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Course and Prognosis of Shoulder Symptoms in General Practice
Course and Prognosis of Shoulder Symptoms in General Practice
1093/rheumatology/ken044
Advance Access publication 14 April 2008
Objectives. To investigate the course and prognosis of shoulder pain in the first 6 months after presentation to the general practitioner.
We separately studied patients with acute, subacute and chronic shoulder pain, as duration of symptoms at presentation has been shown to
be the strongest predictor of outcome.
Methods. A prospective cohort study with 6 months follow-up was carried out in The Netherlands, including 587 patients with a new episode
of shoulder pain. Patients were categorized as having acute (symptoms <6 weeks), subacute (6–12 weeks) or chronic (>3 months) shoulder
pain. The course of shoulder pain, functional disability and quality of life was analysed over 6 months. Patient and disease characteristics,
including physical and psychosocial factors, were investigated as possible predictors of outcome using multivariable regression analyses.
Results. Acute shoulder symptoms showed the most favourable course over 6 months follow-up, with larger pain reduction and improvement
of functional disability. Patients with chronic shoulder symptoms showed the poorest results. The multivariable regression analysis showed
that predictors of a better outcome at 6 months for acute shoulder pain were lower baseline disability scores and higher baseline pain intensity
(explained variance 46%). Predictors of a better outcome for chronic shoulder pain were lower scores on pain catastrophizing and higher
baseline pain intensity (explained variance 21%).
Conclusions. The results indicate that, besides a different course of symptoms in patients presenting with acute or chronic shoulder pain,
predictors of outcome may also differ with psychosocial factors being more important in chronic shoulder pain.
KEY WORDS: Shoulder pain, Disability, Psychosocial factors, General practice, Course, Prognosis, Prospective cohort study.
The GP started treatment according to national Dutch guidelines Predictors were selected based on evidence from the literature on
for shoulder pain, which advise a stepwise approach (advice, their potential predictive value in patients with musculoskeletal
medication, steroid injection or physiotherapy) in which the next pain (age, history of pain, dominant side affected, musculoskeletal
treatment option is only considered for patients returning with pain elsewhere, work load factors and pain catastrophizing) [9, 10,
persistent pain and disability [19]. Information was recorded 12, 14–17, 27]. Another reason for selecting a potential predictor
about the treatment provided to the patients at the first could be differences between patients with acute and chronic pain
consultation. Within 10 days after the consultation a baseline at baseline, indicating potential predictive importance of the
assessment was performed, consisting of a patient history, factor.
standardized physical examination and a questionnaire. Univariable linear regression analyses were performed to
A second questionnaire (first follow-up) was sent after 6 weeks, examine the relationship between each of the potential predictors
the third questionnaire (second follow-up) after 3 months and the and change in pain intensity after 6 months. Predictors measured
fourth questionnaire (third follow-up) after 6 months. The study on a continuous (e.g. age) or interval scale (e.g. baseline pain
was approved by the Medical Ethics Committee of the VU intensity) were entered as continuous variables, which provides an
University Medical Centre in Amsterdam. estimate of the mean reduction in pain for each point increase on
the scale. If a continuous variable showed a non-linear association
Outcome measures and potential prognostic factors with outcome it was dichotomized or divided into tertiles (low,
In each questionnaire, the intensity of shoulder pain, functional medium, high scores). This was the case for external locus of
disability and quality of life was measured. Pain was recorded by control and somatization.
the patient on a numeric rating scale (0–10 points, 0 ¼ no pain; Subsequently, predictors that were associated with the outcome
10 ¼ very severe pain). Functional disability was measured using (P < 0.30) were included simultaneously in a multiple linear
the 16-item Shoulder Disability Questionnaire (SDQ; 0–100) [20]. regression model. Using a manual backward selection procedure,
Quality of life was measured by the EuroQol (EQ-5D; 0–1) we sequentially excluded predictors with the lowest predictive
[21, 22], covering five domains: mobility, self-care, usual activities, value from the model until all predictors were significantly
pain/discomfort and anxiety/depression. associated with outcome (Wald statistic P < 0.10) and further
During the baseline assessment information was collected on elimination resulted in a large deterioration of the explained
a variety of potential prognostic factors. Sociodemographic variance of the model. The percentage of explained variance (R2)
variables included age, gender, educational level and work was calculated to give an indication of the predictive power of the
status. Characteristics of the shoulder pain problem included final models.
