSAIDs, Injection 1 3.1 NSAIDs and referral 1 3.1 NSAIDs gel 1 3.1 Physiotherapy 1 3.1 Rest, analgesia 1 3.1 Physiotherapy and refer to GP colleague 1 3.1 NSAIDs, oral and topical 1 3.1 Forearm clasp, NSAIDs 1 3.1 Remove cause, RICE and NSAIDs 1 3.1 Steroid/local anaesthetic injection 1 3.1 Steroid Injection 1 3.1 Advice 1 3.1 Splinting 1 3.1 Rest, NSAIDs, Splinting 1 3.1 Rest, time 1 3.1

Table 18 Treatment options for rotator cuff syndrome and bicipital tendonitis

First Treatment Option N % Second Treatment Option N % NSAIDs 13 40.6 Steroid Injection 12 37.5 NSAIDs, Rest 5 15.6 Physiotherapy 6 18.8 Physiotherapy 4 12.5 NSAIDs 2 6.3 NSAIDs, injection 1 3.1 Referral to physiotherapy or rheumatology 1 3.1 Advice 1 3.1 Rheumatology advice 1 3.1 NSAIDs and Analgesia 1 3.1 Specialist Referral 1 3.1 NSAIDs and Physiotherapy 1 3.1 Refer to GP Colleague 1 3.1 Rest, Physiotherapy 1 3.1 Steroid Injection or physiotherapy 1 3.1 Physiotherapy, Steroid Injection 1 3.1 Steroid Injection, ultrasound 1 3.1 Rest, time, analgesia 1 3.1 Cortisone Injection, physiotherapy 1 3.1 Exercise, analgesia 1 3.1 Refer Rheumatology 1 3.1 NSAIDs, rest, splinting 1 3.1 Injection and lidocaine 1 3.1

Table 19 Treatment options for shoulder capsulitis

First Treatment Option N % Second Treatment Option N % NSAIDs 13 40.6 Steroid Injection 13 40.6 Physiotherapy 5 15.6 Physiotherapy 4 12.5 Rest, NSAIDs 4 12.5 Steroid Injection, Physiotherapy 3 9.4 Rest 1 3.1 NSAIDs 2 6.3 Steroid Injection 1 3.1 Referral to Shoulder Surgeon 1 3.1 NSAIDs and advice 1 3.1 REF Manipulation under general anaesthetic 1 3.1 NSAIDs and analgesia 1 3.1 Rheumatology Referral 1 3.1 Rest, time 1 3.1 Injection and lidocaine 1 3.1 NSAIDs, Exercise 1 3.1 Local Steroid 1 3.1 NSAIDs, Injection 1 3.1 Refer to GP Colleague 1 3.1 Analgesia and Injection x 3 1 3.1 Physiotherapy, Refer Orthopaedics 1 3.1 Rest, NSAIDs, Splinting 1 3.1 Injection (if patient’s choice) 1 3.1

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Table 20 Treatment options for cervical spondylosis

First Treatment Option N % Second Treatment Option N % NSAIDs 11 34.4 Physiotherapy 16 50.0 Analgesia 6 18.8 NSAIDs 4 12.5 Physiotherapy 4 12.5 Rheumatology Referral 2 6.3 Education, exercise 1 3.1 Simple Analgesia 1 3.1 Analgesia, muscle relaxants 1 3.1 Nil 1 3.1 Analgesia, keeping mobile 1 3.1 Refer Orthopaedics 1 3.1 Advice, simple analgesics 1 3.1 NSAIDs, dependent on age 1 3.1 NSAIDs, McKenzie Exercises 1 3.1 Soft Collar 1 3.1 Paracetomal 1 3.1 Osteopathy 1 3.1 Exercise Regime 1 3.1 Referral 1 3.1 NSAIDs and Physiotherapy 1 3.1 Physiotherapy, collar 1 3.1 Rest, Advice, Orthopaedic Pillow 1 3.1 ?

Table 21 Treatment options for impingement syndrome

First Treatment Option N % Second Treatment Option N % NSAIDs 7 21.9 Physiotherapy 5 18.8 Physiotherapy 7 21.9 NSAIDs 3 9.4 Steroid Injection 3 9.4 Referral 3 9.4 Analgesia 2 6.3 Refer Orthopaedics 3 9.4 What is this? 1 3.1 Steroid Injection 3 9.4 Exercise, NSAIDs 1 3.1 Rheumatology Referral 2 6.3 Rest, time, analgesia 1 3.1 Steroid Injection, Physiotherapy 2 6.3 NJAIO 1 3.1 Specialist Referral 1 3.1 Collar, X-ray 1 3.1 Soft Collar, Physiotherapy 1 3.1 Rest, analgesia 1 3.1 Refer Orthopaedics and Physiotherapy 1 3.1 NSAIDs and Physiotherapy 1 3.1 Refer to GP Colleague 1 3.1 Injection 1 3.1

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Table 22 Treatment options for tension neck

First Treatment Option N % Second Treatment Option N % NSAIDs 6 18.8 Physiotherapy 12 37.5 Analgesia 4 12.5 Antidepressants 2 6.3 Physiotherapy 3 9.4 Analgesia 1 3.1 Exercise 2 6.3 Alexander Technique Exercises 1 3.1 ? 2 6.3 Exercise 1 3.1 Relaxation Techniques 2 6.3 Physiotherapy and antidepressants 1 3.1 Ergonomic Advice 1 3.1 Osteopathy 1 3.1 NSAIDs, Physiotherapy 1 3.1 Exercise, relaxation 1 3.1 Rest 1 3.1 Muscle Relaxants 1 3.1 Rest, time 1 3.1 Stress Management 1 3.1 Manage 1 3.1 Nil 1 3.1 Advice on neck care, self-help 1 3.1 Analgesia, massage 1 3.1 Analgesia, muscle relaxants 1 3.1 Stronger analgesic 1 3.1 Muscle Relaxants 1 3.1 Antidepressants, analgesia 1 3.1 Rest, analgesia and relaxation 1 3.1 Exercise, education, analgesia 1 3.1

Table 23 Treatment options for diffuse non-specific upper limb disorders

First Treatment Option N % Second Treatment Option N % NSAIDs 7 21.9 Physiotherapy 10 31.3 Analgesia 6 18.8 Referral 3 9.4 Physiotherapy 3 9.4 NSAIDs 3 9.4 NSAIDs, rest 2 6.3 Analgesia 2 6.3 Exercise 1 3.1 Antidepressants 2 6.3 What is this? 1 3.1 Muscle relaxants 1 3.1 Investigation, analgesia 1 3.1 ? 1 3.1 Relaxation therapy 1 3.1 Nil 1 3.1 Exercise, yoga 1 3.1 Psychotherapy 1 3.1 Rest 1 3.1 Psychology 1 3.1 Reassurance, analgesia 1 3.1 Rheumatology Referral 1 3.1 Exercise, review 1 3.1 NSAIDs, focal exercises 1 3.1 Rest, analgesia 1 3.1 Stronger Refer Orthopaedics 1 3.1 NSAIDs, analgesia 1 3.1 Assess case, analgesia 1 3.1

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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 N % Yes sometimes 11 34.4 Yes rarely 8 25.0 No 4 12.5 Yes always 4 12.5 Not applicable 3 9.4 Advise Patient to attend 1 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 N % Orthopaedics 29 90.6 Rheumatology 23 71.9 Physiotherapy 32 100.0 Occupational Therapy 5 15.6 Counselling 4 12.5 Rehabilitation 3 9.4 Cognitive Behavioural Therapy 3 9.4 Employment Service 3 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.

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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

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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.

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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

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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.

