Shoulder disorders in general practice: Incidence, patient characteristics, and management

Objectives-To study the incidence and management of intrinsic shoulder disorders in Dutch general practice, and to evaluate which patient characteristics are associated with specific diagnostic categories. Methods-In 11 general practices (35 150 registered patients) all consultations concerning shoulder complaints were registered during a period of one year. Patients with an intrinsic shoulder disorder who had not consulted their general practitioner for the complaint during the preceding year (incident cases) were asked to participate in an observational study. Participants completed a questionnaire regarding the nature and severity of their complaints. The general practitioners recorded data on diagnosis and therapy. Results-The cumulative incidence of shoulder complaints in general practice was estimated to be ll2/1000 patients/year (95% confidence limits 10.1 to 12.3). Rotator cuff tendinitis was the most frequently recorded disorder (29%). There were 349 incident cases enrolled in the observational study. Patient characteristics showed small variations between different diagnostic categories. Age, duration ofsymptoms, precipitating cause and restriction ofmovement seemed to be discriminating factors. Twenty two percent of all participants received injections during the first consultation; most (85%) were diagnosed as having bursitis. The majority of patients with tendinitis (53%) were referred for physiotherapy. Conclusion-With respect to diagnosis and treatment, the practitioners generally appeared to follow the guidelines issued by the Dutch College of General Practitioners. Although the patient characteristics of specific disorders showed some similarities with the clinical pictures described in the literature, further research is required to demonstrate whether the proposed syndromes indeed constitute separate disorders with a different underlying pathology, requiring different treatment strategies

Cost Effectiveness of Interventions for Lateral Epicondylitis: Results from a Randomised Controlled Trial in Primary Care

Objective: Lateral epicondylitis is a common complaint, with an annual incidence between 1% and 3% in the general population. The Dutch College of General Practitioners in The Netherlands has issued guidelines that recommend a wait-and-see policy. However, these guidelines are not evidence based. Design and setting: This paper presents the results of an economic evaluation in conjunction with a randomised controlled trial to evaluate the effects of three interventions in primary care for patients with lateral epicondylitis. Patients and interventions: Patients with pain at the lateral side of the elbow were randomised to one of three interventions: a wait-and-see policy, corticosteroid injections or physiotherapy. Main outcome measures and results: Clinical outcomes included general improvement, pain during the day, elbow disability and QOL. The economic evaluation was conducted from a societal perspective. Direct and indirect costs (in 1999 values) were measured by means of cost diaries over a period of 12 months. Differences in mean costs between groups were evaluated by applying non-parametric bootstrap techniques. The mean total costs per patient for corticosteroid injections were Conclusions: The results of this economic evaluation provided no reason to update or amend the Dutch guidelines for GPs, which recommend a wait-and-see policy for patients with lateral epicondylitis.Corticosteroids, Cost-effectiveness, Cost-utility, Lidocaine, Physiotherapy, Tennis-elbow, Triamcinolone

Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain: A randomized, controlled trial

Background: Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared. Objective: To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner. Design: Randomized, controlled trial. Setting: Outpatient care setting in the Netherlands. Patients: 183 patients, 18 to 70 years of age, who had nonspecific neck pain for at least 2 weeks. Intervention: 6 weeks of manual therapy (specific mobilization techniques) once per week, physical therapy (exercise therapy) twice per week, or continued care by a general practitioner (analgesics, counseling, and education). Measurements: Treatment was considered successful if the patient reported being "completely recovered" or "much improved" on an ordinal six-point scale. Physical dysfunction, pain intensity, and disability were also measured. Results: At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued care. Statistically significant differences in pain intensity with manual therapy compared with continued care or physical therapy ranged from 0.9 to 1.5 on a scale of 0 to 10. Disability scores also favored manual therapy, but the differences among groups were small. Manual therapy scored consistently better than the other two interventions on most outcome measures. Physical therapy scored better than continued care on some outcome measures, but the differences were not statistically significant. Conclusion: In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner