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Ibounig T, Sanders S, Haas R, Jones M, Järvinen TL, Taimela S, Docking S, Rämö L, Buchbinder R. Systematic Review of Shoulder Imaging Abnormalities in Asymptomatic Adult Shoulders (SCRUTINY): Abnormalities of the glenohumeral joint. Osteoarthritis Cartilage 2024; 32:1184-1196. [PMID: 38876437 DOI: 10.1016/j.joca.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/20/2024] [Accepted: 06/04/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE The primary objective was to determine the population prevalence of glenohumeral joint imaging abnormalities in asymptomatic adults. METHOD We systematically reviewed studies reporting the prevalence of X-ray, ultrasound (US), computed tomography, and magnetic resonance imaging (MRI) abnormalities in adults without shoulder symptoms (PROSPERO registration number CRD42018090041). This report presents the glenohumeral joint imaging findings. We searched Ovid MEDLINE, Embase, CINAHL and Web of Science from inception to June 2023 and assessed risk of bias using a tool designed for prevalence studies. The primary analysis was planned for the general population. The certainty of evidence was assessed using a modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) for prognostic studies. RESULTS Thirty-five studies (4 X-ray, 10 US, 20 MRI, 1 X-ray and MRI) reported useable prevalence data. Two studies were population-based (846 shoulders), 15 studies included miscellaneous study populations (1715 shoulders) and 18 included athletes (727 shoulders). All were judged to be at high risk of bias. Clinical diversity precluded pooling. Population prevalence of glenohumeral osteoarthritis ranged from 15% to 75% (2 studies, 846 shoulders, 1 X-ray, 1 X-ray and MRI; low certainty evidence). Prevalence of labral abnormalities, humeral head cysts and long head of biceps tendon abnormalities were 20%, 5%, 30% respectively (1 study, 20 shoulders, X-ray and MRI; very low certainty evidence). CONCLUSION The population-based prevalence of glenohumeral joint imaging abnormalities in asymptomatic individuals remains uncertain, but may range between 30% and 75%. Better estimates are needed to inform best evidence-based management of people with shoulder pain.
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Affiliation(s)
- Thomas Ibounig
- Finnish Centre for Evidence-Based Orthopaedics, University of Helsinki, Helsinki, Finland; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland.
| | - Sharon Sanders
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Romi Haas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Teppo Ln Järvinen
- Finnish Centre for Evidence-Based Orthopaedics, University of Helsinki, Helsinki, Finland; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Simo Taimela
- Finnish Centre for Evidence-Based Orthopaedics, University of Helsinki, Helsinki, Finland; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Sean Docking
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Lasse Rämö
- Finnish Centre for Evidence-Based Orthopaedics, University of Helsinki, Helsinki, Finland; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Haas R, Gorelik A, O'Connor DA, Pearce C, Mazza D, Bennell KL, Hinman RS, Buchbinder R. Referral Patterns for People With Musculoskeletal Complaints in General Practice: An Analysis From an Australian Primary Care Database. Arthritis Care Res (Hoboken) 2024; 76:889-894. [PMID: 38221706 DOI: 10.1002/acr.25299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 01/16/2024]
Abstract
OBJECTIVE Our objective was to examine referral patterns for people with musculoskeletal complaints presenting to Australian general practitioners (GPs). METHODS This longitudinal analysis from the Population Level Analysis Reporting (POLAR) database includes 133,279 patients with low back (≥18 years old) or neck, shoulder, and/or knee (≥45 years old) complaints seen by 4,538 GPs across 269 practices from 2014 through 2018. Referrals to allied health and medical and/or surgical specialists were included. We determined the number of patients with referrals and GPs who made referrals and examined their timing, associations, and trends over time. RESULTS A total of 43,666 patients (33%) received and 3,053 GPs (67%) made at least one referral. Most referrals were to allied health (n = 25,830, 19%), followed by surgeons (n = 18,805, 14%). Surgical referrals were higher for knee complaints (n = 6,140, 24%) compared with low back, neck, and shoulder complaints (range 8%-15%). The referral category varied predominantly by body region followed by gender, socioeconomic status, and primary health network. Time to allied health referral ranged between median (interquartile range [IQR]) 14 days (0-125 days) for neck complaints and 56 days (5-177 days) for knee complaints. Surgical referrals occurred sooner for those with knee complaints (15 days, IQR 0-128 days). There was a 2.2% (95% confidence interval [CI] 1.9%-2.4%) annual increase in the proportion of allied health referrals and a 1.9% (95% CI 1.6%-2.1%) decrease in surgical referrals across all sites. CONCLUSION One-third of patients receive, and two-thirds of GPs make, referrals for musculoskeletal complaints. Understanding the reasons for referral and differences between GPs who refer more and less frequently may identify factors that explain variations in practice.
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Affiliation(s)
- Romi Haas
- Monash University, Melbourne, Victoria, Australia
| | | | | | | | | | - Kim L Bennell
- The University of Melbourne, Parkville, Victoria, Australia
| | - Rana S Hinman
- The University of Melbourne, Parkville, Victoria, Australia
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Zadro JR, O'Keeffe M, Ferreira GE. Is It Time to Reframe How Health Care Professionals Label Musculoskeletal Conditions? Phys Ther 2024; 104:pzae018. [PMID: 38365434 DOI: 10.1093/ptj/pzae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/27/2023] [Accepted: 12/20/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
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Lowry V, Lavigne P, Zidarov D, Matifat E, Cormier AA, Desmeules F. A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders. Arch Phys Med Rehabil 2024; 105:411-426. [PMID: 37832814 DOI: 10.1016/j.apmr.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/20/2023] [Accepted: 09/13/2023] [Indexed: 10/15/2023]
Abstract
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.
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Affiliation(s)
- Véronique Lowry
- School of Rehabilitation, Medicine Faculty, University of Montreal, Montreal, Canada; Maisonneuve-Rosemont Hospital Research Center, Montreal, Canada.
| | - Patrick Lavigne
- Maisonneuve-Rosemont Hospital Research Center, Montreal, Canada; Surgery Department, Medicine Faculty, University of Montreal, Montreal, Canada
| | - Diana Zidarov
- School of Rehabilitation, Medicine Faculty, University of Montreal, Montreal, Canada; Interdisciplinary Rehabilitation Montreal Research Center (CRIR), Montreal, Canada; Montreal University Institute for Physical Impairment Rehabilitation (IURDPM), Montreal, Canada
| | - Eveline Matifat
- Maisonneuve-Rosemont Hospital Research Center, Montreal, Canada
| | | | - François Desmeules
- School of Rehabilitation, Medicine Faculty, University of Montreal, Montreal, Canada; Maisonneuve-Rosemont Hospital Research Center, Montreal, Canada
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Malliaras P, O'Keeffe M, Ridgway J, Whale R, Vasan V, L'Huillier P, Towers M, Farlie MK. Patient experiences of rotator cuff-related shoulder pain and their views on diagnostic shoulder imaging: a qualitative study. Disabil Rehabil 2023:1-8. [PMID: 38153258 DOI: 10.1080/09638288.2023.2296986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/15/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE To explore patient experiences of rotator cuff-related shoulder pain, and their views on the role and value of diagnostic shoulder imaging. MATERIALS AND METHODS Semi-structured interviews were conducted with 20 patients with shoulder pain exploring the impact and management of their shoulder condition, reasons for and experiences of diagnostic imaging, and feelings about and responses to diagnostic imaging findings. Framework analysis was used to analyse the dataset. RESULTS Five themes were identified [1]: Lived experience and beliefs about pain and movement [2]; Contextualisation of imaging findings by health professionals is more important than the imaging report [3]; Factors influencing whether and when to have imaging [4]; Imaging can identify the actual problem and guide treatment; and [5] Treatment responses and treatment decision making. CONCLUSION Patients commonly believe imaging is needed to formulate a diagnosis. There was minimal concern about potential indirect harms that could arise (e.g., inappropriate diagnosis leading to unnecessary treatments). The context of the diagnostic imaging reports (i.e., what needed to be done) was perceived as more important than the exact meaning of the imaging findings. Patients felt that the diagnostic imaging confirmed their existing biomedical beliefs, and these beliefs were not challenged by their healthcare professionals.IMPLICATIONS FOR REHABILITATIONPatients with shoulder pain may believe imaging is necessary for diagnosis and defining treatment yet do not consider potential indirect harms (e.g., unnecessary treatment for findings that are not relevant).Health professionals should ensure patients are aware of imaging limitations and harms and facilitate shared decision-making about whether to have imaging.Health professionals also have an important role in the appropriate contextualisation of imaging findings (i.e., they do not necessarily relate to pain nor guide treatment).
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Affiliation(s)
- Peter Malliaras
- Physiotherapy Department, Monash University, Melbourne, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Jacqueline Ridgway
- Physiotherapy Department, Frankston Hospital, Peninsula Health, Victoria, Australia
| | - Rhiannon Whale
- Physiotherapy Department, Monash University, Melbourne, Australia
| | - Vasish Vasan
- Physiotherapy Department, Monash University, Melbourne, Australia
| | | | - Mitch Towers
- Physiotherapy Department, Monash University, Melbourne, Australia
| | - Melanie K Farlie
- Physiotherapy Department, Monash University, Melbourne, Australia
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6
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Beales D, Mitchell T, Seneque D, Chang SY, Cheng TH, Quek Y, Ranford S. Exploration of the Usual Care Pathway for Rotator Cuff Related Shoulder Pain in the Western Australian Workers' Compensation System. JOURNAL OF OCCUPATIONAL REHABILITATION 2023; 33:506-517. [PMID: 36520348 DOI: 10.1007/s10926-022-10088-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE Investigate components of care for rotator cuff related shoulder pain in workers' compensation in relation to claim outcomes (claim duration, total medical spend, total claim cost, return to work outcome). METHODS Engagement with (had care, time to care) four components of care (prescribed exercise, imaging, injections, surgery) were obtained from auditing 189 closed workers' compensation files. Associations were analysed between components of care and claim outcomes. RESULTS 80% received prescribed exercise, 81% imaging, 42% injection and 35% surgery. Median time to imaging (11 days) was shorter than the prescribed exercise (27 days), with injection at 38 days and surgery 118.5 days. With univariable regression analysis higher age, the involvement of legal representation and the presence of rotator cuff pathology from diagnostic imaging (partial thickness tear or full thickness tear) were all associated with increased claim duration, total medical spend, total claim cost and less successful return to work outcomes. After adjusting for these three associations, having an injection or surgery were both positively associated with longer claim duration and greater medical spend, and surgery with greater total claim costs. In general, longer time to receiving components of care was associated with increased claim duration and reduced odds of returning to full duties at work. CONCLUSION Early management was not consistent with clinical guidelines for managing workers' compensation rotator cuff related shoulder pain. This may negatively affect claims outcomes.
