Radiographic findings in patients suspected of subacromial impingement syndrome: prevalence and reliability

OBJECTIVE

Aims were to (i) report prevalence and (ii) evaluate reliability of the radiographic findings in examinations of patients suspected of subacromial impingement syndrome (SIS), performed before a patient's first consultation at orthopaedic department.

MATERIALS AND METHODS

This cross-sectional study examined radiographs from 850 patients, age 18 to 63 years, referred to orthopaedic clinic on suspicion of SIS. Prevalence (%) of radiographic findings were registered. Inter- and intrarater reliability was analysed using expected and observed agreement (%), kappa coefficients, Bland-Altman plots, or intraclass coefficients.

RESULTS

A total of 850 patients with a mean age of 48.2 years (SD = 8.8) were included. Prevalence of the radiographic findings was as follows: calcification 24.4%, Bigliani type III (hooked) acromion 15.8%, lateral/medial acromial spurs 11.1%/6.6%, acromioclavicular osteoarthritis 12.0%, and Bankart/Hill-Sachs lesions 7.1%. Inter- and intrarater Kappa values for most radiographic findings ranged between 0.40 and 0.89; highest values for the presence of calcification (0.85 and 0.89) and acromion type (0.63 and 0.66). The inter- and intrarater intraclass coefficients ranged between 0.41 and 0.83; highest values for acromial tilt (0.79 and 0.83) and calcification area (0.69 and 0.81).

CONCLUSION

Calcification, Bigliani type III (hooked) acromion, and acromioclavicular osteoarthritis were prevalent findings among patients seen in orthopaedic departments on suspicion of SIS. Spurs and Bankart/Hill-Sachs lesions were less common. Optimal reliabilities were found for the presence of calcification, calcification area, and acromial tilt. Calcification qualities, acromion type, lateral spur, and acromioclavicular osteoarthritis showed suboptimal reliabilities. Newer architectural measures (acromion index and lateral acromial angle) performed well with respect to reliability.

Shoulder function and work disability after decompression surgery for subacromial impingement syndrome: a randomised controlled trial of physiotherapy exercises and occupational medical assistance

BACKGROUND

Surgery for subacromial impingement syndrome is often performed in working age and postoperative physiotherapy exercises are widely used to help restore function. A recent Danish study showed that 10% of a nationwide cohort of patients retired prematurely within two years after surgery. Few studies have compared effects of different postoperative exercise programmes on shoulder function, and no studies have evaluated workplace-oriented interventions to reduce postoperative work disability. This study aims to evaluate the effectiveness of physiotherapy exercises and occupational medical assistance compared with usual care in improving shoulder function and reducing postoperative work disability after arthroscopic subacromial decompression.

METHODS/DESIGN

The study is a mainly pragmatic multicentre randomised controlled trial. The trial is embedded in a cohort study of shoulder patients referred to public departments of orthopaedic surgery in Central Denmark Region. Patients aged ≥18-≤63 years, who still have shoulder symptoms 8-12 weeks after surgery, constitute the study population. Around 130 participants are allocated to: 1) physiotherapy exercises, 2) occupational medical assistance, 3) physiotherapy exercises and occupational medical assistance, and 4) usual care. Intervention manuals allow individual tailoring. Primary outcome measures include Oxford Shoulder Score and sickness absence due to symptoms from the operated shoulder. Randomisation is computerised with allocation concealment by randomly permuted block sizes. Statistical analyses will primarily be performed according to the intention-to-treat principle.

DISCUSSION

The paper presents the rationale, design, methods, and operational aspects of the Shoulder Intervention Project (SIP). SIP evaluates a new rehabilitation approach, where physiotherapy and occupational interventions are provided in continuity of surgical episodes of care. If successful, the project may serve as a model for rehabilitation of surgical shoulder patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55768749.

Cross-cultural adaption and measurement properties of the Danish version of the Shoulder Pain and Disability Index

OBJECTIVE

To cross-culturally adapt the Danish version of the Shoulder Pain and Disability Index and to evaluate its measurement properties in terms of reliability and known-group validity.

DESIGN

Test-retest study.

SETTING

Outpatient Clinic of the Department of Orthopaedic Surgery, Regional Hospital Herning, Denmark.

SUBJECTS

Consecutive shoulder patients referred to an outpatient clinic.

METHODS

The Shoulder Pain and Disability Index was translated from English into Danish according to international guidelines. The questionnaire was posted to patients one to two weeks before their scheduled clinical examination and repeated on the day of the examination.

RESULTS

A total of 65 patients with a variety of shoulder diagnoses were included in the study. No significant differences were found in scores between the first and the second questionnaire. The minimal detectable change was estimated to 19.4 points, and the intraclass correlation coefficient was 0.88 (95% confidence interval 0.83 to 0.94). Internal consistency measured by Cronbach's alpha was 0.94. The questionnaire was found to discriminate well between currently working and non-working patients.

