Predicting response to physiotherapy treatment for musculoskeletal shoulder pain: a systematic review

Factors predicting long-term outcomes following physiotherapy in patients with subacromial pain syndrome: a secondary analysis

BACKGROUND

Although patients with shoulder complaints are frequently referred to physiotherapy, putative predictive factors for outcomes are still unclear. In this regard, only a limited amount of scientific data for patients with subacromial pain syndrome exist, with inconsistent results. An improved knowledge about the ability of baseline variables to predict outcomes could help patients make informed treatment decisions, prevent them from receiving ineffective treatments, and minimize the risk of developing chronic pain.

AIM

The aims of this secondary longitudinal analysis are threefold: First, to investigate baseline differences between patients with and without successful long-term outcomes following physiotherapy. Second, to compare the predictive ability of two sets of putative predictive variables on outcomes, one based on the literature and one based on the data of the original trial. Third, to explore the contribution of short-term follow-up data to predictive models.

METHODS

Differences between responders and nonresponders were calculated. The predictive ability of variables defined through literature and of variables based on the Akaike Information Criterion (AIC) from the original trial dataset on the Shoulder Pain and Disability Index and the Patients' Global Impression of Change at the one-year follow-up were analyzed. To test the robustness of the results, different statistical models were used. To investigate the contribution of follow-up data to prediction, short-term data were included in the analyses.

RESULTS

A sample of 87 patients with subacromial pain syndrome was analyzed. 77% (n = 67) of these participants were classified as responders. Higher expectations and short-term change scores were positive, and higher fear avoidance beliefs, greater baseline disability and pain levels were negative predictors of long-term outcomes in patients with subacromial pain syndrome.

CONCLUSIONS

Although our results are in line with previous research and support the use of clinical factors for prediction, our findings suggest that psychological factors, especially patient expectations and fear avoidance beliefs, also contribute to long-term outcomes and should therefore be considered in the clinical context and further research. However, the hypotheses and recommendations generated from our results need to be confirmed in further studies due to their explorative nature.

TRIAL REGISTRATION

The original trial was registered at Current Controlled Trials under the trial registration number ISRCTN86900354 on March 17, 2010.

Shoulder Symptom Trajectories Over Four Years: Data From a Longitudinal Study on Osteoarthritis

OBJECTIVE

Limited data exist on the natural history of shoulder symptoms. We aimed to describe longitudinal patterns of shoulder symptoms and determine risk factors for incidence and persistence.

METHODS

Data from Osteoarthritis Initiative participants observed annually for four years were used to describe shoulder symptom (yes/no, side) incidence and prevalence using descriptive analyses. Regression analyses investigated the association among three shoulder symptoms outcomes (persistent, incident, and intermittent) and clinical factors. Latent class growth analysis (LCGA) identified trajectories in those reporting pain at one or more time point.

RESULTS

In total, 4,796 participants (58% women, mean age 61.2 years) were included. Baseline shoulder symptom prevalence was 22%; 32% of these reported bilateral symptoms. In those reporting right symptoms, 260 of 1,886 (14%) had persistent symptoms. Those with persistent symptoms had worse baseline and four-year clinical status (poorer function, mental health, and quality of life). In regression analysis, persistent symptoms were associated with sleep disturbance (adjusted odds ratio [aOR] 1.97, 95% confidence interval [95% CI] 1.49-2.62), work absenteeism (aOR 2.16, 95% CI 1.38-2.62), lower limb weakness (aOR 1.76, 95% CI 1.37-2.27), multiple-site joint symptoms (≥3 joints excluding shoulders) (aOR 4.90, 95% CI 2.79-8.58) and White race (aOR 1.39, 95% CI 1.04-1.88). Lower limb weakness was also associated with incident symptoms; no variables were associated with intermittent symptoms. LCGA identified two trajectories: the trajectory with high probability for symptoms (9% of LCGA analysis cohort) showed similar relationships to clinical variables as in the persistent symptoms group.

CONCLUSION

In this large, four-year study, persistent shoulder symptoms were common and associated with worse clinical outcomes. At least one risk factor for incident symptoms is modifiable.

A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders

OBJECTIVE

To perform a systematic review of clinical practice guidelines (CPGs) covering the management of common shoulder disorders.

DATA SOURCES

A systematic search of CPGs on specific shoulder disorders was conducted up to August 2022 in relevant databases.

STUDY SELECTION

Twenty-six CPGs on rotator cuff (RC) tendinopathy, RC tear, calcific tendinitis, adhesive capsulitis, glenohumeral (GH) instability, GH osteoarthritis, or acromioclavicular disorders published from January 2008 onward were screened and included.

DATA EXTRACTION

CPGs methodological quality was assessed with the AGREE II checklist. All recommendations from CPGs were extracted and categorized by shoulder disorder and care components (evaluation, diagnostic imaging, medical, rehabilitation, and surgical treatments). After semantic analysis of the terminology, recommendations for each shoulder disorders were classified by 2 reviewers into "recommended," "may be recommended," or "not recommended." Disagreements were resolved by discussion until reviewers reached consensus.

DATA SYNTHESIS

Only 12 CPGs (46%) were of high quality with major limitations related to the applicability and editorial independence of the guidelines. The initial evaluation of shoulder pain should include patient's history, subjective evaluation focused on red flags, and clinical examination. Magnetic resonance imaging is usually not recommended to manage early shoulder pain, and recommendations for X-rays are conflicting. Acetaminophen, oral non-steroidal anti-inflammatory drugs, and rehabilitation including exercises were recommended or may be recommended to treat all shoulder pain disorders. Guidelines on surgical management recommendations differed; for example, 6 CPGs reported that acromioplasty was recommended or may be recommended in chronic RC tendinopathy, whereas 4 CPGs did not recommend it.

CONCLUSIONS

Recommendations vary for diagnostic imaging, conservative vs surgical treatment to manage shoulder pain, although several care components are consensual. The development of evidence-based, rigorous CPGs with a valid methodology and transparent reporting is warranted to improve overall shoulder pain care.

Effect of a Novel Training Program in Patients With Chronic Shoulder Pain Based on Implicit Motor Learning: Pilot and Feasibility Study

Background

Implicit motor learning has been shown to be effective for learning sports-related motor skills. It facilitates automaticity of movements and thereby improves performance in multitasking and high-pressure environments. Motor learning to develop motor skills and neuroplastic capacities is not sufficiently incorporated in musculoskeletal rehabilitation. Especially in patients with chronic pain conditions like shoulder pain this approach might benefit over traditional exercise programs.

Purpose/hypothesis

The aim of this study was to investigate the feasibility and clinical outcome of a new implicit motor learning exercise program in a group of patients with chronic shoulder pain.

Study design

Pilot and feasibility cohort study.

Methods

Twenty-six patients with chronic shoulder pain performed a 6-week home exercise program with weekly remote follow up by a physiotherapist. The program comprised five exercises designed to challenge overall body balance, simultaneously engaging the upper limbs in a range of reaching tasks. The tasks included reaching above the head, at and below waist level, in various directions. No instructions on correct performance were provided to foster external focus. Feasibility was assessed by (1) recruitment rate, (2) follow up rate, (3) subjective experience, (4) self-reported adverse events and (5) self-reported adherence of subjects. Clinical effects of the program were assessed with (1) the Shoulder Pain and Disability Index (SPADI), (2) the Auto-Constant score, (3) the numeric rating scale (NRS) at rest and at night, (4) the patient specific functional scale (PSFS), (5) the avoidance endurance questionnaire (AEQ), (6) patient acceptable symptom state (PASS) and (7) a global rating of change (GROC).

Results

The study protocol was feasible in terms of follow up rate (16w for 28 patients), exercise adherence (77.1%± 29.41), and adverse events (no serious, 5 light adverse events). Statistically significant improvements were observed for SPADI (p<0.001), NRS at rest (p=0.033), at night (p=0.29), PSFS (p<0.001) and PASS (p<0.001) after only six weeks training.

Conclusion

This study reveals promising results of another way of looking at exercise for patients with chronic shoulder pain. Both feasibility and clinical effects of the program on pain and function was acceptable. Future studies should incorporate a control group, provide longer follow up and include objective measurements.

Level of evidence

2b.

Prognostic factors associated with changes in knee pain outcomes, identified from initial primary care consultation data. A systematic literature review

BACKGROUND

Data collected during initial primary care consultations could be a source of baseline prognostic factors associated with changes in outcome measures for patients with knee pain.

OBJECTIVES

To identify, appraise and synthesize studies investigating prognostic factors associated with changes in outcome for people presenting with knee pain in primary care.

METHODS

EMBASE, CINAHL, AMED, MEDLINE and MedRxiv electronic databases were searched from inception to March 2021 and repeated in August 2022. Prospective cohort studies of adult participants with musculoskeletal knee pain assessing the association between putative prognostic factors and outcomes in primary care were included. The Quality in Prognostic Studies (QUIPS) tool and The Modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, specific to prognostic reviews were used to appraise and synthesize the evidence respectively.

RESULTS

Eight studies were included. Eight knee pain outcomes were identified. Methodological and statistical heterogeneity resulted in qualitative analysis. All evidence was judged to be of low to very low quality. Bilateral knee pain (multivariable odds ratio (OR) range 2.60-2.74; 95%CI range 0.90-8.10, p value = 0.09) and a lower educational level (multivariable (OR) range 1.74-5.6; 95%CI range 1.16-16.20, p value = <0.001) were synonymously associated with persisting knee pain at 12-month follow up. A total of 37 univariable and 63 multivariable prognostic factors were statistically associated with outcomes (p ≤ 0.05) in single studies.

