Costs of shoulder pain in primary care consulters: a prospective cohort study in The Netherlands

Pharmacologic interventions for primary glenohumeral osteoarthritis

ABSTRACT

Primary glenohumeral osteoarthritis is a multifactorial condition with a complex cause that affects patients across different age groups, impairing physiologic and psychologic well-being, and substantially reducing patient quality of life and overall productivity. To effectively manage this condition, healthcare providers need to be well informed about treatment guidelines, as well as the available therapeutic options and the evidence supporting their use. Nonsurgical interventions should be regarded as the primary treatment option, particularly for patients in the initial phases of this condition. No conclusive guidelines exist for treating young and active patients, and the literature lacks high-quality data to evaluate the efficacy, safety, and long-term consequences of several interventions, regardless of patient characteristics and expectations.

Evaluating the effects of mobile application-based rehabilitation on improving disability and pain in patients with disputed thoracic outlet syndrome: A randomized controlled trial

BACKGROUND

Disputed thoracic outlet syndrome (D.TOS) stands as one of the primary global contributors to physical disability, presenting diagnostic and treatment challenges for patients and frequently resulting in prolonged periods of pain and functional impairment. Mobile applications emerge as a promising avenue in aiding patient self-management and rehabilitation for D.TOS. This study aimed to investigate the impact of a certain mobile application-based rehabilitation on pain relief and the improvement of disability in patients experiencing D.TOS.

METHODS

Eighty-eight patients diagnosed with D.TOS randomized 1:1 to either the control group (n = 44) or the intervention group (n = 44). Participants in the control group were provided with a brochure containing standard rehabilitation exercise instructions, a written drug prescription from the physician, and guidance on recommended physical activity levels, including home exercises. In contrast, all participants in the intervention group used the mobile application. Disability and pain levels in patients were assessed after six weeks in both groups.

RESULT

Both groups improved pain and disability based on the scaled measurements. According to the questionnaire scale, the intervention group showed a considerable decline in disability; however, there was a significant difference in just one question (P < 0.05). Furthermore, the intervention group showed significant improvement in neck pain NRS (p = 0.024) compared to the control. Based on the shoulder and head pain numeric rate scale (NRSs), both groups showed improvement in disability conditions; but there were no significant differences between the groups (p > 0.05).

CONCLUSION

Mobile applications are promising tools for alleviating disabilities and pain in patients with musculoskeletal conditions. This study confirmed the potential of mobile technology to enhance active and corrective physical activity, thereby reducing pain in patients with D.TOS.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT) with the identifier IRCT20141221020380N3 (http://www.irct.ir/).

Linking patient reported shoulder outcomes to the international classification of functioning, disability and health

PURPOSE

To link the items from shoulder-specific Patient Reported Outcome Measures (PROMs) to the International Classification of Functioning, Disability and Health (ICF) domains and categories, and to determine if the items fit into the ICF framework.

MATERIALS AND METHODS

The Brazilian versions of the Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST) and Western Ontario Rotator Cuff Index (WORC) were linked to the ICF by two researchers independently. Agreement between raters was determined by calculating the Kappa Index.

RESULTS

Fifty-eight items from the PROMs were linked to eight domains and 27 categories of ICF. The PROMs covered components of body functions, activities, and participation. Components of body structure and environmental factors were not covered by any of the PROMs. ​There was substantial agreement between raters when linking the OSS (Kappa index = 0.66), SPADI (Kappa index = 0.92), SST (Kappa index = 0.72) and WORC (Kappa index = 0.71).

CONCLUSIONS

WORC and SST were the PROMs that covered the highest number of ICF domains (seven and six, respectively). However, SST is short and may be less time consuming in a clinical assessment. Clinicians can benefit from this study to decide which shoulder-specific PROM may be more adequate according to the clinical demand.Implications For RehabilitationWestern Ontario Rotator Cuff Index was the shoulder-specific Patient Reported Outcome Measure (PROM) that best showed a broader view of functionality through the International Classification of Functioning, Disability and Health (ICF) domains that can influence shoulder pain and disability.Simple Shoulder Test seems to be the most recommended shoulder-specific PROM considering the number of domains covered by the ICF and the clinical evaluation time consumption.Shoulder Pain and Disability Index fails to provide a broader view of functioning through other ICF domains that may influence shoulder pain and disability.

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.

Blood Flow Restriction Training in Nonspecific Shoulder Pain: Study Protocol of a Crossover Randomised Controlled Trial

"Nonspecific shoulder pain" encompasses various non-traumatic musculoskeletal shoulder disorders, diverging from diagnostic terminologies that refer to precise tissue-oriented clinical diagnosis. Blood flow restriction (BFR) training, involving partial arterial inflow and complete venous outflow restriction, has exhibited acute hypoalgesic effects primarily in healthy populations by increasing their pain thresholds. This study aims to examine whether a single BFR session with low-load exercises can alleviate pain perception among nonspecific shoulder pain patients. Conducted as a single-blind crossover randomised clinical trial, 48 adults (age range: 18 to 40) presenting with nonspecific shoulder pain will partake in two trial sessions. Random assignment will place participants into BFR or sham BFR groups and ask them to perform one exercise with BFR. Subsequently, participants will complete a shoulder girdle loading regimen comprising six exercises. The second session will involve participants switching treatment groups. Pain pressure thresholds (PPTs), shoulder pain and disability via the shoulder pain and disability index (SPADI), maximal voluntary isometric contraction (MVIC) of shoulder external rotators, pain during active abduction, and peak pain during shoulder external rotation will be evaluated using the numeric pain rating scale (NPRS). Immediate post-exercise assessments will include patient-perceived pain changes using the global rating of change scale (GROC) and participant-rated perceived exertion (RPE), employing a modified Borg's scale (Borg CR10) post-BFR or sham BFR exercise session. Each session will encompass three assessment periods, and a combination of mixed-effect models and descriptive statistics will underpin the analysis. This protocol was approved by Cyprus National Bioethics Committee (ΕΕΒΚ/2023/48), and was registered in ClinicalTrials.gov (Registration number: NCT05956288). Conclusion: The anticipated outcomes of this study illuminated the acute effects of BFR training on pain perception within the context of nonspecific shoulder pain, potentially advancing strategies for managing pain intensity using BFR techniques.

Prognostic factors for high societal costs: a register-based study on 561,665 patients with shoulder disorders

ABSTRACT

Shoulder disorders are common and associated with high societal costs, especially for a small group of patients. Prognostic factors can help identify high-cost patients, which is crucial to optimize early identification and develop tailored interventions. We aimed to identify prognostic factors for high societal costs, to examine whether the prognostic factors were similar for high healthcare costs and high costs of sick leave, and to investigate the model's robustness across 4 diagnostic categories. Using national Danish registers, potential prognostic factors (age, sex, educational level, long-term sick leave, admission, visits to general practitioner and physiotherapist, comorbidity, diabetes, low back pain, and neck pain) were included in a logistic regression model with high societal costs, defined by the top 10th percentile, as the main outcome. The model's prognostic accuracy was assessed using the Nagelkerke R2 and its discriminative ability using area under the receiver operating curve (AUC). Data on 80% of the patients (n = 449,302) were used to develop the model and 20% (n = 112,363) to validate the model. By far the strongest prognostic factor for high societal costs and high costs of sick leave was sick leave at the time of diagnosis (OR: 20.2, 95% CI: 19.5-20.9). Prognostic factors for high healthcare costs were high age, comorbidity, and hospital admission the year before diagnosis. The model was robust across diagnostic categories and sensitivity analyses. In the validation sample, the primary model's discriminative ability was good (AUC = 0.80) and the model explained 28% of the variation in the outcome (Nagelkerke R2 ).

