Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist's Approach

Supraspinatus fatty infiltration on MRI among older adults receiving physical therapy as initial management for clinically suspected rotator cuff tear: A pilot study

Objectives

Rotator cuff (RC) tear is common among adults ≥60 years, with supraspinatus tear most common. Intramuscular fatty infiltration (FI) on imaging is predictive of long-term outcomes following RC tear. Physical therapists routinely diagnose RC tear only by clinical examination since most do not order imaging studies. Thus, there is limited knowledge about FI in older populations receiving physical therapy (PT) for initial management of RC tear. The primary objective of our pilot study is to determine longitudinal differences in supraspinatus FI over time among older adults receiving PT (PT cohort) for initial management of RC tear relative to older adult volunteers (control cohort), and with secondary objective to evaluate longitudinal self-reported shoulder function over time.

Material and Methods

This was a prospective longitudinal cohort study. Forty adults, 60-85 years, were enrolled at baseline; one follow-up visit at ≥6 months. Shoulder magnetic resonance imaging and clinical screening for Charlson comorbidity index (CCI), body mass index (BMI), and American Shoulder and Elbow Surgeon (ASES) score were completed at baseline and follow-up visits. Supraspinatus FI was evaluated by 6-point Dixon fat fraction and Goutallier grade. PT (n = 15) and control (n = 25) cohorts were stratified by supraspinatus status: Intact (no tear), partial-thickness tear (PTT), and full-thickness tear (FTT). Comparisons within cohort were performed by Kruskal-Wallis test and between cohorts by Mann-Whitney U-test. Interobserver reliability was performed for Dixon fat fraction and Goutallier grade.

Results

PT cohort at baseline showed no difference for age, BMI, CCI, and ASES score; supraspinatus FI was highest for FTT by Goutallier grade (no tear, 0.5 ± 0.5; PTT, 1.1 ± 0.2; and FTT, 1.5 ± 0.5; P = 0.033) and by Dixon fat fraction (no tear, 4.6% ± 1.4%; PTT, 6.1% ± 1.9%; and FTT, 6.7% ± 2.5%; P = 0.430). Control cohort at baseline showed no difference for age, BMI, CCI, and ASES score; supraspinatus FI was highest for supraspinatus FTT by Dixon fat fraction (no tear, 5.8% ± 1.2%; PTT, 7.1% ± 6.3%; and FTT, 21.4% ± 10.4%; P = 0.034) and by Goutallier grade (no tear, 0.8 ± 0.5; PTT, 1.0 ± 0.6; and FTT, 2.4 ± 1.7; P = 0.141). No difference between similar PT and control cohort subgroups at baseline except no tear groups for ASES score (PT cohort, 58.9 ± 8.2; control cohort, 84.0 ± 21.9; P = 0.049). No differences were identified for Δ-Dixon fat fraction and Δ-Goutallier grade over time in the PT and control cohorts. PT cohort no tear subgroup showed significant improvement (P = 0.042) for Δ-ASES score over time relative to PTT and FTT subgroups; no difference for Δ-ASES score over time in the control cohort.

Conclusion

Full-thickness RC tear showed higher levels of FI relative to PTT or no tear at baseline. Our pilot study's trend suggested that older adults receiving PT for initial management of RC tear have full-thickness RC tear for shorter duration based on relative lower levels of FI at baseline as compared to older adult volunteers with full-thickness RC tear. Our pilot study also found that older adults in the PT cohort with no tear had superior shoulder functional recovery by ASES score over time relative to full-thickness and PTTs.

Identifying goals, roles and tasks of extended scope physiotherapy in Dutch primary care- an exploratory, qualitative multi-step study

BACKGROUND

Rising healthcare costs, an increasing general practitioner shortage and an aging population have made healthcare organization transformation a priority. To meet these challenges, traditional roles of non-medical members have been reconsidered. Within the domain of physiotherapy, there has been significant interest in Extended Scope Physiotherapy (ESP). Although studies have focused on the perceptions of different stakeholders in relation to ESP, there is a large variety in the interpretation of ESP.

AIM

To identify a paradigm of ESP incorporating goals, roles and tasks, to provide a consistent approach for the implementation of ESP in primary care.

METHODS

An exploratory, qualitative multi-step design was used containing a scoping review, focus groups and semi-structured interviews. The study population consisted of patients, physiotherapists, general practitioners and indirect stakeholders such as lecturers, health insurers and policymakers related to primary care physiotherapy. The main topics discussed in the focus groups and semi-structured interviews were the goals, skills and roles affiliated with ESP. The 'framework' method, developed by Ritchie & Spencer, was used as analytical approach to refine the framework.

RESULTS

Two focus groups and twelve semi-structured interviews were conducted to explore stakeholder perspectives on ESP in Dutch primary care. A total of 11 physiotherapists, six general practitioners, five patients and four indirect stakeholders participated in the study. There was a lot of support for 'decreasing healthcare costs', 'tackling increased health demand' and 'improving healthcare effectiveness' as main goals of ESP. The most agreement was reached on 'triaging', 'referring to specialists' and 'ordering diagnostic imaging' as tasks fitting for ESP. Most stakeholders also supported 'working in a multidisciplinary team', 'working as a consultant' and 'an ESP role separated from a physiotherapist role' as roles of ESP.

CONCLUSIONS

Based on the scoping review, focus groups and interviews with direct and indirect stakeholders, it appears that there is sufficient support for ESP in the Netherlands. This study provides a clear presentation of how ESP can be conceptualized in primary care. A pilot focused on determining the feasibility of ESP in Dutch primary care will be the next step.

Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists

Purpose: The primary purpose of this study was to examine the inter-tester reliability and criterion validity of reduced acromiohumeral distance (AHD; <6 mm) visualized on plain radiographs in detecting rotator cuff (RC) pathology. The secondary objective was to examine the relationship between this radiographic feature and patient demographics and clinical examination. Method: This was a diagnostic study of patients seen in a tertiary care centre. Two advanced-practice physiotherapists measured AHD in two radiographic views. MRI was used as the gold standard. Results: A total of 150 consecutive patients (mean age 59 [SD 11] y, 57 women, 93 men) were included. AHD less than 6 millimetres was highly specific in both views for the presence of tear (99%), tear size (96%-98%), and fatty infiltration in the supraspinatus and infraspinatus muscles (93%-96%). The absence of AHD less than 6 millimetres was associated with a lack of advanced fatty infiltration in the supraspinatus and infraspinatus muscles (92%-100%). Sensitivity values were low for the presence and size of RC tear (21%-55%). We found a statistically significant positive association between the AHD categories and clinically observed muscle wasting and weakness of the RC muscles (p < 0.05). Conclusions: AHD less than 6 millimetres was reliably measured in plain radiographs and was strongly associated with important clinical and imaging features of advanced RC pathology; this may assist with clinical decision making by allowing judicious use of more costly investigations and referral for surgery.