A Multivariable Prediction Model for the Chronification of Non-traumatic Shoulder Pain: A Systematic Review

BACKGROUND

Shoulder pain is the third most common musculoskeletal complaint and many patients have an unfavorable outcome with long-term disability. Only 50% of all new episodes of shoulder pain show complete recovery within 6 months. Little is known about factors that contribute to chronicity of shoulder pain, although such information is needed for the management of patients with acute and sub-acute shoulder pain.

OBJECTIVE

To systematically review the literature for prognostic factors which are potential predictors for either recovery or chronification in patients with acute and sub-acute non-traumatic shoulder pain.

STUDY DESIGN

Systematic review.

SETTING

This systematic review examined all studies involving the prognosis of shoulder pain patients.

METHODS

This systematic review was reported following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two reviewers independently scored the methodological quality of the selected studies. Due to heterogeneity of studies, a best-evidence synthesis of the available prognostic factors was provided.

RESULTS

Nine studies met our inclusion criteria and were included in this systematic review. There is strong evidence that high scores on the Shoulder Pain and Disability Index (SPADI), high scores on shoulder pain severity, and a long duration of complaints are factors that contribute to the chronification of shoulder pain. Moderate evidence was found supportive for other prognostic factors that enhance chronification, like being male, being over 55 years of age, having poor general health, having a gradual onset of complaints, a large amount of sick leave, the perception of high job demand, the perception of low social support, and the amount of visits to a health care professional. Also moderate evidence exists regarding factors that contributed to a reduced possibility of chronification: an active treatment policy and not taking medication on regular basis.

LIMITATIONS

The large variability in definitions of shoulder pain, and patient selection bias. In addition, there is a paucity of strong longitudinal prospective studies.

CONCLUSION

This systematic review found evidence that high scores on the SPADI questionnaire, more shoulder pain, and a longer duration of complaints are associated with chronification of shoulder pain. In order to reduce chronification, clinicians can use the International Classification of Functioning based model presented here that could aid their decision-making.

Tetrahydro-pyrimido-indoles as selective LIMK inhibitors: synthesis, selectivity profiling and structure–activity studies

Extensive structure–activity studies on three different modification sites resulted in a series of LIM kinase inhibitors, containing a novel tricyclic hinge-binding motif based on the pyrrolopyrimidine scaffold.

Effect of an education and activation programme on functional limitations and patient-perceived recovery in acute and sub-acute shoulder complaints - a randomised clinical trial

BACKGROUND

The education and activation programme (EAP) aims at coping with psychosocial determinants to prevent the development of chronic shoulder complaints (SCs). The effect of the EAP on functional limitations and patient-perceived recovery after 6 and 26 weeks is evaluated in a randomised clinical trial.

METHODS

Patients with SCs present at rest or elicited by movement and lasting no longer than 3 months were allocated at random to either EAP as an addition to usual care (UC), or to UC only. Measurements were taken at baseline and after 6 and 26 weeks and were analysed by means of multilevel analysis for the group effect. EAP was administered by GPs or by an ambulant therapist (CDB). Patients in the UC group were given UC by their own GP.

RESULTS

Multilevel analysis failed to show a significant effect of the EAP on either functional limitations or patient-perceived recovery. Analysis showed coincidentally a relation between catastrophising at baseline and functional limitations.

CONCLUSION

The EAP has no significant effect on the outcome of SCs after 6 and 26 weeks. The relation between catastrophising at baseline and functional limitations suggests that an intervention focusing specifically on catastrophising may be more successful in reducing functional limitations in the long term. Further research is however needed to evaluate the effect of catastrophising at baseline on the course of SCs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71777817.

Cost-effectiveness of an education and activation program for patients with acute and subacute shoulder complaints compared to usual care

OBJECTIVES

Shoulder complaints (SCs) constitute the second largest group of musculoskeletal disorders after low back pain. The economic burden in terms of costs of healthcare use and costs due to work absenteeism underlines the need for a cost-effectiveness analysis of the interventions involved. The education and activation program (EAP) is a newly developed early intervention to prevent the development of chronic SCs. A cost-effectiveness analysis should provide more information on the effect of an EAP on total costs related to SCs.

METHODS

We conducted a cost-effectiveness analysis alongside a randomized clinical trial comparing the effectiveness of the EAP in addition to usual care (EAP group) with that of usual care alone (UC group) in terms of preventing chronicity in patients with acute SCs. The aim of the cost-effectiveness analysis was to compare the observed difference in costs with the clinical effectiveness (i.e., patient-perceived recovery after 26 weeks), using bootstraps.

