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Rheumatology Advance Access originally published online on June 24, 2006
Rheumatology 2007 46(1):169-176; doi:10.1093/rheumatology/kel164
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Prognostic indicators for non-recovery of non-traumatic complaints at arm, neck and shoulder in general practice—6 months follow-up

A. Feleus1,2, S. M. A. Bierma-Zeinstra1, H. S. Miedema2, A. P. Verhagen1, A. P. Nauta3, A. Burdorf4, J. A. N. Verhaar5 and B. W. Koes1

1Department of General Practice, Erasmus MC, Rotterdam, 2Netherlands Expert Center for Workrelated Musculoskeletal Disorders, Erasmus MC, Rotterdam, 3The Netherlands Society of Occupational Medicine, Centre of Excellence, Utrecht, 4Department of Public Health, Erasmus MC, Rotterdam and 5Department of Orthopaedics, Erasmus MC, Rotterdam, The Netherlands.

Correspondence to: S. M. A. Bierma-Zeinstra, Department of General Practice, Room Ff 320, Erasmus Medical Center Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands. E-mail: s.bierma-zeinstra{at}erasmusmc.nl


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 
Objectives. To identify predictors of non-recovery in non-traumatic complaints at the arm, neck and shoulder in general practice 6 months after the first consultation.

Methods. A prospective cohort study was set in 21 Dutch general practices. Consulters with a first or new episode of non-traumatic arm, neck or shoulder complaints and age 18 through 64 yrs entered the cohort. Complaint, patient, physical, psychosocial and work characteristics were investigated as possible predictors of non-recovery at 6 months using multiple logistic regression analyses (backward Wald).

Results. At 6 months, 46% of the total population (n = 612) and 42% of the working subpopulation (n = 473) still reported complaints. Complaint characteristics (long duration of the complaint before consultation, recurrent complaint, musculoskeletal comorbidity and complaint mainly located at wrist or hand) were most predictive of non-recovery followed by psychosocial characteristics (more somatization and experiencing less social support). Having a specific diagnosis was associated with recovery. In the working subpopulation, the same variables were predictors of non-recovery. Additionally, low supervisory support was associated with non-recovery. The models correctly classified 72–75% of the patients (explained variance 0.27–0.28).

Conclusions. Besides questions on complaint characteristics, information on somatization and support can help a general practitioner to recognize patients at risk of persistent complaints.

KEY WORDS: Arm, Neck, Shoulder, Prognosis, Primary care


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Acknowledgements
 References
 
Complaints of arm, neck and shoulder are common in Western societies [1, 2]. In The Netherlands, the 12 months prevalence in the general population was estimated at 31% for neck pain, 30% for shoulder pain, 11% for elbow pain and 18% for wrist or hand pain [1]. About 30% of those with pain in the neck or upper extremity reported functional limitations in daily life during the past 12 months, and 16–20% of the workers reported sick leave during the past 12 months, due to these complaints. Roughly 30–40% of the respondents with pain reported contact with a general practitioner (GP) due to these complaints [1].

In The Netherlands, virtually everybody is registered with a GP, who acts as a gatekeeper and refers patients to other care providers within the primary, secondary or tertiary care. Recent figures in Dutch general practice show 66 consultations per 1000 person-years attributable to a new episode of a neck or upper extremity complaint, which is approximately three every week in an average practice with 2500 registered persons [3].

In these common complaints, evidence on the prognosis and factors that may be associated with it is growing. Recent prognostic studies were set in primary care, and investigated the prognosis and the predictive factors of complaints at neck [4], neck–shoulder [5], shoulder [6, 7] or elbow [8, 9]. Research among the general population showed, however, that in about 50% of those reporting pain, the complaint is not restricted to a single site [1, 10]. Besides, prognostic indicators may not be site-specific. Furthermore, the heterogeneous practice population of a GP comprises of patients with and without employment. Studies in neck and upper extremity complaints that also included physical and psychosocial work variables were mainly executed in specific occupational settings [11–14] and are scarce in primary care [9].

