Inter-professional agreement of ultrasound-based diagnoses in patients with shoulder pain between physical therapists and radiologists in the Netherlands

Scoping Review of Curricula and Pedagogical Approaches for Physiotherapist Performed Point of Care Ultrasonography

Purpose

This study collates and maps physiotherapy pre- and post-licensure curricula and pedagogical approaches for point of care ultrasonography (POCUS).

Method

We used a standardized scoping review methodology and reporting framework. A total of 18,217 titles and abstracts, and 1,372 full text citations were screened, with 209 studies classified as physiotherapist performed POCUS.

Results

Of the 209 studies, 15 evaluated pre- and post-licensure curricula and pedagogical approaches. Seventy-two to 98% of pre-licensure programs reported including theoretical knowledge of POCUS and 44-45% reported practical teaching or competency assessment. In post-licensure studies of POCUS, 0-61% of physiotherapists reported training for POCUS. All studies of post-licensure pedagogical approaches included an assessment of theoretical knowledge of POCUS, but only one study included a practical assessment of competency. There was considerable variability in POCUS methods and duration of pedagogical approaches. Except for one study, all pedagogical approaches reported improvement in theoretical knowledge.

Conclusion

Progress in physiotherapy-specific, standardized, competency-based curricula and pedagogical approaches in POCUS has been limited, with minimal research available, and considerable variability both pre- and post-licensure. These findings could be used to advocate for the inclusion of POCUS in pre- and post-licensure physiotherapy curriculum, and suggest a need for clear guidelines from regulatory colleges and licensing bodies, and a common terminology for physiotherapist performed POCUS. Future directions for research include a systematic review of the psychometric properties of physiotherapist performed POCUS within and across anatomical areas, an assessment of value of different forms of training, and an evaluation of the impact of physiotherapist performed POCUS on patient outcomes.

Design and validation of depth camera-based static posture assessment system

Postural abnormalities have become a prevalent issue affecting individuals of all ages, resulting in a diminished quality of life. Easy-use and reliable posture assessment tools can aid in screening for and correcting posture deviation at an early stage. In this study, we present a depth camera-based static posture assessment system to screen for common postural anomalies such as uneven shoulders, pelvic tilt, bowlegs and knock-knees, forward head, scoliosis, and shoulder blade inclination. The system consists of an Azure Kinect camera, a laptop, and evaluation software. Our system accurately measures skeleton and posture indexes and shows favorable agreement with a golden standard optical infrared motion capture system. The findings indicate that the system is a low-cost posture assessment tool with high precision and accuracy, suitable for initial screening of postural abnormalities in individuals of all ages.

An interexaminer agreement and reliability study on cadavers with musculoskeletal ultrasound of the shoulder performed by physiotherapists and radiologists compared with dissection

STUDY DESIGN

A cross-sectional inter-examiner agreement and reliability study on fresh frozen cadaver shoulders.

BACKGROUND

Musculoskeletal ultrasound (MSU) is frequently used by physical therapists and radiologists to improve specific diagnosis in rotator cuff related pathology. The evaluation of the rotator cable seems to be important as stabilizing structure when cuff tears occur.

OBJECTIVES

To evaluate the inter-examiner agreement and reliability of MSU of the shoulder to detect rotator cuff-pathology and the involvement of the rotator cable in comparison to "dissection".

METHODS

Physical therapists, a radiologist and an orthopedic surgeon (dissection) investigated 40 fresh frozen cadaver shoulders in order to detect shoulder pathology including rotator cable involvement. Examiners were blinded to each other's findings.

RESULTS

We found a strong and significant agreement between the raters: PTs, the radiologist and the dissector in this cadaver study for all rotator cuff, the long head of the biceps pathologies and in detecting abnormalities of the rotator cable. The kappa value was substantial to (almost) perfect agreement for all diagnostic outcome categories.

CONCLUSIONS

This study shows that among a limited group of physical therapists, one radiologist and a dissector a strong level of agreement with kappa values from substantial to (almost) perfect in finding subacromial pathology.

