Rheumatology 2008;47:724–730 Advance Access publication 14 April 2008

doi:10.1093/rheumatology/ken044

Course and prognosis of shoulder symptoms in general practice
M. L. Reilingh1, T. Kuijpers2, A. M. Tanja-Harfterkamp1 and D. A. van der Windt1,3
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.

Introduction
Shoulder symptoms are a frequent problem in general practice, affecting between 7% and 34% of adults at any one time [1]. Not everyone consults the general practitioner (GP) for these symptoms. The annual consulting incidence in Dutch general practice for shoulder symptoms is estimated between 12 and 25/1000 persons-years [2–5]. Little is known about the pathophysiology and aetiology of shoulder disorders, although associations with obesity, age, female gender, physical work load and psychosocial factors have been proposed [6–8]. Various studies have contradicted the belief that shoulder pain is a benign and self-limiting problem. Only about 50% of all new episodes of shoulder pain presented in primary care show complete recovery within 6 months, after 1 yr this proportion increases to only 60% [9–12]. In the period 1987–95, the state of Washington (USA) each year accepted over 6000 work disability claims related to shoulder problems [13]. Information about the clinical course of shoulder symptoms after presentation in general practice is still limited. The medical literature on shoulder disorders is predominantly based on hospital surveys, although only a small proportion of shoulder patients in general practice (Æ8%) are referred for a specialist opinion [10]. Yet, knowledge on the course may facilitate treatment decisions and may help to inform patients about their prognosis. Several prospective cohort studies have investigated neck, shoulder or upper limb problems in primary care populations [9–12, 14–17]. The following factors were repeatedly identified as potential predictors of outcome: long duration of symptoms at baseline [10, 12, 15–17], more intense pain [15, 16], history of symptoms [9, 12, 15–17], musculoskeletal pain elsewhere [15, 17] and psychosocial factors [12, 16, 17]. The aim of our study was to investigate the course of shoulder symptoms during the first 6 months after visiting
1 2

the GP, in terms of pain, functional disability and quality of life. We made a distinction between patients with acute shoulder pain (duration of symptoms <6 weeks before consulting the GP), subacute shoulder pain (duration of symptoms between 6 and 12 weeks) and patients with chronic shoulder pain (duration of symptoms at least 3 months), as foregoing research showed that symptom duration is an important predictor of outcome, with acute shoulder pain having a better prognosis than chronic pain. The questions we addressed in our study were: (1) What is the course of shoulder symptoms during the first 6 months after visiting the GP, in terms of pain, functional disability and quality of life? (2) Is the prognosis different in patients with acute, subacute and chronic shoulder pain at consultation? (3) What are predictors of a better outcome after 6 months in patients presenting with either acute or chronic shoulder pain?

Methods Study population
This study is based on the results of a cohort study that was performed in 103 general practices in three geographical regions in The Netherlands (Amsterdam, Groningen and Maastricht) [18]. Patients were selected if they were !18 yrs, and had not consulted their GP or received any form of treatment for the afflicted shoulder in the preceding 3 months. Shoulder pain was characterized as pain in the deltoid and upper arm region, provoked or increased by movement in the shoulder joint. GPs were instructed to select consecutive patients. Sufficient knowledge of the Dutch language was required to complete written questionnaires. Exclusion criteria were acute trauma or systemic, physical or psychological conditions (i.e. fractures or luxation in the shoulder region; rheumatic disease; neoplasm; neurological or vascular disorders; dementia).

Department of General Practice, VU University Medical Center, Amsterdam, Dutch Institute for Healthcare Improvement CBO, Utrecht, The Netherlands and 3 Primary Care Musculoskeletal Research Centre, Keele University, Keele, UK. Submitted 21 August 2007; revised version accepted 18 January 2008. Correspondence to: D. A. van der Windt, EMGO Institute, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. E-mail: dawm.vanderwindt@vumc.nl

Design
The GP informed the patients about the study, after which written consent was obtained according to the Declaration of Helsinki.
