Arendzen, JH

Groenier, KH

Meyboom-de Jong, B

Sobel, JS

Winters, JC

University of Groningen

   University of GroningenThe long-term course of shoulder complaintsWinters, JC; Sobel, JS; Groenier, KH; Arendzen, JH; Meyboom-de Jong, BPublished in:RheumatologyIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:1999Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Winters, JC., Sobel, JS., Groenier, KH., Arendzen, JH., & Meyboom-de Jong, B. (1999). The long-termcourse of shoulder complaints: a prospective study in general practice. Rheumatology, 38(2), 160-163.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 12-11-2019Rheumatology 1999;38:160–163The long-term course of shoulder complaints: aprospective study in general practiceJ. C. Winters, J. S. Sobel, K. H. Groenier, J. H. Arendzen1and B. Meyboom-de JongDepartment of General Practice, University of Groningen, Ant. Deusinglaan 4,9713 AW Groningen and 1Department of Rehabilitation Medicine, UniversityHospital Groningen, 9700 RB, Groningen, The NetherlandsAbstractObjective. Assessment of the long-term course of shoulder complaints in patients in generalpractice with special focus on changes in diagnostic category and fluctuations in the severityof the complaints.Design. Prospective descriptive study.Setting. Four general practices in The Netherlands.Method. All patients (101) with shoulder complaints seen in a 5 month period wereincluded. Assessment took place 26 weeks and 12–18 months after inclusion in the study witha pain questionnaire and a physical examination.Results. A total of 51% of the patients experienced (mostly recurrent) complaints after 26weeks and 41% after 12–18 months. Diagnostic changes were found over the course of time,mostly from synovial disorders towards functional disorders of the structures of the shouldergirdle, but also the other way round. Although 52 of the 101 patients experienced complaintsin week 26, 62% of those patients considered themselves ‘cured’. After 12–18 months, 51% ofthe 39 patients experiencing complaints felt ‘cured’.Conclusion. Many patients seen with shoulder complaints in general practice have recurrentcomplaints. The nature of these complaints varies considerably over the course of time,leading to changes in diagnostic category. Because of the fluctuating severity of the complaintsover time, feeling ‘cured’ or not ‘cured’ is also subject to change over time.Key words: Shoulder complaints, Long-term course, Diagnosis.Two recent studies have been published describing the Because of this apparent lack of consistency in thefindings at subsequent physical examination, and thelong-term course of shoulder complaints in generalpractice [1, 2]. In both studies, it appeared that 50–60% ambiguity attached to feeling ‘cured’, we have doubtsabout the consistency of diagnoses over the course ofof the patients still experienced complaints after 12–18months. In these studies, the long-term evaluation was time. We therefore carried out a long-term follow-upstudy of patients with shoulder complaints in generalcarried out with questionnaires on shoulder and neckcomplaints as well as disability. No physical examination practice that focused on changes in diagnostic categoryand on the concept of feeling ‘cured’.was performed after inclusion in the study. This raisesquestions about the consistency of the initial diagnosticcategories over time. Patients and methodsA follow-up study of patients in general practice, inPatientswhich patients were examined at regular intervals,revealed that the character of the symptoms changed All patients with shoulder complaints seeking consult-considerably in the first few weeks [3]. Furthermore, in ation in four general practices in Groningen, Thea follow-up study of a comprehensive shoulder pain Netherlands, between 1 January and 1 June 1993 werescore, it became evident that the patients did not have included in the study unless one of the exclusion criteriato be completely free of pain to consider themselves applied. These exclusion criteria were: (1) treatment for‘cured’, i.e. some patients with (minor) complaints feel shoulder complaints in the 6 months prior to consult-that they do not require medical care anymore [4]. ation; (2) bilateral shoulder complaints; (3) the presenceof specific rheumatic disorders (polymyalgia rheumatica,rheumatoid arthritis, systemic lupus erythematosus,Submitted 26 March 1998; revised version accepted 14 October 1998.fibromyalgia); (4) shoulder complaints due to acuteCorrespondence to: J. C. Winters, Nieuwe Schoolweg 2a, 9756 BBGlimmen, The Netherlands. severe trauma (e.g. fracture, dislocation, cuV rupture)—© 1999 British Society for Rheumatology160Long-term course of shoulder complaints 161patients with a history of minor trauma were not