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Keywords:

  • Physical impairment;
  • Upper extremity;
  • Pain;
  • Numbness;
  • Tingling;
  • Prevalence

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A

Objective

To estimate the prevalence of self reported chronic upper extremity pain associated with physical impairment in a general population, and its co-occurrence with chronic upper extremity numbness or tingling and chronic pain at other locations.

Methods

A general health questionnaire was mailed to 3,000 persons (age 25–74 years) who were randomly selected from a general population register.

Results

The response rate was 83%. The prevalence of chronic upper extremity pain associated with physical impairment was 20.8% (95% confidence interval [95% CI] 19.2–22.5), and that of co-occurring numbness or tingling was 6.7% (95% CI 5.7–7.7). Among the responders with chronic upper extremity pain associated with physical impairment, 84% reported more than 1 painful area.

Conclusion

Chronic upper extremity pain associated with physical impairment and co-occurring chronic upper extremity numbness or tingling were common in the general population. The presence of more than 1 location for pain in the upper extremity as well as in other parts of the body was frequent.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A

Musculoskeletal symptoms are among the most common reasons people seek primary health care (1). In the working population, musculoskeletal disorders of the upper extremity have been shown to be associated with a high rate of symptoms and disability, resulting in considerable costs (2). The prevalence of upper extremity pain in the general population has previously been investigated (3–5). In these studies, prevalence rates were shown either for the whole upper extremity as an entity (without specifying location) (4) or for each joint separately without describing the type or degree of overlap of painful areas (3, 5). The specific location of painful areas is essential for treatment planning. In addition, it is of importance whether pain is localized to 1 joint area only or if patients frequently have pain in other areas as well. Therefore, presenting specific location as well as analyzing overlap of symptoms in the same population can add important information not provided in previous investigations. Besides pain, numbness and tingling can be part of the upper extremity symptoms that cause patients to seek health care and can lead to work disability. We have not found any population-based study analyzing the prevalence of pain and co-occurring numbness or tingling in the upper extremities. Determining the extent of such association as well as that of co-occurring pain in other parts of the body would be important for enhancing patient management and the allocation of health care resources. This information is also needed when interpreting prevalence rates for musculoskeletal symptoms related to specific jobs or job tasks, as in occupational health research.

The burden of musculoskeletal disorders from the patients' perspective can, in addition to symptoms, include limitation in the ability to perform physical activities. Intervention studies are commonly using outcome measures to assess physical function. We aimed to incorporate physical impairment when estimating the prevalence of pain. An epidemiologic study was therefore conducted in a general population to estimate the prevalence of chronic upper extremity pain associated with physical impairment and its co-occurrence with chronic upper extremity numbness or tingling and chronic pain in the neck, low back, or lower extremities. In addition to sex- and age-specific prevalence estimations, we also aimed to analyze sociodemographic characteristics as related to chronic upper extremity pain.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A

Study population and survey.

The study was conducted in a region of southern Sweden with 170,000 inhabitants with demographic characteristics similar to the Swedish general population (6). From this region's general population register, 3,000 people (age 25–74 years) were randomly selected by computer in an age- and sex-stratified sample.

A questionnaire was used for data collection. The questionnaire contained scales concerning general health, bodily pain, and physical function (7), as well as questions about activities involving the upper extremities and about the presence, location, duration, frequency, and severity of the symptoms of pain (3), numbness, and tingling in any part of the body (see Appendix A). It also contained questions regarding morbidity, sociodemographic data, smoking habits, and physical exercise (3).

Location of symptoms was determined by specific questions covering the different parts of the body. The question regarding duration of the symptoms had 5 response options (ranging from “1 month” to “more than 1 year”) to be indicated for each body location. Symptom severity was reported on a 5-point scale ranging from 1 (mild), to 5 (most severe) for each body location. The question regarding frequency of the symptoms had 5 response options ranging from “almost every day” to “once a month.” The questions concerning physical impairment inquired about the degree of limitation in ability to perform a number of specific daily activities. Each of the questions had the response options “not limited at all,” “limited a little,” and “limited a lot.” The sociodemographic factors studied were age, sex, weight, height, socioeconomic level, work status, smoking habits, and frequency of performing physical exercise.

The ethics committee of the medical faculty of Lund University approved the study.

Following information in the local media, the questionnaire (together with information about the general health survey and a prepaid return envelope) was distributed to the persons by mail in January 1997. Two reminders were sent after 3 and 6 weeks to those who did not respond.

For the analysis, chronic pain and chronic numbness or tingling were defined as current self reported symptoms of at least 6-months duration, with a severity rating of at least 2 on a scale from 1 (mild) to 5 (most severe) and a frequency rating of having been experienced at least weekly. This definition was used for all prevalence calculations, including those for pain in the neck, low back, and lower extremities. Physical function was assessed by inquiring about ability to perform specific daily activities. Physical impairment was defined as a response of “limited a lot” for at least 1 activity involving the upper extremities.

