Rheumatology 2008;47:724–730 doi:10.

1093/rheumatology/ken044
Advance Access publication 14 April 2008

Course and prognosis of shoulder symptoms in general practice

M. L. Reilingh1, T. Kuijpers2, A. M. Tanja-Harfterkamp1 and D. A. van der Windt1,3

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.

KEY WORDS: Shoulder pain, Disability, Psychosocial factors, General practice, Course, Prognosis, Prospective cohort study.

Introduction the GP, in terms of pain, functional disability and quality of

Shoulder symptoms are a frequent problem in general practice,
affecting between 7% and 34% of adults at any one time [1]. Not
everyone consults the general practitioner (GP) for these
symptoms. The annual consulting incidence in Dutch general
practice for shoulder symptoms is estimated between 12 and
25/1000 persons-years [2–5]. Little is known about the pathophys-
iology and aetiology of shoulder disorders, although associations
with obesity, age, female gender, physical work load and
psychosocial factors have been proposed [6–8].
Various studies have contradicted the belief that shoulder pain
is a benign and self-limiting problem. Only about 50% of all new
episodes of shoulder pain presented in primary care show
complete recovery within 6 months, after 1 yr this proportion
increases to only 60% [9–12]. In the period 1987–95, the state of
Washington (USA) each year accepted over 6000 work disability
claims related to shoulder problems [13]. Information about the
clinical course of shoulder symptoms after presentation in general
practice is still limited. The medical literature on shoulder
disorders is predominantly based on hospital surveys, although
only a small proportion of shoulder patients in general practice
(
8%) are referred for a specialist opinion [10]. Yet, knowledge
on the course may facilitate treatment decisions and may help to
inform patients about their prognosis. Several prospective cohort
studies have investigated neck, shoulder or upper limb problems in
primary care populations [9–12, 14–17]. The following factors
were repeatedly identified as potential predictors of outcome: long
duration of symptoms at baseline [10, 12, 15–17], more intense
pain [15, 16], history of symptoms [9, 12, 15–17], musculoskeletal
pain elsewhere [15, 17] and psychosocial factors [12, 16, 17].
The aim of our study was to investigate the course of
shoulder symptoms during the first 6 months after visiting
1
Department of General Practice, VU University Medical Center, Amsterdam,
2
Dutch Institute for Healthcare Improvement CBO, Utrecht, The Netherlands and
3
Primary Care Musculoskeletal Research Centre, Keele University, Keele, UK.
Submitted 21 August 2007; revised version accepted 18 January 2008.
Correspondence to: D. A. van der Windt, EMGO Institute, VU University Medical
Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
E-mail: dawm.vanderwindt@vumc.nl
724
ß The Author 2008. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
life. We made a distinction between patients with acute
shoulder pain (duration of symptoms <6 weeks before consult-
ing the GP), subacute shoulder pain (duration of symptoms
between 6 and 12 weeks) and patients with chronic shoulder
pain (duration of symptoms at least 3 months), as foregoing
research showed that symptom duration is an important
predictor of outcome, with acute shoulder pain having a better
prognosis than chronic pain. The questions we addressed in our
study were:
(1) What is the course of shoulder symptoms during the first 6
months after visiting the GP, in terms of pain, functional
disability and quality of life?
(2) Is the prognosis different in patients with acute, subacute and
chronic shoulder pain at consultation?
(3) What are predictors of a better outcome after 6 months in
patients presenting with either acute or chronic shoulder
pain?
Methods
Study population
This study is based on the results of a cohort study that was
performed in 103 general practices in three geographical regions in
The Netherlands (Amsterdam, Groningen and Maastricht) [18].
Patients were selected if they were 18 yrs, and had not consulted
their GP or received any form of treatment for the afflicted
shoulder in the preceding 3 months. Shoulder pain was char-
acterized as pain in the deltoid and upper arm region, provoked or
increased by movement in the shoulder joint. GPs were instructed
to select consecutive patients. Sufficient knowledge of the Dutch
language was required to complete written questionnaires.
Exclusion criteria were acute trauma or systemic, physical or
psychological conditions (i.e. fractures or luxation in the shoulder
region; rheumatic disease; neoplasm; neurological or vascular
disorders; dementia).
Design
The GP informed the patients about the study, after which written
consent was obtained according to the Declaration of Helsinki.
 Course and prognosis of shoulder symptoms
The GP started treatment according to national Dutch guidelines
for shoulder pain, which advise a stepwise approach (advice,
medication, steroid injection or physiotherapy) in which the next
treatment option is only considered for patients returning with
persistent pain and disability [19]. Information was recorded
about the treatment provided to the patients at the first
consultation. Within 10 days after the consultation a baseline
assessment was performed, consisting of a patient history,
standardized physical examination and a questionnaire.
A second questionnaire (first follow-up) was sent after 6 weeks,
the third questionnaire (second follow-up) after 3 months and the
fourth questionnaire (third follow-up) after 6 months. The study
was approved by the Medical Ethics Committee of the VU
University Medical Centre in Amsterdam.
Outcome measures and potential prognostic factors
In each questionnaire, the intensity of shoulder pain, functional
disability and quality of life was measured. Pain was recorded by
the patient on a numeric rating scale (0–10 points, 0 ¼ no pain;
10 ¼ very severe pain). Functional disability was measured using
the 16-item Shoulder Disability Questionnaire (SDQ; 0–100) [20].
Quality of life was measured by the EuroQol (EQ-5D; 0–1)
[21, 22], covering five domains: mobility, self-care, usual activities,