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Table 2 lists the management of shoulder pain of the participants separately for those with acute. which provides an estimate of the mean reduction in pain for each point increase on the scale. at 3 months 517 (88%) and at 6 months 538 (92%) patients returned the postal questionnaire. baseline pain intensity) were entered as continuous variables. internal (1–6) and external locus of control (1–6). Psychological factors were measured with widely used standardized questionnaires. The drop-outs at 6 weeks and 6 months were significantly younger than the responders (mean difference 4 yrs and 6 yrs. working with hands above shoulder level and the use of vibrating tools on at least 2 days a week (0–5). most patients (n ¼ 451. Functional disability was measured using the 16-item Shoulder Disability Questionnaire (SDQ. overuse due to usual activities. dominant side affected. subacute and chronic shoulder pain. medication. subacute or chronic pain at baseline. Management of shoulder pain At baseline. consisting of a patient history. We present this information separately for patients with acute. Univariable linear regression analyses were performed to examine the relationship between each of the potential predictors and change in pain intensity after 6 months. Patients with acute shoulder pain more often had a paid job. an acute or gradual onset. lifting weights. 77%) received a wait-and-see policy. educational level and work status. Furthermore. Sociodemographic variables included age.10) and further elimination resulted in a large deterioration of the explained variance of the model. gender.g. A second questionnaire (first follow-up) was sent after 6 weeks. the intensity of shoulder pain. 14–17. If a continuous variable showed a non-linear association with outcome it was dichotomized or divided into tertiles (low. and more often reported a gradual onset of their shoulder pain compared with patients with subacute or acute shoulder pain. We measured physical workload with a self-constructed scale of five questions (yes/no) concerning pushing and pulling. we analysed potential predictors of outcome separately for patients with acute and chronic shoulder pain. musculoskeletal pain elsewhere. anxiety). and slightly higher scores on external locus of control compared with those with subacute or chronic shoulder pain. The course of symptoms in terms of pain. on at least 2 days a week. standardized physical examination and a questionnaire. were measured with the 50-item Four-Dimensional Symptoms Questionnaire (4DSQ) [25. Using a manual backward selection procedure. back and upper extremities. respectively). covering five domains: mobility. 22]. 12. 26]. disability and quality of life was also described separately for these three subgroups by plotting the mean scores at each point in time. pain/discomfort and anxiety/depression. 587 patients were interviewed and physically examined. Absolute change in pain intensity between baseline and 6 months follow-up was used as outcome measure. 0 ¼ no pain. while the proportion of physiotherapy referrals was higher in patients with chronic shoulder pain. Next.g. overuse due to unusual activities. Another reason for selecting a potential predictor could be differences between patients with acute and chronic pain at baseline.30) were included simultaneously in a multiple linear regression model. Subsequently. age) or interval scale (e. depressive symptoms. 0–1) [21. self-care. This was the case for external locus of control and somatization. Additionally. 10. Within 10 days after the consultation a baseline assessment was performed. coping with pain (1–6). The study was approved by the Medical Ethics Committee of the VU University Medical Centre in Amsterdam. . Predictors were selected based on evidence from the literature on their potential predictive value in patients with musculoskeletal pain (age. Information was recorded about the treatment provided to the patients at the first consultation. paracetamol or NSAIDs was higher in patients with acute shoulder pain compared with those with chronic shoulder pain. work load factors and pain catastrophizing) [9. At 6 weeks 487 (83%). subacute or chronic pain at baseline. functional disability and quality of life was measured. Anxiety (0–24). usual activities. Repetitive movements. had a higher somatization score. The psychosocial work environment was assessed using the 27-item Job Content Questionnaire which measures all dimensions of the Demand–Control–Support model [23]. During the baseline assessment information was collected on a variety of potential prognostic factors. paracetamol or an NSAID. The percentage of explained variance (R2) was calculated to give an indication of the predictive power of the final models. 