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Musculoskeletal Pain and Overuse Syndromes in Adult Acquired Major Upper-Limb Amputees
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ORIGINAL ARTICLE
Musculoskeletal Pain and Overuse Syndromes in Adult Acquired Major Upper-Limb Amputees Kristin Østlie, MD, Rosemary J. Franklin, Grad Dip Phys, Ola H. Skjeldal, MD, PhD, Anders Skrondal, PhD, Per Magnus, MD, PhD ABSTRACT. Østlie K, Franklin RJ, Skjeldal OH, Skrondal A, Magnus P. Musculoskeletal pain and overuse syndromes in adult acquired major upper-limb amputees. Arch Phys Med Rehabil 2011;92:1967-73. Objectives: (1) To compare the prevalence of self-reported musculoskeletal pain in upper-limb amputees (ULAs) in Norway with that of a control group drawn from the Norwegian general population; (2) to describe musculoskeletal pain bothersomeness in ULAs; (3) to estimate the association between prosthesis wear and self-reported musculoskeletal pain in ULAs; and (4) to describe the occurrence of musculoskeletal overuse syndromes in a sample of ULAs. Design: Cross-sectional study: postal questionnaires and clinical examinations. Setting: Norwegian ULA population. Clinical examinations performed at 3 clinics. Participants: Questionnaires: population-based amputee sample (n⫽224; 57.4% response rate). Random control sample (n⫽318; 33.1% response rate). Clinical examinations: combined referred sample and convenience sample (n⫽70; 83.3% of those invited). Survey inclusion criteria: adult, resident in Norway and mastering Norwegian (amputees and controls), acquired major upper-limb amputation (amputees only). Interventions: Not applicable. Main Outcome Measures: Self-reported musculoskeletal pain and pain bothersomeness. Self-reported pain in prosthesis wearers and nonwearers. Clinically assessed diagnoses of musculoskeletal overuse syndromes. Results: Self-reported musculoskeletal pain was more frequent in ULAs than in the control group except for lower back pain. In ULAs, 57.0% reported neck/upper back pain (odds ratio [OR]⫽2.56; 95% confidence interval [CI], 1.64 –3.98), and 58.9% reported shoulder pain (OR⫽4.00; 95% CI, 2.51– 6.36). The percentage difference for arm pain was 24.8% (P⬍.001). All pain was reported as bothersome. We found no difference in pain prevalence between prosthesis wearers and nonwearers. Musculoskeletal overuse syndromes were found in 6.1% to 24.2% of ULAs, depending on diagnosis and casedefinition criteria.
Conclusions: Upper-limb loss increases the risk of self-reported musculoskeletal pain in the neck/upper back, shoulders, and in the remaining arm. Prosthesis wear does not prevent musculoskeletal pain. Further studies should be conducted to investigate the effects of prosthesis wear and possible preventive measures, and to ascertain our preliminary prevalence estimates of overuse syndromes. Key Words: Amputees; Arm; Nerve compression syndromes; Rehabilitation; Shoulder impingement syndrome; Tennis elbow. © 2011 by the American Congress of Rehabilitation Medicine
RMS AND HANDS ARE USED for most activities of A Major amputation (through or daily living (ADLs). proximal to the wrist) causes a total loss of hand and wrist 1,2
function on the affected side.3 Upper-limb amputees (ULAs) are typically young, healthy persons who should expect a normal life span with many years of productive employment and contribution to society.4,5 Unilateral major arm amputation is followed by the transfer of that hand’s function to the other arm. Although the residual limb can be used for tasks such as fixing and lifting objects, the transfer of function to the nonamputated limb will increase the workload of this arm and the risk of musculoskeletal pain and overuse syndromes such as shoulder impingement, epicondylitis, and peripheral nerve entrapment.4,6-11 Furthermore, the major ULA may need to compensate for lost wrist, forearm, and/or elbow motion by excessive motion at other articulations, resulting in changed kinematics of the shoulder, shoulder girdle, or torso. Such compensatory movements have been demonstrated in users of myoelectric transradial prostheses in the performance of ADL tasks12 and may lead to musculoskeletal dysfunction and an increased risk of musculoskeletal pain. Compensatory movements are also likely to be present in bilateral major ULAs. Furthermore, in our experience, bilateral
List of Abbreviations
From the Department of Physical Medicine and Rehabilitation, Innlandet Hospital Trust, Ottestad (Østlie, Franklin); Vestre Viken Hospital Trust, Drammen (Skjeldal); Division of Epidemiology, Norwegian Institute of Public Health, Oslo (Magnus, Skrondal), Norway; and London School of Hygiene and Tropical Medicine, London, England (Skrondal). Supported by the Innlandet Hospital Trust (grant no. E 06004) and by the Norwegian Extra Foundation for Health and Rehabilitation (grant no. 0225). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Kristin Østlie, MD, Innlandet Hospital Trust, Department of Physical Medicine and Rehabilitation, Jørgen Jensens vei, N-2312 Ottestad, Norway, e-mail: [email protected]., 0003-9993/11/9212-00200$36.00/0 doi:10.1016/j.apmr.2011.06.026
ADLs aOR CE group CI CR group CTS DSF non-CE group non-CR group non-QR group QR group ULA
activities of daily life adjusted odds ratio clinically examined QR-group amputees confidence interval control questionnaire responders carpal tunnel syndrome Norwegian National Population Register Det Sentrale Folkeregister not clinically examined QR-group amputees control questionnaire nonresponders amputee questionnaire nonresponders amputee questionnaire responders upper-limb amputee
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie
ULAs frequently use their teeth, chin, and lower limbs to compensate for the loss of hand/wrist function. Such dysfunctional movement patterns may also increase the risk of musculoskeletal pain. A relatively frequent occurrence of musculoskeletal pain and overuse syndromes has been demonstrated in ULAs.4,6-11 Pain and other overuse complaints may affect both physical function and quality of life.13-15 Musculoskeletal complaints are also frequent in the general population.16,17 In Norway, musculoskeletal disorders were the most frequent reason for sick leave and disability pension in 2009.17 Although overuse injuries have been stated to be 3 times more likely in unilateral ULAs compared with the general workforce,18,19 to our knowledge, no study comparing the occurrence of musculoskeletal pain in ULAs with a control group has previously been performed. Although contralateral limb complications motivate health care providers to encourage prosthesis wear in ULAs, the extent to which prosthesis wear may prevent these conditions is not clear.11,18 The aims of this study were to (1) compare the prevalence of self-reported musculoskeletal pain in adult acquired major ULAs in Norway with that of a control group drawn from the Norwegian general population; (2) describe the bothersomeness of self-reported musculoskeletal pain in ULAs; (3) estimate the association between prosthesis wear and self-reported musculoskeletal pain in ULAs; and (4) describe the occurrence of clinically assessed musculoskeletal overuse syndromes in a sample of ULAs. METHODS Design and Participants We performed a cross-sectional study consisting of a questionnaire survey of ULAs and a control group, and subsequent clinical examinations of a sample of ULAs. Eligible amputees from the known population of adult acquired major ULAs in Norway were invited to participate in the survey. This amputee population was identified through a combined search of the databases of the 2 Norwegian upper-limb prosthesis suppliers and of the medical records of 3 major Norwegian hospitals, going back to 1994 and 1999, respectively. Multiple registrations of the same amputee were frequent. The inclusion process is described in detail in a previous article.20 The control group was randomly drawn from the Norwegian National Population Register (DSF) based on individual national insurance numbers. A combined referred sample (inpatients and outpatients) and convenience sample (solely based on place of residence) of ULA questionnaire responders were invited to be clinically examined (CE group). Survey inclusion criteria were as follows: being an adult (ⱖ18y at October 1, 2006), being a resident in Norway at the time of the survey, and mastering Norwegian. Additional amputee-specific inclusion criteria were having an acquired upperlimb loss and a major amputation. Questionnaire-responding ULAs were invited to be clinically examined if during the inclusion period they were admitted to our ward Innlandet Hospital Trust, Dept of Physical Medicine & Rehabilitation, (Ottestad, nationwide referrals) (nationwide referrals), consulted either of the 2 Norwegian prosthesis suppliers, consulted the arm clinic at Oslo University Hospital Rikshospitalet (outpatients), or were residents in Hamar/Ottestad or Oslo or nearby areas. Exclusion criteria were dementia and aphasia. For the CE group, an additional exclusion criterion was known non–amputation-related arm palsy. Because this study was part of a larger survey of the adult acquired major ULA population in Norway,20-22 congenital ULAs were excluded. The survey inclusion period was from October 1, 2006, until May 30, 2008. Clinical examinations were performed from DeArch Phys Med Rehabil Vol 92, December 2011
cember 11, 2006, until November 28, 2008. The control group was randomly drawn from the DSF on November 3, 2006. Data Collection Data from all eligible amputees and controls were collected by postal questionnaires. Two of the authors (K.Ø. and R.J.F.) performed clinical examinations following a prepared scheme. Before data collection, our study was approved by the Norwegian Regional Ethics Committee. Variables and Procedures Questionnaires. We collected data on demographic features, physical activity, and on the occurrence of specified types of musculoskeletal pain during the last year (yes/no). Physical activity was assessed by asking whether the subjects during the last year had been exercising on a regular basis, more than 30 minutes each time and so intensely that they were sweating (yes/no). ULAs were also asked about amputationspecific features, prosthesis wear, and pain bothersomeness during the last month. Pain bothersomeness, measuring the self-reported clinical significance of pain, was assessed by a 5-point ordinal scale ranging from “no pain” to “very bothersome pain.” Musculoskeletal pain was clearly distinguished from phantom pain and stump pain in the amputee questionnaire. The occurrence of amputation-specific pain is not presented because such analyses were beyond the scope of this article. Clinical examinations. Muscle pain was assessed by the number of positive tender points according to the American College of Rheumatology 1990 criteria for the classification of fibromyalgia.23 We adjusted for the number of tender points possible to examine by using the following formula: Adjusted number of positive points ⫽ (Number of positive points/Number of points examined) ⫻ 18. We ensured that positive tender points were not confused with neuroma or prosthesis-induced stump pain (indicated by sores or pressure marks). We assessed the occurrence of musculoskeletal overuse syndromes in unilateral amputees by criteria described by Sluiter et al.24 Detailed diagnostic criteria for each condition are described in supplemental appendix 1. “Current case” definitions were based on fulfillment of symptom criteria, physical examination sign criteria, and a time rule. “Symptom/sign cases” were defined as amputees who fulfilled the symptom and sign criteria but not the time rule. The amputees were examined for rotator cuff syndrome bilaterally and for lateral and medial epicondylitis, cubital tunnel syndrome, carpal tunnel syndrome (CTS), and Guyon canal syndrome in the nonamputated arm. Data Analysis Data were analyzed using SPSS version 14.0.a For hypothesis testing, the significance level was set at an ␣ value of .05. To assess the representativeness of our samples, we used the independent samples t test (for continuous variables) and the Fisher exact test (for categorical variables). We compared amputee questionnaire responders (QR group) and nonresponders (non-QR group), control questionnaire responders (CR group) and nonresponders (non-CR group), and clinically examined QR amputees (CE group) and not clinically examined QR amputees (non-CE group). We also compared amputee and control responders. Variables considered were sex, age, place of residence (all comparisons), ethnicity (all amputee comparisons, QR vs CR group), unilateral/bilateral amputation, amputation level, amputation side (all amputee comparisons), marital status, educational level, occupational status and gross yearly income (CE vs non-CE group, QR vs CR group), age at
