Open Access Study protocol

Maintained physical activity and physiotherapy in the management of distal upper limb pain – a protocol for a randomised controlled trial (the arm pain trial)

Gareth T Jones19*, Kathrin Mertens1, Gary J Macfarlane1, Keith T Palmer2, David Coggon2, Karen Walker-Bone2, Kim Burton3, Peter J Heine4, Candy McCabe56, Paul McNamee7 and Alex McConnachie8

Author Affiliations

1 Musculoskeletal Research Collaboration (Epidemiology Group), University of Aberdeen, Aberdeen, UK

2 MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK

3 Centre for Health and Social Care Research, University of Huddersfield, Huddersfield, UK

4 Warwick Clinical Trials Unit, University of Warwick, Coventry, UK

5 The Royal National Hospital for Rheumatic Diseases NHS Foundation Trust, Bath, UK

6 University of West of England, Bristol, UK

7 Health Economics Research Unit, University of Aberdeen, Aberdeen, UK

8 Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK

9 Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, School of Medicine and Dentistry, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK

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BMC Musculoskeletal Disorders 2014, 15:71  doi:10.1186/1471-2474-15-71

Published: 10 March 2014



Distal upper limb pain (pain affecting the elbow, forearm, wrist, or hand) can be non-specific, or can arise from specific musculoskeletal disorders. It is clinically important and costly, the best approach to clinical management is unclear. Physiotherapy is the standard treatment and, while awaiting treatment, advice is often given to rest and avoid strenuous activities, but there is no evidence base to support these strategies. This paper describes the protocol of a randomised controlled trial to determine, among patients awaiting physiotherapy for distal arm pain, (a) whether advice to remain active and maintain usual activities results in a long-term reduction in arm pain and disability, compared with advice to rest; and (b) whether immediate physiotherapy results in a long-term reduction in arm pain and disability, compared with physiotherapy delivered after a seven week waiting list period.


Between January 2012 and January 2014, new referrals to 14 out-patient physiotherapy departments were screened for potential eligibility. Eligible and consenting patients were randomly allocated to one of the following three groups in equal numbers: 1) advice to remain active, 2) advice to rest, 3) immediate physiotherapy. Patients were and followed up at 6, 13, and 26 weeks post-randomisation by self-complete postal questionnaire and, at six weeks, patients who had not received physiotherapy were offered it at this time. The primary outcome is the proportion of patients free of disability at 26 weeks, as determined by the modified DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire.

We hypothesise (a) that advice to maintain usual activities while awaiting physiotherapy will be superior than advice to rest the arm; and (b) that fast-track physiotherapy will be superior to normal (waiting list) physiotherapy. These hypotheses will be examined using an intention-to-treat analysis.


Results from this trial will contribute to the evidence base underpinning the clinical management of patients with distal upper limb pain, and in particular, will provide guidance on whether they should be advised to rest the arm or remain active within the limits imposed by their symptoms.

Trial registration

Registered on webcite (reference number: ISRCTN79085082).

Randomised controlled trial; Arm pain; Physiotherapy; Advice; Rest; Active; Pain management