Intertester reliability of a classification system for shoulder pain

Digital mapping of shoulder pain in patients with shoulder disorders: a reliability study

INTRODUCTION

Digital body mapping can be used to document and quantify the area and location (distribution) of pain and discomfort and support assessment, monitoring, and treatment in clinical populations. This study determines the test-retest reliability of drawings detailing pain and pins and needles using digital body charts and their relationship to pain intensity and patient-reported shoulder function.

METHODS

Sixty-two participants with shoulder disorder completed pain and pins and needles drawings with test-retest interval of 30 minutes. Pain intensity in the last week and the patient-reported shoulder function questionnaires were completed. Area and radiating extent were determined using customized software. To assess relative and absolute test-retest reliability, the intraclass correlation coefficient (ICC3,1), standard error of measurement (SEM) and minimal detectable change (MDC95) were calculated. Regression analysis evaluated relation between area and radiating extent of pain and pins and needles with patient-reported function questionnaires.

RESULTS

Relative reliability for pain area and radiating extent was excellent (>0.90). Absolute reliability (SEM and MDC95) values for the pain area and radiating extent were 0.20%/34 pixels and 0.57%/94 pixels. Absolute reliability improves for smaller pain areas. Regression analysis revealed the area and radiation extent for both pain and pins and needles are independent constructs to the patient-reported function outcome when adjusted for pain intensity.

CONCLUSIONS

Digital body mapping assessing pain area and radiation extent in patients with shoulder disorders are reliable. The magnitude of absolute reliability suggests other sources of variability on repeat testing in this population. Pain area and radiation extent appear to be independent constructs.

Investigating the effects of mobilization with movement and exercise on pain modulation processes in shoulder pain - a single cohort pilot study with short-term follow up

OBJECTIVE

To explore the association between manual therapy and exercise and pain modulation and clinical characteristics in people with musculoskeletal shoulder pain.

METHODS

This is a prospective, longitudinal, single cohort pilot study. People with shoulder pain for longer than 6 weeks underwent 4 weeks of glenohumeral mobilization with movement and shoulder exercises. Measures of pain modulation, shoulder pain, disability, range of motion and psychosocial factors were assessed at baseline and immediately after the 4-week period of treatment. Treatment effectiveness was assessed through parametric, non-parametric and multilevel modeling statistics.

RESULTS

Twenty-three individuals participatedwith no loss to follow-up. Significant and meaningful improvements in shoulder pain (NRS mean change 1.6/10, 95% CI 0.4 to 2.7), disability (SPADI mean change 20.5/100, 95% CI 13.1 to 27.9) and range of motion (mean change 33°, 95% CI 23 to 43°) were observed following treatment. Statistical but non-clinically meaningful changes were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55). Significant reductions were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55), however these were not considered clinically important. No association was found between clinical characteristics and sensory measures. No association was found between clinical characteristics and sensory measures.

CONCLUSION

Glenohumeral mobilization with movement and exercise did not improve pain modulation, despite improvements in pain, function and range of motion, in people with shoulder pain.

Shoulder assessment by smartphone: a valid alternative for times of social distancing

BACKGROUND

The delivery of orthopaedic care via telemedicine services has the potential to promote accessibility and decrease medical care expenses, while facilitating the control of infectious disease spreading. The purpose of this study was to assess agreement regarding diagnosis, recommended course of management and the perceived need for additional diagnostic testing between a video examination (VE) and a face to face (FTF) assessment of patients with shoulder disorders.

METHODS

Forty-seven (18 females) patients presenting to a shoulder surgery clinic were assessed consecutively by VE and a FTF examination. All assessments were conducted by a shoulder specialist. Agreement regarding the established diagnosis, the recommended course of management and the need for additional diagnostic tests was assessed using percent agreement and kappa (95% CI) coefficient. Differences in the content, duration and satisfaction between the two examination modes were also assessed.