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 1: Demographic Features and Amputation-Related Features Amputee Group Variable
n* Sex (% men) Mean age (range) at survey (y) Ethnicity, native country (% Norwegian) Marital status at survey (% within group) Married, cohabitant or registered partner Separated, divorced, single, or widowed Educational level (% within group) No education/primary school/other education Comprehensive school (3y) College or university Occupational status at survey (% within group) In paid employment† Not in paid employment‡ Student Place of residence, region (% within group) Eastern Norway Other§ Mean age (range) at amputation (y) Mean time (range) since amputation (y)储 Unilateral amputation: n (% within group) Level of amputation (% within group)¶ Through or above elbow# Below elbow** Unilateral, unknown level (n) Bilateral, not same level on both sides (n)†† Cause of amputation (% within group) Trauma‡‡ Other§§ Current prosthesis wear (% yes)
Control Group
QR Group
CE Group
CR Group
224 83.5 53.7 (20.3–95.3) 90.2
70 87.1 51.6 (22.4–78.8) 84.3
318 46.5 55.9 (18.4–91.5) 93.6
70.7 29.3
66.7 33.3
67.1 32.9
27.5 40.1 32.4
26.0 29.0 44.9
26.6 35.1 38.3
37.9 58.5 3.6
44.3 51.4 4.3
48.7 46.2 5.0
48.7 51.3 29.6 (0.0–80.8) 24.0 (0.3–76.3) 214 (95.5)
77.1 22.9 32.4 (2.1–77.4) 19.2 (0.3–50.8) 66 (94.3)
52.8 47.1 NA NA NA
38.1 61.9 1 5
54.5 45.5 0 4
NA NA NA NA
84.5 15.5 80.8
77.1 22.9 78.6
NA NA NA
Abbreviation: NA, not applicable. *The number of responders was 216 to 224 in the QR group, 69 to 70 in the CE group, and 308 to 318 in the CR group. † Includes employed, self-employed. ‡ Includes working at home, disability pension, retired, unemployed, and occupational rehabilitation. § Includes Western Norway, Northern Norway, Southern Norway, and Trøndelag (⬇ Mid Norway). 储 Amputation year 1942 to 2007. ¶ Percentages include bilateral amputees with same level on both sides, each counted as 1 amputee: QR group, % of 218; CE group, % of 66. # Includes the levels forequarter, shoulder disarticulation, transhumeral and elbow disarticulation. **Includes the levels transradial and wrist disarticulation. †† QR group: 2 wrist ⫹ lower arm, 1 wrist ⫹ elbow, 1 shoulder ⫹ elbow, 1 shoulder ⫹ lower arm. CE group: 2 wrist ⫹ lower arm, 1 wrist ⫹ elbow, 1 shoulder ⫹ lower arm. ‡‡ Includes occupational accidents, traffic accidents, war injury, explosion, high voltage, other accidents, torture, and self-inflicted damage. §§ Includes cancer, infection, arteriosclerosis/poor circulation/diabetes, and overdose.
amputation, time since amputation, amputation cause, current prosthesis wear, and self-reported pain (CE vs non-CE group). For self-reported pain, the number of nonresponders was low, and nonresponse was analyzed as no pain. The effect of upperlimb amputation on the occurrence of self-reported musculoskeletal pain was estimated using logistic regression. Ten amputees who underwent amputation less than 12 months before the survey were omitted from these analyses to avoid conflation with preamputation pain. We conducted separate analyses for pain in the shoulders, neck/upper back, and lower back, obtaining crude and adjusted effect estimates for group (amputee vs control). The adjusted estimates were controlled for factors that could be potential confounders according to previous research and clinical experience17,25-27: sex, age, marital status, occupational status, educational level, gross yearly income, ethnicity, place of residence, and physical activity. Self-reported musculoskeletal pain in the remaining arm in unilateral amputees and in 1 or both arms in controls was
reported. We calculated a sum percentage for arm pain below the shoulder level, using the following formulas: for unilateral amputees, (Number of locations with reported pain/5) ⫻ 100; and for controls, (Number of locations with reported pain/10) ⫻ 100. The numbers 5 and 10 are the total number of possible pain locations in 1 and 2 arms, respectively. Using this sum percentage as the dependent variable, we estimated crude and adjusted effects for group (amputee vs control) using linear regression analyses. The adjusted estimates were controlled for the same covariates as listed above. The distribution of pain bothersomeness was reported. Side differences were analyzed by 1-sample t tests for amputees reporting bilateral pain, and by independent samples t tests for amputees reporting unilateral pain. The effect of prosthesis wear on self-reported musculoskeletal pain was estimated using logistic regression. We conducted separate analyses for pain in the shoulders, neck/upper back, lower back, and nonamputated arm, obtaining crude and Arch Phys Med Rehabil Vol 92, December 2011
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 2: Self-Reported Musculoskeletal Pain in Major ULAs Compared With a Control Group Control Group†
Amputees*
Logistic Regression, OR for Group (Amputee vs Control)
Pain Location
Pain (n)
Pain (%)
Pain (n)
Pain (%)
cOR
95% CI for cOR
aOR
95% CI for aOR
Neck/upper back Lower back Shoulders
122‡ 97§ 126储
57.0 45.3 58.9
126 137 105
39.6 43.1 33.0
2.02 1.10 2.91
1.42–2.87 0.77–1.55 2.03–4.16
2.56 1.16 4.00
1.64–3.98 0.76–1.77 2.51–6.36
NOTE. aOR was controlled for sex, age, marital status, ethnicity, educational level, place of residence, occupational status, gross yearly income, and physical activity. Abbreviations: cOR, crude odds ratio; OR, odds ratio. *Questionnaire responders, pain last 12 months among amputees amputated more than 12 months before the survey (n⫽214; 205 unilateral, 9 bilateral). † Pain last 12 months (n⫽318). ‡ 117 unilateral amputees (76 bilateral pain; 65.0%), 5 bilateral amputees (all bilateral pain). § 94 unilateral amputees (72 bilateral pain; 76.6%), 3 bilateral amputees (all bilateral pain). 储 122 unilateral amputees (54 bilateral pain; 44.3%), 4 bilateral amputees (2 bilateral pain; 50.0%).
adjusted estimates for prosthesis wear (yes vs no). The current wearing status had been unchanged for at least 2.4 years at the time of the survey (mean, 12.6 –13.9y depending on pain location), allowing for wearing status at the time of the survey to be analyzed against pain during the last year before the survey. The covariates controlled for were the same as listed above plus the possible amputation-specific confounders unilateral/bilateral amputation, amputation level, and time since the amputation. The occurrence of clinically evaluated pain and musculoskeletal overuse syndromes in the CE group was reported. We used the Fisher exact test to compare the occurrence of rotator cuff syndrome between the amputated and the nonamputated side. RESULTS Participants and Response Rates Of 390 amputees found eligible for the survey, 224 returned questionnaires (57.4%). Of the 224 questionnaire responders, 84 were invited to undergo a clinical examination (37.5%), and 70 were examined (31.3% [83.3% of those invited]). Of 962 eligible controls, 318 returned questionnaires (33.1%). Population Characteristics Table 1 shows demographic and amputation-specific features for the QR group, the CE group, and the CR group (demographic features only). There were no significant differences between the QR group (n⫽224) and the non-QR group (n⫽166). The CR group (n⫽318) and the non-CR group (n⫽644) differed only in age (P⫽.009, mean age in the CR group 4.1y lower). Between the
CE group (n⫽70) and the non-CE group (n⫽154), there were differences for place of residence (P⬍.001, more CE amputees from Eastern Norway), time since the amputation (P⫽.003, mean time in the CE group 7y shorter), and level of amputation (P⫽.003, more proximal amputations in the CE group). Between the QR group and the CR group there were significant differences for sex (P⬍.001), age (P⬍.001), marital status (P⬍.001), and occupational status (P⬍.001). Self-Reported Musculoskeletal Pain in Amputees Compared With Controls Tables 2 and 3 show that musculoskeletal pain was frequent in both groups, ranging from 45.3% (lower back) to 58.9% (shoulders) in major ULAs, and from 29.2% (arms) to 43.1% (lower back) in control subjects. The amputees reported significantly more pain than controls in the neck/upper back (adjusted odds ratio [aOR]⫽2.56) and in the shoulders (aOR⫽4.00). The occurrence of lower back pain did not differ significantly between the groups. Table 3 indicates that the occurrence of contralateral arm pain in amputees may exceed that of arm pain in the control group. Calculating comparable arm pain percentages, we found that amputees reported pain in 28.6% of possible locations, compared with 6.4% for controls. The adjusted percentage difference between the groups was 24.8% (adjusted regression coefficient, 24.8; 95% confidence interval [CI], 20.2–29.4; P⬍.001). Details on Self-Reported Musculoskeletal Pain in Amputees Footnotes to table 2 show that bilateral musculoskeletal pain was frequent, ranging from 44.3% (shoulders) to 76.6% (lower
Table 3: Self-Reported Musculoskeletal Pain in the Arms Below the Shoulder Level Control Group†
Amputees* Pain Location
Upper arm Elbow Forearm Wrist Hand Sum
Pain (n)
Pain (%)
95% CI
Pain (n)
Pain (%)
95% CI
65 60 58 56 54 117‡
31.7 29.3 28.3 27.3 26.3 57.1
25.3–38.1 23.0–35.5 22.1–34.5 21.2–33.4 20.3–32.4 50.3–63.8
34 32 23 32 28 93§
10.7 10.1 7.2 10.1 8.8 29.2
7.3–14.1 6.8–13.4 4.4–10.1 6.8–13.4 5.7–11.9 24.2–34.2
*Pain in the nonamputated arm last 12 months among unilateral amputees amputated more than 12 months before the survey (n⫽205). Pain in 1 or both arms last 12 months in the control group (n⫽318). ‡ n⫽117 amputees reported pain in at least 1 of 5 locations. § n⫽93 controls reported pain in at least 1 of 10 locations (5 in each arm). †
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 4: Pain Bothersomeness During the Last Month Among Unilateral Amputees* Pain Bothersomeness† n‡
1 (%)
2 (%)
3 (%)
4 (%)
5 (%)
Mean
84§ 67储 96¶ 268#
3.6 1.5 5.2 1.5
8.3 11.9 6.3 16.0
31.0 38.8 39.6 42.2
44.0 37.3 34.4 33.2
13.1 10.4 14.6 7.1
3.5 3.4 3.5 3.3**
96§ 77储 74¶
6.3 3.9 8.1
10.4 14.3 6.8
39.6 46.8 41.9
36.5 27.3 36.5
7.3 7.8 6.8
Pain Location
Nonamputated side Neck/upper back Lower back Shoulder Arm below shoulder level Amputated side Neck/upper back Lower back Shoulder
3.3 3.2 3.3
*Unilateral amputees amputated more than 12 months before the survey who reported pain in each location during the last 12 months before the survey. † Pain bothersomeness categories: 1, no pain; 2, pain, but not bothersome; 3, slightly bothersome pain; 4, rather bothersome pain; 5, very bothersome pain. ‡ n reporting pain bothersomeness. § Including n⫽65 with bilateral pain. 储 Including n⫽56 with bilateral pain. ¶ Including n⫽51 with bilateral pain. # 268 is the sum of pain locations graded in n⫽117 amputees (sum of upper arm, elbow, lower arm, wrist, and hand). Pain bothersomeness is given as an average of the 5 locations graded. **Mean for upper arm, 3.4; mean for elbow, 3.2; mean for forearm, 3.2; mean for wrist, 3.3; and mean for hand, 3.3.
