Occupational Cervicobrachial Syndrome

Occupational cervicobrachial syndrome is work related pain in the neck, shoulder and upper arm, with or without arm symptoms, caused by sustained or repetitive neck and shoulder loading. It includes tension neck syndrome, trapezius myalgia, rotator cuff tendinopathy and, less often, cervical radiculopathy.

Exposure. Keyboard and screen work, assembly, sewing, dentistry, hairdressing, overhead work, and use of hand tools with arms elevated.

Epidemiology. Neck and shoulder pain is among the commonest work related complaints. Women and workers with static postures are affected most.

Risk factors. Sustained neck flexion, arm elevation over 60 degrees, poor workstation set up, static load, low job control and stress.

Course. Many episodes recur. Radicular features carry a worse outlook.

Pathophysiology.

Prolonged low level static muscle activity causes ischaemic overload of the trapezius and neck muscles. Tendon strain at the shoulder follows from elevated arm posture.

Cervical disc and facet degeneration may compress nerve roots. Central sensitisation sustains chronic pain.

• Neck stiffness and aching radiating to the shoulder, upper back and head.
• Muscle tenderness and trigger points; painful arc at the shoulder in rotator cuff disease.
• Radicular pain, paraesthesia or weakness in a dermatomal pattern.
• Tension type headache.

Red flags.

• Gait disturbance, hand clumsiness or bladder symptoms (cervical myelopathy).
• Progressive weakness, fever, weight loss or a history of cancer.
• Arm pain with chest pain or exertional symptoms, arm swelling or limb ischaemia.

• Work and posture history, screen height, desk set up and task duration.
• Examination of neck movement, shoulder, Spurling test, neurological examination of the arms.
• Imaging: ultrasound for the rotator cuff. MRI of the cervical spine for radiculopathy persisting for over 6 weeks, motor deficit or myelopathy.
• Nerve conduction studies when radiculopathy and peripheral entrapment must be separated.
• Blood tests when inflammatory or systemic disease is suspected.

Differential diagnosis. Cervical radiculopathy and myelopathy, rotator cuff tear, adhesive capsulitis, thoracic outlet syndrome, carpal tunnel syndrome, polymyalgia rheumatica, cardiac pain, fibromyalgia.

• Ergonomic correction: monitor at eye level, keyboard and chair height, forearm support, headset use, task variation and micro-breaks.
• Exercise: neck and scapular strengthening and stretching with physiotherapy; manual therapy as an adjunct.
• Paracetamol 1 g orally every 6 hours as needed, maximum 4 g in 24 hours (3 g if under 50 kg, chronic alcohol excess or liver disease), for the shortest period that controls pain. Monitor liver function with prolonged use. Reduce dose in hepatic impairment; extend dosing interval when eGFR is under 30.
• Ibuprofen 400 mg orally three times daily with food for up to 7 days, maximum 2400 mg daily. Monitor blood pressure, renal function and gastrointestinal symptoms. Avoid if eGFR is under 30, in active peptic ulcer, heart failure or the third trimester; add gastroprotection in older adults or those at risk.
• Radicular pain: pregabalin orally, 75 mg twice daily, increased after 3 to 7 days to 300 mg daily and, if needed after a further 7 days, to a maximum of 600 mg daily. Review at 4 weeks and stop if there is no meaningful benefit; withdraw over at least 1 week. Monitor sedation, dizziness, peripheral oedema, weight gain, mood and misuse. Adjust for renal function: creatinine clearance 30 to 60 mL/min, 75 to 300 mg daily in 2 or 3 divided doses; 15 to 30 mL/min, 25 to 150 mg daily; under 15 mL/min, 25 to 75 mg daily. Avoid in pregnancy unless benefit outweighs risk.
• Soft collars and prolonged rest are not advised.
• Myelopathy, progressive motor deficit or radiculopathy persisting after 6 to 12 weeks: surgical assessment.

Monitoring. Review at 4 to 6 weeks and every 3 months until stable.

Referral and escalation. Urgent spinal referral for myelopathy or progressive weakness; occupational physician for workstation assessment; notification and compensation where required.

Special groups. Pregnancy: paracetamol is preferred and ibuprofen is avoided in the third trimester. Older adults: reduce NSAID exposure.