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Background: Research investigating prognosis in musculoskeletal pain conditions has only been moderately successful in predicting which patients are unlikely to recover. Clinical decision making could potentially be improved by combining information taken at baseline and re-consultation., Methods: Data from four prospective clinical cohorts of adults presenting to UK and Dutch primary care with low-back or shoulder pain was analysed, assessing long-term disability at 6 or 12 months and including baseline and 4-6 week assessments of pain. Baseline versus short-term assessments of pain, and previously validated multivariable prediction models versus repeat assessment, were compared to assess predictive performance of long-term disability outcome. A hypothetical clinical scenario was explored which made efficient use of both baseline and repeated assessment to identify patients likely to have a poor prognosis and decide on further treatment., Results: Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. Short-term repeat assessment of pain was only slightly more predictive of long-term recovery (c-statistics 0.78, 95% CI 0.74 to 0.83 and 0.75, 95% CI 0.69 to 0.82) than a multivariable baseline prognostic model in the two cohorts presenting such a model (c-statistics 0.71, 95% CI 0.67 to 0.76 and 0.72, 95% CI 0.66 to 0.78). Combining optimal prediction at baseline using a multivariable prognostic model with short-term repeat assessment of pain in those with uncertain prognosis in a hypothetical clinical scenario resulted in reduction in the number of patients with an uncertain probability of recovery, thereby reducing the instances where patients may be inappropriately referred or reassured., Conclusions: Incorporating short-term repeat assessment of pain into prognostic models could potentially optimise the clinical usefulness of prognostic information.

Background: Shoulder complaints are common and have an unfavourable prognosis in many patients. Prognostic information is helpful for both patients and clinicians in managing the complaints. The research question was which factors have prognostic value on (un)favourable outcome in patients with shoulder complaints in primary care, secondary care and occupational settings., Methods: Update of a systematic review in primary care, secondary care and occupational settings., Results: Nine articles were published since the original review in 2004. Six were of high quality covering a wide variety of prognostic factors and outcome measures. Four studies were conducted in primary care settings. A best evidence synthesis, including the results of the previous systematic review on this topic shows that there is strong evidence that higher shoulder pain intensity, concomitant neck pain and a longer duration of symptoms predict poorer outcome in primary care settings. In secondary care populations, strong evidence was found for the association between greater disability and poorer outcome and between the existence of previous shoulder pain and poorer outcome., Conclusion: Clinicians may take these factors into account in the management of their patients. Those with a worse prognosis may be monitored more frequently and the treatment plan modified if complaints persist.

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.

Objectives: Recently, a rule was developed to predict sick leave related to shoulder pain during a period of 6 months after patients have consulted a general practitioner for a new episode of shoulder pain. The objective was to evaluate the generalizability of this prediction rule by testing it in two other populations of workers who had gone for a consultation in primary care for a new episode of shoulder pain., Methods: The prediction rule was derived in a prognostic cohort study (N=350). The outcome was sick leave related to shoulder pain during 6 months following the first consultation. The rule was tested on merged control groups from three trials on shoulder pain (N=128). In addition to this population, a recently conducted study on musculoskeletal disorders (N=224) was used to validate the prediction rule. The generalizability of the prediction rule was tested by studying calibration and discrimination in the validation cohorts., Results: The prediction rule showed reasonable calibration in both validation cohorts. The discriminative ability, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.70 in the derivation cohort was stable in the cohort of the musculoskeletal disorder study (AUC 0.71). In the control groups of the three randomized controlled trials of a Dutch shoulder study, the discriminative ability decreased to an AUC of 0.66., Conclusions: The prediction rule for sick leave related to shoulder pain in a 6-month period following the first consultation in primary care showed adequate generalizability to another population of workers with shoulder pain participating in an observational cohort study. In the control groups of the three randomized controlled trials the prediction rule performed less well.

Objective: To evaluate the generalizability of recently developed clinical prediction rules for the prognosis of shoulder pain in general practice., Study Design and Setting: A large research program, consisting of a prognostic cohort study and three randomized controlled trials with 6 months follow-up, was carried out in The Netherlands. The clinical prediction rules were derived from the results of the prognostic cohort study (n=587). The main outcome measure was persistent symptoms at 6 weeks or 6 months. The control groups of the trials who received usual care were merged (n=212), and used to validate the prediction rules by studying calibration and discrimination., Results: The prediction rule for short-term outcome showed reasonable calibration and discriminative ability in this validation cohort. The area under the receiver operating characteristic curve (AUC) was 0.72 compared to 0.74 in the derivation cohort. The prediction rule for long-term outcome performed less well. Discriminative ability (AUC) decreased to 0.56 in the validation cohort compared to 0.67 in the derivation cohort., Conclusion: The prediction rule for the short-term (6 weeks) prognosis showed good generalizability. The prediction rule for the long-term prognosis showed poor generalizability.

Background and Objective: Psychological factors are assumed to predict persistent or recurrent musculoskeletal pain. The influence of psychological factors in patients with low-back pain (LBP) or shoulder pain was explored to study whether there is similarity regarding the factors that predict persisting pain and disability., Methods: Patients presenting in primary care with a new episode of shoulder pain or non-specific (sub)acute low back pain (LBP) were enrolled in a prospective study. In both patient groups, pain catastrophising, distress, somatisation and fear-avoidance beliefs were measured at baseline. Primary outcome measures at 3 months were (1) persistent symptoms, and (2) <30% reduction in functional disability. Multivariate logistic regression analysis was used to study the associations between psychological factors and outcome., Results: A total of 587 patients with shoulder pain and 171 patients with LBP were enrolled in the study. In patients with shoulder pain, most associations of psychological factors with outcome were weak and not significant. Only in patients with longer symptom duration at baseline (>or=3 months) were higher scores on catastrophising significantly associated with persistent symptoms (p = 0.04). In patients with LBP, psychological factors were more strongly associated with poor outcome, although most associations were not significant., Conclusion: Psychological factors, with the exception of fear-avoidance beliefs, are more strongly associated with persistent pain and disability in patients with LBP than in those with shoulder pain. This seems to indicate that in a primary care population the influence of psychological factors on outcome may vary across patients with different types of pain.

