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Prevalence, diagnostics and management of musculoskeletal disorders in primary health care in Sweden - an investigation of 2000 randomly selected patient records

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Rationale, aims and objectives: The aims of this study is to investigate the prevalence of patients seeking care due to different musculoskeletal disorders (MSDs) at primary health care centres (PHCs), to chart different factors such as symptoms, diagnosis and actions prescribed for patients that visited the PHCs due to MSD and to make comparisons regarding differences due to gender, age and rural or urban PHC. Methods: Patient records (2000) for patients in working age were randomly selected equally distributed on one rural and one urban PHC. A 3-year period was reviewed retrospectively. For all patient records' background data, cause to the visit and diagnosis were registered. For visits due to MSD, type and location of symptoms and actions to resolve the patients problems were registered. Data was analysed using cross tabulation, multidimensional chi-squared. Results: The prevalence of MSD was high; almost 60% of all patients were seeking care due to MSD. Upper and lower limb problems were most common. Symptoms were most prevalent in the young and middle age groups. The patients got a variety of different diagnoses, and between 13 and 35% of the patients did not receive a MSD diagnose despite having MSD symptoms. There was a great variation in how the cases were handled. Conclusions: The present study points out some weaknesses regarding diagnostics and management of MSD in primary care.
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Prevalence, diagnostics and management of musculoskeletal
disorders in primary health care in Sweden an investigation of
2000 randomly selected patient records
Birgitta Wiitavaara PhD,
1
Martin Fahlström MD PhD
2
and Mats Djupsjöbacka PhD
3
1
Senior Lecturer, Centre for Musculoskeletal Research, Department of Occupational and Public Health Sciences, University of Gävle, Gävle, Sweden
2
Senior Lecturer, Department of Clinical Sciences, Professional Development, Umeå University, Umeå, Sweden
3
Senior Researcher, Associate Professor, Centre for Musculoskeletal Research, Department of Occupational and Public Health Sciences, University of
Gävle, Umeå, Sweden
Keywords
diagnosis, evaluation, health care, health
services research
Correspondence
Wiitavaara Birgitta
Centre for Musculoskeletal Research,
Department of Occupational and Public
Health Sciences
University of Gävle
SE-801 76 Gävle, Sweden
E-mail: biawia@hig.se
Accepted for publication: 1 July 2016
doi:10.1111/jep.12614
Abstract
Rationale, aims and objectives The aims of this study is to investigate the prevalence of
patients seeking care due to different musculoskeletal disorders (MSDs) at primary health
care centres (PHCs), to chart different factors such as symptoms, diagnosis and actions pre-
scribed for patients that visited the PHCs due to MSD and to make comparisons regarding
differences due to gender, age and rural or urban PHC.
Methods Patient records (2000) for patients in working age were randomly selected
equally distributed on one rural and one urban PHC. A 3-year period was reviewed retro-
spectively. For all patient recordsbackground data, cause to the visit and diagnosis were
registered. For visits due to MSD, type and location of symptoms and actions to resolve
the patients problems were registered. Data was analysed using cross tabulation, multidi-
mensional chi-squared.
Results The prevalence of MSD was high; almost 60% of all patients were seeking care
due to MSD. Upper and lower limb problems were most common. Symptoms were most
prevalent in the young and middle age groups. The patients got a variety of different diag-
noses, and between 13 and 35% of the patients did not receive a MSD diagnose despite
having MSD symptoms. There was a great variation in how the cases were handled.
Conclusions The present study points out some weaknesses regarding diagnostics and
management of MSD in primary care.
Introduction/background
Musculoskeletal disorders (MSD) constitute a problem of great
public health importance, which mostly is managed in primary
care settings. The problem is substantial, as about half the adult
population is reported to experience some sort of musculoskeletal
symptoms (4155% point prevalence) and 3945% to have long-
lasting problems [1,2]. Of those who experience musculoskeletal
symptoms, about 3045% can be expected to consult a general
practitioner (GP) for their problems [1,3]. Accordingly, MSD im-
ply signicant individual suffering, individual and societal costs
for sick leave as well as considerable costs for health care. To im-
prove the care of patients suffering from MSD, further knowledge
regarding the prevalence, diagnostics and management of different
MSD in primary care is required.
The course of MSD is marked by periods of remission and ex-
acerbation [46], and most individuals do not experience complete
resolution of their symptoms and disabilities [4,68]. The current
inuence of medical care on the natural history of MSD has been
questioned [9]. In a group of working aged patients seeking care
for non-specic back or neck pain, it can be expected that about
half will report pain and disability after 5 years, and a signicant
proportion will report recurrent or continual pain and health care
consumption [7]. A study on health care utilization among patients
with neckshoulder pain [10] showed that one half of the patients
in the study had one or more additional visit, one quarter had ad-
ditional episodes of care for pain in other locations, and 20% of
the women and 7% of the men had 10 or more visits per year. It
was concluded that the cause to the frequent visits might be that
the local symptomatology is a part of multisite MSD symptoms.
To be able to plan for effective measures in rehabilitation, further
knowledge is needed about the prevalence of different MSD in pri-
mary care, which symptoms patients seek care for and if these are
local or multisite symptoms.
Primary care physiciansdifferent approaches in treatment of
MSD have been described as low action, multimodal and
psycho-social/non-opioid [11] and the most often used options as
diagnostic tests (e.g. radiography), referral to medical specialist
[12], physiotherapy, medication [12,13], no actions at all [12]
and watchful waiting[14]. Different factors can inuence not
Journal of Evaluation in Clinical Practice ISSN1365-2753
Journal of Evaluation in Clinical Practice (2016) © 2016 John Wiley & Sons, Ltd.
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only the management decisions, patient-related factors as diagnos-
tic category, long duration of pain and high functional limitations,
but also GP characteristics such as less clinical experience, solo
practice, working in a rural area [14] and the gender of the physi-
cian and the patient [14,15]. An interesting question worth looking
further into is how different MSDs are managed in practice and
which measures are taken in relation to which symptoms. There
is a need to improve rehabilitation for this group and at the same
time use available funding wisely. As no recent studies of the con-
ditions in Sweden were found, we deemed this important to
investigate.