In this study, we evaluated the clinical course of non-traumatic arm, neck and/or shoulder complaints in general practice and identified prognostic indicators of poor prognosis, including work variables and psychosocial variables. The aim was to identify predictors of non-recovery in non-traumatic complaints at the arm, neck and shoulder in general practice 6 months after the first consultation. Besides, we determined the additive value of the final model compared with the prognosis of the GP alone.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Acknowledgements
 References
 
Design and setting
This prospective cohort study was conducted in general practices in the Southwest region of The Netherlands. At baseline and after 6 months, data were collected by means of self-administered questionnaires. The Medical Ethics Committee of the Erasmus Medical Center in Rotterdam approved the study protocol.

Study population
In total, 36 GPs from 21 practices recruited eligible patients from September 2001 through December 2002. Inclusion criteria were: patients who visited their GP with a new complaint or new episode of complaints of neck, upper back, shoulder, upper arm, elbow, forearm, wrist or hand pain; age 18 through 64 yrs and able to complete questionnaires in Dutch. The episode was considered ‘new’ if patients had not visited their GP for the same complaint during the preceding 6 months. Patients were excluded when complaints could be explained by a trauma, fracture, malignancy, amputation, prosthesis, congenital defect, previously diagnosed existing systemic disorder and/or generalized neurological disorder or when they reported to be recovered at the time of filling in the questionnaire.

Procedures
During the first consultation, patients received study information, a consent form and the baseline questionnaire from their GP. A fax was sent by the GP to the investigators with a patient number, age, gender, diagnosis and expected prognosis of the complaint. After the research team received the completed informed consent and the first questionnaire within 8 weeks, inclusion criteria were verified in the computerized medical records. At 6 months after the first consultation, the follow-up questionnaire was sent from the research centre.

Outcomes
The primary outcome measure was non-recovery of complaints at 6 months. Patients were considered to have persistent complaints if they reported being ‘worse than ever’ to ‘slightly improved’ on a 7-point ordinal scale. The scores ‘much improved’ or ‘completely recovered’ were considered as recovered.

Secondary outcomes included complaint severity during the previous week, functional limitations and general health. Complaint severity was measured on an 11-point numerical rating scale from 0 (no complaints) to 10 (unbearable complaints). Functional limitations of the arm, neck, shoulder or hand were measured with the Disability of Arm Shoulder and Hand (DASH) questionnaire [15]. Each item was scored on a 5-point Likert scale. Response scores were summed and transferred to a score ranging from 0 (no disability) to 100 (completely disabled). General health was measured with the SF-12, containing a physical component summary scale (PCS-12) and a mental component summary scale (MCS-12) ranging from 0 to 100, with higher scores representing better health [16].

Prognostic indicators
At baseline the following possible prognostic indicators were assessed.

Patient characteristics
Age, gender and body mass index (BMI, calculated from reported length and weight) educational level, and work participation. A patient was coded as ‘having paid work’ if the question, ‘Are you currently (self-)employed?’ was answered with the affirmative.

Complaint characteristics
Duration of the complaints at baseline, complaint severity during the last week, functional limitations and perceived health were the characteristics. For perceived health, the categories of the first question of the SF-12 were recoded as ‘good’ (‘excellent’, ‘very good’, ‘good’) and ‘poor’ (‘fair’ or ‘poor’). Besides, a trauma of arm, neck or shoulder in the past, musculoskeletal comorbidity and non-musculoskeletal comorbidity and recurrence were assessed. For the region with the most pain or complaints during the last week, the patient indicated the location on a manikin. We defined three regions: neck–shoulder (including neck, upper part of thoracic spine, shoulder and upper arm), elbow–fore arm and wrist–hand. A complaint was defined as regional if the area of the complaint on the manikin was restricted to one of these three regions, and as multiple region when more than one region was indicated. Moreover, the diagnosis as registered by the treating GP [Appendix 1 (can be viewed online as supplementary data)] was dichotomized by the researcher into specific or non-specific based on a categorization by Sluiter et al. [17] and by a consensus procedure [18], where a diagnosis was categorized as specific when it could be attributed to a specific medically objectifiable disorder. When the GP indicated more than one diagnosis, the specific diagnosis was given priority.

