BMJ 2000;321:676 ( 16 September )

General Practice

Role of mechanical and psychosocial factors in the onset of forearm pain: prospective population based study

Gary J Macfarlane, professor a, Isabelle M Hunt, research assistant b, Alan J Silman, professor b. 

a Unit of Chronic Disease Epidemiology, School of Epidemiology and Health Sciences, Medical School, University of Manchester, Manchester M13 9PT, b Arthritis Research Campaign Epidemiology Unit, School of Epidemiology and Health Sciences, University of Manchester

Correspondence to: G J Macfarlane G.Macfarlane{at}man.ac.uk

    Abstract
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

Objective: To determine the aetiology of forearm pain. In particular to determine the relative contribution of (a) psychological factors, features of somatisation, and health anxiety and behaviour, (b) work related mechanical factors, and (c) work related psychosocial factors in the onset of forearm pain.
Design: 2 year prospective population based cohort study, with retrospective assessment of exposures at work.
Setting: Altrincham, Greater Manchester.
Participants: 1953 individuals aged 18-65 years.
Outcome measures: Forearm pain of new onset.
Results: At follow up, 105 (8.3%) participants reported forearm pain of new onset lasting at least one day in the past month. Among these, 67% also reported shoulder pain, 65% back pain, and 45% chronic widespread pain. Increased risks of onset were associated with high levels of psychological distress (relative risk 2.4, 95% confidence interval 1.5 to 3.8), reporting at least two other somatic symptoms (1.7, 0.95 to 3.0), and high scores on the illness behaviour subscale of the illness attitude scales. The two work related mechanical exposures associated with the highest risk of forearm pain in the future were repetitive movements of the arm (4.1, 1.7 to 10) or wrists (3.4, 1.3 to 8.7), whereas the strongest work related psychosocial risk was dissatisfaction with support from colleagues or supervisors (4.7, 2.2 to 10).
Conclusions: Psychological distress, aspects of illness behaviour, and other somatic symptoms are important predictors of onset of forearm pain in addition to work related psychosocial and mechanical factors. Misleading terms such as "cumulative trauma disorder" or "repetitive strain injury," implying a single uniform aetiology, should be avoided.

    Introduction
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

The aetiology of forearm pain, and conditions of which forearm pain is a feature, has been the subject of intensive controversy.1 Some believe the pain to be integrally related to exposure to physical factors such as frequent repetitive movements of the upper limb, which can be common in some occupational settings. Others believe that the pain is often a regional manifestation of a fibromyalgia-type syndrome, and that it is associated with high levels of psychological distress and features of somatisation. At a workshop in 1997 (sponsored by the United Kingdom Health and Safety Executive) to propose classification criteria for upper limb syndromes that were potentially work related, one of the conditions identified was "diffuse forearm pain."2 But owing to a lack of appropriately designed studies, little is known about the occurrence (outside the clinic setting) or aetiology of forearm pain. We aimed to determine the relative contribution of (a) psychological factors, features of somatisation, and health anxiety and behaviour, (b) work related mechanical factors, and (c) work related psychosocial factors in the onset of new forearm pain.

    Participants and methods
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

We conducted a two year prospective population-based cohort study, with retrospective assessment of exposures in the workplace.

Cohort recruitment
Our study population comprised 1953 participants from a cross sectional survey, conducted one year previously. The study has been described in detail.3 Participants in the original survey were adults aged 18 to 65 years, selected by simple random sampling from the age and sex register of a general practice in Altrincham, Greater Manchester. As over 95% of the United Kingdom population are registered with a general practitioner,4 this provided a convenient sampling frame for the local population. The sociodemographic characteristics and age and sex structure of the study area were similar to that of the United Kingdom population. The study was approved by the local research ethics committee.