CONCLUSIONS

There was consensus from two independent studies that bilateral knee pain and lower educational level were associated with persistent knee pain. Many baseline factors were associated with outcome in individual studies but not consistently between studies. The current understanding, accuracy and reliability of the prognostic value of initial primary care consultation data for knee pain outcomes are limited. This review will provide an essential guide for candidate variable selection in future primary care prognostic confirmatory studies.Key messagesBilateral knee pain and lower educational level were associated with persistent knee pain.Many baseline factors were associated with outcome in individual studies but not consistently between studies.The current understanding, accuracy and reliability of the prognostic value of initial primary care consultation data for knee pain outcomes are limited.

Changes in pain and disability in patients with shoulder pain after three months of digitally delivered exercise and patient education

OBJECTIVE

To describe and examine potential predictors of changes in pain and disability in patients with shoulder pain who have completed 3 months of digitally delivered treatment comprising exercise and patient education.

DESIGN

Retrospective cohort study (clinicaltrials.org Nr: NCT05402514).

SUBJECTS

Patients with shoulder pain who completed treatment (n = 682).

METHODS

Primary outcome was change in shoulder pain (numerical rating scale 0-10; minimal clinical important change: at least 2 points). Pain and disability were reported on the Shoulder Pain and Disability Index. Changes in outcomes were analysed with paired sample t-tests. Association with potential predictors (sex, age, education, body mass index, physical activity, symptom duration, baseline pain/function, and treatment adherence) were explored with linear regression models Results: Statistically significant improvements were found for all treatment outcomes. Minimal clinically important change in pain was reached by 54.5% (n = 372). Higher baseline level of symptoms, short symptom duration, and high treatment adherence were associated with greater changes.

CONCLUSION

Patients with shoulder pain reported significant reductions in pain and disability following treatment, but the clinical relevance of the improvements has not been confirmed. Satisfactory treatment adherence, higher baseline pain and shorter symptom duration predicted larger improvements. A control group is needed to evaluate the actual effect of the treatment.

Virtual embodiment for improving range of motion in patients with movement-related shoulder pain: an experimental study

BACKGROUND

Recent evidence supports the use of immersive virtual reality (VR) as a means of delivering bodily illusions that may have therapeutic potential for the treatment of musculoskeletal conditions. We wanted to investigate whether a single session of an embodiment-based immersive VR training program influences pain-free range of motion in patients with shoulder pain.

METHODS

We designed a rehabilitation program based on developing ownership over a virtual body and then "exercising" the upper limb in immersive VR, while the real arm remains static. We then carried out a single-arm pre-post experiment in which 21 patients with movement-related musculoskeletal shoulder pain were exposed to the 15-min VR program and measured their active pain-free range of motion immediately before and afterwards.

RESULTS

We found that shoulder abduction and hand-behind-back movements, but not shoulder flexion, were significantly and clinically improved post-intervention and that the level of improvement correlated with the level of embodiment. Following this one session, at 1-week follow-up the improvements were not maintained.

CONCLUSIONS

Virtual embodiment may be a useful therapeutic tool to help improve range of motion in patients with movement-related shoulder pain in the short term, which in turn could expedite rehabilitation and recovery in these conditions.

"I wanted to know what was hurting so much": a qualitative study exploring patients' expectations and experiences with primary care management

BACKGROUND

The management of shoulder pain is challenging for primary care clinicians considering that 40% of affected individuals remain symptomatic one year after initial consultation. Developing tailored knowledge mobilization interventions founded on evidence-based recommendations while also considering patients' expectations could improve primary care for shoulder pain. The aim of this qualitative study is to explore patients' expectations and experiences of their primary care consultation for shoulder pain.

METHODS

In this qualitative study, participants with shoulder pain and having consulted a primary care clinician in the past year were interviewed. All the semi-structured interviews were transcribed verbatim, and inductive thematic analysis was performed to identify themes related to the participants' expectations and experiences of primary care consultations for shoulder pain.

RESULTS

Thirteen participants with shoulder pain were interviewed (8 women, 5 men; mean age 50 ± 12 years). Eleven of them initially consulted a family physician or an emergency physician, and two participants initially consulted a physiotherapist. Four overarching themes related to patients' expectations and experiences were identified from our thematic analysis: 1) I can't sleep because of my shoulder; 2) I need to know what is happening with my shoulder; 3) But… we need to really see what is going on to help me!; and 4) Please take some time with me so I can understand what to do!. Several participants waited until they experienced a high level of shoulder pain before making an appointment since they were not confident about what their family physician could do to manage their condition. Although some participants felt that their physician took the time to listen to their concerns, many were dissatisfied with the limited assessment and education provided by the clinician.

CONCLUSIONS

Implementing evidence-based recommendations while considering patients' expectations is important as it may improve patients' satisfaction with healthcare. Several participants reported that their expectations were not met, especially when it came to the explanations provided. One unexpected finding that emerged from this study was the waiting period between the onset of shoulder pain and when patients decided to consult their primary care clinician.

Knowledge and appropriateness of care of family physicians and physiotherapists in the management of shoulder pain: a survey study in the province of Quebec, Canada

BACKGROUND

Shoulder pain is difficult to diagnose and treat with half of those affected still symptomatic six months after initial consultation. This may be explained by primary care management not conforming to evidence-based practice. This survey evaluated physiotherapists (PTs) and family physicians' (FPs) knowledge and appropriateness of care in shoulder pain management.

METHODS

A survey sent to PTs and FPs in the province of Quebec, Canada presented four clinical vignettes with cases of rotator cuff (RC) tendinopathy, acute full-thickness RC tear, adhesive capsulitis and traumatic anterior glenohumeral instability. Respondents indicated diagnosis, indications for imaging, specialists' referrals, and choice of treatments. Answers were compared to recommendations from clinical practice guidelines (CPGs). Participants' responses were compared between types of providers with Fisher's exact test.

RESULTS

Respondents (PTs = 175, FPs = 76) were mostly women with less than ten years of experience. More than 80% of PTs and 84% of FPs correctly diagnosed cases presented. Despite this practice not being recommended, more FPs than PTs recommended an imaging test in the initial management of RC tendinopathy (30% compared to 13%, p = 0.001) and adhesive capsulitis (51% compared to 22%, p = 0.02). For full-thickness RC tear and shoulder instability, up to 72% of FPs and 67% of PTs did not refer to a specialist for a surgical opinion, although recommended by CPGs. For RC tendinopathy, 26% of FPs and 2% of PTs (p < 0.001) would have prescribed a corticosteroid infiltration, which is not recommended in the initial management of this disorder. For adhesive capsulitis, significantly more FPs (76%) than PTs (62%) (p < 0.001) suggested an intra-articular corticosteroid infiltration, as recommended by CPGs. For all presented vignettes, up to 95% of family physicians adequately indicated they would refer patients for physiotherapy. In prioritizing rehabilitation interventions, up to 42% of PTs did not consider active exercises as a priority and up to 65% selected passive modalities that are not recommended for all shoulder pain vignettes.

CONCLUSIONS

Most FPs and PTs were able to make adequate diagnoses and select appropriate treatments for shoulder pain, but practices opposed to evidence-based recommendations were chosen by several respondents. Further training of FPs and PTs may be needed to optimize primary care management of different shoulder disorders.

Post-surgical physiotherapy in frozen shoulder: A review

Despite its prevalence, the optimal management of frozen shoulder is unclear. A range of conservative measures are often undertaken with varying degrees of success. In cases of severe and persistent symptoms, release procedures which could include any combination of manipulation under anaesthetic, arthroscopic capsular release or hydrodilatation are frequently offered, none of which has been shown to offer superior outcome over the others. When surgical release is performed a period of rehabilitation is normally recommended but no best practice guidelines exist resulting in considerable variations in practice which may or may not directly affect patient outcome. During this narrative review, we hypothesise that these differing responses to treatment (both conservative and surgical options) are potentially the result of different causal mechanisms for frozen shoulder and may also suggest that post-release rehabilitation may need to take this into account.

Reliability, validity, and responsiveness of a Canadian French adaptation of the pain self-efficacy questionnaire (PSEQ)

PURPOSE

The objectives of this study were to translate the Pain Self-Efficacy Questionnaire (PSEQ) into Canadian French (PSEQ-F) and to evaluate its validity, reliability and responsiveness in a French-Canadian sample of patients with persistent rotator cuff related shoulder pain (RCRSP).

METHODS

Translation and cross-cultural adaptation of the original English version of the PSEQ into Canadian French were performed according to standard procedures. Thereafter, 78 adults with RCRSP completed the PSEQ-F on three occasions: baseline, 2 days later to evaluate the reliability and 6 weeks later to evaluate responsiveness.

RESULTS

Cross-cultural adaptation was performed without problems with content or language. The PSEQ-F was found to be reliable (Intraclass Correlation Coefficient = 0.96; Minimal Detectable Change = 3 points [5%]), valid (moderate correlations with an abbreviated version of Disability of the Arm, Shoulder and Hand [QuickDASH] and Brief Pain Inventory [BPI] Questionnaires) and responsive (Standardized Response Mean = 0.96; Effect Size = 0.81; Minimal Clinically Important Difference = 6 points [10%]).

CONCLUSION

The PSEQ-F is a reliable, valid and responsive questionnaire that can be used to assess pain self-efficacy in French-speaking individuals with RCRSP. Further studies should use a self-efficacy-specific Global Rating of Change scale to estimate its responsiveness more thoroughly.Implications for rehabilitationHigher levels of pain self-efficacy have been associated with increased odds of symptom resolution in those with persistent rotator cuff related shoulder pain (RCRSP).The Pain Self-Efficacy Questionnaire (PSEQ) has been identified as the most frequently used tool by clinicians to assess pain self-efficacy in patients at risk of developing persistent musculoskeletal pain.The Canadian French version of the PSEQ (PSEQ-F) is a reliable, valid and responsive questionnaire that can be used to assess pain self-efficacy in French-speaking individuals with RCRSP.