58 patients (10%) were referred for physiotherapy and 11 (2%) received other therapies. high scores). Characteristics of the shoulder pain problem included intensity of pain. The proportion of patients receiving wait-and-see policy. Quality of life was measured by the EuroQol (EQ-5D. consisting of the subdomains catastrophizing (1–6). Results Study population and follow-up At baseline. Pain was recorded by the patient on a numeric rating scale (0–10 points. indicating potential predictive importance of the factor. Analysis Descriptive statistics were used to summarize characteristics of the study population. worries. and less repetitive movements in their work (26 vs 36%) in comparison with the responders. were measured with a single question answered with yes or no. predictors that were associated with the outcome (P < 0. Coping was assessed with the 43-item Pain Coping and Cognition List (PCCL) [24]. The questionnaire also included questions on co-existing musculoskeletal pain at the neck. The results show that patients with chronic shoulder pain reported higher pain intensity. accident or sports injury and were measured with questions answered by yes or no. These six factors were considered as potential predictors of outcome in further analyses (in addition to factors suggested by the literature). 0–100) [20]. drop-outs at 6 months more often showed an acute onset (49 vs 36%). previous episodes of shoulder pain and whether or not the dominant side was affected. which advise a stepwise approach (advice. Predictors measured on a continuous (e. Physical activity was measured with a single question (less/ equally/more active than others).g. we sequentially excluded predictors with the lowest predictive value from the model until all predictors were significantly associated with outcome (Wald statistic P < 0. depression (0–12). 725 Outcome measures and potential prognostic factors In each questionnaire. the third questionnaire (second follow-up) after 3 months and the fourth questionnaire (third follow-up) after 6 months. Table 1 lists the baseline characteristics of the participants separately for those with acute. 27]. somatization (0–32) and distress (0–32).Course and prognosis of shoulder symptoms The GP started treatment according to national Dutch guidelines for shoulder pain. Causes of shoulder pain as perceived by the patient were categorized as unexpected movement. steroid injection or physiotherapy) in which the next treatment option is only considered for patients returning with persistent pain and disability [19]. medium. The questionnaire finally included a general one-item question regarding the presence (yes/no) of any psychological problems (e. 10 ¼ very severe pain). history of pain. 68 patients (12%) received an injection with a corticosteroid. more disability.

pain catastrophizing. 0.0) 89 (64. were associated with change in pain intensity during follow-up in patients with acute shoulder pain at baseline. external locus of control.9 (22.9) (2. mean (S.0) 119 (58.1). paid work.9).D.0 0.50).1 (23. Patients with subacute pain at baseline (mean pain reduction 54%) or chronic pain at baseline (mean pain reduction 44%) showed a slower rate of recovery and maintained higher levels of pain at 6 months.5) (38.1 12.) Dominant side affected.4) (1.D.17) (2.24) (2.19 (1. Reilingh et al.6 12.).5) 53 (38.8) 56 (45.9 3. median Repeated movement with arms or wrists.35 (1.D.18 (1. baseline pain intensity. TABLE 1. 2.3 3.5).3). (1.4 3.16) 49.D.5).4 9.52).5 (14.8 13.2 0.9) Chronic (n ¼ 242) >3 months 169 (69. 0.00 75 (54.2 2. (4.0) 2.1). n (% female) Educational level.4 3.2 (2.0 96 (69. n (%) Previous episode. mean (S.0) 9 24 36 4 6 (6.0 188 (77.)a Decision authority Skill discretion Decision latitude Psychological demands Supervisor support Coworker support Disease characteristics Gradual onset.9) (0. (1. 