Epidemiologic screening of occupational neck and upper limb disorders. Methods and criteria.

KUKKONEN, R. Epidemiologic screening of occupa tional neck and upper limb disorders: Methods and criteria. Scand. j. work environ. & health 5 (1979): suppl. 3, 25-38. A method for screening occupational neck and upper limb disorders and criteria for diagnosis are presented. words:

'I1he methods and criteria presented in this a,rtiole are intended £01' use in epidemiologic survey.s of neok .and upper limb disorders in an 'Occupational health setting. 'I1he metihod has heen used in two of the studies (25,33) presented in this issue of the Scandinavian JournaL of Work, Environment & Health.
We have not intended this method as a suibsti,tute for ,tJhe clinical examination of patients. It should be used only by tihose occupational healtJh 'Professionals who have sufficient competence and can judge whether other examinations are needed.
The nature of the soreening principle and ,procedure llimits the nUlmber and type Institute of Occupational Health, Helsinki, Finland. 2 Finnish Broadcasting Corporation, Helsinki, Finland. :{ Private practice, Kerava, Finland. 4 MehiHiinen Hospital, Helsinki, Finland. of tests and examinations ,that can be applied in t!his kind of survey. Therefore all the disease and disorder items presented should ,be considered with respect to the tests ,and criteria used in eadh case. Although our diagnostic criteria fit the criteria used in olinical practice wei'l, there are some differences.
The diseases and disorders included in this survey have been selected on the basis of a ,known or anticipated relation to WOI1k. Therefore inflammatory diseases suoh as rheumatoid :artJhritis have not been included. Because of a lack of appropriate screening methods, we have not included chronic artJhrosis ei,ther. The chosen disease and disol'der items thus ,primarily ooncern ailments of the 'muscle-tendon units. A group of specialists, comprisedoi a <llinical ort!hopedist, a clinical physiatrist, an occupational physiotherapist, and physicians specialized. in occUIPational 0355-3140/79/070025-14 health and erg,onomics, defined the disease entities to be included. They also selected the diagnostic criteria according to a literature review and their own clinical experience.

EXAMINATION PROCEDURE
The examinati'On consisted of functional tests, measurements, and an interview. It was carried out by a specially trained physiotherapist and lasted about 1 h.
In a quiet isolated room, the physiotherapist examined five to six wor,kers daily.
The following functional examination methods were used: ,observation, assessment of active and passive movements, some special test movements, isometric muscle eontraotion against resistance, muscle stretching, and paLpation for muscle tone, hardenings and sore spots. The hand ,girip ,power was measured with a Martins V.igorimeter. This test was performed twice with a straigiht elbow and twice with ;1Jhe elbow :£lexerd. The highest reoorded values were chosen as the measure of the respective function.
After the functional examination the physiotherapist interviewed the worker about his or 'her .previous diseases and subjective symptoms. In hoththe examination and the interview she Tecorded the results on a rSpecial form, which also provided herr with the sequence and order in which to work.
The symptoms of each disoroer tested and examined for are presented in tables 1-8.

