Discrete Pathophysiology is Uncommon in Patients with Nonspecific Arm Pain

Document Type : RESEARCH PAPER

Authors

1 Department of Orthopaedic Surgery, Orthopaedic Hand and Upper Extremity Service Boston, MA, USA, Massachusetts General Hospital, Harvard Medical School

2 Department of Orthopaedic Surgery, Orthopaedic Hand and Upper Extremity Service, Boston, MA, USA, Massachusetts General Hospital, Harvard Medical School

3 Orthopaedic Hand and Upper Extremity Service, Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA

Abstract

 
Background: Nonspecific symptoms are common in all areas of medicine. Patients and caregivers can be frustrated when an illness cannot be reduced to a discrete pathophysiological process that corresponds with the symptoms. We therefore asked the following questions: 1) Which demographic factors and psychological comorbidities are associated with change from an initial diagnosis of nonspecific arm pain to eventual identification of discrete pathophysiology that corresponds with symptoms? 2) What is the percentage of patients eventually diagnosed with discrete pathophysiology, what are those pathologies, and do they account for the symptoms?

Methods: We evaluated 634 patients with an isolated diagnosis of nonspecific upper extremity pain to see if discrete pathophysiology was diagnosed on subsequent visits to the same hand surgeon, a different hand surgeon, or any physician within our health system for the same pain.

Results: There were too few patients with discrete pathophysiology at follow-up to address the primary study question. Definite discrete pathophysiology that corresponded with the symptoms was identified in subsequent evaluations by the index surgeon in one patient (0.16% of all patients) and cured with surgery (nodular fasciitis). Subsequent doctors identified possible discrete pathophysiology in one patient and speculative pathophysiology in four patients and the index surgeon identified possible discrete pathophysiology in four patients, but the five discrete diagnoses accounted for only a fraction of the symptoms.

Conclusion: Nonspecific diagnoses are not harmful. Prospective randomized research is merited to determine if nonspecific, descriptive diagnoses are better for patients than specific diagnoses that imply pathophysiology in the absence of discrete verifiable pathophysiology.

