Background Pain in the distal arm is common, costly and disabling. As with musculoskeletal pain in the lower back, the risk factors are both mechanical and psychosocial. We set out to test the hypothesis that (a) advice to remain active would lead to better outcomes at follow-up than advice to rest and (b) rapid physiotherapy would give superior outcomes than normal (waiting-time) physiotherapy.

Methods This was a multi-centre randomised controlled trial of people referred to physiotherapy with distal arm pain. The principal outcome measure was complete absence of disability on a modified DASH questionnaire at 6 months.

Results 539 patients were randomised evenly between the three groups (179, 182 and 178, respectively). Participants had a mean age of 49 yrs (SD 13.6); 54.5% were female; and 87.6% were right handed. Approximately an equal number of patients reported pain in their elbow, wrist/hand, or both; and pain was most common in the dominant side (45.5%), or bilateral (24.7%). 435 participants (81%) provided follow-up data at 26 weeks.

32.1% of patients who received advice to rest were free of disability at 26 weeks, compared to 45.2% of those who received advice to remain active. Thus, advice to rest was associated with a decrease in the likelihood of recovery (odds ratio: 0.54; 95% CI: 0.32–0.90). There was no difference in recovery between those receiving immediate physiotherapy (35.8%) versus delayed (38.6%). Indeed, there was some evidence to suggest that immediate physiotherapy was inferior to advised activity (odds ratio: 0.64; 95% CI: 0.39–1.07) physiotherapy.

Discussion We have shown, among patients referred to physiotherapy with distal upper limb pain, that advice to remain active is associated with a superior long-term outcome, compared with advice to rest the arm, and the results do not support the provision of ‘fast-track’ physiotherapy for such patients.