TREATMENT OF THE RESULTS
With the exception of grip force, all test results, including the anamnestic ones, were dichotomized into the category of nOlimal (negative) or abnormal (positive). This 'PliocedUire was taught to the physiotherapist during ,the t'raining period.
l1he physiotherapist did not diagnose disoroers on the spot. Instead each fOI1m was later analyzed, and ,the number and type of "positive" symptoms and signs were ohecked and compared to the predetermined set 'of criteria to ascertain the presence of a disorder. The number of "positive" signs was used as a general parameter per se .for 1Jhe illness.
The specialists who had designed the set of diagnostic criteria dealt with the cases in which an evident clinioal diagnosis and the result from the survey ,did no,t matoh.
We regaooed the separation of bhe examination and the diagnostics as necessary because the subjective confounding component of clinical examinations is c.onsiderable and the separation should add to the objectivity of the examination. Tension myalgia, nuchitis, and the occupahonal cervicobrachial syndrome are some of the terms used ·to describe the same type of disorder. The diagnosis is often made by the exolusion of the other common causes of pain in the neck andshoulder area, for example, cervical spondylarthrosis and hUiIIleral tendinitis. Table 1 lists the subjective and objective signs of tension nedk according to ten recent studies.
Pain in the region of the neck and shoulders during rest was the most constant subjective symptom .in all of the ten reviewed studies. A subjective feeling of muscle stiffness and headaohe originating in the cervicobrachial area were reported in seven studies. Muscle weakness, fatigability and reflecrory symptoms in an upper limb (numbness and paresthesia) were almost ascOIlm1on. In most studies gross neurological deficiencies due to cervical spine degeneration or thoracic outlet compre.ssion were excluded. Symptoms of minor 'impor,tance seemed to be vertigo, tremor and insomnia.
'I'he objective signs of ,the tension nedk syndrome vary. Muscle tenderness is an important one, but, since it is also subjec- tive, it is a poorly controllable item for diagnosis. Such tenderness is malinly concentrated in the upper .part of the trapezius, and it has trigger areas in the insertion or along the margin of the muscle (3,46). Tenderness at the site of muscle motor points has been noted to acoompany cervical radiculopathy due ·to cervical spine degeneration (18).
Muscle spasm lis another important diagnostic .sign. Most ,authors have considered it to be mainJly local and often associated with muscle nodules and swellings (3,24,47). Miehllke et al. (35) found muscle spasms to be generalized, even to musole groups.
Muscle tone varies, however, in different individuals and different muscle sites and ,is often unrelated to subjective symptoms. 'I'he determination of tone by palpation is unreliable (50).
Other inconsistently reported clinical findings related to tension neck are iPOstural changes such as drooping shoulder or straightening of the cervical spine. 'Dhese symptoms are however common in healthy persons also (22).

Diagnostic criteria of the present survey
In our survey we considered the following subjective symptoms ,to be suggestive of the tension neck syndrome: neck pain, feeling of fatigue or stiffness in .the neck, and headache radiating from the neck The recorded objective items were Muscle Limitation Decreased Drooping weakness of move-lordosis shoulder ment muscle tightness, palpable 'hardenings and tender spots in muscles, and straightening of the cervical spine (table 1).
Tension neck was diagnosed if the examinee had ,a ,constant feeling of fatigue and/or stif.fness in the neok plus one more subjective symptom; in addition objective signs of at least two tender spots and/or palpable hardenings plus muscle tightness in neck mov€m€nts had to be present.
Examinees having a ·cervical syndrome or glenohumeral joint symptoms and signs were placed in their respective categories.
The diagnostic criteria recorded in our survey seems to coincide with the set of criteria presented in the reviewed literature. The necessary criteria for diagnosis is also congruent, but a stricter set of criteria could be justified.

Review of diagnostic criteria
Osteoartlhrosis of the cervical spine is one of the most frequent causes of upper extremity pain in middle-aged persons (39). The main subjective symptoms noted in all the reviewed studies were pain in the neck during rest, pain radiating down to the upper extremities, and numbness and paresthesia in an upper extremity. Pain during movement, headaohe, and neck stiffness were almost as common (table 2).
Three studies also reported vertebrobasilar autonomi·c symptoms such as vertigo, tinnitus, or diplopia.
The clinical objective signs included neurological disturbances of the affected cervical .roots, disturbances originating from the cervical cord and vertebral arteries, and decreased function of the cervical spine.
Nerve root distu:rbances were tlhe dominant symptoms of tlhe cervical syndrome. Decreased sensation in some of the~ppe,r extremity dermatomes with adjacent muscle weakness or atroPhy was reported by all eight of the reviewed autho,rs. Myelopathy due to cervical spondylosis is often a separate, relatively painless entity; it was refeI1red to in six of the eight reviewed studies.
Limited or painful neck movements with local tenderness and muscle spasm are signs of cervical spondylart'hrosis. They were recorded by six of the eight studies reviewed. Exaggeration of the pain by coughing was presented in 'half of the studies, wihereas opr.ovocative tests such as cervical compression were listed inconsistently.