'Down to the person, the individual patient themselves': A qualitative study of treatment decision-making for shoulder pain

Introduction

Many inconsistencies have been identified in the translation of evidence‐based treatment recommendations for musculoskeletal shoulder pain into healthcare services, with little known about factors influencing decision‐making. The objective of this study was to explore the views and experiences of healthcare providers (HCPs) and people living with shoulder pain on treatment decision‐making.

Methods

Adopting a qualitative design, purposeful sampling was employed to recruit 13 individuals with nonspecific musculoskeletal shoulder pain and 30 HCPs. Data were collected through 1:1 semi‐structured interviews and analysed using an approach informed by Constructivist Grounded Theory. To facilitate analysis, two patient and public involvement (PPI) meetings were conducted.

Results

Most participants (69%) had shoulder pain of ≥1‐year duration. Biomechanical beliefs about shoulder pain predominated and were heavily influential in decision‐making for both patients and HCPs. Despite a consensus that therapeutic alliance facilitated decision‐making, the extent of collaboration between HCPs and patients in treatment decision‐making was rather limited. In addition to condition‐specific factors, Individual patient characteristics and resources also influenced treatment decisions.

Conclusion

Findings revealed the complexity of the decision‐making process for both patients and HCPs, exposing substantial gaps between the reported views and experiences of participants and the principles of client‐centred and evidence‐based practice. There is a pressing need to enhance the translation of evidence‐based knowledge into practice in this clinical area.

Patient or Public Contribution

In line with a consultative approach to collaborative data analysis, a subgroup of participants attended two PPI meetings to provide commentary and feedback on preliminary findings.

Predicting change in symptoms and function in patients with persistent shoulder pain: a prognostic model development study

BACKGROUND

Persistent shoulder pain causes considerable disruption of the individual's life and imposes high costs on healthcare and society. Well-informed treatment and referral pathways are crucial as unsuccessful interventions and longer duration of symptoms minimizes the likelihood of success in future interventions. Although physiotherapy is generally recommended as first line treatment, no prognostic model or clinical prediction rules exists to help guide the treatment of patients with persistent shoulder pain undergoing physiotherapy. Thus, the objective of this study was to develop a prognostic model to inform clinical decision making and predict change in symptoms and function in patients with persistent shoulder pain.

METHODS

This was a prospective cohort study of 243 patients with persistent shoulder pain referred to outpatient physiotherapy rehabilitation centres. Data was collected at baseline and six-month follow-up. The outcome was change in shoulder symptoms and function as measured by the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) from baseline to 6 months follow up. Potential predictors were included in a multivariable linear regression model which was pruned using modified stepwise backwards elimination.

RESULTS

The final model consisted of seven predictors; baseline QuickDASH score, employment status, educational level, movement impairment classification, self-rated ability to cope with the pain, health-related quality of life and pain catastrophizing. Together these variables explained 33% of the variance in QuickDASH-change scores with a model root mean squared error of 17 points.

CONCLUSION

The final prediction model explained 33% of the variance in QuickDASH change-scores at 6 months. The root mean squared error (model SD) was relatively large meaning that the prediction of individual change scores was quite imprecise. Thus, the clinical utility of the prediction model is limited in its current form. Further work needs be done in order to improve the performance and precision of the model before external validity can be examined along with the potential impact of the model in clinical practice. Two of the included predictors were novel and could be examined in future studies; movement impairment classification based on diagnosis and health-related quality of life.

The influence of a cognitive behavioural approach on changing patient expectations for conservative care in shoulder pain treatment: a protocol for a pragmatic randomized controlled trial

BACKGROUND

Despite similar outcomes for surgery and conservative care, the number of surgeries to treat rotator cuff related shoulder pain has increased. Interventions designed to enhance treatment expectations for conservative care have been shown to improve patient expectations, but no studies have yet explored whether such interventions influence patient decisions to pursue surgery. The purpose of this randomized clinical trial is to examine the effect of an intervention designed to improve expectations of conservative care on the decision to have surgery.

METHODS

We will test the effectiveness of the Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention which is intended to change expectations regarding conservative care. The PEERC intervention will be evaluated in a randomized, pragmatic "add-on" trial, to better understand the effect the intervention has on outcomes. Ninety-four (94) participants with rotator cuff related shoulder pain referred for physical therapy will be randomized to receive either impairment-based care or impairment-based care plus PEERC. Both groups will receive impairment-based conservative treatment created by compiling the evidence associated with established, effective interventions. Participants assigned to the impairment-based care plus PEERC condition will also receive the PEERC intervention. This intervention, informed by principles of cognitive behavioral therapy, involves three components: (1) strategies to enhance engagement, (2) education and (3) cognitive restructuring and behavioral activation. Outcomes will be assessed at multiple points between enrolment and six months after discharge. The primary outcome is patient reported decision to have surgery and the secondary outcomes are pain, function, expectations and satisfaction with conservative care.

DISCUSSION

Rotator cuff related shoulder pain is highly prevalent, and because conservative and surgical treatments have similar outcomes, an intervention that changes expectations about conservative care could alter patient reports of their decision to have surgery and ultimately could lead to lower healthcare costs and decreased risk of surgical complications.

TRIAL REGISTRATION

This study is registered as NCT03353272 at ClincialTrials.gov.

Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT

BACKGROUND

Rotator cuff-related shoulder pain is very common, but there is uncertainty regarding which modes of exercise delivery are optimal and the long-term benefits of corticosteroid injections.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of progressive exercise compared with best-practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.

DESIGN

This was a pragmatic multicentre superiority randomised controlled trial (with a 2 × 2 factorial design).

SETTING

Twenty NHS primary care-based musculoskeletal and related physiotherapy services.

PARTICIPANTS

Adults aged ≥ 18 years with a new episode of rotator cuff-related shoulder pain in the previous 6 months.

INTERVENTIONS

A total of 708 participants were randomised (March 2017-May 2019) by a centralised computer-generated 1 : 1 : 1 : 1 allocation ratio to one of four interventions: (1) progressive exercise (n = 174) (six or fewer physiotherapy sessions), (2) best-practice advice (n = 174) (one physiotherapy session), (3) corticosteroid injection then progressive exercise (n = 182) (six or fewer physiotherapy sessions) or (4) corticosteroid injection then best-practice advice (n = 178) (one physiotherapy session).

MAIN OUTCOME MEASURES

The primary outcome was Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes included SPADI subdomains, the EuroQol 5 Dimensions, five-level version, sleep disturbance, fear avoidance, pain self-efficacy, return to activity, Global Impression of Treatment and health resource use. Outcomes were collected by postal questionnaires at 8 weeks and at 6 and 12 months. A within-trial economic evaluation was also conducted. The primary analysis was intention to treat.

RESULTS

Participants had a mean age of 55.5 (standard deviation 13.1) years and 49.3% were female. The mean baseline SPADI score was 54.1 (standard deviation 18.5). Follow-up rates were 91% at 8 weeks and 87% at 6 and 12 months. There was an overall improvement in SPADI score from baseline in each group over time. Over 12 months, there was no evidence of a difference in the SPADI scores between the progressive exercise intervention and the best-practice advice intervention in shoulder pain and function (adjusted mean difference between groups over 12 months -0.66, 99% confidence interval -4.52 to 3.20). There was also no difference in SPADI scores between the progressive exercise intervention and best-practice advice intervention when analysed at the 8-week and 6- and 12-month time points. Injection resulted in improvement in shoulder pain and function at 8 weeks compared with no injection (adjusted mean difference -5.64, 99% confidence interval -9.93 to -1.35), but not when analysed over 12 months (adjusted mean difference -1.11, 99% confidence interval -4.47 to 2.26), or at 6 and 12 months. There were no serious adverse events. In the base-case analysis, adding injection to best-practice advice gained 0.021 quality-adjusted life-years (p = 0.184) and increased the cost by £10 per participant (p = 0.747). Progressive exercise alone was £52 (p = 0.247) more expensive per participant than best-practice advice, and gained 0.019 QALYs (p = 0.220). At a ceiling ratio of £20,000 per quality-adjusted life-year, injection plus best-practice advice had a 54.93% probability of being the most cost-effective treatment.

LIMITATIONS

Participants and physiotherapists were not blinded to group allocation. Twelve-month follow-up may be insufficient for identifying all safety concerns.

CONCLUSIONS

Progressive exercise was not superior to a best-practice advice session with a physiotherapist. Subacromial corticosteroid injection improved shoulder pain and function, but provided only modest short-term benefit. Best-practice advice in combination with corticosteroid injection was expected to be most cost-effective, although there was substantial uncertainty.

FUTURE WORK

Longer-term follow-up, including any serious adverse effects of corticosteroid injection.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16539266 and EudraCT 2016-002991-28.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 48. See the NIHR Journals Library website for further project information.

What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey

OBJECTIVE

Despite usually being considered necessary, the rehabilitation regime that optimises outcomes for patients following release procedures for frozen shoulder has not been established and no accepted best practice guidelines currently exist. The purpose of this study was to gain insight into what physiotherapists considered best practice and factors they considered likely to affect patient outcome.

METHODS

A cross-sectional, self-administered online questionnaire was developed and distributed to UK based Physiotherapists, undergraduate students and support workers via email, social media and professional networks.

