Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial

BACKGROUND

Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated.

METHODS

In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial.

RESULTS

The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0-100 scale. T-tests did not demonstrate any significant between-group differences in range of motion.

CONCLUSION

This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone.

TRIAL REGISTRATION

The study is registered in Current Controlled Trials with the registration number ISRCTN90567697.

Responsiveness of the shoulder pain and disability index in patients with adhesive capsulitis

BACKGROUND

Instruments designed to measure the subjective impact of painful shoulder conditions have become essential in shoulder research. The Shoulder Pain and Disability Index (SPADI) is one of the most extensively used scales of this type. The objective of this study was to investigate reproducibility and responsiveness of the SPADI in patients with adhesive capsulitis.

METHODS

SPADI test-retest reproducibility was estimated by the "intraclass correlation coefficient" (ICC) and the "smallest detectable difference" (SDD). Responsiveness was assessed by exploring baseline and follow-up data recorded in a recently reported clinical trial regarding hydrodilatation and corticosteroid injections in 76 patients with adhesive capsulitis. "Standardized response mean" (SRM) and "reliable change proportion" (RCP) for SPADI were compared with corresponding figures for shoulder range-of-motion (ROM). The relationship between SPADI and ROM change scores was investigated through correlation and linear regression analyses.

RESULTS

Results for test-retest reproducibility indicated a smallest detectable difference of 17 points on the 0-100 scale, and an intraclass correlation coefficient of 0.89. The SPADI was generally more responsive than ROM. Weak to moderately strong associations were identified between SPADI and ROM change scores. According to the regression model, the three variables baseline SPADI, baseline active ROM and change in active ROM together explained 60% of the variance in SPADI improvement.

CONCLUSION

This study supports the use of SPADI as an outcome measure in similar settings.

Hand, shoulder and back stiffness in long-term type 1 diabetes; cross-sectional association with skin collagen advanced glycation end-products. The Dialong study

AIMS

We aimed to: (i) estimate the prevalence of Dupuytren's disease, trigger finger, carpal tunnel syndrome and frozen shoulder; (ii) assess stiffness of the hand, shoulder and back; and (iii) explore the association of joint stiffness with both long-term HbA_1c and collagen advanced glycation end-products (AGEs) in long-term type 1 diabetes mellitus (T1DM).

METHODS

Patients with T1DM from 1970 or earlier attending a specialized diabetes center were included in this cross-sectional controlled study. We collected HbA₁/HbA_1c measurements from 1980 to 2015 and data on hand and shoulder diagnoses and joint stiffness through interviews, charts, and standardized examination. Skin biopsies were analyzed for collagen AGEs by liquid chromatography-mass spectrometry.

RESULTS

Lifetime prevalence of hand and shoulder diagnoses in the diabetes group (n=102) ranged from 37%-76% (frozen shoulder) versus 11%-15% in controls (n=73) (p<0.001). There was an association between joint stiffness and long-term HbA_1c (odds ratio 2.01 [95% CI 1.10-3.7]) and the AGEs methyl-glyoxal-lysine-dimer (odds ratio 1.68 [95% CI 1.03-2.73]) and pentosidine (odds ratio 1.81 [95% CI 1.04-3.16]).

CONCLUSIONS

Patients with T1DM >45years had a very high prevalence of hand and shoulder diagnoses versus controls. Joint stiffness was associated with collagen AGEs. However, joint biopsies and prospective studies must explore this association further.

Range of shoulder motion in patients with adhesive capsulitis; intra-tester reproducibility is acceptable for group comparisons

BACKGROUND

Measurements of range of motion play a key role in shoulder research. The purpose of this study is to investigate intra-observer reproducibility of measurements of active and passive range of motion in patients with adhesive capsulitis.

METHODS

The study was carried out in a population consisting of 32 patients with clinical signs of adhesive capsulitis. A specified measurement protocol was used, and range of motion in affected and non-affected shoulders was measured twice for each patient with a one-week interval.

RESULTS

For most of the investigated individual movements, test-retest differences in range of motion score of more than approximately 15 degrees are not likely to occur as a result of measurement error only. Point-estimates for the intraclass correlation coefficient ranged from 0.61 to 0.93.

CONCLUSION

Range of motion of patients with adhesive capsulitis can be measured with acceptable reproducibility in settings where groups are compared. Scores for individual patients should be interpreted with caution.

Very High Prevalence of Frozen Shoulder in Patients With Type 1 Diabetes of ≥45 Years' Duration: The Dialong Shoulder Study

OBJECTIVES

To compare the prevalence of shoulder disorders and self-reported shoulder disability in patients with long-term type 1 diabetes mellitus and diabetes-free subjects; and to explore the association between the long-term glycemic burden and shoulder disability in the diabetes group.

DESIGN

Cross-sectional study of shoulder diagnoses with 30 years' historical data on glycemic burden in patients with diabetes.

SETTING

Diabetics center and a university hospital.

