Margit Kooijman

Prognostic factors | 83 measures were very diverse and often consisted of a combination of several things at once, such as the SPADI, DASH and UCLA questionnaires, which measure pain and disability and some also range of motion, strength and/or patient satisfaction. Since pain and dis- ability are the most common outcome measures, the choice was either to exclude studies in which other measures were used leaving the problem of combined measures, or to classify outcome as better or poorer. The authors agreed on this simplification, aware of the loss of nuance that might be relevant to the individual patient and clinician. Included tables should provide them with more detailed information or the reference as to where to find it. For future research, we recommend to carry out more research in physiotherapy practices since only one study was conducted in this setting, which indicates that the influence of age, gender, onset and pain on outcome in this setting might be different from general practice. Even more so since these complaints are very common and in many countries patients do not need a referral from a physician (anymore) to visit a physiotherapist. Kuijpers et al. (2004) uncovered the need for well- conducted prospective cohort studies 8 . Those published since are indeed of much higher quality and the prognostic factors, however many, much better de- scribed. However, regardless of the setting, before starting new studies, researchers should consider the wide variety in outcome measures that exists which hamper synthesis of results. In our opinion, research into patient reported outcome measures (PROM’s) is useful here since PROM’s not only reflect the patients’ perception but also because when standardized, they facilitate comparison between studies. The methods for conducting systematic reviews of studies regarding prognostic questions itself are still in development, as well as a system for rating the quality of a body of evidence. In the future the GRADE system, which is widely used for questions regarding interventions, will be available for the subject of prognosis as well 20,21 . There are some implications for clinical practice as well. From previous research it is known that patients with shoulder problems are mainly treated in primary care by general practitioners or physiotherapists. Present review shows that pain severity, concomitant neck pain and duration of symptoms have prognostic value for outcome in primary care settings. Since these are clinical variables that can be influenced, clinicians may take these factors into account in the management of their patients. Whereas current Dutch guidelines for general practitioners advise a wait-and-see policy for all patients with shoulder pain at first, they may decide to monitor those patients with a worse prognosis more frequently and alter the treatment plan timely if complaints persist.