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Affiliation(s)
- Darren Beales
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.
- Pain Options, Ground Floor, 7 Hardy Street, South Perth, WA, 6151, Australia.
| | - Tim Mitchell
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
- Pain Options, Ground Floor, 7 Hardy Street, South Perth, WA, 6151, Australia
| | - David Seneque
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - Shin Yin Chang
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - Tak Ho Cheng
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - YiHui Quek
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia
| | - Stephen Ranford
- Pain Options, Ground Floor, 7 Hardy Street, South Perth, WA, 6151, Australia
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Zadro JR, Michaleff ZA, O'Keeffe M, Ferreira GE, Traeger AC, Gamble AR, Afeaki F, Li Y, Wen E, Yao J, Zhu K, Page R, Harris IA, Maher CG. How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment. BMJ Open 2023; 13:e069779. [PMID: 37147087 PMCID: PMC10163512 DOI: 10.1136/bmjopen-2022-069779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES To explore how people perceive different advice for rotator cuff disease in terms of words/feelings evoked by the advice and treatment needs. SETTING We performed a content analysis of qualitative data collected in a randomised experiment. PARTICIPANTS 2028 people with shoulder pain read a vignette describing someone with rotator cuff disease and were randomised to: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation emphasised that treatment is needed for recovery. PRIMARY AND SECONDARY OUTCOMES Participants answered questions about: (1) words/feelings evoked by the advice; (2) treatments they feel are needed. Two researchers developed coding frameworks to analyse responses. RESULTS 1981 (97% of 2039 randomised) responses for each question were analysed. Guideline-based advice (vs treatment recommendation) more often elicited words/feelings of reassurance, having a minor issue, trust in expertise and feeling dismissed, and treatment needs of rest, activity modification, medication, wait and see, exercise and normal movements. Treatment recommendation (vs guideline-based advice) more often elicited words/feelings of needing treatment/investigation, psychological distress and having a serious issue, and treatment needs of injections, surgery, investigations, and to see a doctor. CONCLUSIONS Words/feelings evoked by advice for rotator cuff disease and perceived treatment needs may explain why guideline-based advice reduces perceived need for unnecessary care compared to a treatment recommendation.
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Affiliation(s)
- Joshua R Zadro
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Zoe A Michaleff
- Northern NSW Local Health District, Lismore, New South Wales, Australia
| | - Mary O'Keeffe
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Giovanni E Ferreira
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Andrew R Gamble
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Frederick Afeaki
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Yaozhuo Li
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Erya Wen
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jiawen Yao
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kejie Zhu
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard Page
- University Hospital Geelong and St. John of God Hospital Geelong, Barwon Centre for Orthopaedic Research and Education (B-CORE), IMPACT, Deakin University, Geelong, Victoria, Australia
| | - Ian A Harris
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
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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. BMC PRIMARY CARE 2023; 24:49. [PMID: 36797670 PMCID: PMC9933814 DOI: 10.1186/s12875-023-01999-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/01/2023] [Indexed: 02/18/2023]
Abstract
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.
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Marks D, Thomas M, Newans T, Bisset L. Immediate response to injection is associated with conservative care outcomes at 12 weeks in subacromial shoulder pain. Musculoskelet Sci Pract 2023; 64:102726. [PMID: 36804722 DOI: 10.1016/j.msksp.2023.102726] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/03/2023] [Accepted: 02/08/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Subacromial injection is known to influence pain of subacromial origin, yet its association with conservative care outcomes is unknown. This study investigated whether immediate response to subacromial injection of corticosteroid and local anaesthetic is associated with conservative care outcomes at 12 weeks post injection and/or progression to surgery. DESIGN prospective prognostic cohort study. METHODS Sixty-four participants with subacromial related shoulder pain attending initial orthopaedic outpatient appointment at an Australian public hospital, received subacromial injection of corticosteroid and local anaesthetic followed by up to 12 weeks of physiotherapy. Immediate response to injection was measured by change in shoulder range of motion (ROM) and pain immediately (within 20 min) before and after injection. The Shoulder Pain and Disability Index (SPADI) was measured at baseline, 6 and 12-weeks. RESULTS Backward stepwise linear regression revealed immediate post-injection improvement in pain-free ROM (p = 0.001) and higher baseline symptoms (p = 0.016) were significantly associated with better 12-week SPADI outcomes. Longer symptom duration (p = 0.029) and higher age (p = 0.013) were significantly associated with poorer outcomes. Only 11 individuals progressed to surgery. The resultant model could explain 35% of the variation in change in SPADI at 12 weeks. CONCLUSION Improvement in pain-free shoulder ROM immediately post injection is significantly associated with better 12-week conservative care outcomes. This information, derived from within consultation injection responses, could help inform decisions about potential treatment options. Further research with higher numbers and longer-term patient-reported outcomes could further clarify these findings. REGISTRATION Australia and New Zealand Clinical Trials Registry 21 May 2012: 12612000532808.
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Affiliation(s)
- Darryn Marks
- Bond University, Faculty of Health Sciences and Medicine, Department of Physiotherapy, Bond Institute of Health and Sport, Promethean Way, Robina, Gold Coast, Queensland, 4226, Australia; Gold Coast University Hospital, Orthopaedic Department, Gold Coast, Qld, Australia.
| | - Michael Thomas
- Gold Coast University Hospital, Orthopaedic Department, Gold Coast, Qld, Australia; Bond University, Department of Medicine, Faculty of Health Science and Medicine, University Drive, Robina, Gold Coast, Qld, 4226, Australia
| | - Tim Newans
- Griffith University, School of Health Science and Social Work, Gold Coast, Qld, 4222, Australia
| | - Leanne Bisset
- Griffith University, School of Health Science and Social Work, Gold Coast, Qld, 4222, Australia
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10
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Haas R, Gorelik A, Busija L, O’Connor D, Pearce C, Mazza D, Buchbinder R. Prevalence and characteristics of musculoskeletal complaints in primary care: an analysis from the population level and analysis reporting (POLAR) database. BMC PRIMARY CARE 2023; 24:40. [PMID: 36739379 PMCID: PMC9898983 DOI: 10.1186/s12875-023-01976-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/06/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND Electronic health record datasets have been used to determine the prevalence of musculoskeletal complaints in general practice but not to examine the associated characteristics and healthcare utilisation at the primary care level. AIM To describe the prevalence and characteristics of patients presenting to general practitioners with musculoskeletal complaints. DESIGN AND SETTING A five-year analysis within three Primary Health Networks (PHNs) in Victoria, Australia. METHOD We included patients with at least one face-to-face consultation 2014 to 2018 inclusive and a low back (≥ 18 years), and/or neck, shoulder or knee (≥ 45 years) complaint determined by SNOMED codes derived from diagnostic text within the medical record. We determined prevalence, socio-demographic characteristics and diagnostic codes for patients with an eligible diagnosis; and number of consultations within one year of diagnosis. RESULTS 324,793/1,294,021 (25%) presented with at least one musculoskeletal diagnosis, of whom 41% (n = 133,279) fulfilled our inclusion criteria. There were slightly more females (n = 73,428, 55%), two-thirds (n = 88,043) were of working age (18-64 years) and 83,816 (63%) had at least one comorbidity. Over half had a low back diagnosis (n = 76,504, 57%) followed by knee (n = 33,438, 25%), shoulder (n = 26,335, 20%) and neck (n = 14,492, 11%). Most codes included 'pain' and/or 'ache' (low back: 58%, neck: 41%, shoulder: 32%, knee 26%). Median (IQR) all-cause consultations per patient within one year of diagnosis was 7 (4-12). CONCLUSION The burden of MSK complaints at the primary care level is high as evidenced by the prevalence of people with musculoskeletal complaints presenting to a general practitioner, the preponderance of comorbidities and the numerous consultations per year. Identification and evaluation of strategies to reduce this burden are needed.
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Affiliation(s)
- Romi Haas
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia. .,Cabrini Health, Malvern, VIC, 3144, Australia.
| | - Alexandra Gorelik
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia ,Cabrini Health, Malvern, VIC 3144 Australia
| | - Ljoudmila Busija
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia
| | - Denise O’Connor
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia ,Cabrini Health, Malvern, VIC 3144 Australia
| | | | - Danielle Mazza
- grid.1002.30000 0004 1936 7857Department of General Practice, Monash University, Notting Hill, VIC 3168 Australia
| | - Rachelle Buchbinder
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia ,Cabrini Health, Malvern, VIC 3144 Australia
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McKenzie BJ, Haas R, Ferreira GE, Maher CG, Buchbinder R. The environmental impact of health care for musculoskeletal conditions: A scoping review. PLoS One 2022; 17:e0276685. [PMID: 36441677 PMCID: PMC9704655 DOI: 10.1371/journal.pone.0276685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 10/12/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Health care has significant environmental impact. We performed a scoping review to map what is known about the environmental impact of health care for musculoskeletal conditions. METHODS We included published papers of any design that measured or discussed environmental impact of health care or health support services for any musculoskeletal condition in terms of climate change or global warming (e.g., greenhouse gas emissions it produces). We searched MEDLINE and Embase from inception to 2 May 2022 using keywords for environmental health and musculoskeletal conditions, and performed keyword searches using Google and Google Scholar. Two independent reviewers screened studies. One author independently charted data, verified by a second author. A narrative synthesis was performed. RESULTS Of 12,302 publications screened and 73 identified from other searches, 122 full-text articles were assessed for eligibility, and 49 were included (published 1994 to 2022). Of 24 original research studies, 11 measured environmental impact relating to climate change in orthopaedics (n = 10), and medical aids for the knee (n = 1), one measured energy expenditure of laminar versus turbulent airflow ventilation systems in operating rooms during simulated hip replacements and 12 measured waste associated with orthopaedic surgery but did not relate waste to greenhouse gas emissions or environmental effects. Twenty-one editorials described a need to reduce environmental impact of orthopaedic surgery (n = 9), physiotherapy (n = 9), podiatry (n = 2) or occupational therapy (n = 1). Four narrative reviews discussed sustainability relating to hand surgery (n = 2), orthopaedic surgery (n = 1) and orthopaedic implants (n = 1). CONCLUSION Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. These data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.