Body mass index (BMI) was categorized according to the World Health Organization's cut points (BMI ≥ 25.0 classified as overweight). For the analysis, socioeconomic level was grouped according to the method used by Statistics Sweden into blue-collar workers, white-collar employees, and others. Long-term work absence was defined as sick leave of more than 3-months' duration, disability pension, or early retirement. Smoking was categorized as “current or former smoker” or “nonsmoker.” Physical exercise was categorized as regular (at least weekly) and not regular (less often than weekly).

The accuracy of the responses to the questionnaire was assessed by interview and clinical evaluation of 421 of the responders (287 symptomatic and 134 asymptomatic) 2 months after the mail survey (8).

Data analysis.

The prevalence rates for pain and numbness or tingling in the upper extremities were estimated. The rates were calculated as the number of subjects reporting the target symptom divided by the total number of survey responders. For the prevalence rates of chronic pain in the shoulder/upper arm, elbow/forearm, wrist/hand, 95% confidence intervals were calculated. Sociodemographic categorical variables were analyzed using the Mantel-Haenzel test for homogeneity; age-adjusted odds ratios for the differences between the symptomatic groups and the group with no musculoskeletal pain were calculated.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A

Survey.

Of the 3,000 randomly selected persons, 5 had recently deceased and 35 could not participate in the survey due to recent relocation out of the target area, relocation to an unknown address, severe illness, or severe cognitive impairment, leaving 2,960 persons eligible for the study (Figure 1). Questionnaires were returned by 2,466 people, resulting in a response rate of 83%. The mean ± SD age of the participants was 50 ± 14 years and 54% were women.

thumbnail image

Figure 1. Study profile showing prevalence rates of self reported upper extremity pain in a general population sample. Percentage values are calculated as the number of participants with the target symptom divided by the total number of participants (n = 2,466).

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Nonresponder analysis.

A total of 494 persons (52% men) with a mean age of 47 ± 14 years did not return the questionnaire. A sample (n = 49) of the nonresponders was randomly selected for a telephone interview. Twenty-four persons (11 men) with a mean age of 48 ± 15 years could be contacted and agreed to a short telephone interview consisting of the questions regarding pain from the original questionnaire. Ten persons (5 men) with a mean age 56 ± 13 years reported pain (5 reported mild, 3 moderate, and 2 severe pain).

Assessment of accuracy of responses.

The interview and clinical evaluation of 287 symptomatic participants revealed 3.5% (n = 10) of the participants did not present with the upper extremity symptoms reported in the questionnaire. Among the 134 asymptomatic participants, 6% (n = 8) presented with upper extremity symptoms not reported in the questionnaire.

Missing data.

Thirty-one participants (19 women) with a mean age of 55 ± 15 years reported upper extremity symptoms but did not complete the questions regarding duration, severity, or frequency of symptoms. These were considered as not having chronic symptoms.

Chronic upper extremity pain associated with physical impairment.

Chronic upper extremity pain was reported by 522 participants. Chronic upper extremity pain associated with physical impairment was reported by 21% (n = 513) of the participants (mean age 52 ± 13 years). Of these, 68% (n = 347) were women. The shoulder/upper arm was the most common painful area, being reported by 19% (n = 255) of the women and by 11% (n = 127) of the men (Table 1).

Table 1. Prevalence rates for physical impairment-associated chronic pain in different areas within the upper extremity*
Age, yearsResponders, nPrevalence, % (95% CI)
Shoulder/upper arm painElbow/forearm painHand/wrist pain
  • *

    The prevalence rates are presented in percentage of the total number of participants within each age group. 95% CI = 95% confidence interval.

Men1,13411.2 (9.4–13.2)4.5 (3.4–5.9)4.9 (3.7–6.3)
 25–342195.0 (2.5–8.8)0.9 (0.1–3.3)3.7 (1.6–7.1)
 35–442137.0 (4.0–11.4)0.9 (0.1–3.4)4.2 (2.0–7.9)
 45–5420911.0 (7.1–16.0)9.1 (5.6–13.8)8.1 (4.8–12.7)
 55–6425920.8 (16.1–26.3)9.3 (6.0–13.5)6.2 (3.6–9.8)
 65–7423410.3 (6.7–14.9)1.7 (0.5–4.3)2.1 (0.7–4.9)
Women1,33219.1 (17.1–21.4)9.6 (8.1–11.3)14.4 (12.6–16.4)
 25–3424411.1 (7.4–15.7)2.9 (1.2–5.8)7.0 (4.1–10.9)
 35–4428020.0 (15.5–25.2)9.3 (6.2–13.3)12.9 (9.2–17.4)
 45–5428017.9 (13.5–22.9)11.1 (7.6–15.4)14.3 (10.4–18.9)
 55–6425226.6 (21.2–32.5)16.3 (11.9–21.4)23.0 (18.0–28.7)
 65–7427619.9 (15.4–25.1)8.3 (5.4–12.2)14.9 (10.9–19.6)
Whole population2,46615.5 (14.1–17.0)7.3 (6.3–8.4)10.0 (8.9–11.3)

Chronic numbness or tingling.