Diagnostic criteria of the present survey
The following subjective symptoms of the cervical syndrome were trecorded in our study: neck pain radiating to one or both arms and numbness in the hands.
The recorded objective items included limitation of neck movement and radiating pain provoked by test movements, as well as diminished muscle force of the deltoid, triceps and biceps muscles, as judged by the observer's manual test.
A diagnosis of cervical syndrome was assured if tJhe ex;aminee ex;perienced pain radiating from the neok to the u,pper extremities, and limited neok movement and radiating pain provoked by test movements were recorded in the functional examination.
The cervical syndrome is a well-defined clinical entity ,in contrast to tension neck. The symptoms and signs reco.vded in our study, as well as the items necessary for a diagnosis, were coherent with the literature reviewed.

Review of diagnostic criteria
The thoracic outlet syndrome contains at least three different pathological oonditions, namely, the anterior scalene, hyperabduction and costoclavicular syndromes. They have however common cardinal symptoms and signs and were therefore considered as a unit in the survey. The subjective symptoms are predominantly neurological -pain and paresthesia Iradiating to an upper extremity (table 3).
These symptoms, as well as fatigabilit'Y or weakness in the arms, were noted in all ten of the studies reviewed. Vascular syrrnptoms, coolness and Raynaud-li'ke autonomic vasomotor changes were almost as common and were reported in eight studies. Numbness, swelling, and stiffness are reflectory neurogenic complaints, or are caused by impaired venous backflow; they were reported in half of the reviewed studies, as was upper extremity claudication.
The objective clinical signs of the thoracic outlet syndrome are also relatively consistent. The most important of these are reduced sensibility, muscle weakness or atrophy, and a positive Adson's maneuver, all of which were reported in nine of the ten reviewed investigations. The other provocative tests, Allen's hyperabduction maneuver and the costoclavicular compression test, were considered to be almost as important. However, these tests can also be positive in 15-82 % of normal, asymptomatic persons (59,62), and a weakening of the radial pulse during the maneuver is not sufficient for diagnosis.
Supraclavicular bruit in the test maneuvers and Morley's sign of tenderness in the scalenic pouch are additional criteria. Postural changes were considered to be of importance by six authors.
a Item necessary for diagnosis is in parentheses.
a Items necessary for diagnosis are in parentheses.
a Items necessary for diagnosis are in parentheses.
Present study a (X) a Item necessary for diagnosis is in parentheses.
pain radiating down to the upper extremities, weakness of the hands in carrying burdens, and numbness of an upper limb while sleeping. The recorded objective items were tenderness in the shoulder pouch (Morley's sign), Adson's test, and asymmetric brachial posture. Limited movements of the neck and glenohumeral joint were ruled out.
A diagnosis of thoracic outlet syndrome was accepted if the examinee reported pain radiating to an upper extremity and Morley's sign was positive; in addition Adson's test had to be positive or drooping shoulder present.
Our study ignored the hyperabduction (Allen's) test, known to be the most nonspecific of the provocative maneuvers (57). Again, examinees with cervical and glenohumeral joint disorders were ruled out by specific tests for these illnesses.

Review of diagnostic criteria
The main symptoms and signs of humeral tendinitis are listed in tables 4 and 5. The subjective symptoms of the two syndromes involved are much the same. The patients experience local pain that is often bothersome at night. Pain is exaggerated by glenohumeral movements, which result in reflectory splinting of the humerus. The pain in bicipital tendinitis seems to radiate more commonly to the anterior aspect of the arm (4). Local tenderness on the supraspinous or bicipital tendon is the principal diagnostic criterion. In supraspinous tendinitis an important additional symptom is pain during the abduction or elevation of the arm. This response was noted in five of the six reviewed studies. A painful abduction arc or pain during isometric abduction stress was noted in 75 Ofo of the studies reviewed.
Most investigators differentiate between degenerative and calcific tendinitis, the latter being more acute and painful. In these acute cases also secondary muscle 32 spasm and reflectory splinting can sometimes be noticed. Muscle weakness is generally a reflection of pain, and muscle atrophy occurs only in the most chronic cases. The diagnosis of bicipital tendinitis is based primarily on local tenderness in the intertubercular sulcus. Yergason's sign of resisted supination with the elbow flexed 90°was mentioned as an additional important sign by five of the six reviewed studies. Abduction with the arm in external rotation compresses the tendon of the biceps and is painful or limited in some cases. Speed's test -resisted flexion of the shoulder with a supinated arm -was recommended by three investigators. Other specific tests for bicipital tendinitis are inconsistently referred to in the literature.