RESULTS

260 eligible and fully completed surveys were received. Clear preference for early (within 72 h), frequent (2-3 times per week or weekly) and prolonged (greater than 6 weeks) treatment delivered in a 1:1 setting was expressed. 99% were highly likely/likely to advocate education and advice, range of movement exercises (99.6%), stretching (73.5%) and strengthening (61.9%). More passive modalities (manual therapy, massage, electrotherapy, acupuncture) were highly unlikely/unlikely to be used and lack of manual therapy and insufficient contact with a physiotherapist were the reasons deemed least likely to affect outcome. Most clinicians (89.2%) were likely to prescribe exercises that patients reported as painful but persistent pain and poor adherence by patients to exercises were the top reasons given for poor outcome along with psychological and psychosocial patient characteristics.

CONCLUSION

Physiotherapists consistently advocate early, frequent, prolonged, 1:1 treatment following release procedures for frozen shoulder. Most patients are discharged whilst still experiencing symptoms, particularly pain. Further work is needed to establish high value pathways for this patient group.

Adherence Patterns and Dose Response of Physiotherapy for Rotator Cuff Pathology: Longitudinal Cohort Study

BACKGROUND

Physiotherapy is considered to be essential for the successful operative and nonoperative management of rotator cuff pathology; however, the extent to which patients adhere to assigned physiotherapy activities and how this impacts recovery is unknown.

OBJECTIVE

The purpose of this study was to measure the rate and patterns of participation in physiotherapy for rotator cuff disorders, assess the dose response between physiotherapy activity and recovery, and explore patient factors predictive of physiotherapy participation.

METHODS

We report a prospective longitudinal study of 42 patients undergoing physiotherapy for symptomatic rotator cuff pathology. The patients were issued a smartwatch that recorded inertial sensor data while they performed physiotherapy exercises both in the clinic and in the home setting. A machine learning approach was used to assess total physiotherapy participation from smartwatch inertial data. Primary outcomes were the Disabilities of the Arm Shoulder and Hand and numeric pain rating scale assessed every 4 weeks until 12 weeks follow-up. The relationships between participation, outcomes, and clinical patient variables were assessed in univariable analyses.

RESULTS

Mean physiotherapy exercise participation in clinic and at home were 11 minutes per week and 33 minutes per week, respectively, with patients participating in physiotherapy on 41% of days assigned to treatment. Home physiotherapy participation decreased significantly over time (P=.03). There was a statistically significant and clinically meaningful relationship between cumulative physiotherapy participation and recovery demonstrated by pain scores at 8 weeks (P=.02) and 12 weeks (P=.05) and disability scores at 8 weeks (P=.04) and 12 weeks (P=.04). Low patient expectations and self-efficacy were associated with low rates of physiotherapy participation.

CONCLUSIONS

There was a low rate of participation in home shoulder physiotherapy exercise, and a statistically and clinically significant dose response of physiotherapy on treatment outcome in patients with rotator cuff pathology. The findings highlight the opportunity to develop novel methods and strategies to improve the participation in and efficacy of physiotherapy exercises for rotator cuff disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/17841.

Shoulder patients in primary and specialist health care. A cross-sectional study

OBJECTIVES

Shoulder pain is a prevalent problem and has a considerable impact on the use of primary and specialist health care in Norway. It is important to improve short-term recovery and reduce long-term consequences regarding pain and disability, the high costs of treatment and the amount of sick-leave. Treatment for non-specific shoulder pain is mainly non-operative. The aims of this study were to investigate if there are differences in main characteristics, pain and disability (SPADI-score) and psycho-social factors between patients in primary and specialist health care.

METHODS

This cross-sectional study included patients consulting physiotherapy in primary health care and patients at an outpatient clinic in specialist health care. Well-known and tested questionnaires for these populations were used and variables were divided into clinical, sociodemographic, psycho-social, and shoulder pain and disability. Descriptive statistics were applied. Two-sample t-test and linear regression were used for continuous data whereas chi-square tests and logistic regression were applied to test differences in categorical data between the two study populations.

RESULTS

Two hundred and 36 patients were recruited from primary health care (FYSIOPRIM, Physiotherapy In Primary Care) and 167 from specialist health care. Patients in primary health care reported less regular use of pain medication (30.7 vs. 61.3%) and fewer patients had symptom duration >12 months (41.9 vs. 51.0%). Furthermore, they reported lower pain intensity, less shoulder pain and disability (SPADI-score), lower scores on psycho-social factors, but higher on expectations of recovery.

CONCLUSIONS

Patients with shoulder pain treated in primary health care and in specialist health care are different according to factors such as duration of symptoms, pain and disability, and some of the psycho-social variables. However, the differences are small and the variations within the two study samples is large. Patients treated in primary health care seemed to be less affected and to have higher expectations concerning their recovery. However, based on our results we may question why many patients are referred to specialist health care rather than continuing treatment in primary health care.

The effect of pain severity on balance, postural stability and fall risk in patients with shoulder pathologies

INTRODUCTION

The study aimed to investigate how pain severity in the shoulder region affects balance ability, postural stability and fall risk.

MATERIAL AND METHODS

Sixty participants with shoulder pain, aged 42.45 ±6.51 years, were assessed using a Visual Analog Scale (VAS); they were divided into 2 subgroups as a mild pain group (group 1) and a moderate/severe pain group (group 2). According to VAS-at rest the mild-pain group included 39 and the moderate/severe-pain group included 21 subjects. According to VAS-during movement, the mild-pain group included 19 and the moderate/severe-pain group included 41 subjects. Balance ability-postural stability, fall risk and fear of falling were assessed by the Sportkat System, Berg Balance Scale (BBS), and Fall Efficacy scale (FES) respectively. Differences of variables between mild pain and moderate/severe pain groups were analyzed by the independent groups t-test in groups conforming to a normal distribution and the Mann-Whitney U test for the variables that did not fit a normal distribution.

RESULTS

A positive relationship was found between VAS-at rest and double-foot static balance test score right-left (RL) ratio, while a negative relationship was found between VAS-at rest and BBS score (p < 0.05). Significant differences were found between right foot static balance left score and RL ratio according to pain at rest (p < 0.05).

CONCLUSIONS

The results indicated that shoulder pain severity affects balance parameters. As pain level at rest increases, postural sway increases in a medio-lateral direction, and towards the left while standing on the right foot. Approaches regarding increasing balance and postural instability should be included in physiotherapy and rehabilitation programs of patients with shoulder pain at an early phase to protect patients from balance problems and fall risk.

Rotator cuff-related shoulder pain: does the type of exercise influence the outcomes? Protocol of a randomised controlled trial

INTRODUCTION

Lifetime prevalence of shoulder pain is 70%, and approximately 50% of people with shoulder pain will experience pain for more than a year. Rotator cuff-related shoulder pain (RCRSP) is the most common shoulder condition and the main non-surgical intervention is exercise therapy. For approximately 30% of people with RCRSP, this approach does not lead to a significant reduction in symptoms. This may be due to an inappropriate dosage or choice of exercises. The aim of this investigation is to compare the short, mid and long-term effects, in terms of symptoms, functional limitations, kinesiophobia and pain catastrophising, of three different shoulder rehabilitation approaches (education, strengthening, motor control) in adults with RCRSP.

METHODS AND ANALYSIS

In this single-blind (assessor), parallel-group, randomised clinical trial, 123 adults presenting with RCRSP will take part in a 12-week rehabilitation programme. They will be randomly assigned to one of three groups (education only, strengthening approach or motor control-focused approach). Abbreviated version of the Disabilities of the Arm, Shoulder and Hand Questionnaire, the primary outcome, Western Ontario Rotator Cuff Index and Brief Pain Inventory will evaluate symptoms and functional limitations, while Tampa Scale of Kinesiophobia and Pain Catastrophizing Scale will evaluate pain-related fear and catastrophising at baseline and at 3, 6, 12 and 24 weeks. Ultrasonographic acromiohumeral distances and tendon thickness will be assessed at baseline and 12 weeks. Intervention groups will be compared on outcomes with intention-to-treat analyses using two-way repeated measures analysis of variance if the data are normally distributed or non-parametric analysis of longitudinal data if they are not.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Sectorial Rehabilitation and Social Integration Research Ethics Committee of the Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale Nationale (CIUSSS-CN). Results will be disseminated through international publications in peer-reviewed journals, in addition to international conference presentations.

TRIAL REGISTRATION NUMBER

NCT03892603; pre-results.

Patients with shoulder pain referred to specialist care; treatment, predictors of pain and disability, emotional distress, main symptoms and sick-leave: a cohort study with a six-months follow-up

Objectives

Recommendations for referral of patients with shoulder pain from primary to specialist care are mainly clinical. Several patients are referred without meeting these criteria for referral, whereas some are referred for a second opinion although surgery is not recommended. The aims of this study were to describe a shoulder pain cohort in specialist healthcare according to demographic data, clinical, and psychological factors; evaluate changes in pain and disability, distress and main symptoms from baseline to six-month follow-up; and to assess predictors of pain and disability, changes in the main symptoms and sick-leave at six-months. Results were compared to previous randomised trials conducted at the same clinic in patients with subacromial shoulder pain.

Methods

This prospective study included 167 patients from an outpatient clinic in specialist healthcare with shoulder pain for more than 6 weeks. Clinical (pain duration, intensity, pain sites), sociodemographic (age, gender, educational level, work status) and psychological variables (emotional distress (HSCL-10), fear of pain, screening of “yellow flags”, health-related quality of life) were collected. Shoulder pain and disability (SPADI-score) were assessed and the patients were asked about their outcome expectation and to predict their status of their shoulder problem the next month. They underwent a clinical interview, a clinical assessment of shoulder function and orthopaedic tests for diagnostic purposes. After six months they received a questionnaire with main variables.