RESULTS

Percent agreement and kappa (95% CI) coefficient for agreement regarding diagnosis were 85.1% and 0.82 (0.69-0.94), respectively. Percent agreement and kappa (95% CI) coefficient regarding the recommended course of management and the need for additional diagnostic testing were 61.7% and 0.43 (0.22-0.63), and 74.5% and 0.49 (0.25-0.74), respectively. The VE resulted in collection of less physical examination information, took longer to complete and was associated with less satisfaction by both patient and examiner.

CONCLUSIONS

Video examination of patients with shoulder disorders may present a valid alternative to FTF examination. Nevertheless, the content of the video-based physical examination may need to be modified to facilitate a clearer detection of indications for specific interventions or diagnostic tests.

Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon

BACKGROUND

Role substitution is a strategy employed to assist health services manage the growing demand for musculoskeletal care. Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic standards. This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinically and cost effective as that from an orthopaedic surgeon.

METHODS

A double blind non-inferiority randomized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service, from January 2013 to June 2014. Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon. The main outcome measure was total Shoulder Pain and Disability Index (SPADI) score at baseline, six and 12 weeks, applying a non-inferiority margin of 15 points. Secondary outcomes tested for superiority included pain, shoulder movement, perceived improvement, adverse events, satisfaction, quality of life and costs.

RESULTS

278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon, with 64 randomised (physiotherapist 33, orthopaedic surgeon 31). There were no significant differences in baseline characteristics between groups. Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks (upper limit of the 95% one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks, respectively). There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks. From the perspective of the health funder, the physiotherapist was less expensive.

CONCLUSIONS

Corticosteroid injection for shoulder pain, provided by a suitably qualified physiotherapist is at least as clinically effective, and less expensive, compared with similar care delivered by an orthopaedic surgeon. Policy makers and service providers should consider implementing this model of care.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry 12612000532808.

Intertester reliability of shoulder complaints diagnoses in primary health care

OBJECTIVE

Shoulder complaints are frequently encountered in general practice, but precise diagnosing is challenging. This study investigated agreement of shoulder complaints diagnoses between clinicians in a primary health care setting.

DESIGN

Cross-sectional study.

SETTING

Four primary health care clinicians used patients' history and functional examination of the shoulder by selective tissue tension techniques (STTs), to diagnose shoulder complaints.

SUBJECTS

62 patients, aged 18-75 years.

MAIN OUTCOME MEASURE

Reliability of diagnoses was assessed by observed intertester agreement and Cohen's kappa. A total of 372 diagnostic pairs were available for intertester comparisons.

RESULTS

Six diagnoses were assigned by all clinicians; supraspinatus-, infraspinatus-, subscapularis-tendinopathies; chronic subacromial bursitis; glenohumeral capsulitis, and acromioclavicular joint lesion. The observed agreement on these diagnoses ranged from 0.84 for glenohumeral capsulitis to 0.97 for acromioclavicular joint lesion. Kappa scores were 0.46 (95% CI 0.33, 0.58) for chronic subacromial bursitis; 0.53 (95% CI 0.34, 0.68), 0.59 (95% CI 0.47, 0.70), and 0.68 (95% CI 0.53, 0.82) for infraspinatus -, supraspinatus -, and subscapularis-tendinopathy, respectively. For glenohumeral capsulitis and acromioclavicular lesion kappa scores were 0.66 (95% CI 0.57, 0.73) and 0.78 (95% CI 0.61, 0.90). Kappa scores were higher for individual diagnoses than for individual tests, except for limitation in passive abduction (0.70, 95% CI 0.62, 0.78) and passive lateral rotation (0.66, 95% CI 0.57, 0.73).