back) in unilateral amputees, and from 50.0% (shoulders) to 100.0% (neck/back) in bilateral amputees. Many amputees reported arm pain in more than 1 location (mean, 2.5 of 5 locations). Table 4 shows that unilateral amputees, on average, graded their pain during the last month between slightly and rather bothersome. The occurrence of very bothersome pain ranged from 7.1% (contralateral arm) to 14.6% (contralateral shoulder). A tendency to more bothersome pain contralateral to the amputation was observed, the side difference statistically significant only for unilateral neck pain (mean difference, .80; 95% CI, .25–1.34; P⫽.005). Effect of Prosthesis Wear on Self-Reported Musculoskeletal Pain Table 5 shows that we found no significant differences in the occurrence of pain comparing prosthesis wearers and nonwearers. Musculoskeletal Pain in the CE Group We found that 48.6% (95% CI, 36.9 – 60.3) of the examined amputees had no positive tender points, 38.6% (95% CI, 27.2– 50.0) had 1 to 5 positive tender points, 8.6% (95% CI, 2.0 –
15.1) had 6 to 10 positive tender points, and 4.3% (95% CI, 0.0 –9.0) had 11 to 12 positive tender points. Musculoskeletal Overuse Syndromes Table 6 shows that the most frequent current case diagnosis was rotator cuff syndrome on the nonamputated side, with an occurrence of 15.2% for current cases and 18.2% for symptom/ sign cases. Rotator cuff syndrome was more frequent on the nonamputated side both for current cases (P⫽.010) and symptom/sign cases (P⫽.011). For peripheral nerve entrapment, the difference between the occurrence of current cases and symptom/sign cases was substantial. The most frequent diagnosis was CTS, with an occurrence of 12.1% for current cases and 24.2% for symptom/sign cases. DISCUSSION Musculoskeletal Pain Our findings indicating that ULAs have an increased risk of musculoskeletal pain in the neck/upper back, shoulders, and in the remaining arm are important contributions to the existing literature. Analyzing movements in work-related activities, Black et al19 found that ULAs are at greater risk of cumulative trauma
Table 5: Musculoskeletal Pain in Prosthesis Wearers and Nonwearers Wearers
Nonwearers
Logistic Regression, OR for Prosthesis Wear (Yes vs No)
Pain Location
Pain (n)
Pain (%)
Pain (n)
Pain (%)
cOR
95% CI for cOR
aOR
95% CI for aOR
Neck/upper back Lower back Shoulders Contralateral arm*
97 80 105 98
55.4 45.7 60.0 58.7
25 17 21 19
64.1 43.6 53.8 50.0
0.70 1.09 1.29 1.42
0.34–1.43 0.54–2.19 0.64–2.59 0.70–2.88
0.64 1.07 1.46 2.50
0.23–1.74 0.40–2.82 0.53–4.05 0.83–7.53
NOTE. Pain refers to pain in the given location during the last 12 months before the survey among amputees amputated more than 12 months before the survey (n⫽214). aOR was controlled for sex, age, marital status, ethnicity, educational level, place of residence, occupational status, gross yearly income, physical activity, unilateral/bilateral amputation, level of amputation, and time since the amputation. Abbreviations: cOR, crude odds ratio; OR, odds ratio. *Unilateral amputees only (n⫽205). The occurrence of contralateral arm pain was defined as pain in at least 1 of 5 locations (upper arm, elbow, forearm, wrist, or hand) during the last 12 months before the survey.
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 6: Rotator Cuff Syndrome, Epicondylitis, and Peripheral Nerve Entrapment in Unilateral Amputees Examined
Current Cases
Symptom/Sign Cases
Diagnosis
n
n
%
95% CI
n
%
95% CI
Rotator cuff syndrome Amputated side Nonamputated side Lateral epicondylitis‡ Medial epicondylitis‡ Cubital tunnel syndrome‡ Carpal tunnel syndrome‡ Guyon canal syndrome‡
58* 66 66 66 66 66 66
1 10 4 4 7 8 6
1.7 15.2 6.1 6.1 10.6 12.1 9.1
0.0–5.1 6.5–23.8 0.3–11.8 0.3–11.8 3.2–18.0 4.2–20.0 2.2–16.0
2† 12† 6 4 11 16 11
3.4 18.2 9.1 6.1 16.7 24.2 16.7
0.0–8.1 8.9–27.5 2.2–16.0 0.3–11.8 7.7–25.7 13.9–34.6 7.7–25.7
NOTE. Current cases fulfill symptom criteria, sign criteria, and a time rule, as described in supplemental Appendix 1. Symptom/sign cases fulfill symptom and sign criteria but fail to fulfill the time rule. *Eight unilateral amputees were amputated through the shoulder joint or at the forequarter level, leaving n⫽58. † Including 1 unilateral amputee with rotator cuff syndrome in both shoulders. ‡ Nonamputated side.
disorders. However, the sample size of that study (3 prosthesiswearing ULAs vs 20 nonamputated persons) was too small for generalization. The occurrence and distribution of self-reported musculoskeletal pain in our ULA sample were similar to those reported by Jones and Davidson,11 Datta,10 and Hanley15 and colleagues. None of those studies, however, included a control group. A high percentage of bilateral pain suggests that not just the contralateral side is at risk of developing overuse complaints. The proportion of amputees reporting bothersome pain is in accordance with the findings of Ephraim et al,8 and may indicate clinically significant pain possibly increasing the risk of painrelated disability in ULAs.15 Furthermore, overuse pain has been shown to be an important mediator of decreased life satisfaction in ULAs.22 Thus, prevention and treatment of musculoskeletal pain may be important in ULA rehabilitation. Our findings indicate that prosthesis wear does not prevent musculoskeletal pain, as previously noted by Jones and Davidson.11 However, the wearing time and actual prosthesis use in ADLs among prosthesis wearers vary considerably,9,10,28-35 and further studies of the effects of prosthesis wear on musculoskeletal pain should be conducted. The prevalence of fibromyalgia in Norway is about 0.3% in men and 1.3% to 3.2% in women.27 The low number of ULAs with 11 to 12 positive adjusted tender points in our CE group indicates that although self-reported musculoskeletal pain was increased in ULAs, the occurrence of generalized pain and/or fibromyalgia may not be increased. Musculoskeletal Overuse Syndromes Our current-case prevalence estimate of rotator cuff syndrome contralateral to the amputation was of the same magnitude as that reported from questionnaire data by Jones and Davidson,11 whereas our prevalence estimates of epicondylitis were substantially lower. It is likely that the self-reported occurrence of these syndromes will be higher than prevalence estimates based on clinical examinations. Also, the severity of the symptoms may vary over time, leading to an underestimation of the problem applying current-case definitions. Earlier reports on nerve entrapment in the nonamputated arm are scarce. Five case studies published by Reddy36 suggest that especially contralateral CTS may be frequent, in accordance with the findings of Datta10 reporting CTS in 26.6% of proximal ULAs. Our symptom/sign case estimate of CTS prevalence is consistent with Datta’s prevalence estimate. However, as argued for rotator cuff syndrome and epicondylitis, symptoms may vary over time, and applying current-case definitions Arch Phys Med Rehabil Vol 92, December 2011
may lead to an underestimation of prevalence. Judged by our data, this seems to be more prominent for the nerve entrapment diagnoses than for rotator cuff syndrome and epicondylitis. Study Limitations A relatively low response rate in both groups may have produced selection bias. However, our statistical analyses indicate that there were no large differences between the responders and the nonresponders. Selection bias may also have been introduced by including more CE amputees from Eastern Norway than from other regions. Also, some amputees may have sought health care because of musculoskeletal problems. To minimize this bias, we also included CE amputees solely based on place of residence. The CE and non-CE groups did not differ significantly regarding self-reported pain, suggesting that the bias may not have seriously affected the results. Self-reported pain data may be influenced by recall bias, and information bias may have been introduced by missing data. Analyzing nonresponse as no pain may have led to an underestimation of pain prevalence. If the dominant hand/arm has the highest risk of developing overuse pain in control subjects, our estimate of the percentage difference of arm pain in amputees versus control subjects (including nondominant arm pain in controls) may be somewhat too high. Because arm palsy may lead to musculoskeletal dysfunction and contralateral limb strain,37 non–amputation-related arm palsy (ie, poststroke) may cause an overestimation of musculoskeletal problems in affected ULAs, and these were excluded from the CE group. Non–amputation-related arm palsy and pain syndromes such as complex regional pain syndrome could also have been exclusion criteria for the questionnaire study. However, ULAs are not at higher risk of comorbidities than the general population,4,5,38 suggesting that a bias caused by these diagnoses may not have seriously affected our comparisons between amputees and controls. Differences between amputees and control subjects regarding sex, age, marital status, and occupational status were controlled for in the multiple regression analyses. CONCLUSIONS Our findings indicate that upper-limb loss increases the risk of self-reported musculoskeletal pain in the neck/upper back, shoulders, and in the remaining arm and that prosthesis wear does not prevent such pain. Prevention and treatment of musculoskeletal pain may be important in ULA rehabilitation. We recommend
MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie
further, longitudinal studies to investigate the development of such pain and the effect of prosthesis wear and possible preventive measures. Overuse syndromes may be frequent in ULAs. Further studies of large, randomly selected samples should be conducted to ascertain our preliminary prevalence estimates. Acknowledgments: We thank Beate Garfelt, MD, for her clinical advice in the production and review of this article. References 1. Saradjian A, Thompson AR, Datta D. The experience of men using an upper limb prosthesis following amputation: positive coping and minimizing feeling different. Disabil Rehabil 2008; 30:871-83. 2. Roeschlein RA, Domholdt E. Factors related to successful upper extremity prosthetic use. Prosthet Orthot Int 1989;13:14-8. 3. Freeland AE, Psonak R. Traumatic below-elbow amputations [review]. Orthopedics 2007;30:120-6. 4. Durance JP, O’Shea BJ. Upper limb amputees: a clinic profile. Int Disabil Stud 1988;10:68-72. 5. Dudkiewicz I, Gabrielov R, Seiv-Ner I, Zelig G, Heim M. Evaluation of prosthetic usage in upper limb amputees. Disabil Rehabil 2004;26:60-3. 6. Shaperman J, Landsberger SE, Setoguchi Y. Early upper limb prosthesis fitting: when and what do we fit? J Prosthet Orthot 2003;15:11-7. 7. Davidson J. A survey of the satisfaction of upper limb amputees with their prostheses, their lifestyles, and their abilities. J Hand Ther 2002;15:62-70. 8. Ephraim PL, Wegener ST, Mackenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 2005;86:1910-9. 9. Jones LE, Davidson JH. The long-term outcome of upper limb amputees treated at a rehabilitation centre in Sydney, Australia. Disabil Rehabil 1995;17:437-42. 10. Datta D, Selvarajah K, Davey N. Functional outcome of patients with proximal upper limb deficiency—acquired and congenital. Clin Rehabil 2004;18:172-7. 11. Jones LE, Davidson JH. Save that arm: a study of problems in the remaining arm of unilateral upper limb amputees. Prosthet Orthot Int 1999;23:55-8. 12. Carey SL, Highsmith MJ, Maitland ME, Dubey RV. Compensatory movements of transradial prosthesis users during common tasks. Clin Biomech 2008;23:1128-35. 13. Desmond DM, Maclachlan M. Psychosocial perspectives on postamputation rehabilitation: a review of disease, trauma, and war related literature. Crit Rev Phys Rehabil Med 2004;16:77-93. 14. Demet K, Martinet N, Guillemin F, Paysant J, Andre JM. Health related quality of life and related factors in 539 persons with amputation of upper and lower limb. Disabil Rehabil 2003;25: 480-6. 15. Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR. Chronic pain associated with upper-limb loss. Am J Phys Med Rehabil 2009;88:742-51. 16. Walker-Bone K, Cooper C. 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 2006;64:1391-6. 17. Ihlebæk C, Brage S, Natvig B, Bruusgaard D. Forekomst av muskel- og skjelettlidelser i Norge. Tidsskr Nor Laegeforen 2010; 130:2365-8. 18. Biddiss E, Chau T. The roles of predisposing characteristics, established need, and enabling resources on upper extremity prosthesis use and abandonment. Disabil Rehabil Assist Technol 2007; 2:71-84.
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19. Black N, Biden E, Rickards J. Using potential energy to measure work related activities for persons wearing upper limb prostheses. Robotica 2005;23:319-27. 20. Østlie K, Skjeldal OH, Garfelt B, Magnus P. Adult acquired major upper limb amputation in Norway: prevalence, demographic features and amputation specific features. A population based survey. Disabil Rehabil 2011;33:1636-49. 21. Østlie K, Franklin RJ, Skjeldal OH, Skrondal A, Magnus P. Assessing physical function in adult acquired major upper-limb amputees by combining the Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire and clinical examination. Arch Phys Med Rehabil 2011;92:1636-45. 22. Østlie K, Magnus P, Skjeldal OH, Garfelt B, Tambs K. Mental health and satisfaction with life among upper limb amputees: A Norwegian population based survey comparing adult acquired major upper limb amputees with a control group. Disabil Rehabil 2011;33:1594-1607. 23. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160-72. 24. Sluiter JK, Rest KM, Frings-Dresen MH. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. Scand J Work Environ Health 2001;27(Suppl 1):1-102. 25. Brox JI. Muskelsmerter. In: Juel NG, editor. Norsk fysikalsk medisin. Bergen: Fagbokforlaget; 1999. p 231-43. 26. Hagen EM, Svensen E, Eriksen HR. Predictors and modifiers of treatment effect influencing sick leave in subacute low back pain patients. Spine 2005;30:2717-23. 27. Ween E. Bevegelsesapparatet. In: Wekre LL, Vardeberg K, editors. Lærebok i rehabilitering. 1st ed. Bergen: Fagbokforlaget; 2004. p 175-89. 28. Sener G, Algun C, Karaduman A, Yakut Y. Outcome of activities of daily living in upper limb amputees. Clin Rehabil 1989;3:103-5. 29. Jones LE, Davidson J. A review of the management of upper-limb amputees. Crit Rev Phys Rehabil Med 1997;8:297-322. 30. Bhaskaranand K, Bhat AK, Acharya KN. Prosthetic rehabilitation in traumatic upper limb amputees (an Indian perspective). Arch Orthop Trauma Surg 2003;123:363-6. 31. Herberts P, Korner L, Caine K, Wensby L. Rehabilitation of unilateral below-elbow amputees with myoelectric prostheses. Scand J Rehabil Med 1980;12:123-8. 32. Kestner S. Defining the relationship between prosthetic wrist function and its use in performing work tasks and activities of daily living. J Prosthet Orthot 2006;18:80-6. 33. Stein RB, Walley M. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses. Arch Phys Med Rehabil 1983;64:243-8. 34. McFarland LV, Winkler SLH, Heinemann AW, Jones M, Esquenazi A. Unilateral upper-limb loss: satisfaction and prostheticdevice use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev 2010;47:299-316. 35. Berger N. Studies of the upper-extremity amputee. II. The population (1953–55). Artif Limbs 1958;5:57-72. 36. Reddy MP. Nerve entrapment syndromes in the upper extremity contralateral to amputation. Arch Phys Med Rehabil 1984;65:24-6. 37. Lake C, Dodson R. Progressive upper limb prosthetics. Phys Med Rehabil Clin N Am 2006;17:49-72. 38. Esquenazi A. Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disabil Rehabil 2004; 26:831-6. Supplier a. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
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SUPPLEMENTAL APPENDIX 1: CASE DEFINITION CRITERIA FOR THE DIAGNOSIS OF OVERUSE SYNDROMES IN THE CE GROUP Rotator Cuff Syndrome (ICD-10 codes M 75.1, M 75.2) Symptoms At least intermittent pain in the shoulder region without paresthesias; pain worsened by active elevation movement of the upper arm as in scratching of the upper back AND Signs At least one of the following tests positive: resisted shoulder abduction, external rotation or internal rotation; resisted elbow flexion; painful arc on active upper arm elevation AND Time rule Symptoms present now or on at least 4 days during the last 7 days Epicondylitis (ICD-10 codes M 77.0, M 77.1) Symptoms At least intermittent, activity-dependent pain directly located around the lateral or medial epicondyle AND Signs Local pain on resisted wrist extension (lateral) or on resisted wrist flexion (medial) AND Time rule Symptoms present now or on at least 4 days during the last 7 days Cubital Tunnel Syndrome (ICD-10 code G 56.2) Symptoms At least intermittent paresthesias in the 4th or 5th digit or both OR on the ulnar border of the forearm, wrist, or hand AND Signs A positive combined pressure and flexion test AND Time rule Symptoms present now or on at least 4 days during the last 7 days Carpal Tunnel Syndrome (ICD-10 code G 56.0) Symptoms Intermittent paresthesias or pain in at least 2 of digits I, II, or III; either may be present at night as well (allowing pain in the palm, wrist, or radiation proximal to the wrist) AND Signs At least one of the following tests positive: flexion compression test; carpal compression test; Tinel’s sign; Phalen’s test; 2-point discrimination test; resisted thumb abduction or motor loss with wasting of abductor pollicis brevis muscle AND Time rule Symptoms present now or on at least 4 days during the last 7 days Guyon Canal Syndrome (ICD-10 code G 56.2) Symptoms Intermittent paresthesias in the palmar ulnar nerve distribution of the hand, distal to the wrist OR Pain in the ulnar-innervated area of the hand, which may radiate to the forearm AND Signs At least one of the following tests positive: weakness or atrophy in the ulnar-innervated intrinsic hand muscles; Tinel’s sign; reversed Phalen’s test; pressure test over the Guyon canal AND Time rule Symptoms present now or on at least 4 days during the last 7 days NOTE. “Current cases” fulfill the symptom criteria, the sign criteria, and the time rule. “Symptom/sign cases” fulfill the symptom and sign criteria but fail to fulfill the time rule. Descriptions and photographs of the tests involved can be found in the criteria document by Sluiter et al.24 Abbreviation: ICD-10, International Classification of Diseases, 10th Revision.