Physical activity in leisure time
Patients were coded as active in sports when participating at least 1 h a week. The frequency of doing physical activities (besides sports) was scored using six items (housekeeping, taking care of chronic patients and/or disabled persons, do-it-yourself work, gardening, computer use and handcrafts). These items were scored from 0 ‘seldom’ to 3 ‘almost always’. The item scores were summed and resulted in a sum score for ‘heavy physical activities in leisure time’ (four items) and for ‘static repetitive activities in leisure time’ (two items).

Psychosocial characteristics
Somatization and distress were both measured with the Four Dimensional Symptom Questionnaire (4DSQ) [19]. Social support was measured with the Social Support Scale (SOS), a Dutch version of the Social Support Questionnaire (SSQ) [20]. Catastrophizing was measured with a subscale of the Dutch adaptation of the Coping Strategy Questionnaire [21]. Kinesiophobia was measured using the shortened version of the Tampa scale without the four reversed items [22]. Of all psychosocial variables, higher scores indicate more of the measured characteristic. Health locus of control was assessed by one simple question ‘Do you believe you can influence your health through your behaviour?’ scored on a 4-point Likert scale. The scores ‘considerable’ or ‘to a large extent’ were considered as ‘yes’.

Work characteristics
Full-time work (working 36 h a week or more) or part-time work (working <36 h a week), <5 yrs working in current job, sick leave due to complaints of arm, neck or shoulder in the past 6 months, and work-relatedness of complaints were included. Complaints were defined as work-related if participants with a paid job confirmed one of the three following questions:

  1. Do the complaints return or worsen during the activities at work?
  2. Have you adapted or reduced your activities at work because of your complaints?
  3. Do the complaints diminish after several days off work?
Physical load at work was measured with the physical workload questionnaire (PWQ), a validated short version of the Dutch Musculoskeletal Questionnaire. The items were scored on a 4-point Likert scale ranging from 1 ‘seldom’ to 4 ‘always’. Two sum scores were calculated: ‘heavy physical workload’ and ‘long-lasting postures and repetitive movements’ [23]. The psychosocial factors at work were measured with the Dutch translation of the core of Job Content Questionnaire (JCQ) [24], including quantitative job demands, skill discretion, decision authority, supervisor support and coworker support. Job insecurity was measured with the item ‘My job security is good’. High job strain was derived from the combination high (above the sample median) demands combined with low (below the sample median) control (a weighted sum of decision authority and skill discretion).

Prognosis GP
The treating GP scored expected non-recovery at 6 months on a 4-point Likert scale ranging from 1 ‘very likely’ to 4 ‘very unlikely’ at the first consultation. These scores were dichotomized into likely or unlikely.

Statistical methods
The relation between the prognostic variables and ‘non-recovery’ was modelled with logistic regression analysis. For possible prognostic factors with clinically relevant classifications or validated classes, the existing cut-offs were used. If not, ordinal scores were split based on the median score of the total population at baseline. Variables that were univariately associated with ‘non-recovery of complaints’ (P < 0.10) were selected for a multivariate analysis by a step-backward procedure (backward Wald).

First, the backward procedure was executed per domain. Variables with a statistically significant odds ratio (P < 0.10) entered the final model. Only variables with a statistically significant odds ratio (P < 0.05) were retained in the final model. To also include work factors, two models were built: one in the total population and one in the working subpopulation separately. In order to retain comparable multivariate models, prognostic factors present in the model of the total population were also included in the workers’ model and vice versa. In both multivariate models, we adjusted for gender and age.

The percentage of explained variance (Nagelkerke's R2) and percentage correctly predicted (with a cut-off value of 0.5 for the estimated probability) were calculated to give an indication of the fit of the final regression models.

To check whether the variables associated with non-recovery in the total population also applied for different regions of complaints, we also executed stratified univariate logistic regression per region.

We also used logistic regression analysis to identify available baseline variables (Table 1) associated with ‘dropout at 6 months’, according to the approach stated above. Variables related to ‘dropout at 6 months’ were included in the multivariate analysis of ‘non-recovery of complaints’, irrespective of their association with non-recovery.