Variations in the Course and Diameter of the Suprascapular Nerve: Anatomical Study

(1) Background: Suprascapular neuropathy is an important factor contributing to shoulder pain. Given the prevalence of nerve injury and nerve block in the suprascapular notch region, as well as the frequency of arthroscopic procedures on the suprascapular notch, which are recommended in shoulder pain management, its morphology is relevant from a clinical perspective. (2) Methods: Suprascapular nerve course was studied in twelve shoulders by dissection. Its diameter was measured at omohyoid level, proximal to the suprascapular notch and distal to the spinoglenoid notch. A multi-vari chart was used in order to descriptively visualize the results. The variations found were analyzed with a mixed linear model. (3) Results: In two of the six subjects, the suprascapular nerve was divided into two motor branches proximal to the superior transverse scapular ligament. An increase in diameter around the suprascapular notch was detected, with an estimated difference between diameter means of 2.008 mm at the suprascapular notch level and 2.047 mm at the spinoglenoid notch level. (4) Conclusions: A difference in the estimated diameter detected and the fact that the motor branches, which innervate supraspinatus and infraspinatus muscle, were divided proximal to the suprascapular notch may be relevant in the diagnosis and treatment of suprascapular neuropathy and arthroscopic procedures.

Diagnostic ultrasound in patients with shoulder pain: An inter-examiner agreement and reliability study among Dutch physical therapists

STUDY DESIGN

A cross-sectional inter-examiner agreement and reliability study among physical therapists in primary care.

BACKGROUND

musculoskeletal ultrasound (MSU) is frequently used by physical therapists to improve specific diagnosis in patients with shoulder pain, especially for the diagnosis rotator cuff tendinopathy (RCT) including tears.

OBJECTIVES

To estimate the inter-examiner agreement and reliability in physical therapists using MSU for patients with shoulder pain.

METHODS

Physical therapists performed diagnostic MSU in 62 patients with shoulder pain. Both physical therapists were blinded to each other's results and patients were not informed about the test results. We calculated the overall inter-examiner agreement, specific positive and negative inter-examiner agreement, and inter-examiner reliability (Cohen's Kappa's).

RESULTS

Overall agreement for detecting RC ruptures ranged from 61.7% to 85.5% and from 43.9% to 91.4% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures. Overall agreement for other pathology than ruptures related to SAPS, ranged from 72.6% to 93.6% and from 77.3% to 96% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures and 52.5%-83.3% for other pathology than ruptures related to SAPS. Reliability values varied from substantial for any thickness ruptures to moderate for partial thickness ruptures and fair for full thickness tears. Moreover, reliability was fair for cuff tendinopathy. The reliability for AC arthritis and no pathology found was fair and moderate. There was substantial agreement for the calcifying tendinopathy.

CONCLUSIONS

Physical therapists using MSU agree on the diagnosis of cuff tendinopathy and on the presence of RCT in primary care, but agree less on the absence of pathology.

One in six physiotherapy practices in primary care offer musculoskeletal ultrasound - an explorative survey

BACKGROUND

The first aim of this research was to investigate the current prevalence of musculoskeletal ultrasound in Dutch physiotherapy practices. The second aim was to explore experiences of physiotherapists with musculoskeletal ultrasound in a primary care setting with patients presenting with shoulder complaints.

METHODS

A random sample of 1000 owners of primary care physiotherapy practices was sent a questionnaire to investigate the prevalence of musculoskeletal ultrasound. A second questionnaire was sent to physiotherapists using musculoskeletal ultrasound to explore experiences with it in patients with shoulder complaints.

RESULTS

The net response rate of the first questionnaire was 57.7%. In 18% of the physiotherapy practices musculoskeletal ultrasound was offered. Sixty-nine physiotherapists returned the second questionnaire. Physiotherapists indicated they most often used musculoskeletal ultrasound in patients with shoulder complaints, mainly for suspected tissue damage (83.7%), followed by making a diagnosis (63.3%) and for determining the choice of treatment (36.7%). Physiotherapists reported the biggest advantage was that they were better able to diagnose presenting shoulder complaints. The most frequently mentioned disadvantage of the use of musculoskeletal ultrasound was that assessment is difficult and that there is a risk that findings may not be sufficiently linked to history and physical examination.