A questionnaire was posted to all participants at baseline, with up to two further questionnaires posted to non-responders. The questionnaire contained a picture of a blank manikin on which respondents were asked to shade the site of any pain experienced during the previous month and lasting at least one day. The information provided by this exercise was coded by using a template, and those respondents who had shaded within the area from the elbow to the wrist were considered to have forearm pain (fig 1). This enabled a cohort of participants free of forearm pain to be identified, and these participants were eligible for follow up. Among participants free of forearm pain, we obtained data on other physical and psychological measures: (a) the 12 item general health questionnaire,5 an instrument that identifies psychological distress; (b) the somatic symptom scale,6 a brief measure of the propensity to present somatic complaints; (c) two subscales of the illness attitude scales---health anxiety and illness behaviour,7 (high scores on the scales indicated, respectively, high levels of health related anxiety and an increased propensity to seek care when experiencing symptoms); and (d) other syndromes of regional and widespread pain. We identified participants with low back pain or shoulder pain (experienced during the past month and lasting at least one day) according to the body areas shaded in figure 1. We defined chronic widespread pain according to that used by the American College of Rheumatology criteria for fibromyalgia.8



View larger version (22K):
[in this window]
[in a new window]
  		Definitions of pain according to site shaded

Follow up
At two years follow up we sent a postal questionnaire to those respondents who had been free of forearm pain at baseline. We posted up to two further questionnaires to non-respondents.

Pain status
We inquired about forearm pain experienced during the previous month and lasting at least one day. Among participants reporting forearm pain, we collected further information on date of onset, radiation of the pain to other parts of the upper limb, health seeking behaviour, and whether the pain was associated with disability.

Work related factors
To determine work related mechanical and psychosocial factors experienced at the time of a new onset of forearm pain, we retrospectively assessed exposures at work. We obtained an occupational history for all participants for the entire follow up period. For each job we requested the date of starting and finishing, occupational title, and detailed information on mechanical and psychosocial factors experienced in the job. The questionnaires relating to mechanical and psychosocial factors have been used in previous population studies.9

Analysis
Participants free of forearm pain at baseline and who provided data at both baseline and follow up were included in the analyses. The risk of developing forearm pain associated with each factor was calculated with Cox regression models and is expressed as relative risk. The effects of occupational activities on the occurrence of new episodes of forearm pain were analysed by an assessment of those participants who were working during the follow up period. Among those who reported forearm pain at follow up, occupational exposures were defined as those carried out at the time of onset of the pain. Participants who did not develop forearm pain were assigned a dummy date during the follow up year, chosen at random on the basis of the distribution of dates of onset derived from the participants who developed forearm pain. The work related exposures were then assessed by the date of onset of pain (participants with forearm pain) and the dummy date (others). To determine whether an individual exposure or a small group of exposures could reliably identify a group at high risk of developing forearm pain, those factors that on univariate analysis showed a significant risk were selected as candidate variables for entry into forward stepwise Cox regression models, in each of the dimensions considered.

    Results
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

Of the 1953 individuals posted a questionnaire at baseline, 1715 returned a completed questionnaire. Excluding from the denominator those participants who were unlikely to have received the questionnaire (82 no longer at registered address, one dead), the adjusted participation rate was 92%. At two years' follow up, 317 of the original 1715 respondents were not followed up (14 had died, 251 were no longer either registered with the general practitioner or at the registered address, and 52 had reported forearm pain at baseline). The remaining 1398 participants were sent a follow up postal questionnaire. This was completed by 1260 participants (adjusted follow up rate of 90%).

The prevalence of forearm pain at follow up was 8.3% (105 participants), with little difference between men and women (table 1). Overall, prevalence increased with age among the men but not the women. Around one third of participants (34%) reporting forearm pain had consulted their general practitioner about the pain, with a similar proportion (35%) having some related disability. Pain was rarely confined only to the forearm region of the upper limb (9%). Pain was also reported in the wrist (61 participants; 66%), hand (42; 45%), and elbow (45; 48%). Regional pain syndromes at other sites were also common among those reporting forearm pain: 67% reported shoulder pain and 65% low back pain whereas 45% satisfied the American College of Rheumatology's definition of chronic widespread pain.


                              
View this table:
[in this window]
[in a new window]
 

Table 1. Prevalence of forearm pain at follow up

Risk factors

Morbidities
Participants reporting another regional pain syndrome or chronic widespread pain at baseline were at increased risk of reporting new onset of forearm pain at follow up (table 2). Increased risks (twofold or threefold) for developing forearm pain were observed for those with shoulder pain, low back pain, or chronic widespread pain. Table 3 shows the associations of other baseline measurements with forearm pain of new onset. Participants scoring in the middle or highest groups for the general health questionnaire, who reported ever having at least one symptom on the somatic symptom scale or with high scores on the health behaviour subscale of the illness attitude scales, had a significantly increased risk of forearm pain. In contrast, health anxiety showed only a weak, and not significant, relation with onset of symptoms.