pain/discomfort and anxiety/depression.
During the baseline assessment information was collected on
a variety of potential prognostic factors. Sociodemographic
variables included age, gender, educational level and work
status. Characteristics of the shoulder pain problem included
intensity of pain, an acute or gradual onset, previous episodes of
shoulder pain and whether or not the dominant side was affected.
The questionnaire also included questions on co-existing muscu-
loskeletal pain at the neck, back and upper extremities.
Causes of shoulder pain as perceived by the patient were
categorized as unexpected movement, overuse due to unusual
activities, overuse due to usual activities, accident or sports injury
and were measured with questions answered by yes or no.
Physical activity was measured with a single question (less/
equally/more active than others). We measured physical workload
with a self-constructed scale of five questions (yes/no) concerning
pushing and pulling, lifting weights, working with hands above
shoulder level and the use of vibrating tools on at least 2 days a
week (0–5). Repetitive movements, on at least 2 days a week, were
measured with a single question answered with yes or no. The
psychosocial work environment was assessed using the 27-item
Job Content Questionnaire which measures all dimensions of the
Demand–Control–Support model [23].
Psychological factors were measured with widely used
standardized questionnaires. Coping was assessed with the
43-item Pain Coping and Cognition List (PCCL) [24], consisting
of the subdomains catastrophizing (1–6), coping with pain (1–6),
internal (1–6) and external locus of control (1–6).
Anxiety (0–24), depression (0–12), somatization (0–32) and
distress (0–32), were measured with the 50-item Four-Dimensional
Symptoms Questionnaire (4DSQ) [25, 26].
The questionnaire finally included a general one-item question
regarding the presence (yes/no) of any psychological problems
(e.g. worries, depressive symptoms, anxiety).
Analysis
Descriptive statistics were used to summarize characteristics of the
study population. We present this information separately for
patients with acute, subacute and chronic shoulder pain. The
course of symptoms in terms of pain, disability and quality of life
was also described separately for these three subgroups by plotting
the mean scores at each point in time. Next, we analysed potential
predictors of outcome separately for patients with acute and
chronic shoulder pain. Absolute change in pain intensity between
baseline and 6 months follow-up was used as outcome measure.
725
Predictors were selected based on evidence from the literature on
their potential predictive value in patients with musculoskeletal
pain (age, history of pain, dominant side affected, musculoskeletal
pain elsewhere, work load factors and pain catastrophizing) [9, 10,
12, 14–17, 27]. Another reason for selecting a potential predictor
could be differences between patients with acute and chronic pain
at baseline, indicating potential predictive importance of the
factor.
Univariable linear regression analyses were performed to
examine the relationship between each of the potential predictors
and change in pain intensity after 6 months. Predictors measured
on a continuous (e.g. age) or interval scale (e.g. baseline pain
intensity) were entered as continuous variables, which provides an
estimate of the mean reduction in pain for each point increase on
the scale. If a continuous variable showed a non-linear association
with outcome it was dichotomized or divided into tertiles (low,
medium, high scores). This was the case for external locus of
control and somatization.
Subsequently, predictors that were associated with the outcome
(P < 0.30) were included simultaneously in a multiple linear
regression model. Using a manual backward selection procedure,
we sequentially excluded predictors with the lowest predictive
value from the model until all predictors were significantly
associated with outcome (Wald statistic P < 0.10) and further
elimination resulted in a large deterioration of the explained
variance of the model. The percentage of explained variance (R2)
was calculated to give an indication of the predictive power of the
final models.
Results
Study population and follow-up
At baseline, 587 patients were interviewed and physically
examined. At 6 weeks 487 (83%), at 3 months 517 (88%) and at
6 months 538 (92%) patients returned the postal questionnaire.
The drop-outs at 6 weeks and 6 months were significantly younger
than the responders (mean difference 4 yrs and 6 yrs, respectively).
Additionally, drop-outs at 6 months more often showed an acute
onset (49 vs 36%), and less repetitive movements in their work
(26 vs 36%) in comparison with the responders.
Table 1 lists the baseline characteristics of the participants
separately for those with acute, subacute or chronic pain at
baseline. The results show that patients with chronic shoulder pain
reported higher pain intensity, more disability, had a higher
somatization score, and more often reported a gradual onset of
their shoulder pain compared with patients with subacute or acute
shoulder pain. Patients with acute shoulder pain more often had a
paid job, and slightly higher scores on external locus of control
compared with those with subacute or chronic shoulder pain.
These six factors were considered as potential predictors of
outcome in further analyses (in addition to factors suggested by
the literature).
Management of shoulder pain
At baseline, most patients (n ¼ 451, 77%) received a wait-and-see
policy, paracetamol or an NSAID. Furthermore, 68 patients
(12%) received an injection with a corticosteroid, 58 patients
(10%) were referred for physiotherapy and 11 (2%) received other
therapies. Table 2 lists the management of shoulder pain of the
participants separately for those with acute, subacute or chronic
pain at baseline.
The proportion of patients receiving wait-and-see policy,
paracetamol or NSAIDs was higher in patients with acute
shoulder pain compared with those with chronic shoulder pain,
while the proportion of physiotherapy referrals was higher in
patients with chronic shoulder pain.
726 M. Reilingh et al.