There is a multitude of diagnoses used in the area of MSD, and
many of those are symptom-based. In a study of patients seeking
care (20012002) for neck pain (traumatic and non-traumatic), a
symptom-based diagnosis was used in 64% of the visits, and the
single most common diagnosis was neck sprain or strain [16].
Many patients in this group do not even get a diagnosis assigned
to their problems [16]. In a Swedish study of patients seeking care
(19941997) for neck or shoulder disorders did as few as 58% of
the male cases, and 71% of the female cases receive a conrmed
diagnosis [17]. A study of treatment in eight European countries
(20012002) showed similar results, as 4875% of those who
sought care for musculoskeletal pain got a diagnosis [18]. De-
ciencies regarding diagnose registration related to the social insur-
ance system have also been found. The Swedish National Board of
Health and Welfare has investigated the documentation of diag-
nostic codes regarding sick leaves (in general) that ended during
2005 [19]. They found a decient documentation, as only about
500 000 of 624 000 cases had been assigned diagnose codes.
The aims of this study were-To investigate the prevalence of pa-
tients seeking care due to different MSDs at primary health care
centers (PHCs); and-To chart different factors as symptoms, diag-
nosis and actions prescribed for patients that visited the PHCs due
to MSD; and nally-To make comparisons regarding differences
due to gender, age and rural or urban PHC.
Methods
Design
The study was a cross-sectional study comprising content analysis
of patient records from two PHCs in Sweden and descriptive sta-
tistics of the content.
Sample
Considering aspects of societal structure, as well as differences be-
tween PHCs regarding the organization of care, one urban and one
rural PHC were chosen. The urban PHC was located in a univer-
sity city, while the rural PHC was located in the countryside, both
in northern Sweden. The population that was allocated to the dif-
ferent PHCs were 10000 and 7000 persons respectively. The num-
ber of visits per year to the different PHCs were approximately
9000 and 7000 respectively.
The population in the present study constituted of people seek-
ing care from a physician at either the rural or urban PHC. The in-
tent was to collect 2000 patient records, disregarding diagnosis,
equally distributed on the PHCs. The sample was delimited to
records for patients in working age (1865). Patient records were
sampled for visits to a physician between 1 January and 31 De-
cember 2007. Sampling of records was made by using randomly
selected work week dates to collect records from. Every time a
specic date occured, a record was selected from that date, starting
with the last visit of the day, followed by the one before, etc. As
the dates were selected randomly did the number of selected re-
cords differ between dates. As many records were extensive, a
time limit of 3 years of notes was chosen. First, a random sample
of 100 records to a pilot study were attained, and a test of the
workability of the database was made. Then, the remaining 1900
dates were sampled.
Data extraction
Obtained data was registered in a database. For all patient records,
age, gender, date of visit, if it was a new visit or re-visit, cause of
the visit and diagnosis related to the visit were registered. A visit
was considered to be due to MSD if the patient was given a MSD
diagnose, a musculoskeletal condition was named or described in
aeld for cause of visit or in the anamestic data in the patient record
at the day of visit or the analysed period (3 years). For visits due to
MSD, the location of the patient symptoms, which symptoms were
described in the patient record, the type of those symptoms, which
actions were prescribed to resolve the patients problems and also
sickleave prior to and after the visit were registered.
Definition of variables
Regarding diagnosis, the analysis specically focused non-
specic, non-traumatic musculoskeletal conditions that means
ICD-10 codes M00M99, with the exclusion of trauma, infection,
systemic diseases (as systemic lupus erythematosus, psoriasis,
gout, rheumatoid arthritis), periferal osteoarthritis, congenital or
acquired deformities (as cox plana, Morbus Bechterew, hallux val-
gus). Included, besides M0099, were ICD-10 codes R29 (Other
symptoms and signs of disease from the nervous and musculoskel-
etal system) and R52 (Pain and ache which is not classied
elsewhere).
Symptoms for MSD cases were classied into six anatomical
pain locations, head,neckshoulder,upper limb,thoracic spine,
lower back and lower limb, based on descriptions in the records
at the day of visit.
MSD cases were grouped based on pain location, and the most
common diagnoses were counted.
Measures taken for MSD cases were categorized separately for
neckshoulder and low back pain. Neckshoulder and low back
pain were selected as problems in these regions and often are char-
acterized as non-specicand thereby constitute a challenge to
treat. Categories were created based on a content analyses of mea-
sures described in the records. This resulted in nine categories.
Data analysis
Data for MSD at the day of visit was analysed using cross tabula-
tion, multidimensional chi-squared (Pearson), logistic regression
and a probability level of P<0.05. All statistical analyses were
performed using PASW statistics for Windows 18.0 (SPSS).
B. Wiitavaara et al.Prevalence, diagnostics and management of musculoskeletal disorders
© 2016 John Wiley & Sons, Ltd.
Ethical considerations
This project has been reviewed and approved by the ethics com-
mittee in Uppsala, Sweden (no. 2007/333). Measures to assure
condentiality and to comply with current Swedish laws and reg-
ulations have been taken.
Results
Of the selected and reviewed 2000 patient records, 49 were ex-
cluded (due to, e.g. wrong age of the patient or that the patient
had not met the doctor at the visit as, a result of human error in
sampling) that left 1951 records for further analysis. Mean age
of the sample was 44 years. As evident from Table 1, the number
of patient rose by age, which was true for both for the whole sam-
ple and the rural PHC. The urban PHC differed a bit regarding age
distribution of patients as the amount of patients in the younger pa-
tient groups was almost twice as high compared with the rural
PHC and the lowest count of patients was in the age group 55
65 years. The representation of women in the sample was slightly
higher than of men totally, at the rural PHC and at the urban PHC.
Prevalence of different musculoskeletal disorders among
patients seeking care
The prevalence of MSD in the sample (Table 1) was high; almost
60% of the patients had some sort of MSD described in the record
either at the day of the visit or in the rest of the reviewed 3-year
time period. The distribution of MSD between the PHCs showed
a slight overweight of patient with MSDs at visit in the rural
PHC sample compared with the urban, while the opposite was
present for MSD during the preceding 3-year period.
