Physician Bulletins

Rest & Protect or Stay Active? Conditions of the Elbow, Wrist and Hand.

What’s the Evidence-Based Recommendation?

Upper limb pain is common, disabling, and – without treatment – prone to recurrence. 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.¹ 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 an injury such as a fall 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, cumulative microtrauma, 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 long-standing practice of advice to rest productive or counterproductive?

This past May, Gareth Jones and colleagues addressed this question in a multi-site, randomized trial.⁷ They followed 538 patients referred to outpatient physical therapy for distal arm pain – mostly lateral epicondylitis, tenosynovitis, and thumb osteoarthritis. At baseline, patients averaged one month of pain. Researchers randomized 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 physical therapy, in cases of chronic distal arm pain such as epicondylalgia, advice to stay active may improve outcomes. When your patients present with distal arm pain, remember Back to Action Physical Therapy. Our physical therapy expertise includes hand therapy so you can count on us for all your therapy referrals.

Specialized Treatment for Enhanced Outcomes

Back to Action invests in training, equipment, and facilities well beyond the standard training of physical therapists. This includes aquatic therapy, hand therapy, vestibular rehab, myofascial release, Mulligan technique, Maitland technique and much more. The availability of specialty approaches gives us greater opportunity for faster and better outcomes for all your patients.

References:

1. Palmer KT, Calnan M, Wainwright D, et al. Upper limb pain in primary care: health beliefs, somatic distress, consulting and patient sat-isfaction. 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, et al. 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, et al. Maintained physical activity and physiother-apy in the management of distal arm pain: a randomised controlled trial. RMD Open. 2019 Mar 1;5(1):e000810.

Articles in the Physician Article category are not intended for public consumption. They are news bulletins for clinicians licensed to refer to physical therapy. In reviewing this data, you agree that this is not medical advice and that medical advice should only be heeded after a proper assessment from a licensed healthcare professional.