TABLE 1. Baseline characteristics of patients with shoulder pain, separately for those with acute, subacute or chronic pain at baseline

Acute (n ¼ 205) <6 weeks Subacute (n ¼ 139) 6–12 weeks Chronic (n ¼ 242) >3 months
Demographic and work variables
Age (yrs), mean (S.D.) 49.5 (14.7) 51.9 (13.9) 52.9 (13.3)
Gender, n (% female) 105 (51.2) 62 (55.4) 127 (52.5)
Educational level, n (%)
Low 74 (36.1) 37 (26.6) 98 (40.5)
Middle 80 (39.0) 61 (43.9) 93 (38.4)
High 48 (23.4) 40 (28.8) 47 (19.4)
Paid work 139 (67.8) 77 (55.4) 134 (55.4)
Psychosocial work environment (n ¼ 350), mean (S.D.)a
Decision authority 9.4 (1.74) 9.2 (1.77) 9.4 (1.84)
Skill discretion 15.4 (2.92) 15.4 (2.68) 15.1 (2.80)
Decision latitude 24.8 (4.07) 24.6 (3.99) 24.6 (4.17)
Psychological demands 13.2 (2.88) 12.9 (2.24) 12.3 (2.57)
Supervisor support 12.2 (2.44) 11.1 (2.22) 11.3 (2.83)
Coworker support 12.4 (2.02) 12.3 (1.37) 12.2 (2.16)
Disease characteristics
Gradual onset, n (%) 78 (38.0) 96 (69.1) 188 (77.7)
Previous episode, n (%) 119 (58.0) 63 (45.3) 161 (66.5)
Pain intensity, mean (S.D.) 4.4 (2.5) 4.7 (2.1) 5.2 (2.2)
Functional disability (SDQ 0–100), mean (S.D.) 56.8 (28.3) 59.1 (23.0) 62.9 (22.7)
Dominant side affected, n (%) 120 (58.5) 89 (64.0) 152 (62.8)
Psychological factors
PCCL, mean (S.D.)a
Catastrophizing (1–6) 2.2 (0.8) 2.2 (0.9) 2.3 (0.9)
Coping with pain (1–6) 3.0 (1.0) 2.9 (0.9) 3.0 (1.0)
Internal locus of control (1–6) 3.4 (1.0) 3.4 (0.9) 3.3 (0.9)
External locus of control (1–6) 3.4 (0.9) 3.1 (0.9) 3.1 (0.9)
4DSQ, mean (S.D.), mediana
Distress (0–32) 2.1 (4.5), 0.0 2.5 (5.1), 0.0 2.4 (4.1), 0.0
Depression (0–12) 0.2 (1.4), 0.0 0.2 (1.3), 0.0 0.3 (1.1), 0.0
Anxiety (0–24) 0.4 (1.5), 0.0 0.4 (1.3), 0.0 0.3 (1.0), 0.0
Somatization (0–32) 2.9 (3.6), 2.0 2.8 (3.9), 2.0 4.0 (4.5), 3.0
Physical load
Physical burden (0–5), mean (S.D.), median 1.35 (1.50), 1.00 1.19 (1.52), 0.00 1.18 (1.40), 1.00
Repeated movement with arms or wrists, n (%) 138 (67.3) 75 (54.0) 170 (70.2)
Perceived cause according to patient, n (%)
Unexpected movement 12 (5.9) 9 (6.5) 12 (5.0)
Overuse unusual activities 32 (15.6) 24 (17.3) 39 (16.1)
Overuse usual activities 43 (21) 36 (25.9) 59 (24.4)
Accident 10 (4.9) 4 (2.9) 19 (7.9)
Sports injury 6 (2.9) 6 (4.3) 17 (7.0)
Physical activity, n (%)
>30 min/day walking or biking 70 (34.1) 53 (38.1) 93 (38.4)
Regular long walk or cycling tour 87 (42.4) 72 (51.8) 116 (47.9)
Pain elsewhere, n (%)
Neck or upper extremities 86 (45.3) 56 (45.5) 131 (58.5)
Low back 44 (21.5) 31 (22.3) 64 (26.4)