disorders; (2) functional disorders of the shoulder girdle;(3) combinations of synovial and shoulder girdle dis-excluded; (5) presence of cervical disc herniation; (6)presence of dementia or other psychiatric disorder. orders. This diagnostic classification was chosen because>50% of the patients did not meet the criteria for theShoulder complaints syndrome classification of the National Guidelines forShoulder Complaints of the Dutch College of GeneralShoulder complaints were defined as pain localized inthe region of the deltoid muscle, the acromioclavicular Practitioners, which is based on the Cyriax classifica-tion [5–7].joint, the superior part of the trapezius muscle, and thescapula. The pain could be present with or without Synovial disorder. Pain and/or limitation of motion inone or several directions of the range of motion of theradiation into the arm. Also, limitation of motion ofthe upper arm and/or the shoulder girdle could be scapulohumeral joint. These complaints originate fromdisorders of the subacromial structures, the acromio-present.The severity of shoulder complaints was assessed with clavicular joint, the glenohumeral joint or combin-ations thereof.the use of the Shoulder Pain Score. This is a six-itemquestionnaire together with a 101-point numerical pain Shoulder girdle disorder. The pain and/or the some-times present (slight) limitations of active motion of thescale. The six questions, viz. pain at rest, pain duringmotion, pain during the night, sleeping problems due to scapulohumeral joint are not related to the synovialstructures. Instead, pain or limitation in one or severalpain, inability to lie on the aVected side, and presenceof radiating pain, were scored on a four-point scale of directions of the range of motion of the cervical spineand/or the upper thoracic spine and/or the upper ribs isseverity. The score on the 101-point numerical pain scalewas also converted to a four-point scale in order to found (the shoulder girdle). The complaints originatefrom functional disorders of these structures.calculate the sum score of the Shoulder Pain Score[between 7 points (no pain) and 28 points (severe pain)]. Combination group. Pain and sometimes slight limita-tion in the range of motion at the scapulohumeral joint,The Shoulder Pain Score was validated in an earlierstudy and proved to be a useful instrument for following together with pain or limitation of the range of motionof the cervical spine and/or the upper thoracic spinethe course of the disorder over time [4].One of the questions on the Shoulder Pain Score form and/or the upper ribs. Both the synovial structures andthe structures of the cervical spine, the upper thoracicwas whether the patient felt ‘cured’. Feeling ‘cured’ wasdefined as the disappearance of shoulder complaints or spine or the upper ribs may cause the complaints.a decrease of shoulder complaints to such an extent thatTreatmentthe complaints were no longer inconvenient, did notrequire therapy, or no longer interfered with normal During the first 2 weeks after inclusion, all patientswere given the same treatment, i.e. a non-steroidalwork duties.anti-inflammatory drug (NSAID; diclofenac sodiumFollow-up examination 3× 50 mg), after which the general practitionersinvolved were allowed to prescribe therapies tailored toFollow-up examination by means of the Shoulder PainScore and a physical examination took place 26 weeks the complaints of the patient, i.e. physiotherapy, injec-tion therapy, manipulative therapy, or monitoring theafter inclusion in the study (T1). Twelve to 18 monthsafter inclusion in the study (T2), a questionnaire enquir- course of the complaints so that NSAID or paracetamolcould be administered if needed.ing about past and present complaints, together withthe Shoulder Pain Score, was sent to all patients. Thosepatients who indicated ‘not cured’ were called in for a Resultsrepeat physical examination.A total of 101 patients were included in the study. ThePhysical examination patients’ characteristics are summarized in Table 1.The physical examination consisted of inspection, andexamination of active and passive range of motion in Table 1. Characteristics of the survey population (n= 101)the glenohumeral joint, cervical spine and upper thoracicAge (yr) 47.3 (s.d.= 15.4)spine. Resisted movement testing, and palpation of theWomen/men 59/42muscle tendons on the head of the humerus, the acromio- Right-handed 91clavicular joint and the upper ribs were also undertaken. Previous complaints 41The physical examinations were performed by the four History of minor trauma 18Working situationparticipating general practitioners. In order to limitFull time 24inter-doctor variation, the general practitioners had pre-Part time 30viously had several practice sessions on physical exam- No paid employment 47ination techniques. Period of complaints before first consultation∏1 week 26Diagnosis 2–4 weeks 255–25 weeks 25After physical examination, the patients were classified 26 weeks 25into one of three diagnostic groups: (1) synovialJ. C. Winters et al.162Upon re-examination of the 101 patients at week 26 Five patients were referred to a specialist. One patienthad surgical subacromial decompression.