Transarterial Embolization of Neovascularity for Refractory Nighttime Shoulder Pain: A Multicenter, Open-Label, Feasibility Trial

PURPOSE

To assess the feasibility of transarterial embolization (TAE) for recalcitrant nighttime shoulder pain in a multicentric study.

MATERIALS AND METHODS

This prospective, open-label, feasibility trial included 100 patients treated at 5 institutions. TAE was performed in 76 patients with adhesive capsulitis (AC) and 24 patients with symptomatic rotator cuff tears (sRCTs). The ipsilateral radial artery was punctured, and imipenem/cilastatin sodium was infused as an embolic agent. Adverse events, 10 point pain numerical rating scale (NRS), range of motion (ROM) of the shoulder joint, and quality of life (via the EuroQol-5D [EQ-5D]) were evaluated.

RESULTS

All patients exhibited neovascularity on baseline angiography, and all TAE procedures were performed successfully. No patient experienced a major adverse event. The mean nighttime pain NRS scores at baseline and 1, 3, and 6 months after TAE were 6.4 ± 2.2, 3.4 ± 2.6, 2.3 ± 2.5, and 1.6 ± 2.2, respectively (for all, P < .001). The mean ROM of anterior elevation at baseline and 1, 3, and 6 months after TAE were 97° ± 29°, 119° ± 28°, 135° ± 27°, and 151° ± 17°, respectively (for all, P < .001). The mean EQ-5D scores at baseline and 1, 3, and 6 months after TAE were 0.63 ± 0.17, 0.73 ± 0.16, 0.80 ± 0.17, and 0.84 ± 0.17, respectively (for all, P < .001). There was no significant difference in the clinical success rate between the AC and sRCT groups.

CONCLUSIONS

TAE for nighttime shoulder pain caused by AC and sRCTs was feasible with sufficient safety and efficacy.

Prognosis of shoulder pain in those with and without a psychological disorder: A prospective cohort study with a six-month follow-up

BACKGROUND

Because shoulder pain can have an unfavorable prognosis, it is important to have a better understanding of factors that may influence recovery.

OBJECTIVE

To determine the association between recovery from shoulder pain and the presence of depression, anxiety, and pain catastrophizing.

METHODS

In a prospective cohort study with a six months follow-up, we included patients visiting an orthopaedic department with shoulder pain. Primary outcome was recovery from shoulder pain measured with the Shoulder Pain and Disability Index at three and six months. Information about depression and anxiety (Hospital Anxiety and Depression Scale), pain catastrophizing (Pain Catastrophizing Scale), and demographic and clinical factors were collected at baseline. A linear mixed model was used to estimate the effects of depression, anxiety, pain catastrophizing, and underlying shoulder disorders on recovery.

RESULTS

We included 190 patients. There were no statistically significant associations between the presence of depression, anxiety, and pain catastrophizing, and three- and six-month recovery. Also between the underlying shoulder disorders and recovery at three and six months, there were no statistically significant associations.

CONCLUSIONS

We could not prove that depression, anxiety, and pain catastrophizing, as well as underlying shoulder disorders, were associated with recovery of shoulder pain at six months.

Assessing shoulder disability in orthopaedic specialist care: Introducing the Copenhagen Shoulder Abduction Rating (C-SAR)

BACKGROUND

Differences in shoulder-disability among common shoulder-disorders in orthopaedic specialist care is unknown. Furthermore, rating of shoulder-disability using patient-reported outcomes is time-consuming, and a faster approach is needed.

OBJECTIVES

First, compare shoulder-disability among common shoulder-disorders. Secondly, rate shoulder-disability according to the new and quick Copenhagen Shoulder Abduction Rating (C-SAR) and investigate criterion validity of C-SAR.

METHODS

Cross-sectional study including 325 consecutive patients with shoulder-disorders in orthopaedic specialist care. We assessed shoulder abduction range-of-motion and pain during testing (NRS:0-10), and shoulder-disability using Shoulder Pain and Disability Index (SPADI) subscales. Patients were sub-grouped using C-SAR, which is based on shoulder abduction range-of-motion and pain during testing: Severe (range-of-motion ≤90°), Medium (range-of-motion >90°, NRS:>5), Mild (range-of-motion >90°, NRS:≤5). Shoulder-disability was compared among diagnostic categories and C-SAR subgroups using ANCOVA-models.

RESULTS

Most patients were diagnosed with either subacromial impingement (n = 211) or full-thickness/complete rotator-cuff tear (n = 18), but adhesive capsulitis (n = 22) was the diagnostic category related to worst SPADI scores. Data for C-SAR subgrouping were available from 187/229 (82%) patients with rotator-cuff related disorders (subacromial impingement or rotator-cuff tears). C-SAR subgrouping was not feasible for patient with adhesive capsulitis or glenohumeral injury. Differences in shoulder-disability between Mild (n = 67) and Medium (n = 56) C-SAR subgroups were large for both SPADI-subscales (ES: 1.0, p < .0001). Only SPADI-function differed significantly between Severe (n = 64) and Medium C-SAR subgroups (ES: 0.4, p = .017).

CONCLUSION

In orthopaedic specialist care, adhesive capsulitis relates to highest level of shoulder-disability, while C-SAR is a promising test to rate shoulder-disability for most patients, namely those with rotator-cuff related disorders.

Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review

OBJECTIVES

The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials.

METHODS

Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories.

RESULTS

Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education.

CONCLUSION

Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes.

IMPACT

The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.

Costs of shoulder disorders in Denmark; a nationwide cost-off-illness study investigating 617,334 patients and matched controls

ABSTRACT

Shoulder disorders are very common musculoskeletal conditions. Few studies have focused on the costs associated with shoulder disorders, and the economic burden has never been established in a nationwide cost-of-illness study. We aimed to evaluate the healthcare costs and costs of productivity loss (sick leave), and to evaluate if costs were higher for specific subgroups. Using national Danish registers, we identified individuals with shoulder disorders (subacromial pain, stiffness, fracture or dislocation) diagnosed between 2005 and 2017 and controls matched on age and gender without shoulder disorders. Health care usage, sick leave and related costs were estimated. During the 13-year inclusion period, 617,334 unique individuals were identified and the incidence rate was 1,215 per 100,000 person years in 2017. The expected additional societal costs were €1.21 billion annually. The mean additional total costs for the 6-years period were €11,334 (11,014; 11,654) for individuals aged ≥65 years and €25,771 (25,531; 26,012) for individuals aged <65 years. For individuals in the working age, the costs of sick leave accounted for approximately 70% of the total costs. Individuals aged ≥65 years had health care costs that were twice as high as individuals aged <65 years. Additionally, the 20% of cases accruing the highest costs accounted for 66% of the total costs. In conclusion, incidence rates of shoulder disorders were high and costs of sick leave accounted for a large proportion of total costs associated with illness in working age people. Furthermore, a minority of patients accounted for a substantial share of the total costs.

Development of the Avoidance Daily Activities Photo Scale for Patients With Shoulder Pain

OBJECTIVES

The purpose of this study was to develop the Avoidance of Daily Activities Photo Scale (ADAP Shoulder Scale) to measure shoulder pain-related avoidance behavior in patients with shoulder pain and evaluate and report the structural validity and internal consistency of the scale.