Chronic numbness or tingling was reported by 269 participants (168 women), yielding a prevalence rate of 11%. Among the participants reporting chronic upper extremity pain associated with physical impairment, 32% (n = 164) also reported chronic upper extremity numbness or tingling (Figure 2).

thumbnail image

Figure 2. Rates of chronic upper extremity pain associated with physical impairment and co-occurring numbness or tingling among the 2,466 survey responders.

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Chronic pain at multiple areas.

Chronic neck, low back, or lower extremity pain was indicated by 81% (n = 415) of the participants reporting chronic upper extremity pain associated with physical impairment. The rate was 85% (n = 296) among women and 72% (n = 119) among men. Eighty-one participants (43 women) reported physical impairment-associated chronic upper extremity pain that was isolated to a single area only. Chronic pain in the upper extremity co-occurring with pain in other locations was more frequent than chronic pain in the upper extremity only, except among men in the age interval 25–44 years (Table 2).

Table 2. Prevalence rates for chronic pain in different areas of the body cooccurring with physical impairment-associated chronic upper extremity pain*
Age, yearsResponders, nPain isolated to upper extremities, %Chronic upper extremity pain combined with chronic pain in
Neck, %Low back, %Lower extremity, %
  • *

    The prevalence rates are presented in percentage of the total number of participants within each age group (overlap may be present among the groups with neck, low back, and lower extremity pain).

Men1,1344.16.55.66.0
 25–342193.22.71.82.3
 35–442135.64.22.33.3
 45–542094.88.17.67.2
 55–642596.211.611.610.4
 65–742340.85.13.85.5
Women1,3323.817.214.613.0
 25–342443.79.46.62.9
 35–442793.918.615.010.0
 45–542814.318.511.712.1
 55–642524.424.224.222.2
 65–742762.914.915.217.4
Whole population2,4664.012.310.59.7

Rheumatic disease was reported by 65 participants, of whom 57 reported chronic upper extremity pain. Thirty-seven of 38 participants reporting fibromyalgia reported chronic upper extremity pain.

Sociodemographic characteristics.

Participants reporting physical impairment-associated chronic upper extremity pain or pain with co-ocurring numbness or tingling were significantly more likely to be blue-collar workers, long-term work absentees, overweight (only among women), and current or former smokers (except for women with numbness or tingling) (Table 3).

Table 3. Odds ratios for sociodemographic characteristics as related to chronic upper extremity symptoms
VariableMenWomen
Pain (n = 166) OR (95% CI)*Pain and numbness/tingling (n = 57) OR (95% CI)*Pain (n = 347) OR (95% CI)*Pain and numbness/tingling (n = 107) OR (95% CI)*
  • *

    Age-adjusted odds ratio (OR) with 95% confidence interval (95% CI) for the comparison between the participants in each symptomatic group and those with no musculoskeletal symptoms in any part of the body (527 men, 466 women); the OR is considered statistically significant when the 95% CI does not include 1.

  • Analysis restricted to actively working participants.

  • Sick leave lasting at least 3 months, disability pension or early retirement; analysis restricted to participants below 65 years of age.

Overweight1.4(0.9–1.9)1.5 (0.8–2.6)1.6 (1.2–2.1)1.6 (1.04–2.6)
Socioeconomic group, blue collar versus white collar2.9 (1.7–4.9)3.8 (1.6–9)2.2(1.5–3.3)2.6 (1.4–4.8)
Long term work absence5.9 (3.3–10)13 (6.5–29)9.1(4.9–17)15 (7.1–31)
Current or former smoker1.9 (1.3–2.9)3.2 (1.5–6.6)1.4 (1.1–1.9)1.4 (0.9–2.2)
Exercise regularly, at least weekly0.8 (0.5–1.1)0.6 (0.3–1.02)0.8 (0.6–1.1)0.8 (0.5–1.2)

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A

Among participants with chronic upper extremity pain, 84% reported more than 1 painful area. This finding shows that reporting prevalence rates for pain at each specific joint region separately gives a very fragmented picture. The shoulder/upper arm was the most frequently reported painful area for both sexes and all age groups, in agreement with previous studies (3, 5). Shoulder and neck pain has in previous general population studies been described as 1 entity (3, 9, 10). However, our study showed that shoulder pain co-occurred frequently with chronic pain in not only the neck but also the low back and lower extremities. Co-occurring pain at other locations can be important to consider in treatment planning, even when the pain is not widespread enough to fulfill the criteria for generalized pain.