(T1), 49 patients felt ‘cured’ and no longer hadcomplaints; 32 patients reported that they had minor The 19 patients of the ‘not cured’ group were calledin for a physical examination, and 18 were examined.complaints, but felt ‘cured’. The remaining 20 patientsdid not feel ‘cured’; of these, only three were not able All patients in this last group were able to work.Table 3 shows, for each diagnostic category at T1, theto work because of the complaints. The Shoulder PainScore in week 26 was 7 in the ‘cured’ group, 10 (s.d.= diagnosis at T2. There are minor changes in diagnosticcategory. Thirteen patients had a recurrence of com-1.5) in the group ‘cured with complaints’ and 13.7(s.d.= 3.2) in the ‘not cured’ group. The diVerences plaints at T2, of whom seven did not feel ‘cured’. AtT2, most patients suVered from functional disorders ofwere significant for all three groups (P< 0.05).Table 2 shows the diagnoses at week 26 (T1) of the the shoulder girdle.patients of each diagnostic category at inclusion. Fortyper cent of the patients with complaints at T1, and upon Discussioninclusion diagnosed as synovial disorder, were diagnosedas functional disorder of the shoulder girdle at T1. Of The results of this study show that 51% of the patientswith shoulder complaints in general practice havethe patients diagnosed upon inclusion as combinationdiagnosis, 66% showed this shift toward the shoulder (recurrent) complaints after 26 weeks and 41% of thepatients after 12–18 months. These results are in agree-girdle group at T1. Five patients showed no disordersin function at all. Two of the six patients ‘not cured’ ment with the findings of Croft et al. [1] and Van derWindt et al. [2]. However, our results indicate twowith a synovial disorder were found to have developeda frozen shoulder. findings that are of importance in the long-term follow-up of patients with shoulder complaints.Ninety-four patients returned their final assessmentquestionnaires at 12–18 months after inclusion in the First, it appeared that the diagnostic category issubject to change over the course of time. Most changesstudy (T2). Fifty-five patients reported no complaints.Of this group, 14 reported having had complaints after were seen at the examination at T1 as a shift towardsthe group with a shoulder girdle disorder. At the exam-week 26, but were without complaints at present. Twentypatients still had complaints, but considered themselves ination at T2, most patients ‘not cured’ were diagnosedas having functional disorders of the shoulder girdle.‘cured’. Nineteen patients felt ‘not cured’. The ShoulderPain Score was 8.2 (s.d.= 2.9) for the group ‘cured’, This change in diagnostic category over the course oftime has to be considered in follow-up studies on11.6 (s.d.= 3.0) for the group ‘cured with complaints’and 15.9 (s.d.= 3.9) for the group ‘not cured’. The shoulder complaints. Only with a physical examinationcan this be properly described. The changes in diagnosticdiVerences were significant for all three groups(P< 0.05). category also influence the therapeutic approach. In aTable 2. Distribution of the diagnoses at T1 (26 weeks after inclusion in the study) of the patients in the three diagnostic categories at inclusionShoulder girdle Synovial CombinationInclusion 22 58 21T1 cured 12 28 9T1 cured with complaints 6 16 10DiagnosisShoulder girdle 3 8 7Synovial 0 2 1Combination 1 4 1No disorders 2 2 1T1 not cured 4 14 2DiagnosisShoulder girdle 3 4 1Synovial 1 5 0Combination 0 5 1Table 3. Distribution of the diagnoses at T2 (12–18 months after inclusion in the study) of the patients in the four diagnostic categories of T1(26 weeks after inclusion)DiagnosisT2 T2 cured with T2T1 cured complaints not cured Girdle Synovial CombinationShoulder girdle 25 7 11 7 7 0 0Synovial 9 6 0 3 1 0 2Combination 10 5 3 2 1 0 1Cured 50 37 6 6 3 3 0Long-term course of shoulder complaints 163recent study, it appeared that synovial disorders are best participation in this study, and Michel Dings for hisassistance in collecting the data. This study was con-treated with a steroid injection and shoulder girdledisorders with manipulative therapy [8]. Thus, the ducted with a grant from the Ministry of Welfare,Health and Culture.therapy has to be adapted if the diagnostic categorychanges.Secondly, more than half of the patients with