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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 Waiting time Travel Not Not sure Not barrier unacceptably distance available if applicable

long too far available Specialist N % N % N % N % N % N % Rheumatology 8 25.0 24 75.0 * * * * * * * * Orthopaedics 8 25.0 24 75.0 * * * * * * * * Physiotherapy 21 65.6 11 34.4 * * * * * * * * Rehabilitation 2 6.3 13 40.6 * * 6 18.8 10 31.3 * * Occupational Therapy 8 25.0 11 34.4 * * 4 12.5 8 25.0 * * Employment Service 4 12.5 2 6.3 * * 6 18.8 16 49.9 * * Cognitive Behavioural 1 3.1 16 50.0 1 3.1 7 21.9 5 15.6 1 3.1 Therapy

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

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the role of other physical therapies including Chiropracty and Osteopathy. Additional comments were:

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.

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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

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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

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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 Work Related Upper limb disorders musculoskeletal disorders Mean S.D. Min Max Mean S.D. Min Max

Musculoskeletal skeletal training during 2.24 1.244 1 6 1.66 1.111 1 6 medical school During your House Officer years 2.00 0.926 1 4 1.31 0.541 1 3 During your Registrar years 2.68 1.244 1 6 1.90 1.205 1 4 During your Occupational Health trainee 4.11 1.553 1 7 4.22 1.695 1 7 years Continuing Medical Education 4.43 1.399 2 7 4.25 1.602 1 7

Range on questionnaire 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 N % Orthopaedics 12 41.4 Rheumatology 15 51.7 Sports Medicine 7 24.4 Rehabilitation Medicine 5 17.2 Occupational Health 23 79.3 None 1 3.4 Other 9 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.

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Table 29 Courses undertaken in relation to upper limb disorders

Course N % Diploma, advance diploma in occupational medicine 13 44.8 None 3 10.3 Disability Assessment 2 6.8 MSc in Occupational Health 1 3.4 Society of Occupational Medicine Meetings 1 3.4 Sports Medicine 1 3.4 Only in rheumatology 1 3.4 HAVS course 1 3.4 Occupational Health SMASHER course 1 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.

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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 N % Consultant Physician 1 3.4 GP 22 75.9 GP Military 1 3.4 GP Disability Analysis 1 3.4 GP Ophthalmology Assistant 1 3.4 GP Medical Manager 1 3.4 GP and Rheumatology 1 3.4 S.H.O. Orthopaedics 1 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.

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Table 31 Treatment options for tenosynovitis

First Treatment Option N % Second Treatment Option N % Rest, NSAIDs 6 20.7 Physiotherapy 13 44.8 Rest 5 17.2 Referral 2 6.9 Temporary removal from work 1 3.4 Steroid Injection 2 6.9 NSAIDs 1 3.4 NSAIDs 2 6.9 Ice, NSAIDs 1 3.4 NSAIDs, Physiotherapy 1 3.4 Load reduction at workstation 1 3.4 Refer to rheumatology 1 3.4 NSAIDs, avoid precipitant agent 1 3.4 Education and training 1 3.4 Physiotherapy 1 3.4 Refer to GP 1 3.4 Rest, physiotherapy, job rotation 1 3.4 Referral for injections 1 3.4 NSAIDs, analgesia 1 3.4 Medication 1 3.4 Reduce usage, wrist support 1 3.4 Ergonomic workplace assessment 1 3.4 Manual therapy 1 3.4 Change of job, physiotherapy 1 3.4 Work adjustment and 1 3.4 physiotherapy Workplace 1 3.4 assessment/modification NSAIDs, physiotherapy 1 3.4 Employment limitations 1 3.4 Avoid repetitive activity 1 3.4 Rotation of work 1 3.4 Rest, ergonomic assessment, advice 1 3.4

Table 32 Treatment options for hand/forearm tendonitis

First Treatment Option N % Second Treatment Option N % Rest 6 20.7 Physiotherapy 13 44.8 Rest, NSAIDs 7 24.0 NSAIDs 3 10.3 NSAIDs 2 6.9 Referral 2 6.9 Work adjustment, physiotherapy 1 3.4 Education and training 1 3.4 Workplace 1 3.4 NSAIDs, Physiotherapy 1 3.4 assessment/modification Light job, muscle strengthening 1 3.4 Refer to GP 1 3.4 exercises Employment limitations, 1 3.4 Steroid Injection 1 3.4 physiotherapy and rest Load reduction 1 3.4 Refer to GP, NSAIDs 1 3.4 NSAIDs, avoid precipitating 1 3.4 Medication 1 3.4 factors Rest, NSAIDs 1 3.4 Ergonomic workplace assessment 1 3.4 Physiotherapy 1 3.4 Change of job, physiotherapy 1 3.4 Rest, physiotherapy, job rotation 1 3.4 Refer to Rheumatology 1 3.4 Temporary removal from work 1 3.4 Ice, NSAIDs 1 3.4 Work assessment, redeployment 1 3.4 Rest, ergonomic assessment, advice 1 3.4 NSAIDs, analgesia, reduce usage, 1 3.4 wrist support Manual Therapy 1 3.4

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Table 33 Treatment options for carpal tunnel syndrome

First Treatment Option N % Second Treatment Option N % Rest 4 13.8 Nerve conduction studies 3 10.3 Splint 2 6.9 Refer for Surgery 3 10.3 NSAIDs 2 6.9 Physiotherapy 2 6.9 Referral for surgery 1 3.4 Referral 2 6.9 Conservative treatment 1 3.4 Steroid injection 2 6.9 Splint and rest 1 3.4 Workplace assessment 2 6.9 NSAIDs, analgesia 1 3.4 Diuretics, surgery 1 3.4 Nerve conduction study, 1 3.4 NSAIDs 1 3.4 reassurance NSAIDs, avoid precipitating 1 3.4 Splint 1 3.4 factors Avoid repetitive wrist movements 1 3.4 Rest 1 3.4 Rest, physiotherapy, job rotation 1 3.4 Refer to GP, splint 1 3.4 Temporary removal from work 1 3.4 Refer to GP 1 3.4 Work assessment, redeployment 1 3.4 Diuretics, physiotherapy 1 3.4 Work adjustment, referral 1 3.4 Physiotherapy, splinting 1 3.4 Refer to orthopaedics 1 3.4 Injection or decompression 1 3.4 NSAIDs, splint 1 3.4 Steroid injection 1 3.4 NSAIDs, rest and employment 1 3.4 limitations Medication 1 3.4 Wait and see, referral 1 3.4 Work restriction 1 3.4 Manual therapy 1 3.4

Table 34 Treatment options for De Quervain’s disease

First Treatment Option N % Second Treatment Option N % Rest 6 20.7 Physiotherapy 7 24.1 Rest, NSAIDs 5 17.2 Steroid injection 3 10.3 NSAIDs 2 6.9 Refer to Orthopaedics 3 10.3 NSAIDs, review job 1 3.4 Referral 2 6.9 Work adjustment, physiotherapy 1 3.4 NSAIDs 2 6.9 Avoid precipitating causes 1 3.4 Refer to Rheumatology 1 3.4 NSAIDs, analgesia 1 3.4 Alter work practices 1 3.4 NSAIDs, avoid precipitating 1 3.4 NSAIDs, Physiotherapy 1 3.4 factors Load reduction 1 3.4 Splint 1 3.4 Lighter job, physiotherapy 1 3.4 Refer to GP 1 3.4 Rest, physiotherapy, job rotation 1 3.4 Immobilisation 1 3.4 Temporary removal from work 1 3.4 Refer for injection 1 3.4 Work assessment, redeployment 1 3.4 Injection, splint 1 3.4 Workplace Assessment 1 3.4 Ergonomic workplace assessment 1 3.4 Rest, ergonomic assessment, advice 1 3.4 Referral, workplace assessment 1 3.4 Physiotherapy, eliminate cause 1 3.4 Medication 1 3.4 Referral for injection 1 3.4 Manual therapy 1 3.4

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Table 35 Treatment options for epicondylitis