intensity of pain, an acute or gradual onset, previous episodes of
shoulder pain and whether or not the dominant side was affected.
The questionnaire also included questions on co-existing muscu- Results
loskeletal pain at the neck, back and upper extremities.
Causes of shoulder pain as perceived by the patient were
Study population and follow-up
categorized as unexpected movement, overuse due to unusual At baseline, 587 patients were interviewed and physically
activities, overuse due to usual activities, accident or sports injury examined. At 6 weeks 487 (83%), at 3 months 517 (88%) and at
and were measured with questions answered by yes or no. 6 months 538 (92%) patients returned the postal questionnaire.
Physical activity was measured with a single question (less/ The drop-outs at 6 weeks and 6 months were significantly younger
equally/more active than others). We measured physical workload than the responders (mean difference 4 yrs and 6 yrs, respectively).
with a self-constructed scale of five questions (yes/no) concerning Additionally, drop-outs at 6 months more often showed an acute
pushing and pulling, lifting weights, working with hands above onset (49 vs 36%), and less repetitive movements in their work
shoulder level and the use of vibrating tools on at least 2 days a (26 vs 36%) in comparison with the responders.
week (0–5). Repetitive movements, on at least 2 days a week, were Table 1 lists the baseline characteristics of the participants
measured with a single question answered with yes or no. The separately for those with acute, subacute or chronic pain at
psychosocial work environment was assessed using the 27-item baseline. The results show that patients with chronic shoulder pain
Job Content Questionnaire which measures all dimensions of the reported higher pain intensity, more disability, had a higher
Demand–Control–Support model [23]. somatization score, and more often reported a gradual onset of
Psychological factors were measured with widely used their shoulder pain compared with patients with subacute or acute
standardized questionnaires. Coping was assessed with the shoulder pain. Patients with acute shoulder pain more often had a
43-item Pain Coping and Cognition List (PCCL) [24], consisting paid job, and slightly higher scores on external locus of control
of the subdomains catastrophizing (1–6), coping with pain (1–6), compared with those with subacute or chronic shoulder pain.
internal (1–6) and external locus of control (1–6). These six factors were considered as potential predictors of
Anxiety (0–24), depression (0–12), somatization (0–32) and outcome in further analyses (in addition to factors suggested by
distress (0–32), were measured with the 50-item Four-Dimensional the literature).
Symptoms Questionnaire (4DSQ) [25, 26].
The questionnaire finally included a general one-item question
regarding the presence (yes/no) of any psychological problems Management of shoulder pain
(e.g. worries, depressive symptoms, anxiety). At baseline, most patients (n ¼ 451, 77%) received a wait-and-see
policy, paracetamol or an NSAID. Furthermore, 68 patients
Analysis (12%) received an injection with a corticosteroid, 58 patients
Descriptive statistics were used to summarize characteristics of the (10%) were referred for physiotherapy and 11 (2%) received other
study population. We present this information separately for therapies. Table 2 lists the management of shoulder pain of the
patients with acute, subacute and chronic shoulder pain. The participants separately for those with acute, subacute or chronic
course of symptoms in terms of pain, disability and quality of life pain at baseline.
was also described separately for these three subgroups by plotting The proportion of patients receiving wait-and-see policy,
the mean scores at each point in time. Next, we analysed potential paracetamol or NSAIDs was higher in patients with acute
predictors of outcome separately for patients with acute and shoulder pain compared with those with chronic shoulder pain,
chronic shoulder pain. Absolute change in pain intensity between while the proportion of physiotherapy referrals was higher in
baseline and 6 months follow-up was used as outcome measure. patients with chronic shoulder pain.