CONCLUSION

One in six physiotherapy practices in the Netherlands offer musculoskeletal ultrasound. It is mainly used for patients with shoulder complaints, with an emphasis on detecting tissue damage and as an aid for diagnosis. Physiotherapists trained to work with musculoskeletal ultrasound seem enthusiastic and are at the same time aware of its disadvantages.

Does the outcome of diagnostic ultrasound influence the treatment modalities and recovery in patients with shoulder pain in physiotherapy practice? Results from a prospective cohort study

STUDY DESIGN

Prospective cohort study including patients with shoulder pain in primary care physiotherapy.

BACKGROUND

There is an increased tendency to use diagnostic ultrasound to aid the diagnostic strategy and target treatment. It is a relatively cheap and accessible imaging technique but the implications for practice and patients are unknown.

OBJECTIVES

To study the influence of diagnostic ultrasound (DUS) on diagnostic work-up, treatment modalities and recovery.

METHODS

Participants (n = 389) with a new episode of shoulder pain were assessed at baseline and followed for 6, 12 and 26 weeks. Diagnostic work-up, including the use of DUS, and treatment strategies were reported by the therapists at 3, 6 and 12 weeks.

RESULTS

Most patients (41%) were diagnosed with subacromial impingement/pain syndrome after physical examination or DUS. DUS was used in 31% of the participants. Tendinopathy was the most found abnormality in this sub-population. Patients who underwent DUS were more frequently treated using exercise therapy. Patients that not had DUS were more likely to receive massage therapy, trigger point therapy or mobilisation techniques. Logistic regression analyses did not show a significant association between DUS and recovery after 26 weeks (0.88, 95%CI:0.50-1.57). Correcting for the therapist as a confounder using a multilevel binary logistic regression did not show a significant cluster effect.

CONCLUSION

Diagnostic US as a work-up component does not seem to influence diagnosis or recovery but does influence the choice of treatment modality. Conclusions are limited to observational data. High quality randomized trials should study the effect of DUS on recovery.

Agreement between physical therapists and radiologists of stratifying patients with shoulder pain into new treatment related categories using ultrasound; an exploratory study

STUDY DESIGN

A systematic overview of the literature and an agreement study.

OBJECTIVES

The aim of this study is to explore the inter-professional agreement of diagnostic musculoskeletal ultrasound (DMUS) between physical therapists (PT) and radiologists, using a new classification strategy based upon the therapeutic consequences in patients with shoulder pain.

BACKGROUND

DMUS is frequently used by PTs, although the agreement regarding traditional diagnostic labels between PTs and radiologists is only fair. Nevertheless, DMUS could be useful when used as a stratifying-tool.

METHODS

First, a systematic overview of current evidence was performed to assess which traditional diagnostic labels could be recoded into new treatment related categories (referral to secondary care, corticosteroid injections, physical therapy, watchful waiting). Next, kappa values were calculated for these categories between PTs and radiologists.

RESULTS

Only three categories were extracted, as none of the traditional diagnostic labels were classified into the 'corticosteroid injection' category. Overall, we found moderate agreement to stratify patients into treatment related categories and substantial agreement for the category 'referral to secondary care'. Both categories 'watchful waiting' and 'indication for physical therapy' showed moderate agreement between the two professions.

CONCLUSION

Our results indicate that the agreement between radiologists and PTs is moderate to substantial when labelling is based on treatment consequences. DMUS might be able to help the PT to guide treatment, especially for the category 'referral to secondary care' as this showed the highest agreement. However, as this is just an explorative study, more research is needed, to validate and assess the consequences of this stratification classification for clinical care.

Musculoskeletal ultrasound-guided physical therapy in hemiplegic shoulder pain: A CARE-compliant case report

RATIONALE

The use of musculoskeletal ultrasound (MU) method in the diagnosis of shoulder pain and injury and guidance of injection and pain blocking has been established. However, the treatment of posthemiplegic shoulder pain (HSP) with MU-guided precise physical therapy has not been reported.