First Treatment Option N % Second Treatment Option N % Rest, NSAIDs 6 20.7 Steroid injection 6 20.7 NSAIDs 5 17.2 Physiotherapy 5 17.2 Rest 3 10.3 Referral 3 10.3 Physiotherapy 2 6.9 Refer to GP 2 6.9 NSAIDs, keep active, support 1 3.4 Refer to Rheumatology 1 3.4 Work adjustment, physiotherapy 1 3.4 Alter work practices 1 3.4 Forearm strap 1 3.4 Steroid injection, physiotherapy, 1 3.4

clamp NSAIDs, avoid precipitating 1 3.4 Refer to Orthopaedics 1 3.4 factors Load reduction 1 3.4 Change of job, steroid injection 1 3.4 Work rotation 1 3.4 Steroid injection, liase with GP 1 3.4 NSAIDs, employment limitations, 1 3.4 Ergonomic workplace assessment 1 3.4 rest Workplace modification 1 3.4 Surgery 1 3.4 Rest, physiotherapy, job rotation 1 3.4 NSAIDs, physiotherapy, Injection 1 3.4 Temporary removal from work 1 3.4 Ergonomic workplace assessment 1 3.4 Avoid precipitating actions 1 3.4 Referral, workplace assessment 1 3.4 Conservative treatments, NSAIDs 1 3.4 Steroid injection 1 3.4 Rest, ergonomic assessment, advice 1 3.4 Medication 1 3.4 Temporary lighter job, 1 3.4 physiotherapy Manual therapy 1 3.4

Table 36 Treatment options for rotator cuff syndrome and bicipital tendonitis

First Treatment Option N % Second Treatment Option N % Physiotherapy 4 13.8 Steroid injection 8 27.6 Rest 3 10.3 Physiotherapy 4 13.8 NSAIDs 3 10.3 Referral 4 13.8 NSAIDs, avoid precipitating 1 3.4 NSAIDs. 2 6.9 factors NSAIDs, physiotherapy 1 3.4 Refer to Rheumatology 1 3.4 Load reduction 1 3.4 NSAIDs, physiotherapy 1 3.4 Work adjustment, physiotherapy, 1 3.4 Alter work practices 1 3.4 NSAIDs Rest, NSAIDs 1 3.4 Refer to GP 1 3.4 Explanation, advice 1 3.4 I.A. Injection 1 3.4 X-ray, NSAIDs, analgesia 1 3.4 Medication 1 3.4 Workplace assessment, duty 1 3.4 Ergonomic workplace assessment 1 3.4 modification I.A. Injection 1 3.4 Lighter job, physiotherapy 1 3.4 Workplace assessment 1 3.4 NSAIDs, physiotherapy, Injection 1 3.4 Conservative treatments NSAIDs 1 3.4 Ergonomic workplace assessment 1 3.4 Steroid injection 1 3.4 Referral, workplace assessment 1 3.4 Rest, ergonomic assessment, advice 1 3.4 Temporary removal from work, 1 3.4 physiotherapy Rest, NSAIDs, job rotation 1 3.4 Manual therapy 1 3.4

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Table 37 Treatment options for shoulder capsulitis

First Treatment Option N % Second Treatment Option N % Physiotherapy 4 13.8 Physiotherapy 6 20.7 NSAIDs 3 10.3 Steroid injection 5 17.2 Rest 3 10.3 Referral 5 17.2 Referral 1 3.4 NSAIDs 3 10.3 Work adjustment, physiotherapy 1 3.4 Refer to GP 2 6.9 Physiotherapy, employment 1 3.4 Medication 2 6.9 limitations, rest Work modification 1 3.4 NSAIDs, physiotherapy, injection 1 3.4 NSAIDs, physiotherapy 1 3.4 Surgery 1 3.4 NSAIDs, physiotherapy and work 1 3.4 Ergonomic workplace assessment 1 3.4 adjustment NSAIDs, avoid precipitating 1 3.4 Refer to Orthopaedics 1 3.4 factors Load reduction 1 3.4 Refer to Neurology 1 3.4 Rest, NSAIDs 1 3.4 Rotatory movements 1 3.4 Physiotherapy and advice 1 3.4 Workplace assessment and duty 1 3.4 modification I.A. Injection 1 3.4 Physiotherapy and steroid injection 1 3.4 Steroid injection 1 3.4 Temporary removal from work, 1 3.4 physiotherapy Rest, NSAIDs, job rotation 1 3.4 Manual therapy 1 3.4

Table 38 Treatment options for cervical spondylosis

First Treatment Option N % Second Treatment Option N % NSAIDs 6 20.7 Physiotherapy 13 44.8 Physiotherapy 4 13.8 Referral 4 13.8 Workplace assessment 2 6.9 Exercise, education 1 3.4 Rest 2 6.9 Surgical fixation 1 3.4 NSAIDs, avoid precipitating agent 1 3.4 Refer to Neurology 1 3.4 Load reduction 1 3.4 Ergonomic workplace assessment 1 3.4 Rest, NSAIDs, job rotation 1 3.4 Refer to GP 1 3.4 Exercise 1 3.4 Analgesia 1 3.4 NSAIDs, physiotherapy and work 1 3.4 Physiotherapy, collar 1 3.4 adjustment Analgesia 1 3.4 NSAIDs 1 3.4 Medication 1 3.4 Employment limitations, rest 1 3.4 Ergonomic assessment, advice 1 3.4 Work adjustment, physiotherapy 1 3.4 Analgesia, maintain mobility 1 3.4 Conservative, pain relief 1 3.4 Rest, NSAIDs 1 3.4 Manual Therapy 1 3.4

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Table 39 Treatment options for impingement syndrome

First Treatment Option N % Second Treatment Option N % Physiotherapy 5 17.2 Physiotherapy 8 27.6 NSAIDs 3 10.3 Steroid injection 3 10.3 Rest 2 6.9 Referral 3 10.3 Steroid injection 2 6.9 Refer to Orthopaedics 2 6.9 Employment limitations, rest 1 3.4 NSAIDs, Physiotherapy 1 3.4 NSAIDs, physiotherapy and work 1 3.4 Subacromial injection 1 3.4 adjustment NSAIDs, avoid precipitating 1 3.4 Steroid injection, ultrasound 1 3.4 factors Load reduction 1 3.4 Surgery 1 3.4 Rest, NSAIDs, job rotation 1 3.4 Medication 1 3.4 Work adjustment, physiotherapy 1 3.4 Ergonomic workplace assessment 1 3.4 Exercise 1 3.4 Refer to GP 1 3.4 Injection 1 3.4 Liase with GP 1 3.4 NSAIDs, physiotherapy 1 3.4 Ergonomic assessment, advice 1 3.4 Referral 1 3.4 Temporary removal from work 1 3.4 Workplace assessment 1 3.4 Redeployment, duty modification 1 3.4 Pain relief, physiotherapy 1 3.4 Manual therapy 1 3.4

Table 40 Treatment options for tension neck

First Treatment Option N % Second Treatment Option N % NSAIDs 4 13.8 Physiotherapy 9 31.0 Physiotherapy 4 13.8 NSAIDs 2 6.9 Analgesia 3 10.3 Referral 2 6.9 Workplace assessment 2 6.9 Medication 1 3.4 Identify psychological issues 1 3.4 Psychological assessment 1 3.4 NSAIDs, relaxation exercise 1 3.4 Refer to G.P 1 3.4 programme Ergonomic assessment, advice 1 3.4 Physiotherapy, antidepressants 1 3.4 Rest 1 3.4 Refer to Rheumatology 1 3.4 Rest, NSAIDs, workplace 1 3.4 Education 1 3.4 assessment Employment limitations, 1 3.4 Analgesia 1 3.4 physiotherapy, rest Exercise and advice 1 3.4 Manipulation 1 3.4 Antidepressants 1 3.4 Work adjustment, physiotherapy 1 3.4 NSAIDs, physiotherapy, workplace 1 3.4 Ergonomic workplace assessment 1 3.4 adjustments Rest, NSAIDs, job rotation 1 3.4 Counselling 1 3.4 Exercise 1 3.4 Analgesia, advice 1 3.4 Load reduction 1 3.4 Temporary removal from work 1 3.4 Manual therapy 1 3.4 NSAIDs, avoid precipitating 1 3.4 factors