The sample was reviewed for registered ICD-10 diagnose codes
at the selected visit and for the reviewed 3-year period (Table 1).
Some patients had several diagnoses registered at the day of the
visit. Among those, there were patients where the MSD symptoms
were not the main cause of the visit but still a part of the patients
problems and registered as a diagnose. In the rural PHC, 19% of
patients visiting the PHC had an ICD-10 code related to MSD reg-
istered as diagnose. For the urban PHC, the corresponding number
was 13% and for the total sample 16%.
The prevalence of MSD symptoms was higher among women
than men both regarding patients seeking care for MSD at the ac-
tual visit and MSD in the record for the 3-year period. Of the
whole sample, 29% had MSDs at visit; of those were 15% women
and 14% men. Within gender, this constituted 27% of the women
and 31% of the men. There were no signicant differences be-
tween the genders regarding getting a MSD ICD-10 diagnose
assigned to their problems. When controlling for covariates in a lo-
gistic regression model with PHC rural/urban as independent var-
iable, the signicant results for age and MSD in record were
conrmed. However, for the differences regarding gender, MSD
diagnose and MSD at the visit, the signicance did not remain.
In the logistic regression, all dependent variables were entered as
covariates (age, gender, MSD diagnose, MSD status at visit/in
record).
Symptoms patients with musculoskeletal disorder seek
care for
The total amount of patients seeking care for musculoskeletal
symptoms was larger at the rural PHC than the urban (Table 2).
Visits for all sorts of symptoms, except for pain in the thoracic
spine, were signicantly more common at the rural PHC than the
urban. Most common were lower and upperlimb symptoms,
followed by symptoms from the low back and neckshoulder.
Table 1 Base data and prevalence of musculoskeletal disorders (MSDs)
in the sample (%)
Primary Health
Care Centre
Rural Urban Total x
2
P
Age
1825 11.4 18.9 15.1
0.000
***
2635 11.9 18.4 15.1 82.07
3645 17.7 21.6 19.6
4655 25.8 23.2 24.5
5665 33.2 17.9 25.6
Gender
52.9 59.3 56.1 7.88 0.005
**
47.1 40.7 43.9
MSD symptoms
-At visit 32.8 24.4 28.7 19.13 0.000
***
-In record 26.1 32.4 29.2
MSD diagnose 18.6 13.2 15.9 10.46 0.001
***
Table 2 Symptoms people seek care for
Primary Health Care Centre
Rural Urban Total
x
2
PPain location n%n%n%
Head 17 0.9 6 0.3 23 1.2 5.132 0.023
*
Neckshoulder 55 2.8 34 1.7 89 4.6 4.816 0.028
*
Upper limb 131 6.7 74 3.8 205 10.5 16.618 0.000
***
Thoracic spine 38 1.9 26 1.3 64 3.3 2.115 0.146ns
Lower limb 154 7.9 96 4.9 250 12.8 14.297 0.000
***
Low back 66 3.4 48 2.5 114 5.8 2.695 0.101ns
Total 461 23.6 284 14.5 745 38.2
n= 1951.
Prevalence, diagnostics and management of musculoskeletal disordersB. Wiitavaara et al.
© 2016 John Wiley & Sons, Ltd.
There were some differences regarding the age distribution for
different pain locations (Fig. 1). Neckshoulder symptoms were
most prevalent in the younger age groups. Among those 89 pa-
tients with symptoms from this location, 33% were 2635 years
old, while only 6% were 4655 years old. Upper limb pain was
also most prevalent in the youngest age groups. Pain in the tho-
racic spine was most prevalent among patients 3645 years old
and least prevalent in the oldest age group 5665 years old.
The occurrence of multiple pain locations was also investigated
(Table 3). The highest number of patients with only one pain loca-
tion was among those with lower or upper limb symptoms, while
the lowest was for head symptoms. On the opposite, patients with
head symptoms or thoracic spine symptoms had the highest num-
bers for multiple pain locations [46]. However, the co-morbidity
regarding symptoms is high among most of these patients. As an
example did 35% of those with head symptoms have symptoms
from three different locations, as well as 21% of those with
neckshoulder symptoms, 20% of those with pain in thoracic spine
and 9% of those with upper limb symptoms.
Diagnoses patients get assigned to their symptoms
As expected, the majority of the patients (between 35 and 70%)
were assigned M diagnoses (Diseases of the musculoskeletal sys-
tem and connective tissue) to their musculoskeletal symptoms,
but there were also other diagnose codes registered (Table 4).
The larger amount of M diagnoses among low back patients may
indicate that it is easier to assign a M diagnose to such symptoms.
Besides M diagnoses, the patients received R diagnoses, as R29
(Other symptoms and signs involving the nervous and musculo-
skeletal systems), R51 (Headache) and R52 (Pain, not elsewhere
classied). G diagnoses also were quite common, as for example
G 44 (Tension-type head ache), as well as Z diagnoses that cover
Factors inuencing health status and contact with health services].
0
5
10
15
20
25
30
35
40
45
18-25 26-35 36-45 46-55 56-65
% within NeckShoulde
r
n=89, X2=9.6, p*
% within UpperLimb
n=205, X2=10.8, p*
% within ThxSpine
n=64, X2=13.9, p**
% within LBP
n=114, X2=5.5, ns
% within LowerLimb
n=250, X2=2.8, ns
% within Head n=23,
X2=6.3, ns
Figure 1 Age distribution among people seeking care for different
symptoms.
Table 3 Engagement of different symptom locations
Number of symptom locations
Reported
symptoms
1 2 3 4-6 Total
n%n%n%n%n
Head 1 4 9 39 8 35 5 22 23
Neck
shoulder 14 16 46 52 19 21 10 11 89
Upper limb 131 64 43 21 19 9 13 6 205
Thoracic
spine 25 39 17 27 13 20 9 14 64
Low back 51 45 43 38 9 8 11 9 114
Lower limb 175 70 52 21 13 5 10 4 250
n= 745.