Results

Of the 167 patients (55% women), 50% had symptoms for more than 12 months and 37 (22%) were on sick-leave. Characteristics were in general comparable to patients previously included in clinical trials at the same department. The SPADI-score was 46 (23) points. Mean emotional distress was within the normal range (1.7 (SD 0.6)). More than 80% had received treatment before, mainly physiotherapy in addition to the GPs treatment. One hundred and thirty-seven patients (82%) were re-referred to physiotherapy, 74 (44%) in the outpatient clinic specialist healthcare, and 63 (38%) in primary care. One hundred and eighteen (71%) answered the follow-up questionnaire. Mean change in SPADI-score was 10.5 points (95% CI (6.5–14.5)), and 29% of the patients improved more than the smallest detectable difference (SDD). The percentage sick-listed was 19.5%, and mean change in main symptoms (−9 to +9) was 3.4 (SD 3.9). The subgroup of patients receiving physiotherapy in outpatient specialist care did not show any significant change in the main variables. The prediction models suggested that a lower level of education, more fear of pain and a high baseline SPADI-score, predicted a higher SPADI-score at follow-up. A high baseline HSCL-10 score was the only significant predictor for a high HSCL-10 score. At follow-up, less pain at rest predicted more change in main symptoms and more yellow flags (a higher score on the Örebro screening test) predicted sick-leave.

Conclusions

Within the limitations of a cohort study, patients with persistent shoulder pain referred to an outpatient specialist clinic had similar baseline characteristics but shorter treatment duration, inferior clinical results and predictors somewhat different compared with previous clinical trials conducted at the same clinic. The study raises some questions about the effectiveness of the routines in daily clinical practice, the selection of patients, the treatment duration and content.

Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of rotator cuff disorders: statistical analysis plan for the Getting it Right: Addressing Shoulder Pain (GRASP) 2 × 2 factorial multicentre randomised controlled trial

BACKGROUND

The Getting it Right: Addressing Shoulder Pain (GRASP) trial assesses the clinical and cost-effectiveness of individually tailored, progressive exercise compared with best practice advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. This article describes the statistical analysis plan for the GRASP randomised controlled trial.

METHODS/DESIGN

GRASP is a multicentre randomised controlled trial using a 2 × 2 factorial design. Adults aged ≥ 18 years with a new episode of shoulder pain related to a rotator cuff disorder, not currently receiving physiotherapy or being considered for surgery, are randomised (centralised computer-generated 1:1:1:1 allocation ratio) to one of four interventions: (1) progressive exercise (up to 6 physiotherapy sessions), (2) best practice advice (one physiotherapy session), (3) subacromial corticosteroid injection then progressive exercise and (4) subacromial corticosteroid injection then best practice advice. The primary outcome is the mean difference in Shoulder Pain and Disability Index (SPADI) total score over 12 months. Secondary outcomes are as follows: pain and function SPADI subdomains, health-related quality of life (EuroQol EQ-5D-5L), sleep disturbance, return to activity, global impression of change, health resource use, out-of-pocket expenses and work disability. Here, we describe in detail the following: sample size calculation, descriptive statistics of the primary and secondary outcomes, statistical models used for the analysis of the main outcomes, handling of missing data, planned sensitivity and subgroup analyses. This pre-specified statistical analysis plan was written and submitted without prior knowledge of the trial results.

DISCUSSION

Publication of the statistical analysis plan for the GRASP trial aims to reduce the risk of outcome reporting bias and increase transparency of the data analysis. Any deviations or changes to the current SAP will be described and justified in the final study report and any results publications.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN16539266 . Registered on 14 June 2016. EudraCT number 2016-002991-28. Registered on 12 June 2016.

Adherence Tracking With Smart Watches for Shoulder Physiotherapy in Rotator Cuff Pathology: Protocol for a Longitudinal Cohort Study

Background

Physiotherapy is essential for the successful rehabilitation of common shoulder injuries and following shoulder surgery. Patients may receive some training and supervision for shoulder physiotherapy through private pay or private insurance, but they are typically responsible for performing most of their physiotherapy independently at home. It is unknown how often patients perform their home exercises and if these exercises are performed correctly without supervision. There are no established tools for measuring this. It is, therefore, unclear if the full benefit of shoulder physiotherapy treatments is being realized.

Objective

The proposed research will (1) validate a smartwatch and machine learning (ML) approach for evaluating adherence to shoulder exercise participation and technique in a clinical patient population with rotator cuff pathology; (2) quantify the rate of home physiotherapy adherence, determine the effects of adherence on recovery, and identify barriers to successful adherence; and (3) develop and pilot test an ethically conscious adherence-driven rehabilitation program that individualizes patient care based on their capacity to effectively participate in their home physiotherapy.

Methods

This research will be conducted in 2 phases. The first phase is a prospective longitudinal cohort study, involving 120 patients undergoing physiotherapy for rotator cuff pathology. Patients will be issued a smartwatch that will record 9-axis inertial sensor data while they perform physiotherapy exercises both in the clinic and in the home setting. The data collected in the clinic under supervision will be used to train and validate our ML algorithms that classify shoulder physiotherapy exercise. The validated algorithms will then be used to assess home physiotherapy adherence from the inertial data collected at home. Validated outcome measures, including the Disabilities of the Arm, Shoulder, and Hand questionnaire; Numeric Pain Rating Scale; range of motion; shoulder strength; and work status, will be collected pretreatment, monthly through treatment, and at a final follow-up of 12 months. We will then relate improvement in patient outcomes to measured physiotherapy adherence and patient baseline variables in univariate and multivariate analyses. The second phase of this research will involve the evaluation of a novel rehabilitation program in a cohort of 20 patients. The program will promote patient physiotherapy engagement via the developed technology and support adherence-driven care decisions.

Results

As of December 2019, 71 patients were screened for enrollment in the noninterventional validation phase of this study; 65 patients met the inclusion and exclusion criteria. Of these, 46 patients consented and 19 declined to participate in the study. Only 2 patients de-enrolled from the study and data collection is ongoing for the remaining 44.

Conclusions

This study will provide new and important insights into shoulder physiotherapy adherence, the relationship between adherence and recovery, barriers to better adherence, and methods for addressing them.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17841

Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: A systematic review and meta-analysis

OBJECTIVE

To determine whether supervised physiotherapy is more effective for functional improvement and pain relief than a home exercise program in subjects with subacromial impingement syndrome.

DESIGN

Systematic review and meta-analysis of randomized clinical trials.

METHODS

An electronic search was performed in Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared supervised physiotherapy versus home exercise program, in the shoulder function, pain, and range of motion in subjects older than 18 years of age with a medical diagnosis of subacromial impingement syndrome treated conservatively.

RESULTS

Seven clinical trials met the eligibility criteria, and for the quantitative synthesis, four studies were included. The standardized mean difference for shoulder function was -0.14 points (95% CI: -1.04 to 0.76; p = 0.760), mean difference 0.21 cm (95% CI: -1.36 to 1.78; p = 0.790) for pain, and mean difference 0.62° (95% CI: -7.15 to 8.38; p = 0.880) for range of motion of flexion.

CONCLUSION

Supervised physical therapy and home-based progressive shoulder strengthening and stretching exercises for the rotator cuff and scapular muscles are equally effective in patients with subacromial impingement syndrome treated conservatively.

TRIAL REGISTRATION NUMBER

CRD42018086348.

Can clinical assessment differentiate partial thickness rotator cuff tears from full thickness rotator cuff tears? A secondary analysis

Purpose: Shoulder pain causes significant disability, with rotator cuff disease as a common diagnosis. Differentially diagnosing partial tears of the rotator cuff tendons is difficult despite use of imaging and clinical examination. Our objective was to determine if a clinical assessment framework could discriminate between patients with partial and full thickness tears.Materials and Methods: Pre-operative baseline data from two randomized controlled trials of 452 adult patients awaiting rotator cuff repair were analyzed in this secondary analysis. Nineteen items from a pre-defined clinical assessment framework were investigated for association with the outcome of surgically confirmed partial or full thickness tear. Logistic regression tested independent associations and multivariable models were developed to create the most parsimonious model.Results: Thirty-two participants (7%) had partial thickness tears. Constant Power Score was the sole item associated with partial thickness tears (OR 1.07, 95% CI 1.02-1.12). Traumatic mechanism of injury trended toward significance (OR 2.17, 95% CI 1.06-4.48).Conclusions: Greater abduction strength (i.e., Constant Power Score) was associated with partial thickness tears. Other clinical assessment items did not differentiate between partial and full tears. Our results add to the growing body of research showing most clinical findings are not associated with a diagnosis in rotator cuff disease.Implications for RehabilitationGreater shoulder abduction strength (as measured with the Constant Power Score) was associated with partial thickness rotator cuff tears.Most findings within our clinical assessment framework did not distinguish between partial thickness and full thickness rotator cuff tears and thus, did not contribute to a differential pathoanatomical diagnosis.Since structural integrity of the rotator cuff and patient presentation show poor association, and rehabilitation intervention is often impairment-based, pathoanatomical diagnosis may not adequately direct non-surgical treatment. Including movement-based diagnoses or treatment classification systems in evaluation of rotator cuff disease may improve selection of appropriate conservative treatment.

Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis

OBJECTIVES

To (i) identify predictors of outcome for the physiotherapy management of shoulder pain and (ii) enable clinicians to subgroup people into risk groups for persistent shoulder pain and disability.

METHODS

1030 people aged ≥18 years, referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited. 810 provided data at 6 months for 4 outcomes: Shoulder Pain and Disability Index (SPADI) (total score, pain subscale, disability subscale) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH). 34 potential prognostic factors were used in this analysis.

RESULTS

Four classification trees (prognostic pathways or decision trees) were created, one for each outcome. The most important predictor was baseline pain and/or disability: higher or lower baseline levels were associated with higher or lower levels at follow-up for all outcomes. One additional baseline factor split participants into four subgroups. For the SPADI trees, high pain self-efficacy reduced the likelihood of continued pain and disability. Notably, participants with low baseline pain but concomitant low pain self-efficacy had similar outcomes to patients with high baseline pain and high pain self-efficacy. Cut-off points for defining high and low pain self-efficacy differed according to baseline pain and disability. In the QuickDASH tree, the association between moderate baseline pain and disability with outcome was influenced by patient expectation: participants who expected to recover because of physiotherapy did better than those who expected no benefit.