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Table 41 Treatment options for diffuse non-specific upper limb disorders

First Treatment Option N % Second Treatment Option N % Physiotherapy 5 17.2 Physiotherapy 8 27.6 Rest 3 10.3 Referral 3 10.3 NSAIDs 2 6.9 NSAIDs 1 3.4 Analgesia 2 6.9 Ergonomic workplace assessment 1 3.4 Psychological assessment 2 6.9 Refer to GP 1 3.4 Explanation, reassurance 1 3.4 Workplace assessment 1 3.4 Rest, NSAIDs, job rotation 1 3.4 Relaxation 1 3.4 Employment limitations, 1 3.4 Antidepressants 1 3.4 physiotherapy, rest NSAIDs, avoid precipitating agent 1 3.4 Refer to Rheumatology 1 3.4 Rest, NSAIDs 1 3.4 Review 1 3.4 General assessment 1 3.4 Ongoing multidisciplinary pain 1 3.4

clinic Ergonomics 1 3.4 Refer to Neurology 1 3.4 Ergonomic assessment and advice 1 3.4 Job modification 1 3.4 Temporary removal from work 1 3.4 Counselling 1 3.4 NSAIDs, workplace assessment 1 3.4 Work adjustment 1 3.4 Manual therapy 1 3.4 NSAIDs, physiotherapy, work 1 3.4 adjustment Load reduction 1 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 N % Yes sometimes 17 58.6 Yes always 7 24.1 Not applicable 2 6.9 Yes rarely 1 3.4 No 1 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.

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Table 43 Referrals for musculoskeletal problems

Referral to N % General Practice 11 37.9 Orthopaedics 14 48.3 Rheumatology 10 34.5 Physiotherapy 23 79.3 Occupational Therapy 4 13.8 Counselling 10 34.5 Rehabilitation 5 17.2 Cognitive Behavioural Therapy 12 41.4 Employment Service 6 20.7 None/not applicable 2 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.

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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

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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.

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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

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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.

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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.

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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 Waiting time Travel Not Not sure Not barrier unacceptably distance available if applicable

long too far available N % N % N % N % N % N %

Rheumatology 10 34.5 9 31.0 * * 4 13.8 * * 1 3.4 Orthopaedics 8 27.6 13 44.8 * * 2 6.9 * * 1 3.4 Physiotherapy 17 58.6 6 20.7 * * 1 3.4 * * * * Rehabilitation 9 31.0 7 24.1 * * 5 17.2 3 10.3 * * Occupational Therapy 9 31.0 2 6.9 * * 8 27.6 3 10.3 * * Employment Service 14 48.3 1 3.4 * * 4 13.8 1 3.4 1 3.4 Cognitive Behavioural 11 37.9 8 27.6 * * 4 13.8 1 3.4 * * Therapy

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

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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.

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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

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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.

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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.

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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, long-term 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.

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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.

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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

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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 physician- patient 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.

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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.

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APPENDIX 1 FOCUS GROUP CONTENT ANALYSIS

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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

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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

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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

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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

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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

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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 patientAvoid 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

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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

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Table A1.8 Content analysis of the ‘training’ dimension based on the TOPs’ quotes. DIMENSIONHigher 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

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Table A1.9 Content analysis of the ‘training’ dimension based on the GPs’ quotes. DIMENSIONHigher 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

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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 learnScientific 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 importantText 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

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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

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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

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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

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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

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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

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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

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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

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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

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APPENDIX 2. QUESTIONNAIRES USED IN QUESTIONNAIRE SURVEY

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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 anyfurther 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 A lot During medical school 1 2 3 4 5 6 7 (undergraduate)

During your ‘House Officer’ years 1 2 3 4 5 6 7 (HO/SHO)

During your ‘Registrar’ years 1 2 3 4 5 6 7 (Non O.P.)

During your ‘Occupational Health 1 2 3 4 5 6 7 Trainee’ years

Continuing Medical Education 1 2 3 4 5 6 7

2. Please indicate how much training you have had with regard to work related upper limb musculoskeletal disorders (Please circle the appropriate number):

None A lot During medical school 1 2 3 4 5 6 7 (undergraduate)

During your ‘House Officer’ years 1 2 3 4 5 6 7 (HO/SHO)

During your ‘Registrar’ years 1 2 3 4 5 6 7 (Non O.P.)

During your ‘Occupational Health 1 2 3 4 5 6 7 Trainee’ years

Continuing Medical Education 1 2 3 4 5 6 7

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

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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

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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

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…………………………………………………………………………….

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 RheumatologyPhysiotherapy Occupational therapyRehabilitation Cognitive behavioural therapyCounselling 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):

Not at all Extremely Confident Confident

Patient’s history 1 2 3 4 5 6 7

Physical examination 1 2 3 4 5 6 7 11

143

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):

Never Always Previous clinical experience

Previous training

Consultation with other O.P.s

Consultation with medical specialists

Continuing Medical Education

Accredited websites

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

144

Journals

Text books

Available guidelines e.g. FOM, HSE

Patient’s positive feedback

Clinical evidence e.g. BMJ website

Other (please specify) ……………………………………….

……………………………………….

……………………………………….

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

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 Always1 2 3 4 5 6 7

b) Hand/forearm tendonitis

Never Always1 2 3 4 5 6 7

c) Carpal tunnel syndrome

Never Always1 2 3 4 5 6 7

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

f) Shoulder tendonitis

Never Always 1 2 3 4 5 6 7

g) Shoulder capsulitis

Never Always 1 2 3 4 5 6 7

h) Cervical spondylosis

Never Always 1 2 3 4 5 6 7

i) Impingement syndrome

Never Always 1 2 3 4 5 6 7

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 1 2 3 4 5 6 7 injury allowance

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 1 2 3 4 5 6 7 levels during recovery

Limited access to the workplace 1 2 3 4 5 6 7 Uncooperative workplace Management 1 2 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 1 2 3 4 5 6 7 factors

Other (Please Specify) ………………………………………. 1 2 3 4 5 6 7

………………………………………. 1 2 3 4 5 6 7

………………………………………. 1 2 3 4 5 6 7

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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 unacceptably long

Travel time unacceptably long

Not available

Not sure if available

Not applicable

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?

.…………………………………………………………………………………………………...

……………………………………………………………………………………………………

……………………………………………………………………………………………………

……………………………………………………………………………………………………

…………………………………………………………………………………..………………..

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Training Needs

19. O.P.s 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 INTERESTED Comprehensive musculoskeletal examination 1 2 3 4 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 2 3 4 5 6 7 conditions (e.g., tendonitis, tenosynovitis, epicondylitis)

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 1 2 3 4 5 6 7 workplace Management

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:

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.…………………………………………………………………………………………………..

……………………………………………………………………………………………………

……………………………………………………………………………………………………

……………………………………………………………………………………………………

……………………………………………………………………………………………………

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)

Part-time (less than 35 hours per week)

Work Alone Work as part of an Organisation Urban Rural NHS Non NHS

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Thank you for taking the time to fill the questionnaire. If you have any additional comments to make, please use this space:

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: J.O.Crawford@bham.ac.uk Email: LaiouN@medgp3.bham.ac.uk

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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

During medical school 1 2 3 4 5 6 7 (undergraduate)

During your ‘House Officer’ years 1 2 3 4 5 6 7 (HO/SHO)

During your ‘Registrar’ years 1 2 3 4 5 6 7 (Non-GP)

Continuing Medical Education 1 2 3 4 5 6 7

8. Please indicate how much training you have had with regard to work related upper limb musculoskeletal disorders (Please circle the appropriate number):

None A lot During medical school 1 2 3 4 5 6 7 (undergraduate)

During your ‘House Officer’ years 1 2 3 4 5 6 7 (HO/SHO)

During your ‘Registrar’ years 1 2 3 4 5 6 7 (Non-GP)

Continuing Medical Education 1 2 3 4 5 6 7

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

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 e.g., Primary

1

1

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

4

4

4

Always 5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

5 6 7

154

Care Rheumatology Society 1 2 3 4 5 6 7

Other (Please Specify) ……………………………………………… 1 2 3 4 5 6 7 ……………………………………………… 1 2 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 Extremely Confident Confident

Patient’s history 1 2 3 4 5 6 7

Physical examination 1 2 3 4 5 6 7

Diagnosis 1 2 3 4 5 6 7

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 Always Previous clinical experience

Previous training

Consultation with other GPs

Consultation with medical specialists

Continuing Medical Education

Accredited websites

Journals

Text books

MRCGP guidelines

Patient’s positive feedback

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

158

Clinical evidence e.g. BMJ website

Other (please specify) ……………………………………….

