Research ArticleOriginal Research

Management Decisions in Nontraumatic Complaints of Arm, Neck, and Shoulder in General Practice

Anita Feleus, Sita M. A. Bierma-Zeinstra, Roos M. D. Bernsen, Harald S. Miedema, Jan A. N. Verhaar and Bart W. Koes
The Annals of Family Medicine September 2009, 7 (5) 446-454; DOI: https://doi.org/10.1370/afm.993

Article Figures & Data

Tables

  • Table 1.

    Data on Patient, Complaint, and General Practitioner Characteristics Included in the Model

    VariablesValue
    GP = general practitioner; DASH = Disability of Arm, Shoulder and Hand questionnaire; 4DSQ = Four-Dimensional Symptom Questionnaire; SF-12 = SF-12 Health Survey; SOS = Social Support Scale, a Dutch version of the Social Support Questionnaire.
    aDichotomous, with split based on median score of the total population.
    bScored on a range from 1 to 10 with 10 being the most severe, and 6 is the median.
    cEach item scored on a 5-point Likert scale and summed and transferred to a score ranging from 0 (no disability) to 100 (completely disabled).15
    dFour answer categories dichotomized as poor (fair or poor) vs good (excellent or very good).16
    eArea with the most pain or complaints during the previous week indicated area on a mannequin: multiple regional vs regional. Defined regions are neck-shoulder, including neck; upper part of thoracic spine, shoulder and upper arm; elbow-forearm; and wrist-hand.17
    fScored on a range from 12 to 60; a higher score indicates more support.18
    gScored on a range from 0 to 32; a higher score indicates more somatization or distress.19
    hUrbanization rate: rural = addresses ≤ 1,000/km2, urban=addresses >1,000/km2.20
    Diagnosis (n = 682 patients)6,7,14
    Epicondylitis, n (%)95 (14)
    Impingement, biceps tendonitis, frozen shoulder, n (%)229 (34)
    Other specific diagnosis, n (%)78 (11)
    Nonspecific diagnosis, n (%)280 (41)
    Patient and complaint characteristics (n = 682 patients)
    Age, y, median (range) a45 (18–64)
    Female, n (%)399 (58)
    Not having paid work, n (%)148 (22)
    Duration of the complaint at consultation
        0–6 wk, n (%)344 (51)
        6 wk–6 mo, n (%)162 (24)
        >6 mo, n (%)175 (25)
    Complaint severity in last week, median (range)a,b6 [1–10]
    Functional limitations, DASH, median (range) a,c35.4 (2.9–99.1)
    Poor perceived general health, SF-12 question No. 1, n (%)d86 (13)
    Musculoskeletal comorbidity, n (%)331 (49)
    Recurrent complaint vs incident complaint, n (%)191 (28)
    Multiple-region complaint, n (%)e287 (42)
    Low social support, SOS score <56, n (%)a,f342 (50)
    Somatization, 4DSQ, n (%)g
        Low (score 0–10)503 (74)
        Medium (score 11–20)148 (22)
        High (score 21–32)30 (4)
    Distress, 4DSQ, n (%)g432 (63)
        Low (score 0–10)
        Medium (score 11–20)170 (25)
        High (score 21–32)79 (12)
    GP characteristics (n = 31)
    Female, n (%)5 (16)
    Years of practice, median (range)13 (1–35)
    Special interest in musculoskeletal complaints, n (%)16 (53)
    Continuing medical education in musculoskeletal complaints, n (%)13 (41)
    GP practice characteristics (n = 21)
    Group practice11 (52)
    Rural vs urbanh8 (38)
  • Table 2.

    Management of Nontraumatic Arm, Neck, and Shoulder Complaints

    Management OptionTotal Population (n = 682) n (%)Epicondylitis (n = 95) n (%)Impingement, Biceps Tendonitis, Frozen Shoulder (n = 229) n (%)Other Specific Diagnosis (n = 78) n (%)Nonspecific Diagnosis (n = 280) n (%)
    Note: More than 1 management option is possible.
    Additional diagnostic tests59 (9)3 (3)13 (6)13 (17)30 (11)
    Corticosteroid injection71 (11)5 (5)50 (22)9 (12)7 (3)
    Prescribe a medication235 (35)31 (33)97 (42)23 (30)84 (30)
    Refer to physiotherapy158 (23)24 (25)40 (18)9 (12)85 (30)
    Refer to medical specialist31 (5)3 (3)12 (5)9 (12)7 (3)
    Watchful waiting276 (41)46 (48)74 (32)36 (46)120 (43)
  • Table 3.

