Wrist pain: a systematic review of prevalence and risk factors– what is the role of occupation and activity?

A comprehensive search strategy was created in collaboration with a research librarian (NT) and was designed to capture all relevant articles pertaining to observational studies relating to wrist pain (Additional file 1:). The full search strategy is detailed on the PROSPERO website. The search strategy was applied to the following bibliographic databases from database inception until 9th March 2018: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO from database inception until 9th March 2018.

The inclusion and exclusion criteria were defined prospectively during the protocol stage. Inclusion criteria included any cross sectional study or longitudinal study with a study population of any age and any setting with signs and/or symptoms of wrist pain reported within this group. There was no restriction on the type of setting for potential included papers. Included studies were required to report prevalence data, and had to be published in English or where an English translation was available. Exclusion criteria included: if the study population was defined on the basis of wrist pain (e.g.a solely asymptomatic and/or symptomatic group); if the study population was selected from a specific disease area (e.g. diabetes, rheumatoid arthritis, osteoarthritis); if patients with acute traumatic wrist pathology were deliberately included as new ‘incident’ cases (e.g. scaphoid fracture, distal radius fracture, scapholunate ligament rupture). Only studies which had asked participants specifically about wrist pain were included, studies which had amalgamated hand and wrist pain together in their questioning were excluded. Therefore wrist pain was defined as any pain attributed to the wrist by the patient or an observer/assessor, and pain attributed non-specifically to the wrist (for example to both the wrist and hand in a question or diagram) was not included within this definition. Studies in which the data had not been broken down to exclusively relate to wrist pain (for example by combining hand and wrist pain) were excluded. This underpinned the stated aim of the review which was to summarise information relating to wrist pain, not hand and wrist pain. Case reports and systematic reviews were excluded. A paediatric/adolescent population was defined as a population containing entirely members under the age of 18 years.

Duplicates were removed and relevant studies identified from the search were imported into Covidence for screening. Studies were independently screened by title and abstract by two authors (BD and RF). The references of all included studies and all relevant review articles on the topic were also reviewed to identify other potential studies for inclusion. This was followed by a full-text evaluation of the selected studies. Disagreement between the two reviewers was solved by consensus involving a third author (NR).

Two reviewers (BD and RF) independently extracted data. Data was extracted using a custom data extraction sheet in Covidence (http://​www.​covidence.​org). The data extracted included the author name, year of publication, journal, setting of study, type of study, population type and demographics, type of measurement used, prevalence of wrist pain, risk factors and predictive risk factors. Risk factors were defined as factors associated with wrist pain at one time point; while a predictive risk factor was defined as a factor which was assessed for predicting the development of wrist pain, meaning that a minimum of two time points would need to be studied. Risk factors were divided into the non-modifiable and modifiable groups. Any inconsistencies between the two reviewers’ forms were resolved by consensus discussion. A third review (NR) was available for any disagreement that could not be resolved by this initial discussion.

If data was not available from full-text articles or trial registrations, authors were contacted to provide this information. If authors were not contactable as regards additional data, then this aspect of the study was excluded from the data synthesis. If contactable authors did not respond to initial requests, they were sent two subsequent reminders over a minimum of 6 weeks. If there was still no response for the additional data, then this aspect of the study could not be included in the data synthesis.

The prevalence and risk factors of wrist pain were of primary interest. The time frame over which incident wrist pain was reported was grouped as short term (current or up to and including past 7 days) and medium term (beyond 1 week and up to and including 1 year).

Included studies were assessed for risk of bias by two independent raters (BD and NR) using a custom checklist based on that used by Lewis et al. [10]. It included six sections that assessed the study population, participant attrition, prognostic factor measurement, outcome measurement, confounding measurement, and statistical analysis. Each section had from 3 to 6 questions that were rated as high, low or unclear risk of bias (Additional File 4). Where appropriate, separate questions were used to evaluate studies which investigated risk factors and predictive risk factors. Any disagreements between ratings were resolved by discussion between the raters. A third party (NR) was available in any case where disagreements persisted after discussion. The checklist is attached a Additional file 2.

Descriptive analysis was performed for all data to facilitate narrative interpretation and comparison across studies. We analysed the prevalence data by dividing it into six groups based upon the time period over which the wrist pain was assessed and the type of participant group (general population and non-manual workers, higher risk groups (physically demanding occupations and sportspeople) and children/adolescents. We excluded the data from studies which did not state the time period over which the prevalence of wrist pain was assessed over.

A total of 1342 studies were identified by the search, after duplicates were removed. Following initial screening 82 studies remained for screening by full-text, 32 studies were then identified as eligible for inclusion (Fig. 1). The number of studies identified and excluded at each stage is detailed in Fig. 1.

Study characteristics of the included studies including the demographics, study design and wrist pain measurement method are provided in Table 1. The results are summarised in Tables 1 and 2. Table 1 details the prevalence of wrist pain. Table 2 details any extra information, as well as the associated factors and risk factors for wrist pain.

Of the 32 included studies, all of which were cross sectional studies (1 with a longitudinal component); seven of these studies compared two distinct populations while the remainder analysed only one population. Seven studies related to solely children and adolescents, while the remaining 25 studies related solely to adult populations. The studies by Davatchi et al. and Fiori et al. do have overlap in terms of the population group studied, although they have described different results relating to these populations. The method of assessing the prevalence of wrist pain was highly variable. The CMDQ (Cornell Musculoskeletal Disorder Questionnaire) was used by three studies, the COPCORD Core Questionnaire (CCQ) by two studies and a version of the NMDQ (Nordic Musculoskeletal Disorder Questionnaire) by three studies. The other methods for assessing wrist pain are summarised in Table 1. The time frame over which wrist pain was assessesed was also highly variable, varying from ‘current’ to pain within the last year as is detailed in Table 1.

