The enormous body of evidence on the management of low back pain—with more than 5000 randomized controlled trials—may offer important lessons for other musculoskeletal conditions.
A new study suggests that a common strategy in the management of low back pain may transform the treatment of distal arm pain—such as symptoms in the elbow, forearm, wrist, and hand.
In a recent RCT, Gareth T. Jones, PhD, and colleagues found that an active approach to arm pain was superior to therapy oriented around rest and limited function.
“This is the first trial to compare the effectiveness of advice to [remain] active, versus advice to rest, among patients with distal arm pain. Advice to remain active results in better functional outcomes at 26 weeks, compared with advice to rest,” according to the research team from multiple universities and research centers across Great Britain.
“The current study questions current guidance for the management of distal arm pain. These findings show that the ‘keep active’ management approach long advocated for low back pain has parallels in other regional musculoskeletal pain conditions.”
Arm Pain a Common Complaint in Healthcare
The background to this study is fascinating. Distal arm pain is common in the general population, and is a common indication for medical care, work absence, and disability claims. And coming up with effective treatments for arm pain has proven frustrating.
Several years ago, Jones and colleagues started looking seriously at the management of arm pain. And they noted that treatments were less than successful.
In a 2012 editorial in Pain Management, Jones and Peter J. Heine, PhD, noted that about half of people with distal arm symptoms were still in pain months after treatment. (See Jones and Heine, 2012.)
“A recent population-based study found that approximately one in seven working-aged adults in England consulted their general practitioner with upper limb pain per annum. Of these, 42% had pain in the distal arm and, at 12-month follow-up, nearly half were still in pain, with one in five reporting unremitting pain (never pain-free for as many as 7 consecutive days),” according to Jones and Heine.
Abundant Parallels with Back Pain
After extensive literature searches, these researchers found that distal arm pain had abundant parallels with low back pain: diagnostic uncertainty, varying unvalidated definitions of arm conditions, a complex mix of physical and psychosocial influences on these problems; and a lack of relevant clinical trials for most conditions.
In short, the management of distal arm pain was based mostly on the consensus of experts with scant scientific grounding.
The various arm conditions they studied had broad similarities with low back pain. “Thus, in epidemiological terms, distal arm pain is very similar to low back pain: it is common and disabling, its etiology comprises both mechanical and psychosocial elements and beliefs are of demonstrable importance, not only in determining consultation but also in prognosis, as are aspects of general health. It also exhibits a similar lack of evidence for many of the diagnostic categories and treatment modalities commonly used,” they observed.
The research team found rest was a major component of treatment recommendations for arm pain. Patients were often referred for physical therapy. But they were advised to rest the “injured” anatomy while they waited for physical therapy slots to open up.
Rest a Common Treatment for Back Pain 30 Years Ago
Sound familiar? These were common recommendations in the management of low back pain for decades. It was not uncommon 30, 40, or 50 years ago for physicians to send patients with back pain to bed for days, weeks, and months to let the spine “recover” from whatever alleged injury or condition had caused the pain.
Yet back pain treatment guidelines had moved away from this approach in the mid-1990s after RCTs showed that bed rest slowed rather than enhanced recovery. (See Malmivaara et al., 1995.) And in all too many real-world cases, extensive use of rest prevented functional recovery altogether.
Given the broad similarities between the evidence on back pain and arm pain, Jones and a large research team came up with the idea of evaluating continuing activity as a treatment for distal arm pain.
In the NHS, people referred for physical therapy for arm typically have to wait several weeks for a PT slot to open up. So Jones et al. designed their trial within that context.
Randomized Trial Involving 538 Patients
Jones et al. identified 1663 patients who were referred for community-based physical therapy. They randomly allocated 538 of those subjects to one of three management approaches:
- Advice to remain active while awaiting usual physical therapy care (via waiting list);
- Advice to rest while awaiting usual physical therapy care (via waiting list); or
- Immediate physical therapy.
The primary outcome was level of disability six months after randomization. “Reflecting a move away from pain as the primary outcome in many pain trials, and the concept that function is a more meaningful end point, the primary outcome was a complete absence of disability at 26-weeks post-randomization, as assessed using a modified version of the DASH questionnaire,” according to Jones et al.
The study used intention-to-treat analysis. Eighty-one percent of the study participants provided primary outcome data, with similar proportions dropping out in each group.
Continuing Activity Provided Superior Results
The results favored continuing activity while awaiting physical therapy. Forty-four percent of the continuing activity group made a full recovery after 26 weeks, compared with 32% of the rest group, and 35% of the immediate physical therapy group.
“Those advised to rest experienced a lower probability of recovery (OR: 0.54; 95% CI 0.32 to 0.90) versus advice to remain active,” according to the authors.
There was no benefit to immediate physical therapy over delayed physical therapy.
The lack of benefit from early physical therapy seems at first glance to be counter-intuitive. However, it is possible that patients seeing a physical therapist in the early stages of arm pain may be managed as if they have an acute injury in need of protection.
“A comparison of treatment modalities between those randomized to immediate or ‘waiting list’ physiotherapy revealed that those in the ‘immediate’ groups were more likely to receive Protection, Rest, Ice, Compression and Elevation (PRICE), but this is to be expected since PRICE is recommended in response to acute pain. Indeed, the ‘immediate’ group, possibly as part of ‘protection’, were more likely to be given an orthotic device,” Jones et al. explained.
So patients in the early physical therapy may not have been as active as those in the delayed PT group. And this study seemed to point to continuing activity as a key to early recovery.
Jones et al. don't expect other research teams to conduct similarly complex and expensive trials any time soon. So they recommend that healthcare providers, and healthcare systems, act on these results.
“Therefore, based on the previous epidemiological data, an extensive evidence base about back pain, and from the current trial results, we recommend that, for the majority of cases, the most sensible course of action would be to stop advising that patients with distal arm pain rest while awaiting physiotherapy,” according to the authors.
Disclosures: None declared.