……………………………………….

……………………………………….

1 2 3 4 5 6 7

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 Always1 2 3 4 5 6 7

m) Hand/forearm tendonitis

Never Always1 2 3 4 5 6 7

n) Carpal tunnel syndrome

Never Always1 2 3 4 5 6 7

o) De Quervain’s tenosynovitis

Never Always1 2 3 4 5 6 7

p) Lateral/Medial epicondylitis

Never Always1 2 3 4 5 6 7

q) Shoulder tendonitis

159

Never Always 1 2 3 4 5 6 7

r) Shoulder capsulitis

Never Always 1 2 3 4 5 6 7

s) Cervical spondylosis

Never Always 1 2 3 4 5 6 7

t) Impingement syndrome

Never Always 1 2 3 4 5 6 7

u) Tension Neck

Never Always 1 2 3 4 5 6 7

v) Diffuse non-specific upper limb disorders

Never Always1 2 3 4 5 6 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 1 2 3 4 5 6 7 injury allowance

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 1 2 3 4 5 6 7 levels during recovery

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 unacceptably long

Travel time unacceptably long

Not available

Not sure if available

Not applicable

Rheumatology

Orthopaedics

Physiotherapy

Rehabilitation

Occupational Therapy

Employment Service

Cognitive Behavioural Therapy Other (Please specify) ………………

161

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 INTERESTED Comprehensive musculoskeletal examination 1 2 3 4 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 2 3 4 5 6 7 conditions (e.g., tendonitis, tenosynovitis, epicondylitis)

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)

Part-time (less than 35 hours per week)

Work Alone In Group Practice Urban Rural NHS Private practice

Thank you for taking the time to fill the questionnaire. If you have any additional comments to make, please use this space:

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

Tel 0121 414 3623Email: J.O.Crawford@bham.ac.uk

Miss Niki Laiou Institute of Occupational and Environmental Medicine, The University of Birmingham,

Edgbaston, Birmingham B15 2TT

Tel 0121 414 6015 Email:LaiouN@medgp3.bham.ac.uk

164

APP

END

IX 3

QU

ESTI

ON

NA

IRE

DA

TA

Tabl

e A

3.1

GP

trai

ning

in u

pper

lim

b m

uscu

losk

elet

al d

isor

ders

Non

e A

Lot

1

2 3

4 5

6 7

Mea

nN

%

N

%N

%

N

%N

%

N

%N

%

Mus

culo

skel

etal

skel

etal

trai

ning

dur

ing

med

ical

scho

ol

Dur

ing

your

Hou

se O

ffic

er y

ears

D

urin

g yo

ur R

egis

trar y

ears

C

ontin

uing

Med

ical

Edu

catio

n

2.81

4

12.5

13

40.6

5

15.6

7

21.9

2

6.3

1 3.

1 0

0 2.

56

10

31.3

9

28.1

4

12.5

4

12.5

4

12.5

1

3.1

0 0

2.79

8

27.6

5

17.2

9

31.0

2

6.9

2 6.

9 9

10.3

0

0 4.

41

1 3.

1 2

6.3

6 18

.8

7 21

.9

9 28

.1

4 12

.5

3 9.

4

165

Tabl

e A

3.2

GP

trai

ning

in w

ork

rela

ted

uppe

r lim

b m

uscu

losk

elet

al d

isor

ders

N

one

A L

ot

1 2

3 4

5 6

7 N

%

N

%

N

%N

%

N

%

N

%N

%

M

uscu

losk

elet

al sk

elet

al tr

aini

ng d

urin

g m

edic

al sc

hool

D

urin

g yo

ur H

ouse

Off

icer

yea

rs

Dur

ing

your

Reg

istra

r yea

rs

Con

tinui

ng M

edic

al E

duca

tion

18

56.3

9

28.1

1

3.1

2 6.

3 1

3.1

1 3.

1 0

0 20

62

.5

8 25

.0

2 6.

3 1

3.1

1 3.

1 1

3.1

0 0

18

62.1

5

17.2

3

10.3

1

3.4

0 0

1 3.

4 1

3.4

5 15

.6

5 15

.6

8 25

.0

2 6.

3 5

15.6

4

12.5

3

9.4

166

Tabl

e A

3.3

GP

sou

rces

of i

nfor

mat

ion

in p

rofe

ssio

nal d

evel

opm

ent Nev

er/n

ot

Alw

ays

appl

icab

le

1 2

3 4

5 6

7 So

urce

s M

ean

S.D

. M

in

Max

N

%

N

%

N

%

N

%N

%

N

%N

%

167

Med

ical

Jour

nals

Text

Boo

ksM

RC

GP

guid

ance

Con

tact

with

you

r GP

partn

er(s

) C

onta

ct w

ith o

ther

GPs

C

onta

ct w

ith o

ther

med

ical

spec

ialis

ts

Con

tact

with

oth

er n

on-m

edic

al

prof

essi

onal

sO

bser

vatio

n of

col

leag

ues d

urin

g pr

actic

e

Prac

tice

mee

tings

C

onfe

renc

es, s

emin

ars

Acc

redi

ted

web

site

s C

D-R

OM

sPr

ofes

sion

al g

roup

s

3.90

3.32

2.48

3.61

2.90

3.61

3.00

2.35

2.13

3.23

2.53

1.70

1.77

1.73

9 1

1.37

6 1

1.76

5 1

1.52

0 1

1.29

6 1

1.47

6 1

1.46

4 1

1.19

9 1

1.65

8 1

1.52

1 1

1.71

7 1

1.08

8 1

1.33

1 1

7 3

7 4

6 13

6

3 5

6 6

3 6

5

5 9

6 13

7

4 6

14

5 19

6

20

9.7

12.9

44.8 9.7

20.0 9.7

17.2

29.0

43.3

12

.946

.7

63.3

66.7

4 3 5 6 5 5 6 10 8 8 3 4 3

12.9 9.7

17.2

19.4

16.7

16.1

20.7

32.3

26.7

25.8

10.0

13.3

10.0

5 10 3 4 8 6 9 5 4 5 3 5 4

16.1

32.3

10.3

12.9

26.7

19.4

31.0

16.1

13.3

16.1

10.0

16.7

13.3

9 29

.0

9 29

.0

3 10

.3

8 25

.8

8 26

.7

6 19

.4

4 13

.8

6 19

.4

3 10

.0

7 22

.6

4 13

.3

1 3.

3 1

3.3

4 12

.9

4 12

.9

2 6.

9 7

22.6

3

10.0

9

29.0

3

10.3

1 3.

2 1

3.3

6 19

.4

5 16

.7

1 3.

3 1

3.3

3 9.

7 0

0 3

10.3

3

9.7

0 0

2 6.

5 2

6.9

0 0

1 3.

3 0

0 1

3.3

0 0

1 3.

3

3 9.

7 1

3.2

0 0

0 0

0 0

0 0

0 0

0 0

0 0

1 3.