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Affiliation(s)
- Bayden J. McKenzie
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Romi Haas
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Giovanni E. Ferreira
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Chris G. Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
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Zadro JR, O'Keeffe M, Ferreira GE, Traeger AC, Gamble AR, Page R, Herbert RD, Harris IA, Maher CG. Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment. J Physiother 2022; 68:269-276. [PMID: 36257876 DOI: 10.1016/j.jphys.2022.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/05/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022] Open
Abstract
QUESTION What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease? DESIGN 2×2 factorial online randomised experiment. PARTICIPANTS People with shoulder pain. INTERVENTION Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery. OUTCOME MEASURES Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work. RESULTS A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect -0.5 on a 0-to-10 scale, 98.3% CI -0.7 to -0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect -1.0, 98.3% CI -1.3 to -0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome. CONCLUSION Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition). TRIAL REGISTRATION ACTRN12621001370897.
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Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Andrew R Gamble
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Richard Page
- University Hospital Geelong and St. John of God Hospital Geelong, Barwon Centre for Orthopaedic Research and Education (B-CORE), IMPACT, School of Medicine, Deakin University, Geelong, Australia
| | - Robert D Herbert
- Neuroscience Research Australia (NeuRA), University of New South Wales, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia; Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Zadro JR, Michaleff ZA, O'Keeffe M, Ferreira GE, Haas R, Harris IA, Buchbinder R, Maher CG. How do people perceive different labels for rotator cuff disease? A content analysis of data collected in a randomised controlled experiment. BMJ Open 2021; 11:e052092. [PMID: 34952877 PMCID: PMC8710860 DOI: 10.1136/bmjopen-2021-052092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Explore how people perceive different labels for rotator cuff disease in terms of words or feelings evoked by the label and treatments they feel are needed. SETTING We performed a content analysis of qualitative data collected in a six-arm, online randomised controlled experiment. PARTICIPANTS 1308 people with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomised to one of six labels: subacromial impingement syndrome, rotator cuff tear, bursitis, rotator-cuff-related shoulder pain, shoulder sprain and episode of shoulder pain. PRIMARY AND SECONDARY OUTCOMES Participants answered two questions (free-text response) about: (1) words or feelings evoked by the label; (2) what treatments they feel are needed. Two researchers iteratively developed coding frameworks to analyse responses.Results1308/1626 (80%) complete responses for each question were analysed. Psychological distress (21%), uncertainty (22%), serious condition (15%) and poor prognosis (9%) were most often expressed by those labelled with subacromial impingement syndrome. For those labelled with a rotator cuff tear, psychological distress (13%), serious condition (9%) and poor prognosis (8%) were relatively common, while minor issue was expressed least often compared with the other labels (5%). Treatment/investigation and surgery were common among those labelled with a rotator cuff tear (11% and 19%, respectively) and subacromial impingement syndrome (9% and 10%) compared with bursitis (7% and 5%). CONCLUSIONS Words or feelings evoked by certain labels for rotator cuff disease and perceived treatment needs may explain why some labels drive management preferences towards surgery and imaging more than others.
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Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, School of Public Health, The University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Zoe A Michaleff
- Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, School of Public Health, The University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
- School of Allied Health, Faculty of Education & Health Sciences, University of Limerick, Limerick, Ireland
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, School of Public Health, The University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Romi Haas
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, School of Public Health, The University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Monash University, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, School of Public Health, The University of Sydney and Sydney Local Health District, Camperdown, New South Wales, Australia
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Evaluation of Interfascial Plane and Pericapsular Nerve Blocks to the Shoulder Joint: A Preliminary Analysis of Shoulder Anterior Capsular Block. Pain Ther 2021; 10:1741-1754. [PMID: 34669181 PMCID: PMC8586108 DOI: 10.1007/s40122-021-00326-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The aim of this study is to verify if the shoulder anterior capsular block (SHAC), combined with other nerve blocks, is effective in relieving shoulder pain, avoiding motor block and allowing an early rehabilitation program. METHODS Seventy-five consecutive patients with painful shoulder were treated with the SHAC, alone (30 patients) or in combination with a suprascapular nerve block (SSnb: 25 patients) or with pectoralis and serratus plane block (PECS-2: 20 patients). All blocks were performed with 0.2% ropivacaine plus 8 mg dexamethasone. All patients were treated with three-weekly physiotherapy sessions for the following 2 weeks and then with home exercises. RESULTS The post-procedural analgesic effect was strong in all groups, with a mean change in numeric rating scale (NRS) values of -6.05 in group 1, -6.25 in group 2, and -6.19 in group 3 (p < .0001), allowing all patients to complete an immediate physiotherapy session. Only a few patients needed to repeat the procedure 1 week after the first treatment for the recurrence of pain. From the treatment to the end of the follow-up, we noted a further drop in mean pain NRS values of 1.90 in group 1 and 1.80 in groups 2 and 3. No difference in effect over time was observed among the different groups. No adverse event or motor block was recorded. CONCLUSION This study demonstrates that the SHAC, alone or in combination with other peripheral nerve blocks, is an attractive alternative for shoulder pain management, especially when physiotherapy is required to recover shoulder function.
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15
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Cox JL, Laughlin MS, Elkousy HA, Baker HM, Badman BL, Ziegler DW, Buford DA, Kruse KK. Determination of rotator cuff tear reparability: an ultrasound-based investigation. JSES Int 2021; 7:21-24. [PMID: 36820432 PMCID: PMC9937814 DOI: 10.1016/j.jseint.2021.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Background The use of ultrasound as a viable diagnostic tool for routine office visit evaluation of rotator cuff integrity is slowly gaining acceptance in orthopedic practice. However, the reliability of accurately assessing rotator cuff tear reparability by ultrasound has limited evidence in the literature. The purpose of this study was to compare preoperative assessment of cuff tear reparability via ultrasound with the arthroscopic determination of reparability at the time of surgery. Methods We prospectively collected preoperative ultrasound and arthroscopic imaging data on 145 patients (80 or 55% men and average age of 60.7 years) who underwent arthroscopic posterior superior rotator cuff repair. Three independent experienced orthopedic surgeons retrospectively reviewed all ultrasound studies and arthroscopic imaging and determined if the posterior superior rotator cuff tendon edge was able to be viewed via ultrasound and determined with the arthroscopic images if the tear was reparable. Results On review of the ultrasound and arthroscopic data, if the edge of the rotator cuff tendon was able to be viewed on the coronal ultrasound image, it was most likely reparable with a positive predictive value of 97.6% and a positive likelihood ratio of 5.8. Sensitivity was 84.4%, and specificity was 76.9%. The negative predictive value was 37.5%, and the negative likelihood ratio was 0.17. The interobserver reliability was 0.63, and the observers were unanimous in determining the tendon edge was able to be visualized in 99 of 145 cases (68%). Conclusion Preoperative ultrasound evaluation of the shoulder for posterior superior rotator cuff tears is a useful tool for assessing rotator cuff integrity and may help predict intraoperative reparability of the tendon. This study demonstrates that if the cuff tear edge is able to be visualized, there is a high probability of successful arthroscopic restoration of the tendon to its native attachment. Conversely, if the tear edge is unable to be visualized, there is a moderate chance of the tear being irreparable. These results help expand the knowledge base of the usefulness of in-office ultrasound performed by the surgeon in predicting the results of surgical intervention for rotator cuff tears.
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Affiliation(s)
- Jacob L. Cox
- Texas Education and Research Foundation for Shoulder and Elbow Surgery, Inc. (TERFSES), Houston, TX, USA,Fondren Orthopedic Research Institute (FORI), Houston, TX, USA
| | - Mitzi S. Laughlin
- Texas Education and Research Foundation for Shoulder and Elbow Surgery, Inc. (TERFSES), Houston, TX, USA,Fondren Orthopedic Research Institute (FORI), Houston, TX, USA,Corresponding author: Mitzi S. Laughlin, PhD, 7401 Main St., Houston, TX 77030, USA
| | - Hussein A. Elkousy
- Texas Education and Research Foundation for Shoulder and Elbow Surgery, Inc. (TERFSES), Houston, TX, USA,Fondren Orthopedic Research Institute (FORI), Houston, TX, USA,Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
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16
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van Doorn PF, de Schepper EIT, Rozendaal RM, Ottenheijm RPG, van der Lei J, Bindels PJ, Schiphof D. The incidence and management of shoulder complaints in general practice: a retrospective cohort study. Fam Pract 2021; 38:582-588. [PMID: 33860787 PMCID: PMC8463812 DOI: 10.1093/fampra/cmab022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Shoulder pain is the third most common musculoskeletal complaint in primary care. The international guidelines for general practitioners (GPs) recommend a stepwise treatment of shoulder pain. Little is known about the actual distribution of these treatments in current practice. OBJECTIVE To gain insight in the incidence and current management of shoulder complaints in Dutch general practice. METHODS A retrospective cohort study was conducted using a health care database containing the full electronic medical records of approximately 200 000 patients in Dutch general practice. A search algorithm was constructed to identify incident cases of shoulder complaints from January 2012 to December 2017. Data on the management of shoulder complaints were manually validated in a random sample of 1000 cases. RESULTS The overall incidence of shoulder complaints was 30.3 (95% confidence interval 29.9-30.7) per 1000 person-years. More than half of the patients (58.6%) consulted their GP only once, 44.4% two times or more and 19.7% three times or more. For most patients (58.1%), the GP applied a wait-and-see policy or prescription of oral medication in the first consultation. However, no less than 42.9% of the patients were referred or received an injection already in the first consultation. CONCLUSIONS There is a wide variety of treatments for shoulder complaints applied by the GP. Some patients are referred or received an injection already in the first consultation. The stepwise approach recommended by the guideline, might not always be applicable due to the diversity of patient- and shoulder characteristics presented in general practice.
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Affiliation(s)
- Pieter F van Doorn
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Rianne M Rozendaal
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ramon P G Ottenheijm
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Patrick J Bindels
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dieuwke Schiphof
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
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17
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Shoulder Pain — Where Are We Now? CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00184-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose of Review
Shoulder pain is common and costly. For the past century, diagnosis and management has been based upon presumed patho-anatomical abnormalities. With the evolution of imaging techniques and new insight about the causes of musculoskeletal pain, this review evaluates the evidence that a patho-anatomical approach remains justified.
Recent Findings
Imaging modalities have developed considerably but, so far, have only proven value in evaluating full thickness rotator cuff tears prior to surgery. Correlation between imaging findings and symptoms is otherwise poor, with limited evidence of the value and impact of imaging for decision-making. Much of shoulder pain is chronic and few people have single-site musculoskeletal pain. Pain studies suggest that chronic shoulder pain is associated with both central and peripheral pain sensitisation. Moreover, functional MRI points to an effect of cognitive affective pain processing rather than nociception. Few of the established therapies, medical or surgical, that treat the presumed patho-anatomical cause have been shown to have lasting benefit.