com- Referencesplaints felt ‘cured’. This is consistent with Van de1. Croft P, Pope D, Silman A. The clinical course of shoulderLisdonk’s [9] finding in an open population study. Manypain: prospective cohort study in primary care. Br Medpatients have minor complaints for which they do notJ 1996;313:601–2.consult their general practitioner. Despite their com- 2. van der Windt DAWM, Koes B, Boeke AP, Deville´ W,plaints, they feel ‘cured’. The Shoulder Pain Score de Jong BA, Bouter LM. Shoulder disorders in generalproved to be indicative of whether a patient felt ‘cured’ practice: prognostic indicators of outcome. Br J Gen Practor not. With a pain score of about 10 or 11, patients 1996;46:519–23.felt ‘cured’ and did not seek medical help; with a pain 3. Winters JC, Sobel JS, Groenier KH, Arendzen JH.Meyboom-de Jong B. The course of pain and the restric-score of 13 or more, patients did not feel ‘cured’ andtion of mobility in patients with shoulder complaints inmight seek medical help. This is in accordance with angeneral practice. Rheumatol Int 1997;16:219–25.earlier study on the Shoulder Pain Score which showed4. Winters JC, Sobel JS, Groenier KH, Arendzen JH,that the margin between having complaints and feelingMeyboom-de Jong B. A shoulder pain score: A compre-‘cured’ is a very narrow one [4].hensive questionnaire for assessing pain in patients withThe diYculty we encountered in this study was that shoulder complaints. Scand J Rehabil Med 1996;28:163–7.50% of the patients did not meet the criteria for the 5. Sobel JS, Winters JC, Arendzen JH, Groenier KH,syndrome classification of the National Guidelines Meyboom-de Jong B. Schouderklachten in de huisarts-for Shoulder Complaints. We therefore used another praktijk. (Shoulder complaints in general practice.)diagnostic classification. Interestingly, arguments Huisarts Wetenschap 1995;33:342–7.6. Bakker JF, de Jongh AC, Jonquie`re M, Mens J,against too detailed a diagnostic classification haveOosterhuis WW, Poppelaars A et al. NHG Standaardrecently been published. In a cluster analysis of variablesSchouderklachten (National Guidelines for Shoulderof the medical history and the physical examination ofComplaints of the Dutch College of General Practitioners).patients with shoulder complaints, only three groups ofHuisarts Wetenschap 1990;33:196–202.patients could be distinguished [10]. No specific patterns 7. Cyriax J. Textbook of orthopaedic medicine, 11th edn,in the limitation of mobility were found. Moreover, Vol. 1. Diagnosis of soft tissue lesions. London: Baillie`reBamji et al. [11] and Liesdek et al. [12] describe only a Tindall, 1984:127–42, 143–58.moderate rate of correspondence in the diagnosis of 8. Winters JC, Sobel JS, Groenier KH, Arendzen JH,shoulder complaints. Our diagnostic classification may Meyboom-de Jong B. Comparison of physiotherapy,manipulation, and corticosteroid injection for treatingseem superficial, but it is a practical one. Even with thisshoulder complaints in general practice: randomised, singlesuperficial classification, changes in diagnostic categoryblind study. Br Med J 1997;314:1320–5.were found.9. Van de Lisdonk EH. Ziekten in de huisartspraktijk.As to the objective of this study, it may be concluded(Diseases in general practice) Utrecht: Bunge, 1990.that many patients seen with shoulder complaints in10. Winters JC, Groenier KH, Sobel JS, Arendzen JH,general practice experience recurrence. However, the Meyboom-de Jong B. Classification of shoulder com-nature of their complaints may change considerably plaints in general practice by means of cluster analysis.over the course of time. As a result, changes in diagnostic Arch Phys Med Rehabil 1997;78:1369–74.category and changes in the patients feeling ‘cured’ or 11. Bamji AN, Erhardt CC, Price TR, Williams PL. Thenot ‘cured’ take place. painful shoulder: can consultants agree? Br J Rheumatol1996;35:1172–4.12. Liesdek C, van der Windt DAWM, Koes BW, BouterLM. Soft-tissue disorders of the shoulder. A study ofAcknowledgementsinter-observer agreement between general practitionersWe thank our colleague general practitioners, Henk and physiotherapists and an overview of physiotherapeutictreatment. Physiotherapy 1997;83:12–7.Spelde and Jan Woudhuizen, for their enthusiasticJ. C. Winters et al.164BRHEUM – MSS No. 8A/0130dThe long-term course of shoulder complaints: a prospective study in generalpractice J. C. Winters, J. S. Sobel, K. H. Groenier, H. J. 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The long-term course of shoulder complaints:a prospective study in general practice

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The long-term course of shoulder complaints:a prospective study in general practice

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