Chronic numbness and tingling in the upper extremities were found to be common in the general population and frequently co-occurred with chronic pain. These symptoms may also cause disability and lead to health care seeking and are therefore important from the patients' as well as caregivers' perspective.

We estimated the prevalence of chronic upper extremity pain that was associated with physical impairment involving the upper extremities. Only 9 of the 522 participants with chronic upper extremity pain were not classified as having physical impairment. Chronic pain at the severity level described appears to be commonly associated with limitations of function.

The prevalence rate for chronic pain in the general population has previously been shown to be highest in the age group of 45–64 years (3, 4, 11). In our study, there was an earlier rise in the prevalence of chronic pain among women, starting in the age group 35–44 years. More women than men reported symptoms, in agreement with previous reports for chronic pain in general (11, 12) and upper extremity pain in particular (3). As in previous reports, this study showed significant differences between persons with chronic pain and asymptomatic persons regarding socioeconomic level (3), rate of long-term work absence, disability pension and early retirement (11, 13), and smoking (14); but the relation with overweight was present only among women.

In conclusion, chronic upper extremity pain associated with physical impairment and co-occurring chronic upper extremity numbness or tingling were common in the general population. The presence of more than 1 location for pain in the upper extremity as well as in other parts of the body was frequent. These findings might be of value when evaluating and treating patients presenting with pain in the upper extremity and when interpreting prevalence rates found in specific populations.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A
  • 1
    The National Board of Health and Welfare. Yearbook of health and medical care 2000, Stockholm, Sweden: National Board of Health and Welfare; 2000 [in Swedish].
  • 2
    Feuerstein M, Miller VL, Burrell LM, Berger R. Occupational upper extremity disorders in the federal workforce: prevalence, health care expenditures, and patterns of work disability. J Occup Environ Med 1998; 40: 54655.
  • 3
    Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization. Clin J Pain 1993; 9: 17482.
  • 4
    Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population: the results of a postal survey in a county of Sweden. Pain 1989; 37: 21522.
  • 5
    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: 64955.
  • 6
    Statistics Sweden. Statistical yearbook of Sweden 1997. Stockholm, Sweden: National Board of Health and Welfare; 1998.
  • 7
    Sullivan M, Karlsson J, Ware JE. The Swedish SF-36 health survey: evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden. Soc Sci Med 1995; 41: 134958.
  • 8
    Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA 1999; 282: 1538.
  • 9
    Hasvold T, Johnsen R. Headache and neck or shoulder pain: frequent and disabling complaints in the general population. Scand J Prim Health Care 1993; 11: 21924.
  • 10
    Ektor-Andersen J, Isacsson SO, Lindgren A, Orbaek P, the Malmo Shoulder-Neck Study Group. The experience of pain from the shoulder-neck area related to the total body pain, self-experienced health and mental distress. Pain 1999; 82: 28995.
  • 11
    Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999; 354: 124852.
  • 12
    Croft P, Rigby AS, Boswell R, Schollum J, Silman A. The prevalence of chronic widespread pain in the general population. J Rheumatol 1993; 20: 7103.
  • 13
    Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Characteristics of subjects with chronic pain, in relation to local and widespread pain report: a prospective study of symptoms, clinical findings and blood tests in subgroups of a geographically defined population. Scand J Rheumatol 1996; 25: 14654.
  • 14
    Andersson H, Ejlertsson G, Leden I. Widespread musculoskeletal chronic pain associated with smoking: an epidemiological study in a general rural population. Scand J Rehabil Med 1998; 30: 18591.

APPENDIX A

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  8. APPENDIX A

ENGLISH SCRIPTS OF THE SURVEY QUESTIONS

Question 1.

Have you experienced pain, numbness or tingling during the past 4 weeks?

Response choices for each symptom:

 Yes, No.

Question 2.

Where is the pain, numbness, or tingling located and since when have you had the symptoms? Please indicate appropriate part of the body and duration.

Response choices for each part of the body (head/face, neck, shoulder/upper arm, elbow/forearm, wrist/hand, chest/upper back, stomach, lower back, hip/thigh, knee/lower leg, ankle/foot):

Since 1 month, Since 3 months, Since 6 months, Since 1 year, More than 1 year.

Question 3.

How often do you have pain, numbness, or tingling?

Response choices for each symptom:

Almost every day, A few times every week, Once a week, Once a month.

Question 4.

To get an estimation of the severity of the pain, numbness, or tingling you are experiencing we want you to give an estimate of your pain, numbness, or tingling for each part of the body you marked in question 2. Rate your estimation between 1 and 5, 1 reflects mild pain,numbness, or tingling and 5 reflects the most severe pain, numbness, or tingling.

Response choices for each symptom and for each part of the body:

1, 2, 3, 4, 5.