2 0

0 0

0 0

0

7

Tabl

e A

3.4

GP

leve

l of c

onfid

ence

with

diff

eren

t asp

ects

of u

pper

lim

b m

anag

emen

t

Not

at a

llE

xtre

mel

y co

nfid

ent

conf

iden

t 1

2 3

4 5

6 M

ean

S.D

. M

in

Max

N

%

N%

N

%N

%

N

%N

%

N

%

Pa

tient

’s h

isto

ry

Phys

ical

exa

min

atio

n D

iagn

osis

Jo

int i

njec

tion

Use

of N

SAID

s U

se o

f cor

ticos

tero

ids

Ref

erra

ls

Esta

blis

hing

wor

k re

late

dnes

s A

dvic

e on

app

ropr

iate

act

ivity

5.41

5.

09

4.97

4.

72

5.81

4.

58

5.19

4.

53

4.59

1.16

0 0.

963

1.06

2 1.

746

0.89

6 1.

608

1.17

6 1.

502

1.36

5

3 3 3 1 4 1 2 2 2

7 7 7 7 7 7 7 7 7

0 0 0 3 0 2 0 0 0

0 0 09.

4 06.

5 0 0 0

0 0 0 1 0 1 1 3 2

0 0 03.

1 03.

1 3.

1 9.

4 6.

3

3 1 4 3 0 5 2 7 6

9.4

3.1

12.5

9.

4 015

.6

6.3

21.9

18

.8

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

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

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

5 1 2 4 7 3 2 2 1

15.6

3.

1 6.

3 12

.5

21.9

9.

4 6.

3 6.

3 3.

1

168

Tabl

e A

3.5

GP

evi

denc

e ba

se in

the

choi

ce o

f tre

atm

ent o

f mus

culo

skel

etal

dis

orde

rs

Nev

er

Alw

ays

1 2

3 4

5 6

7 M

ean

S.D

. M

axM

inN

%

N

%N

%

N

%N

%

N

%N

%

169

Prev

ious

clin

ical

exp

erie

nce

Prev

ious

trai

ning

C

onsu

ltatio

ns w

ith o

ther

GPs

C

onsu

ltatio

n w

ith m

edic

al

spec

ialis

ts

Con

tinui

ng m

edic

al e

duca

tion

Acc

redi

ted

web

site

s Jo

urna

ls

Text

boo

ks

MR

CG

P G

uide

lines

Pa

tient

’s p

ositi

ve fe

edba

ck

Clin

ical

Evi

denc

e

5.72

4.

69

3.33

3.

87

4.31

2.

44

3.84

3.

16

2.27

4.

66

2.77

1.08

5 1.

469

1.47

0 1.

204

1.25

6 1.

435

1.63

5 1.

416

1.50

7 1.

494

1.83

2

3 2 1 2 2 1 1 1 1 1 1

7 7 6 6 7 6 7 7 5 7 6

0 0 3 0 0 11 2 4 14 1 12

0 010

.0 0 0

34.4

6.

5 12

.9

46.7

3.1

40.0

0 3 6 6 4 7 7 7 6 0 4

09.

4 20

.0

19.4

12.5

21

.9

22.6

22

.6

20.0

013

.3

2 4 9 4 3 8 3 6 2 9 2

6.3

12.5

30

.0

12.9

9.4

25.0 9.7

19.4

6.

7 28

.1

6.7

2 7 5 11 9 2 7 10 4 3 7

6.3

21.9

16

.7

35

.5

28.1

6.

3 22

.632

.3

13.3

9.

423

.3

6 7 4 8 12 3 7 3 4 7 1

18.8

21.9

12

.5

25.8

37

.5

9.4

22.6

9.

7 13

.3

21.9

3.

3

15 8 3 2 3 1 4 0 0 10 4

46.9

25

.0

9.4

6.5

9.4

3.1

12.9

0 031

.3

13.3

7 3 0 0 1 0 1 1 0 2 0

21.9

9.

4 0 0

3.1 0

3.2

3.2 0

6.3 0

Tabl

e A

3.6

GP

perc

eive

d di

fficu

lties

in e

stab

lishi

ng a

dia

gnos

is Nev

er

Alw

ays

1 2

3 4

5 6

7 D

isor

der

Mea

n S.

D.

Min

Max

N

%

N

%

N

%

N

%N

%

N

%N

%

170

Han

d/fo

rear

m te

nosy

novi

tis

Han

d/fo

rear

m te

ndon

itis

Car

pal T

unne

l Syn

drom

e D

e Q

uerv

ain’

s te

nosy

novi

tis

Epic

ondy

litis

Sh

ould

er te

ndon

itis

Shou

lder

cap

sulit

is

Cer

vica

l Spo

ndyl

osis

Im

ping

emen

t Syn

drom

e Te

nsio

n N

eck

Diff

use

non-

spec

ific

uppe

r lim

b di

sord

ers

3.28

3.

34

2.59

2.

91

2.00

2.

97

3.03

2.

84

3.68

2.

93

4.19

1.27

6 1.

181

1.07

3 1.

027

0.98

4 1.

121

1.28

2 1.

298

1.55

8 1.

172

1.60

0

1 2 1 2 1 2 1 1 2 1 2

6 6 6 6 6 6 6 6 7 6 7

1 0 3 0 8 0 1 2 0 2 0 3.

1 09.

4 0

25.0

0

3.1

6.3 0

6.7 0

10 9 15 14 20

14

13

14 10 10 7

31.3

28

.1

46.9

43

.8

62.5

43

.8

40.6

43

.8

32.3

33

.322

.6

7 10 8 10 2 9 9 9 5 10 2

21.9

31.3

25

.0

31

.3

6.3

28.1

28

.1

28.1

16

.1

33

.3

6.5

9 8 5 6 1 7 4 4 7 5 11

28.1

25

.0

15.6

18

.8

3.1

21

.9

12.5

12

.5

22.6

16

.7

35.5

3 3 0 1 0 0 3 0 5 2 2 9.

4 9.

4 03.

1 0 0

9.4 0

16.1

6.

7 6.

5

2 2 1 1 1 2 2 3 2 1 7 6.

3 6.

3 3.

1 3.

1

3.1

6.3

6.

3 9.

4 6.

5 3.

3 22

.6

0 0 0 0 0 0 0 0 2 0 2

0 0 0 0 0 0 0 06.

5 06.

5

Tabl

e A

3.7

GP

diff

icul

ties

in m

anag

ing

uppe

r lim

b di

sord

ers

Nev

er

Alw

ays

1 2

3 4

5 6

7 D

iffic

ultie

s M

ean

S.D

. M

in

Max

N

%

N

%N

%

N

%N

%

N

%N

%

171

Sym

ptom

s/Si

gns d

o no

t mat

ch a

re

cogn

ised

clin

ical

ent

ity

Elus

ive

diag

nosi

s A

bsen

ce o

f clin

ical

sign

s N

o re

spon

se to

trea

tmen

ts

Del

ayed

resp

onse

to tr

eatm

ents

R

ecur

rent

sym

ptom

s C

hron

icity

Patie

nt’s

hig

h ex

pect

atio

ns

Patie

nt’s

dis

satis

fact

ion

Psyc

hoso

cial

fact

ors

Patie

nt’s

invo

lvem

ent i

n lit

igat

ion

Opp

osin

g pr

evio

us m

edic

al

man

agem

ent

The

patie

nt

is

rece

ivin

gte

mpo

rary

inju

ry a

llow

ance

A

cces

s to

spec

ialis

t ser

vice

s is

diff

icul

t A

cces

s to

phys

ioth

erap

y is

di

ffic

ult

Diff

icul

ty in

adv

isin

g ap

prop

riate

act

ivity

leve

ls d

urin

g re

cove

ry

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

1.22

4

1.03

9 1.

448

1.09

9 1.

243

1.39

1 1.

218

1.21

8 1.

338

1.45

9 1.

696

1.36

2

1.92

0

1.81

1

1.90

0

1.25

0

2 2 1 2 2 1 2 2 2 2 2 1 1 1 1 1

7 6 7 6 6 6 6 7 7 7 7 6 7 7 7 6

0 0 1 0 0 1 0 0 0 0 0 2 6 2 3 1

0 03.