CONCLUSIONS

Patient expectation and pain self-efficacy are associated with clinical outcome. These clinical elements should be included at the first assessment and a low pain self-efficacy response considered as a target for treatment intervention.

Predictors of the effects of treatment for shoulder pain: protocol of an individual participant data meta-analysis

BACKGROUND

Shoulder pain is one of the most common presentations of musculoskeletal pain with a 1-month population prevalence of between 7 and 26%. The overall prognosis of shoulder pain is highly variable with 40% of patients reporting persistent pain 1 year after consulting their primary care clinician. Despite evidence for prognostic value of a range of patient and disease characteristics, it is not clear whether these factors also predict (moderate) the effect of specific treatments (such as corticosteroid injection, exercise, or surgery).

OBJECTIVES

This study aims to identify predictors of treatment effect (i.e. treatment moderators or effect modifiers) by investigating the association between a number of pre-defined individual-level factors and the effects of commonly used treatments on shoulder pain and disability outcomes.

METHODS

This will be a meta-analysis using individual participant data (IPD). Eligible trials investigating the effectiveness of advice and analgesics, corticosteroid injection, physiotherapy-led exercise, psychological interventions, and/or surgical treatment in patients with shoulder conditions will be identified from systematic reviews and an updated systematic search for trials, and risk of bias will be assessed. Authors of all eligible trials will be approached for data sharing. Outcomes measured will be shoulder pain and disability, and our previous work has identified candidate predictors. The main analysis will be conducted using hierarchical one-stage IPD meta-analysis models, examining the effect of treatment-predictor interaction on outcome for each of the candidate predictors and describing relevant subgroup effects where significant interaction effects are detected. Random effects will be used to account for clustering and heterogeneity. Sensitivity analyses will be based on (i) exclusion of trials at high risk of bias, (ii) use of restricted cubic splines to model potential non-linear associations for candidate predictors measured on a continuous scale, and (iii) the use of a two-stage IPD meta-analysis framework.

DISCUSSION

Our study will collate, appraise, and synthesise IPD from multiple studies to examine potential predictors of treatment effect in order to assess the potential for better and more efficient targeting of specific treatments for individuals with shoulder pain.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018088298.

Ultrasound-Guided Application of Percutaneous Electrolysis as an Adjunct to Exercise and Manual Therapy for Subacromial Pain Syndrome: A Randomized Clinical Trial

This randomized clinical trial compared the effects of adding ultrasound (US)-guided percutaneouselectrolysis into a program consisting of manual therapy and exercise on pain, shoulder-related disability, function, and pressure sensitivity in subacromial pain syndrome. Fifty patients with subacromial pain syndrome were randomized into manual therapy and exercise or percutaneous electrolysis group. All patients received the same manual therapy and exercise program, 1 session per week for 5 consecutive weeks. Patients assigned to the electrolysis group also received the application of percutaneous electrolysis at each session. The primary outcome was assessed using the Disabilitiesof the Arm, Shoulder and Hand (DASH) questionnaire. Secondary outcomes included pain, function (Shoulder Pain and Disability Index [SPADI]) pressure pain thresholds (PPTs) and Global Ratingof Change (GROC). They were assessed at baseline, post-treatment, and 3 and 6 months after treatment. Both groups showed similar improvements in the primary outcome (DASH) at all follow-ups (P = .051). Subjects receiving manual therapy, exercise, and percutaneous electrolysis showed significantlygreater changes in shoulder pain (P < .001) and SPADI (P < .001) than did those receiving manual therapy and exercise alone at all follow-ups. Effect sizes were large (standardized mean difference >.91) for shoulder pain and function at 3 and 6 months in favor of the percutaneous electrolysis group. No between-group differences in PPT were found. The current clinical trial found that the inclusion of US-guided percutaneous electrolysis in combination with manual therapy and exercise resulted in no significant differences for related disability (DASH) compared with the application of manual therapy and exercise alone in patients with subacromial pain syndrome. Nevertheless, differences were reported for some secondary outcomes such as shoulder pain and function (SPADI). Whether these effects are reliable should be addressed in future studies.

PERSPECTIVE

This study found that the inclusion of US-guided percutaneous electrolysis into a manual therapy and exercise program resulted in no significant differences for disability and pressure pain sensitivity compared with the application of manual therapy and exercise alone in patients with subacromial pain syndrome.

Factors influencing final outcomes in patients with shoulder pain: A retrospective review

STUDY DESIGN

Retrospective cohort.

INTRODUCTION

Rehabilitation interventions are commonly prescribed for patients with shoulder pain, but it is unclear what factors may help clinicians' prognosis for final outcomes.

PURPOSE OF THE STUDY

The purpose of this study is to determine what factors are the best predictors of improved patient-reported outcomes at discharge in patients with shoulder pain.

METHODS

Retrospective chart review of 128 patients presenting with shoulder pain to an outpatient physical therapy clinic. Chart review captured data regarding patient demographics, treatment interventions, patient history, and patient-reported outcome scores. The primary dependent variable was the overall change score of the QuickDASH (initial to discharge). Thirty-eight predictor variables were entered into a forward stepwise multivariate linear regression model to determine which variables and to what degree contributed to the dependent variable.

RESULTS

The linear regression model identified 5 predictor variables that yielded an R = 0.74 and adjusted R² = 0.538 (P < .001). The 5 predictor variables identified in order of explained variance are QuickDASH change at the fifth visit, a total number of visits, initial QuickDASH score, scapular retraction exercise, and age.

DISCUSSION

Early change scores, equal to minimal detectable change scores on patient-reported outcomes appear to be strong indicators that patients with shoulder pain are on a positive trajectory to benefit from rehabilitation.

CONCLUSION

Using patient-reported outcomes throughout care, not just at the start and end of care, will provide therapist feedback regarding patient's progress and indicate treatment effectiveness.

LEVELS OF EVIDENCE

4.

Rehabilitation of symptomatic atraumatic degenerative rotator cuff tears: A clinical commentary on assessment and management

STUDY DESIGN

Clinical Commentary.

INTRODUCTION

Atraumatic rotator cuff (RC) disease, is one of the most common cause of shoulder pain, which encompasses a continuum from tendinopathy to full thickness cuff tears. Extrinsic, intrinsic and environmental factors have been implicated in the pathophysiology of this disorder, affecting the clinical presentation of symptoms including pain and irritability. Successful rehabilitation of symptomatic atraumatic degenerative rotator cuff (SADRC) tears must address the underlying mechanisms causing dysfunction and correct modifiable factors.

PURPOSE OF THE STUDY

The purpose of this paper is to review the shoulder complex anatomy, introduce atraumatic degenerative RC pathology, differentiate between symptomatic and asymptomatic degenerative RC tears, propose an assessment and introduce the Rotator Cuff Protocol 1 (RCP1) designed by the clinical reasoning of one of the lead authors (LW) as a rehabilitation management approach for those clients who present with SADRC tears.

METHODS/RESULTS/DISCUSSION

N/A for clinical commentary.

CONCLUSIONS

The ability to identify SADRC tears should consider shoulder anatomy, extrinsic, intrinsic and environmental factors, and the consideration for the natural history of atraumatic partial and full thickness tears in the general population. A thorough clinical history and examination, which includes shoulder symptom modification tests, allows the examiner to determine at what phase the patient may start their exercise program. The RCP1 is a program that has been used clinically by many therapists and clients over the years and research is underway to test this protocol in atraumatic rotator cuff disease including SADRC tears.

LEVEL OF EVIDENCE

5.

A systematic review of thrust manipulation combined with one conservative intervention for rotator cuff and related non-surgical shoulder conditions

OBJECTIVE

To determine effects of thrust manipulation plus one conservative intervention for non-surgical shoulder pain and disability due to rotator cuff dysfunction.

METHODS

This review followed PRISMA guidelines. The databases searched were PubMed, PEDro, ICL, CINAHL, and AMED. Included were randomized trials with at least one group assigned to receive thrust manipulation and one adjunct conservative therapy. The PEDro scale was used to assess methodological quality and GRADE for analysis.

RESULTS

The search yielded 2088 articles with one meeting eligibility criteria. The trial examined thrust manipulation with exercise compared to sham. Statistically significant improvements in pain and disability were reported within but not between groups. Evidence quality according to the PEDro scale was good; GRADE was moderate.

CONCLUSION

Few trials have been conducted studying thrust manipulation plus another conservative intervention for rotator cuff conditions rendering available evidence of thrust manipulation plus exercise insufficient to determine effects of this combined treatment.

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

BACKGROUND/AIM

Shoulder pain is a major musculoskeletal problem. We aimed to identify which baseline patient and clinical characteristics are associated with a better outcome, 6 weeks and 6 months after starting a course of physiotherapy for shoulder pain.

METHODS

1030 patients aged ≥18 years referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited and provided baseline data. 840 (82%) provided outcome data at 6 weeks and 811 (79%) at 6 months. 71 putative prognostic factors were collected at baseline. Outcomes were the Shoulder Pain and Disability Index (SPADI) and Quick Disability of the Arm, Shoulder and Hand Questionnaire. Multivariable linear regression was used to analyse prognostic factors associated with outcome.