METHODS

Potential daily activities involving the shoulder were selected from the activities and participation domain of the International Classification of Functioning, Disability and Health. The selected activities were presented to an expert panel, health care professionals, and patients with shoulder pain with the question "How much do you think it is important to ask patients with shoulder pain about this activity?" Activities attaining a content validity index (CVI) ≥ 0.8 were represented using a digitally colored photograph. Activity photographs were evaluated by health care professionals and patients with shoulder pain. Photographs with a CVI ≥ 0.8 were included in the scale. To evaluate structural validity and internal consistency of the scale, exploratory factor analysis was performed to determine the presence of any scale domain. Cronbach alpha was calculated to indicate the internal consistency of each domain.

RESULTS

Of the 107 preselected activities, 21 attained a CVI ≥ 0.8. Eighteen photographs (CVI ≥ 0.8) were included in the scale after being analyzed by 120 health care professionals and 50 patients with shoulder pain. Exploratory factor analysis (N = 156) showed that the ADAP Shoulder Scale consists of 3 domains: free movement, high effort, and self-care. The internal consistencies of the domains were 0.92, 0.89, and 0.92, respectively.

CONCLUSION

The ADAP Shoulder Scale included 15 photographs distributed in 3 domains. All domains had a high internal consistency. The scale is easily applicable, well understood, and relevant for shoulder pain.

IMPACT

The ADAP Shoulder Scale can be used to rate shoulder pain-related avoidance behaviors.

Deep learning for accurately recognizing common causes of shoulder pain on radiographs

OBJECTIVE

Training a convolutional neural network (CNN) to detect the most common causes of shoulder pain on plain radiographs and to assess its potential value in serving as an assistive device to physicians.

MATERIALS AND METHODS

We used a CNN of the ResNet-50 architecture which was trained on 2700 shoulder radiographs from clinical practice of multiple institutions. All radiographs were reviewed and labeled for six findings: proximal humeral fractures, joint dislocation, periarticular calcification, osteoarthritis, osteosynthesis, and joint endoprosthesis. The trained model was then evaluated on a separate test dataset, which was previously annotated by three independent expert radiologists. Both the training and the test datasets included radiographs of highly variable image quality to reflect the clinical situation and to foster robustness of the CNN. Performance of the model was evaluated using receiver operating characteristic (ROC) curves, the thereof derived AUC as well as sensitivity and specificity.

RESULTS

The developed CNN demonstrated a high accuracy with an area under the curve (AUC) of 0.871 for detecting fractures, 0.896 for joint dislocation, 0.945 for osteoarthritis, and 0.800 for periarticular calcifications. It also detected osteosynthesis and endoprosthesis with near perfect accuracy (AUC 0.998 and 1.0, respectively). Sensitivity and specificity were 0.75 and 0.86 for fractures, 0.95 and 0.65 for joint dislocation, 0.90 and 0.86 for osteoarthrosis, and 0.60 and 0.89 for calcification.

CONCLUSION

CNNs have the potential to serve as an assistive device by providing clinicians a means to prioritize worklists or providing additional safety in situations of increased workload.

Measurement properties of the Brazilian versions of Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in individuals with shoulder pain

PURPOSE

To verify the measurement properties of the Brazilian versions of Fear-avoidance Beliefs Questionnaire (FABQ) and Tampa Scale of Kinesiophobia (TSK) in individuals with shoulder pain.

METHODS

Individuals with shoulder pain (>18 years) were included in this study. Structural validity was verified by exploratory factor analysis, which was used to identify dimensionality of the FABQ and TSK. Test-retest reliability was assessed with intraclass correlation coefficient(3,1) and internal consistency with Cronbach's alpha. Floor or ceiling effects were also investigated. Responsiveness was verified by effect sizes and area under the receiver operating characteristic curve (AUC).

RESULTS

Exploratory factor analysis identified two and one factor in the FABQ and TSK, respectively. FABQ and TSK presented moderate to good reliability and adequate internal consistency (Cronbach's alpha > 0.70). The floor effect was present in one factor of the FABQ. The FABQ and TSK showed small to moderate effect sizes and did not show adequate AUC.

CONCLUSION

FABQ and TSK are multidimensional and unidimensional instruments, respectively. Those instruments presented moderate to good reliability and the responsiveness was considered to be suboptimal in individuals with shoulder pain.

Large to massive rotator cuff tendon tears: a protocol for a systematic review investigating the effectiveness of exercise therapy on pain, disability and quality of life

Background: Chronic non-traumatic rotator cuff tendon tears are inextricably linked with the natural process of aging often resulting in severe disability, poor quality of life and an added burden to the health care system. The occurrence of rotator cuff tendon tears increases exponentially with every decade of life to approximately 60% in individuals over 80 years of age. Exercise is a commonly prescribed intervention although research on its efficacy is in its infancy and often conflicting. The purpose of this systematic review is to investigate the effectiveness of exercise interventions for people diagnosed with large to massive rotator cuff tendon tears.

Methods: This systematic review will adhere to the PRISMA reporting guidelines. A comprehensive search of five databases will be conducted. Randomised clinical trials (RCT) or quasi-randomised control trials will be included if they evaluate exercise as the core intervention or as part of the intervention in the management of large to massive rotator cuff tears. To quantify response to treatment we will compare changes in pain, disability and quality of life (QoL). The Consensus on Exercise Reporting Template (CERT) will be used to characterise the different types of exercise intervention. The Cochrane Risk of Bias Tool will be used to assess study quality.

A narrative synthesis with meta-analysis will be performed, and the certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

Discussion: This review will synthesise the totality of GRADE A and B evidence on the effectiveness of exercise for large to massive rotator cuff tendon tears. It will provide clinically important information and guidance for immediate implementation by clinicians, health policymakers and may be used to guide future research.

PROSPERO registration: 244502 (24/03/2021)

Predicting pain and function outcomes in people consulting with shoulder pain: the PANDA-S clinical cohort and qualitative study protocol

INTRODUCTION

People presenting with shoulder pain considered to be of musculoskeletal origin is common in primary care but diagnosing the cause of the pain is contentious, leading to uncertainty in management. To inform optimal primary care for patients with shoulder pain, the study aims to (1) to investigate the short-term and long-term outcomes (overall prognosis) of shoulder pain, (2) estimate costs of care, (3) develop a prognostic model for predicting individuals' level and risk of pain and disability at 6 months and (4) investigate experiences and opinions of patients and healthcare professionals regarding diagnosis, prognosis and management of shoulder pain.

METHODS AND ANALYSIS

The Prognostic And Diagnostic Assessment of the Shoulder (PANDA-S) study is a longitudinal clinical cohort with linked qualitative study. At least 400 people presenting to general practice and physiotherapy services in the UK will be recruited. Participants will complete questionnaires at baseline, 3, 6, 12, 24 and 36 months. Short-term data will be collected weekly between baseline and 12 weeks via Short Message Serevice (SMS) text or software application. Participants will be offered clinical (physiotherapist) and ultrasound (sonographer) assessments at baseline. Qualitative interviews with ≈15 dyads of patients and their healthcare professional (general practitioner or physiotherapist).Short-term and long-term trajectories of Shoulder Pain and Disability Index (using SPADI) will be described, using latent class growth analysis. Health economic analysis will estimate direct costs of care and indirect costs related to work absence and productivity losses. Multivariable regression analysis will be used to develop a prognostic model predicting future levels of pain and disability at 6 months using penalisation methods to adjust for overfitting. The added predictive value of prespecified physical examination tests and ultrasound findings will be examined. For the qualitative interviews an inductive, exploratory framework will be adopted using thematic analysis to investigate decision making, perspectives of patients and clinicians on the importance of diagnostic and prognostic information when negotiating treatment and referral options.