Summary
Much of the evidence suggests that shoulder pain is more similar than different from mechanical low back pain. For most people with shoulder pain, the best approach might well be de-medicalisation, support to (self)manage pain, emphasis on retaining movement and identifying adverse beliefs and risk factors for disability and chronicity. Approaches like this are currently being evaluated and more research is desperately required.
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18
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Maxwell C, Robinson K, McCreesh K. Managing shoulder pain: a meta-ethnography exploring healthcare providers' experiences. Disabil Rehabil 2021; 44:3772-3784. [PMID: 33847548 DOI: 10.1080/09638288.2021.1897886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To review and synthesize qualitative research studies exploring the experiences of Healthcare Providers (HCPs) of managing shoulder pain. METHODS A meta-ethnographic approach was adopted to review and synthesize eligible studies. The findings from each included study were translated into one another using Noblit and Hares' seven-stage process. A systematic search of eleven electronic databases was conducted in February 2021. Methodological quality was assessed using the CASP Appraisal Tool. RESULTS Ten studies were included in the meta-synthesis, all deemed of high methodological quality. Three themes were identified; (1) Lack of consensus: "we all have different approaches." (2) Challenges to Changing Practice: It's "really hard to change and switch to a different approach," (3) Getting "Buy in" to Treatment: "…so you have to really sell it early". CONCLUSION Healthcare providers working with people with shoulder pain struggle to reconcile, often conflicting, research recommendations with their own clinical experience, beliefs and patient expectations. These findings help explain the continued lack of consensus on how best to manage shoulder pain in clinical practice.IMPLICATIONS FOR REHABILITATIONHealthcare providers (HCPs) working with people with shoulder pain struggle to resolve conflicts between evidence-based recommendations, clinical experience, their own shoulder pain beliefs and patient expectations and preferences.Stronger collaboration across professional disciplines is needed to address the current lack of consensus on the management of shoulder pain.Many HCP's find it difficult to engage patients with shoulder pain in exercise and they work hard to "sell" this approach to patients using strategies such as education, shared decision making and therapeutic alliance.
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Affiliation(s)
- Christina Maxwell
- Health Research Institute, School of Allied Health, University of Limerick, Limerick, Ireland.,Ageing Research Centre, Health Research Institute, School of Allied Health, University of Limerick, Limerick, Ireland
| | - Katie Robinson
- Health Research Institute, School of Allied Health, University of Limerick, Limerick, Ireland.,Ageing Research Centre, Health Research Institute, School of Allied Health, University of Limerick, Limerick, Ireland
| | - Karen McCreesh
- Health Research Institute, School of Allied Health, University of Limerick, Limerick, Ireland.,Ageing Research Centre, Health Research Institute, School of Allied Health, University of Limerick, Limerick, Ireland
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Lee DYL, Haas R, Wallis JA, O'Connor DA, Buchbinder R. Clinical practice guidelines for the management of atraumatic shoulder conditions: protocol for a systematic review. BMJ Open 2021; 11:e048297. [PMID: 33827850 PMCID: PMC8031683 DOI: 10.1136/bmjopen-2020-048297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Shoulder conditions are a major cause of morbidity in the general population. Many clinical practice guidelines (CPGs) for shoulder conditions have been developed. Their purpose is to provide evidence-based recommendations to assist clinicians in providing optimal care to maximise patient outcomes. The aim of this systematic review is to identify, appraise, and compare the content and quality of CPGs for atraumatic shoulder conditions. METHODS AND ANALYSIS CPGs for atraumatic shoulder conditions will be included provided they make recommendations about diagnosis and/or management, are identified by their authors as a guideline and are consistent with the Appraisal of Guidelines for Research and Evaluation (AGREE) II definition of a guideline. A systematic search of electronic databases, online guideline repositories and the websites of relevant professional societies will be conducted to identify eligible CPGs. Search terms relating to shoulder conditions (eg, 'adhesive capsulitis', 'rotator cuff' and 'bursitis') will be combined with a validated search filter for CPGs. Pairs of independent reviewers will determine eligibility of CPGs identified by the search. Quality appraisal of included CPGs will be performed using the AGREE II instrument. Recommendations from each CPG and how they were determined will be extracted and compared across similar CPGs. Results from this systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review. The results from this study will be published in a peer-reviewed journal and disseminated to professional societies that publish shoulder CPGs, clinical policy groups, clinicians, researchers and consumers. PROSPERO REGISTRATION NUMBER CRD42020182723.
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Affiliation(s)
- Dana Yen Lin Lee
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
| | - Romi Haas
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jason A Wallis
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Denise A O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Smythe A, Rathi S, Pavlova N, Littlewood C, Connell D, Haines T, Malliaras P. Self-reported management among people with rotator cuff related shoulder pain: An observational study. Musculoskelet Sci Pract 2021; 51:102305. [PMID: 33249362 DOI: 10.1016/j.msksp.2020.102305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rotator cuff related shoulder pain is the most common cause of shoulder pain. Whilst guidelines recommend conservative management prior to imaging, injection or surgical management, recent findings suggest that patients experience management contrary to guideline recommendations. OBJECTIVES The aim of this study was to investigate self-reported management among people with rotator cuff related shoulder pain (RCRSP) and their beliefs towards management. MATERIALS AND METHODS Cross-sectional survey of people with RCRSP recruited when referred for imaging (n = 120). Electronic survey about demographic factors, management people had had (including imaging, injections, surgery, exercise, adjuncts), and beliefs about treatments. The frequency of various treatments was reported (separately for each cohort and traumatic onset) as well as the timing of interventions related to first-line care. RESULTS Most people had tried exercise (99/120, 82.5%) but only one in five people reported exercise was helpful, and one in six reported it was unhelpful or made their symptoms worse. Approximately a third of the cohort reported not receiving activity modification advice (34.2%, 41/120), those that did received inconsistent information. People with both traumatic (imaging 31/43, 72.1%; injections 13/24, 54.2%, surgery 8/21, 38.1%) and atraumatic onset pain (imaging 43/77, 55.8%; injections 31/51, 60.8%, surgery 4/19, 21.1%) had similarly high rates of intervention prior to trialling conservative management. Patient beliefs in regards to management showed trends towards interventionalist care. CONCLUSION Patient reported management of RCRSP is often inconsistent with guideline recommended management.
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Affiliation(s)
- A Smythe
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Building B, Peninsula Campus, Monash University, Victoria, 3199, Australia; A-Game Physiotherapy, Somerville, Victoria, 3912, Australia.
| | - S Rathi
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Building B, Peninsula Campus, Monash University, Victoria, 3199, Australia
| | - N Pavlova
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Building B, Peninsula Campus, Monash University, Victoria, 3199, Australia
| | - C Littlewood
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Brooks Building, 53 Bonsall Street, M15 6GX, UK. https://twitter.com/ChrisLittlew00d
| | - D Connell
- Imaging at Olympic Park, AAMI Park, Melbourne, Australia; Department of Medical Imaging and Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - T Haines
- School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Building G, Peninsula Campus, Monash University, Victoria, 3199, Australia
| | - P Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Building B, Peninsula Campus, Monash University, Victoria, 3199, Australia. https://twitter.com/DrPeteMalliaras
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21
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Cridland K, Pritchard S, Rathi S, Malliaras P. 'He explains it in a way that I have confidence he knows what he is doing': A qualitative study of patients' experiences and perspectives of rotator-cuff-related shoulder pain education. Musculoskeletal Care 2020; 19:217-231. [PMID: 33258225 DOI: 10.1002/msc.1528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patient education is recommended in clinical practice guidelines for rotator-cuff-related shoulder pain (RCRSP), yet there are no guidelines for clinicians. A gap in the current literature relates to patients' perspectives. AIMS The aim of this study was to explore the experiences and perspectives of people with RCRSP about education for their condition. MATERIALS AND METHODS An inductive qualitative design was adopted. Eight participants with RCRSP participated in individual telephone interviews that were audio-recorded, transcribed and de-identified. Four researchers completed inductive thematic analysis. Institutional ethics approval was obtained. RESULTS Results are detailed as a thematic analysis from the interview responses. Three primary themes were identified: (1) a therapeutic alliance leads to trust of education; (2) education of RCRSP should be individualized and practical; and (3) delivery of educational interventions should be varied and multi-modal. DISCUSSION The results demonstrated that trust in the health professional providing the education facilitates adherence and increases belief that the condition is being effectively treated. Participants believed imaging were necessary for an individual diagnosis despite clinical practice guidelines not recommending imaging for the first 6-12 weeks of initial presentation. There was a general caution about generic online information which may adversely impact the value of exclusively online educational intervention in the future. Participants preferred clear and practical education about RCRSP, including activity modification, timeframes for recovery and potential detriments to their recovery. There was consensus that education is best delivered early in the rehabilitation process, however there were mixed preferences for delivery method between written, video and face-to-face which perhaps reflects different learning styles and indicates that a 'one size fits all' approach is not effective in adult education in this condition. CONCLUSION People with RCRSP believe education about their condition is important and is best delivered by a trusted source early in their rehabilitation. There is a belief that scans are necessary to provide an individualized diagnosis and assists in their understanding of the condition. There is an opportunity for online education; however, this may best be utilised as an adjunct method to face-to-face care.