Table 4 Proportion of different ICD-10 diagnoses at the day of visit at
the PHC
Symptoms %
ICD-10
diagnoses Head
Neck
shoulder
Upper
limb
Thoracic
spine
Low
back
Lower
limb
M diagnoses 35 57 58 45 70 58
R diagnoses 9 6 1 11 9 3
G diagnoses 13 4 3 3 0 1
Z diagnoses 22 11 12 8 7 10
Other
diagnoses 17 14 22 27 9 24
No diagnose 4 8 4 6 5 4
100 100 100 100 100 100
Diagnose groups: M = musculoskeletal system and connective tissue,
R = symptoms, signs and clinical ndings not classied elsewhere,
G = nervous system, Z = encounter for examination.
Table 5 Common diagnoses in the symptom groups
Symptom n
Most prevalent
diagnoses n%
Head 23 M53.0 Cervicocranial syndrome 3 14
G44.2 Tension-type headache 3 14
M53.1 Cervicobrachial syndrome 2 9
R51 Headache 2 9
Neckshoulder 89 M53.1 Cervicobrachial syndrome 11 12
M54.9 Dorsalgia, unspecied 8 9
M79.1 Myalgia 6 7
M54.2 Cervicalgia 5 6
Upper limb 205 M77.9 Enthesopathy, unspecied 17 8
M25.5 Pain in joint 13 6
M53.1 Cervicobrachial syndrome 10 5
M54.9 Dorsalgia, unspecied 10 5
M79.9 Soft tissue disorder,
unspecied 9 4
Thoracic spine 64 M54.9 Dorsalgia, unspecied 9 14
M54.6 Pain in thoracic spine 7 11
R07.0 Pain in throat 4 6
Low back 114 M54.9 Dorsalgia, unspecied 25 22
M54.5 Low back pain 23 20
M54.4 Lumbago with sciatica 14 12
R10.3 Pain localized to other parts
of lower abdomen or pelvis 5 4
Lower limb 250 M25.5 Pain in joint 30 12
M79.9 Soft tissue disorder,
unspecied 13 5
M54.4 Lumbago with sciatica 12 5
M54.9 Dorsalgia, unspecied 11 4
M77.9 Enthesopathy, unspecied 11 4
B. Wiitavaara et al.Prevalence, diagnostics and management of musculoskeletal disorders
© 2016 John Wiley & Sons, Ltd.
Between 4 and 8% of the patients did not receive any diagnose at
all, and between 9 and 27% had another diagnose registered,
which was not related to their musculoskeletal symptoms.
The most common diagnoses (Table 5) for head symptoms were
M53.0 cervicocranial syndrome and G44.2 Tension-type head-
ache. For those with neckshoulder symptoms, M53.1
Cervicobrachial syndrome was the most common. For patients
with upper limb symptoms, M77.9 Enthesopathy unspecied
was the most prevalent. Symptoms in the thoracic spine most often
got the diagnose M54.9 Dorsalgia unspecied assigned. The pa-
tients with low back pain most often got the diagnoses M54.9
Dorsalgia, unspecied or M54.5 Low back pain. Those with lower
limb symptoms most often not onlt obtained the diagnosis M25.5
Pain in joint but also diagnoses related to back pain and unspeci-
ed disordes in soft or connective tissue.
Measures taken at the visit to resolve the patients
problems
There was a great variation in how the cases were handled (Ta-
bles 6 and 7). Many different measures were taken for the patients,
varying between individuals. Each individual often received sev-
eral different measures. Most common measure for those with
low back pain was medication (mostly analgesics, sick leave cer-
ticates, followed by medical rehabilitation as physiotherapy,
group rehabilitation, e.g.), and further referral to other clinic for
continued examination or treatment. Work-related rehabilitation,
such as workplace adjustment, work training or similar, was less
commonly registered.
For patients seeking care for neck pain, the most common mea-
sures taken were the same: medication (mostly analgesics) and
sick leave. Further referral to other clinic for continued examina-
tion or treatment was also quite common, as was medical rehabil-
itation. Work-related rehabilitation, such as workplace adjustment,
work training or similar, was more often registered for neck pain
than for low back pain. About a tenth of the group had an ordina-
tion of sample taking or advice. Await future development of the
disorder was the measure for 4%.
Discussion
The prevalence of MSD in the studied group shows high gures:
29% of the patients that sought care at the PHCs had musculoskel-
etal symptoms at the day of visit. Other studies indicate that there
is a high prevalence of different musculoskeletal problems in gen-
eral, which is compared with our result among PHC visitors. A re-
view of prevalence studies [20] shows that one third of the adult
population report shoulder pain, up to one half low back pain
and one fth wide spread pain during a 1-month period. According
to the Eumusc.net report no. 5 [21], MSD constitutes 38% of the
total of work-related disorders. This is in accordance with the
numbers that apply for Sweden. Looking at the incidence of new
cases for long-term sick leave (>90 days), 30% for municipal
and county council employees and 40% for Swedish trade and
industry/private sector employees were caused by MSD (M00
M99) [22]. Worth noting is that all visits included in this study
was to see a doctor, so those who sought directly to a physical
therapist adds to the total number of patients who seek care for
MSD. So, the results are not applicable for all patient seeking all
sorts of care for MSD, only those seeking care from a physician.
The prevalence of MSD at the visit was higher in the rural PHC
sample than in the urban, while the prevalence of MSD in the
Table 6 Measures taken at the visit to resolve the low back pain patientsproblems
Measure
Diagnose
n/
Diagnose
None/
await
Sick
leave Advice
Medical
rehab
Work rel.
rehab Medication
Sample
taking
Further
referral Aids
M51.9 Intervertebral disc disorder, unspecied 3 3 1 1
M54.3 Sciatica 1 1
M54.4 Lumbago with sciatica 14 13 1 11 1 9 1 2
M54.5 Low back pain 20 1 10 2 4 1 8 1 6 1
M54.9 Dorsalgia, unspecied 23 4 10 2 10 7 1
R10.3P Pain localized to other parts
of lower abdomen 5 1 2 2 2
R52 Pain, not elsewhere
classied 3 1 3 1
Z03.9
Observation for suspected
disease or condition,
unspecied 1 1 1 1
Z71.9 Counselling, unspecied 3 1 1 2 1
2. Diagnose missing,
continued investigation 1 1 1 1
4. Diagnose missing
symptoms investigated 4 4 3
Individuals that received different measure n78 2 34 5 19 5 38 4 22 3
% 3 44 6 24 6 49 5 28 4
Note that each individual often received a combination of several different measures.