ETHICS AND DISSEMINATION

The PANDA-S study has ethical approval from Yorkshire and The Humber-Sheffield Research Ethics Committee, UK (18/YH/0346, IRAS Number: 242750). Results will be disseminated through peer-reviewed publications, social and mainstream media, professional conferences, and the patient and public involvement and engagement group supporting this study, and through newsletters, leaflets and posters in participating sites.

TRIAL REGISTRATION NUMBER

ISRCTN46948079.

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.

Large to massive rotator cuff tendon tears: a protocol for a systematic review investigating the effectiveness of exercise therapy on pain, disability and quality of life

Background: Rotator cuff tendon tears are inextricably linked with the natural process of aging often resulting in severe disability, poor quality of life and an added burden to the health care system. The occurrence of rotator cuff tendon tears increases exponentially with every decade of life to approximately 60% in individuals over 80 years of age. Exercise is a commonly prescribed intervention although research on its efficacy is in its infancy and often conflicting. The purpose of this systematic review is to investigate the effectiveness of exercise interventions for people diagnosed with large to massive rotator cuff tendon tears. Methods: This systematic review will adhere to the PRISMA reporting guidelines. A comprehensive search of five databases will be conducted. Randomised clinical trials (RCT) or quasi-randomised control trials will be included if they evaluate exercise as the core intervention or as part of the intervention in the management of large to massive rotator cuff tears. To quantify response to treatment we will compare changes in pain, disability and quality of life (QoL). The Consensus on Exercise Reporting Template (CERT) will be used to characterise the different types of exercise intervention. The Cochrane Risk of Bias Tool will be used to assess study quality. A narrative synthesis with meta-analysis will be performed, and the certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Discussion: This review will synthesise the totality of GRADE A and B evidence on the effectiveness of exercise for large to massive rotator cuff tendon tears. It will provide clinically important information and guidance for immediate implementation by clinicians, health policymakers and may be used to guide future research. PROSPERO registration: 244502 (24/03/2021)

Elastofibroma presented as shoulder pain in an amateur swimmer: screening for referral in physiotherapy. A case report

Elastofibroma is a benign and rare fibroblast/myofibroblast tumor usually located near the periosteum of the ribs. Patients with elastofibroma can remain asymptomatic or can experience a clicking sensation during shoulder movements, shoulder stiffness, scapular and shoulder pain and dysfunction. Importantly, the symptoms can mimic a musculoskeletal condition being mistaken for orthopedic shoulder joint disease. A 54 years-old amateur swimmer self-referred to physiotherapy for left subscapular and shoulder pain. Concerns from the patient's history that caused suspicion of a medical condition included an insidious onset of nagging deep pain that increased with upper limb exertion and an audible thoracic clunk at arm end range flexion. Deep palpatory examination revealed a mass below the latissimus dorsi and rhomboids further screened by the physiotherapist with Rehabilitative Ultrasound Imaging. The physiotherapist referred the patient to a thoracic surgeon who removed the mass. After an exercise-based physiotherapy management program, the patient returned to previous activities including swimming after 5 months. The challenge for clinicians is to screen patients in whom shoulder pain may be related to non-musculoskeletal conditions. Prompt referral of patients presenting with the suspicion of elastofibroma to an appropriate physician may lead to a timely diagnosis and could avoid expensive and unnecessary rehabilitation procedures.

Clinical and cost effectiveness of a corticosteroid injection versus exercise therapy for shoulder pain in general practice: protocol for a randomised controlled trial (SIX Study)

INTRODUCTION

Shoulder pain is common and the prognosis is often unfavourable. Dutch guidelines on the treatment of shoulder pain in primary care recommend a corticosteroid injection or a referral to exercise therapy, if initial pain management fails and pain persists. However, evidence of the effectiveness of a corticosteroid injection compared with exercise therapy, especially in the long term, is limited. This trial will assess the clinical effectiveness and cost effectiveness of a corticosteroid injection compared with physiotherapist-led exercise therapy over 12 months follow-up in patients with shoulder pain in primary care.

METHODS AND ANALYSIS

The SIX Study is a multicentre, pragmatic randomised clinical trial in primary care. A total of 213 patients with shoulder pain, aged ≥18 years presenting in general practice will be included. Patients will be randomised (1:1) into two groups: a corticosteroid injection or 12 sessions of physiotherapist-led exercise therapy. The effect of the allocated treatment will be assessed through questionnaires at 6 weeks and after 3, 6, 9 and 12 months. The primary outcome is patient's reported shoulder pain-intensity and function, measured with the Shoulder Pain and Disability Index, over 12 months follow-up. Secondary outcomes include cost effectiveness, pain-intensity, function, health-related quality of life, sleep quality, patient's global perceived effect, work absence, healthcare utilisation and adverse events. Between group differences will be evaluated using a repeated measurements analysis with linear effects models. A cost-utility analysis will be performed to assess the cost effectiveness using quality-adjusted life years from a medical and societal perspective.

ETHICS AND DISSEMINATION

This study was approved by the Medical Ethics Committee of Erasmus MC University Medical Center Rotterdam (MEC 2020-0300). All participants will give written informed consent prior to data collection. The results from this study will be disseminated in international journals and implemented in the primary care guidelines on shoulder pain.

TRIAL REGISTRATION NUMBER

Dutch Trial Registry (NL8854).

Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to evaluate the effects of trigger point (TrP) dry needling alone or as an adjunct to other interventions on pain intensity and related disability in nontraumatic shoulder pain.

METHODS

Ten databases were searched from inception to January 2020 for randomized clinical trials in which at least 1 group received TrP dry needling for shoulder pain of musculoskeletal origin with outcomes collected on pain intensity and related disability. Data extraction including participant and therapist details, interventions, blinding strategy, blinding assessment outcomes, and results were extracted by 2 reviewers. The risk of bias (Cochrane Risk of Bias, Cochrane Guidelines), methodological quality (Physiotherapy Evidence Database score), and evidence level (Grading of Recommendations Assessment, Development, and Evaluation approach) were assessed. The search identified 551 publications with 6 trials eligible for inclusion.

RESULTS

There was moderate-quality evidence that TrP dry needling reduces shoulder pain intensity with a small effect (mean difference = -0.49 points, 95% CI = -0.84 to -0.13; standardized mean difference = -0.25, 95% CI = -0.42 to -0.09) and low-quality evidence that TrP dry needling improves related disability with a large effect (mean difference = -9.99 points, 95% CI -15.97 to -4.01; standardized mean difference = -1.14, 95% CI -1.81 to -0.47) compared with a comparison group. The effects on pain were only found at short term. The Cochrane Risk of Bias was generally low, but the heterogenicity of the results downgraded the evidence level.

CONCLUSION

Moderate- to low-quality evidence suggests positive effects of TrP dry needling for pain intensity (small effect) and pain-related disability (large effect) in nontraumatic shoulder pain of musculoskeletal origin, mostly at short term. Future clinical trials investigating long-term effects are needed.

IMPACT

Dry needling is commonly used for the management of musculoskeletal pain. This is the first meta-analysis to examine the effects of dry needling on nontraumatic shoulder pain.

Reduced psychosocial functioning in subacromial pain syndrome is associated with persistence of complaints after 4 years

BACKGROUND

Patients with subacromial pain syndrome (SAPS) frequently present with coexisting psychosocial problems; however, whether this also associates with long-term outcome is currently unknown. We assessed whether psychosocial functioning in patients with SAPS is associated with persistence of complaints after 4 years of routine care.