                              
View this table:
[in this window]
[in a new window]
 

Table 2. Risk of forearm pain at follow up in relation to pain status at baseline


                              
View this table:
[in this window]
[in a new window]
 

Table 3. Risk of forearm pain at follow up in relation to morbidities or attitudes to illness

Work related mechanical factors
Of the 105 participants with forearm pain at follow up, 42 (40%) reported being in employment at the time of onset of pain. Of the 1155 participants without forearm pain, 740 were in employment on their assigned dummy date. These 782 participants form the subgroup on whom an analysis of the role of work related exposures on the onset of forearm pain was undertaken. Most (84%; 657 participants) reported only one job during the total follow up period; 14% (109) and 2% (n=16) had two and three jobs respectively.

Moderately increased risks of forearm pain were found for those who reported that for "half or most of the time" in their job they were lifting or carrying weights with one or both hands or pushing or pulling weights (table 4 ). The two mechanical exposures associated with the highest (and most important) risk of future forearm pain were both related to repetitive movements of the upper limb. The risk associated with repetitive movements of the arms increased from 1.8 (95% confidence interval 0.6 to 5.1) for occasional exposure to 4.1 (1.7 to 10) for exposure "half or most of the time." Similarly, the risks associated with repetitive movements of the wrists were 1.4 (0.4 to 4.2) and 3.4 (1.3 to 8.7) respectively (table 4 ). No increased risk was associated with typing for more than 30 minutes without a break.


                              
View this table:
[in this window]
[in a new window]
 

Table 4. Risk of forearm pain at follow up in relation to occupational mechanical and psychosocial exposures

Work related psychosocial factors
The strongest psychosocial factor associated with the onset of forearm pain was related to the level of satisfaction with support from supervisors and colleagues (table 4). Compared with those who were satisfied most of the time, those who were only occasionally or never satisfied had a risk of 4.7 (2.2 to 10). Participants who believed that they could rarely make their own decisions at work had double the risk of new onset of forearm pain, whereas non-significant increased risks were also observed in those who thought that their job was too hectic (relative risk 2.0), too boring or monotonous (2.5), or caused stress (3.3).

Multivariate model
To ascertain whether, when considered together, a small group of factors collected at baseline could reliably characterise those participants who would develop forearm pain, we conducted further Cox regression analyses by using a forward stepwise model. In the model for mechanical exposures, the only factor entered was repetitive use of the arms, whereas in the model for work related psychosocial factors, only the level of satisfaction with support from supervisor or colleagues was included. The model considering other morbidities and illness attitudes included two factors: high scores on the illness behaviour subscale of the illness attitude scales and high scores on the general health questionnaire. When these four factors were entered into a single multivariate model, all factors remained important independent predictors of the onset of symptoms (table 5). For each participant we calculated the number of factors (among the four in the final model) for which they reported exposure in the highest category. The prevalence of forearm pain increased from 0.4% among those exposed to none of the factors to 15.4% for those reporting all factors.


                              
View this table:
[in this window]
[in a new window]
 

Table 5. Combined regression model of risk factors for new onset of forearm pain



    Discussion
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

This is the first population based prospective study, of which we are aware, examining the epidemiology of diffuse forearm pain. Forearm pain is a common symptom, which frequently results in interference with daily activities or consultation to a general practitioner. Forearm pain rarely, however, occurs in isolation. Given its co-occurrence with other syndromes of regional and widespread pain, it is not surprising that the aetiology is similar. Onset was independently related to psychological factors, aspects of illness behaviour, other somatic symptoms, and work related mechanical and psychosocial factors. 9 10 This remained true even when analysis was restricted to those participants with forearm pain or upper limb pain only (data not shown).

The role of mechanical factors in the onset of forearm pain has long been suspected, in particular repetitive movements of the arms and wrists. It is a common symptom in occupations that involve writing or keyboard work, with particularly high exposures.11 One study of 17 patients diagnosed with "repetitive strain injury" found symptoms and objective signs consistent with a minor polyneuropathy, whereas a group of 29 keyboard workers (most without symptoms) showed early signs of the condition.12 Other studies have shown vascular abnormalities in affected upper limbs. 13 14

The onset of forearm pain was not related to mechanical factors alone: high levels of distress and adverse psychosocial factors also predicted the onset of symptoms. The strongest psychosocial predictor was dissatisfaction with support form work supervisors or colleagues, but aspects of demand such as stress, worry, job pace, and level of interest were also associated (although not significantly) with future symptoms. Further, the concept that forearm pain may be one feature of a wider process of somatisation was supported by the observation that participants who developed forearm pain were more likely to report having previously had other somatic symptoms. Similar risk factors have been found for other syndromes of regional pain such as shoulder and back pain, and these are common features of chronic widespread pain and fibromyalgia. 15 16 These observations support the view that in many cases forearm pain may be a regional manifestation of a more widespread pain syndrome.