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  		TABLE 1. Baseline characteristics

 
Last, we determined the additive value of the final model compared with the GP prognosis alone.

Therefore, we determined the univariate relationship of the prognosis of the treating GP with non-recovery. We reported the percentage correctly predicted as persistent or recovered at 6 months by both the prognosis of the GP and the final model. The additive value of the model was tested with the likelihood ratio test (P < 0.05).

All analyses were performed with the Statistical Package of Social Sciences, version 11.0 for Windows (SPSS Inc., Chicago, IL, USA).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Acknowledgements
 References
 
In total, 798 patients fulfilled the criteria, of which 682 (86%) entered the cohort after they returned the completed questionnaire and informed consent. The mean time between consultation and filling in the questionnaire was 2 weeks.

Table 1 shows the distribution of the baseline characteristics for both the total study population and the subgroup with paid work. Of the total study population, 47% was male and 78% reported having a paid job. The duration of the complaint was for 50% of the population less than 6 weeks before consulting their GP. Musculoskeletal comorbidity was experienced by 49% and non-musculoskeletal comorbidity by 21%. The complaints were most frequent mainly located at neck, shoulder or upper arm (n = 528), followed by elbow or forearm (n = 170) and wrist or hand (n = 128). The area in which patients experienced complaints was, in 42%, not restricted to one region.

Of the subgroup workers, 58% reported to work full-time and 71% reported that their complaints were influenced by work activities. About 24% of workers reported sick leave in the previous 6 months due to complaints of arm, neck or shoulder.

At 6 months, 70 participants (10%) had dropped out. Logistic regression analysis showed that younger age (18–44 yrs) (odds ratio 2.85, 1.65–4.93) and being a male (odds ratio 1.84, 1.11–3.04) were significantly related to being a dropout.

Course
In the total population, 25% of the participants reported complete recovery and 29% reported much improvement at 6 months (Table 2). In 46% of the total population and 42% of the working subgroup, the complaints were persistent. In both populations, the scores on mean complaint severity and functional limitations had roughly halved at 6 months. The mean scores on the physical component of general health improved half a S.D., while scores on the mental component remained stable.


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  		TABLE 2. Course of arm, neck and shoulder complaints.

 
Predictors of non-recovery
The results of the univariate regression analyses are presented in Table 3. In the domains of complaint-specific variables and psychosocial characteristics, the strongest univariate associations with non-recovery were seen.


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  		TABLE 3. Predictors of non-recovery of complaints at 6 months after the first consultation among patients with arm, neck and shoulder complaints: results of univariate logistic regression analyses

 
Multivariate regression analyses (Table 4) resulted in four characteristics of the complaint (duration of the complaint before consultation, recurrent complaint, musculoskeletal comorbidity and a complaint located at wrist or hand) that were independent predictors of non-recovery in the total population. Having a specific diagnosis was associated with recovery. Of the psychosocial characteristics, low social support and high somatization were predictive of non-recovery of complaints.


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  		TABLE 4. Predictors of non-recovery of complaints at 6 months after the first consultation among patients with arm, neck or shoulder complaints: results of multiple regression analyses

 
Among workers, we found the same results, though the association of the complaint location at wrist or hand was less strong. In line with low social support, we found low supervisor support to be predictive of persistent complaints.

In the calculations for the final model among workers, 449 of the 473 cases were included. Of the 24 cases that had a missing, 18 reported that questions on supervisor support were not applicable to their situation because they were self-employed.

No correlations higher than 0.24 were found between the variables that remained in the multivariate model. The explained variance of the multivariate models was 0.27 (72% correctly classified) for the total population and 0.28 (75% correctly classified) for the working subpopulation.

Stratified univariate analyses per region are presented in Appendix 2 (can be viewed online as supplementary data). In general, we found the same associations for the three subgroups, though the strength of the relation sometimes differed, which can be due to the different population sizes. In the subgroup elbow or forearm complaints, having a recurrent complaint and experiencing little social support seems to be of less importance in non-recovery compared with the other regions. Also older age (45–64 yrs) and high scores on functional limitations were found to be more important in non-recovery of complaints at wrist or hand compared with complaints mainly located at the neck–shoulder or elbow–forearm.