PARTICIPANTS

Subjects attending the Norwegian Diabetics Center in 2015 with type 1 diabetes since 1970 or earlier were eligible (N=136). One hundred and five patients were included, and 102 (50% women; mean age, 61.9y) completed the study together with 73 diabetes-free subjects (55% women; mean age, 62.5y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Shoulder diagnoses decided through clinical examination according to scientific diagnostic criteria.

RESULTS

Frozen shoulder was diagnosed in 60 (59%) patients with diabetes and 0 diabetes-free subjects, with a lifetime prevalence of 76% in the diabetes group versus 14% in the diabetes-free subjects. Patients with diabetes had higher disability and higher mean QuickDASH scores (23.0±19.9) than diabetes-free subjects (8.9±12.0), with a mean difference of -14.2 (95% confidence interval, -19.3 to -9.0) points (P<.001). We found an association between chronic hyperglycemia and QuickDASH scores, with a 6.16-point increase in QuickDASH scores per unit increase in glycated hemoglobin A_1c (HbA_1c) (P=.014).

CONCLUSIONS

The point prevalence of frozen shoulder in patients with long-lasting type 1 diabetes was 59%, and the lifetime prevalence was 76%. The diabetes group had more shoulder disability than diabetes-free subjects. The historical HbA_1c level was associated with increased shoulder disability.

Factor structure of the Shoulder Pain and Disability Index in patients with adhesive capsulitis

BACKGROUND

The Shoulder Pain and Disability Index (SPADI) is a self-administered questionnaire that aims to measure pain and disability associated with shoulder disease. It consists of a pain section and a disability section with 13 items being responded to on visual analogue scales. Few researchers have investigated SPADI validity in specified diagnostic groups, although the selection of an evaluative instrument should be based on evidence of validity in the target patient group. The aim of the present study was to investigate factor structure of the SPADI in a study population of patients with adhesive capsulitis.

METHODS

The questionnaire was administered to 191 patients with adhesive capsulitis. Descriptive statistics for items and a comparison of scores for the two subscales were produced. Internal consistency was analyzed by use of the Cronbach alpha and a principal components analysis with varimax rotation was conducted. Study design was cross-sectional.

RESULTS

Two factors were extracted, but the factor structure failed to support the original division of items into separate pain and disability sections.

CONCLUSION

We found minimal evidence to justify the use of separate subscales for pain and disability. It is our impression that the SPADI should be viewed as essentially unidimensional in patients with adhesive capsulitis.

Effectiveness of Isolated Hip Exercise, Knee Exercise, or Free Physical Activity for Patellofemoral Pain: A Randomized Controlled Trial

BACKGROUND

Exercise for patellofemoral pain (PFP) is traditionally knee focused, targeting quadriceps muscles. In recent years, hip-focused exercise has gained popularity. Patient education is likely an important factor but is underresearched.

PURPOSE

To compare 3 treatment methods for PFP, each combined with patient education: hip-focused exercise, knee-focused exercise, or free physical activity.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A single-blind randomized controlled trial was performed with 112 patients who were 16 to 40 years old (mean, 27.6 years) and had a symptom duration >3 months (mean, 39 months) with a clinical diagnosis of PFP and no radiograph or magnetic resonance evidence of other pathology. Patients were randomized to a 6-week intervention consisting of patient education combined with isolated hip-focused exercise (n = 39), traditional knee-focused exercise (n = 37), or free physical activity (n = 36). The primary outcome was Anterior Knee Pain Scale (0-100) at 3 months. Secondary outcomes were visual analog scale for pain, Tampa Scale for Kinesiophobia, Knee Self-efficacy Scale, EuroQol, step-down, and isometric strength.

RESULTS

There were no between-group differences in any primary or secondary outcomes at 3 months except for hip abduction strength and knee extension strength. Between-group differences at 3 months for Anterior Knee Pain Scale were as follows: knee versus control, 0.2 (95% CI, -5.5 to 6.0); hip versus control, 1.0 (95% CI, -4.6 to 6.6); and hip versus knee, 0.8 (95% CI, -4.8 to 6.4). The whole cohort of patients improved for all outcomes at 3 months except for knee extension strength.

CONCLUSION

The authors found no difference in short-term effectiveness in combining patient education with knee-focused exercise, hip-focused exercise, or free training for patients with PFP.

REGISTRATION

NCT02114294 (ClinicalTrials.gov identifier).

Effectiveness of Radial Extracorporeal Shock Wave Therapy (rESWT) When Combined With Supervised Exercises in Patients With Subacromial Shoulder Pain: A Double-Masked, Randomized, Sham-Controlled Trial

BACKGROUND

Subacromial shoulder pain is a common complaint, and radial extracorporeal shock wave therapy (rESWT) is increasingly used to treat this condition. Although many therapists use rESWT in combination with supervised exercises, no studies have evaluated the additional effect of rESWT with supervised exercises for subacromial shoulder pain.

PURPOSE

To assess whether rESWT is more effective than sham rESWT when combined with supervised exercises for improving pain and function in patients with subacromial shoulder pain.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients between 25 and 70 years of age with subacromial shoulder pain with and without calcification in the rotator cuff lasting at least 3 months were assessed for eligibility; 143 patients were recruited. Participants were allocated (1:1) by computer-generated randomization in blocks of 20 to receive either rESWT or sham rESWT in addition to supervised exercises. The rESWT and sham rESWT were performed once a week with additional supervised exercises once a week for the first 4 weeks. The following 8 weeks, the patients received supervised exercises twice a week. The primary outcome was change in the Shoulder Pain and Disability Index (SPADI) after 24 weeks. Patients and outcome assessors were masked to group assignment.