1 0 03.

1 0 0 0 0 0

6.3

18.8 6.3

9.4

3.1

3 1 4 2 5 4 4 2 4 4 6 4 4 3 8 4

9.4

3.1

12.5 6.3

15.6

12.5

12.5 6.3

12.5

12.5

18.8

12.9

12.5 9.4

25.0

12.5

5 9 6 8 7 8 4 2 6 5 2 10 6 5 2 10

15.6

28.1

18.8

25.0

21.9

25.0

12.5 6.3

18.8

15.6 6.3

32.3

18.8

15.6 6.3

31.3

9 6 9 5 8 4 8 9 11 5 5 9 4 3 5 7

28.1

18.8

28.1

15.6

25.0

12.5

25.0

28.1

34.4

15.6

15.6

29.0

12.5 9.4

15.6

21.9

11 14 8 15 9 11 12 9 5 10 8 2 2 6 5 8

34.4

43.8

25.0

46.9

28.1

34.4

37.5

28.1

15.6

31.3

25.0 6.5

6.3

18.8

15.6

25.0

3 2 2 2 3 4 4 9 5 6 6 4 6 9 7 2

9.4

6.3

6.3

6.3

9.4

12.5

12.5

28.1

15.6

18.8

18.8

12.9

18.8

28.1

21.9 6.3

1 0 2 0 0 0 0 1 1 2 5 0 1 4 2 0

3.1 0

6.3 0 0 0 0

3.1

3.1

6.3

15.6 0

3.1

12.5 6.3 0

Tabl

e A

3.8

GP

leve

l of i

nter

est i

n co

ntin

uing

med

ical

edu

catio

n to

pics

172

Not

at a

ll in

tere

sted

1

Edu

catio

n T

opic

s M

ean

S.D

. M

in

Max

N

%

Ext

rem

ely

Inte

rest

ed

2 3

4 5

6 7

N%

N

%N

%

N%

N

%N

%

C

ompr

ehen

sive

4.

44

1.88

3 1

mus

culo

skel

etal

exa

min

atio

n

Diff

eren

tial d

iagn

osis

4.

91

1.51

0 2

Join

t inj

ectio

n 4.

62

1.68

0 2

Use

of N

SAID

s 3.

44

1.52

3 1

Use

of c

ortic

oste

roid

s 3.

87

1.77

3 1

Man

agin

g co

mm

on

4.61

1.

564

2 m

uscu

losk

elet

al c

ondi

tions

Ps

ycho

soci

al a

spec

ts o

f ULD

s 3.

84

1.68

7 1

Med

ico

lega

l asp

ects

of U

LDs

3.59

1.

794

1 C

ompl

emen

tary

Med

icin

e

3.16

1.

762

1 W

ork

rela

tedn

ess o

f ULD

s 4.

19

1.71

2 1

Adv

ice

on a

ctiv

ity le

vel d

urin

g 4.

59

1.56

3 1

reco

very

7 2

6.3

4 12

.5

5 15

.6

4 12

.5

7 21

.9

4 12

.5

6 18

.8

7 0

0 3

9.4

3 9.

4 5

15.6

9

28.1

7

21.9

5

15.6

7

0 0

6 18

.8

2 6.

3 6

18.8

6

18.8

8

25.0

4

12.5

7

2 6.

3 9

28.1

6

18.8

7

21.9

5

15.6

2

6.3

1 3.

1 7

1 3.

1 10

31

.3

3 9.

4 5

18.8

4

12.5

6

18.8

2

6.3

7 0

0 4

12.9

3

9.7

8 25

.8

6 19

.4

6 19

.4

4 12

.9

7 2

6.3

6 18

.8

6 18

.8

7 21

.9

6 18

.8

2 6.

3 3

9.4

7 4

12.5

6

18.8

7

21.9

4

12.5

7

21.9

1

3.1

3 9.

4 7

5 15

.6

10

31.3

5

15.6

5

15.6

3

9.4

2 6.

3 2

6.3

7 2

6.3

5 15

.6

3 9.

4 7

21.9

8

25.0

4

12.5

3

9.4

7 2

6.3

1 3.

1 3

9.4

9 28

.1

7 21

.9

7 21

.9

3 9.

4

Occ

upat

iona

l Phy

sici

ans

Tabl

e A

3.9

TOP

trai

ning

in u

pper

lim

b m

uscu

losk

elet

al d

isor

ders

N

one

A L

ot

1 2

3 4

5 6

7 N

%

N

%N

%N

%N

%

N

%N

%

173

Mus

culo

skel

etal

skel

etal

trai

ning

durin

g m

edic

al sc

hool

D

urin

g yo

ur H

ouse

O

ffic

er y

ears

Dur

ing

your

Reg

istra

r ye

ars

Dur

ing

your

O

ccup

atio

nal H

ealth

train

ee y

ears

Con

tinui

ng M

edic

al

Educ

atio

n

9 10 7 2 0

31.0

34.5

25.0

7.4 0

10 11 7 1 4

34.5

37.9

25.0

3.7

14.3

7 6 6 7 3

24.1

20.7

21.4

25.9

10.7

1 2 5 5 5

3.4

6.9

17.2

18.5

17.9

1 0 2 8 10

3.4 0

6.9

29.6

35.7

1 0 1 2 5

3.4

0 0

0 0

0

3.4

0 0

7.4

2 7.

4

17.9

1

3.6

Tabl

e A

3.10

TO

P tr

aini

ng in

wor

k re

late

d up

per l

imb

mus

culo

skel

etal

dis

orde

rs

N

one

A L

ot

1 2

3 4

5 6

7 N

%

N

%

N

%

N

%N

%

N

%N

%

M

uscu

losk

elet

alsk

elet

al tr

aini

ng d

urin

g m

edic

al sc

hool

D

urin

g yo

ur H

ouse

O

ffic

er y

ears

Dur

ing

your

Reg

istra

r ye

ars

Occ

upat

iona

l Hea

lthtra

inee

yea

rsC

ontin

uing

Med

ical

Ed

ucat

ion

17 21 16 2 1

58.6

72.4

55.2

7.4

3.6

9 7 6 2 5

31.0

24.1

20.7

7.4

17.9

1 1 1 6 2

3.4

3.4

3.4

22.2

7.1

1 0 6 4 6

3.4 0

20.7

14.8

21.4

0 0 0 6 7

0 0 0

22.2

25.0

1 0 0 5 6

3.4 0 0

18.5

21.4

0 0 0 2 1

0 0 0

7.4

3.6

174

Tabl

e A

3.11

TO

P s

ourc

es o

f inf

orm

atio

n in

pro

fess

iona

l dev

elop

men

t Nev

er/n

ot

Alw

ays

appl

icab

le

1 2

3 4

5 6

7 So

urce

s M

ean

S.D

M

in

Max

N

%

N

%N

%

N

%N

%

N

%N

%

175

Med

ical

Jour

nals

Te

xt B

ooks

FO

M g

uida

nce

HSE

gui

danc

e C

onta

ct w

ith o

ther

O.P

.s C

onta

ct w

ith o

ther

med

ical

spec

ialis

ts

Con

tact

with

oth

er n

on-m

edic

al p

rofe

ssio

nals

O

bser

vatio

n of

col

leag

ues d

urin

g pr

actic

e

Con

fere

nces

, sem

inar

s A

ccre

dite

d w

ebsi

tes

Vid

eos

CD

-RO

Ms

Prof

essi

onal

gro

ups

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

1.81

1 1.

476

1.73

8 1.

843

1.77

2 1.

738

1.89

0 1.

354

1.60

1 1.

898

0.79

3 1.

213

1.88

7

1 7

2 1

7 1

1 7

4 1

7 7

1 6

4 1

6 5

1 6

7 1

6 11

1

6 2

1 6

11

1 4

19

1 6

18

1 6

9

6.9

3.4

14.8

25

.0

14.8

17

.2

25.0

37

.9

6.9

39.3

67

.9

64.3

31

.0

7 24

.1

4 13

.8

4 14

.8

3 10

.7

4 14

.8

1 3.