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Affiliation(s)
- Kate Cridland
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - Shane Pritchard
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - Sangeeta Rathi
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - Peter Malliaras
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
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Malliaras P, Cridland K, Hopmans R, Ashton S, Littlewood C, Page R, Harris I, Skouteris H, Haines T. Internet and Telerehabilitation-Delivered Management of Rotator Cuff-Related Shoulder Pain (INTEL Trial): Randomized Controlled Pilot and Feasibility Trial. JMIR Mhealth Uhealth 2020; 8:e24311. [PMID: 33206059 PMCID: PMC7710452 DOI: 10.2196/24311] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rotator cuff-related shoulder pain (RCRSP) is a common and disabling musculoskeletal condition. Internet-based and telerehabilitation delivery of recommended care may improve access to care and improve adherence and outcomes. OBJECTIVE The primary aim of this pilot randomized controlled trial was to assess the feasibility of a 12-week internet-delivered intervention for RCRSP comparing advice only, recommended care, and recommended care with group-based telerehabilitation. METHODS Reporting was in accordance with the Consolidated Standards of Reporting Trials (CONSORT) checklist for pilot and feasibility trials. People with a primary complaint of RCRSP for 3 months or longer were identified via a paid Facebook strategy. Screening involved an online questionnaire followed by a 20-minute telehealth assessment. Participants were randomly allocated (via a Zelen design) to receive (1) advice only, (2) recommended care (internet-delivered evidence-based exercise and education), or (3) recommended care and telerehabilitation (including a weekly group teleconference session). Progression criteria for a full-scale trial included (1) recruitment of 20% or greater of eligible participants, (2) acceptable adherence (two or more of the three prescribed weekly sessions) among 70% or greater of participants, (3) 80% or greater retention of participants, (4) absence of intervention-related serious adverse events, and (5) 80% or greater response rates to questionnaires. Secondary clinical and patient knowledge outcomes were collected (via email or text) at baseline, six weeks, and 12 weeks (for clinical and patient knowledge), and within-group change was reported descriptively. RESULTS We enrolled 36 of 38 (95%) eligible participants and all participants were recruited within a 3-week period. Of the 36 participants, 12 participants were allocated to each of the three trial arms. The mean age of participants was between 51 and 56 years, and 83% (10/12) to 92% (11/12) were female. Retention at the 12-week endpoint was 94% (34/36) and response to email questionnaires at other time points was 83% or greater. We found acceptable adherence (defined as greater than 70% of participants performing exercise 2 or 3 times/week) in the recommended care group with telerehabilitation but not in the recommended care group without telerehabilitation. There was a total of 24 adverse events over 108 person-months of observation. All adverse events were mild or moderate (mainly muscle and shoulder symptoms), with the exception of one instance of elective surgery (unrelated to the person's shoulder condition). CONCLUSIONS Our prespecified success criteria were met or exceeded, but there was a gender imbalance toward women. It is feasible to progress to a fully powered trial, but strategies to address the gender imbalance need to be implemented. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12620000248965); https://tinyurl.com/yy6eztf5.
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Affiliation(s)
- Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Kate Cridland
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Ruben Hopmans
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Simon Ashton
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Chris Littlewood
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
| | - Richard Page
- Barwon Orthopaedic Research and Education, Barwon Health and School of Medicine, Deakin University, Geelong, Australia
| | - Ian Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
| | - Helen Skouteris
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
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23
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Marks D, Comans T, Bisset L, Thomas M, Scuffham PA. Shoulder pain cost-of-illness in patients referred for public orthopaedic care in Australia. AUST HEALTH REV 2020; 43:540-548. [PMID: 30318033 DOI: 10.1071/ah17242] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 06/25/2018] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Darryn Marks
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia.
| | - Tracy Comans
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Level 2,Building 33, Princess Alexandra Hospital, Woolloongabba, Qld 4102, Australia. Email
| | - Leanne Bisset
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, Qld 4222, Australia. Email
| | - Michael Thomas
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Qld 4215, Australia.
| | - Paul A Scuffham
- Centre for Applied Health Economics, School of Medicine, Griffith University, Sir Samuel Griffith Centre, Nathan, Qld 4111, Australia.
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24
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Smythe A, White J, Littlewood C, Bury J, Haines T, Malliaras P. Physiotherapists deliver management broadly consistent with recommended practice in rotator cuff tendinopathy: An observational study. Musculoskelet Sci Pract 2020; 47:102132. [PMID: 32148327 DOI: 10.1016/j.msksp.2020.102132] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/02/2019] [Accepted: 02/13/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Rotator cuff tendinopathy is a common and disabling cause of shoulder pain. While conservative treatment is recommended as initial management, recent findings suggest that general practitioners and rheumatologists do not consistently align with recommended care. This study aimed to survey Australian physiotherapists to explore the extent to which recommended management is being applied. METHODS A cross-sectional online survey. RESULTS Five hundred and two Australian physiotherapists completed the survey. Results demonstrated the majority of physiotherapists provide conservative management consistent with guideline recommendations, through delivery of exercise and education, comparable to management by physiotherapists in the United Kingdom, Belgium and the Netherlands. Parameters and construction of exercise treatment programs were highly variable within the cohort, qualitative analysis highlighting varied reasoning underpinning these management decisions. CONCLUSIONS Australian physiotherapists are broadly consistent with providing recommended management, however heterogeneity exists in the methods and parameters of treatment delivery.
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Affiliation(s)
- A Smythe
- A Game Physiotherapy, Somerville, Melbourne, 3912, Australia.
| | - J White
- School of Primary and Allied Health Care, Monash University, Frankston, 3199, Australia
| | - C Littlewood
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, ST54 5BG, UK
| | - J Bury
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster Royal Infirmary, Doncaster, DN2 5LT, UK
| | - T Haines
- School of Primary and Allied Health Care, Monash University, Frankston, 3199, Australia
| | - P Malliaras
- School of Primary and Allied Health Care, Monash University, Frankston, 3199, Australia
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25
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Naunton J, Harrison C, Britt H, Haines T, Malliaras P. General practice management of rotator cuff related shoulder pain: A reliance on ultrasound and injection guided care. PLoS One 2020; 15:e0227688. [PMID: 31929588 PMCID: PMC6957186 DOI: 10.1371/journal.pone.0227688] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/26/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To describe general practitioner's (GP's) current management of rotator cuff related shoulder pain (RCRP) in Australia and identify if this is consistent with recommended care and best available evidence. The secondary aim was to determine if GP management of RCRP changed over time. METHODS Data about management of RCRP by Australian GPs was extracted from the Bettering the Evaluation of Care of Health program database over its final five years (April 2011-March 2016). Patient and GP characteristics and encounter management data were extracted. Results are reported using descriptive statistics with point estimates and 95% confidence intervals. A secondary analysis over a 16 year period (2000-2016) examined management data for RCRP in four year periods. RESULTS RCRP was the most common shoulder condition managed by GPs at 5.12 per 1,000 encounters; and at an estimated 732,000 times nationally in 2015-2016. Management rate was higher among male patients (5.5 per 1000 encounters c.f. 4.8 for female patients) and was highest in the 45-64 year old age group (8.6 per 1000). RCRP was most frequently managed with medications (54.7%), steroid injection (19.5%) followed by non-steroidal anti-inflammatory drugs (NSAIDs) (19.1%). Imaging was ordered for 43.4% (ultrasound 41.2% and x-ray 11.6%) of all RCRP presentations (new and returning). Over half (53.0%) of new RCRP presentations were referred for ultrasound imaging. In the 16 year period 2000-16 ultrasound imaging more than doubled from 19.1% to 41.9% of management occasions. In parallel, prescribed steroid injection increased from 9.8% to 19.7%. CONCLUSION The usual care provided by GPs for RCRP relies on the use of ultrasound and steroid injection. This is not consistent with recommended care and clinical guidelines that recommend these are delayed until after 6-12 weeks of NSAID medication, exercise and activity modification. There has been a significant increase in the rate of steroid injection and ultrasound imaging, which may be due in part to policy change.
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Affiliation(s)
- Josh Naunton
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Christopher Harrison
- Menzies Centre for Health Policy, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Helena Britt
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Terrence Haines
- School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Sciences, Monash University, Victoria, Australia
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26
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Protheroe J, Saunders B, Bartlam B, Dunn KM, Cooper V, Campbell P, Hill JC, Tooth S, Mallen CD, Hay EM, Foster NE. Matching treatment options for risk sub-groups in musculoskeletal pain: a consensus groups study. BMC Musculoskelet Disord 2019; 20:271. [PMID: 31153364 PMCID: PMC6545223 DOI: 10.1186/s12891-019-2587-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/24/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Musculoskeletal (MSK) pain represents a considerable worldwide healthcare burden. This study aimed to gain consensus from practitioners who work with MSK pain patients, on the most appropriate primary care treatment options for subgroups of patients based on prognostic risk of persistent disabling pain. Agreement was sought on treatment options for the five most common MSK pain presentations: back, neck, knee, shoulder and multisite pain, across three risk subgroups: low, medium and high. METHODS Three consensus group meetings were conducted with multi-disciplinary groups of practitioners (n = 20) using Nominal Group Technique, a systematic approach to building consensus using structured in-person meetings of stakeholders which follows a distinct set of stages. RESULTS For all five pain presentations, "education and advice" and "simple oral and topical pain medications" were agreed to be appropriate for all subgroups. For patients at low risk, across all five pain presentations "review by primary care practitioner if not improving after 6 weeks" also reached consensus. Treatment options for those at medium risk differed slightly across pain-presentations, but all included: "consider referral to physiotherapy" and "consider referral to MSK-interface-clinic". Treatment options for patients at high risk also varied by pain presentation. Some of the same options were included as for patients at medium risk, and additional options included: "opioids"; "consider referral to expert patient programme" (across all pain presentations); and "consider referral for surgical opinion" (back, knee, neck, shoulder). "Consider referral to rheumatology" was agreed for patients at medium and high risk who have multisite pain. CONCLUSION In addressing the current lack of robust evidence on the effectiveness of different treatment options for MSK pain, this study generated consensus from practitioners on the most appropriate primary care treatment options for MSK patients stratified according to prognostic risk. These findings can help inform future clinical decision-making and also influenced the matched treatment options in a trial of stratified primary care for MSK pain patients.
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Affiliation(s)
- Joanne Protheroe
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Benjamin Saunders
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.
| | - Bernadette Bartlam
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Lee Kong Chian School of Medicine, Nanyang Technological University, 50 Nanyang Ave, Singapore, 63979, Singapore
| | - Kate M Dunn
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Vince Cooper
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Paul Campbell
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Jonathan C Hill
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Stephanie Tooth
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit (CTU), David Weatherall Building, Keele University, Staffordshire, ST5 5BG, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Elaine M Hay
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit (CTU), David Weatherall Building, Keele University, Staffordshire, ST5 5BG, UK
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27
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Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O'Sullivan PPB. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med 2019; 54:79-86. [PMID: 30826805 DOI: 10.1136/bjsports-2018-099878] [Citation(s) in RCA: 453] [Impact Index Per Article: 90.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs). DESIGN Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations. ELIGIBILITY CRITERIA Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment. DATA SOURCES Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. RESULTS 6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work. CONCLUSION These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.