a
The psychosocial work environment was only assessed in patients with paid work.

quality of life during follow-up. Mean scores were consistently

TABLE 2. Management of patients with shoulder pain at first consultation,
separately for those with acute, subacute or chronic pain
lower among patients with chronic shoulder pain. For each
outcome measure the differences between the three subgroups
Acute Subacute Chronic
were statistically significant at each moment of follow-up.
(n ¼ 205) (n ¼ 139) (n ¼ 242)
<6 weeks 6–12 weeks >3 months Predictors of change in pain intensity
Management of shoulder pain, n (%)
Wait-and-see policy, 174 (84.9) 107 (77.0) 169 (69.8) The results of the univariable regression analyses demonstrating
paracetamol or NSAIDs the association of each putative predictor with change in pain
Injection with corticosteroid 22 (10.7) 12 (8.6) 34 (14.0) intensity after 6 months are presented in Table 3, separately for
Physiotherapy 6 (2.9) 18 (12.9) 34 (14.0) patients with acute and chronic shoulder pain. Baseline shoulder
disability, catastrophizing, somatization, paid work, baseline pain
intensity, previous episode, gradual onset, repeated movements
Course. Figure 1 shows that patients with acute pain at with arms or wrists and co-existing pain in the neck or upper
baseline had the most favourable outcome over 6 months follow- extremities, were associated with change in pain intensity during
up, with pain decreasing from a mean score of 4.3 (S.D. 2.6) at follow-up in patients with acute shoulder pain at baseline. In those
baseline to 1.3 (S.D. 2.2) at 6 months (mean pain reduction since with chronic shoulder pain, baseline shoulder disability, age, pain
baseline 70%). Patients with subacute pain at baseline (mean pain catastrophizing, external locus of control, gradual onset and
reduction 54%) or chronic pain at baseline (mean pain reduction baseline pain intensity with chronic shoulder pain showed an
44%) showed a slower rate of recovery and maintained higher univariable association (P  0.30) with outcome. These variables
levels of pain at 6 months. The course of functional disability were selected for the multivariable regression analyses.
presented in Fig. 2 shows very similar patterns; patients with acute Table 4 presents the variables included in the prediction models
pain at baseline reported the largest decrease in shoulder disability for persistent symptoms at 6 months after backward stepwise
after 6 months (mean reduction in functional disability 69%). The selection. Predictors of a better outcome at 6 months for acute
results of the EQ-5D (Fig. 3) show that there was little change in shoulder pain were lower baseline disability scores and higher
 Course and prognosis of shoulder symptoms 727

10 1

8 0.8

7
Pain intensity (0–10)

EQ-5D (0–1)
0.6
5

4 0.4
3

2
0.2
1

0
0 5 10 15 20 25 30 0
0 5 10 15 20 25 30
Follow-up time (weeks)
Follow-up time (weeks)
Acute (0–6 weeks) Subacute (6–12 weeks)
Acute (0-6 weeks) Subacute (6–12 weeks)
Chronic (> 12 weeks) Chronic (> 12 weeks)

FIG. 1. Course of shoulder pain intensity over 6 months after GP consultation.