3) show that there was little change in .5) 31 (22.0).6) (21) (4.5) 56.1) 87 (42.8 (28. n (%) >30 min/day walking or biking Regular long walk or cycling tour Pain elsewhere.4).7) Physiotherapy 6 (2.00 170 (70.9 11. TABLE 2.2) 12 39 59 19 17 (5.7) 161 (66.9) (2.4) (1.0 0.2 15.0 3.0) 12 (8.4) 37 61 40 77 (26. n (%) Pain intensity.4) 86 (45.1 2.2 12.9) 1. mean (S.80) (4.9) (0.4) (19.6) at baseline to 1.9) (0.9) (0.9) (5.5) 64 (26. For each outcome measure the differences between the three subgroups were statistically significant at each moment of follow-up.7) 152 (62.7) 105 (51.6 12.9 (13.3). Table 4 presents the variables included in the prediction models for persistent symptoms at 6 months after backward stepwise selection.1).5).8) 34 (14. These variables were selected for the multivariable regression analyses. patients with acute pain at baseline reported the largest decrease in shoulder disability after 6 months (mean reduction in functional disability 69%).8 (0.3) 44 (21. repeated movements with arms or wrists and co-existing pain in the neck or upper extremities. 0.0 1.0 0.3 11.1) (24.02) 9. 1. mediana Distress (0–32) Depression (0–12) Anxiety (0–24) Somatization (0–32) Physical load Physical burden (0–5).3 (S.6) 18 (12.8) (1.3) 120 (58.4 15.4 2.3) 1.9 (0.3 4.3 12.4 2.).6) (43. The course of functional disability presented in Fig. The results of the EQ-5D (Fig.4) 116 (47.9) (15. previous episode.2) 62. 174 (84.30) with outcome. subacute or chronic pain Acute (n ¼ 205) <6 weeks Management of shoulder pain.D.5) 2.4) The psychosocial work environment was only assessed in patients with paid work. Management of patients with shoulder pain at first consultation.77) (2.83) (2.3) 127 (52.0 (0.8) 2.1) (39. (1. n (%) Wait-and-see policy. Predictors of change in pain intensity The results of the univariable regression analyses demonstrating the association of each putative predictor with change in pain intensity after 6 months are presented in Table 3.1 2. (1. mean (S. Mean scores were consistently lower among patients with chronic shoulder pain.0) (0. baseline shoulder disability. (3.5) 5. 2.99) (2.37) Chronic (n ¼ 242) >3 months 52.0 2.2 12. n (%) Psychological factors PCCL. (1. gradual onset and baseline pain intensity with chronic shoulder pain showed an univariable association (P 0. 2 shows very similar patterns.9) (4. subacute or chronic pain at baseline Acute (n ¼ 205) <6 weeks Demographic and work variables Age (yrs).3) 4. (3.92) (4.4 0.D.726 M.68) (3.9) (1.4 24. mean (S.0 2.3) 12 32 43 10 6 (5. In those with chronic shoulder pain.2 78 (38.5) (17.4 (2.9) 62 (55.3) 93 (38.D.40).0 3.3 0.1 0. Figure 1 shows that patients with acute pain at baseline had the most favourable outcome over 6 months followup.) Functional disability (SDQ 0–100).9) (7. n (%) Unexpected movement Overuse unusual activities Overuse usual activities Accident Sports injury Physical activity.9) (4.0) 4. separately for patients with acute and chronic shoulder pain.5) 98 93 47 134 (40.0 0.4 15. 1.) Gender.1 24. Baseline shoulder disability.3 9.0) (1.4 2.8) (55.9) (28.2) 74 80 48 139 (36.2) at 6 months (mean pain reduction since baseline 70%).D.8) (1.1) 72 (51.0) 70 (34.0) (23. gradual onset.0) quality of life during follow-up.22) (1.D.44) (2.3 (S. n (%) Perceived cause according to patient.57) (2.9) Subacute (n ¼ 139) 6–12 weeks 107 (77.0) 34 (14.1) 63 (45.00 138 (67.0) (16.4) (67.9) (4.4 24. with pain decreasing from a mean score of 4. (1.7 (2.0 0. Baseline characteristics of patients with shoulder pain.84) (2.4) (55.4) (7. catastrophizing. separately for those with acute.2 3.2 0. somatization.3 3. n (%) Low Middle High Paid work Psychosocial work environment (n ¼ 350).)a Catastrophizing (1–6) Coping with pain (1–6) Internal locus of control (1–6) External locus of control (1–6) 4DSQ.07) (2.5 0. separately for those with acute.88) (2.0 0.0) (0. mean (S. Predictors of a better outcome at 6 months for acute shoulder pain were lower baseline disability scores and higher Course.9) 131 (58.1) 59.0 3. mean (S.9 (13.74) (2. n (%) Neck or upper extremities Low back a Subacute (n ¼ 139) 6–12 weeks 51. 0.9) paracetamol or NSAIDs Injection with corticosteroid 22 (10.3) (25.6). age.