Prevalence, diagnostics and management of musculoskeletal disordersB. Wiitavaara et al.
© 2016 John Wiley & Sons, Ltd.
record during the examined 3-year period was higher in the urban
PHC. It is difcult to draw any conclusions regarding this, but we
know that there are differences regarding the population in the dif-
ferent areas. The urban PHC had a larger amount of young pa-
tients, as well as of a higher educational level, as a university is
situated there. The rural PHC had an older population consisting
of a large amount of blue collar worker with a lower educational
level, which can explain the higher prevalence of MSDs at visit.
However, further analysis is required to be able to draw conclu-
sions regarding differences between the rural and urban areas.
The analysis of age distribution of patients seeking care for dif-
ferent symptoms showed that neckshoulder and upper limb pain
were most prevalent in the youngest age groups, while thoraco-
spinal pain was most prevalent among those 3645 years old.
These results differ from studies of prevalence in the general pop-
ulation. For example, the prevalence of neck pain have shown ei-
ther no association with age or a peak prevalence at 3050 years of
age [23], and the 1-year prevalence of thoracic spine pain was
shown to increase up to 50 years of age and then level out [24].
Thus, the prominent decline in the prevalence of MSDs for pa-
tients older than 45 years in our study cannot likely be explained
by the prevalence in the general population but must be saught
in other causes. Our results also contrasts to previous studies on
the prevalence of MSD in primary care that suggest symptoms to
become more prevalent with increasing age up to 50 years and
then level out [25,26]. As often in research on MSD, differing def-
initions of MSD can make comparisons difcult. In the present
study, we used both symptoms registered in the medical chart
and ICD-10 diagnose when available. Previous studies on consul-
tation in primary care did, for example, either focus one condidion
as low back pain [27,28] or shoulder pain [26,29] or included spe-
cic diseases as osteoarthritis, osteoporosis or psoriatric arthritis
[25,30] and did not present data separately for non-specic, non-
traumatic MSD in relation to age, as the present study.
The co-morbidity was high regarding symptom engagement. A
great portion of the patients had multiple pain locations engaged.
Patients with head or thoracic spine symtoms had the highest num-
bers for multiple pain locations [46] (22 and 14% respectively).
The high co-morbidity found for patients with pain in the head
may reect that chronic tension-type headache, the most common
type of headache, is associated with generalized pain hypersensi-
tivity in skin and muscles [31].
Regarding diagnoses, M diagnoses were most common, as ex-
pected. However, there was a quite wide spectre to be found
among the diagnoses. Beside the M diagnoses, the patients also re-
ceived R, G, Z or other diagnoses. The R, G and Z diagnoses were
Table 7 Measures taken at the visit to resolve the neck shoulder pain patientsproblems
Measure
Diagnose
n/
Diagnose
None/
await
Sick
leave Advice
Medical
rehab
Work rel.
rehab Medication
Sample
taking
Further
referral Aids
G44.2 Tension-type headache 2 1 1 1
M15.9 Polyarthrosis, unspecied 2 2
M25.5 Pain in joint 3 1 3 1
M43.6 Torticollis 2 2 1
M50.9 Cervical disc disorder, unspecied 1 1
M53.0 Cervicocranial syndrome 1 1
M53.1 Cervicobrachial syndrome 8 1 5 1 3 1 3 1
M54.2 Cervicalgia 5 1 2 1 3 1 2
M54.6 Pain in thoracic spine 3 2 1 1 1 2
M54.9 Dorsalgia, unspecied 6 2 1 3 1 2
M75.1 Rotator cuff syndrome 1 1
M77.9 Enthesopathy, unspecied 1 1
M79.1 Myalgia 5 2 1 1 2 3 2 1
R51 Headache 1 1 1
R52 Pain, not elsewhere classied 2 1 1 1 2
Z00.0 General medical examination 2 1 1 1
Z02 Examination and encounter for
administrative purposes 1
Z03.9 Observation for suspected disease
or condition, unspecied 2 1 1 2
Z54.P Convalescence 1 1 1
Z71.9 Counselling, unspecied 1 1
2. Diagnose missing, continued
investigation 3 1 1 1
4. Diagnose missing symptoms
investigated 1 1
Individuals that received different measures: n54 2 20 5 12 9 24 6 15 0
% 4% 37% 9% 22% 17% 44% 11% 28% 0%
Note that each individual often received a combination of several different measures.
B. Wiitavaara et al.Prevalence, diagnostics and management of musculoskeletal disorders
© 2016 John Wiley & Sons, Ltd.
somewhat logically related to the patientsmusculoskeletal symp-
toms. However, some patient had no diagnose registered at the
visit, while others had a diagnose that was not related to their mus-
culoskeletal symptoms. Combining those two latter groups gives a
number between 13 and 35% of the patients that did not receive a
specic MSD diagnose related to the symptoms they sought care
for. Being believed and getting a diagnosis has previously been ac-
knowledged as an important part of patients possibility to build
self-esteem and coping strategies in rehabilitation [32], why we
see this as a possible problem both for the individual patient as
well as for the health care system. So, based on our ndings, there
seems to be some room for improvement regarding uniformity in
documentation of diagnoses in the patient charts, which previously
has been conrmed [19]. The major reform regarding sick leave
and rehabilitation that has been set in practice in Sweden from
2008 and forth [19,33] has hopefully led to improvement. The
aim of this reform was to lower the high numbers of sick leave,
by several changes of the process. One of the measures that have
been taken is the introduction of a web-based tool for the diagnos-
tics of different diagnoses, with recommendations regarding treat-
ment and normal length of sick leave [34].