METHODS

In a longitudinal study, 34 patients with SAPS were selected after clinical and radiologic evaluation and assessed at baseline and after 4 years. For the assessment of psychosocial functioning, the RAND-36 questionnaire domains of social functioning, role limitations due to emotional problems, mental health, vitality, and general health were evaluated. Complaint persistence at follow-up was assessed by (1) an anchor question (reduced, persistent, or increased symptoms), (2) change in pain (change in visual analog scale score), and (3) change in quality of life (change in Western Ontario Rotator Cuff index score).

RESULTS

Lower baseline mental health (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.85-0.98; P = .013), vitality (OR, 0.90; 95% CI, 0.83-0.98; P = .011), and general health (OR, 0.93; 95% CI, 0.88-0.98; P = .009) were associated with persistent complaints as reported by the anchor question, change in visual analog scale score, and change in Western Ontario Rotator Cuff index score.

CONCLUSIONS

Evaluating psychosocial functioning parallel to physical complaints is currently not standard procedure in the treatment of SAPS. In this study, we showed that factors related to psychosocial functioning are associated with long-term persistence of complaints in SAPS. Future studies may investigate whether a multimodal treatment with assessment of psychosocial functioning may facilitate pain relief and recovery in SAPS.

Effects of electromyographic biofeedback interventions for shoulder pain and function: Systematic review and meta-analysis

OBJECTIVE

To systematically review the effectiveness of electromyographic biofeedback interventions to improve pain and function of patients with shoulder pain.

DESIGN

Systematic review of controlled clinical trials.

LITERATURE SEARCH

Databases (Medline, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and SCOPUS) were searched in December 2020.

STUDY SELECTION CRITERIA

Randomized clinical trials that investigated the effects of electromyographic biofeedback for individuals with shoulder pain. Patient-reported pain and functional outcomes were collected and synthesized.

DATA SYNTHESIS

The level of evidence was synthesized using GRADE and Standardized Mean Differences and 95% confidence interval were calculated using a random-effects inverse variance model for meta-analysis.

RESULTS

Five studies were included with a total sample of 272 individuals with shoulder pain. Very-low quality of evidence indicated that electromyographic biofeedback was not superior to control for reducing shoulder pain (standardized mean differences = -0.21, 95% confidence interval: -0.67 to 0.24, P = 0.36). Very-low quality of evidence indicated that electromyographic biofeedback interventions were not superior to control for improving shoulder function (standardized mean differences = -0.11, 95% confidence interval: -0.41 to 0.19, P = 0.48).

CONCLUSION

Electromyographic biofeedback may be not effective for improving shoulder pain and function. However, the limited number of included studies and very low quality of evidence does not support a definitive recommendation about the effectiveness of electromyographic biofeedback to treat individuals with shoulder pain.

Does balneotherapy provide additive effects to physical therapy in patients with subacute supraspinatus tendinopathy? A randomized, controlled, single-blind study

This study assessed the additional contribution of balneotherapy on physical therapy in subacute supraspinatus tendinopathy. Ninety patients with subacute supraspinatus tendinopathy were included. They were randomized into two equal groups. In group 1 (n = 45), transcutaneous electrical nerve stimulation (TENS), hot pack, ultrasound treatments, and Codman's and range of motion (ROM) exercises were performed. In group 2 (n = 45), balneotherapy was added to the treatment program. In both groups, shoulder active ROM and handgrip strength were measured. Pain was evaluated using a Visual Analogue Scale (VAS) (rest, sleep, movement); functional assessment and quality of life were measured respectively with the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), and the Short Form-36 health survey (SF 36) form. All measurements were repeated before and after 15 treatment sessions. There were statistically significant differences between the before and after assessment parameters in group 1 (all p < 0.05), but not for SF-36 General Health Perceptions, SF-36 Mental Health sub-parameters, and handgrip strengths. However, there were statistically significant differences between all the evaluation before and after the treatment in group 2 (all p < 0.05). When the two groups were compared in terms of alpha gains, statistically significant differences were observed in favor of group 2 in all measurements (all p < 0.05) except for SF-36 Emotional Role Difficulty and SF-36 Mental Health sub-parameters. This study shows that the addition of balneotherapy to physical therapy for subacute supraspinatus tendinopathy can make additional contributions to shoulder ROM, pain, handgrip strength, functional status, and quality of life.

Accuracy of long head of the biceps tendon palpation by physical therapists; an ultrasonographic study

[Purpose] Examination and treatment of the long head of the biceps tendon (LHBT) requires accurate palpation. The purpose of this study was to determine physical therapists’ reliability and ability to accurately palpate the LHBT in two arm positions with ultrasound as the gold standard. [Participants and Methods] Examiners palpated the LHBT within the intertubercular groove (ITG) of the humerus on the bilateral shoulders of 32 asymptomatic (21 female; 24.3 ± 1.9 years) participants in 2 arm positions. The magnitude of distance between a marker and the border of the ITG was compared between 2 positions using an independent t-test. Percent accuracy was calculated. [Results] Inter-rater reliability was poor (position 1, k=1.04; position 2, k=0.016). Overall accuracy rate was 45.7% (117/256). Accuracy was 49.2% (63/128) and 42.2% (54/128) for testing position 1 and position 2 respectively. Mean distance palpated from the groove was M=2.58 mm (± 6.2 mm) for position 1 and M=3.77 mm (± 6.6 mm) for position 2. Inaccurate palpation occurred medially 72.3% (47/65) and 93.2% (69/74) in position 1 and position 2 respectively. [Conclusion] Results of this study did not support one arm position being more accurate over another for LHBT palpation.

Reduced force entropy in subacromial pain syndrome: A cross-sectional analysis

BACKGROUND

Generating a force at the hand requires moments about multiple joints by a theoretically infinite number of arm and shoulder muscle force combinations. This allows for learning and adaptation and can possibly be captured using the complexity (entropy) of an isometrically generated force curve. Patients with Subacromial Pain Syndrome have difficulty to explore alternative, pain-avoiding, motor strategies and we questioned whether loss of motor complexity may contribute to this. We assessed whether patients with Subacromial Pain Syndrome have reduced entropy of an isometrically generated abduction and adduction force curve.

METHODS

Forty patients and thirty controls generated submaximal isometric ab- and adduction force at the wrist. The force curve was characterized by the magnitude of force variability [standard deviation and coefficient of variation], and the entropy (complexity) of force variability [approximate entropy].

FINDINGS

Patients showed reduced entropy both during the abduction (-0.16, confidence interval: [-0.33; -0.00], p: 0.048) and adduction task (-0.20, confidence interval: [-0.37; -0.03], p: 0.024) and reduced force variability during abduction (standard deviation: -0.006, confidence interval: [-0.011; -0.001], p: 0.013 and coefficient of variation: -0.51, confidence interval: [-0.93; -0. 10], p: 0.016).

INTERPRETATIONS

Isometric force curves of patients with Subacromial Pain Syndrome show reduced complexity compared to asymptomatic controls, which may indicate more narrow and stereotype use of motor options. In future studies, it should be investigated whether the finding of reduced force (motor) entropy indicates functional decline, contributing to decreased ability to acquire and optimize motor strategies in Subacromial Pain Syndrome.

LEVEL OF EVIDENCE

Level II prognostic study.

Do the Number of Visits and the Cost of Musculoskeletal Care Improve Outcomes? More May Not Be Better

OBJECTIVES

To determine the relationship between health care use and the magnitude of change in patient-reported outcomes in individuals who received treatment for subacromial pain syndrome. The secondary objective was to determine the value of care, as measured by change in pain and disability per dollar spent.