What is already known on this topic

Several countries have experienced "epidemics" of forearm pain in occupational settings

Little is known about risk factors for onset of forearm pain

What this study adds

High levels of psychological distress, experiencing other somatic symptoms, and aspects of illness behaviour predict onset of forearm pain

In the workplace, repetitive movements of the arms or wrists and adverse psychosocial factors (for example, lack of support from supervisors and colleagues) both predict onset of forearm pain

Forearm pain commonly co-occurs with other regional musculoskeletal pain syndromes

Our study emphasises the multifactorial nature of forearm pain in the population. It confirms a long suspected relation between work related repetitive movements and onset of forearm pain but also that the onset of symptoms can be predicted by high levels of psychological distress and adverse work related psychosocial experiences. Future studies examining and refining hypotheses about the aetiology of diffuse forearm pain should consider each of these domains, and misleading terms such as "cumulative trauma disorder" or "repetitive strain injury," implying a single uniform cause, should be avoided.

    Acknowledgments

We thank the doctors and patients of the participating general practices and Dr Sidney Benjamin and Ann Papageorgiou who helped design and coordinate the original survey.

Contributors: GJM and AJS conceived the original idea, designed and supervised conducting the study and the analysis of results. IMH conducted the study and the analysis of results. GJM took the lead in writing the paper, with AJS and IMH revising the manuscript. All authors will act as guarantors for the paper.

    Footnotes

Funding: The Arthritis Research Campaign and the Health and Safety Executive.

Competing interests: None declared.

    References
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

1. Helliwell P. The elbow, forearm, wrist and hand. In Clinical rheumatology: regional musculoskeletal pain. Eds P Croft and PM Brooks. In: London: Baillière Tindall, 1999:311-328.
2. Harrington JM, Carter JT, Birrell L, Gompertz D. Surveillance case definitions for work-related upper limb syndromes. Occup Environ Med 1998; 55: 264-271[Abstract/Free Full Text].
3. Hunt IM, Silman AJ, Benjamin S, McBeth J, Macfarlane GJ. The prevalence and associated features of chronic widespread pain in the community using the "Manchester" definition of chronic widespread pain. Rheumatology 1999; 38: 275-279[Abstract/Free Full Text].
4. Ritchie J, Jacoby A, Bone M. Access to primary health care. London: Office for Population Censuses and Surveys social survey division: HMSO, 1981.
5. Goldberg D, Williams P. A user's guide to the general health questionnaire. Windsor: NEFR-Nelson, 1988.
6. Othmer E, DeSouza C. A screening test for somatisation disorder (hysteria). Am J Psychiatry 1985; 142: 1146-1149[Abstract/Free Full Text].
7. Speckens AE, Spinhoven P, Sloeckers PPA, Bolk JH, van Hemert AM. A validation study of the Whitely index, the illness attitude scales, and the somatosensory amplification scale in general medical and general practice patients. J Psychosom Res 1996; 40: 95-104[CrossRef][Medline].
8. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990; 33: 160-172[Medline].
9. Pope DP, Croft PR, Pritchard CM, Silman AJ, Macfarlane GJ. Occupational factors related to shoulder pain and disability. Occup Environ Med 1997; 54: 316-321[Abstract/Free Full Text].
10. Papageorgiou AC, Macfarlane GJ, Thomas E, Croft PR, Jayson MIV, Silman AJ. Psychosocial factors in the workplace---do they predict new episodes of low back pain? Spine 1997; 22: 1137-1142[CrossRef][Medline].
11. Punnet L, Robins JM, Wegman DH, Keyserling WM. Soft tissue disorders in the upper limbs of female garment workers. Scand J Work Environ Health 1985; 11: 417-425[Medline].
12. Greening J, Lynn B. Vibration sense in the upper limb in patients with repetitive strain injury and a group of at-risk office workers. Int Arch Occup Environ Health 1998; 71: 29-34[CrossRef][Medline].
13. Sharma SD, Smith EM, Hazelman BL, Jenner JR. Thermographic changes in keyboard operators with chronic forearm pain. BMJ 1997; 314: 118[Free Full Text].
14. Pritchard MH, Pugh N, Wright I, Brownlee M. A vascular basis for repetitive injury. Rheumatology 1999; 38: 636-639[Abstract/Free Full Text].
15. Bongers PM, de Winter CR, Kompier MAJ, Hildebrandt VH. Psychosocial factors at work and musculoskeletal disease. Scand J Work Environ Health 1993; 19: 297-312[Medline].
16. Macfarlane GJ. Generalised pain, fibromyalgia and regional pain: an epidemiological view. Baillières Clin Rheumatol 1999; 13: 403-414.