The course of functional disability presented very similar patterns. The explained variance was 46% at 6 months. but our analyses now show that in patients with chronic shoulder pain. 31] are likely to predict a poor outcome of painful musculoskeletal conditions. for example. 14–17].6 0.4 FIG. The model shows. The model explained 21% of the variance in pain reduction at 6 months. catastrophizing [28]. This finding may be explained by the fact that more pain at baseline leaves more room for improvement during follow-up [12]. and changes in symptoms during follow-up. subacute and chronic pain at presentation. creating more homogeneous subgroups with different characteristics. 32]. but the association was no longer significant in the multivariable model. that with each point increase in baseline pain intensity (scale 0–10) the mean change in pain at 6 months increased by 0. There was little change in quality of life during follow-up.84 points (95% CI 0. Course of shoulder pain-related disability (SDQ) over 6 months after GP consultation. and demonstrating a different prognosis. For the current analysis. Our analyses confirmed the association between baseline levels of pain and disability. and used the total cohort that was heterogeneous with respect to baseline symptom duration. FIG. somatization was associated with poorer outcome in the univariable analyses. Prognostic factors partly differed between patients with acute/chronic shoulder pain. 24% of patients reported complete recovery after 3 .71.8 1 727 0. catastrophizing is the baseline pain intensity. somatization [17. and by investigating prognostic factors in more homogeneous subgroups of patients. but included very heterogeneous populations. however. We previously reported an association between catastrophizing thoughts and perceived recovery of shoulder pain at 3 months follow-up [33]. Course of shoulder pain intensity over 6 months after GP consultation. was significantly related to smaller reductions of pain at follow-up in patients with chronic shoulder pain. Course of shoulder symptoms In a previous study on neck and shoulder complaints in general practice. The association between psychosocial factors and musculoskeletal pain has mainly been established in patients with chronic pain syndromes [31.98). we decided to study the influence of potential prognostic factors in more detail. More catastrophizing. 12. Given the strong evidence for the prognostic value of symptom duration we decided to stratify our analyses for acute. in a recent study on non-traumatic arm. distress [28. In our population.Course and prognosis of shoulder symptoms 10 9 8 Pain intensity (0–10) 7 EQ-5D (0–1) 6 5 4 3 2 1 0 0 5 10 15 20 25 30 Follow-up time (weeks) Acute (0–6 weeks) Chronic (> 12 weeks) Subacute (6–12 weeks) 0 0 5 10 15 20 25 30 Follow-up time (weeks) Acute (0-6 weeks) Chronic (> 12 weeks) Subacute (6–12 weeks) 0. Course of quality of life (EQ-5D) over 6 months after GP consultation for shoulder pain. 10. 30. In our study. FIG. In a previous analysis of our cohort [18]. 28]. increasing to only 32% after 12 months [24]. Predictors of a better outcome at 6 months for chronic shoulder pain were lower scores on pain catastrophizing and higher baseline pain intensity scores. 100 90 80 Shoulder disability (0–100) 70 60 50 40 30 20 10 0 0 5 10 15 20 25 30 Follow-up time (weeks) Acute (0–6 weeks) Chronic (> 12 weeks) Subacute (6–12 weeks) months. 25% of participants reported complete recovery after 6 months. 3. 29] and fear-avoidance beliefs [28. 2. Similarly. higher pain intensity at baseline was associated with larger reductions of pain at follow-up in both patients with acute or chronic shoulder pain. Prognostic factors Previous prognostic cohort studies have showed that several disease characteristics (symptom duration. These studies demonstrate a poor outcome of neck and shoulder symptoms. 1. 0. by looking at their effect on absolute changes in shoulder pain intensity. It has previously been suggested that psychosocial factors such as worrying [12]. compared with 54% in those with subacute symptoms and 44% in patients with chronic pain at baseline. Discussion The results of our prospective cohort study showed a mean pain reduction of 70% among patients presenting with acute shoulder pain. we developed a prediction rule for shoulder pain with perceived recovery as outcome measure. levels of disability and more intense pain) are indicators of a poor outcome of neck or shoulder complaints [9.2 0. neck and shoulder complaints [17].