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ORIGINAL ARTICLE
Musculoskeletal Pain and Overuse Syndromes in Adult Acquired Major Upper-Limb Amputees Kristin Østlie, MD, Rosemary J. Franklin, Grad Dip Phys, Ola H. Skjeldal, MD, PhD, Anders Skrondal, PhD, Per Magnus, MD, PhD ABSTRACT. Østlie K, Franklin RJ, Skjeldal OH, Skrondal A, Magnus P. Musculoskeletal pain and overuse syndromes in adult acquired major upper-limb amputees. Arch Phys Med Rehabil 2011;92:1967-73. Objectives: (1) To compare the prevalence of self-reported musculoskeletal pain in upper-limb amputees (ULAs) in Norway with that of a control group drawn from the Norwegian general population; (2) to describe musculoskeletal pain bothersomeness in ULAs; (3) to estimate the association between prosthesis wear and self-reported musculoskeletal pain in ULAs; and (4) to describe the occurrence of musculoskeletal overuse syndromes in a sample of ULAs. Design: Cross-sectional study: postal questionnaires and clinical examinations. Setting: Norwegian ULA population. Clinical examinations performed at 3 clinics. Participants: Questionnaires: population-based amputee sample (n⫽224; 57.4% response rate). Random control sample (n⫽318; 33.1% response rate). Clinical examinations: combined referred sample and convenience sample (n⫽70; 83.3% of those invited). Survey inclusion criteria: adult, resident in Norway and mastering Norwegian (amputees and controls), acquired major upper-limb amputation (amputees only). Interventions: Not applicable. Main Outcome Measures: Self-reported musculoskeletal pain and pain bothersomeness. Self-reported pain in prosthesis wearers and nonwearers. Clinically assessed diagnoses of musculoskeletal overuse syndromes. Results: Self-reported musculoskeletal pain was more frequent in ULAs than in the control group except for lower back pain. In ULAs, 57.0% reported neck/upper back pain (odds ratio [OR]⫽2.56; 95% confidence interval [CI], 1.64 –3.98), and 58.9% reported shoulder pain (OR⫽4.00; 95% CI, 2.51– 6.36). The percentage difference for arm pain was 24.8% (P⬍.001). All pain was reported as bothersome. We found no difference in pain prevalence between prosthesis wearers and nonwearers. Musculoskeletal overuse syndromes were found in 6.1% to 24.2% of ULAs, depending on diagnosis and casedefinition criteria.
Conclusions: Upper-limb loss increases the risk of self-reported musculoskeletal pain in the neck/upper back, shoulders, and in the remaining arm. Prosthesis wear does not prevent musculoskeletal pain. Further studies should be conducted to investigate the effects of prosthesis wear and possible preventive measures, and to ascertain our preliminary prevalence estimates of overuse syndromes. Key Words: Amputees; Arm; Nerve compression syndromes; Rehabilitation; Shoulder impingement syndrome; Tennis elbow. © 2011 by the American Congress of Rehabilitation Medicine
RMS AND HANDS ARE USED for most activities of A Major amputation (through or daily living (ADLs). proximal to the wrist) causes a total loss of hand and wrist 1,2
function on the affected side.3 Upper-limb amputees (ULAs) are typically young, healthy persons who should expect a normal life span with many years of productive employment and contribution to society.4,5 Unilateral major arm amputation is followed by the transfer of that hand’s function to the other arm. Although the residual limb can be used for tasks such as fixing and lifting objects, the transfer of function to the nonamputated limb will increase the workload of this arm and the risk of musculoskeletal pain and overuse syndromes such as shoulder impingement, epicondylitis, and peripheral nerve entrapment.4,6-11 Furthermore, the major ULA may need to compensate for lost wrist, forearm, and/or elbow motion by excessive motion at other articulations, resulting in changed kinematics of the shoulder, shoulder girdle, or torso. Such compensatory movements have been demonstrated in users of myoelectric transradial prostheses in the performance of ADL tasks12 and may lead to musculoskeletal dysfunction and an increased risk of musculoskeletal pain. Compensatory movements are also likely to be present in bilateral major ULAs. Furthermore, in our experience, bilateral
List of Abbreviations
From the Department of Physical Medicine and Rehabilitation, Innlandet Hospital Trust, Ottestad (Østlie, Franklin); Vestre Viken Hospital Trust, Drammen (Skjeldal); Division of Epidemiology, Norwegian Institute of Public Health, Oslo (Magnus, Skrondal), Norway; and London School of Hygiene and Tropical Medicine, London, England (Skrondal). Supported by the Innlandet Hospital Trust (grant no. E 06004) and by the Norwegian Extra Foundation for Health and Rehabilitation (grant no. 0225). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Kristin Østlie, MD, Innlandet Hospital Trust, Department of Physical Medicine and Rehabilitation, Jørgen Jensens vei, N-2312 Ottestad, Norway, e-mail: [email protected]., 0003-9993/11/9212-00200$36.00/0 doi:10.1016/j.apmr.2011.06.026
ADLs aOR CE group CI CR group CTS DSF non-CE group non-CR group non-QR group QR group ULA
activities of daily life adjusted odds ratio clinically examined QR-group amputees confidence interval control questionnaire responders carpal tunnel syndrome Norwegian National Population Register Det Sentrale Folkeregister not clinically examined QR-group amputees control questionnaire nonresponders amputee questionnaire nonresponders amputee questionnaire responders upper-limb amputee
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ULAs frequently use their teeth, chin, and lower limbs to compensate for the loss of hand/wrist function. Such dysfunctional movement patterns may also increase the risk of musculoskeletal pain. A relatively frequent occurrence of musculoskeletal pain and overuse syndromes has been demonstrated in ULAs.4,6-11 Pain and other overuse complaints may affect both physical function and quality of life.13-15 Musculoskeletal complaints are also frequent in the general population.16,17 In Norway, musculoskeletal disorders were the most frequent reason for sick leave and disability pension in 2009.17 Although overuse injuries have been stated to be 3 times more likely in unilateral ULAs compared with the general workforce,18,19 to our knowledge, no study comparing the occurrence of musculoskeletal pain in ULAs with a control group has previously been performed. Although contralateral limb complications motivate health care providers to encourage prosthesis wear in ULAs, the extent to which prosthesis wear may prevent these conditions is not clear.11,18 The aims of this study were to (1) compare the prevalence of self-reported musculoskeletal pain in adult acquired major ULAs in Norway with that of a control group drawn from the Norwegian general population; (2) describe the bothersomeness of self-reported musculoskeletal pain in ULAs; (3) estimate the association between prosthesis wear and self-reported musculoskeletal pain in ULAs; and (4) describe the occurrence of clinically assessed musculoskeletal overuse syndromes in a sample of ULAs. METHODS Design and Participants We performed a cross-sectional study consisting of a questionnaire survey of ULAs and a control group, and subsequent clinical examinations of a sample of ULAs. Eligible amputees from the known population of adult acquired major ULAs in Norway were invited to participate in the survey. This amputee population was identified through a combined search of the databases of the 2 Norwegian upper-limb prosthesis suppliers and of the medical records of 3 major Norwegian hospitals, going back to 1994 and 1999, respectively. Multiple registrations of the same amputee were frequent. The inclusion process is described in detail in a previous article.20 The control group was randomly drawn from the Norwegian National Population Register (DSF) based on individual national insurance numbers. A combined referred sample (inpatients and outpatients) and convenience sample (solely based on place of residence) of ULA questionnaire responders were invited to be clinically examined (CE group). Survey inclusion criteria were as follows: being an adult (ⱖ18y at October 1, 2006), being a resident in Norway at the time of the survey, and mastering Norwegian. Additional amputee-specific inclusion criteria were having an acquired upperlimb loss and a major amputation. Questionnaire-responding ULAs were invited to be clinically examined if during the inclusion period they were admitted to our ward Innlandet Hospital Trust, Dept of Physical Medicine & Rehabilitation, (Ottestad, nationwide referrals) (nationwide referrals), consulted either of the 2 Norwegian prosthesis suppliers, consulted the arm clinic at Oslo University Hospital Rikshospitalet (outpatients), or were residents in Hamar/Ottestad or Oslo or nearby areas. Exclusion criteria were dementia and aphasia. For the CE group, an additional exclusion criterion was known non–amputation-related arm palsy. Because this study was part of a larger survey of the adult acquired major ULA population in Norway,20-22 congenital ULAs were excluded. The survey inclusion period was from October 1, 2006, until May 30, 2008. Clinical examinations were performed from DeArch Phys Med Rehabil Vol 92, December 2011
cember 11, 2006, until November 28, 2008. The control group was randomly drawn from the DSF on November 3, 2006. Data Collection Data from all eligible amputees and controls were collected by postal questionnaires. Two of the authors (K.Ø. and R.J.F.) performed clinical examinations following a prepared scheme. Before data collection, our study was approved by the Norwegian Regional Ethics Committee. Variables and Procedures Questionnaires. We collected data on demographic features, physical activity, and on the occurrence of specified types of musculoskeletal pain during the last year (yes/no). Physical activity was assessed by asking whether the subjects during the last year had been exercising on a regular basis, more than 30 minutes each time and so intensely that they were sweating (yes/no). ULAs were also asked about amputationspecific features, prosthesis wear, and pain bothersomeness during the last month. Pain bothersomeness, measuring the self-reported clinical significance of pain, was assessed by a 5-point ordinal scale ranging from “no pain” to “very bothersome pain.” Musculoskeletal pain was clearly distinguished from phantom pain and stump pain in the amputee questionnaire. The occurrence of amputation-specific pain is not presented because such analyses were beyond the scope of this article. Clinical examinations. Muscle pain was assessed by the number of positive tender points according to the American College of Rheumatology 1990 criteria for the classification of fibromyalgia.23 We adjusted for the number of tender points possible to examine by using the following formula: Adjusted number of positive points ⫽ (Number of positive points/Number of points examined) ⫻ 18. We ensured that positive tender points were not confused with neuroma or prosthesis-induced stump pain (indicated by sores or pressure marks). We assessed the occurrence of musculoskeletal overuse syndromes in unilateral amputees by criteria described by Sluiter et al.24 Detailed diagnostic criteria for each condition are described in supplemental appendix 1. “Current case” definitions were based on fulfillment of symptom criteria, physical examination sign criteria, and a time rule. “Symptom/sign cases” were defined as amputees who fulfilled the symptom and sign criteria but not the time rule. The amputees were examined for rotator cuff syndrome bilaterally and for lateral and medial epicondylitis, cubital tunnel syndrome, carpal tunnel syndrome (CTS), and Guyon canal syndrome in the nonamputated arm. Data Analysis Data were analyzed using SPSS version 14.0.a For hypothesis testing, the significance level was set at an ␣ value of .05. To assess the representativeness of our samples, we used the independent samples t test (for continuous variables) and the Fisher exact test (for categorical variables). We compared amputee questionnaire responders (QR group) and nonresponders (non-QR group), control questionnaire responders (CR group) and nonresponders (non-CR group), and clinically examined QR amputees (CE group) and not clinically examined QR amputees (non-CE group). We also compared amputee and control responders. Variables considered were sex, age, place of residence (all comparisons), ethnicity (all amputee comparisons, QR vs CR group), unilateral/bilateral amputation, amputation level, amputation side (all amputee comparisons), marital status, educational level, occupational status and gross yearly income (CE vs non-CE group, QR vs CR group), age at