726 M. Reilingh et al.
TABLE 1. Baseline characteristics of patients with shoulder pain, separately for those with acute, subacute or chronic pain at baseline
Acute (n ¼ 205) <6 weeks Subacute (n ¼ 139) 6–12 weeks Chronic (n ¼ 242) >3 months
Demographic and work variables
Age (yrs), mean (S.D.) 49.5 (14.7) 51.9 (13.9) 52.9 (13.3)
Gender, n (% female) 105 (51.2) 62 (55.4) 127 (52.5)
Educational level, n (%)
Low 74 (36.1) 37 (26.6) 98 (40.5)
Middle 80 (39.0) 61 (43.9) 93 (38.4)
High 48 (23.4) 40 (28.8) 47 (19.4)
Paid work 139 (67.8) 77 (55.4) 134 (55.4)
Psychosocial work environment (n ¼ 350), mean (S.D.)a
Decision authority 9.4 (1.74) 9.2 (1.77) 9.4 (1.84)
Skill discretion 15.4 (2.92) 15.4 (2.68) 15.1 (2.80)
Decision latitude 24.8 (4.07) 24.6 (3.99) 24.6 (4.17)
Psychological demands 13.2 (2.88) 12.9 (2.24) 12.3 (2.57)
Supervisor support 12.2 (2.44) 11.1 (2.22) 11.3 (2.83)
Coworker support 12.4 (2.02) 12.3 (1.37) 12.2 (2.16)
Disease characteristics
Gradual onset, n (%) 78 (38.0) 96 (69.1) 188 (77.7)
Previous episode, n (%) 119 (58.0) 63 (45.3) 161 (66.5)
Pain intensity, mean (S.D.) 4.4 (2.5) 4.7 (2.1) 5.2 (2.2)
Functional disability (SDQ 0–100), mean (S.D.) 56.8 (28.3) 59.1 (23.0) 62.9 (22.7)
Dominant side affected, n (%) 120 (58.5) 89 (64.0) 152 (62.8)
Psychological factors
PCCL, mean (S.D.)a
Catastrophizing (1–6) 2.2 (0.8) 2.2 (0.9) 2.3 (0.9)
Coping with pain (1–6) 3.0 (1.0) 2.9 (0.9) 3.0 (1.0)
Internal locus of control (1–6) 3.4 (1.0) 3.4 (0.9) 3.3 (0.9)
External locus of control (1–6) 3.4 (0.9) 3.1 (0.9) 3.1 (0.9)
4DSQ, mean (S.D.), mediana
Distress (0–32) 2.1 (4.5), 0.0 2.5 (5.1), 0.0 2.4 (4.1), 0.0
Depression (0–12) 0.2 (1.4), 0.0 0.2 (1.3), 0.0 0.3 (1.1), 0.0
Anxiety (0–24) 0.4 (1.5), 0.0 0.4 (1.3), 0.0 0.3 (1.0), 0.0
Somatization (0–32) 2.9 (3.6), 2.0 2.8 (3.9), 2.0 4.0 (4.5), 3.0
Physical load
Physical burden (0–5), mean (S.D.), median 1.35 (1.50), 1.00 1.19 (1.52), 0.00 1.18 (1.40), 1.00
Repeated movement with arms or wrists, n (%) 138 (67.3) 75 (54.0) 170 (70.2)
Perceived cause according to patient, n (%)
Unexpected movement 12 (5.9) 9 (6.5) 12 (5.0)
Overuse unusual activities 32 (15.6) 24 (17.3) 39 (16.1)
Overuse usual activities 43 (21) 36 (25.9) 59 (24.4)
Accident 10 (4.9) 4 (2.9) 19 (7.9)
Sports injury 6 (2.9) 6 (4.3) 17 (7.0)
Physical activity, n (%)
>30 min/day walking or biking 70 (34.1) 53 (38.1) 93 (38.4)
Regular long walk or cycling tour 87 (42.4) 72 (51.8) 116 (47.9)
Pain elsewhere, n (%)
Neck or upper extremities 86 (45.3) 56 (45.5) 131 (58.5)
Low back 44 (21.5) 31 (22.3) 64 (26.4)
a
The psychosocial work environment was only assessed in patients with paid work.