Diagnostic criteria of the present survey
In our survey we recorded local pain in the shoulder joint and pain during shoulder movements as subjective symptoms.
The recorded objective items were limited, painful active movements, painful arc during abduction, pain during resisted abduction, and tenderness in the bicipital or supraspinous tendon during palpation.
Our set of items necessary for a diagnosis of humeral tendinitis was pain in the shoulder joint region, limited active movement because of pain, and local tenderness.
To distinguish supraspinous tendinitis and bicipital tendinitis, we should have used additional specific test movements, for instance, Yergason's maneuver. However symptoms of the cervical spine or superior thoracic aperture were ruled out. Humeral tendinitis might overlap with another entity, that of the acute stage of frozen shoulder.

Review of diagnostic criteria
The frozen shoulder syndrome is the outcome of several pathological conditions leading to a stiff and painful shoulder (4,46). Also an idiopathic type without any recognizable cause is common (40). The principal subjective symptom is pain, often nocturnal and related to activity (table 6). The objective signs include loss of active and passive movements, especially abduction and external rotation, and atrophy of the shoulder muscles. In the initial phase both muscle spasm and anterior capsular tenderness have been noted by two of the investigators, but in the chronic stage the shoulder is relatively painless when immobile (4,5,40).

Diagnostic criteria of the present survey
As the subjective symptom for frozen shoulder we defined a progressive ache and stiffness of the shoulder joint within the last three to four months. Table 6. The frozen shoulder syndrome.

Subjective symptoms
The objective items recorded were limitation and pain during active and passive movements of the shoulder joint. In addition the shoulder had to show a loss of cutaneous lateral folds when inspected from behind.
Capsular contractura was diagnosed if the examinee had had progressive pain and shoulder stiffness during the last three to four months, and both active and passive outward rotation were limited.

Review of diagnostic criteria
Arthrosis of the acromioclavicular joint is relatively common, but often symptomless X X X X X X X a Items necessary for diagnosis are in parentheses.  (5,9,40). When symptomatic, it generally causes local pain and tenderness, with or without radiation proximally to the neck or distally to the deltoid area (2,61). Pain during movement, especially during abduction and/or elevation, was recorded in half of the studies we reviewed (table 7). Adduction of the arm across the chest compresses the joint, thus producing pain, and was considered a sign of the acromioclavicular syndrome by three investigators. Additional criteria were crepitation of the joint and pain during the telescoping of the clavicle.

Diagnostic criteria of the present survey
We recorded local pain at the acromioclavicular joint as the subjective symptom of the acromioclavicular syndrome in our survey.
The objective sign was local pain during percussion on the clavicle while the examinee pushed straight downward against resistance. According to the literature, the joint could have been examined by an additional specific test, e.g., an adduction or abduction test.
For clinical practice, most of the investigations consulted also recommended diagnostic anesthesia as an important part of examining the shoulder joint, both for tendinitis (2,4,40) and other clinical entities (6,61).

Review of diagnostic criteria
The most common subjective symptom of lateral epicondylitis found in the literature was pain in the elbow during hand movements; it was met in all of the articles reviewed (table 8). The next common symptom was pain during rest; it was present in five of the articles.
The most common functional objective sign was local tenderness at the epicondyle during palpation, also reported in all ten 34 of the investigations consulted. Pain during resisted movements of the wrist and fingers was reported in nine of the ten investigations. Also a decrease in hand grip power and local swelling at the elbow were common signs. Radiographic changes at the epicondyles were reported in five investigations, but muscle atrophy was found in only two.

Diagnostic criteria of the present survey
In our survey one subjective symptom of lateral epicondylitis was recorded, i.e., pain at the epicondyle either during rest or motion.
The following objective items were also recorded: local tenderness at the lateral epicondyle, pain during resisted extension of the fingers and wrist with the elbow straight, palpated local tenderness at the medial epicondyle, pain during resisted flexion of the fingers and wrist with the elbow flexed, and swelling at the medial epicondyle. Hand grip power was measured with the elbow straight and flexed.
A diagnosis of lateral epicondylitis was made if palpated tenderness at the lateral epicondyle and pain during resisted extension of the wrist and fingers were found. A diagnosis of medial epicondylitis required palpated tenderness at the medial epicondyles and pain during resisted flexion of the fingers and wrist. The necessary subjective symptom in both lateral and medial epicondylitis was local pain during rest and/or active movements of the wrist and fingers.