4 3

10.7

8

27.6

6

20.7

5

17.9

6

21.4

4

14.3

3

10.3

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

5 17

.2

5 17

.2

2 7.

4 4

14.3

5

18.5

2

6.9

3 10

.7

3 10

.3

4 13

.8

2 7.

1 1

3.6

1 3.

6 6

20.7

3 10

.3

8 27

.6

8 29

.6

4 14

.3

4 14

.8

5 17

.2

3 10

.7

1 3.

4 6

20.7

3

10.7

0

0 0

0 4

13.8

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

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

Tabl

e A

3.12

TO

P le

vel o

f con

fiden

ce w

ith d

iffer

ent a

spec

ts o

f upp

er li

mb

man

agem

ent

Not

at

al

lco

nfid

ent

1 A

rea

Mea

n S.

D.

Min

M

ax

N

%

Ext

rem

ely

conf

iden

t 2

3 4

5 6

N

%N

%

N

%N

%N

%

N

%

176

Patie

nt’s

his

tory

Ph

ysic

al e

xam

inat

ion

Dia

gnos

is

Join

t inj

ectio

n U

se o

f NSA

IDs

Use

of c

ortic

oste

roid

s R

efer

rals

Es

tabl

ishi

ng w

ork

rela

tedn

ess

Adv

ice

on a

ppro

pria

te a

ctiv

ity

Wor

kpla

ce A

sses

smen

t A

ddre

ssin

g th

e er

gono

mic

side

M

akin

g re

com

men

datio

ns to

the

empl

oyer

5.34

4.

83

4.59

2.

97

5.43

3.

50

5.37

4.

93

4.96

4.

624.

24

4.90

1.14

3 1.

136

0.98

3 1.

936

1.20

0 1.

953

1.18

2 0.

923

0.99

9 1.

568

1.48

0 1.

496

3 3 3 1 1 1 3 3 3 1 1 1

7 7 6 6 7 7 7 7 7 7 6 6

0 0 0 10 1 5 0 0 0 1 2 1

0 0 034

.5

3.4

17.9

0 0 03.

46.

9 3.

4

0 0 0 5 0 7 0 0 0 1 1 2

0 0 017

.2 0

25.0

0 0 03.

4 3.

4 6.

9

3 5 5 3 0 3 3 1 2 7 6 2

10.3

17

.2

17.2

10

.3 0

10.7

11

.1

3.4

7.1

24.1

20.7

6.

9

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

.320

.7

17.2

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

.724

.1

10.3

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

3 1 0 0 2 1 4 1 1 2 0 0

10.3

3.

4 0 07.

1 3.

6 14

.8

3.4

3.6

6.9 0 0

Tabl

e A

3.13

TO

P e

vide

nce

base

in th

e ch

oice

of t

reat

men

t of m

uscu

losk

elet

al d

isor

ders

Nev

er

Alw

ays

1 2

3 4

5 6

7 E

vide

nce

Bas

e M

ean

S.D

.M

in

Max

N

%

N

%N

%

N

%N

%

N

%N

%

Pr

evio

us c

linic

al e

xper

ienc

e Pr

evio

us tr

aini

ng

Con

sulta

tions

with

oth

er O

.P.s

Con

sulta

tion

with

med

ical

spec

ialis

ts

Con

tinui

ng m

edic

al e

duca

tion

Acc

redi

ted

web

site

s Jo

urna

ls

Text

boo

ks

Ava

ilabl

e gu

idel

ines

, e.g

., FO

M, H

SE

Patie

nt’s

pos

itive

feed

back

C

linic

al e

vide

nce

5.21

4.

96

3.76

4.

18

4.32

2.

96

3.43

4.

04

3.64

4.

54

3.75

1.19

7 1.

347

1.56

2 1.

307

1.18

8 1.

774

1.45

1 1.

503

1.74

7 1.

138

1.66

9

3 2 1 1 2 1 1 1 1 2 1

7 7 6 6 6 6 6 7 6 6 6

0 0 2 1 0 7 2 1 3 0 4

0 08.

0 3.

6 025

.0

7.1

3.6

10.7

014

.3

0 1 5 2 4 7 6 3 6 2 2

03.

6 20

.0

7.1

14.3

25

.0

21.4

10

.7

21.4

7.

1 7.

1

3 4 3 6 1 5 8 8 6 3 7

10.7

14

.3

12.0

21

.4

3.6

17.9

28

.6

28.6

21

.4

10

.7

25.0

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

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

11 8 3 3 3 4 3 4 6 5 5

39.3

3

10.7

28

.6

3 10

.7

12.0

0 0

10.7

0 0

10.7

0 0

14.3

0 0

10.7

0 0

14.3

1

3.6

21.4

0 0

17

.9

0 0

17.9

0 0

177

Tabl

e A

3.14

TO

P p

erce

ived

diff

icul

ties

in e

stab

lishi

ng a

dia

gnos

is

Nev

er

Alw

ays

1 2

3 4

5 6

7 D

isor

der

Mea

n S.

D.

Min

M

aN

%

N

%

N

%

N

%N

%

N

%N

%

x

178

Han

d/fo

rear

m te

nosy

novi

tis

Han

d/fo

rear

m te

ndon

itis

Car

pal T

unne

l Syn

drom

e D

e Q

uerv

ain’

s ten

osyn

oviti

s Ep

icon

dylit

is

Shou

lder

tend

oniti

s Sh

ould

er c

apsu

litis

C

ervi

cal S

pond

ylos

is

Impi

ngem

ent S

yndr

ome

Tens

ion

Nec

k D

iffus

e no

n-sp

ecifi

c up

per l

imb

diso

rder

s

3.46

3.

64

2.86

3.

11

2.25

3.

48

3.50

2.

86

3.46

3.

39

4.39

1.37

4 1.

311

1.23

9 1.

286

.701

1.

424

1.45

3 1.

533

1.45

3 1.

873

1.83

3

2 2 1 1 1 1 1 1 1 1 1

7 7 5 6 5 6 6 7 6 7 7

0 0 1 1 1 1 1 2 1 4 2

0 03.

6 3.

6 3.

6 3.

7 3.

6 7.

1 3.

6 14

.3

7.1

7 4 15 10

21 7 8 15 7 7 4 25

.0

14

.3

53

.6

35.7

75.0

25.9

28.6

53.6

25

.0

25.0

14

.3

11 13 4 9 5 7 6 4 9 5 2 39

.3

46

.4

14.3

32

.1

17

.9

25

.9

21

.4

14.3

32

.1

17.9

7.

1

4 4 3 2 0 5 5 3 4 6 6

14.3

14

.3

10.7

7.

1 018

.5

17.9

10

.7

14.3

21

.4

21.4

3 4 5 5 1 4 5 1 3 1 4

10.7

14

.3

17.9

17

.9

3.6

14.8

17

.9

3.6

10.7

3.

6 14

.3

2 2 0 1 0 3 3 2 4 2 7

7.1

7.1 0

3.6 0

11

.1

10

.7

7.1

14.3

7.

1 25

.0

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

Tabl

e A

3.15

TO

P d

iffic

ultie

s in

man

agin

g up

per l

imb

diso

rder

s

179

Nev

er

Alw

ays

1 2

3 4

5 6

7 D

iffic

ulty

M

ean

S.D

. M

in

Max

N

%

N

%N

%

N

%N

%

N

%N

%

Sy

mpt

oms/

Sign

s do

not m

atch

a rc

ogni

sed

clin

ical

4.

17

1.19

7 2

6 0

0 3

10.3

5

17.2

9

31.0

8

27.6

4

13.8

0

0 en

tity

Elus

ive

diag

nosi

s 4.

28

1.27

9 2

6 0

0 4

13.8

4

13.8

5

17.2

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41

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