    Associations of Watchful Waiting, Additional Diagnostic Testing, and Prescription of Medication: Results of Multivariate Logistic Regression Analyses (Multilevel)

    VariablesWatchful Waiting OR (95% CI)Additional Diagnostic Testing OR (95% CI)Prescription of Medication OR (95% CI)
    Note: All variables in the final model have a multivariate association with a P value <.05.
    CI=confidence interval; DASH = Disability of Arm Shoulder and Hand questionnaire; 4DSQ = Four-Dimensional Symptom Questionnaire; OR = odds ratio; ref=reference group.
    aScored on a range from 1 to 10 with 10 being the most severe, and 6 is the median.
    bEach item scored on a 5-point Likert scale and summed and transferred to a score ranging from 0 (no disability) to 100 (completely disabled).15
    cScored on a range from 0 to 32; a higher score indicates more somatization or distress.19
    Diagnosis
    Epicondylitis1.2 (0.8–1.7)0.2 (0.1–0.5)1.2 (0.8–1.6)
    Impingement, biceps tendonitis, frozen shoulder0.6 (0.4–1.2)0.5 (0.2–1.2)1.7 (1.2–2.5)
    Other specific diagnosis1.1 (0.7–1.7)1.3 (0.9–2.0)1.1 (0.7–1.8)
    Nonspecific diagnosis, ref1.01.01.0
    Patient and complaint characteristics
    Duration of the complaint at consultation
        0–6 wk (ref)1.01.01.0
        6 wk–6 mo0.7 (0.5–1.0)2.1 (0.9–5.1)0.7 (0.5–1.0)
        >6 mo0.6 (0.4–0.8)5.0 (2.4–10.5)0.6 (0.4–0.9)
    High complaint severity in the last week (score >6) vs lowa0.6 (0.4–0.9)––
    Many functional limitations (DASH score >35.34) vs fewb0.6 (0.5–0.9)1.7 (1.2–2.4)
    Recurrent complaint vs incident complaint0.7 (0.6–0.9)––
    Multiple-region complaint vs single region–2.3 (1.2–4.3)
    Somatization, 4DSQc–––
        Low (score 0–10)––1.0
        Medium (score 11–20)––1.0 (0.7–1.5)
        High (score 21–32)––2.5 (1.2–5.2)
    GP characteristics
    Female vs male––0.6 (0.4–0.9)
    Few years of practice (<13 years) vs many–2.9 (1.8–4.7)–
    Group practice vs solo practice–0.5 (0.3–0.9)–
  • Table 4.

    Associations of Steroid Injection, Referral to Physiotherapist, and Medical Specialist: Results of Multivariate Logistic Regression Analyses (Multilevel)

    VariablesSteroid Injection OR (95% CI)Physical Therapist OR (95% CI)Medical Specialist OR (95% CI)
    All variables in the final model have a multivariate association with a P <.05.
    DASH = Disability of Arm Shoulder and Hand questionnaire; 4DSQ = Four-Dimensional Symptom Questionnaire; OR = odds ratio; n = number of patients; ref = reference group.
    aScored on a range from 1 to 10 with 10 being the most severe, and 6 is the median.
    bEach item scored on a 5-point Likert scale and summed and transferred to a score ranging from 0 (no disability) to 100 (completely disabled).15
    cScored on a range from 0 to 32; a higher score indicates more somatization or distress.19
    dUrbanization rate: rural = addresses ≥ 1,000/km2, urban=addresses >1,000/km2.20
    Diagnosis
    Epicondylitis2.0 (0.8–5.2)0.9 (0.4–2.2)1.6 (0.5–4.7)
    Impingement, biceps tendonitis, frozen shoulder9.6 (4.9–18.7)0.5 (0.3–0.8)2.0 (0.9–4.6)
    Other specific diagnosis3.7 (1.4–9.7)0.3 (0.2–0.5)5.0 (2.2–11.3)
    Nonspecific diagnosis, ref1.01.01
    Patient and complaint characteristics
    Younger age (18–45 y) vs older (46–64 y)0.6 (0.4–0.9)––
    Duration of the complaint at consultation:
        0–6 wk (ref)1.01.01
        6 wk – 6 mo1.3 (0.8–2.1)1.7 (0.9–3.1)4.9 (1.2–20.4)
        >6 mo1.7 (1.0–2.8)2.4 (1.4–4.3)16.4 (4.9–54.8)
    High complaint severity in the last week (score >6) vs lowa1.8 (1.1–2.9)––
    Many functional limitations (DASH score >35.34) vs littleb1.6 (1.1–2.4)–2.1 (1.1–4.1)
    Recurrent complaint vs incident complaint–1.6 (1.2–2.1)–
    Distress, 4DSQc––
        Low (score 0–10)–1.0–
        Medium (score 11–20)–1.4 (1.0–2.0)–
        High (score 21–32)–1.9 (1.3–2.8)–
    GP characteristics
    Few years of practice (<13 years) vs many––2.3 (1.2–4.6)
    Special interest in musculoskeletal complaints vs no4.4 (1.7–11.4)––
    Rural vs urband–1.9 (1.2–3.1)–
  • Table 5.