DESIGN

Secondary analysis of a randomized clinical trial that investigated the effects of nonsurgical care for subacromial pain syndrome.

METHODS

Two groups of treatment responders were created, based on 1-year change in Shoulder Pain and Disability Index (SPADI) score (high, 46.83 points; low, 8.21 points). Regression analysis was performed to determine the association between health care use and 1-year change in SPADI score. Baseline SPADI score was used as a covariate in the regression analysis. Value was measured by comparing health care visits and costs expended per SPADI 1-point change between responder groups.

RESULTS

Ninety-eight patients were included; 38 were classified as high responders (mean 1-year SPADI change score, 46.83 points) and 60 were classified as low responders (1-year SPADI change score, 8.21 points). Neither unadjusted medical visits (5.89; 95% confidence interval [CI]: 4.35, 7.44 versus 6.30; 95% CI: 5.14, 7.46) nor medical costs ($1404.86; 95% CI: $1109.34, $1779.09 versus $1679.26; 95% CI: $1391.54, $2026.48) were significantly different between high and low responders, respectively.

CONCLUSION

Neither the number of visits nor the financial cost of nonsurgical shoulder- related care was associated with improvement in shoulder pain and disability at 1 year. J Orthop Sports Phys Ther 2020;50(11):642-648. doi:10.2519/jospt.2020.9440.

Shoulder pain cost-of-illness in patients referred for public orthopaedic care in Australia

Objective The aim of this study was to calculate the societal economic burden of shoulder pain in patients on the orthopaedic waiting list at an Australian public hospital and calculate the cost (from the government's perspective) of care delivered by the hospital for those patients. Methods A cost-of-illness analysis was undertaken in a cohort of 277 orthopaedic patients on the Gold Coast in Australia. Outcomes included a health care costs and impacts questionnaire, work absenteeism, presenteeism questionnaires (Work Limitations Questionnaire (WLQ) and Work Productivity and Activity Impairment Questionnaire (WPAI)) and hospital care provision over a 2-year period. Results The mean societal cost of healthcare and domestic support was AU$20.72 per day (AU$7563 annually) per patient on the orthopaedic waiting list. When absenteeism and presenteeism were included, the cost per patient who was employed was AU$38.04 per day (AU$13885 annually) calculated with the WLQ and AU$61.31 per day (AU$22378 annually) calculated with the WPAI. The mean per-patient cost to government of public hospital care was AU$2622 in Year 1 and AU$3835.78 (s.d. 4961.28) over 2 years. The surgical conversion rate was 22%, and 51% of hospital care cost was attributable to outpatient services. Conclusions Public orthopaedic shoulder waiting lists create a large economic burden for society; few referrals require surgery and just over half the hospital care costs are for out-patient services. New models of care that better manage shoulder pain and identify surgical candidates before orthopaedic referral could reduce this burden. What is known about the topic? Little is known about the cost of shoulder pain in Australia, or the cost of patients referred for public orthopaedic care. What does this paper add? This article quantifies the costs of shoulder pain and the value of lost production from shoulder pain. The time spent waiting for public hospital orthopaedic appointments and the costs associated with waiting demonstrate that the time spent on a waiting list is a key driver of the economic burden. What are the implications for practitioners? Greater resourcing to reduce public orthopaedic shoulder waiting lists may be helpful, but system change is also required. Earlier and more accurate identification of surgical cases could reduce inefficient referrals and improve hospital productivity. Collaboration between clinicians and policy makers is needed to design more economically efficient shoulder care.

The effect of obesity on pain and disability in chronic shoulder pain patients

OBJECTIVE

This study aimed to investigate the relationship between chronic shoulder pain and the increase in BMI.

METHODS

A prospective, cross-sectional study design was adopted for the study. Two hundred and eighty-five patients with chronic shoulder pain were evaluated for eligibility. A total of 94 patients were excluded from the study. The 191 remaining volunteers filled out a questionnaire (Pain (VAS), Shoulder Pain and Disability Index (SPADI)) and weight, height, C-reactive protein (CRP) results and 1-hour-rate of erythrocyte sedimentation rate (ESR) were measured. The participants were dived into the normal weight, overweight or obese group, considering the obesity classification defined by the World Health Organization (WHO).

RESULTS

A statistically significant correlation was found between the increase in BMI and pain (VAS), SPADI (pain, activity and total) and ESR. Although there was no statistically significant difference between the normal weight and overweight groups in all parameters, there was a statistically significant difference between the obese group and other groups.

CONCLUSIONS

Shoulder pain may associated with obesity and we recommend the addition of weight control to the treatment of patients with shoulder pain.

Physiotherapists' ability to diagnose and manage shoulder disorders in an outpatient orthopedic clinic: results from a concordance study

BACKGROUND

Advanced practice physiotherapy has emerged as a promising solution to improve health care access because access to orthopedic care is limited in several countries. However, evidence supporting advanced practice physiotherapy models for the management of shoulder pain remains scarce. The purpose of this study was to establish diagnostic, surgical triage, and medical imaging agreement between advanced practice physiotherapists (APPs) and orthopedic surgeons (OSs) for the management of patients with shoulder disorders in an outpatient orthopedic clinic.

METHODS

Patients referred to an OS for shoulder complaints were recruited and independently assessed by an OS and an APP. Each provider completed a standardized form indicating diagnosis, imaging test requests, and triage of surgical candidates. Patient satisfaction with care was recorded with the 9-item Visit-Specific Satisfaction Questionnaire (VSQ-9). Inter-rater concordance was calculated with the Cohen κ, prevalence-adjusted bias-adjusted κ, and associated 95% confidence interval (CI). We used χ² tests to compare differences between providers in terms of treatment plan options and Student t tests to compare patient satisfaction between providers.

RESULTS

Fifty participants were evaluated. Good diagnostic agreement was observed between providers (κ, 0.80; 95% CI, 0.67-0.93). Agreement for triage of surgical candidates was moderate (κ, 0.46; 95% CI, 0.21-0.71) as APPs tended to refer patients more often to OSs for further evaluation. Imaging test request agreement was moderate as well (κ, 0.42; 95% CI, 0.19-0.66). Patient satisfaction with care was high, with no significant differences found between providers (P = .70).

CONCLUSION

APPs could improve access to orthopedic care for shoulder disorders by safely initiating patient care without compromising satisfaction. These results support further development and evaluation of APP care for orthopedic patients presenting with shoulder disorders.

Psychological factors are associated with local and generalized pressure pain hypersensitivity, pain intensity, and function in people with chronic shoulder pain: A cross-sectional study

OBJECTIVES

To explore the association between psychological factors and shoulder pain intensity, function, as well as local and generalized pressure pain hypersensitivity.

DESIGN

a cross-sectional study.

METHODS

90 participants with chronic shoulder pain were included. Pressure pain thresholds determined the presence of pain hypersensitivity. Pain intensity, function, pain self-efficacy, emotional distress, and pain catastrophizing were also assessed. Analyses were adjusted for gender and age.