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Affiliation(s)
- Ivan Lin
- WA Centre for Rural Health, University of Western Australia, Geraldton, Western Australia, Australia
| | - Louise Wiles
- Centre for Population Health Research, University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Rob Waller
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Roger Goucke
- Pain Management Centre, Sir Charles Gardner Hospital, Perth, Western Australia, Australia
| | - Yusuf Nagree
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Emergency Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Michael Gibberd
- Emergency Department, Geraldton Hospital, Geraldton, Western Australia, Australia
| | - Leon Straker
- School of Physiotherapy and Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Chris G Maher
- School of Public Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter P B O'Sullivan
- Department of Physiotherapy, Curtin University, Perth, Western Australia, Australia
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28
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van der Windt DA, Burke DL, Babatunde O, Hattle M, McRobert C, Littlewood C, Wynne-Jones G, Chesterton L, van der Heijden GJMG, Winters JC, Rhon DI, Bennell K, Roddy E, Heneghan C, Beard D, Rees JL, Riley RD. Predictors of the effects of treatment for shoulder pain: protocol of an individual participant data meta-analysis. Diagn Progn Res 2019; 3:15. [PMID: 31410370 PMCID: PMC6686538 DOI: 10.1186/s41512-019-0061-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/16/2019] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Danielle A. van der Windt
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
| | - Danielle L. Burke
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
| | - Opeyemi Babatunde
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
| | - Miriam Hattle
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
| | - Cliona McRobert
- 0000 0004 1936 8470grid.10025.36School of Health Sciences, University of Liverpool, Liverpool, UK
| | - Chris Littlewood
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
| | - Gwenllian Wynne-Jones
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
| | - Linda Chesterton
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
| | - Geert J. M. G. van der Heijden
- 0000000084992262grid.7177.6Department of Social Dentistry, Academic Center for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jan C. Winters
- 0000 0000 9558 4598grid.4494.dDepartment of General Practice and Elderly Care Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Daniel I. Rhon
- San Antonio Military Medical Center, Fort Sam Houston, San Antonio, TX USA
| | - Kim Bennell
- 0000 0001 2179 088Xgrid.1008.9Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne, Melbourne, Australia
| | - Edward Roddy
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent Partnership Trust, Stoke-on-Trent, UK
| | - Carl Heneghan
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care and Health Science, University of Oxford, Oxford, UK
| | - David Beard
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Jonathan L. Rees
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Richard D. Riley
- 0000 0004 0415 6205grid.9757.cInstitute for Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Centre for Prognosis Research, Keele University, Keele, UK
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29
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Daron C, Deschaumes C, Soubrier M, Mathieu S. Viewpoints of dentists on the use of bisphosphonates in rheumatology patients. Int Dent J 2018; 68:279-286. [PMID: 29446061 DOI: 10.1111/idj.12363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Alhough typically prescribed in oncology, bisphosphonates (BPs) are also employed in rheumatology, particularly for the treatment of osteoporosis, sometimes resulting in complications, such as osteonecrosis of the jaw. Because of different opinions between rheumatologists and dentists on BP use, this study aimed to assess the views of dentists regarding administration of BPs in rheumatology. METHODS A questionnaire was sent to 880 dentists from the Auvergne region of France to determine their views on BP treatment. RESULTS We obtained 382 (43.4%) responses and analysed 376 (58.7% men). In total, 156 (41.5%) of the responders analysed had attended an in-service training course (ISTC) on the topic. A total of 237 (63.0%) systematically inquired as to whether their patients were undergoing BP treatment; this proportion was higher among those who had been practicing for fewer than 10 years (P < 0.004). For patients receiving BPs, 84.5% of practitioners felt ill at ease about performing dental surgery (n = 318) and 11% felt ill at ease about performing nonsurgical dental care (n = 41); 67% stated that their practice differed depending on the method of BP administration (per os or intravenously). Overall, 53.7% of practitioners felt uncomfortable when asked by a rheumatologist whether a given patient's dental status permitted prescription of BP (n = 202). This proportion was higher among those who had never attended an ISTC (62.6% vs. 50.7%; P < 0.03). CONCLUSIONS Dentists feel ill at ease providing dental surgery to patients receiving BPs. Closer collaboration and better information-sharing between rheumatologists and dentists is necessary to facilitate the administration of BPs in rheumatology.
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Affiliation(s)
- Coline Daron
- Service de Rhumatologie, CHU Gabriel Montpied, Clermont-Ferrand, France
| | | | - Martin Soubrier
- Service de Rhumatologie, CHU Gabriel Montpied, Clermont-Ferrand, France
| | - Sylvain Mathieu
- Service de Rhumatologie, CHU Gabriel Montpied, Clermont-Ferrand, France
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Lin I, Wiles LK, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O’Sullivan PPB. Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. Br J Sports Med 2017; 52:337-343. [DOI: 10.1136/bjsports-2017-098375] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 12/31/2022]
Abstract
ObjectivesUndertake a systematic critical appraisal of contemporary clinical practice guidelines (CPGs) for common musculoskeletal (MSK) pain conditions: spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis) and shoulder.DesignSystematic review of CPGs (PROSPERO number: CRD42016051653).Included CPGs were written in English, developed within the last 5 years, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment.Data sources and method of appraisalFour scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used for critical appraisal.Results4664 records were identified, and 34 CPGs were included. Most were for osteoarthritis (n=12) or low back pain (n=11), most commonly from the USA (n=12). The mean overall AGREE II score was 45% (SD=19.7). Lowest mean domain scores were for applicability (26%, SD=19.5) and editorial independence (33%, SD=27.5). The highest score was for scope and purpose (72%, SD=14.3). Only 8 of 34 CPGS were high quality: for osteoarthritis (n=4), low back pain (n=2), neck (n=1) and shoulder pain (n=1).
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Artus M, van der Windt DA, Afolabi EK, Buchbinder R, Chesterton LS, Hall A, Roddy E, Foster NE. Management of shoulder pain by UK general practitioners (GPs): a national survey. BMJ Open 2017; 7:e015711. [PMID: 28637737 PMCID: PMC5734284 DOI: 10.1136/bmjopen-2016-015711] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/13/2017] [Accepted: 05/03/2017] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES Studies in Canada, the USA and Australia suggested low confidence among general practitioners (GPs) in diagnosing and managing shoulder pain, with frequent use of investigations. There are no comparable studies in the UK; our objective was to describe the diagnosis and management of shoulder pain by GPs in the UK. METHODS A national survey of a random sample of 5000 UK GPs collected data on shoulder pain diagnosis and management using two clinical vignettes that described primary care presentations with rotator cuff tendinopathy (RCT) and adhesive capsulitis (AdhC). RESULTS Seven hundred and fourteen (14.7%) responses were received. 56% and 83% of GPs were confident in their diagnosis of RCT and AdhC, respectively, and a wide range of investigations and management options were reported. For the RCT presentation, plain radiographs of the shoulder were most common (60%), followed by blood tests (42%) and ultrasound scans (USS) (38%). 19% of those who recommended a radiograph and 76% of those who recommended a USS did so 'to confirm the diagnosis'. For the AdhC presentation, the most common investigations were blood tests (60%), plain shoulder radiographs (58%) and USS (31%). More than two-thirds of those recommending a USS did so 'to confirm the diagnosis'. The most commonly recommended treatment for both presentations was physiotherapy (RCT 77%, AdhC 71%) followed by non-steroidal anti-inflammatory drugs (RCT 58%, AdhC 74%). 17% opted to refer the RCT to secondary care (most often musculoskeletal interface service), compared with 31% for the AdhC. CONCLUSIONS This survey of GPs in the UK highlights reliance on radiographs and blood tests in the management of common shoulder pain presentations. GPs report referring more than 7 out of 10 patients with RCT and AdhC to physiotherapists. These findings need to be viewed in the context of low response to the survey and, therefore, potential non-response bias.
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Affiliation(s)
- Majid Artus
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Danielle A van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Ebenezer K Afolabi
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Linda S Chesterton
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Alison Hall
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Edward Roddy
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
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Ottenheijm RPG, Cals JWL, Winkens B, Weijers RE, de Bie RA, Dinant GJ. Ultrasound imaging to tailor the treatment of acute shoulder pain: a randomised controlled trial in general practice. BMJ Open 2016; 6:e011048. [PMID: 27872111 PMCID: PMC5128954 DOI: 10.1136/bmjopen-2016-011048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/18/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To determine the clinical effectiveness of ultrasound tailored treatment in patients with acute subacromial disorders. DESIGN Pragmatic randomised controlled trial. SETTING Dutch general practice. PARTICIPANTS Patients aged 18-65 years with acute (duration <3 months) unilateral shoulder pain and no previous treatment, in whom the general practitioner suspected a subacromial disorder was enrolled. INTERVENTIONS All patients underwent ultrasound imaging of the affected shoulder. Patients who were still symptomatic after a qualification period of 2 weeks with standard treatment were randomised to treatment tailored to ultrasound diagnosis (disclosure of the ultrasound diagnosis) or usual care (non-disclosure of the ultrasound diagnosis). PRIMARY OUTCOME MEASURE Patient-perceived recovery using the Global Perceived Effect questionnaire at 1 year. RESULTS 129 patients were included. 18 patients recovered during the 2-week qualification period, resulting in 111 randomised patients; 56 were allocated to ultrasound tailored treatment and 55 to usual care. After 1 year, no statistically significant differences in recovery were found between the ultrasound tailored treatment group (72.5% (37/51)) and the usual care group (60% (30/50), OR 2.24 (95% CI 0.72 to 6.89; p=0.16)). Also, healthcare use was similar. CONCLUSIONS This study has shown no clinically significant difference in the primary outcome measure between the ultrasound tailored treatment and usual care groups. Furthermore, there was no overall difference in healthcare resources used between groups. Although no formal cost data are included, one can only assume that the ultrasound examinations are additional costs for the intervention group, which cannot be justified in routine practice based on this trial. Based on this study, no change in current pragmatic guidelines to incorporate early ultrasound imaging can be recommended. TRIAL REGISTRATION NUMBER NTR2403; Results.