PATIENT CONCERNS

Here, we present the first case report of a 64-year-old man with a right basal ganglia hemorrhage. Left side shoulder pain remained unbearable, which seriously affected sleep and shoulder-related activities.

INTERVENTIONS

The patient received MU-guided precise drug administration, laser, and other physical therapy in addition to exercise training for 2 months.

OUTCOMES

The pain was significantly relieved and shoulder function was improved. Effusion extent and tendon thickness were reduced.

LESSONS

MU-guided precise physical therapy can effectively reduce symptoms of HSP and improve inflammation and effusion absorption of lesioned tissue.

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background

Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings.

Objectives

Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.

Review methods

We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.

Results

We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.

Conclusions

In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.

Limitations

We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.

Future work

There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Physiotherapy for patients with shoulder pain in primary care: a descriptive study of diagnostic- and therapeutic management

BACKGROUND

Shoulder pain is one of the three main musculoskeletal complaints and more than 50% of the patients have symptoms longer than 6 months. Until now, limited data exist about the content of physiotherapy for patients with shoulder pain in primary care.

OBJECTIVE

Describe current physiotherapeutic diagnostic- and therapeutic management, including the use of diagnostic ultrasound, in patients with shoulder pain in primary care.

DESIGN AND SETTING

A prospective cohort study in primary care physiotherapy with a 12 week follow-up.

METHODS

Descriptive data from physiotherapists was collected, such as: the diagnostic hypotheses after patient history and physical examination, the use of specific tests and diagnostic ultrasound, the interventions used and possible changes in treatment plan.

RESULTS

Subacromial impingement syndrome was the most common hypothesis after patient history (48%) as well as physical examination (39%). Diagnostic ultrasound was used in 31% and of these patients the clinical diagnosis changed in 29%. Various interventions were used in all clinical diagnoses. After 12 weeks 41% of patients still received physiotherapy treatment.

CONCLUSIONS

Patients with shoulder pain in physiotherapy practice frequently show signs of subacromial impingement syndrome. The interventions used by the physiotherapists were generally in line with the guideline for subacromial impingement syndrome however a small proportion of physiotherapists used massage and tape/bracing techniques. A large proportion of patients were still receiving treatment after 12 weeks when no improvement was observed. If treatment for patients with subacromial impingement shows no benefit patients should be referred back to the general practitioner or orthopedic surgeon. Conclusions from this study might be slightly biased because of the selection of physiotherapists.

Ultrasound assessment for grading structural tendon changes in supraspinatus tendinopathy: an inter-rater reliability study

AIM

To evaluate the inter-rater reliability of measuring structural changes in the tendon of patients, clinically diagnosed with supraspinatus tendinopathy (cases) and healthy participants (controls), on ultrasound (US) images captured by standardised procedures.

METHODS

A total of 40 participants (24 patients) were included for assessing inter-rater reliability of measurements of fibrillar disruption, neovascularity, as well as the number and total length of calcifications and tendon thickness. Linear weighted κ, intraclass correlation (ICC), SEM, limits of agreement (LOA) and minimal detectable change (MDC) were used to evaluate reliability.

RESULTS

'Moderate-almost perfect' κ was found for grading fibrillar disruption, neovascularity and number of calcifications (k 0.60-0.96). For total length of calcifications and tendon thickness, ICC was 'excellent' (0.85-0.90), with SEM(Agreement) ranging from 0.63 to 2.94 mm and MDC(group) ranging from 0.28 to 1.29 mm. In general, SEM, LOA and MDC showed larger variation for calcifications than for tendon thickness.

CONCLUSIONS

Inter-rater reliability was moderate to almost perfect when a standardised procedure was applied for measuring structural changes on captured US images and movie sequences of relevance for patients with supraspinatus tendinopathy. Future studies should test intra-rater and inter-rater reliability of the method in vivo for use in clinical practice, in addition to validation against a gold standard, such as MRI.

TRIAL REGISTRATION NUMBER

NCT01984203; Pre-results.