RESULTS

Parameter estimates (β) are presented for the untransformed SPADI at 6 months, a negative value indicating less pain and disability. 4 factors were associated with better outcomes for both measures and time points: lower baseline disability (β=-0.32, 95% CI -0.23 to -0.40), patient expectation of 'complete recovery' compared to 'slight improvement' as 'a result of physiotherapy' (β=-12.43, 95% CI -8.20 to -16.67), higher pain self-efficacy (β=-0.36, 95% CI -0.50 to -0.22) and lower pain severity at rest (β=-1.89, 95% CI -1.26 to -2.51).

CONCLUSIONS

Psychological factors were consistently associated with patient-rated outcome, whereas clinical examination findings associated with a specific structural diagnosis were not. When assessing people with musculoskeletal shoulder pain and considering referral to physiotherapy services, psychosocial and medical information should be considered.

STUDY REGISTRATION

Protocol published at http://www.biomedcentral.com/1471-2474/14/192.

One question might be capable of replacing the Shoulder Pain and Disability Index (SPADI) when measuring disability: a prospective cohort study

Questions

Is it possible to replace the Shoulder Pain and Disability Index (SPADI) with a single substitute question for people with shoulder pain, when measuring disability and how well does this substitute question perform as a predictor for recovery.

Design

A prospective cohort study.

Participants

A total of 356 patients with shoulder pain in primary care.

Analyses

Convergent, divergent, and “known” groups validity were assessed by using hypotheses testing. Responsiveness was assessed using the Receiver Operating Curve and hypothesis testing. In addition, we performed multivariate regression to assess if the substitute question showed similar properties as the SPADI and if it affected the model itself, using recovery as an outcome.

Results

The Spearman correlation coefficient between the total SPADI score and the substitute question was high, and moderate with the Shoulder Disability Questionnaire. The correlation between the substitute question and the EQ-5D-3L was low and the responsiveness was acceptable. The substitute question did not significantly contribute to both prognostic prediction models as opposed to the SPADI. Regardless all models showed poor to fair discrimination.

Conclusion

The single question is a reasonable substitute for the SPADI and can be used as a screening instrument for shoulder disability in primary clinical practice. It has slightly poorer predictive power and should therefore not be used for prognosis.

Physiotherapist-led suprascapular nerve blocks for persistent shoulder pain: Evaluation of a new service in the UK

INTRODUCTION

This service evaluation explored and reported findings from a new physiotherapist-led service offering suprascapular nerve blocks (SSNBs) to patients with persistent shoulder pain.

METHODS

We collected data before the SSNB injection and at the 6-weeks and 6-month follow-up from consecutive patients with persistent shoulder pain being treated by physiotherapists or an anaesthetist. Outcomes were patient-reported pain (numerical rating scale [NRS 0 to 10]), patient-specific functional score (PSFS) and health-related quality of life [the EuroQol five dimensions questionnaire (EQ5D-5 L)]. Exploratory analyses compared baseline and follow-up scores within each clinician delivery group (physiotherapists, anaesthetist).

RESULTS

Forty patients (mean age 57 years [standard deviation {SD} 12]; 63% female) received an SSNB from a physiotherapist, eight patients (mean age 59 years [SD 11]; female 88%) received an SSNB from an anaesthetist. At the 6-week follow-up, the physiotherapy group showed a mean reduction in pain (on the NRS): 2.2 (95% confidence interval [CI] 1.3 to 3.0) and an improvement in function (on the PSFS): -1.3 (95% CI -1.9 to -0.4). Similar changes were found in those treated by the anaesthetist (pain: 1.3 [95% CI -1.18 to 3.80]; function: -1.4 (95% CI -3.18 to 0.35]). Very small changes, that were not statistically significant, were found in EQ5D-5 L scores. At the 6-month follow-up, the mean reduction in pain (NRS) was maintained at 2.0 (95% CI 0.99 to 2.95) for the physiotherapy group.

CONCLUSION

The results provide early, exploratory evidence that patients with persistent shoulder pain treated by physiotherapists using palpation-guided SSNBs achieve clinically important changes in pain and function in the short and medium term.

Examination of the Validity of a Clinical Prediction Rule to Identify Patients With Shoulder Pain Likely to Benefit From Cervicothoracic Manipulation

Study Design Secondary analysis of a randomized controlled trial. Background Prognostic variables identifying patients with shoulder pain who are likely to respond to cervicothoracic manipulation have been reported; however, they have yet to be validated. Objective To examine the validity of previously reported prognostic variables in predicting which patients with shoulder pain will respond to cervicothoracic manipulation. Methods Participants (n = 140) with a report of shoulder pain were randomly assigned to receive either 2 sessions of range-of-motion exercises plus 6 sessions of stretching and strengthening exercises (exercise group), or 2 sessions of cervicothoracic manipulation and range-of-motion exercises followed by 6 sessions of stretching and strengthening exercise (manipulative-therapy-plus-exercise group). Outcomes of disability (Shoulder Pain and Disability Index, shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire) and pain (numeric pain-rating scale) were collected at baseline, 1 week, 4 weeks, and 6 months. Time, treatment group, status of predictor variables, and 2-way and 3-way interactions were analyzed using linear mixed models with repeated measures. Results There were no significant 3-way interactions for either disability (P = .27) or pain scores (P = .70) for time, group, and predictor status for any of the predictor variables. Conclusion The results of the current study did not validate the previously identified prognostic variables; therefore, we cannot support using these in clinical practice. Further updating of the existing prediction rule may be warranted and could potentially result in new prognostic variables and improved generalizability. Limitations of the study were a mean duration of symptoms of greater than 2 years and a loss to follow-up of 19% at 6 months. Level of Evidence Prognosis, level 1b. Trial prospectively registered March 30, 2012 at www.clinicaltrials.gov (NCT01571674). J Orthop Sports Phys Ther 2017;47(4):252-260. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7100.

Risk stratification of patients with shoulder pain seen in physical therapy practice

RATIONALE, AIMS AND OBJECTIVES

Musculoskeletal shoulder pain is commonly treated in physical therapy. There is inconsistency in the literature regarding patient characteristics related to prognosis. Having prognostic information could be useful for improving clinical efficiency and decreasing the cost of associated care. The objective of this study was to identify predictive characteristics related to patients with shoulder pain who have a high-risk of a bad prognosis (lowest functional recovery compared with visit utilization) as well as those who are at low-risk of a bad prognosis (highest functional recovery compared with visit utilization).

METHODS

We completed a secondary analysis of a retrospective cohort using data obtained from an existing commercial outcomes database. Data from 5214 patients with shoulder pain were analysed to determine predictive characteristics that identify patients who either have a low-risk or a high-risk of a bad prognosis to physical therapy care. Multinomial regression was used to identify significant patient characteristics predictive of treatment response.

RESULTS

Statistically significant predictors of high-risk categorization included older age, no surgical history, insurance designated as worker's compensation, litigation or automotive and three or more co-morbidities. Predictors of low risk categorization were younger age, shorter duration of symptoms, no surgical history and payer type.

CONCLUSION

Selected variables were associated with both poor and good recovery. Further research on prognosis, efficacy of physical therapy care and cost appear warranted for patients with shoulder pain.

Clinical course and prognosis of musculoskeletal pain in patients referred for physiotherapy: does pain site matter?

Background

Danish patients with musculoskeletal disorders are commonly referred for primary care physiotherapy treatment but little is known about their general health status, pain diagnoses, clinical course and prognosis.

The objectives of this study were to 1) describe the clinical course of patients with musculoskeletal disorders referred to physiotherapy, 2) identify predictors associated with a satisfactory outcome, and 3) determine the influence of the primary pain site diagnosis relative to those predictors.

Methods

This was a prospective cohort study of patients (n = 2,706) newly referred because of musculoskeletal pain to 30 physiotherapy practices from January 2012 to May 2012. Data were collected via a web-based questionnaire 1–2 days prior to the first physiotherapy consultation and at 6 weeks, 3 and 6 months, from clinical records (including primary musculoskeletal symptom diagnosis based on the ICPC-2 classification system), and from national registry data. The main outcome was the Patient Acceptable Symptom State. Potential predictors were analysed using backwards step-wise selection during longitudinal Generalised Estimating Equation regression modelling. To assess the influence of pain site on these associations, primary pain site diagnosis was added to the model.

Results

Of the patients included, 66% were female and the mean age was 48 (SD 15). The percentage of patients reporting their symptoms as acceptable was 32% at 6 weeks, 43% at 3 months and 52% at 6 months. A higher probability of satisfactory outcome was associated with place of residence, being retired, no compensation claim, less frequent pain, shorter duration of pain, lower levels of disability and fear avoidance, better mental health and being a non-smoker. Primary pain site diagnosis had little influence on these associations, and was not predictive of a satisfactory outcome.

Conclusion

Only half of the patients rated their symptoms as acceptable at 6 months. Although satisfactory outcome was difficult to predict at an individual patient level, there were a number of prognostic factors that were associated with this outcome. These factors should be considered when developing generic prediction tools to assess the probability of satisfactory outcome in musculoskeletal physiotherapy patients, because the site of pain did not affect that prognostic association.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1487-3) contains supplementary material, which is available to authorized users.

Development of a Prognostic Model for Patients With Shoulder Complaints in Physical Therapist Practice

BACKGROUND

Health care providers need prognostic factors to distinguish between patients who are likely to recover and those who are not likely to recover.

OBJECTIVE

The aim of this study was to: (1) describe the clinical course of recovery and (2) identify prognostic factors of recovery in patients with shoulder pain at the 26-week follow-up.

DESIGN

A prospective cohort study was carried out in the Netherlands and included 389 patients who consulted a physical therapist for a new episode of shoulder pain.

METHOD

Participants were followed for 26 weeks. Potential predictors of recovery were selected from the literature and, with the addition of 2 new variables (ie, use of diagnostic ultrasound and working alliance), evaluated in the multivariable regression analysis. Multiple imputation was used to handle missing data, and bootstrap methods were used for internal validation.