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 1: Demographic Features and Amputation-Related Features Amputee Group Variable
n* Sex (% men) Mean age (range) at survey (y) Ethnicity, native country (% Norwegian) Marital status at survey (% within group) Married, cohabitant or registered partner Separated, divorced, single, or widowed Educational level (% within group) No education/primary school/other education Comprehensive school (3y) College or university Occupational status at survey (% within group) In paid employment† Not in paid employment‡ Student Place of residence, region (% within group) Eastern Norway Other§ Mean age (range) at amputation (y) Mean time (range) since amputation (y)储 Unilateral amputation: n (% within group) Level of amputation (% within group)¶ Through or above elbow# Below elbow** Unilateral, unknown level (n) Bilateral, not same level on both sides (n)†† Cause of amputation (% within group) Trauma‡‡ Other§§ Current prosthesis wear (% yes)
Control Group
QR Group
CE Group
CR Group
224 83.5 53.7 (20.3–95.3) 90.2
70 87.1 51.6 (22.4–78.8) 84.3
318 46.5 55.9 (18.4–91.5) 93.6
70.7 29.3
66.7 33.3
67.1 32.9
27.5 40.1 32.4
26.0 29.0 44.9
26.6 35.1 38.3
37.9 58.5 3.6
44.3 51.4 4.3
48.7 46.2 5.0
48.7 51.3 29.6 (0.0–80.8) 24.0 (0.3–76.3) 214 (95.5)
77.1 22.9 32.4 (2.1–77.4) 19.2 (0.3–50.8) 66 (94.3)
52.8 47.1 NA NA NA
38.1 61.9 1 5
54.5 45.5 0 4
NA NA NA NA
84.5 15.5 80.8
77.1 22.9 78.6
NA NA NA
Abbreviation: NA, not applicable. *The number of responders was 216 to 224 in the QR group, 69 to 70 in the CE group, and 308 to 318 in the CR group. † Includes employed, self-employed. ‡ Includes working at home, disability pension, retired, unemployed, and occupational rehabilitation. § Includes Western Norway, Northern Norway, Southern Norway, and Trøndelag (⬇ Mid Norway). 储 Amputation year 1942 to 2007. ¶ Percentages include bilateral amputees with same level on both sides, each counted as 1 amputee: QR group, % of 218; CE group, % of 66. # Includes the levels forequarter, shoulder disarticulation, transhumeral and elbow disarticulation. **Includes the levels transradial and wrist disarticulation. †† QR group: 2 wrist ⫹ lower arm, 1 wrist ⫹ elbow, 1 shoulder ⫹ elbow, 1 shoulder ⫹ lower arm. CE group: 2 wrist ⫹ lower arm, 1 wrist ⫹ elbow, 1 shoulder ⫹ lower arm. ‡‡ Includes occupational accidents, traffic accidents, war injury, explosion, high voltage, other accidents, torture, and self-inflicted damage. §§ Includes cancer, infection, arteriosclerosis/poor circulation/diabetes, and overdose.
amputation, time since amputation, amputation cause, current prosthesis wear, and self-reported pain (CE vs non-CE group). For self-reported pain, the number of nonresponders was low, and nonresponse was analyzed as no pain. The effect of upperlimb amputation on the occurrence of self-reported musculoskeletal pain was estimated using logistic regression. Ten amputees who underwent amputation less than 12 months before the survey were omitted from these analyses to avoid conflation with preamputation pain. We conducted separate analyses for pain in the shoulders, neck/upper back, and lower back, obtaining crude and adjusted effect estimates for group (amputee vs control). The adjusted estimates were controlled for factors that could be potential confounders according to previous research and clinical experience17,25-27: sex, age, marital status, occupational status, educational level, gross yearly income, ethnicity, place of residence, and physical activity. Self-reported musculoskeletal pain in the remaining arm in unilateral amputees and in 1 or both arms in controls was
reported. We calculated a sum percentage for arm pain below the shoulder level, using the following formulas: for unilateral amputees, (Number of locations with reported pain/5) ⫻ 100; and for controls, (Number of locations with reported pain/10) ⫻ 100. The numbers 5 and 10 are the total number of possible pain locations in 1 and 2 arms, respectively. Using this sum percentage as the dependent variable, we estimated crude and adjusted effects for group (amputee vs control) using linear regression analyses. The adjusted estimates were controlled for the same covariates as listed above. The distribution of pain bothersomeness was reported. Side differences were analyzed by 1-sample t tests for amputees reporting bilateral pain, and by independent samples t tests for amputees reporting unilateral pain. The effect of prosthesis wear on self-reported musculoskeletal pain was estimated using logistic regression. We conducted separate analyses for pain in the shoulders, neck/upper back, lower back, and nonamputated arm, obtaining crude and Arch Phys Med Rehabil Vol 92, December 2011
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 2: Self-Reported Musculoskeletal Pain in Major ULAs Compared With a Control Group Control Group†
Amputees*
Logistic Regression, OR for Group (Amputee vs Control)
Pain Location
Pain (n)
Pain (%)
Pain (n)
Pain (%)
cOR
95% CI for cOR
aOR
95% CI for aOR
Neck/upper back Lower back Shoulders
122‡ 97§ 126储
57.0 45.3 58.9
126 137 105
39.6 43.1 33.0
2.02 1.10 2.91
1.42–2.87 0.77–1.55 2.03–4.16
2.56 1.16 4.00
1.64–3.98 0.76–1.77 2.51–6.36
NOTE. aOR was controlled for sex, age, marital status, ethnicity, educational level, place of residence, occupational status, gross yearly income, and physical activity. Abbreviations: cOR, crude odds ratio; OR, odds ratio. *Questionnaire responders, pain last 12 months among amputees amputated more than 12 months before the survey (n⫽214; 205 unilateral, 9 bilateral). † Pain last 12 months (n⫽318). ‡ 117 unilateral amputees (76 bilateral pain; 65.0%), 5 bilateral amputees (all bilateral pain). § 94 unilateral amputees (72 bilateral pain; 76.6%), 3 bilateral amputees (all bilateral pain). 储 122 unilateral amputees (54 bilateral pain; 44.3%), 4 bilateral amputees (2 bilateral pain; 50.0%).
adjusted estimates for prosthesis wear (yes vs no). The current wearing status had been unchanged for at least 2.4 years at the time of the survey (mean, 12.6 –13.9y depending on pain location), allowing for wearing status at the time of the survey to be analyzed against pain during the last year before the survey. The covariates controlled for were the same as listed above plus the possible amputation-specific confounders unilateral/bilateral amputation, amputation level, and time since the amputation. The occurrence of clinically evaluated pain and musculoskeletal overuse syndromes in the CE group was reported. We used the Fisher exact test to compare the occurrence of rotator cuff syndrome between the amputated and the nonamputated side. RESULTS Participants and Response Rates Of 390 amputees found eligible for the survey, 224 returned questionnaires (57.4%). Of the 224 questionnaire responders, 84 were invited to undergo a clinical examination (37.5%), and 70 were examined (31.3% [83.3% of those invited]). Of 962 eligible controls, 318 returned questionnaires (33.1%). Population Characteristics Table 1 shows demographic and amputation-specific features for the QR group, the CE group, and the CR group (demographic features only). There were no significant differences between the QR group (n⫽224) and the non-QR group (n⫽166). The CR group (n⫽318) and the non-CR group (n⫽644) differed only in age (P⫽.009, mean age in the CR group 4.1y lower). Between the
CE group (n⫽70) and the non-CE group (n⫽154), there were differences for place of residence (P⬍.001, more CE amputees from Eastern Norway), time since the amputation (P⫽.003, mean time in the CE group 7y shorter), and level of amputation (P⫽.003, more proximal amputations in the CE group). Between the QR group and the CR group there were significant differences for sex (P⬍.001), age (P⬍.001), marital status (P⬍.001), and occupational status (P⬍.001). Self-Reported Musculoskeletal Pain in Amputees Compared With Controls Tables 2 and 3 show that musculoskeletal pain was frequent in both groups, ranging from 45.3% (lower back) to 58.9% (shoulders) in major ULAs, and from 29.2% (arms) to 43.1% (lower back) in control subjects. The amputees reported significantly more pain than controls in the neck/upper back (adjusted odds ratio [aOR]⫽2.56) and in the shoulders (aOR⫽4.00). The occurrence of lower back pain did not differ significantly between the groups. Table 3 indicates that the occurrence of contralateral arm pain in amputees may exceed that of arm pain in the control group. Calculating comparable arm pain percentages, we found that amputees reported pain in 28.6% of possible locations, compared with 6.4% for controls. The adjusted percentage difference between the groups was 24.8% (adjusted regression coefficient, 24.8; 95% confidence interval [CI], 20.2–29.4; P⬍.001). Details on Self-Reported Musculoskeletal Pain in Amputees Footnotes to table 2 show that bilateral musculoskeletal pain was frequent, ranging from 44.3% (shoulders) to 76.6% (lower
Table 3: Self-Reported Musculoskeletal Pain in the Arms Below the Shoulder Level Control Group†
Amputees* Pain Location
Upper arm Elbow Forearm Wrist Hand Sum
Pain (n)
Pain (%)
95% CI
Pain (n)
Pain (%)
95% CI
65 60 58 56 54 117‡
31.7 29.3 28.3 27.3 26.3 57.1
25.3–38.1 23.0–35.5 22.1–34.5 21.2–33.4 20.3–32.4 50.3–63.8
34 32 23 32 28 93§
10.7 10.1 7.2 10.1 8.8 29.2
7.3–14.1 6.8–13.4 4.4–10.1 6.8–13.4 5.7–11.9 24.2–34.2
*Pain in the nonamputated arm last 12 months among unilateral amputees amputated more than 12 months before the survey (n⫽205). Pain in 1 or both arms last 12 months in the control group (n⫽318). ‡ n⫽117 amputees reported pain in at least 1 of 5 locations. § n⫽93 controls reported pain in at least 1 of 10 locations (5 in each arm). †
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 4: Pain Bothersomeness During the Last Month Among Unilateral Amputees* Pain Bothersomeness† n‡
1 (%)
2 (%)
3 (%)
4 (%)
5 (%)
Mean
84§ 67储 96¶ 268#
3.6 1.5 5.2 1.5
8.3 11.9 6.3 16.0
31.0 38.8 39.6 42.2
44.0 37.3 34.4 33.2
13.1 10.4 14.6 7.1
3.5 3.4 3.5 3.3**
96§ 77储 74¶
6.3 3.9 8.1
10.4 14.3 6.8
39.6 46.8 41.9
36.5 27.3 36.5
7.3 7.8 6.8
Pain Location
Nonamputated side Neck/upper back Lower back Shoulder Arm below shoulder level Amputated side Neck/upper back Lower back Shoulder
3.3 3.2 3.3
*Unilateral amputees amputated more than 12 months before the survey who reported pain in each location during the last 12 months before the survey. † Pain bothersomeness categories: 1, no pain; 2, pain, but not bothersome; 3, slightly bothersome pain; 4, rather bothersome pain; 5, very bothersome pain. ‡ n reporting pain bothersomeness. § Including n⫽65 with bilateral pain. 储 Including n⫽56 with bilateral pain. ¶ Including n⫽51 with bilateral pain. # 268 is the sum of pain locations graded in n⫽117 amputees (sum of upper arm, elbow, lower arm, wrist, and hand). Pain bothersomeness is given as an average of the 5 locations graded. **Mean for upper arm, 3.4; mean for elbow, 3.2; mean for forearm, 3.2; mean for wrist, 3.3; and mean for hand, 3.3.