(Accepted 16 June 2000)

© BMJ 2000
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati    What's this?

Relevant Article

Onset of forearm pain can be predicted
BMJ 2000 321: 0. [Full Text]

This article has been cited by other articles:

  • Burton, K., Kendall, N., Pearce, B., Birrell, L., Bainbridge, C. (2009). Reply. Occup Med (Lond) 59: 204-205 [Full text]  
  • Burton, A. K., Kendall, N. A. S., Pearce, B. G., Birrell, L. N., Bainbridge, L. C. (2009). Management of work-relevant upper limb disorders: a review. Occup Med (Lond) 59: 44-52 [Abstract] [Full text]  
  • Madan, I., Reading, I., Palmer, K. T, Coggon, D. (2008). Cultural differences in musculoskeletal symptoms and disability. Int J Epidemiol 37: 1181-1189 [Abstract] [Full text]  
  • Carnes, D, Ashby, D, Parsons, S, Underwood, M (2008). Chronic forearm pain presents as a transient and indistinct pain site in a community setting: results from a UK population survey. Fam Pract 25: 197-201 [Abstract] [Full text]  
  • Dekkers-Sanchez, P M, Hoving, J L, Sluiter, J K, Frings-Dresen, M H W (2008). Factors associated with long-term sick leave in sick-listed employees: a systematic review. Occup. Environ. Med. 65: 153-157 [Abstract] [Full text]  
  • Spies-Dorgelo, M. N., van der Windt, D. A. W. M., van der Horst, H. E., Prins, A. P. A., Stalman, W. A. B. (2007). Hand and wrist problems in general practice patient characteristics and factors related to symptom severity. Rheumatology (Oxford) 46: 1723-1728 [Abstract] [Full text]  
  • Lacey, R. J., Lewis, M., Sim, J. (2007). Piecework, musculoskeletal pain and the impact of workplace psychosocial factors. Occup Med (Lond) 57: 430-437 [Abstract] [Full text]  
  • Jones, G. T, Harkness, E. F, Nahit, E. S, McBeth, J., Silman, A. J, Macfarlane, G. J (2007). Predicting the onset of knee pain: results from a 2-year prospective study of new workers. Ann Rheum Dis 66: 400-406 [Abstract] [Full text]  
  • Palmer, K. T., Calnan, M., Wainwright, D., Poole, J., O'Neill, C., Winterbottom, A., Watkins, C., Coggon, D. (2005). Disabling musculoskeletal pain and its relation to somatization: a community-based postal survey. Occup Med (Lond) 55: 612-617 [Abstract] [Full text]  
  • Walker-Bone, K, Cooper, C (2005). Hard work never hurt anyone: or did it? A review of occupational associations with soft tissue musculoskeletal disorders of the neck and upper limb. Ann Rheum Dis 64: 1391-1396 [Abstract] [Full text]  
  • Lacey, R. J., Lewis, M., Sim, J. (2005). The relationship between hand paraesthesia and occupational factors: results from a population study. Rheumatology (Oxford) 44: 1287-1293 [Abstract] [Full text]  
  • Walker-Bone, K, Cooper, C (2005). Hard work never hurt anyone--or did it? A review of occupational associations with soft tissue musculoskeletal disorders of the neck and upper limb. Ann Rheum Dis 64: 1112-1117 [Abstract] [Full text]  
  • Cole, D. C., Ibrahim, S., Shannon, H. S. (2005). Predictors of Work-Related Repetitive Strain Injuries in a Population Cohort. Am. J. Public Health 95: 1233-1237 [Abstract] [Full text]  
  • Harkness, E. F., Macfarlane, G. J., Silman, A. J., McBeth, J. (2005). Is musculoskeletal pain more common now than 40 years ago?: two population-based cross-sectional studies. Rheumatology (Oxford) 44: 890-895 [Abstract] [Full text]  