Background: Shoulder pain is common in primary care, and has an unfavourable outcome in many patients. Information about predictors of shoulder pain related sick leave in workers is scarce and inconsistent. The objective was to develop a clinical prediction rule for calculating the risk of shoulder pain related sick leave for individual workers, during the 6 months following first consultation in general practice., Methods: A prospective cohort study with 6 months follow-up was conducted among 350 workers with a new episode of shoulder pain. Potential predictors included the results of a physical examination, sociodemographic variables, disease characteristics (duration of symptoms, sick leave in the 2 months prior to consultation, pain intensity, disability, comorbidity), physical activity, physical work load, psychological factors, and the psychosocial work environment. The main outcome measure was sick leave during 6 months following first consultation in general practice., Results: Response rate to the follow-up questionnaire at 6 months was 85%. During the 6 months after first consultation 30% (89/298) of the workers reported sick leave. 16% (47) reported 10 days sick leave or more. Sick leave during this period was predicted in a multivariable model by a longer duration of sick leave prior to consultation, more shoulder pain, a perceived cause of strain or overuse during regular activities, and co-existing psychological complaints. The discriminative ability of the prediction model was satisfactory with an area under the curve of 0.70 (95% CI 0.64-0.76)., Conclusion: Although 30% of all workers with shoulder pain reported sick leave during follow-up, the duration of sick leave was limited to a few days in most workers. We developed a prediction rule and a score chart that can be used by general practitioners and occupational health care providers to calculate the absolute risk of sick leave in individual workers with shoulder pain, which may help to identify workers who need additional attention. The performance and applicability of our model needs to be tested in other working populations with shoulder pain to enable valid and reliable use of the score chart in everyday practice.

Background: Shoulder pain is common in primary care, and has an unfavourable outcome in many patients. Information on the costs associated with health care use and loss of productivity in patients with shoulder pain is very scarce. The objective of this study was to determine shoulder pain related costs during the 6 months after first consultation in general practice, Methods: A prospective cohort study consisting of 587 patients with a new episode of shoulder pain was conducted with a follow-up period of 6 months. Data on costs were collected by means of a cost diary during 6 months., Results: 84% of the patients completed all cost diaries. The mean consumption of direct health care and non-health related care was low. During 6 months after first consultation for shoulder pain, the mean total costs a patient generated were 689 euro. Almost 50% of this total concerned indirect costs, caused by sick leave from paid work. A small proportion (12%) of the population generated 74% of the total costs., Conclusion: The total costs in the 6 months after first consultation for shoulder pain in primary care, mostly generated by a small part of the population, are not alarmingly high.

Shoulder pain is common in primary care and has an unfavourable outcome in many patients. Information about predictors of outcome is scarce and inconsistent. The objective of this study was to develop clinical prediction rules for calculating the absolute risk of persistent shoulder symptoms for individual patients, 6 weeks and 6 month after the first consultation in general practice. A prospective cohort study with 6 months follow-up was carried out in three geographic areas in The Netherlands. In this study, 587 patients with a new episode of shoulder pain were included. The main outcome measure was persistent symptoms at 6 weeks and 6 months, perceived by the patient. Potential predictors included the results of a physical examination, sociodemographic variables, disease characteristics (duration of symptoms, pain intensity, disability and comorbidity), physical activity, physical workload and psychosocial factors. Response rates to the follow-up questionnaires were 83% at 6 weeks and 92% at 6 months. A longer duration of symptoms, gradual onset of pain and high pain severity at presentation were consistently associated with persistent symptoms at 6 weeks and 6 months. The discriminative validity of our prediction rules was satisfactory with area under the curves of 0.74 (95% CI 0.70, 0.79) at 6 weeks and 0.67 (95% CI 0.63, 0.71) at 6 months. The performance of our rules needs to be tested in other populations of patients with shoulder pain to enable valid and reliable use of the rules in everyday clinical practice.

Shoulder complaints are common and have an unfavourable outcome in many patients. Only 50% of all new episodes of shoulder disorders end in complete recovery within 6 months. There is no consensus about prognostic indicators that can identify patients at high and low risk of chronicity. By a systematic search of the literature we identified 16 studies focusing on the prognosis of shoulder disorders. The methodological quality of these 16 studies was assessed. Six of these were considered to be of relatively 'high quality'. There was a wide variety among the studies in length of follow-up, study population, evaluated prognostic factors, type of outcome measure and method of analysis. Due to this large heterogeneity, we refrained from statistical pooling. Instead, we used a best-evidence synthesis. There is strong evidence that high pain intensity predicts a poorer outcome in primary care populations and that middle age (45-54) is associated with poor outcome in occupational populations. There is moderate evidence that a long duration of complaints, and high disability score at baseline predict a poorer outcome in primary care. These results need to be interpreted with caution because of the small number of studies on which these conclusions are based, and the large heterogeneity among studies regarding follow-up, outcome measures, and analysis.

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. [ABSTRACT FROM AUTHOR]