Keywords

References

1. Isaac ML, Paauw DS. Medically unexplained
symptoms. Med Clin North Am. 2014; 98(3):663-72.
2. Katon W, Ries RK, Kleinman A. The prevalence of
somatization in primary care. Compr Psychiatry.
1984; 25(2):208-15.
3. Kroenke K, Mangelsdorff AD. Common symptoms in
ambulatory care: incidence, evaluation, therapy, and
outcome. Am J Med. 1989; 86(3):262-6.
4. Bot SD, van der Waal JM, Terwee CB, van der Windt
DA, Schellevis FG, Bouter LM, et al. Incidence and
prevalence of complaints of the neck and upper
extremity in general practice. Ann Rheum Dis. 2005;
64(1):118-23.
5. Chabok HA, Ring D. Arm ache. Hand (N Y). 2014;
9(2):151-5.
6. Feleus A, Bierma-Zeinstra SM, Miedema HS, Bernsen
RM, Verhaar JA, Koes BW. Incidence of non-traumatic
complaints of arm, neck and shoulder in general
practice. Man Ther. 2008; 13(5):426-33.
7. Winspur I. Arm pain without physical findings:
medicine vs. the law? J Hand Surg Br. 2001;
26(5):409-13.
8. Picavet HS, Schouten JS. Musculoskeletal pain in the
Netherlands: prevalences, consequences and risk
groups, the DMC(3)-study. Pain. 2003; 102(1-2):167-78.
9. Urwin M, Symmons D, Allison T, Brammah T,
Busby H, Roxby M, et al. Estimating the burden
of musculoskeletal disorders in the community:
the comparative prevalence of symptoms at
different anatomical sites, and the relation to social
deprivation. Ann Rheum Dis. 1998; 57(11):649-55.
10. Walker-Bone K, Palmer KT, Reading I, Coggon D,
Cooper C. Prevalence and impact of musculoskeletal
disorders of the upper limb in the general population.
Arthritis Rheum. 2004; 51(4):642-51.
11. Wade DT, Halligan PW. Do biomedical models of
illness make for good healthcare systems? BMJ.
2004; 329(7479):1398-401.
12. Harrington JM, Carter JT, Birrell L, Gompertz D.
Surveillance case definitions for work related upper
limb pain syndromes. Occup Environ Med. 1998;
55(4):264-71.
13. Moradi A, Ebrahimzadeh MH, Ring D. Nonspecific
arm pain. Arch Bone Jt Surg. 2013; 1(2):53-8.
14. Rasmussen BK, Olesen J. Symptomatic and
nonsymptomatic headaches in a general population.
Neurology. 1992; 42(6):1225-31.
15. Becker SJ, Teunis T, Blauth J, Kortlever JT, Dyer GS,
Ring D. Medical services and associated costs vary
widely among surgeons treating patients with
hand osteoarthritis. Clin Orthop Relat Res. 2015;
473(3):1111-7.
16. Bongers PM, Kremer AM, ter Laak J. Are psychosocial
factors, risk factors for symptoms and signs of the
shoulder, elbow, or hand/wrist?: A review of the
epidemiological literature. Am J Ind Med. 2002;
41(5):315-42.
17. Buckle P. Upper limb disorders and work: the
importance of physical and psychosocial factors. J
Psychosom Res. 1997; 43(1):17-25.
18. Harkness EF, Macfarlane GJ, Nahit ES, Silman AJ,
McBeth J. Mechanical and psychosocial factors
predict new onset shoulder pain: a prospective
cohort study of newly employed workers. Occup
Environ Med. 2003; 60(11):850-7.
19. Macfarlane GJ, Hunt IM, Silman AJ. Role of mechanical
and psychosocial factors in the onset of forearm
pain: prospective population based study. BMJ. 2000;
321(7262):676-9.
20. MacIver H, Smyth G, Bird HA. Occupational disorders:
non-specific forearm pain. Best Pract Res Clin
Rheumatol. 2007; 21(2):349-65.
21. Ostergren PO, Hanson BS, Balogh I, Ektor-Andersen
J, Isacsson A, Orbaek P, et al. Incidence of shoulder
and neck pain in a working population: effect
modification between mechanical and psychosocial
exposures at work? Results from a one year follow
up of the Malmo shoulder and neck study cohort. J
Epidemiol Community Health. 2005; 59(9):721-8.
22. Palmer KT. Regional musculoskeletal conditions:
pain in the forearm, wrist and hand. Best Pract Res
Clin Rheumatol. 2003; 17(1):113-35.
23. Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri
LM. Psychological aspects of persistent pain: current
state of the science. J Pain. 2004; 5(4):195-211.
24. Michael ES, Burns JW. Catastrophizing and pain
sensitivity among chronic pain patients: moderating
effects of sensory and affect focus. Ann Behav Med.
2004; 27(3):185-94.
25. Ring D, Kadzielski J, Malhotra L, Lee SG, Jupiter JB.
Psychological factors associated with idiopathic arm
pain. J Bone Joint Surg Am. 2005; 87(2):374-80.
26. Ryall C, Coggon D, Peveler R, Reading I, Palmer KT.
A case-control study of risk factors for arm pain
presenting to primary care services. Occup Med
(Lond). 2006; 56(2):137-43.
27. Vranceanu AM, Safren S, Zhao M, Cowan J, Ring D.
Disability and psychologic distress in patients with
nonspecific and specific arm pain. Clin Orthop Relat
Res. 2008; 466(11):2820-6.
28. Tota-Faucette ME, Gil KM, Williams DA, Keefe FJ,
Goli V. Predictors of response to pain management
treatment. The role of family environment and
changes in cognitive processes. Clin J Pain. 1993;
9(2):115-23.
29. Vranceanu AM, Barsky A, Ring D. Psychosocial
aspects of disabling musculoskeletal pain. J Bone
Joint Surg Am. 2009; 91(8):2014-8.
30. Barsky AJ. Clinical practice. The patient with
hypochondriasis. N Engl J Med. 2001; 345(19):1395-9.
31. Barsky AJ, Ahern DK. Cognitive behavior therapy
for hypochondriasis: a randomized controlled trial.
JAMA. 2004; 291(12):1464-70.
32. Vranceanu AM, Safren SA, Cowan J, Ring DC. Health
concerns and somatic symptoms explain perceived
disability and idiopathic hand and arm pain in an
orthopedics surgical practice: a path-analysis model.
Psychosomatics. 2010; 51(4):330-7.
33. Keijsers E, Feleus A, Miedema HS, Koes BW,
Bierma-Zeinstra SM. Psychosocial factors predicted
nonrecovery in both specific and nonspecific
diagnoses at arm, neck, and shoulder. J Clin Epidemiol.
2010; 63(12):1370-9.
34. Dick FD, Graveling RA, Munro W, Walker-Bone K,
Guideline Development G. Workplace management
of upper limb disorders: a systematic review. Occup
Med (Lond). 2011; 61(1):19-25.
35. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Metaanalysis
of psychological interventions for chronic
low back pain. Health Psychol. 2007; 26(1):1-9.
36. Meijer EM, Sluiter JK, Heyma A, Sadiraj K, Frings-
Dresen MH. Cost-effectiveness of multidisciplinary
treatment in sick-listed patients with upper
extremity musculoskeletal disorders: a randomized,
controlled trial with one-year follow-up. Int Arch
Occup Environ Health. 2006; 79(8):654-64.
Nielson WR, Weir R. Biopsychosocial approaches to
the treatment of chronic pain. Clin J Pain. 2001; 17(4
Suppl):S114-27.
38. Sveinsdottir V, Eriksen HR, Reme SE. Assessing
the role of cognitive behavioral therapy in the
management of chronic nonspecific back pain. J Pain
Res. 2012; 2012(5):371-80.
39. Huisstede BM, Bierma-Zeinstra SM, Koes BW, Verhaar
JA. Incidence and prevalence of upper-extremity
musculoskeletal disorders. A systematic appraisal
of the literature. BMC Musculoskelet Disord. 2006;
7(7):1-7.
40. Huisstede BM, Miedema HS, Verhagen AP, Koes
BW, Verhaar JA. Multidisciplinary consensus on the
terminology and classification of complaints of the
arm, neck and/or shoulder. Occup Environ Med.
2007; 64(5):313-9.
41. Ireland DC. Psychological and physical aspects
of occupational arm pain. J Hand Surg Br. 1988;
13(1):5-10.
42. van Tulder M, Malmivaara A, Koes B. Repetitive strain
injury. Lancet. 2007; 369(9575):1815-22.
43. Vranceanu AM, Barsky A, Ring D. Less specific arm
illnesses. J Hand Ther. 2011; 24(2):118-22.
44. Ring D, Guss D, Malhotra L, Jupiter JB. Idiopathic arm
pain. J Bone Joint Surg Am. 2004; 86-A(7):1387-91.
The Archives of Bone and Joint Surgery
Volume 4, Issue 3
July 2016
Pages 213-219

Files

History

  • Receive Date: 28 August 2015
  • Revise Date: 21 October 2015
  • Accept Date: 25 September 2015

Share

How to cite

Statistics