Review of diagnostic criteria
The principal symptoms and signs of peritendinitis and tenosynovitis are well documented and agreed upon in the literature (table 9). The different names for these two variants of the muscle-tendon syndrome originate from the location of the disease, not from the clinical picture, which is essentially the same for both (26).
The most constant symptom, and usually the first one, is pain over the muscletendon structures involved. The pain is felt as a dull ache at rest. It is greatly exaggerated on motion of the tendon and may sometimes be neuralgic in character. There is often an associated weakness of the extremity because of the pain.
Swelling that is fusiform in shape appears in more severe cases. The swelling is localized if the condition affects ten- Table 8. The epicondylitis syndrome.
Subjective symptoms dons with a definite sheath. When it affects the peritendinous tissue of tendons which have no sheath, the swelling is diffuse (17). The swelling may be tender to the touch and covered by hot and reddened skin.
Crepitation may appear simultaneously with the swelling or after it. In character it has been compared to the creaking of a chamois skin or to the crunching sound of dry snow (51). Crepitation is usually pal- pable, but in some cases it can only be detected during auscultation with a stethoscope. Although crepitation can be verified in the majority of acute cases, it by no means is always found in every case of tenosynovitis (10,32).

Diagnostic criteria of the present survey
The subjective symptoms recorded in our survey were muscle pain during effort, local swelling, and local ache at rest. The recorded objective signs were tenderness along the course of the tendon or on the muscle-tendon junction, swelling, crepitation, pain during movement, weakness in gripping (less than 70 kPa or an asymmetry of more than 33 %), and sausagelike thickening along the course of the tendon.
The diagnosis for a current case of peritendinitis or tenosynovitis was made if all of the aforementioned criteria were found except crepitation and thickening along the tendon course. A distinct thickening along the course of the muscle-tendon unit, associated with a history of pain in the respective area, was considered as sufficient evidence of past tenosynovitis or peritendinitis.

OTHER DISORDERS
In our survey we also included the following upper limb diseases: -pronator teres syndrome -carpal tunnel syndrome -de Quervain's disease Both the pronator teres syndrome and the carpal tunnel syndrome had a definite set of criteria based on clinical experience and textbook sources. Since we found only a few cases, no review has been presented. The third disorder listed, de Quervain's disease (stenosing tenosynovitis of the thumb extensor, abductor tendon), was included with the other dorsal tendinitises.

CONCLUSIONS
In this paper we have presented the clinical epidemiologic screening method employed in the investigation of occupational neck and upper limb disorders in a working population.
The main features of the method are as follows: 1. A predetermined set of tests and othel diagnostic inquiries for each disease or disorder are included in the survey.

2.
A preplanned examination procedure is applied by a specially trained physiotherapist.
3. A set of diagnostic criteria must be fulfilled in each case of disease or disorder.

A group of specialists handles the problem cases.
Our method differs from a clinical examination of patients in many respects. The most important deviation is the separation of the clinical examination and the making of the diagnosis. This division was made in order to lessen the subjective component and to add to the reliability and comparability between studies.
A critical review has been presented for each disease and disorder entity; in it our diagnostic criteria are compared with those found in literature dealing mostly with clinical signs and symptoms. An overview of the comparison shows that the criteria we have used match fairly well with the clinical signs and symptoms presented in earlier reports. There are some deviations, however. Our criteria for tension neck and chronic tenosynovitis might yield more positive findings in comparison to restrictive clinical diagnoses. According to our estimation the difference should not exceed (at worst) 25 % of false positives.
The different maneuvers and tests used in our survey have been called by the names commonly found in most textbooks and related sources. Because no generally accepted code exists for the performance of these maneuvers, they may yield differing results for persons with different teaching backgrounds, and thus the comparability of one study to another is lessened. The combination of several tests should, however, alleviate this drawback.