back) in unilateral amputees, and from 50.0% (shoulders) to 100.0% (neck/back) in bilateral amputees. Many amputees reported arm pain in more than 1 location (mean, 2.5 of 5 locations). Table 4 shows that unilateral amputees, on average, graded their pain during the last month between slightly and rather bothersome. The occurrence of very bothersome pain ranged from 7.1% (contralateral arm) to 14.6% (contralateral shoulder). A tendency to more bothersome pain contralateral to the amputation was observed, the side difference statistically significant only for unilateral neck pain (mean difference, .80; 95% CI, .25–1.34; P⫽.005). Effect of Prosthesis Wear on Self-Reported Musculoskeletal Pain Table 5 shows that we found no significant differences in the occurrence of pain comparing prosthesis wearers and nonwearers. Musculoskeletal Pain in the CE Group We found that 48.6% (95% CI, 36.9 – 60.3) of the examined amputees had no positive tender points, 38.6% (95% CI, 27.2– 50.0) had 1 to 5 positive tender points, 8.6% (95% CI, 2.0 –
15.1) had 6 to 10 positive tender points, and 4.3% (95% CI, 0.0 –9.0) had 11 to 12 positive tender points. Musculoskeletal Overuse Syndromes Table 6 shows that the most frequent current case diagnosis was rotator cuff syndrome on the nonamputated side, with an occurrence of 15.2% for current cases and 18.2% for symptom/ sign cases. Rotator cuff syndrome was more frequent on the nonamputated side both for current cases (P⫽.010) and symptom/sign cases (P⫽.011). For peripheral nerve entrapment, the difference between the occurrence of current cases and symptom/sign cases was substantial. The most frequent diagnosis was CTS, with an occurrence of 12.1% for current cases and 24.2% for symptom/sign cases. DISCUSSION Musculoskeletal Pain Our findings indicating that ULAs have an increased risk of musculoskeletal pain in the neck/upper back, shoulders, and in the remaining arm are important contributions to the existing literature. Analyzing movements in work-related activities, Black et al19 found that ULAs are at greater risk of cumulative trauma
Table 5: Musculoskeletal Pain in Prosthesis Wearers and Nonwearers Wearers
Nonwearers
Logistic Regression, OR for Prosthesis Wear (Yes vs No)
Pain Location
Pain (n)
Pain (%)
Pain (n)
Pain (%)
cOR
95% CI for cOR
aOR
95% CI for aOR
Neck/upper back Lower back Shoulders Contralateral arm*
97 80 105 98
55.4 45.7 60.0 58.7
25 17 21 19
64.1 43.6 53.8 50.0
0.70 1.09 1.29 1.42
0.34–1.43 0.54–2.19 0.64–2.59 0.70–2.88
0.64 1.07 1.46 2.50
0.23–1.74 0.40–2.82 0.53–4.05 0.83–7.53
NOTE. Pain refers to pain in the given location during the last 12 months before the survey among amputees amputated more than 12 months before the survey (n⫽214). aOR was controlled for sex, age, marital status, ethnicity, educational level, place of residence, occupational status, gross yearly income, physical activity, unilateral/bilateral amputation, level of amputation, and time since the amputation. Abbreviations: cOR, crude odds ratio; OR, odds ratio. *Unilateral amputees only (n⫽205). The occurrence of contralateral arm pain was defined as pain in at least 1 of 5 locations (upper arm, elbow, forearm, wrist, or hand) during the last 12 months before the survey.
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MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie Table 6: Rotator Cuff Syndrome, Epicondylitis, and Peripheral Nerve Entrapment in Unilateral Amputees Examined
Current Cases
Symptom/Sign Cases
Diagnosis
n
n
%
95% CI
n
%
95% CI
Rotator cuff syndrome Amputated side Nonamputated side Lateral epicondylitis‡ Medial epicondylitis‡ Cubital tunnel syndrome‡ Carpal tunnel syndrome‡ Guyon canal syndrome‡
58* 66 66 66 66 66 66
1 10 4 4 7 8 6
1.7 15.2 6.1 6.1 10.6 12.1 9.1
0.0–5.1 6.5–23.8 0.3–11.8 0.3–11.8 3.2–18.0 4.2–20.0 2.2–16.0
2† 12† 6 4 11 16 11
3.4 18.2 9.1 6.1 16.7 24.2 16.7
0.0–8.1 8.9–27.5 2.2–16.0 0.3–11.8 7.7–25.7 13.9–34.6 7.7–25.7
NOTE. Current cases fulfill symptom criteria, sign criteria, and a time rule, as described in supplemental Appendix 1. Symptom/sign cases fulfill symptom and sign criteria but fail to fulfill the time rule. *Eight unilateral amputees were amputated through the shoulder joint or at the forequarter level, leaving n⫽58. † Including 1 unilateral amputee with rotator cuff syndrome in both shoulders. ‡ Nonamputated side.
disorders. However, the sample size of that study (3 prosthesiswearing ULAs vs 20 nonamputated persons) was too small for generalization. The occurrence and distribution of self-reported musculoskeletal pain in our ULA sample were similar to those reported by Jones and Davidson,11 Datta,10 and Hanley15 and colleagues. None of those studies, however, included a control group. A high percentage of bilateral pain suggests that not just the contralateral side is at risk of developing overuse complaints. The proportion of amputees reporting bothersome pain is in accordance with the findings of Ephraim et al,8 and may indicate clinically significant pain possibly increasing the risk of painrelated disability in ULAs.15 Furthermore, overuse pain has been shown to be an important mediator of decreased life satisfaction in ULAs.22 Thus, prevention and treatment of musculoskeletal pain may be important in ULA rehabilitation. Our findings indicate that prosthesis wear does not prevent musculoskeletal pain, as previously noted by Jones and Davidson.11 However, the wearing time and actual prosthesis use in ADLs among prosthesis wearers vary considerably,9,10,28-35 and further studies of the effects of prosthesis wear on musculoskeletal pain should be conducted. The prevalence of fibromyalgia in Norway is about 0.3% in men and 1.3% to 3.2% in women.27 The low number of ULAs with 11 to 12 positive adjusted tender points in our CE group indicates that although self-reported musculoskeletal pain was increased in ULAs, the occurrence of generalized pain and/or fibromyalgia may not be increased. Musculoskeletal Overuse Syndromes Our current-case prevalence estimate of rotator cuff syndrome contralateral to the amputation was of the same magnitude as that reported from questionnaire data by Jones and Davidson,11 whereas our prevalence estimates of epicondylitis were substantially lower. It is likely that the self-reported occurrence of these syndromes will be higher than prevalence estimates based on clinical examinations. Also, the severity of the symptoms may vary over time, leading to an underestimation of the problem applying current-case definitions. Earlier reports on nerve entrapment in the nonamputated arm are scarce. Five case studies published by Reddy36 suggest that especially contralateral CTS may be frequent, in accordance with the findings of Datta10 reporting CTS in 26.6% of proximal ULAs. Our symptom/sign case estimate of CTS prevalence is consistent with Datta’s prevalence estimate. However, as argued for rotator cuff syndrome and epicondylitis, symptoms may vary over time, and applying current-case definitions Arch Phys Med Rehabil Vol 92, December 2011
may lead to an underestimation of prevalence. Judged by our data, this seems to be more prominent for the nerve entrapment diagnoses than for rotator cuff syndrome and epicondylitis. Study Limitations A relatively low response rate in both groups may have produced selection bias. However, our statistical analyses indicate that there were no large differences between the responders and the nonresponders. Selection bias may also have been introduced by including more CE amputees from Eastern Norway than from other regions. Also, some amputees may have sought health care because of musculoskeletal problems. To minimize this bias, we also included CE amputees solely based on place of residence. The CE and non-CE groups did not differ significantly regarding self-reported pain, suggesting that the bias may not have seriously affected the results. Self-reported pain data may be influenced by recall bias, and information bias may have been introduced by missing data. Analyzing nonresponse as no pain may have led to an underestimation of pain prevalence. If the dominant hand/arm has the highest risk of developing overuse pain in control subjects, our estimate of the percentage difference of arm pain in amputees versus control subjects (including nondominant arm pain in controls) may be somewhat too high. Because arm palsy may lead to musculoskeletal dysfunction and contralateral limb strain,37 non–amputation-related arm palsy (ie, poststroke) may cause an overestimation of musculoskeletal problems in affected ULAs, and these were excluded from the CE group. Non–amputation-related arm palsy and pain syndromes such as complex regional pain syndrome could also have been exclusion criteria for the questionnaire study. However, ULAs are not at higher risk of comorbidities than the general population,4,5,38 suggesting that a bias caused by these diagnoses may not have seriously affected our comparisons between amputees and controls. Differences between amputees and control subjects regarding sex, age, marital status, and occupational status were controlled for in the multiple regression analyses. CONCLUSIONS Our findings indicate that upper-limb loss increases the risk of self-reported musculoskeletal pain in the neck/upper back, shoulders, and in the remaining arm and that prosthesis wear does not prevent such pain. Prevention and treatment of musculoskeletal pain may be important in ULA rehabilitation. We recommend