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Affiliation(s)
- Ramon P G Ottenheijm
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - René E Weijers
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rob A de Bie
- Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Marks D, Comans T, Thomas M, Ng SK, O'Leary S, Conaghan PG, Scuffham PA, Bisset L. Agreement between a physiotherapist and an orthopaedic surgeon regarding management and prescription of corticosteroid injection for patients with shoulder pain. ACTA ACUST UNITED AC 2016; 26:216-222. [PMID: 27744222 DOI: 10.1016/j.math.2016.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/29/2016] [Accepted: 10/01/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Physiotherapists increasingly manage shoulder referrals in place of orthopaedic doctors. Better understanding the agreement between these professionals will help inform the safety, quality and potential costs of these care models. OBJECTIVE To establish the level of agreement between a physiotherapist and an orthopaedic surgeon regarding diagnosis, management and corticosteroid injection, in a representative sample of orthopaedic shoulder referrals. DESIGN Blinded inter-rater agreement study. METHOD 274 public orthopaedic shoulder patients were independently assessed by a physiotherapist and an orthopaedic surgeon. Management, subacromial corticosteroid injection, diagnosis and investigation decisions were compared using inter-rater reliability statistics. RESULTS Agreement between the physiotherapist and the orthopaedic surgeon was near perfect for surgical versus nonsurgical management (Gwets agreement coefficient AC1 = 0.93, 95%CI: 0.90-0.93), safety of injection (AC1 = 0.85, CI: 0.79-0.91) and investigations requested (AC1 = 0.87, CI: 0.83-0.91); substantial for the presence of subacromial pain (AC1 = 0.74, CI: 0.66-0.81) and diagnosis (AC1 = 0.72, CI: 0.66-0.78); and moderate regarding delivery of subacromial corticosteroid injection as an immediate treatment (AC1 = 0.48, CI 0.33-0.53), with the physiotherapist less inclined to select corticosteroid injection as the first intervention. CONCLUSION In this study a physiotherapist with prescribing and injection training made decisions analogous to those of an orthopaedic surgeon at initial consultation for orthopaedic shoulder pain, including the safe identification of patients for subacromial injection, without prior screening of referrals by orthopaedic doctors. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Registry, number 12612000532808.
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Affiliation(s)
- Darryn Marks
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia; Menzies Health Institute Queensland, Griffith University, Parklands Drive Southport, QLD 4222, Gold Coast, Australia.
| | - Tracy Comans
- Menzies Health Institute Queensland, Griffith University, Parklands Drive Southport, QLD 4222, Gold Coast, Australia; Metro North Hospital and Health Service, 112 Alfred Street, Fortitude Valley, QLD 4006, Brisbane, Australia
| | - Michael Thomas
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia
| | - Shu Kay Ng
- Menzies Health Institute Queensland, Griffith University, Parklands Drive Southport, QLD 4222, Gold Coast, Australia
| | - Shaun O'Leary
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane St Lucia, QLD 4072, Australia; Physiotherapy Department, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4006, Australia
| | - Philip G Conaghan
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, UK
| | - Paul A Scuffham
- Menzies Health Institute Queensland, Griffith University, Parklands Drive Southport, QLD 4222, Gold Coast, Australia
| | - Leanne Bisset
- Menzies Health Institute Queensland, Griffith University, Parklands Drive Southport, QLD 4222, Gold Coast, Australia
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Marks D, Bisset L, Comans T, Thomas M, Ng SK, O’Leary S, Conaghan PG, Scuffham PA. Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon. PLoS One 2016; 11:e0162679. [PMID: 27631987 PMCID: PMC5025143 DOI: 10.1371/journal.pone.0162679] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 08/23/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Role substitution is a strategy employed to assist health services manage the growing demand for musculoskeletal care. Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic standards. This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinically and cost effective as that from an orthopaedic surgeon. METHODS A double blind non-inferiority randomized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service, from January 2013 to June 2014. Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon. The main outcome measure was total Shoulder Pain and Disability Index (SPADI) score at baseline, six and 12 weeks, applying a non-inferiority margin of 15 points. Secondary outcomes tested for superiority included pain, shoulder movement, perceived improvement, adverse events, satisfaction, quality of life and costs. RESULTS 278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon, with 64 randomised (physiotherapist 33, orthopaedic surgeon 31). There were no significant differences in baseline characteristics between groups. Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks (upper limit of the 95% one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks, respectively). There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks. From the perspective of the health funder, the physiotherapist was less expensive. CONCLUSIONS Corticosteroid injection for shoulder pain, provided by a suitably qualified physiotherapist is at least as clinically effective, and less expensive, compared with similar care delivered by an orthopaedic surgeon. Policy makers and service providers should consider implementing this model of care. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Registry 12612000532808.
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Affiliation(s)
- Darryn Marks
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
| | - Leanne Bisset
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
| | - Tracy Comans
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
- Metro North Hospital and Health Service, 112 Alfred Street, Fortitude Valley, QLD 4006, Brisbane, Australia
| | - Michael Thomas
- Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia
| | - Shu Kay Ng
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
| | - Shaun O’Leary
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, St Lucia, QLD 4072, Australia
- Physiotherapy Department, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, QLD 4006, Australia
| | - Philip G. Conaghan
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, United Kingdom
| | - Paul A. Scuffham
- Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia
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Morgan S, Morgan A, Kerr R, Tapley A, Magin P. Test ordering by GP trainees: Effects of an educational intervention on attitudes and intended practice. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:733-741. [PMID: 27629671 PMCID: PMC5023346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the effectiveness of an educational intervention on test-ordering attitudes and intended practice of GP trainees, and any associations between changes in test ordering and trainee characteristics. DESIGN Preworkshop and postworkshop survey of attitudes to test ordering, intended test-ordering practices for 3 clinical scenarios (fatigue, screening, and shoulder pain), and tolerance for uncertainty. SETTING Three Australian regional general practice training providers. PARTICIPANTS General practice trainees (N = 167). INTERVENTION A 2-hour workshop session and an online module. MAIN OUTCOME MEASURES Proportion of trainees who agreed with attitudinal statements before and after the workshop; proportion of trainees who would order tests, mean number of tests ordered, and number of appropriate and inappropriate tests ordered for each scenario before and after the workshop. RESULTS Of 167 trainees, 132 (79.0%) completed both the preworkshop and postworkshop questionnaires. A total of 122 trainees attended the workshop. At baseline, 88.6% thought that tests can harm patients, 84.8% believed overtesting was a problem, 72.0% felt pressured by patients, 52.3% believed that tests would reassure patients, and 50.8% thought that they were less likely to be sued if they ordered tests. There were desirable changes in all attitudes after the workshop. Before the workshop, the mean number of tests that trainees would have ordered was 4.4, 4.8, and 1.5 for the fatigue, screening, and shoulder pain scenarios, respectively. After the workshop there were decreases in the mean number of both appropriate tests (decrease of 0.94) and inappropriate tests (decrease of 0.24) in the fatigue scenario; there was no change in the mean number of appropriate tests and a decrease in inappropriate tests (decrease of 0.76) in the screening scenario; and there was an increase in the proportion of trainees who would appropriately not order tests in the shoulder pain scenario. There were no significant associations between changes in test ordering and trainee demographic characteristics or tolerance for uncertainty subscale scores. CONCLUSION General practice trainees have conflicting attitudes to test ordering and demonstrate nonrational test ordering in 3 common scenarios. A workshop on rational test ordering led to desirable changes in attitudes and more rational intended test ordering. Our findings inform the development of appropriate educational interventions that address nonrational testing in family medicine.
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Affiliation(s)
- Simon Morgan
- GP and Medical Educator with General Practice Training Valley to Coast, practising in Newcastle, NSW, Australia.
| | - Andy Morgan
- Senior Medical Educator at Victorian Metropolitan Alliance and Senior Lecturer in the Department of General Practice at Monash University in Melbourne, Australia
| | - Rohan Kerr
- Senior Medical Educator with General Practice Training Tasmania and a GP at Claremont Village Medical Centre in Hobart, Australia
| | - Amanda Tapley
- Research officer at General Practice Training Valley to Coast
| | - Parker Magin
- GP and Medical Educator at General Practice Training Valley to Coast, and Conjoint Professor in the Discipline of General Practice at the University of Newcastle
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Ultrasound-guided intra-articular and rotator interval corticosteroid injections in adhesive capsulitis of the shoulder. Pain 2015; 156:1683-1691. [DOI: 10.1097/j.pain.0000000000000209] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Morgan S, van Driel M, Coleman J, Magin P. Rational test ordering in family medicine. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2015; 61:535-537. [PMID: 26071157 PMCID: PMC4463896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Simon Morgan
- General practitioner and medical educator with General Practice Training Valley to Coast in Newcastle, New South Wales, Australia.
| | - Mieke van Driel
- Head of the Discipline of General Practice at the University of Queensland in Australia and a primary care physician with the Kalwun Health Service on the Gold Coast
| | - Justin Coleman
- General practitioner with the Inala Indigenous Health Service, Senior Lecturer at Griffith University and the University of Queensland, President of the Australasian Medical Writers Association, and Chair of the Royal Australian College of General Practitioners Choosing Wisely Committee
| | - Parker Magin
- Medical educator with General Practice Training Valley to Coast and Conjoint Professor in the Discipline of General Practice at the University of Newcastle
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Abstract
Shoulder pain is a common musculoskeletal disorder and has a substantial negative effect on quality of life. Its monthly prevalence in the general population is reported to be between 18% and 31%, whereas lifetime prevalence ranges between 6.7% and 66.7%. Shoulder pain is the third most frequent musculoskeletal reason to present to primary care and accounts for up to 10% of all referrals to physical therapists. Although the natural history of shoulder pain varies and is often self-limiting,up to half of persons who present for care, particularly the elderly, might continue to have pain and/or functional disturbance for up to 2 years after presentation.
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Marks D, Bisset L, Thomas M, O’Leary S, Comans T, Ng SK, Conaghan PG, Scuffham P. An experienced physiotherapist prescribing and administering corticosteroid and local anaesthetic injections to the shoulder in an Australian orthopaedic service, a non-inferiority randomised controlled trial and economic analysis: study protocol for a randomised controlled trial. Trials 2014; 15:503. [PMID: 25527842 PMCID: PMC4307887 DOI: 10.1186/1745-6215-15-503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 11/28/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The early management of orthopaedic outpatients by physiotherapists may be useful in reducing public hospital waiting lists. Physiotherapists in Australia are prevented by legislation and funding models from investigating, prescribing, injecting and referring autonomously. This gap in service is particularly noticeable in the management of shoulder pain in early-access physiotherapy services, as patients needing corticosteroid injection face delays or transfer to other services for this procedure. This trial will investigate the clinical (decision making and outcomes) and economic feasibility of a physiotherapist prescribing and delivering corticosteroid and local anaesthetic injections for shoulder pain in an Australian public hospital setting. METHODS/DESIGN A double-blinded (patient and assessor) non-inferiority randomised controlled trial will compare an orthopaedic surgeon and a physiotherapist prescribing and delivering corticosteroid injections to the shoulder. Agreement in decision making between the two clinicians will be investigated, and economic information will be obtained for estimating disease burden and an economic evaluation. The surgeon and the physiotherapist will independently assess patients, and 64 eligible participants will be randomised to receive subacromial injection of corticosteroid and local anaesthetic from either the surgeon or the physiotherapist. Post-injection, all participants will receive physiotherapy. The primary outcome measure will be the Shoulder Pain and Disability Index measured at baseline, and at 6 and 12 weeks post-injection. Analysis will be conducted on an intention-to-treat basis and compared to a per-protocol analysis. A cost-utility analysis will be undertaken from the perspective of the health funder. DISCUSSION Findings will assist policy makers and services in improving access for orthopaedic patients. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Registry: 12612000532808 First registered: 21 May 2012. First participant randomized: 16 January 2013.