  • Miranda, H., Viikari-Juntura, E., Heistaro, S., Heliovaara, M., Riihimaki, H. (2005). A Population Study on Differences in the Determinants of a Specific Shoulder Disorder versus Nonspecific Shoulder Pain without Clinical Findings. Am J Epidemiol 161: 847-855 [Abstract] [Full text]  
  • Ring, D., Kadzielski, J., Malhotra, L., Lee, S.-G. P., Jupiter, J. B. (2005). Psychological Factors Associated with Idiopathic Arm Pain. JBJS 87: 374-380 [Abstract] [Full text]  
  • Hobby, J. L., Venkatesh, R., Motkur, P. (2005). The effect of psychological disturbance on symptoms, self-reported disability and surgical outcome in carpal tunnel syndrome. J Bone Joint Surg Br 87-B: 196-200 [Abstract] [Full text]  
  • Helliwell, P S, Taylor, W J (2004). Repetitive strain injury. Postgrad. Med. J. 80: 438-443 [Abstract] [Full text]  
  • Ring, D., Guss, D., Malhotra, L., Jupiter, J. B. (2004). Idiopathic Arm Pain. JBJS 86: 1387-1391 [Abstract] [Full text]  
  • Harkness, E F, Macfarlane, G J, Nahit, E S, Silman, A J, McBeth, J (2003). Mechanical and psychosocial factors predict new onset shoulder pain: a prospective cohort study of newly employed workers. Occup. Environ. Med. 60: 850-857 [Abstract] [Full text]  
  • Kryger, A I, Andersen, J H, Lassen, C F, Brandt, L P A, Vilstrup, I, Overgaard, E, Thomsen, J F, Mikkelsen, S (2003). Does computer use pose an occupational hazard for forearm pain; from the NUDATA study. Occup. Environ. Med. 60: e14-14 [Abstract] [Full text]  
  • Haahr, J. P., Andersen, J. H. (2003). Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Rheumatology (Oxford) 42: 1216-1225 [Abstract] [Full text]  
  • Andersen, J H, Kaergaard, A, Mikkelsen, S, Jensen, U F, Frost, P, Bonde, J P, Fallentin, N, Thomsen, J F (2003). Risk factors in the onset of neck/shoulder pain in a prospective study of workers in industrial and service companies. Occup. Environ. Med. 60: 649-654 [Abstract] [Full text]  
  • Nahit, E S, Hunt, I M, Lunt, M, Dunn, G, Silman, A J, Macfarlane, G J (2003). Effects of psychosocial and individual psychological factors on the onset of musculoskeletal pain: common and site-specific effects. Ann Rheum Dis 62: 755-760 [Abstract] [Full text]  
  • Haahr, J P, Andersen, J H (2003). Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study. Occup. Environ. Med. 60: 322-329 [Abstract] [Full text]  
  • Reading, I., Walker-Bone, K., Palmer, K. T., Cooper, C., Coggon, D. (2003). Anatomic Distribution of Sensory Symptoms in the Hand and Their Relation to Neck Pain, Psychosocial Variables, and Occupational Activities. Am J Epidemiol 157: 524-530 [Abstract] [Full text]  
  • Mueller, M. J, Maluf, K. S (2002). Tissue Adaptation to Physical Stress: A Proposed "Physical Stress Theory" to Guide Physical Therapist Practice, Education, and Research. ptjournal 82: 383-403 [Abstract] [Full text]  
  • Barr, A. E, Barbe, M. F (2002). Pathophysiological Tissue Changes Associated With Repetitive Movement: A Review of the Evidence. ptjournal 82: 173-187 [Abstract] [Full text]  
  • Amadio, P. C., Frymoyer, J., Szabo, R. M., King, K. J. (2001). Repetitive Stress Injury. JBJS 83: 136-136 [Full text]  

Rapid Responses:

Read all Rapid Responses

Multifactorial aetiology of forearm pain.
Joanne Dawson, et al.
bmj.com, 22 Sep 2000 [Full text]
Doc2Doc Vacancy
Access jobs at BMJ Careers
Whats new online at Student BMJ