RESULTS

The recovery rate was 60% for the total population and 65% for the working population after 26 weeks. Short duration of complaints, lower disability scores, having a paid job, better working alliance, and no feelings of anxiety or depression were associated with recovery. In the working population, only duration of complaints and disability remained in the final model. The area under the receiver operating characteristic curve (AUC) for the final model was 0.67 for the total population and 0.63 for the working population. After internal validation, the AUC was corrected to 0.66 and 0.63, respectively.

LIMITATIONS

External validation of the prognostic model should be done prior to its use in clinical practice.

CONCLUSION

The results of this study indicate that several factors can predict recovery.

Exercises and Dry Needling for Subacromial Pain Syndrome: A Randomized Parallel-Group Trial

This randomized clinical trial investigated the effectiveness of exercise versus exercise plus trigger point (TrP) dry needling (TrP-DN) in subacromial pain syndrome. A randomized parallel-group trial, with 1-year follow-up was conducted. Fifty subjects with subacromial pain syndrome were randomly allocated to receive exercise alone or exercise plus TrP-DN. Participants in both groups were asked to perform an exercise program of the rotator cuff muscles twice daily for 5 weeks. Further, patients allocated to the exercise plus TrP-DN group also received dry needling to active TrPs in the muscles reproducing shoulder symptoms during the second and fourth sessions. The primary outcome was pain-related disability assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire. Secondary outcomes included mean current pain and the worst pain experienced in the shoulder during the previous week. They were assessed at baseline, 1 week, and 3, 6, and 12 months after the end of treatment. Analysis was according to intention to treat with mixed analysis of covariance adjusted for baseline outcomes. At 12 months, 47 patients (94%) completed follow-up. Statistically larger improvements (all, P < .01) in shoulder disability was found for the exercise plus TrP-DN group at all follow-up periods (post: Δ -20.6 [95% confidence interval (CI) -23.8 to -17.4]; 3 months: Δ -23.2 [95% CI -28.3 to -18.1)]; 6 months: Δ -23.6 [95% CI -28.9 to -18.3]; 12 months: Δ -13.9 [95% CI -17.5 to -10.3]). Both groups exhibited similar improvements in shoulder pain outcomes at all follow-up periods. The inclusion of TrP-DN with an exercise program was effective for improving disability in subacromial pain syndrome. No greater improvements in shoulder pain were observed.

PERSPECTIVE

This study found that the inclusion of 2 sessions of TrP-DN into an exercise program was effective for improving shoulder pain-related disability at short-, medium-, and long-term; however, no greater improvement in shoulder pain was observed.

Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial

Study Design Multicenter randomized controlled trial. Background Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objectives To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. Level of Evidence Therapy, level 1b. Prospectively registered March 30, 2012 at www.ClinicalTrials.gov (NCT01571674). J Orthop Sports Phys Ther 2016;46(8):617-628. doi:10.2519/jospt.2016.6319.

Prognostic Models in Adults Undergoing Physical Therapy for Rotator Cuff Disorders: Systematic Review

BACKGROUND

Rotator cuff-related disorders represent the largest subgroup of shoulder complaints. Despite the availability of various conservative and surgical treatment options, the precise indications for these options remain unclear.

PURPOSE

The purpose of this systematic review was to synthesize the available research on prognostic models for predicting outcomes in adults undergoing physical therapy for painful rotator cuff disorders.

DATA SOURCES

The MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and PEDro databases and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) up to October 2015 were searched.

STUDY SELECTION

The review included primary studies exploring prognostic models in adults undergoing physical therapy, with or without other conservative measures, for painful rotator cuff disorders. Primary outcomes were pain, disability, and adverse events. Inclusion was limited to prospective investigations of prognostic factors elicited at the baseline assessment. Study selection was independently performed by 2 reviewers.

DATA EXTRACTION

A pilot-tested form was used to extract data on key aspects of study design, characteristics, analyses, and results. Risk of bias and applicability were independently assessed by 2 reviewers using the Prediction Study Risk of Bias Assessment tool (PROBAST).

DATA SYNTHESIS

Five studies were included in the review. These studies were extremely heterogeneous in many aspects of design, conduct, and analysis. The findings were analyzed narratively.

LIMITATIONS

All included studies were rated as at high risk of bias, and none of the resulting prognostic models was found to be usable in clinical practice.

CONCLUSIONS

There are no prognostic models ready to inform clinical practice in the context of the review question, highlighting the need for further research on prognostic models for predicting outcomes in adults who undergo physical therapy for painful rotator cuff disorders. The design and conduct of future studies should be receptive to developing methods.

The Maintaining Musculoskeletal Health (MAmMOTH) Study: Protocol for a randomised trial of cognitive behavioural therapy versus usual care for the prevention of chronic widespread pain

BACKGROUND

Cognitive behavioural therapy (CBT) has been shown to improve outcomes for patients with fibromyalgia, and its cardinal feature chronic widespread pain (CWP). Prediction models have now been developed which identify groups who are at high-risk of developing CWP. It would be beneficial to be able to prevent the development of CWP in these people because of the high cost of symptoms and because once established they are difficult to manage. We will test the hypothesis that among patients who are identified as at high-risk, a short course of telephone-delivered CBT (tCBT) reduces the onset of CWP. We will further determine the cost-effectiveness of such a preventative intervention.

METHODS

The study will be a two-arm randomised trial testing a course of tCBT against usual care for prevention of CWP. Eligible participants will be identified from a screening questionnaire sent to patients registered at general practices within three Scottish health boards. Those returning questionnaires indicating they have visited their doctor for regional pain in the last 6 months, and who have two of, sleep problems, maladaptive behaviour response to illness, or high number of somatic symptoms, will be invited to participate. After giving consent, participants will be randomly allocated to either tCBT or usual care. We aim to recruit 473 participants to each treatment arm. Participants in the tCBT group will have an initial assessment with a CBT therapist by telephone, then 6 weekly sessions, and booster sessions 3 and 6 months after treatment start. Those in the usual care group will receive no additional intervention. Follow-up questionnaires measuring the same items as the screening survey questionnaire will be sent 3, 12 and 24 months after start of treatment. The main outcome will be CWP at the 12 month questionnaire.

DISCUSSION

This will be the first trial of an intervention aimed at preventing fibromyalgia or CWP. The results of the study will help to inform future treatments for the prevention of chronic pain, and aetiological models of its development.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02668003URL: Please check that the following URLs are working. If not, please provide alternatives: NCT02668003Alternative is: https://www.clinicaltrials.gov/ct2/show/NCT02668003> . Date registered: 28-Jan-2016.

The Effect of the Modified Lateral Suprascapular Block on Shoulder Function in Patients With Chronic Shoulder Pain

Background:

Suprascapular nerve block (SSNB) is commonly used in pain therapy for patients with chronic shoulder pain. The effect of SSNB on shoulder function has, however, not been investigated so far. If in shoulder function, i.e. the range of motion is increased after application of the nerve block, it can be expected that subsequent physiotherapy, besides being less painful, is also more effective in terms of restoring shoulder mobility.

Objectives:

Our aim was to evaluate the effect of SSNB on shoulder function, in patients with chronic shoulder pain.

Patients and Methods:

Patients were evaluated using the Constant-Murley Score (CMS) and number rating scale values for pain. The SSN was blocked using the Feigl approach, with 5 ml ropivacaine 0.5%. Shoulder function and pain were assessed 60 minutes and 24 hours after the block.

Results:

Totally, 20 patients completed the study. The CMS and pain scores significantly improved after the block.

Conclusions:

The use of the modified lateral SSNB of Feigl significantly reduces pain and increases shoulder function, in chronic shoulder pain.

Influence of fear-avoidance beliefs on disability in patients with subacromial shoulder pain in primary care: a secondary analysis

BACKGROUND

Little information exists about the role of fear-avoidance beliefs and catastrophizing in subacromial pain syndrome.

OBJECTIVE

The purpose of this study was to investigate the associations among pain, catastrophizing, fear, and disability and the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up.

DESIGN

A cross-sectional and longitudinal analysis was conducted.

METHODS

Baseline demographic and clinical data, including fear-avoidance beliefs and catastrophizing, of 90 patients were assessed for this analysis. Disability was measured with the Shoulder Pain and Disability Index at baseline and at 3-month follow-up. First, bivariate and partial correlations were calculated among pain, fear-avoidance beliefs, catastrophizing, and disability, based on the fear-avoidance model. Second, the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up was examined with hierarchical regression analyses.

RESULTS

Correlations between clinical variables and disability were largely in line with the fear-avoidance model. Regression analyses identified a significant contribution of fear-avoidance beliefs to baseline disability but not to disability at 3 months.

LIMITATIONS

Patients with subacromial pain syndrome were studied; therefore, the results should be transferred with caution to other diagnoses. A modified version of the Fear-Avoidance Beliefs Questionnaire was used, which was not validated for this patient group.

CONCLUSIONS

Fear-avoidance beliefs contribute significantly to baseline disability but not to disability change scores after 3-month follow-up. Duration of complaints and baseline disability were the main factors influencing disability change scores. Although the results help to improve understanding of the role of fear-avoidance beliefs, further studies are needed to fully understand the influence of psychological and clinical factors on the development of disability in patients with subacromial shoulder pain.

Physiotherapy assessment of patients with rotator cuff pathology

Pathology of the rotator cuff and sub-acromial bursa are considered to be the main cause of shoulder pain and dysfunction. In the absence of trauma, conservative care, including physiotherapy is the primary treatment. This paper aims to present the key features of a physiotherapy assessment, excluding diagnostic tests for rotator cuff pathology. It describes and explores how assessment can be used to direct management options and develop a treatment plan.