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Affiliation(s)
- Darryn Marks
- />Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215 Gold Coast Australia
| | - Leanne Bisset
- />School of Allied Health Sciences, Griffith Health Institute, Griffith University, Gold Coast Campus, Kragujevac, Queensland 4222 Australia
| | - Michael Thomas
- />Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215 Gold Coast Australia
| | - Shaun O’Leary
- />NHMRC CCRE (Spinal Pain, Injury and Health), The University of Queensland, Brisbane, 4072 Australia
- />The Physiotherapy Department, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, Queensland 4029 Australia
| | - Tracy Comans
- />School of Medicine, Griffith Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131 Australia
| | - Shu Kay Ng
- />School of Medicine, Griffith Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131 Australia
| | - Philip G Conaghan
- />Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA UK
| | - Paul Scuffham
- />School of Medicine, Griffith Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131 Australia
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Ottenheijm RPG, Hesselmans NJJM, Kemper A, Moser A, de Bie RA, Dinant GJ, Cals JWL. GPs' perspectives on the diagnostic work-up in patients with shoulder pain: a qualitative study. J Eval Clin Pract 2014; 20:239-45. [PMID: 24593829 DOI: 10.1111/jep.12114] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The diagnostic work-up of patients with shoulder pain in general practice is complex. General practitioners' (GPs) guidelines advise a pragmatic diagnostic work-up in which additional imaging has a limited role. However, diagnostic ultrasounds are increasingly ordered by GPs, which seems to reflect complexity in management of shoulder pain. This study aimed to explore GPs' perspectives on the diagnostic work-up of patients with shoulder pain. METHOD This study has a qualitative exploratory design with an inductive approach and was carried out in Dutch general practice. The study population consisted of 18 Dutch GPs who were sampled purposefully with a spread in clinical experience and ordering diagnostic ultrasound. Data were gathered by means of semi-structured interviews and analysed following principles of the constant comparative method. RESULTS Three main categories with subcategories emerged that captured the diagnostic work-up of shoulder pain: variety in diagnostic classifications [(non-)specific diagnosis and interdisciplinary differences], establishing strategies for diagnostic work-up (use of existing tools and motives to deviate from existing tools), and strategies dealing with diagnostic uncertainties (accepting diagnostic uncertainties, diagnostic imaging tests, and interdisciplinary consultation and referral). CONCLUSIONS Despite the availability of evidence-based shoulder guidelines, GPs experience uncertainties during diagnostic work-up and apply different strategies when dealing with these uncertainties. At some point, GPs as well as patients seem to have a need for a specific diagnosis. Currently, there appears to be little agreement if, or in which phase of shoulder pain, diagnostic ultrasound is useful or indicated.
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Affiliation(s)
- Ramon P G Ottenheijm
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Abstract
Shoulder pain is a common symptom in the adult population. The most common cause of shoulder pain is SIS, reflecting a problem with the rotator cuff or subacromial bursa. Determining the cause of a patient’s pain is usually a clinical diagnosis based on careful history taking and physical examination. Limited use of imaging studies will be needed in the setting of trauma, possible glenohumeral arthritis, or when a complete tendon tear is suspected. Therapy is based on pain control and therapeutic exercises in almost all cases. Despite the prevalence of shoulder pain, there is no consensus on the best way to achieve pain control or on the type of exercise most likely to achieve speedy recovery.
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Affiliation(s)
- Deborah L Greenberg
- Division of General Internal Medicine, University of Washington School of Medicine, 4245 Roosevelt Way Northeast, Seattle, WA 98105, USA.
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42
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Carroll JC, Blaine S, Permaul J, Dicks E, Warner E, Esplen MJ, Rothenmund H, Semotiuk K, Worrall G, McLaughlin J. Efficacy of an educational intervention on family physicians' risk assessment and management of colorectal cancer. J Community Genet 2014; 5:303-11. [PMID: 24715212 DOI: 10.1007/s12687-014-0185-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 03/10/2014] [Indexed: 12/31/2022] Open
Abstract
We developed a point-of-care tool indicating risk categories for colorectal cancer (CRC) based on family history (FH) and management recommendations tailored to risk. The study objective was to determine if this CRC Risk Triage/Management Too would enable family physicians (FPs) to appropriately triage and make screening and genetics referral recommendations for patients with CRC FH. Baseline questionnaires were mailed to a random sample of FPs in Ontario and Newfoundland, Canada. Participants were asked to use the tool for 3 months and then complete a follow-up questionnaire. The primary outcomes were correct responses to questions regarding CRC risk category, screening method, starting age, frequency, and decision to refer to genetics, for eight clinical vignettes. The study was completed by 75/121 (62 %) participating FPs. Most (77 %) agreed they routinely recommended fecal occult blood testing for average risk patients age ≥50. This did not change significantly following the intervention. There was a significant increase in confidence in CRC risk assessment (52 % pre; 88 % post; p < 0.001), correct management recommendations for patients with CRC FH (51 % pre; 84 % post; p < 0.001), and improvement in total mean scores on outcome measures for all vignettes. Most (90 %) agreed the tool would improve practice. Receipt of the CRC Risk Triage/Management Tool was associated with improvement in FPs' CRC risk assessment, screening, and genetics referral recommendations for clinical vignettes. This demonstrates the value of point-of-care tools and illustrates a process for development, evaluation, and dissemination of tools needed by FPs if potential impacts of genomic advances are to be achieved.
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Affiliation(s)
- J C Carroll
- Department of Family and Community Medicine, Mount Sinai Hospital, University of Toronto, 60 Murray St., Toronto, ON, M5T 3L9, Canada,
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Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database Syst Rev 2013; 2013:CD009020. [PMID: 24065456 PMCID: PMC6464715 DOI: 10.1002/14651858.cd009020.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Shoulder pain is a very common symptom. Disorders of the rotator cuff tendons due to wear or tear are among the most common causes of shoulder pain and disability. Magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and ultrasound (US) are increasingly being used to assess the presence and size of rotator cuff tears to assist in planning surgical treatment. It is not known whether one imaging method is superior to any of the others. OBJECTIVES To compare the diagnostic test accuracy of MRI, MRA and US for detecting any rotator cuff tears (i.e. partial or full thickness) in people with suspected rotator cuff tears for whom surgery is being considered. SEARCH METHODS We searched the Cochrane Register of Diagnostic Test Accuracy Studies, MEDLINE, EMBASE, and LILACS from inception to February 2011. We also searched trial registers, conference proceedings and reference lists of articles to identify additional studies. No language or publication restrictions were applied. SELECTION CRITERIA We included all prospective diagnostic accuracy studies that assessed MRI, MRA or US against arthroscopy or open surgery as the reference standard, in people suspected of having a partial or full thickness rotator cuff tear. We excluded studies that selected a healthy control group, or participants who had been previously diagnosed with other specific causes of shoulder pain such as osteoarthritis or rheumatoid arthritis. Studies with an excessively long period (a year or longer) between the index and reference tests were also excluded. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on study characteristics and results of included studies, and performed quality assessment according to QUADAS criteria. Our unit of analysis was the shoulder. For each test, estimates of sensitivity and specificity from each study were plotted in ROC space and forest plots were constructed for visual examination of variation in test accuracy. Meta-analyses were performed using the bivariate model to produce summary estimates of sensitivity and specificity. We were unable to formally investigate potential sources of heterogeneity because of the small number of studies. MAIN RESULTS We included 20 studies of people with suspected rotator cuff tears (1147 shoulders), of which six evaluated MRI and US (252 shoulders), or MRA and US (127 shoulders) in the same people. Many studies had design flaws, with the potential for bias, thus limiting the reliability of their findings. Overall, the methodological quality of the studies was judged to be low or unclear. For each test, we observed considerable heterogeneity in study results, especially between studies that evaluated US for the detection of full thickness tears and studies that evaluated MRA for the detection of partial thickness tears. The criteria for a positive diagnostic test (index tests and reference standard) varied between studies.Meta-analyses were not possible for studies that assessed MRA for detection of any rotator cuff tears or partial thickness tears. We found no statistically significant differences in sensitivity or specificity between MRI and US for detecting any rotator cuff tears (P = 0.13), or for detecting partial thickness tears (P = 1.0). Similarly, for the comparison between MRI, MRA and US for detecting full thickness tears, there was no statistically significant difference in diagnostic performance (P = 0.7). For any rotator cuff tears, the summary sensitivity and specificity were 98% (95% CI 92% to 99%) and 79% (95% CI 68% to 87%) respectively for MRI (6 studies, 347 shoulders), and 91% (95% CI 83% to 95%) and 85% (95% CI 74% to 92%) respectively for US (13 studies, 854 shoulders). For full thickness tears, the summary sensitivity and specificity were 94% (95% CI 85% to 98%) and 93% (95% CI 83% to 97%) respectively for MRI (7 studies, 368 shoulders); 94% (95% CI 80% to 98%) and 92% (95% CI 83% to 97%) respectively for MRA (3 studies, 183 shoulders); and 92% (95% CI 82% to 96%) and 93% (95% CI 81% to 97%) respectively for US (10 studies, 729 shoulders).Because few studies were direct head-to-head comparisons, we could not perform meta-analyses restricted to these studies. The test comparisons for each of the three classifications of the target condition were therefore based on indirect comparisons which may be prone to bias due to confounding. AUTHORS' CONCLUSIONS MRI, MRA and US have good diagnostic accuracy and any of these tests could equally be used for detection of full thickness tears in people with shoulder pain for whom surgery is being considered. The diagnostic performance of MRI and US may be similar for detection of any rotator cuff tears. However, both MRI and US may have poor sensitivity for detecting partial thickness tears, and the sensitivity of US may be much lower than that of MRI. The strength of evidence for all test comparisons is limited because most studies were small, heterogeneous and methodologically flawed, and there were few comparative studies. Well designed studies that directly compare MRI, MRA and US for detection of rotator cuff tears are needed.
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Affiliation(s)
- Mário Lenza
- Hospital Israelita Albert EinsteinOrthopaedic and Trauma DepartmentAv. Albert Einstein, 627/701São PauloSao PauloBrazilCEP 05651‐901
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Yemisi Takwoingi
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Nigel CA Hanchard
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughTees ValleyUKTS1 3BA
| | - Flávio Faloppa
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783‐5th FloorSão PauloSão PauloBrazil
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