Additive value of the final model vs the GP prognosis
The prognosis of the treating GP was a strong predictor of non-recovery at 6 months (odds ratio 3.3, 2.3–4.7). The explained variance of the GP prognosis was 0.10 and 64.3% of the patients were classified correctly, compared with 0.27 and 72% with the final model in the total population and 0.28 and 75% in the working population. When we added the final model of the total population and the working population to the GP prognosis, all variables remained independently predictive of non-recovery though the association of the prognosis of the GP with non-recovery, became less strong (odds ratio 2.0, 1.3–3.0). The changes in the odds ratios of the other variables were 10% or less.

The likelihood ratio test showed a significant additive value of the models (both P-values <0.001).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Acknowledgements
 References
 
In this prognostic cohort study in general practice, 46% of the subjects reported non-recovery of non-traumatic arm, neck and shoulder complaints 6 months after the first consultation. Similar results on non-recovery were found after 6 months in shoulder pain [7]. In a study on neck and shoulder complaints [5], 24% reported complete recovery after 3 months, increasing to 32% after 12 months. Moreover, a study on elbow complaints reported 13% complete recovery and 24% much improvement (63% non-recovery) at 3 months compared with 34 and 21% at 12 months (45% non-recovery), respectively [8]. A study on neck pain in general practice, reported 37% [4] non-recovery after 12 months. Most studies [5, 7, 8] consisted of patients with a ‘new’ complaint or episode meaning that the GP had not been consulted in the previous 3 months, correspondingly 6 months as in our study. Our population consisted mostly of patients with complaints at neck, shoulder or elbow.

The complaint-specific predictors of poor outcome in our study were long duration of the complaint, having a recurrent complaint and musculoskeletal comorbidity. Of these complaint-specific predictors, long duration is most frequently reported in studies on neck, shoulder and elbow complaints [4–8, 11]. The predictor recurrent complaint was also found in several studies on complaints of neck [4], neck–shoulder [5] and elbow [8]. Musculoskeletal comorbidity is more difficult to compare, because of differences in definition. We defined it as concomitant musculoskeletal complaints, mainly consisting of low–back pain, followed by osteoartritis of hip or knee; only a few (n = 23) reported comorbidity of arm, neck or shoulder. Though these were not the complaints they consulted for, these complaints may be related. When we ran the analyses excluding these cases, it did not change the model.

In other studies concomitant musculoskeletal complaints [8] or low–back pain [4, 7, 25] was also predictive of poor outcome.

We found no association of baseline complaint severity and functional limitations with non-recovery, as in two studies on neck pain [4, 25]. In contrast, Kuijpers et al. [7] and Haahr et al. [9] found high pain severity to be predictive of persistence at 6 months. Bot et al. [5] only found baseline pain intensity predictive at 3 months, not at 12 months. Besides, studies reported on other outcomes as (change in) pain intensity or severity and (change in) functional limitations [4, 5, 8].

Having a complaint mainly located at wrist or hand was related to non-recovery at 6 months in the total population. When we looked closer at the group with mainly wrist–hand complaints, more non-recovery was present among participants with a non-specific diagnosis and concomitant complaints at neck–shoulder (data not shown).

Further, we found that having a specific diagnosis was associated with recovery. However, the total group with specific diagnoses mainly consisted of specific shoulder complaints (e.g. bursitis, rotator cuff and frozen shoulder) followed by epicondylitis, and the non-specific complaints were mainly located at the neck–shoulder region, the same trend being found in the three regions separately.

The variable ‘specific diagnosis’ was accomplished by dichotomization of the diagnosis given by the treating GP at the first consultation. Because of this and the fact that this diagnosis was realized in a non-standardized manner, we cannot rule out some misclassification. This may have resulted in less contrast between the two groups and a less strong relation with non-recovery.