10 1
8 0.8
7
Pain intensity (0–10)
EQ-5D (0–1)
0.6
5
4 0.4
3
2
0.2
1
0
0 5 10 15 20 25 30 0
0 5 10 15 20 25 30
Follow-up time (weeks)
Follow-up time (weeks)
Acute (0–6 weeks) Subacute (6–12 weeks)
Acute (0-6 weeks) Subacute (6–12 weeks)
Chronic (> 12 weeks) Chronic (> 12 weeks)
100
months, increasing to only 32% after 12 months [24]. Similarly,
90 in a recent study on non-traumatic arm, neck and shoulder
80
complaints [17], 25% of participants reported complete recovery
after 6 months. These studies demonstrate a poor outcome of neck
Shoulder disability (0–100)
Acute shoulder pain (n ¼ 190) Significance Chronic shoulder pain (n ¼ 224) Significance
Mean change (95% CI)a Mean change (95% CI)a
Age (per year older) 0.01 (0.02, 0.04) 0.50 0.02 (0.01, 0.05) 0.30
Baseline disability score (SDQ, per point increase) 0.02 (0.00, 0.03) 0.01 0.02 (0.00, 0.04) 0.04
Catastrophizing (PCCL, per point increase) 1.00 (0.44, 1.57) 0.01 0.26 (0.72, 0.20) 0.26
External locus of control (PCCL, compared < 3)
3–4 0.35 (0.63, 1.32) 0.49 0.79 (1.60, 0.02) 0.06
>4 0.22 (0.89, 1.33) 0.70 0.21 (0.92, 1.35) 0.71
Somatization (4-DSQ, 5 vs < 5) 0.87 (0.23, 1.98) 0.12 0.16 (1.01, 0.68) 0.71
Paid work (yes vs no) 0.95 (1.85, 0.06) 0.04 0.31 (1.07, 0.45) 0.42
Gradual onset (vs sudden) 0.56 (1.43, 0.3) 0.21 0.59 (1.51, 0.34) 0.21
Previous episode (yes vs no) 0.61 (0.25, 1.47) 0.16 0.07 (0.75, 0.88) 0.87
Baseline pain intensity (per point increase) 0.78 (0.65, 0.90) 0.00 0.59 (0.43, 0.74) 0.00
Dominant side affected (yes vs no) 0.28 (0.58, 1.14) 0.52 0.01 (0.78, 0.79) 0.99
Repeated movement with arms or wrists (yes vs no) 0.65 (1.53, 0.24) 0.15 0.11 (0.72, 0.94) 0.79
Pain in neck or upper extremities (yes vs no) 1.05 (0.21, 1.89) 0.02 0.19 (0.95, 0.58) 0.63
a
Positive values indicate larger reductions in pain, negative values indicate an increase in pain (per point increase on the predictor).
TABLE 4. Predictors of change in pain intensity for patients with acute shoulder pain (R2 ¼ 0.46) or chronic shoulder pain (R2 ¼ 0.21) after 6 months follow-up: results of
multiple linear regression analyses
Acute shoulder pain (n ¼ 190) Significance Chronic shoulder pain (n ¼ 224) Significance
Mean change (95% CI)a Mean change (95% CI)a
Baseline disability score (per point increase) 0.01 (0.03, 0.00) 0.03
Catastrophizing (per point increase) 0.62 (1.03, 0.20) 0.001
Baseline pain intensity (per point increase) 0.84 (0.71, 0.98) 0.001 0.65 (0.48, 0.81) 0.001
a
Positive values indicate larger reductions in pain, negative values indicate an increase in pain (per point increase on the predictor).