This lead to the next point worth noticing: measures taken to re-
solve the patientsproblems. For both low back pain and neck
shoulder pain, the most common measures taken were sick leave
certicates, medication (mostly non-steroid analgesics, non-
steroidal anti-inammatory drugs [NSAIDs]), medical rehabilita-
tion (as physiotherapy or group therapy) or further referral to other
clinic for continued examination or treatment. The dominant pre-
scription of NSAIDs for musculoskeletal pain, 79% compared
with under 10% for alternative drugs, is found by others [35].
There were low numbers for work-related rehabilitation. The pre-
viously mentioned reform [33,34] was aimed at improving return
to work, including increased responsibility and engagement of
the workplace in the rehabilitation process and governmental eco-
nomical support for multimodal rehabilitation of patients with
MSD [36]. The results from the present study are based on patient
records assessed just before this reform was implemented and can
thus provide a valuable baseline for evaluation of the effect of this
reform on diagnosis of patients with MSDs as well as on the mea-
sures taken for rehabilitation.
Conclusion
The present study points out some weaknesses regarding diagnos-
tics and management of MSD in primary care. Further studies to
compare the results regarding diagnoses for musculoskeletal
symptoms and measures taken to solve the patientsproblems
and to make a comparison before and after the reform would be
of interest.
Author contributions
BW, MF and MD all made substantial contributions to conception,
design and acquisition of data. BW and MD made the analysis and
interpretation of data. BW, MF and MD all were involved in
drafting the manuscript or revising it critically for important intel-
lectual content.
Conict of interest
The authors declare that they have no competing interests.
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Introduction The world’s population is experiencing an increasing prevalence of depressive disorders. A comprehensive literature review identifies a schism between current medical interventions and the increasing prevalence. Current treatment paradigms warrant analysis. Objective This manuscript theorizes an interdisciplinary team inclusive of physiotherapy as a standard would reverse the increasing prevalence. Physiotherapists’ musculoskeletal expertise and biopsychosocial approach play a valuable role in mental health. Methods A clinical narrative review of depression, including parallels with chronic pain, is provided as a substantive foundation. The review includes challenges in primary care as the gateway to mental health. Depression’s underlying mechanisms, standard interventions, current theories, and future paradigms are explored. Results A theoretical construct was formulated. This construct identified compromised emotion-regulation and self-efficacy as common dysfunctions that enables and perpetuates depression. Physical activity with cognitive reappraisals positively influences these common dysfunctions and improves general intervention outcomes. The psychologically informed physiotherapist is defined. Physiotherapists can provide functional interventions and cognitive reappraisals that address biopsychosocial needs and build resilience. Conclusion Individualized physical and functional activity that facilitate therapeutic alliance, functional improvements, cognitive reappraisals, emotion-regulation and self-efficacy delivered by a physiotherapist provide sustainable behavioral change and completes the interdisciplinary mental health team.
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Introduction. The prevalence of musculoskeletal disorders (MSDs) and non-communicable diseases (NCDs) increases with age. Purpose. The study examined the impact of MSDs and NCDs on work ability, using the Work Ability Index (WAI), among aging office workers (between 45-60 years old) and determined factors associated with WAI scores. Methods. A cross-sectional study was conducted in office workers from 27 government offices in Bangkok and nearby provinces using an online questionnaire. Analyses were conducted using Mann-Whitney U test and multivariable logistic regression model. Results. Of 689 workers (452 females and 237 males), 34%, 13%, 12%, and 41% reported MSDs, NCDs, MSDs + NCDs, and no MSDs/NCDs, respectively, in the past year. Median scores (interquartile range) of WAI were 37.0 (6) for MSDs, 37.0 (4) for NCDs, 34.5 (6) for MSDs + NCDs, and 40.0 (4) for no MSDs/NCDs. Significant difference in WAI scores was found between the MSDs and MSDs + NCDs (p = 0.005); and between the NCDs and MSDs + NCDs (p < 0.001). Female, high work experience, and low job control were significantly associated with reduced WAI scores (WAI ≤ 36). Conclusion. The presence of MSDs or NCDs reduced work ability among aging office workers compared to their healthy counterparts. Having MSDs + NCDs further reduced work ability.
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Isolated biceps tendon rupture is rarely reported at primary care level. A 78-year-old man presented with deformity over his right mid arm for one week, following a low impact trauma over his right shoulder six weeks prior. Physical examination revealed the classical sign of rupture of the long head of biceps tendon (LHBT) which showed bulging of his right biceps muscle, resembling the famous cartoon character, "Popeye The Sailorman". Diagnosis of rupture of LHBT was made in the primary care clinic without the need of imaging modality based on the identification of the "Popeye Sign". Diagnosis and condition have been explained well to patient and caretaker without the need for inappropriate investigation and procedures. Conservative treatment approach was opted. His condition was stable without new active complaints on subsequent follow up. This case proved that stable ruptures of LHBT are still possible to be managed at primary care level.
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Background Uncertainty exists with regards to the extent of prevalence and health care use for musculoskeletal disorders in Norway. The aim of this study was to estimate the prevalence of chronic musculoskeletal disorders and to estimate the prevalence of persons receiving primary and specialist health services for these disorders. Methods We used three data-sources. First, four discrete years of the nationally representative cross-sectional Survey of Health and Living Conditions (SHLC) conducted in 2002, 2005, 2008 and 2012 by Statistics Norway. Second, we used the Norwegian Patient Registry (NPR) to estimate the proportion of the population who used specialist health services in 2012. Third, we used the national register dataset for reimbursement of primary care physicians, chiropractors and physiotherapists (KUHR) to estimate the proportion of the population attending primary care physicians, chiropractors or physiotherapists in 2012. Age- and sex-specific prevalence/utilization estimates for musculoskeletal disorders were calculated. Results In 2012, 18% of men and 27% of women reported musculoskeletal disorders lasting for six months or more in the SHLC. Primary health care services reimbursed for musculoskeletal disorders were used by 37% of women and 30% of men. Of these 32% (women) and 26% (men) were physician contacts and between 5 and 9% physiotherapist or chiropractor or combined contact types. Corresponding numbers for specialist services were 5% in men and 7% in women, where the majority was out-patient consultations. Low back and neck pain were the most common diagnoses both in the general population and as reason for health care utilization. We found that musculoskeletal disorders increased with age, however our results showed no variation in prevalence of chronic disorders between 2002 and 2012. Conclusion Chronic musculoskeletal disorders were common in the general population, with higher prevalence among women compared to men, and increasing prevalence with age. Musculoskeletal disorders had considerable impact on the use of primary and specialist health services in Norway. The use of register data on health service utilization may be a useful source for monitoring population trends, and for estimating the burden in terms of health and health service use.