Many psychosocial variables were univariately related to non-recovery at 6 months, but only two were independent predictors. Less social support predicted non-recovery at 6 months. Bot et al. [8] found an association with changes in pain severity and disability at 3 months and Bonde et al. [14] with slow recovery at 12 months. Social support may be important in order to cope with the consequences of these complaints.

Besides, high scores on somatization predicted non-recovery. Thus, when having a musculoskeletal complaint and bodily symptoms such as reaction to stress, this was predictive of poor outcome. This was analogous to poor outcome in shoulder pain [7], musculoskeletal complaints [26], back pain [27] and acute whiplash [28].

On work variables, we found that low supervisory support was related to non-recovery of complaints at 6 months. This was similar to the results of Bonde et al. [14] on slow recovery after 1 yr in a working population with shoulder tendonitis. Haahr et al. [9], however, found no relation of supervisor support with unchanged or worse overall development in tennis elbow state after 1 yr.

An explanation for the influence of such support may be that it helps emotionally and, in a practical way, to make adjustments to the work situation in order to continue one's tasks. In contrast to others [11, 14], we did not find an impact of job demands on poor outcome. Neither did we find an impact of physical work strain, which was in line with Bonde et al. [14], where worker-independent observational methods were used to quantify physical strain, but in contrast to Haahr et al. [9], where job title was used to classify physical strain.

Because our heterogeneous population consisted mostly of patients with complaints at neck, shoulder or elbow, we checked whether the univariate results for the total population applied for the separate regions. In the subgroup of elbow or forearm complaints, having a recurrent complaint and experiencing little social support seems to be of less importance for non-recovery compared with the other regions. Further, age and functional limitations seems more important in wrist or hand complaints. But, in general, we found the same associations for the three subgroups, though the strength of the relation sometimes differed, which can be due to the different population sizes.

Further, we found additive value of the final models compared with the prognosis of the GP alone.

Thus, information on these variables at the first consultation can help a GP to make a better estimation whether a patient will still have complaints after 6 months. The decline in relationship of the GP prognosis with non-recovery, when the variables of the final model are added, indicates that the prognosis is at least partly based on information of these variables.

Although we investigated a wide range of possible prognostic variables, we could only correctly identify some as predictive of non-recovery of complaints. In our observational study, no data on physical examination were available. A reduced range of motion might be a prognostic variable that possibly overlaps the variable functional limitations we included. Here, we chose to measure functional limitations with DASH [15], a validated complaint-specific instrument for arm, hand and shoulder. Though this questionnaire was originally not developed for neck complaints, we saw similar scores in patients with neck complaints compared with patients with arm, shoulder and hand complaints.

Also, we checked whether the DASH was equally predictive of non-recovery in both ‘only neck complaints’ and ‘no neck complaints’ with stratified univariate logistic regression. The strength of the relation in both subgroups seemed comparable, but the difference of group sizes is large.

Apart from the variables included in the final model, treatment may also predict outcome. However, we chose not to add treatment in the model because treatment decisions depend on differences in the presented complaints (e.g. diagnosis, severity of complaints and comorbidity) and treatment can be adapted when changes occur in the presentation of these complaints. Interpretation of treatment as a predictive variable is therefore very difficult.

In a heterogeneous general practice population, we have identified variables predictive of non-recovery of arm, neck and shoulder complaints at 6 months after the first consultation. In the total population, 46% reported non-recovery at 6 months. Variables most predictive of non-recovery included in the final model were complaint characteristics, high somatization, little social support and little supervisory support. Having a specific complaint was positively associated with recovery. According to these results, including questions on complaint characteristics, information on psychosocial characteristics can help a GP to identify patients at risk of non-recovery at 6 months. Attention should therefore also be paid to somatization and experienced support both in the private and the work situation.

Formula


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
References
 
We thank the participating GPs and participating patients for the invaluable contribution to the data collection. Further, our special thanks to Dr Roos MD Bernsen for statistical advice. This study is funded by Internal funding of Erasmus MC (Revolving Fund).

The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 

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Submitted 20 January 2006; revised version accepted 7 April 2006.
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