Management
Management of non-traumatic arm, neck and shoulder complaints presented in general practice up to 6 months after the first consultation mainly consisted of prescribed analgesics (51%) and referral to physiotherapy (49%), followed by corticosteroid injections (17%) and referral for medical specialist care (12%). In 19% of the patients none of these options was applied.
Medical care in general, will most likely match the diagnosis [30] and the expected corresponding natural course [9]. From the distribution of the management options in patients diagnosed with impingement and frozen shoulder, it seems that management is in accordance with the Dutch guideline [2] that recommends a stepwise approach: i.e. information and wait and see, analgesics (ideally: paracetamol; NSAID as second line intermittently if no contraindications exist), followed by corticosteroid injections and, if functional limitations are still present after 6 weeks referral for exercise therapy. Studies on cost effectiveness in shoulder pain, favoured injection over physiotherapy [16].
In epicondylitis a similar approach is recommended; information and wait and see, followed by analgesics or corticosteroid injections if pain hinders function. In the present study, 46% of the patients was prescribed medication.
In the present study, 50% of the patients was referred for physiotherapy although there is no explicit recommendation for physiotherapy in the guideline [1]. Additionally, cost effectiveness studies, concluded no preference for physiotherapy over a brace [25], and no preference for physiotherapy or corticosteroid injections over ‘wait and see’ [18]. Reasons for the large percentage of referral may be that obvious options do not give the desired results. Besides, patient’s circumstances and preferences may play a role as well [13].
The low percentages of additional diagnostic tests in specific shoulder diagnoses and epicondylitis, seem in line with the practice guidelines, where additional diagnostic tests are not recommended (unless in case of deviating course or severe pathology) because the results have no consequences for management [1, 2].
The results of management in the small group with CTS (n = 11), seems to be in line with a Dutch multidisciplinary guideline published after our study closed [7]. In which is noted that a probability diagnosis of CTS can be stated in primary care based on information from history taking, and the GP can start matching treatment. Referral to secondary care is advised when complaints persist. For this relatively small group special treatment or confirmation from a medical specialist seems to be preferred.
Regarding the prescription of analgesics, we could not always distinguish between paracetamol and NSAIDs from our own data. Data from the second Dutch national survey of general practice, based on the International Classification of Primary Care, demonstrated that in many musculoskeletal complaints (ranging from shoulder complaints, arm symptoms, elbow complains, wrist and hand complaints, cervical syndromes, shoulder syndromes, epicondylitis), diclofenac is the most frequently prescribed medication [6]. Despite the rationale behind the choice for NSAIDs, analgesic potential and their inflammatory action, so far no studies evaluated the effectiveness of NSAIDs versus paracetamol (acetaminophen) or additional to paracetamol in non-traumatic arm, neck and shoulder complaints. In 1995, a review on NSAIDs in shoulder complaints already pointed out that future studies should establish whether the use of NSAIDs is more favourable than simple analgesics, especially in the light of the higher risk of adverse reactions from NSAIDs [26].
Karels et al. evaluated the contents of physical therapy treatment in patients with non-traumatic arm, neck and shoulder complaints. They reported that most patients were treated with exercise therapy (93%), massage (87%) or a combination of both. In 30% of the patients, the treatment included physical modalities (such as ultrasound), and in 20% of the patients treatment included manipulation techniques [17].
Differences in management
Differences between the specific and non-specific diagnostic groups, on the distribution of referral to a medical specialist, was mainly due to specific diagnoses of forearm, wrist and hand. This may be for confirmation of the diagnosis, non-conservative treatment or reassuring the patient, but we have no data to verify this hypothesis.
The application of corticosteroid injections, mainly in specific shoulder diagnoses, is according to the practice guideline. However, the effect of the application of corticosteroid injections in epicondylitis, shoulder pain and carpal tunnel syndrome, seems to be mainly restricted to short term relief of symptoms [3, 5, 24].