FIG. 3. Course of quality of life (EQ-5D) over 6 months after GP consultation for
shoulder pain.

100
months, increasing to only 32% after 12 months [24]. Similarly,
90 in a recent study on non-traumatic arm, neck and shoulder
80
complaints [17], 25% of participants reported complete recovery
after 6 months. These studies demonstrate a poor outcome of neck
Shoulder disability (0–100)

70 and shoulder symptoms, but included very heterogeneous

60 populations. In a previous analysis of our cohort [18], we
developed a prediction rule for shoulder pain with perceived
50
recovery as outcome measure, and used the total cohort that was
40 heterogeneous with respect to baseline symptom duration. For the
30
current analysis, we decided to study the influence of potential
prognostic factors in more detail, by looking at their effect on
20 absolute changes in shoulder pain intensity, and by investigating
10 prognostic factors in more homogeneous subgroups of patients.
Given the strong evidence for the prognostic value of symptom
0
0 5 10 15 20 25 30 duration we decided to stratify our analyses for acute, subacute
Follow-up time (weeks) and chronic pain at presentation, creating more homogeneous
subgroups with different characteristics, and demonstrating a
Acute (0–6 weeks) Subacute (6–12 weeks) different prognosis.
Chronic (> 12 weeks)

FIG. 2. Course of shoulder pain-related disability (SDQ) over 6 months after GP

consultation.
baseline pain intensity. The model shows, for example, that with
each point increase in baseline pain intensity (scale 0–10) the mean
change in pain at 6 months increased by 0.84 points (95% CI 0.71,
0.98). The explained variance was 46% at 6 months. Predictors
of a better outcome at 6 months for chronic shoulder pain were
lower scores on pain catastrophizing and higher baseline pain
intensity scores. The model explained 21% of the variance in pain
reduction at 6 months.
Discussion
The results of our prospective cohort study showed a mean pain
reduction of 70% among patients presenting with acute shoulder
pain, compared with 54% in those with subacute symptoms and
44% in patients with chronic pain at baseline. The course of
functional disability presented very similar patterns. There was
little change in quality of life during follow-up. Prognostic factors
partly differed between patients with acute/chronic shoulder pain.
Course of shoulder symptoms
In a previous study on neck and shoulder complaints in general
practice, 24% of patients reported complete recovery after 3
Prognostic factors
Previous prognostic cohort studies have showed that several
disease characteristics (symptom duration, levels of disability and
more intense pain) are indicators of a poor outcome of neck or
shoulder complaints [9, 10, 12, 14–17]. Our analyses confirmed the
association between baseline levels of pain and disability, and
changes in symptoms during follow-up. In our study, higher pain
intensity at baseline was associated with larger reductions of pain
at follow-up in both patients with acute or chronic shoulder pain.
This finding may be explained by the fact that more pain at
baseline leaves more room for improvement during follow-up [12].
It has previously been suggested that psychosocial factors such
as worrying [12], somatization [17, 28], catastrophizing [28],
distress [28, 29] and fear-avoidance beliefs [28, 30, 31] are likely to
predict a poor outcome of painful musculoskeletal conditions. The
association between psychosocial factors and musculoskeletal
pain has mainly been established in patients with chronic pain
syndromes [31, 32]. In our population, somatization was
associated with poorer outcome in the univariable analyses, but
the association was no longer significant in the multivariable
model. More catastrophizing, however, was significantly related
to smaller reductions of pain at follow-up in patients with chronic
shoulder pain. We previously reported an association between
catastrophizing thoughts and perceived recovery of shoulder pain
at 3 months follow-up [33], but our analyses now show that in
patients with chronic shoulder pain, catastrophizing is the
728 M. Reilingh et al.

TABLE 3. Predictors of change in pain intensity after 6 months: univariable associations

Acute shoulder pain (n ¼ 190) Significance Chronic shoulder pain (n ¼ 224) Significance
Mean change (95% CI)a Mean change (95% CI)a

Age (per year older) 0.01 (0.02, 0.04) 0.50 0.02 (0.01, 0.05) 0.30
Baseline disability score (SDQ, per point increase) 0.02 (0.00, 0.03) 0.01 0.02 (0.00, 0.04) 0.04
Catastrophizing (PCCL, per point increase) 1.00 (0.44, 1.57) 0.01 0.26 (0.72, 0.20) 0.26
External locus of control (PCCL, compared < 3)
3–4 0.35 (0.63, 1.32) 0.49 0.79 (1.60, 0.02) 0.06
>4 0.22 (0.89, 1.33) 0.70 0.21 (0.92, 1.35) 0.71
Somatization (4-DSQ,  5 vs < 5) 0.87 (0.23, 1.98) 0.12 0.16 (1.01, 0.68) 0.71
Paid work (yes vs no) 0.95 (1.85, 0.06) 0.04 0.31 (1.07, 0.45) 0.42
Gradual onset (vs sudden) 0.56 (1.43, 0.3) 0.21 0.59 (1.51, 0.34) 0.21
Previous episode (yes vs no) 0.61 (0.25, 1.47) 0.16 0.07 (0.75, 0.88) 0.87
Baseline pain intensity (per point increase) 0.78 (0.65, 0.90) 0.00 0.59 (0.43, 0.74) 0.00
Dominant side affected (yes vs no) 0.28 (0.58, 1.14) 0.52 0.01 (0.78, 0.79) 0.99
Repeated movement with arms or wrists (yes vs no) 0.65 (1.53, 0.24) 0.15 0.11 (0.72, 0.94) 0.79
Pain in neck or upper extremities (yes vs no) 1.05 (0.21, 1.89) 0.02 0.19 (0.95, 0.58) 0.63

a
Positive values indicate larger reductions in pain, negative values indicate an increase in pain (per point increase on the predictor).

TABLE 4. Predictors of change in pain intensity for patients with acute shoulder pain (R2 ¼ 0.46) or chronic shoulder pain (R2 ¼ 0.21) after 6 months follow-up: results of
multiple linear regression analyses

Acute shoulder pain (n ¼ 190) Significance Chronic shoulder pain (n ¼ 224) Significance
Mean change (95% CI)a Mean change (95% CI)a

Baseline disability score (per point increase) 0.01 (0.03, 0.00) 0.03
Catastrophizing (per point increase) 0.62 (1.03, 0.20) 0.001
Baseline pain intensity (per point increase) 0.84 (0.71, 0.98) 0.001 0.65 (0.48, 0.81) 0.001

a
Positive values indicate larger reductions in pain, negative values indicate an increase in pain (per point increase on the predictor).