CONCLUSION

The Shoulder Pain and Disability Index provides a sensitive and reliable tool to assess pain and disability in Danish-speaking orthopaedic shoulder patients.

The significance of health anxiety and somatization in care-seeking for back and upper extremity pain

BACKGROUND

Patients with musculoskeletal pain account for a large number of consultations in primary care. Improving our understanding of factors that make patients seek care could be of interest in decision making and prevention in the health care system.

OBJECTIVES

Our objectives were to examine if health anxiety, somatization and fear-avoidance beliefs were of importance for care-seeking with either back pain or upper extremity pain and to look at possible differences between the two groups.

METHODS

This is a prospective study with a baseline questionnaire and 18 months follow-up. Using the International Classification for Primary Care (ICPC), we identified care-seekers with either back pain or upper extremity pain among the potential patients of eight GPs. For analysis, we used Cox proportional hazards regression analysis. Analysis was stratified by gender.

RESULTS

We found that previous regional pain was a strong predictor of care-seeking. Somatization was associated with seeking care for back pain. Health anxiety was a predictor among women suffering from back pain. Only previous pain was a predictor of care-seeking for upper extremity pain.

CONCLUSION

The study implies that prevention of back pain and upper extremity pain requires different strategies and that gender and health anxieties should be taken into account.

Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4–8‐years' follow‐up in a prospective, randomized study

OBJECTIVES

To compare the prognosis of subacromial impingement (SAI) stage II treated conservatively or with subacromial decompression.

METHODS

A follow-up study after 4-8 years in a randomized controlled trial (RCT) with 90 adult cases with SAI treated in a Danish hospital from 1996 to 2000 with graded physiotherapy and exercises or arthroscopic subacromial decompression. Outcomes were proportion of time per year with income transfers (indexed 0-1), including total transfers (marginalization), sick leave and disability pension obtained from the registry at the Ministry of Work. Self-reported function, working capability, employment status and global improvement were obtained by questionnaire in September 2004. The main outcomes are given as differences in development from baseline.

RESULTS

Seventy-nine (88%) responded to the questionnaire and registry data were obtained from 81. After 1 year the marginalization index increased by 0.45 [95% confidence interval (CI) 0.35-0.56] for surgery and 0.25 (0.16-0.34) for physiotherapy. Cases undergoing surgery also tended to have more sick payments during the first year, but the difference was not significant. Four years after inclusion, changes in indices did not differ between treatment groups. Self-reported outcomes after 4-8 years did not differ between treatment groups.

CONCLUSION

The results of surgical decompression were equal to those of conservative treatment, and the surgery group had more income transferrals during the first year of follow-up.

Reduction of pain-related disability in working populations: a randomized intervention study of the effects of an educational booklet addressing psychosocial risk factors and screening workplaces for physical health hazards

STUDY DESIGN

Cluster randomized controlled trial with 6 and 8 quarters of follow-up.

OBJECTIVE

To test the effects of giving evidence-based information addressing psychosocial risk factors for pain-related disability and of screening workplaces for physical health hazards at work on reducing new episodes and duration of pain-related and general absence taking.

SUMMARY OF BACKGROUND DATA

The "flag strategy" for handling low back pain problems is recommended in many Western countries but, so far, randomized intervention studies addressing psychosocial risk factors for disability related to low back pain show mixed results.

METHODS

We followed employees from 39 different work sites in western Denmark, who had received interventions consisting of either a carefully prepared booklet providing evidence-based information on common musculoskeletal pain problems alone or in combination with systematic workplace screening for physical work hazards. Absence due to pain for at least 7 days and the cumulative numbers of absence days were the main outcome measures. General absence taking was analyzed, too. Company registrations of sickness absence in combination with self-report on the cause of a given absence spell was used to inform absence spells.

RESULTS

A total of 3808 of 4006 eligible employees provided information. Among 1063 participants in the control arm, 1458 in the information arm, and 1287 in the information and workplace screening arm, 4.6%, 6.9%, and 4.6%, respectively, experienced pain-related absence, and 27.8%, 27.2%, and 24.0%, respectively, experienced general absence taking during follow-up. No positive effect on the risk of the 2 measures of absence or on the cumulative duration of absence among cases was seen.

CONCLUSION

Results did not support population-based interventions addressing psychosocial risk factors for pain-related disability alone or in combination with workplace screening as effective in reducing the risk of pain-related absence taking or the duration of absence.

Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up

OBJECTIVES

To compare the effect of graded physiotherapeutic training of the rotator cuff versus arthroscopic subacromial decompression in patients with subacromial impingement.

METHODS

Randomised controlled trial with 12 months' follow up in a hospital setting. Ninety consecutive patients aged 18 to 55 years were enrolled. Symptom duration was between six months and three years. All fulfilled a set of diagnostic criteria for rotator cuff disease, including a positive impingement sign. Patients were randomised either to arthroscopic subacromial decompression, or to physiotherapy with exercises aiming at strengthening the stabilisers and decompressors of the shoulder. Outcome was shoulder function as measured by the Constant score and a pain and dysfunction score. "Intention to treat" analysis was used, with comparison of means and control of confounding variables by general equation estimation analysis.