For the largest subgroup with ‘non-specific diagnoses’ in arm, neck, and shoulder, no guidelines are available. That patients with non-specific diagnoses are more frequently referred for physiotherapy than patients with specific diagnoses, seems in line with the distribution of the diagnoses in a cohort study in physiotherapy practice where the majority of the study population were patients with non-specific diagnoses [17].
However, a Cochrane review reported only limited evidence for the effectiveness of exercises in patients with chronic non-specific neck and shoulder complaints [28].
Variance within a certain diagnostic group may (partly) be explained by differences in hindrance, as mentioned in both guidelines for epicondylitis [1] and shoulder pain [2]. Another reason may be lack of solid evidence in favour of one of the studied treatment options in the total range of non-traumatic arm, neck and shoulder complaints. Although there is limited or short term effect (mainly short-term pain relief) of some of the treatment options, solid evidence in favour of any one of the studied treatment options in this population lacks [27]. The lack of clear evidence of effective treatments may leave more room for personal preferences of both GP and patient.
Besides, patient- and other complaint-characteristics, such as age, employment or psychosocial factors may lead to differences in management decisions as well. These factors probably contribute to the GP’s prognosis [11], which may influence management. Therefore, we checked the univariate association of the 6-months prognosis according to the GP with the five different management options. Poor GP-prognosis showed a positive association with additional diagnostic tests (OR 2.7; 1.7–4.6) and with referral for physiotherapy (OR 2.1; 1.5–3.0). The association with referral for medical specialist care (OR 1.6; 0.7–3.5) was not significant. Besides the low OR, the prevalence of the outcome was also low. Prescription of medication (OR 1.1; 0.9–1.5) and application of corticosteroid injection (OR 0.9; 0.6–1.1), however, did not show a relation with the expected prognosis. This is in line with short-term relief of symptoms as treatment goal in these options.
Strengths and the limitations of this study
This is the first study to compare the management of different diagnostic groups in non-traumatic arm, neck and shoulder complaints. Some of the diagnostic subgroups are large (e.g. shoulder complaints and epicondylitis) and others are very small, reflecting everyday clinical practice [4, 10]. Therefore, the reported management mainly represents these larger diagnostic subgroups.
In the present study, we used the diagnosis registered at the first consultation. However, in some cases the initial diagnosis may have changed after time; due to difficult differential diagnostics within the limited consultation time or the need for additional diagnostic tests, or true changes [30], what may affect the therapeutic approach. Because of this, and the fact that the diagnosis was realised in a non-standardised manner, we cannot rule out some misclassification. This may have resulted in less contrast between the specific and non-specific group.
In the present study, 15 out of the 682 participants received two diagnoses of whom 8 participants received two specific diagnoses within the same region, which may indicate difficult differential diagnostics. Besides, seven participants were diagnosed with both impingement syndrome and a specific forearm diagnosis (epicondylitis/tendonitis/carpal tunnel syndrome). We chose to work with the most centrally located diagnosis, here impingement syndrome.
Due to the response time of 8 weeks, in 21% of the patients the data on management at baseline were not restricted to a single consultation.
Another issue was that the follow-up questionnaire referred to the previous 6 months. We accounted for possible overlap of treatment options due to recollection of information by reporting ‘management up to 6 months’.
In the small group that is referred to a medical specialist, part of the reported decisions on management may be made on the specialists’ own initiative.
A recent development in the Netherlands is that since January 2006, patients no longer need a referral for physiotherapy. This may have implications for the overall treatment in the future.
Conclusions
In non-traumatic arm, neck and shoulder complaints, analgesics and referral for physiotherapy were the treatment options most frequently used, followed by corticosteroid injections and referral for medical specialist care. Patients with a non-specific diagnosis were more frequently referred for physiotherapy and less frequently to a medical specialist compared to patients with a specific diagnosis. Corticosteroid injections were mainly applied in specific diagnoses (e.g. impingement syndrome, frozen shoulder, carpal tunnel and M. Quervain).
Future intervention studies could provide evidence of effective treatments, especially for the large group of non-specific diagnoses, mainly located at the neck-shoulder region. Others may help to clarify the influence of variables, other than diagnoses, on the variance in management decisions between and within diagnostic groups.