We Recommend Staying Active for Back Pain. Should We Do it for Distal Arm Pain?

Upper limb pain is common, disabling, and prone to recurrence without treatment. Each year, up to one-half of adults report upper limb pain lasting a day or longer, and roughly a third of them seek health care.

Transient disability frequently results in lost work days.2 Those seeking health care often receive advice to rest the involved joint so it can heal, and this is concordant with guidelines.3 However, resting distal arm pain is not well supported in the literature. 
 
It seems to be based on a concept that distal arm pain is an injury that needs to heal, and that rest and protection will result in the most efficient healing. To the contrary, research suggests that most distal arm pain presented in primary care is not a true injury.4 Much like back pain,5 many of the conditions we have previously described as injuries or inflammatory conditions are more akin to failed healing responses and deconditioning syndromes - without an important inflammatory component. More than twenty years ago, the first systematic review on the subject concluded that advice for bed rest was counterproductive in back pain.6 Have we been ignoring upper limb pain in this consideration? Is the longstanding practice of advice to rest productive or counterproductive?
 
This past May, Gareth Jones and colleagues addressed this question in a multi-site, randomised trial.7 They followed 538 patients referred to outpatient physiotherapy for distal arm pain - mostly “lateral epicondylitis,” “tenosynovitis,” and thumb osteoarthritis. At baseline, patients averaged one month of pain. Researchers randomised patients between a group advised to stay active and a group advised to rest the injury according to established practice. Patients advised to stay active proved 40% more likely to achieve full recovery at 26 weeks. Advice to rest these distal arm pain conditions was associated with poorer outcomes. 
 
Patients in the stay-active group received advice to stay active to recover quickly. Patients were told that distal arm pain is common, lasting damage is rare, and that recovery can be expected. They were advised that early return to work with gradually increasing activity was helpful. The advice-to-rest group received advice to rest the involved joint and avoid activities that might further aggravate the symptoms. 
 
It appears that, even with physiotherapy, in cases of chronic distal arm pain such as epicondylalgia, advice to stay active may improve outcomes. Our free patient e-book, Guide to Elbow Injuries, recommends staying active and gradually increasing activity, in keeping with the current science. 

References
 
1. Palmer KT, Calnan M, Wainwright D, O'neill C, Winterbottom A, Watkins C, Poole J, Coggon D. Upper limb pain in primary care: health beliefs, somatic distress, consulting and patient satisfaction. Family Practice. 2006 Oct 11; 23(6): 609-17. 
2. Buckley P. Work-related Musculoskeletal Disorder (WRMSDs) statistics. Health and Safety Executive, Great Britain. 2016:1-20. 
3. Informed Health. How can tenosynovitis be treated? Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG). 2018 Jul 26. 
4. Khan K, Cook J, Kannus P, et al. Time to abandon the ‘tendinitis’ myth. BMJ. 2002; 324: 626-7.
5. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ. What low back pain is and why we need to pay attention. The Lancet. 2018 Jun 9;391(10137):2356-67. 
6. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. Br J Gen Pract. 1997 Oct 1;47(423):647-52. 
7. Jones GT, Macfarlane GJ, Walker-Bone K, Burton K, Heine P, McCabe C, McNamee P, McConnachie A, Zhang R, Whibley D, Palmer K. Maintained physical activity and physiotherapy in the management of distal arm pain: a randomised controlled trial. RMD Open. 2019 Mar 1;5 (1):e000810. 

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