RESULTS

The diagnosis of depression (yes/no answer) was associated with both greater local (standardized β = -0.19[95%CI -0.37 to -0.00]) and generalized (standardized β = -0.20[95%CI -0.39 to -0.01]) pressure pain hypersensitivity. Greater pain self-efficacy was associated with lower local pressure pain hypersensitivity (standardized β = 0.19[95%CI 0.04 to 0.38]). The standardized beta coefficient for the diagnosis of depression indicated that this variable showed the strongest association with pressure pain hypersensitivity. Additionally, greater pain self-efficacy was associated with lower pain intensity (standardized β = -0.34[95%CI -0.51 to -0.17]) and better function (standardized β = -0.47[95%CI -0.63 to -0.30]). Greater pain catastrophizing was associated with more pain intensity (standardized β = 0.35[95%CI 0.18 to 0.52]) and worse function (standardized β = 0.26[95%CI 0.10 to 0.43]). The standardized beta coefficients for pain catastrophizing and pain self-efficacy indicated that both variables showed the strongest association with shoulder pain intensity and function, respectively CONCLUSION: Psychological factors were associated with local and generalized pressure pain hypersensitivity, pain intensity, and function in people with chronic shoulder pain.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears

BACKGROUND AND OBJECTIVES

Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted.

METHODS

We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care.

RESULTS

A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management.

CONCLUSION

The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Cost-effectiveness Evaluation of the Inclusion of Dry Needling into an Exercise Program for Subacromial Pain Syndrome: Evidence from a Randomized Clinical Trial

Objective

To evaluate the cost-effectiveness of the inclusion of trigger point-dry needling (TrP-DN) into an exercise program for the management of subacromial pain syndrome.

Methods

Fifty patients with unilateral subacromial pain syndrome were randomized with concealed allocation to exercise alone or exercise plus TrP-DN. Both groups were asked to perform an exercise program targeting the rotator cuff musculature twice daily for five weeks. Patients allocated to the exercise plus TrP-DN group also received dry needling during the second and fourth sessions. Societal costs and health-related quality of life (estimated by EuroQol-5D-5L) over a one-year follow-up were used to generate incremental cost per quality-adjusted life-year (QALY) ratios for each intervention.

Results

Intention-to-treat analysis was possible for 48 (96%) of the participants. Those in the exercise group made more visits to medical doctors and received a greater number of other treatments (P < 0.001). The major contributor to societal costs (77%) was the absenteeism paid labor in favor of the exercise plus TrP-DN group (P = 0.03). The combination of exercise plus TrP-DN was less costly (mean difference cost/patient = €517.34, P = 0.003) than exercise alone. Incremental QALYs showed greater benefit for exercise plus TrP-DN (difference = 2.87, 95% confidence interval = 2.85-2.89). Therefore, the inclusion of TrP-DN into an exercise program was more likely to be cost-effective than an exercise program alone, with 99.5% of the iterations falling in the dominant area.

Conclusions

The inclusion of TrP-DN into an exercise program was more cost-effective for individuals with subacromial pain syndrome than exercise alone. From a cost-benefit perspective, the inclusion of TrP-DN into multimodal management of patients with subacromial pain syndrome should be considered.

Cryotherapy or gradual reloading exercises in acute presentations of rotator cuff tendinopathy: a randomised controlled trial

Objectives

Rotator cuff tendinopathies are the most common shoulder disorders. As persistent symptoms lasting more than 3 months have been shown to be a strong indicator of poor outcomes, it is important to have successful interventions in the acute stage. However, there is no evidence yet to guide clinical interventions in an acute pain context. The objective of this study was to compare the short-term effect of a 2-week gradual reloading exercises programme with the use of cryotherapy on symptoms and function for acute rotator cuff tendinopathy.

Methods

This simple-blind, randomised controlled trial included 44 participants with acute rotator cuff tendinopathy who were randomly allocated to either the exercises or cryotherapy group. Symptoms and functional limitations were evaluated at weeks 0, 2 and 6 using self-reported questionnaires (Disabilities of the Arm, Shoulder and Hand, Western Ontario Rotator Cuff, and Brief Pain Inventory), while acromiohumeral distance, shoulder strength and active range of motion were evaluated at weeks 0 and 2.

Results

Following interventions, both groups showed statistically significant improvements on symptoms and function at week 2 and week 6 compared with baseline. However, there was no significant group × time interaction. There was no time effect on acromiohumeral distance, shoulder strength and active range of motion, as well as no time × group interaction.

Conclusion

The results showed a statistically significant improvement in symptoms and function in both groups, but there was no difference between the short-term effect of a cryotherapy based-approach and a gradual reloading exercises programme.

Trial registration number

NCT02813304.

A comparison of one-year treatment utilization for shoulder osteoarthritis patients initiating care with non-orthopaedic physicians and orthopaedic specialists

Background

In this paper we investigate patients seeking care for a new diagnosis of shoulder osteoarthritis (OA) and the association between a patient’s initial physician specialty choice and one-year surgical and conservative treatment utilization.

Methods

Using retrospective data from a single large regional healthcare system, we identified 572 individuals with a new diagnosis of shoulder OA and identified the specialty of the physician which was listed as the performing physician on the index shoulder visit. We assessed treatment utilization in the year following the index shoulder visit for patients initiating care with a non-orthopaedic physician (NOP) or an orthopaedic specialist (OS). Descriptive statistics were calculated for each group and subsequent one-year surgical and conservative treatment utilization was compared between groups.

Results

Of the 572 patients included in the study, 474 (83%) received care from an OS on the date of their index shoulder visit, while 98 (17%) received care from a NOP. There were no differences in baseline patient age, gender, BMI or pain scores between groups. OS patients reported longer symptom duration and a higher rate of comorbid shoulder diagnoses. Patients initiating care with an OS on average received their first treatment much faster than patients initiating care with NOP (16.3 days [95% CI, 12.8, 19.7] vs. 32.3 days [95% CI, 21.0, 43.6], Z = 4.9, p < 0.01). Additionally, patients initiating care with an OS had higher odds of receiving surgery (OR = 2.65, 95% CI: 1.42, 4.95) in the year following their index shoulder visit.

Conclusions

Patients initiating care with an OS received treatment much faster and were treated with more invasive services over the year following their index shoulder visit. Future work should compare patient-reported outcomes across patient groups to assess whether more expensive and invasive treatments yield better outcomes for patients with shoulder OA.

Reliability of Common Provocative Tests for Shoulder Tendinitis

OBJECTIVE

Accurate and reliable shoulder tendinopathy examination maneuvers are essential for diagnosing and treating shoulder pain; however, studies have reported varying results as to the accuracy of common maneuvers. Thus, data from a large, cross-sectional study were used to systematically quantify the reliability and accuracy of clinical diagnostic tests.

METHODS

Baseline data from the WISTAH cohort study were used to evaluate inter-tester reliability and accuracy of common provocative shoulder examination tests compared with a case definition of shoulder tendinitis.

RESULTS

Inter-tester reliability showed reliable consistency between providers with kappa coefficients between 89.5% and 94.8% for all tests. However, sensitivity was generally poor (3.0% to 60.6%). Specificity was consistently high (96.2% to 99.6%).

CONCLUSION

Common shoulder provocative tests show low sensitivity but high specificity, which implies that the primary utility of examination maneuvers is for their negative predictive values.

Spa therapy together with supervised self-mobilisation improves pain, function and quality of life in patients with chronic shoulder pain: a single-blind randomised controlled trial

To determine whether spa therapy has a beneficial effect on pain and disability in patients with chronic shoulder pain, this single-blind randomised controlled clinical trial included patients with chronic shoulder pain due to miscellaneous conditions attending one of four spa centres as outpatients. Patients were randomised into two groups: spa therapy (18 days of standardised treatment combining thermal therapy together with supervised mobilisation in a thermal pool) and controls (spa therapy delayed for 6 months: 'immediate versus delayed treatment' paradigm). All patients continued usual treatments during the 6-month follow-up period. The main endpoint was the mean change in the French-Quick DASH (F-QD) score at 6 months. The effect size of spa therapy was calculated, and the proportion of patients reaching minimal clinically important improvement (MCII) was compared. Secondary endpoints were the mean change in SF-36, treatment use and tolerance. One hundred eighty-six patients were included (94 patients as controls, 92 in the spa group) and analysed by intention to treat. At 6 months, the mean change in the F-QD score was statistically significantly greater among spa therapy patients than controls (- 32.6 versus - 8.15%; p < 0.001) with an effect size of 1.32 (95%CI: 0.97-1.68). A significantly greater proportion of spa therapy patients reached MCII (59.3 versus 17.9%). Spa therapy was well tolerated with a significant impact on SF-36 components but not on drug intake. Spa therapy provided a statistically significant benefit on pain, function and quality of life in patients with chronic shoulder pain after 6 months compared with usual care.

