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Preventative strategies for CANS among master students, a comparison study

Freriks, CJ    

Complaints of arm, neck and shoulder (CANS) is a major health problem in the work and study population in the Western countries. CANS has wide spread symptoms varying from pain in the neck during computer work to radiating sensation in the arm/hand while the person is at rest.

Hulst et al (2) found in their prospective population-based cohort study (n=3050) in the general population of the Netherlands that over an period of 15 years only 47% of the participants were free of CANS. A cohort study in a university population by Bruls et al (3) tended to give insight in the course of CANS and it’s severity. The results show mild to moderate CANS in terms of the different International Classification of Functioning, Disability and Health (ICF) domains. A possible explanation could be they have already adapted their work techniques or learned to avoid certain activities that cause pain (3). Miedema et al (4) focused on the disability trajectories in patients with CANS. Three disability trajectories were identified in their prospective cohort study in 21 general practices in the southwest region of the Netherlands that of all persons (n=682) who had a new episode of CANS; fast recovery (67.6%), modest recovery (23.6%), and continuous high disability (8.8%). At the Wageningen University (WUR) it is seen that when students do their master thesis, complaints aggravate. This is supported by experts and students who were interviewed for this study to give insight in the problem at the WUR.

Concerning prognostic factors that are associated with recovery, Bruls et al found that longer duration of complaints, higher symptom severity, more functional limitations, the use of specific coping styles, and accident as ‘patients opinion regarding cause’ were negatively associated with recovery (5). Hutting et al (6) used a focus group study with experts to develop an self management intervention for CANS. During data analyses, it appeared that identified categories emerging from the data, showed similarities with the I-Change model (2.0), which consists of three phases of behavioural change (Awareness, Motivation and Behaviour). When looked at the available literature there is a lack of preventive studies for CANS. A lot of studies focus on prognostic factors or therapy/ self management when developed CANS. To our knowledge there is no study done yet that focusses on prevention of the development of CANS. This study will compare three different approaches in preventing CANS among students during their Master at the WUR in a randomised clinical trial.

This is a randomised clinical trial with an follow up of 3 years. Participation is voluntary and
participants can withdraw at any moment without any consequences. All participants will sign an
informed consent.

Participants and recruitment
Participants will be recruited from students of the Wageningen University (WUR) located in Wageningen, the Netherlands. These potential participants will be recruited by email, advertising within the organisation and will be informed about the project by student council, occupational health coordinators and supervisors. Candidates willing to apply can contact the first author (CF) of this study who will arrange an consultation. At least 7 days before consultation the eligible candidates will receive an letter with information about the study included an informed consent. If needed at first consultation there will be additional information about the implications of participation provided. After this the eligibility of the student based on the inclusion and exclusion criteria (appendix 2) is being questioned. Each participant will be asked to sign informed consent.

Study design
This study is a 3 parallel-group randomized clinical trial. Outcomes will be assessed at 3 months, 6 months, 1 year, 2 year and 3 years following enrolment. The primary outcome is CANS assessed with Maastricht Upper Extremity Questionnaire (MUEQ) and the quick Disability Arm Shoulder Hand (Quick DASH) (Dutch and English version available for both).
Secondary outcome will be pain intensity when developed CANS with the Numeric Pain Rating Scale (NPRS).

After participation randomisation will be performed. Participants will be randomized to usual care, extended care or alternative extended care combined with exercise following a computer generated randomization list with randomly varying block sizes prepared by the study statisticians prior to beginning enrolment. To conceal allocation, sealed envelopes containing the assignment will be used.

Following baseline examination but before randomization, all participants are being educated about the current tools available at the WUR to prevent CANS during the study period (Usual care).
After randomization: The usual care group receives no further information (control group).
The extended care group will receive additional information about how to prevent CANS and will be given once instruction about how to sit/work and they will be provided an ergonomic keyboard and mouse. The alternative extended care group will receive instructions, education about CANS and exercises to correct the shoulder position during daily activities. They have also access to an CANS prevention app where they can quickly find feedback.

Power and statistical analysis
To estimate the number of participants needed to have a power of P 0.05 there will be an power analysis performed using G*Power Statistical analysis of the therapy effect will be done using an ANOVA analysis with an POST-HOC test to evaluate the difference between the 3 groups in means.

1. Tijdschrift N, Jaargang F. KNGF-richtlijn. 2017;(1).
2. Van Hulst R, Van Oostrom SH, Ostelo RWJG, Verschuren WMM, Picavet HS. Long-term patterns of chronic complaints of the arms, neck, and shoulders and their determinants - The Doetinchem Cohort Study. Pain. 2016;157(5):1114–21.
3. Bruls VEJ, Jansen NWH, Van Kuijk SMJ, Kant I, Bastiaenen CHG. The course of complaints of arm, neck and/or shoulder: A cohort study in a university population participating in work or study. BMC Musculoskelet Disord. BMC Musculoskeletal Disorders; 2018;19(1):1–17.
4. Miedema HS, Feleus A, Bierma-Zeinstra SMA, Hoekstra T, Burdorf A, Koes BW. Disability Trajectories in Patients With Complaints of Arm, Neck, and Shoulder (CANS) in Primary Care: Prospective Cohort Study. Phys Ther [Internet]. 2016;96(7):972–84. Available from: https://academic.oup.com/ptj/article/2864917/Disability
5. Bruls VEJ, Bastiaenen CHG, De Bie RA. Prognostic factors of complaints of arm, neck, and/or shoulder: A systematic review of prospective cohort studies. Pain. 2015. 765-788 p.
6. Hutting N. Program for Employees With Complaints of the Arm ,. 2017.