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Objective: The aim of this study was to calculate the incidence and prevalence of radiating low back pain, to explore the long-term clinical course of radiating low back pain including the influence of radiculopathy (in a subsample of the study population) and non-radiating low back pain thereon, and to describe general practitioners' (GPs') treatment strategies for radiating low back pain. Design: A historic prospective cohort study. Setting: Dutch general practice. Subjects: Patients over 18 years of age with a first episode of radiating low back pain, registered by the ICPC code L86. Main outcome measures: Incidence and prevalence, clinical course of illness, initial diagnoses established by the GPs, and treatment strategies. Results: Mean incidence was 9.4 and mean prevalence was 17.2 per 1000 person years. In total, 390 patients had 1193 contacts with their GPs; 50% had only one contact with their GP. Consultation rates were higher in patients with a history of non-radiating low back pain and in patients with a diagnosis of radiculopathy in the first five years. In this study's subsample of 103 patients, L86 episodes represented radiculopathy in 50% of cases. Medication was prescribed to 64% of patients, mostly NSAIDs. Some 53% of patients were referred, mainly to physiotherapists and neurologists; 9% of patients underwent surgery. Conclusion: Watchful waiting seems to be sufficient general practice care in most cases of radiating low back pain. Further research should be focused on clarifying the relationship between radicular radiating low back pain, non-radicular radiating low back pain, and non-radiating low back pain.
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Objectives To assess the consultation prevalence of musculoskeletal (MSK) conditions as presented in different healthcare systems, and to determine the feasibility of comparing prevalence figures between nations. Methods The settings were an English regional database (Consultations in Primary Care Archive (CiPCA)) and the Swedish Skåne County Health Care Register. Case definitions, data extraction and analysis procedures were harmonised. The number of people consulting per 10 000 registered population in primary care, and in primary or secondary care, in the year 2010 (annual consultation prevalence) were determined for doctor-diagnosed osteoarthritis (OA), rheumatoid arthritis (RA), low back pain, and spondyloarthritis including psoriatic arthritis and ankylosing spondylitis (AS). Seven-year period consultation prevalences were also determined. Results Combining primary and secondary care, annual consultation prevalences of any MSK condition (2143 vs 1610/10 000) and low back pain (587 vs 294/10 000) were higher in England than in Sweden, but higher for RA, spondyloarthritis and psoriatic arthritis in Sweden. Annual primary care prevalence figures for OA (176 vs 196/10 000), RA (25 vs 26/10 000), spondyloarthritis (both 8/10 000) and psoriatic arthritis (5 vs 3/10 000) were similar between England and Sweden. AS was rarely recorded in Swedish primary care. These patterns were also observed for 7-year period consultation prevalences. Conclusions A rigorous methodological approach allowed feasible comparison of MSK consultation prevalence between England and Sweden. Differences in prevalence of inflammatory and unspecific pain conditions may be partially explained by known variations in healthcare systems and recording practice. Routine healthcare data offers potential for investigating variations in occurrence and outcome of MSK conditions between nations.
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Background To assess the annual consultation prevalence and new onset consultation rate for doctor-diagnosed shoulder pain conditions. Methods We identified all residents in the southernmost county in Sweden who received a shoulder pain diagnosis during 2006 (ICD-10 code M75). In subjects who did not consult due to such disorders during 2004 and 2005, we estimated the new onset consultation rate. The distribution of specific shoulder conditions and the length of the period of repeated consultation were calculated. Results Annual consultation prevalence was 103/10 000 women and 98/10 000 men. New onset consultation rate was 80/10 000 women (peak in age 50–59 at 129/10 000) and 74/10 000 men (peak in age 60–69 at 116/10 000). About one fifth of both genders continued to consult more than three months after initial presentation, but only a few percent beyond two years. Rotator cuff - and impingement syndromes were the most frequent diagnoses. Conclusion The annual consultation prevalence for shoulder pain conditions (1%) was similar in women and men, and about two thirds of patients consulted a doctor only once. Impingement and rotator cuff syndromes were the most frequent diagnoses.
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The aim of this study was to explore the experience of bodily illness among people with musculoskeletal disorders (MSDs) in the neck/shoulder region. The study had a grounded theory approach, with constant comparisons and simultaneous data collection and analysis. Initially, parts of interviews about health experiences related to MSDs previously performed among men and women with musculoskeletal symptoms in the neck/shoulder and/or back were analysed. Next, complementary semi-structured interviews among men and women with neck/shoulder problems were performed, focusing on the experience of bodily illness, until saturation was reached. The results describe the experiences of bodily illness among people with MSDs in the neck/shoulder region as being characterized by uncontrollable fluctuations. The experiences are presented as a model of the disease course as experienced by the affected. The process usually developed from a beginning with insidious symptoms to a state of constant discomfort. Along the line of this development, periods of intermittent events of increasing illness occurred with peaks of consuming intensity. A variety of different symptoms was present during the process, which are presented in this paper. An increased knowledge of the disease course can be useful in prevention and treatment as communication about the disorder can be more specific.