RESULTS

The comparison of total costs between treatment groups showed no significant (p = .077) difference after 26 weeks. The majority (82 percent) of the cost-effect pairs after bootstrap analysis were located in the northeast quadrant, suggesting more effect but at higher costs.

CONCLUSIONS

In view of the clinical relevance of the clinical outcomes and the considerable costs needed to achieve this, it can be concluded that the EAP is currently not cost-effective.

General practitioners apply the usual care for shoulder complaints better than expected--analysis of videotaped consultations

Background

The education and activation program (EAP) is a newly developed intervention to prevent the development of chronic shoulder complaints (SCs). Trained general practitioners (GPs) administer the EAP. The EAP addresses inadequate cognitions and maladaptive behavior related to the SCs. The effect of the EAP is evaluated in a randomized clinical trial.

The aim of the present study is to use videotaped consultations to study (1) the performance of trained GPs administering the EAP and (2) the presence of key features of the EAP already embedded in usual care (UC).

Methods

Five trained GPs were videotaped while treating a standardized patient with EAP. Additionally, five GPs administering UC were videotaped. Two blinded observers evaluated the videotapes in relation to key features of the EAP which were scored on the EAP checklist.

Results

The mean total score on the EAP checklist was 4.7 (SD = 2.9) for the UC group and 7.1 (SD = 2.1) for the EAP group. Neither group reached a score higher than 8, which was considered to reflect an acceptable number of key EAP features.

Conclusion

Our comparison of the presence of key features of EAP shows that the UC and EAP groups differed less than was expected. GPs in the UC group performed above expectation, with a mean total score of 4.7. Moreover, the low number of key features present in the EAP group may very well have led to a reduced effectiveness of the EAP. The results of this study can be used to optimize the training of GPs using the EAP.

Evaluation of an education and activation programme to prevent chronic shoulder complaints: design of an RCT [ISRCTN71777817]

BACKGROUND

About half of all newly presented episodes of shoulder complaints (SC) in general practice are reported to last for at least six months. Early interventions aimed at the psychological and social determinants of SC are not common in general practice, although such interventions might prevent the development of chronic SC. The Education and Activation Programme (EAP) consists of an educational part and a time-contingent activation part. The aim of the EAP is to provide patients with the proper cognitions by means of education, and to stimulate adequate behaviour through advice on activities of daily living.

DESIGN

The article describes the design of a randomised clinical trial (RCT) to evaluate the effectiveness and cost-effectiveness of an EAP in addition to usual care, compared to usual care only, in the prevention of chronic SC after six months. It also describes the analysis of the cost and effect balance. Patients suffering from SC for less than three months are recruited in general practice and through open recruitment. A trained general practitioner or a trained therapist administers the EAP.Primary outcome measures are patient-perceived recovery, measured by self-assessment on a seven-point scale, and functional limitations in activities of daily living. Questionnaires are used to study baseline measures, prognostic measures, process measures and outcome measures.

DISCUSSION

The inclusion of patients in the study lasted until December 31st 2003. Data collection is to end in June 2004.

Remediation of fine fractions of dredged sediments by flotation

In the Netherlands, large quantities of contaminated dredged sludge have to be deposited or treated in the near future. Because of the large amounts of small particles involved, successful treatment is difficult. In this study a new flotation method on laboratory scale was used as an alternative remediation technique. Dissolved air was used to create small bubbles. Tests were performed with the finest fractions of sediments of Overschie (Rotterdam) and Petrol Harbor (Amsterdam) sludges contaminated with Polycyclic Aromatic Hydrocarbons (PAH). Several agents and conditions were tested with respect to the flotation efficiency. For Overschie sludge the best results were obtained without collector and SDS as frother. The PAH concentration in the Froth was up to 8 times higher than that in the non-floating fractions. The collected amount of dry matter in the froth was around 13%. With a two step flotation, the PAH concentration of the non-floating "clean" fraction was reduced from 240 mg (kg d m(-1)) to 99 mg (kg d m(-1)). For Petrol Harbor sludge the best results were obtained with the alcohol-based frothers Aerofroth and Montanol. The flotation was less selective than with Overschie sediment. Around 50%. solids were collected in the froth and the PAH concentration in the Froth was around 2 times higher than in the Settled fraction and 3-5 times higher than in the fraction Remains.