    Associations of 6 Management Options: Results of Multivariate Logistic Regression Analyses (Multilevel)

    VariablesWWADTPMSIPTMS
    Note: The associations of variables with the 6 management options are as follows: + represents a positive association; − represents a negative association; = represents an association similar to the reference category; • represents a variable not associated with a management option.
    ADT = additional diagnostic tests; DASH = Disability of Arm Shoulder and Hand questionnaire; 4DSQ = Four-Dimensional Symptom Questionnaire; GP = general practitioner; MS = medical specialist; PM = prescribe a medication; PT=physical therapist; SI=steroid injection; WW=watchful waiting.
    aScored on a range from 1–10 with 10 being the most severe, and 6 is the median.
    bEach item scored on a 5-point Likert scale and summed and transferred to a score ranging from 0 (no disability) to 100 (completely disabled).15
    cArea with the most pain or complaints during the previous week indicated area on a mannequin. Defined regions are neck-shoulder, including neck; upper part of thoracic spine, shoulder and upper arm; elbow-forearm; and wrist-hand.17
    dScored on a range from 0–32; a higher score indicates more somatization or distress.19
    eUrbanization rate: rural = addresses ≤ 1,000/km2, urban=addresses >1,000/km2.20
    Diagnosis compared to nonspecific diagnosis
    Epicondylitis=+====
    Impingement, biceps tendonitis, frozen shoulder==++−=
    Other specific diagnosis===+−+
    Patient and complaint characteristics
    Younger (18–45 y) vs older (46–64 y)•••−••
    Duration of the complaint: compared with 0–6 wk
        6 wk-6 mo−=−==+
        >6 mo−+−+++
    High complaint severity in the last week (score >6) vs lowa−••+••
    Many functional limitations (DASH score >35.34) vs fewb−•++•+
    Recurrent complaint vs incident complaint−•••+•
    Multiple-region complaint vs single regionc•+••••
    Somatization, 4DSQ: compared with low (score 0–10)d
        Medium (11–20)••=•••
        High (21–32)••+•••
    Distress, 4DSQ: compared with low (score 0–10)d
        Medium (11–20)••••+•
        High (21–32)••••+•
    GP characteristics
    Female vs male••−•••
    Few years of practice (<13 y) vs many•+•••+
    Special interest in musculoskeletal complaints vs no•••+••
    Group practice vs solo practice•−••••
    Rural vs urbane••••+•

Additional Files

  • Supplemental Tables

    Supplemental Table 1. Specific Diagnoses Included in Study; Supplemental Table 2. Univariate Associations With Common Management Options; Results of Univariate Logistic Regression Analyses (Multilevel)

    Files in this Data Supplement:

  • The Article in Brief

    Management Decisions in Nontraumatic Complaints of Arm, Neck, and Shoulder in General Practice

    Anita Feleus, and colleagues

    Background Complaints about the arm, neck, and shoulder are common in Western societies, but there is wide variation in the management of these complaints. This study evaluated associations between diagnosis and characteristics of the patient, complaint, and general practitioner and 6 common management decisions in patients with nontraumatic arm, neck, and shoulder complaints.

    What This Study Found In treating arm, neck, and should conditions, a long duration of complaints and many limitations in functioning were most frequently associated with the choice of a management option. This study of 682 patients seen in 21 Dutch general practices also identified several physician characteristics that appear to play a role in determining the course of treatment.

    Implications

    • The lack of solid evidence in favor of the treatment options explored in this study may explain variability in management of these conditions and may leave more room for personal preferences of both the patient and doctor.
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