These results are detailed in Table 1 and shown in Fig. 2. The median prevalence of wrist pain in all populations combined within the short term (within last week) was 10% (IQR 3.3 to 15.6) and 19.1% (IQR 8.5 to 40.5) within the medium term (> 1 week and within a year).

The median prevalence of wrist pain in the general population and non-manual workers within the short term (within last week) was 6% (IQR 0.5 to 10.3) and 4.2% (IQR 43.75 to 5.6) within the medium term (> 1 week and within a year). The median prevalence of wrist pain in physically demanding occupations and in sportspeople was 10% (IQR 5.6 to 17.8) within the short term and 24% (IQR 12.7 to 38.6) within the medium term. The median prevalence of wrist pain in the medium term in female child/adolescent gymnasts was 57% (IQR 56 to 73). Figure 2 represent a scatter plot of the prevalence of wrist pain in the different groups, we wish to make it clear this is not a form of meta-analysis. The prevalence of wrist pain was much lower in the non-gymnastic general paediatric population as reported by Kirby et al., however no time frame was reported for the wrist pain so this was not included within the scatter plot [11].

These results are detailed in Table 2, while Fig. 2 shows the prevalence of wrist pain in the different groups.

The non-modifiable factors associated with wrist pain included increased age (1 study in adults [12] and 2 studies in children/adolescents [13‐15]), and female sex [16, 17]. Kihlberg et al. demonstrated an odds ratio of 1.4 (95% CI 1.1–1.7) with increased age [12], while the studies by Di Fiori et al. did not provided an odds or risk ratio, Davatchi et al. showed that the frequency of wrist pain was 14.7% (CI 13.6–15.8) in women, higher than in men 5.6% (CI 4.9–6.3), however no odds or risk ratio was provided [16]. Harutunian et al. found a higher prevalence of wrist pain in women but provided no further data relating to the strength of this association [17].

The impact of occupation was investigated by several studies. The prevalence of wrist pain was in higher in brick field (85%) vs officer workers (3%) [18], brass metal (62%) vs officer workers (4%) [19], athletes vs university staff [20], gymnasts (33%) versus non gymnasts (2%) [11], endoscopists versus non endoscopists [21], garment workers vs hospital employees (RR 3.9 (95% CI 1.4–10.9) [22], and sewing machine operators versus controls [23].

The modifiable factors associated with wrist pain included high job physical strain ( [24, 25], 2 studies), high job psychological strain [25], abnormal physeal morphology in children/adolescents (2 studies [13, 26]), high frequency impact tool use [12] and effort reward umbalance [25]. Yu et al. demonstrated that wrist pain was more common in men and women with high job strain (psychological demands) (men OR 1.4 (95%CI 1.02–1.91) and women OR 2.20 (95%CI 1.31–3.69)) and high job strain (physical demands) (men OR 1.37 (95%CI 1.05–1.80) and women OR 1.56 (95%CI 1.02–2.40)); wrist pain was also more common in men and women with a effort reward imbalance (ERI) (men OR 1.29 (95% CI 1.02–1.23) and women OR 1.56 (95% CI 1.00–2.42, 25). Celik et al. nurses who often lifted/carried heavy materials felt significantly more pain in the wrist (37.8%; OR, 0.17; 95% CI, 0.05–0.49). Chang et al. found that 24.6% of the 171 painful wrists had abnormal growth plate morphology compared to 19 (10.5%) of the 181 asymptomatic wrists (RR 2.3, 26). While Kihlberg et al. found a higher risk of wrist pain with high frequency impact tool use (OR 1.5 (95% CI 1.0–2.3)) [12].

Only one study assessed predictive risk factors and this was observed at a follow up time of five years, demonstrating that in workers who use power tools a higher rate of wrist pain at 5 years associated with high frequency impact tool use (RR 1.6 (95%CI 0.8–3.4)) and number of years in occupation (RR 1.5 (95% CI 0.9–2.5)) [12].

The risk of bias summary is shown in Fig. 3 and the risk of bias graph in the Additional file 3. The risk of bias was generally low for the study population domains (description of sampling, inclusion/exclusion criteria and reporting of basic participant characteristics). In terms of response rate and wrist pain measurement the risk of bias was higher on average, with a majority of studies judged to be at high risk of bias in these domains. Again the results were mixed in the confounding and statistics domains for studies which investigated associated factors. A significant proportion of studies investigating the associated factors did not report odds ratios or risk ratios with their 95% confidence intervals, as well as those adjusted for confounding. Only one study assessed the risk factors of wrist pain and was scored against the relevant domains for prognostic studies.

The main limitations of this systematic review relate to the included studies’ limitations. There are significant methodological flaws present within the included studies. These include the use of unvalidated methods of assessing wrist pain, the low response rates and the lack of adjustment for confounding factors in some studies. Another significant limitation is the number of studies (n = 41) which had to be excluded due to study design (Fig. 1), this was largely down to the way in which wrist pain had not been specifically investigated. As previously stated our specific aim was to assess wrist pain as a distinct entity and this underlies the exclusion of studies which did not separate hand and wrist pain.