strongest predictor of change in pain intensity over 6 months predictors, we may have missed relevant predictors, such as social
follow-up, next to baseline levels of pain. support or aspects of the psychosocial work environment [17, 35,
Catastrophizing [34] is considered to be an ineffective coping 36]. We may also have been unable to measure important
strategy in which pain is perceived as overly destructive, and predictors with sufficient accuracy. Exposure to physical load,
patients have a pessimistic view of their prognosis. The fact that for example, was measured using a few simple questions, but has
catastrophizing was especially important in patients with chronic been shown to be associated with neck or shoulder pain in other
shoulder pain may indicate that catastrophizing is a consequence of cohorts [36, 37]. Further research is needed to identify relevant and
pain, rather than a predictor of the development of chronic pain. preferably modifiable predictors of outcome, especially in patients
Surprisingly, Table 3 also shows that in patients with acute pain, with chronic shoulder symptoms. Studies carried out in occupa-
catastrophizing was associated with larger improvements of tional settings may be more suitable to address the importance of
pain, even though the association was weak and not statistically work-related factors in the prognosis of shoulder pain.
significant in the multivariable model. Possibly, this is a chance We decided not to include treatment in our models, as we
finding. Alternatively, based on the assumption that the catastro- assumed that confounding by indication could influence our
phizing scale measures if patients are more strongly oriented findings. Patients with more severe symptoms and thus, probably
towards pain stimuli, one may hypothesize that patients with high a poorer outcome, are more likely to receive more exten-
scores on catastrophizing avoid pain-provoking activities, which sive treatment. Our results seem to confirm this assumption;
may actually be an effective strategy in the acute phase of a shoulder the proportion of patients receiving wait-and-see policy or pain
problem. Inadequate beliefs and attributions of pain, however, may medication was higher in patients with acute pain compared with
become stronger when pain persists, or when recurrences of pain chronic pain, while the proportion of physiotherapy referrals was
occur. If the negative influence of catastrophizing can be confirmed higher among those with chronic shoulder pain. However, the
in other shoulder pain populations, future research might be aimed large majority of patients in each subgroup was treated by
at the development and evaluation of interventions aimed at wait-and-see or medication in the first month, indicating that our
reducing such negative processes, from which patients with chronic GPs largely adhered to the Dutch practice guidelines for shoulder
shoulder pain in primary care may benefit. complaints, which recommend such a policy during the first 2–4
weeks after presentation [19]. This means that our subgroups
Strengths and weaknesses were relatively homogeneous regarding treatment at baseline.
Treatment variables were, indeed, not strongly associated with
Our sample of shoulder pain patients is relatively large, allowing outcome nor strongly influenced the association of other
stratification of patients according to duration of their symptoms. predictors (data not shown).
Drop out among patients was low (8% at 6 months). Although
drop-outs were younger, more often showed an acute onset and
less repetitive movements in their work, the absolute differences in
Clinical usefulness
age, acute onset and repetitive movements were not large and it is In The Netherlands, nearly every Dutch resident is registered with
unlikely that these differences have strongly influenced the a GP. Patients first visit their GP before visiting a specialist in
reported associations between potential predictors and outcome. rheumatology or orthopaedics. This is comparable with, for
The prognostic model for patients presenting with acute instance, the British healthcare system. The participating prac-
shoulder pain explained 46% of the variance in pain scores at tices, being situated in both rural and urban areas in various
follow-up, but for chronic pain patients this was only 21%. This provinces, form a representative sample of Dutch GPs. Although
means that much of the variance in this patient group remains we encouraged GPs to select every eligible patient, we do not
unexplained. Even though we included a wide variety of potential know what proportion of patients was invited or whether this was
Course and prognosis of shoulder symptoms 729
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