Beilby, J.

Broadhurst, N.

Gialamas, A.

McElroy, H.

Adelaide Research &amp; Scholarship

Reprinted from Australian Family Physician Vol. 33, No. 10, October 2004 861Shoulder pain is the third most commonmusculoskeletal presentation in general prac-tice, following back and neck pain.1,2 Although50–60% of acute shoulder pain resolves in8–10 weeks, many patients anticipateimaging. Pain persisting beyond 3 months isstrongly related to personality traits, copingstyle and occupational factors.3,4 There hasbeen an increase in the use of shoulder diag-nostic imaging by Australian generalpractitioners.5 However, current practice inimaging and management of shoulder pain isnot supported by the evidence.6In response to this, we undertook a retro-spective medical record audit of shoulderpain presentations in general practice tostudy diagnostic and treatment management.MethodEthics approval was obtained from theUniversity of Adelaide Human ResearchEthics Committee. We audited computerisedcase notes from Medic-GP© – a general prac-tice medical record system used by 15 GPsfrom nine South Australian practices for 8years. We searched the records using thekey word ‘shoulder’; the text of the medicalrecords to identify patients from 1 July 2000to 30 November 2002. Further searches of these records identi-fied patients undergoing imaging. Shouldertrauma, patients under 18 years of age andpregnant women were excluded. Traineddata entry staff coded relevant details foreach episode of care using a controlledvocabulary list.We used descriptive statistics to describepatients investigated with and withoutimaging, univariate analyses to test the asso-ciation between investigation, and a varietyof factors and logistic regression to estimateodds ratios. ResultsDuring the audit period, the database had 17233 patients, of whom 1867 presented witha shoulder problem either primarily or com-bined with another problem; a totalprevalence of 10.8%. Imaging was orderedfor 324 patients and not for 1543. This is asimilar proportion to that found in theBEACH study;7 a ratio of 1:4.8. We used a random number generator toobtain a sample of 183 patients, 84 withimaging and 99 without. These patients weretreated by 15 GPs; 457 visits for the imagedgroup (5.4 visits per episode of care) and 167for the nonimaged group (1.7 visits perepisode of care). An ‘episode of care’ wasdefined as all care related to shoulder pain.8Univariate logistic regression of thesociodemographic factors (Table 1) identifiedthree significant predictors for imaging(p0.02): age over 45 years, pain with activity, and duration of pain lasting more than 5 weeks.A physical examination of shoulder move-ment in two or more planes was recorded atthe first visit for 138 (75%) patients, equallydivided between the groups. There was norecord of what restricted range of movementprecipitated imaging. Twenty-nine (16%)patients had no record of a physical examina-tion. Nor did the 10 out of 84 patients (12%)who were referred to a specialist. Imaging was recorded at the first visit for58 (69%) patients. This was most commonlyultrasound alone (57/95, 60%), with an addi-tional 30 (32%) ultrasounds conducted inconjunction with a plain film (occasionally ata second visit). Normal results were reportedin 25% of cases, a similar result when com-pared with the BEACH study.7There were differences in GP managementfor patients with and without imaging. TotalGP visits were higher in the former (5.4 com-pared with 1.7), as was the use of NSAIDS(55% vs. 30%) and specialist referrals (45%vs. 6%); (p<0.001). Use of analgesics (29%vs. 23%) and physiotherapy (32% vs. 23%)were not significantly different.Where a diagnosis was recorded, eightout of 25 (32%) were in agreement with theimaging report. Nonspecific diagnosis pre-vailed (70%), eg. ‘shoulder syndrome’,‘strain’ or ‘pain’. No imaging reports men-tioned imaging the contralateral side, or whether pain was reproduced during imaging.How do Australian GPs manageshoulder dysfunction?Norman A Broadhurst, PhD, MBBS, MSc, FRACGP, FAFRM, is Associate Professor of Musculoskeletal Medicine,Flinders Medical Centre, South Australia.Angela Gialamas, BHSc, is Project Officer, Department of General Practice, University of Adelaide, South Australia.Heather J McElroy, BSc, GradDipApplStat, is Statistician, Department of General Practice, University of Adelaide,South Australia.Justin J Beilby, MD, MBBS, FRACGP, is Professor of General Practice, University of Adelaide, South Australia.Short report • RESEARCHDiscussionOur results parallel those of BEACH data,7 areport from the National MusculoskeletalMedicine Init iative (NMMI),9 and otherresults.10This retrospective audit can only speculatethat there are deficiencies in management ofnontraumatic shoulder pain because wecould not discover the clinical reasons forordering imaging, duration of shoulder painepisodes, or the effects imaging had on man-agement of shoulder pain (and our GPs maynot have been representative).We found the imaging rate for shoulderdysfunction lower than the GPs in theNMMI study, but higher