Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study

The purpose of this study was to develop a short, reliable, and valid measure of physical function and symptoms related to upper-limb musculoskeletal disorders by shortening the full, thirty-item DASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure. Three item-reduction techniques were used on the cross-sectional field-testing data derived from a study of 407 patients with various upper-limb conditions. These techniques were the concept-retention method, the equidiscriminative item-total correlation, and the item response theory (Rasch modeling). Three eleven-item scales were created. Data from a longitudinal cohort study in which the DASH questionnaire was administered to 200 patients with shoulder and wrist/hand disorders were then used to assess the reliability (Cronbach alpha and test-retest reliability) and validity (cross-sectional and longitudinal construct) of the three scales. Results were compared with those derived with the full DASH. The three versions were comparable with regard to their measurement properties. All had a Cronbach alpha of > or = 0.92 and an intraclass correlation coefficient of > or = 0.94. Evidence of construct validity was established (r > or = 0.64 with single-item indices of pain and function). The concept-retention method, the most subjective of the approaches to item reduction, ranked highest in terms of its similarity to the original DASH. The concept-retention version is named the QuickDASH. It contains eleven items and is similar with regard to scores and properties to the full DASH. A comparison of item-reduction approaches suggested that the retention of clinically sensible and important content produced a comparable, if not slightly better, instrument than did more statistically driven approaches.

To estimate the national prevalence and incidence of adults consulting for a shoulder condition and to investigate patterns of diagnosis, treatment, consultation and referral 3 yr after initial presentation. Prevalence and incidence rates were estimated for 658469 patients aged 18 and over in the year 2000 using a primary care database, the IMS Disease Analyzer-Mediplus UK. A cohort of 9215 incident cases was followed-up prospectively for 3 yr beyond the initial consultation. The annual prevalence and incidence of people consulting for a shoulder condition was 2.36% [95% confidence interval (CI) 2.32-2.40%] and 1.47% (95% CI 1.44-1.50%), respectively. Prevalence increased linearly with age whilst incidence peaked at around 50 yr then remained static at around 2%. Around half of the incident cases consulted once only, while 13.6% were still consulting with a shoulder problem during the third year of follow-up. During the 3 yr following initial presentation, 22.4% of patients were referred to secondary care, 30.8% were prescribed non-steroidal anti-inflammatory drugs and 10.6% were given an injection by their general practitioner (GP). GPs tended to use a limited number of generalized codes when recording a diagnosis; just five of 426 possible Read codes relating to shoulder conditions accounted for 74.6% of the diagnoses of new cases recorded by GPs. The prevalence of people consulting for shoulder problems in primary care is substantially lower than community-based estimates of shoulder pain. Most referrals occur within 3 months of initial presentation, but only a minority of patients are referred to orthopaedic specialists or rheumatologists. GPs may lack confidence in applying precise diagnoses to shoulder conditions.

Most clinicians would probably agree that what patients think will happen can influence what does happen over the clinical course. Yet despite useful narrative reviews on expectancy of therapeutic gain and the mechanisms by which expectancy can affect health outcomes, we were unable to locate a systematic review of the predictive relation between patients' recovery expectations and their health outcomes. We searched MEDLINE for English-language articles published from 1966 to June 1998 with a title or abstract containing at least 1 of the medical subject headings (MeSH) "self-assessment," "self-concept" or "attitude to health," or the MeSH subheading "psychology," and at least 1 word from each of 3 sets: "patient" and similar words; a form of "expectation," "belief" or "prediction"; and a form of "recover," "outcome," "survival" or "improve." Relevant articles contained original research data, measured patients' recovery expectations, independently measured a subsequent health outcome and analyzed the relation between expectations and outcomes. We assessed internal validity using quality criteria for prognostic studies based on 6 categories (case definition; patient selection; extent of follow-up; objective outcome criteria; measurement and reporting of recovery expectations; and analysis). A total of 1243 titles or abstracts were identified through the computer search, and 93 full-text articles were retrieved. Forty-one of these articles met the relevance criteria, along with 4 additional articles identified through other means. Agreement beyond chance on quality assessments of 18 randomly selected articles was high (kappa = 0.87, p = 0.001). Sixteen of the 45 articles provided moderate-quality evidence and included a range of clinical conditions and study designs; 15 of the 16 showed that positive expectations were associated with better health outcomes. The strength of the relation depended on the clinical conditions and the measured used. Consistency across the studies reviewed and the evidence they provided support the need for clinicians to clarify patients' expectations and to assist them in having appropriate expectations of recovery. The understanding of the nature, extent and clinical implications of the relation between expectations and outcomes could be enhanced by more conceptually driven and methodologically sound research, including evaluations of intervention effectiveness.