RESULTS

Of 90 patients enrolled, 84 completed follow up (41 in the surgery group, 43 in the training group). The mean Constant score at baseline was 34.8 in the training group and 33.7 in the surgery group. After 12 months the mean scores improved to 57.0 and 52.7, respectively, the difference being non-significant. No group differences in mean pain and dysfunction score improvement were found.

CONCLUSIONS

Surgical treatment of rotator cuff syndrome with subacromial impingement was not superior to physiotherapy with training. Further studies are needed to qualify treatment choice decisions, and it is recommended that samples are stratified according to disability level.

Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice

OBJECTIVES

To determine whether minimal intervention by occupational specialists involving information about the disorder, encouragement to stay active and instruction in graded self-performed exercises could enhance the prognosis of lateral epicondylitis compared with the treatment usually given in general practice, to quantify workplace factors associated with the prognosis, and to consider treatments given in general practice.

METHODS

A randomized controlled trial was performed in a cohort of 266 consecutive new cases of lateral epicondylitis diagnosed in general practice. Workplace factors were assessed with questionnaires at the time of inclusion, and patients completed follow-ups at 3, 6 and 12 months. Status at 1 yr was assessed as overall improvement and pain reduction compared with the time of diagnosis. General practitioners (GPs) registered the treatments given for both cases and controls during follow-up. Numbers of contacts with GPs and physiotherapists were obtained from the National Health Insurance registry. Prognostic factors were analysed by multiple logistic regression analysis.

RESULTS

After 1 yr, 83% of cases showed improvement in the condition, but the intervention was found to have had no advantage. Poor overall improvement was associated with employment in manual jobs [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.0-8.7], a high level of physical strain at work (OR 8.5, CI 1.0-74.7) and a high level of pain at baseline (OR 2.3, CI 1.0-5.3). Pain reduction less than 50% was associated with manual jobs (OR 2.3, CI 1.1-5.1), high physical strain at work (OR 3.6, CI 1.0-12.9), high baseline distress (OR 1.9, CI 1.0-4.0) and tennis elbow on the dominant side (OR 3.1, CI 1.4-6.8). The intervention group received less treatment and fewer treatment modalities, but the intervention was not followed by a reduction in the number of visits to GPs and physiotherapist clinics during 12 months of follow-up.

CONCLUSIONS

Poor prognosis at 1 yr of follow-up for lateral epicondylitis was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given/chosen and prognosis. This may have implications for the future management of lateral epicondylitis in terms of a greater focus on interaction with the workplace regarding job modification to reduce physical demands during recovery.

Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study

AIMS

To assess the importance of physical and psychosocial risk factors for lateral epicondylitis (tennis elbow).

METHODS

Case-referent study of 267 new cases of tennis elbow and 388 referents from the background population enrolled from general practices in Ringkjoebing County, Denmark.

RESULTS

Manual job tasks were associated with tennis elbow (odds ratio (OR) 3.1, 95% confidence interval (CI) 1.9 to 5.1). The self reported physical risk factors "posture" and "forceful work" were related to tennis elbow. Among women, work involving performing repeated movements of the arms was related to tennis elbow (OR 3.7, CI 1.7 to 8.3). Among men, work with precision demanding movements was related to tennis elbow (OR 5.2, CI 1.5 to 17.9). Among both males and females, the results for work with hand held vibrating tools were inconsistent, partly because of few exposed subjects. A physical strain index was established based on posture, repetition, and force. The adjusted ORs for tennis elbow at low, medium, and high strain were 1.4 (CI 0.8 to 2.7), 2.0 (CI 1.1 to 3.7), and 4.4 (CI 2.3 to 8.7). Low social support at work, adjusted for physical strain, was a risk factor among women (OR 2.4, CI 1.3 to 4.6).

CONCLUSION

Results indicate that being a new case of tennis elbow is associated with non-neutral postures of hands and arms, use of heavy hand held tools, and high physical strain measured as a combination of forceful work, non-neutral posture of hands and arms, and repetition. Furthermore, tennis elbow among women was associated with low social support at work. The results for precision demanding movements and for vibration were less consistent.

[Epoxy in occupational environment--an old acquaintance in a new dress]

This article describes a cluster of epoxy related contact dermatitis in a glassfibre reinforcement plant, using mostly preimpregnated epoxylaminate (Pre-Preg), but also fluid epoxy-products. An occupational medical and dermatological examination revealed nine of 26 cases as allergic contact eczema, 14 as toxic epoxyrelated eczema and three cases of other non-occupationally related skin diseases. The plant uses seven different epoxyresins with 15 epoxyhardeners. Preventive measures were gradually improved, but even then it was difficult to rule the production into safe procedures with this potent allergen used in large scale production of windmill wings.