than for evidencebased clinics (6%).9 However, the high per-centage of image ordering at the first visit isof concern. If this practice is widespread,then few GPs are following guidelines sug-gested by The Royal Australian and NewZealand College of Radiologists which rec-ommend al l  shoulder ultrasounds bepreceded by plain film.11 On the other hand,this may be better care as a recent studyshowed that plain film is usually uninforma-tive in this situation.12The association of imaging with increasednumber of visits, use of NSAIDS, referral tospecialists (and according to the BEACHstudy, longer consultations) may simply befrom confounding evidence. If not, there ispotential for cost savings and better care.Since 2002, the Medical Benefits Scheduleconsiders ultrasound scanning of the shoul-ders to be standard, and requires a diagnosisbefore a rebate is paid.862Reprinted from Australian Family Physician Vol. 33, No. 10, October 2004Research: How do Australian GPs manage shoulder dysfunction?Table 1. Sociodemographic profile of patients with shoulder painFactor Imaged Not imagedn (%) n (%)Total number 84 100 99 100GenderMale 38 (45) 42 (42)Female 46 (55) 57 (58)Age group<45 17 (20) 41 (41)45> 67 (80) 58 (59)OccupationNot recorded 54 (64) 45 (45)Manual work 14 (17) 16 (16)Nonmanual work 4 (5) 8 (8)Other 12 (14) 30 (30)When pain first noticedNot recorded 36 (43) 42 (42)<=1 week 13 (15) 35 (35)2–4 weeks 11 (13) 11 (11)5–13 weeks 12 (14) 4 (4)14–25 weeks 7 (8) 3 (3)>=26 weeks 5 (6) 4 (4)Total number of GP visits for shoulder management1 6 (7) 58 (59)2 22 (26) 25 (25)3–5 35 (42) 14 (14)>=6 21 (25) 2 (2)Number of GP visits before imaging order1 58 (69) 58 (59)>1 26 (31) 41 (41)Earliest visit documenting a physical examination Never 10 (12) 19 (19)First 65 (77) 73 (74)Second-fourth 8 (10) 7 (7)Fifth 1 (1) 0 (0)Pain with activity documented at first visitYes 37 (44) 21 (21)No 47 (56) 78 (79)History of shoulder painYes 35 (42) 30 (30)No 49 (58) 69 (70)Patient perspective of causeTrauma related 21 (25) 29 (29)Other 22 (26) 25 (25)Not stated 41 (49) 45 (45)Any comorbidityYes 58 (69) 60 (61)No 26 (31) 39 (39)Pathology from imagingSubacromial space* 46 (70)Acromioclavicular joint problem 5 (8)Tendonitis 5 (8)Other 5 (8)Nonrecorded 4 (6)Capsulitis 1 (2)* Within the subacromial space there were eight tears (17%) with only one reported as full thickness• Most patients presenting with nontrau-matic shoulder pain over the age of 50years had degenerative changes.• The reason for their pain may not beidentified.Implications of this study for general practicecontinued page 864Reprinted from Australian Family Physician Vol. 33, No. 9, September 2004 863Acknowledgment Thanks to Katherine Duszynski and Chris Barton forhelpful suggestions, and to the Department ofHealth and Ageing for funding the study.Conflict of interest: none declared.References 1. Cailliet R. Shoulder pain. 2nd edn. Philadelphia:FA Davis, 1981.2. Van der Heijden GJ, van der Windt DA, KleijnenJ, Koes BW, Bouter LM. Steroid injections forshoulder disorders: a systematic review of ran-domised controlled trials. Br J Gen Pract1996;46:309–316.3. Van der Windt DA, Koes BW, Boeke AJ, DevilleW, DeJong BA, Bouter LM. Shoulder disorders ingeneral practice: prognostic indicators ofoutcome. Br J Gen Pract 1996;46:519–523.4. Van der Heijden GJ. Shoulder disorders: a stateof the art review. Baillieres Clin Rheumatology1999;13:287–309.5. Broadhurst NA, McLaren SJ. Shoulder pain: whatultrasound imaging reveals. Aust Mus Med2003;8:29–31.6. Australian Acute Musculoskeletal PainGuidelines Group. Ch 7. Acute shoulder pain.In: Evidence based management of acute mus-culoskeletal pain. Brisbane: Australian AcademicPress, 2003;119–154. Available at:http://www.nhmrc.gov.au/publications/pdf/cp94.pdf7. Britt H, Miller GC, Knox S. Shoulder syndrome.In: Imaging orders by general practitioners inAustralia 1999–2000. AIHW Cat. No. GEP 7.General Practice Series No. 7. Canberra:Australian Institute of Health and Welfare2001;101–104.8. Lamberts H, Hofmans-Okkes I. Episode of care:a core concept in family practice. J Fam Pract1996;42:161–167.9. Australasian Faculty of MusculoskeletalMedicine. Report on the NationalMusculoskeletal Medicine Initiative. Section IIIE. Newcastle: August, 2001. 10. Green S, Buchbinder R, Hetrick S.Physiotherapy interventions for shoulder pain(Cochrane Review). In: The Cochrane Library,Issue 1. Chichester, UK: John Wiley & Sons Ltd,2004.11. Lau L. Imaging Guidelines. 4th edn. Melbourne:The Royal Australian and New Zealand Collegeof Radiologists 2001;191–193.12. Fraenkel L, Shearer P, Mitchell P, La Valley M,Feldman J, Felson DT. Improving the selectiveuse of plain radiographs in the initial evaluationof shoulder pain. J Rheum 2000;27:200–204.Research: How do Australian GPs manage shoulder dysfunction?CorrespondenceEmail: norm.broadhurst@flinders.edu.auAFP

How do Australian GPs manage shoulder dysfunction?

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How do Australian GPs manage shoulder dysfunction?

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