strongest predictor of change in pain intensity over 6 months
follow-up, next to baseline levels of pain.
Catastrophizing [34] is considered to be an ineffective coping
strategy in which pain is perceived as overly destructive, and
patients have a pessimistic view of their prognosis. The fact that
catastrophizing was especially important in patients with chronic
shoulder pain may indicate that catastrophizing is a consequence of
pain, rather than a predictor of the development of chronic pain.
Surprisingly, Table 3 also shows that in patients with acute pain,
catastrophizing was associated with larger improvements of
pain, even though the association was weak and not statistically
significant in the multivariable model. Possibly, this is a chance
finding. Alternatively, based on the assumption that the catastro-
phizing scale measures if patients are more strongly oriented
towards pain stimuli, one may hypothesize that patients with high
scores on catastrophizing avoid pain-provoking activities, which
may actually be an effective strategy in the acute phase of a shoulder
problem. Inadequate beliefs and attributions of pain, however, may
become stronger when pain persists, or when recurrences of pain
occur. If the negative influence of catastrophizing can be confirmed
in other shoulder pain populations, future research might be aimed
at the development and evaluation of interventions aimed at
reducing such negative processes, from which patients with chronic
shoulder pain in primary care may benefit.
Strengths and weaknesses
Our sample of shoulder pain patients is relatively large, allowing
stratification of patients according to duration of their symptoms.
Drop out among patients was low (8% at 6 months). Although
drop-outs were younger, more often showed an acute onset and
less repetitive movements in their work, the absolute differences in
age, acute onset and repetitive movements were not large and it is
unlikely that these differences have strongly influenced the
reported associations between potential predictors and outcome.
The prognostic model for patients presenting with acute
shoulder pain explained 46% of the variance in pain scores at
follow-up, but for chronic pain patients this was only 21%. This
means that much of the variance in this patient group remains
unexplained. Even though we included a wide variety of potential
predictors, we may have missed relevant predictors, such as social
support or aspects of the psychosocial work environment [17, 35,
36]. We may also have been unable to measure important
predictors with sufficient accuracy. Exposure to physical load,
for example, was measured using a few simple questions, but has
been shown to be associated with neck or shoulder pain in other
cohorts [36, 37]. Further research is needed to identify relevant and
preferably modifiable predictors of outcome, especially in patients
with chronic shoulder symptoms. Studies carried out in occupa-
tional settings may be more suitable to address the importance of
work-related factors in the prognosis of shoulder pain.
We decided not to include treatment in our models, as we
assumed that confounding by indication could influence our
findings. Patients with more severe symptoms and thus, probably
a poorer outcome, are more likely to receive more exten-
sive treatment. Our results seem to confirm this assumption;
the proportion of patients receiving wait-and-see policy or pain
medication was higher in patients with acute pain compared with
chronic pain, while the proportion of physiotherapy referrals was
higher among those with chronic shoulder pain. However, the
large majority of patients in each subgroup was treated by
wait-and-see or medication in the first month, indicating that our
GPs largely adhered to the Dutch practice guidelines for shoulder
complaints, which recommend such a policy during the first 2–4
weeks after presentation [19]. This means that our subgroups
were relatively homogeneous regarding treatment at baseline.
Treatment variables were, indeed, not strongly associated with
outcome nor strongly influenced the association of other
predictors (data not shown).
Clinical usefulness
In The Netherlands, nearly every Dutch resident is registered with
a GP. Patients first visit their GP before visiting a specialist in
rheumatology or orthopaedics. This is comparable with, for
instance, the British healthcare system. The participating prac-
tices, being situated in both rural and urban areas in various
provinces, form a representative sample of Dutch GPs. Although
we encouraged GPs to select every eligible patient, we do not
know what proportion of patients was invited or whether this was
 Course and prognosis of shoulder symptoms
a selective sample. When asking GPs about their success in
recruiting patients, they indicated that common reasons for not
including patients concerned the exclusion criteria and lack of
time or motivation to ask all patients during consultation hours.
Patient characteristics at baseline and overall recovery rates (30%
after 6 weeks and 54% after 6 months) were similar to those found
in other studies carried out in primary care populations [9–11],
which may strengthen the generalizability of our findings to other
primary care patients with shoulder problems.
The GPs in our study adhered to the stepwise approach
recommended by the national guidelines, and offered injections or
physiotherapy to only a few patients. Our findings indicate that
GPs can take duration of symptoms at presentation into account,
and do not necessarily have to apply the same stepwise approach to
each patient with shoulder pain. A more targeted approach (with
for example, advice regarding pain coping strategies, or more
early referral for exercise) might lead to better patient outcomes in
chronic shoulder pain patients, but this needs to be confirmed by
randomized research. As yet, the results from our study may help
GPs to provide patients with more accurate information on the
expected course of their symptoms. By separately analysing acute,
subacute and chronic shoulder pain, we were able to present
prognostic information for more homogeneous subgroups of
patients compared with previous cohorts.
Conclusion
The results of this study indicate that patients presenting with acute,
subacute or chronic shoulder pain show different baseline character-
istics, a different course of symptoms, and possibly, also different
predictors of outcome after 6 months. Improvement of symptoms in
patients presenting with acute shoulder pain was mainly predicted by
the severity of pain and disability, whereas psychological factors may
influence outcome in those with chronic shoulder pain. The
importance of psychosocial factors in patients with chronic shoulder
pain needs to be confirmed in further research, as this may provide
input for the development of future interventions.
Rheumatology key messages
 Previous studies demonstrate poor outcome of shoulder symp-
toms, but have included heterogeneous populations.
 Our study shows that both course and prognosis differs between
patients presenting with either acute or chronic shoulder pain.
Acknowledgements
We would like to acknowledge the contribution of all patients and
general practitioners who participated in this project.
Funding: This study was supported by a grant (No. 904-65-09)
from The Netherlands Organisation for Scientific Research
(NWO), The Hague, The Netherlands.
Disclosure statement: The authors have declared no conflicts of
interest.
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