CONCLUSIONS

Although experienced clinicians showed substantial intertester agreement, precise diagnoses of shoulder complaints in primary health care remain a challenge. The present results call for further research on refined diagnoses of shoulder complaints. Key points   Based on medical history and a systematic functional examination by selective tissue tension techniques (STTs), we investigated the agreement of shoulder complaints diagnoses across four primary health care clinicians and 62 patients. • Agreements on diagnoses were generally better than the agreement on individual tests. • Good kappa scores were obtained for the diagnoses glenohumeral capsulitis, rotator cuff tendinopathy, and acromioclavicular lesion. • Further research is necessary to investigate the diagnostic validity of functional shoulder examination by the STTs method.

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain

OBJECTIVE

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.

METHODS

Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.

RESULTS

There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).

DISCUSSION

Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

Efficacy of exercise intervention as determined by the McKenzie System of Mechanical Diagnosis and Therapy for knee osteoarthritis: a randomized controlled trial

STUDY DESIGN

Randomized controlled trial. Objectives To examine the efficacy of exercise intervention in patients with knee osteoarthritis (OA), as directed by Mechanical Diagnosis and Therapy (MDT) assessment, and, secondarily, to explore outcomes between MDT assessment-defined subgroups within the exercise group.

BACKGROUND

Due to the high physical and economic burden of knee OA, the effectiveness of conservative interventions and determining those patients who will respond to them should be investigated.

METHODS

Patients with knee OA (n = 180) were randomized to an exercise intervention group or a control group. The intervention group, in which patients classified as having knee derangements (MDT derangement) received MDT directional exercises and patients classified as nonresponders (MDT nonresponders) received evidence-based exercises, was compared to a control group that received no exercise intervention. Pain and function were assessed at baseline, 2 weeks, and 3 months, using the P4 pain scale and Knee injury and Osteoarthritis Outcome Score (KOOS) pain and function subscales. Two-way analysis of covariance was used to examine treatment and time effects. Multiple comparisons were examined, and mean differences with 95% confidence intervals (CIs) were reported.

RESULTS

The exercise intervention group had significantly improved P4 scores (mean difference, -6; 95% CI: -8, -3), KOOS pain scores (mean difference, 9; 95% CI: 5, 13), and KOOS function scores (mean difference, 11; 95% CI: 7, 15) compared to those of the control group at 2 weeks. At 3 months, the exercise intervention group had significantly improved KOOS pain scores (mean difference, 7; 95% CI: 3, 11) and KOOS function scores (mean difference, 5; 95% CI: 1, 9) compared to controls.

CONCLUSION

Patients with knee OA who were prescribed exercises based on an MDT assessment had superior outcomes compared to those of wait-list controls. The MDT subgroup of knee derangement may warrant further investigation in patients with knee OA. Protocol registered at ClinicalTrials.gov (NCT01641874).

LEVEL OF EVIDENCE

Therapy, level 1b-.

Assessment and Diagnosis of Musculoskeletal Shoulder Disorders over the Internet

Shoulder disorders are common, debilitating, and represent a considerable burden on society. As primary contact practitioners, physiotherapists play a large role in the management and rehabilitation of people with these conditions. For those living outside of urban areas, however, access to physiotherapy can be limited. The aim of this study was to evaluate the validity and reliability of using a telerehabilitation system to collect physical examination findings and correctly identify disorders of the shoulder. Twenty-two participants with 28 shoulder disorders were recruited and underwent a face-to-face physical examination and a remote telerehabilitation examination. Examination findings and diagnoses from the two modes of assessment were used to determine validity and reliability of the new method. Diagnostic agreement and agreement on individual findings between the two methods were found to be consistent with the reliability of conventional assessment methods. This study provides important preliminary findings on the validity and reliability of musculoskeletal examinations conducted via telerehabilitation.

Patient safety in interventional pain procedures

The objective of this article was to present a systematic review of the safety issues encountered in interventional pain management. Patient safety is an important consideration in the practice of interventional pain management. Although there is a paucity of scientific articles addressing this topic, the authors have reviewed the literature and present a review of the topic, as well as strategies to minimize the risk to patients undergoing interventional spine procedures.