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To study the incidence, prevalence, and consultation rates of patients with shoulder complaints in general practice in the Netherlands during 10 years following initial presentation. A primary care database with an average population of 30,000 patients per year aged 18 years or older was used to select patients who consulted their general practitioner (GP) with shoulder complaints in the northern part of the Netherlands in the year 1998. Information about consultations for shoulder complaints was extracted. Incidence and prevalence for men, women, and different age groups were calculated for 9 and 10 years. A total of 526 patients consulted their GP with a new shoulder complaint. During an average follow-up of 7.6 years, these patients consulted their GP 1331 times because of their shoulder complaints (average of 0.33 consultations per year). Almost half of the patients consulted their GP only once. Patients in the 45-64 age category had the highest probability of repeated GP consultations during follow-up. Average incidence was 29.3 per 1000 person-years. Women and patients in the 45-64 age category have the highest incidence. The annual prevalence of shoulder complaints ranged from 41.2 to 48.4 per 1000 person-years, calculated for the period 1998 to 2007, and was higher among women than among men. Although the incidence of shoulder complaints in general practice is as high as 29.3 per 1000 person-years, GPs' workload is generally low, as nearly half of these patients consult their GP only once for their complaint.
Article
OBJECTIVE To investigate factors associated with visiting a general practitioner (GP) for non-inflammatory musculoskeletal pain, and to examine whether these factors were affected by duration (chronic vnon-chronic) or location (widespread vregional) of pain. METHODS From a cross sectional postal survey of 20 000 (response rate 59%) randomly selected adults in two counties of Norway, 6408 subjects who had experienced musculoskeletal pain during the past month were included. Patients who reported inflammatory rheumatic diagnoses made by a doctor were excluded. RESULTS 2909 (45%) had consulted a GP for their musculoskeletal pain during the past 12 months. The odds of consulting were significantly increased by being a woman, by having a higher age and lower education, and by being a pensioner or on sick leave. Patients with widespread pain were more likely to consult than those with regional pain, as were patients with chronic compared with non-chronic pain. Greater than median pain intensity was the factor most prominently associated with consultation for men (odds ratio (OR)=2.4; 95% confidence interval (95% CI) 2.0 to 2.9) and for women (OR=2.6; 95% CI 2.3 to 2.9). Overall, consultation was significantly associated with mental distress for women but not for men. Subgroup analyses showed that consultation for chronic pain was significantly associated with greater than median mental distress for both women (OR=1.3; 95% CI 1.1 to 1.6) and men (OR=1.2; 95% CI 1.0 to 1.4), whereas consultation for non-chronic pain was not. CONCLUSION The results show that about half of the patients with musculoskeletal pain consult a general practitioner (GP) each year, that demographic factors are associated with consulting, and that the role of mental distress for consulting a GP varies with duration of pain.
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Study Design. A 2-year follow-up study was conducted to investigate new patients who sought care for low back pain from all the caregivers in a specific region with a population of approximately 17,000 men and women ages 20 to 59 years. Objectives. To describe care-seeking behavior for low back pain in a general population; to characterize pain, disability, and sick leave among the patients; and to study predictors of recovery. An additional aim was to find a simple way of classifying low back pain in epidemiologic studies. Summary of Background Data. Low back pain is very common, but its natural history in a general population and predictors of recovery are not fully known. Methods. All the patients went through a clinical examination, and data on personal, medical, and occupational history were collected. Follow-up assessments were made during a 2-year period. Results. Whereas 50% of the patients went to physicians and physiotherapists for treatment, 50% went to other caregivers. Some improvements in pain and disability were reported after 3 months, but not many after that. Approximately 70% of the care seekers had not been on sick leave during the follow-up period. Care seeking during the follow-up period was not associated with reduced pain and disability. No predictive factors for recovery were found. A simple pain drawing made by the patient gave information about pain distribution similar to that found by clinical examination. Conclusions. In a general working population in Sweden ages 20–59 years, approximately 5% sought care because of a new low back pain episode during a 3-year period. Few of the care seekers became pain-free during the follow-up period. This study strengthens the hypothesis that low back pain often becomes chronic even when sick leave is rare.
Article
The aim of this study was to assess the influence of work-related physical and psychosocial factors on seeking care for neck or shoulder disorders among men and women in a general working population. The study population comprised gainfully employed (>17 hours per week) men and women in the municipality of Norrtälje, altogether 392 cases and 1,511 controls. Cases were defined as persons seeking care because of neck or shoulder disorders by any caregiver in the region. The study began in 1994 and continued to 1997. We assessed physical and psychosocial exposures by questionnaires and interviews. The pattern of seeking care for neck or shoulder disorders differed between men and women. Among men, work with vibrating tools [relative risk (RR) = 1.6], not having a fixed salary (RR = 1.9), and low demands in relation to competence (RR = 1.5) were the strongest risk indicators obtained in analyses stratified for age and previous symptoms. Among women, repetitive hand or finger movements (RR = 1.6), constrained sitting (RR = 1.6), not having a fixed salary (RR = 2.0), and solitary work (RR = 1.8) were the strongest risk indicators. A large proportion of the general population was exposed to several of these moderately harmful conditions, and their concomitant effect may explain the high incidence of neck and shoulder disorders in the general working population.
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Low back pain (LBP) affects most people at some stage in life. However, the burden on the health care system is unclear. We studied: 1) the 1-year consultation prevalence, 2) the rate of first-time consultation for LBP and the relationship of the frequency to other musculoskeletal conditions, and 3) the health care utilization of patients with LBP compared to the general population. Using the health care register in Southern Sweden (population 1.2 million), including diagnoses (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) by physicians, we identified all patients who in 2009 were diagnosed with LBP, defined as lumbago with sciatica, low back pain, or other/unspecified dorsalgia. We defined first-time consultation as a consultation in 2009 without a record of an LBP diagnosis in 2004-2008. Standardized health care utilization ratios were calculated for LBP patients compared to the general population seeking care. The 1-year consultation prevalence of LBP in the population was 3.8% (4.3% for women, 3.3% for men) and increased with age. LBP had been recorded in 17.1% of all patients (16.5% for women, 18.0% for men) who had been diagnosed with any musculoskeletal condition. The rate of first-time consultation was 238 per 10,000 adults (265 for women, 209 for men). The health care utilization ratios in female and male patients with LBP were 1.74 (95% confidence interval [95% CI] 1.73-1.75) and 1.81 (95% CI 1.80-1.82), respectively. LBP, diagnosed in every sixth patient who consulted due to a musculoskeletal problem, is a public health concern that needs structured management. Patients with LBP consume close to twice as much health care as the general population and this warrants more awareness.