Discussion
epicondylitis, low back pain, less disability, pain, reduced disability, disability
EPICONDYLITIS, SECONDARY
Among workers with distal arm pain, advice to remain active was associated with less disability than advice to rest at 26 weeks. There was no evidence of improvement in the odds of recovery conveyed by early, as compared with delayed (usual waiting time) physiotherapy. There was no evidence of differential response in the three groups amongst people doing manual versus non-manual work, or exposed versus not exposed to a range of physically demanding activities nor were there differences in freedom from disability or sickness absence at 6, 13 or 26 weeks. However, there was some evidence amongst workers who lift/carry weights >10 kg that advice to rest while awaiting physiotherapy led to poorer chances of achieving recovery at 26 weeks (0.13, 95% CI 0.03–0.57). Furthermore, amongst 82 workers with clinical epicondylitis, we found no evidence of poorer outcomes in terms of disability or sickness absence from advice to remain active.Some limitations must be considered. First, the ARM trial was powered on the assumption that 50% of participants would achieve mDASH = 0 by 26 weeks and assuming a 20% improvement with advice to remain active. When fewer than 50% of participants achieved mDASH = 0, a re-estimation of the power suggested that the main trial had 89% to detect an increase in recovery from 32% to 52% [In the 1990s, the paradigm for the management of low back pain changed substantially [That early physiotherapy was not better than physiotherapy after a waiting period was perhaps surprising. For the most part, early intervention is recommended amongst people with musculoskeletal conditions, not least because the longer duration of sickness absence is associated with reducing odds of ever returning to work [There is an established evidence base for an increased risk of epicondylitis in association with physically demanding activities of the upper limb, for example, in the meat processing industry [These secondary analyses in the ARM trial suggest that advice to remain active was as effective at reducing disability among workers and did not increase sickness absence or job loss. In particular, workers who believed their pain was caused by work and those who carried/lifted weights at work were less likely to have recovered at 6 months when advised to rest. There was also no evidence that early physiotherapy reduced disability among workers compared with physiotherapy after waiting 6–8 weeks.