59 0. 0.24) (0.53.65. 0.02 (À0. while the proportion of physiotherapy referrals was higher among those with chronic shoulder pain.16 À0.16 0. Clinical usefulness In The Netherlands.21 À0.02 0. allowing stratification of patients according to duration of their symptoms. catastrophizing was associated with larger improvements of pain.57) 0. Inadequate beliefs and attributions of pain.49 0.94) (À0.95 À0.75.88) (0. 0. per point increase) External locus of control (PCCL. Table 3 also shows that in patients with acute pain. rather than a predictor of the development of chronic pain.72.20) À0. Exposure to physical load.05) 0.58) Significance 0. next to baseline levels of pain. 0.28 À0.04) À0. 1. probably a poorer outcome.43. Possibly.47) (0.21. The participating practices.001 Positive values indicate larger reductions in pain. Although drop-outs were younger.71. 0.35) (À1. TABLE 3.07 0. Treatment variables were. but for chronic pain patients this was only 21%.11 À0.34) (À0. 0.04 0.71 0.32) (À0. 0. 1. more often showed an acute onset and less repetitive movements in their work.99 0.26 (À0.728 M.63. especially in patients with chronic shoulder symptoms. 0. À0.01 0. but has been shown to be associated with neck or shoulder pain in other cohorts [36. being situated in both rural and urban areas in various provinces. 1.03.74) (À0.20) 0.05 (À0. 37].07.61 0. If the negative influence of catastrophizing can be confirmed in other shoulder pain populations. 0.70 0.00 (0.01.89.46) or chronic shoulder pain (R2 ¼ 0. such as social support or aspects of the psychosocial work environment [17.65 1.00.3) (À0.14) (À1. based on the assumption that the catastrophizing scale measures if patients are more strongly oriented towards pain stimuli.00 0. Alternatively. À0.03 0.04) 0. This means that our subgroups were relatively homogeneous regarding treatment at baseline.21 0.35 0. not strongly associated with outcome nor strongly influenced the association of other predictors (data not shown). 0. strongest predictor of change in pain intensity over 6 months follow-up.65 (0. the absolute differences in age. We decided not to include treatment in our models. Our results seem to confirm this assumption.30 0. from which patients with chronic shoulder pain in primary care may benefit. are more likely to receive more extensive treatment. indeed. 0.001 0.79 0.95. 1. 0. which recommend such a policy during the first 2–4 weeks after presentation [19].01 0. 1.001 0.26 0.00 0.01 0. one may hypothesize that patients with high scores on catastrophizing avoid pain-provoking activities. and patients have a pessimistic view of their prognosis.23. the British healthcare system.02) (À0.42 0. for instance.01. or when recurrences of pain occur. which may actually be an effective strategy in the acute phase of a shoulder problem. the large majority of patients in each subgroup was treated by wait-and-see or medication in the first month.87 0.03. we may have missed relevant predictors.21 0. This means that much of the variance in this patient group remains unexplained.98) (À1.06 0.02 (0.78. however. Patients with more severe symptoms and thus.58.45) (À1. Predictors of change in pain intensity after 6 months: univariable associations Acute shoulder pain (n ¼ 190) Mean change (95% CI)a Age (per year older) Baseline disability score (SDQ.04 0. form a representative sample of Dutch GPs. 1. The fact that catastrophizing was especially important in patients with chronic shoulder pain may indicate that catastrophizing is a consequence of pain. Predictors of change in pain intensity for patients with acute shoulder pain (R2 ¼ 0. this is a chance finding. Surprisingly. 1.89) 0.90) (À0.62 (À1.01 (À0.85. Reilingh et al.72. indicating that our GPs largely adhered to the Dutch practice guidelines for shoulder complaints.78 0. 0.63 Positive values indicate larger reductions in pain.44.12 0. 0. 0.25. the proportion of patients receiving wait-and-see policy or pain medication was higher in patients with acute pain compared with chronic pain. 0. ! 5 vs < 5) Paid work (yes vs no) Gradual onset (vs sudden) Previous episode (yes vs no) Baseline pain intensity (per point increase) Dominant side affected (yes vs no) Repeated movement with arms or wrists (yes vs no) Pain in neck or upper extremities (yes vs no) a Significance Chronic shoulder pain (n ¼ 224) Mean change (95% CI)a 0.33) (À0.15 0.21) after 6 months follow-up: results of multiple linear regression analyses Acute shoulder pain (n ¼ 190) Mean change (95% CI)a Baseline disability score (per point increase) Catastrophizing (per point increase) Baseline pain intensity (per point increase) a Significance Chronic shoulder pain (n ¼ 224) Mean change (95% CI)a À0. nearly every Dutch resident is registered with a GP. TABLE 4.02 (0. We may also have been unable to measure important predictors with sufficient accuracy.79 0. even though the association was weak and not statistically significant in the multivariable model.06) (À1. negative values indicate an increase in pain (per point increase on the predictor). 