MUSCULOSKELETAL PAIN IN MAJOR UPPER LIMB AMPUTEES, Østlie
further, longitudinal studies to investigate the development of such pain and the effect of prosthesis wear and possible preventive measures. Overuse syndromes may be frequent in ULAs. Further studies of large, randomly selected samples should be conducted to ascertain our preliminary prevalence estimates. Acknowledgments: We thank Beate Garfelt, MD, for her clinical advice in the production and review of this article. References 1. Saradjian A, Thompson AR, Datta D. The experience of men using an upper limb prosthesis following amputation: positive coping and minimizing feeling different. Disabil Rehabil 2008; 30:871-83. 2. Roeschlein RA, Domholdt E. Factors related to successful upper extremity prosthetic use. Prosthet Orthot Int 1989;13:14-8. 3. Freeland AE, Psonak R. Traumatic below-elbow amputations [review]. Orthopedics 2007;30:120-6. 4. Durance JP, O’Shea BJ. Upper limb amputees: a clinic profile. Int Disabil Stud 1988;10:68-72. 5. Dudkiewicz I, Gabrielov R, Seiv-Ner I, Zelig G, Heim M. Evaluation of prosthetic usage in upper limb amputees. Disabil Rehabil 2004;26:60-3. 6. Shaperman J, Landsberger SE, Setoguchi Y. Early upper limb prosthesis fitting: when and what do we fit? J Prosthet Orthot 2003;15:11-7. 7. Davidson J. A survey of the satisfaction of upper limb amputees with their prostheses, their lifestyles, and their abilities. J Hand Ther 2002;15:62-70. 8. Ephraim PL, Wegener ST, Mackenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 2005;86:1910-9. 9. Jones LE, Davidson JH. The long-term outcome of upper limb amputees treated at a rehabilitation centre in Sydney, Australia. Disabil Rehabil 1995;17:437-42. 10. Datta D, Selvarajah K, Davey N. Functional outcome of patients with proximal upper limb deficiency—acquired and congenital. Clin Rehabil 2004;18:172-7. 11. Jones LE, Davidson JH. Save that arm: a study of problems in the remaining arm of unilateral upper limb amputees. Prosthet Orthot Int 1999;23:55-8. 12. Carey SL, Highsmith MJ, Maitland ME, Dubey RV. Compensatory movements of transradial prosthesis users during common tasks. Clin Biomech 2008;23:1128-35. 13. Desmond DM, Maclachlan M. Psychosocial perspectives on postamputation rehabilitation: a review of disease, trauma, and war related literature. Crit Rev Phys Rehabil Med 2004;16:77-93. 14. Demet K, Martinet N, Guillemin F, Paysant J, Andre JM. Health related quality of life and related factors in 539 persons with amputation of upper and lower limb. Disabil Rehabil 2003;25: 480-6. 15. Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR. Chronic pain associated with upper-limb loss. Am J Phys Med Rehabil 2009;88:742-51. 16. Walker-Bone K, Cooper C. 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 2006;64:1391-6. 17. Ihlebæk C, Brage S, Natvig B, Bruusgaard D. Forekomst av muskel- og skjelettlidelser i Norge. Tidsskr Nor Laegeforen 2010; 130:2365-8. 18. Biddiss E, Chau T. The roles of predisposing characteristics, established need, and enabling resources on upper extremity prosthesis use and abandonment. Disabil Rehabil Assist Technol 2007; 2:71-84.
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19. Black N, Biden E, Rickards J. Using potential energy to measure work related activities for persons wearing upper limb prostheses. Robotica 2005;23:319-27. 20. Østlie K, Skjeldal OH, Garfelt B, Magnus P. Adult acquired major upper limb amputation in Norway: prevalence, demographic features and amputation specific features. A population based survey. Disabil Rehabil 2011;33:1636-49. 21. Østlie K, Franklin RJ, Skjeldal OH, Skrondal A, Magnus P. Assessing physical function in adult acquired major upper-limb amputees by combining the Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire and clinical examination. Arch Phys Med Rehabil 2011;92:1636-45. 22. Østlie K, Magnus P, Skjeldal OH, Garfelt B, Tambs K. Mental health and satisfaction with life among upper limb amputees: A Norwegian population based survey comparing adult acquired major upper limb amputees with a control group. Disabil Rehabil 2011;33:1594-1607. 23. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160-72. 24. Sluiter JK, Rest KM, Frings-Dresen MH. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. Scand J Work Environ Health 2001;27(Suppl 1):1-102. 25. Brox JI. Muskelsmerter. In: Juel NG, editor. Norsk fysikalsk medisin. Bergen: Fagbokforlaget; 1999. p 231-43. 26. Hagen EM, Svensen E, Eriksen HR. Predictors and modifiers of treatment effect influencing sick leave in subacute low back pain patients. Spine 2005;30:2717-23. 27. Ween E. Bevegelsesapparatet. In: Wekre LL, Vardeberg K, editors. Lærebok i rehabilitering. 1st ed. Bergen: Fagbokforlaget; 2004. p 175-89. 28. Sener G, Algun C, Karaduman A, Yakut Y. Outcome of activities of daily living in upper limb amputees. Clin Rehabil 1989;3:103-5. 29. Jones LE, Davidson J. A review of the management of upper-limb amputees. Crit Rev Phys Rehabil Med 1997;8:297-322. 30. Bhaskaranand K, Bhat AK, Acharya KN. Prosthetic rehabilitation in traumatic upper limb amputees (an Indian perspective). Arch Orthop Trauma Surg 2003;123:363-6. 31. Herberts P, Korner L, Caine K, Wensby L. Rehabilitation of unilateral below-elbow amputees with myoelectric prostheses. Scand J Rehabil Med 1980;12:123-8. 32. Kestner S. Defining the relationship between prosthetic wrist function and its use in performing work tasks and activities of daily living. J Prosthet Orthot 2006;18:80-6. 33. Stein RB, Walley M. Functional comparison of upper extremity amputees using myoelectric and conventional prostheses. Arch Phys Med Rehabil 1983;64:243-8. 34. McFarland LV, Winkler SLH, Heinemann AW, Jones M, Esquenazi A. Unilateral upper-limb loss: satisfaction and prostheticdevice use in veterans and servicemembers from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev 2010;47:299-316. 35. Berger N. Studies of the upper-extremity amputee. II. The population (1953–55). Artif Limbs 1958;5:57-72. 36. Reddy MP. Nerve entrapment syndromes in the upper extremity contralateral to amputation. Arch Phys Med Rehabil 1984;65:24-6. 37. Lake C, Dodson R. Progressive upper limb prosthetics. Phys Med Rehabil Clin N Am 2006;17:49-72. 38. Esquenazi A. Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disabil Rehabil 2004; 26:831-6. Supplier a. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
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SUPPLEMENTAL APPENDIX 1: CASE DEFINITION CRITERIA FOR THE DIAGNOSIS OF OVERUSE SYNDROMES IN THE CE GROUP Rotator Cuff Syndrome (ICD-10 codes M 75.1, M 75.2) Symptoms At least intermittent pain in the shoulder region without paresthesias; pain worsened by active elevation movement of the upper arm as in scratching of the upper back AND Signs At least one of the following tests positive: resisted shoulder abduction, external rotation or internal rotation; resisted elbow flexion; painful arc on active upper arm elevation AND Time rule Symptoms present now or on at least 4 days during the last 7 days Epicondylitis (ICD-10 codes M 77.0, M 77.1) Symptoms At least intermittent, activity-dependent pain directly located around the lateral or medial epicondyle AND Signs Local pain on resisted wrist extension (lateral) or on resisted wrist flexion (medial) AND Time rule Symptoms present now or on at least 4 days during the last 7 days Cubital Tunnel Syndrome (ICD-10 code G 56.2) Symptoms At least intermittent paresthesias in the 4th or 5th digit or both OR on the ulnar border of the forearm, wrist, or hand AND Signs A positive combined pressure and flexion test AND Time rule Symptoms present now or on at least 4 days during the last 7 days Carpal Tunnel Syndrome (ICD-10 code G 56.0) Symptoms Intermittent paresthesias or pain in at least 2 of digits I, II, or III; either may be present at night as well (allowing pain in the palm, wrist, or radiation proximal to the wrist) AND Signs At least one of the following tests positive: flexion compression test; carpal compression test; Tinel’s sign; Phalen’s test; 2-point discrimination test; resisted thumb abduction or motor loss with wasting of abductor pollicis brevis muscle AND Time rule Symptoms present now or on at least 4 days during the last 7 days Guyon Canal Syndrome (ICD-10 code G 56.2) Symptoms Intermittent paresthesias in the palmar ulnar nerve distribution of the hand, distal to the wrist OR Pain in the ulnar-innervated area of the hand, which may radiate to the forearm AND Signs At least one of the following tests positive: weakness or atrophy in the ulnar-innervated intrinsic hand muscles; Tinel’s sign; reversed Phalen’s test; pressure test over the Guyon canal AND Time rule Symptoms present now or on at least 4 days during the last 7 days NOTE. “Current cases” fulfill the symptom criteria, the sign criteria, and the time rule. “Symptom/sign cases” fulfill the symptom and sign criteria but fail to fulfill the time rule. Descriptions and photographs of the tests involved can be found in the criteria document by Sluiter et al.24 Abbreviation: ICD-10, International Classification of Diseases, 10th Revision.
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