Towards an integrated clinical framework for patient with shoulder pain

Background

Shoulder pain (SP) represents a common musculoskeletal condition that requires physical therapy care. Along the years, the usual evaluation strategies based on clinical tests and diagnostic imaging has been challenged. Clinical tests appear unable to clearly identify the structures that generated pain and interpretation of diagnostic imaging is still controversial. The current patho-anatomical diagnostic categories have demonstrated poor reliability and seem inadequate for the SP treatment.

Objectives

The present paper aims to (1) describe the different proposals of clinical approach to SP currently available in the literature; to (2) integrate these proposals in a single framework in order to help the management of SP.

Conclusion

The proposed clinical framework, based on a bio-psychosocial vision of health, integrates symptoms characteristics, pain mechanisms and expectations, preferences and psychosocial factors of patients that may guide physiotherapist to make a diagnostic triage and to choose the right treatment for the individual patient.

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.

The Strengthening Exercises in Shoulder Impingement trial (The SExSI-trial) investigating the effectiveness of a simple add-on shoulder strengthening exercise programme in patients with long-lasting subacromial impingement syndrome: Study protocol for a pragmatic, assessor blinded, parallel-group, randomised, controlled trial

Background

Subacromial impingement syndrome (SIS) is a painful, and often long lasting, shoulder condition affecting patient function and quality of life. In a recent study, we observed major strength impairments in shoulder external rotation and abduction (~30%) in a population of patients with pronounced and long-lasting SIS. However, the current rehabilitation of such strength impairments may be inadequate, with novel rehabilitation programmes including exercise therapy only improving external rotation strength by 4–13%.

As these previous studies are the basis of current practice, this suggests that the strengthening component could be inadequate in the rehabilitation of these patients, and it seems likely that more emphasis should be placed on intensifying this part of the rehabilitation.

The purpose of this study is to investigate the effectiveness of a programme consisting of progressive home-based resistance training using an elastic band, aimed at improving shoulder external rotation and abduction strength, added to usual care and initiated shortly after diagnosis has been established.

Methods

A pragmatic randomised controlled superiority trial will be conducted, including 200 patients with pronounced and long-lasting SIS, diagnosed using predefined criteria. Participants will be randomised to receive either an add-on intervention of progressive home-based resistance training using an elastic band in addition to usual care or usual care alone in a 1:1 allocation ratio. The randomisation sequence is computer generated, with permuted blocks of random sizes. The primary outcome will be change in Shoulder Pain And Disability Index (SPADI) score from baseline to 16 weeks follow-up. Outcome assessors are blinded to group allocation. Intervention receivers will be kept blind to treatment allocation through minimal information about the content of the add-on intervention and control condition until group allocation is final. Analyses are performed by blinded data analysts.

Discussion

If effective, the simple shoulder strengthening exercise programme investigated in this trial could easily be added to usual care. The usefulness of the trial is further supported by the magnitude of the problem, the information gained from the study and the pragmatism, patient centeredness and transparency of the trial.

Trial registration

The trial is pre-registered at ClinicalTrials.gov with the ID NCT02747251 on April 19, 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2509-7) contains supplementary material, which is available to authorized users.

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.

Ultrasound-detected pathologies cluster into groups with different clinical outcomes: data from 3000 community referrals for shoulder pain

Background

Ultrasound is increasingly used to evaluate shoulder pain, but the benefits of this are unclear. In this study, we examined whether ultrasound-defined pathologies have implications for clinical outcomes.

Methods

We extracted reported pathologies from 3000 ultrasound scans of people with shoulder pain referred from primary care. In latent class analysis (LCA), we identified whether individual pathologies clustered in groups. Optimal group number was determined by the minimum Bayesian information criterion. A questionnaire was sent to all patients scanned over a 12-month period (n = 2322). Data collected included demographics, treatments received, current pain and function. The relationship between pathology-defined groups and clinical outcomes was examined.

Results

LCA revealed four groups: (1) bursitis with limited inflammation elsewhere (n = 1280), (2) bursitis with extensive inflammation (n = 595), (3) rotator cuff tears (n = 558) and (4) limited pathology (n = 567). A total of 777 subjects (33%) completed questionnaires. The median (IQR) duration post-ultrasound scan was 25 (22–29) months. Subsequent injections were most common in groups 1 and 2 (groups 1–4 76%, 67%, 48% and 61%, respectively); surgery was most common in group 3 (groups 1–4 23%, 21%, 28% and 16%, respectively). Shoulder Pain and Disability Index scores were highest in group 3 (median 48 and 30, respectively) and lowest in group 4 (median 32 and 9, respectively). Patients in group 4 who had surgery reported poor outcomes.

Conclusions

In a community-based population, we identified clusters of pathologies on the basis of ultrasound. Our retrospective data suggest that these groups have different treatment pathways and outcomes. This requires replication in a prospective study to determine the value of a pathology-based classification in people with shoulder pain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1235-y) contains supplementary material, which is available to authorized users.

Rotator Cuff Disorders: A Survey of Current Uk Physiotherapy Practice

Background

Shoulder pain is a common problem and disorders of the rotator cuff are considered to be the commonest cause of this pain. Despite this, there is a paucity of high-quality research upon which to base practice. There is a clear need to determine the range of current practice as a basis upon which to inform future research.

Objectives

To describe current physiotherapy practice in relation to the assessment and management of rotator cuff disorders and to gain an insight into the perceived research needs of physiotherapists in the UK.

Methods

An electronic survey was developed and responses were sought in relation to a case report considered to represent a patient with a typical rotator cuff disorder.

Results

A total of 110 surveys were completed. The respondents stated that they would undertake a range of diagnostic tests, offer a wide variety of interventions and offer a broad prediction of prognosis.

Conclusion

Current physiotherapy practice in relation to rotator cuff disorders is variable, which might reflect the lack of high-quality evidence available. There is a clear need for high-quality research to inform physiotherapy practice in this burdensome area.

A systematic and technical guide on how to reduce a shoulder dislocation

OBJECTIVES

Our objective is to provide a systematic and technical guide on how to reduce a shoulder dislocation, based on techniques that have been described in literature for patients with anterior and posterior shoulder instability.

MATERIALS AND METHODS

A PubMed and EMBASE query was performed, screening all relevant literature on the closed reduction techniques. Studies regarding open reduction techniques and studies with fracture dislocations were excluded.

RESULTS

In this study we give an overview of 23 different techniques for closed reduction and 17 modifications of these techniques.

DISCUSSION

In this review article we present a complete overview of the techniques, that have been described in the literature for closed reduction for shoulder dislocations. This manuscript can be regarded as a clinical guide how to perform a closed reduction maneuver, including several technical tips and tricks to optimize the success rate and to avoid complications.

CONCLUSION

There are 23 different reduction techniques with 17 modifications of these techniques. Knowledge of the different techniques is highly important for a good reduction.