0.22 0. Catastrophizing [34] is considered to be an ineffective coping strategy in which pain is perceived as overly destructive. acute onset and repetitive movements were not large and it is unlikely that these differences have strongly influenced the reported associations between potential predictors and outcome. compared < 3) 3–4 >4 Somatization (4-DSQ.56 0.92.31 À0.68) (À1.84 (0.00) 0. 1. However.43.19 (À1. Further research is needed to identify relevant and preferably modifiable predictors of outcome. Strengths and weaknesses Our sample of shoulder pain patients is relatively large. 35.01 (À0.71 0.52 0.79) (À0. was measured using a few simple questions.98) 0. Studies carried out in occupational settings may be more suitable to address the importance of work-related factors in the prognosis of shoulder pain. future research might be aimed at the development and evaluation of interventions aimed at reducing such negative processes.81) Significance À0. may become stronger when pain persists. as we assumed that confounding by indication could influence our findings.00. À0. 0. negative values indicate an increase in pain (per point increase on the predictor).02. Even though we included a wide variety of potential predictors. The prognostic model for patients presenting with acute shoulder pain explained 46% of the variance in pain scores at follow-up.50 0. Patients first visit their GP before visiting a specialist in rheumatology or orthopaedics.59 0.51. Drop out among patients was low (8% at 6 months).87 À0. per point increase) Catastrophizing (PCCL. Although we encouraged GPs to select every eligible patient. we do not know what proportion of patients was invited or whether this was . This is comparable with. 0. for example.48. 36].60.03) 1.

Heuts PHTG. 2005.54:959–64. Rheumatology 2007. Ann Rheum Dis 2005. Work Stress 2004. 1998 [in Dutch]. 22 Dolan P. Jongh AC.46:519–23. 6 Walker-Bone KE. van der Windt DA et al. anxiety and somatization. Vlaeyen JWS.a new facility for the measurement of health-related quality of life. The importance of psychosocial factors in patients with chronic shoulder pain needs to be confirmed in further research.16:199–208. Scand J Rheumatol 2004.46:169–76. 16 Kjellman G. they indicated that common reasons for not including patients concerned the exclusion criteria and lack of time or motivation to ask all patients during consultation hours. Lysens S. A more targeted approach (with for example. Arendzen JH. and possibly.64:1391–6. and offered injections or physiotherapy to only a few patients.64:118–23. Prognostic factors for neck pain in general practice. Pijn coping en cognitie lijst]. Burdorf A.30:459–70. Ader HJ et al. Occup Environ Med 2000. depression. Systematic review of prognostic cohort studies on shoulder disorders. Our findings indicate that GPs can take duration of symptoms at presentation into account. 7 Van der Windt DAWM. Modeling valuations for EuroQol health states. Spine 2002. Psychol Assess 1995.7:524–32. 28 Pincus T. 11 Winters JC. Pain 1999. Acknowledgements We would like to acknowledge the contribution of all patients and general practitioners who participated in this project. 25 Terluin B. 13 Silverstein B. van der Windt DAWM. Bouter LM. 1985. The EuroQol Group. De Haan M. Occupational risk factors for shoulder pain: a systematic review. Van der Heijden GJ. Improvement of symptoms in patients presenting with acute shoulder pain was mainly predicted by the severity of pain and disability. Predictors of outcome in neck and shoulder symptoms: a cohort study in general practice. Boeke AJ et al. Field AP. Pivik J. Evidence on the role of pain-related fear in chronic back pain disability. Patient characteristics at baseline and overall recovery rates (30% after 6 weeks and 54% after 6 months) were similar to those found in other studies carried out in primary care populations [9–11]. Silman AJ. Ter Kuil MM. van Marwijk HW. Miedem HS. Fear of pain is more disabling than pain itself. 18 Kuijpers T. Rheumatology 1999. Meyboom-de Jong B. 27 Kuijpers T. De Jong BA. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. we were able to present prognostic information for more homogeneous subgroups of patients compared with previous cohorts. Disclosure statement: The authors have declared no conflicts of interest. Incidence and prevalence of complaints at the neck and upper extremity in general practice.  Our study shows that both course and prognosis differs between patients presenting with either acute or chronic shoulder pain. Van Rhenen W. 29 Macfarlane GJ. 10 Van der Windt DAWM. Oskam SK. Koes BW. 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