RESULTS

At 24 weeks, participants in both the sham group and the rESWT group had improved ( P < .001) in SPADI score compared with baseline (-23.9 points [SD, 23.8 points] and -23.3 points [SD, 25.0 points], respectively), but there were no differences between the groups (mean difference 0.7; 95% CI, -6.9 to 8.3; P = .76). Prespecified subgroup analysis of patients with calcification in rotator cuff showed that the rESWT group had a greater improvement in SPADI score after 24 weeks (mean difference -12.8; 95% CI, -24.8 to -0.8; P = .018).

CONCLUSION

Radial ESWT offered no additional benefit to supervised exercises in the treatment of subacromial shoulder pain after 24 weeks, except in the subgroup of patients with calcification in the rotator cuff. Registration: NCT01441830 ( ClinicalTrials.gov identifier).

Patellofemoral pain: One year results of a randomized trial comparing hip exercise, knee exercise, or free activity

OBJECTIVE

Extended follow-up of a randomized trial comparing hip-focused exercise, knee-focused exercise, and free physical activity in patellofemoral pain (PFP).

METHODS

A single-blind randomized controlled trial included 112 patients aged 16-40 years (mean 27.6 years) with a clinical diagnosis of PFP ≥3 months (mean 39 months) and pain ≥3/10 on a Visual Analog Scale. Patients were randomized to a 6-week exercise-based intervention consisting of either isolated hip-focused exercises (n = 39), traditional knee-focused exercise (n = 37), or free physical activity (n = 36). All patients received the same patient education. The primary outcome measure was the Anterior Knee Pain Scale (AKPS, 0-100). Secondary outcomes were usual and worst pain, Tampa Scale of Kinesiophobia, Knee Self-Efficacy Score, Euro-Qol (EQ-5D-5L), step-down test, and isometric strength. Blinded observers assessed outcomes at baseline, 3, and 12 months. The study was designed to detect a difference in AKPS >10 at 12 months.

RESULTS

After 1 year, there were no significant between-group differences in any primary or secondary outcomes. Between-group differences for AKPS were as follows: knee versus free physical activity -4.3 (95% CI -12.3 to 3.7); hip versus free physical activity -1.1 (95% CI -8.9 to 6.7); and hip versus Knee 3.2 (95% CI -4.6 to 11.0). The cohort as a whole improved significantly at 3 and 12 months compared to baseline for all measures except for knee extension strength.

CONCLUSION

After 1 year, there was no difference in effectiveness of knee exercise, hip exercise, or free physical activity, when combined with patient education in PFP.

Shoulder MRI features with clinical correlations in subacromial pain syndrome: a cross-sectional and prognostic study

Background

Previous studies on shoulder patients have suggested that the prevalence of rotator cuff or bursa abnormalities are weakly related to symptoms and that similar findings are often found in asymptomatic persons. In addition, it is largely unknown whether structural changes identified by magnetic resonance imaging (MRI) affect outcome after treatment for shoulder pain. The purpose of this study was therefore to evaluate the presence of structural changes on MRI in patients with subacromial pain syndrome and to determine to what extent these changes are associated with symptoms and predict outcome after treatment (evaluated by the Shoulder Pain and Disability Index (SPADI)).

Methods

A prospective, observational assessment of a subset of shoulder patients who were included in a randomized study was performed. All participants had an MRI of the shoulder. An MRI total score for findings at the AC joint, subacromial bursa and rotator cuff was calculated. Multiple linear regression analysis was applied to examine the relationship between the MRI total score and the outcome measure at baseline and to examine to what extent the MRI total score was associated with the change in the SPADI score from baseline to the one year follow-up.

Results

There was a weak, inverse association between the SPADI score at baseline and the MRI total score (β = −3.1, with 95% CI −5.9 to −0.34; p = 0.03), i.e. the SPADI score was higher for patients with a lower MRI total score. There was an association between the change in the SPADI score from baseline to the one year follow-up and the MRI total score (β = 8.1, 95% CI -12.3 to −3.8; p < 0.001), with a poorer outcome for patients with a higher MRI total score. Both tendinosis (p = 0.01) and bursitis (p = 0.04) were associated with a poorer outcome after one year.

Conclusions

In this study, MRI findings were significantly associated with the change in the SPADI score from baseline and to one year follow-up, with a poorer outcome after treatment for the patients with higher MRI total score, tendinosis and bursitis on MRI.

Trial registration

Clinicaltrials.gov no NCT01441830. September 28, 2011.

Study protocol: a randomised controlled trial comparing the long term effects of isolated hip strengthening, quadriceps-based training and free physical activity for patellofemoral pain syndrome (anterior knee pain)

BACKGROUND

Patellofemoral pain syndrome (PFPS), also known as Anterior Knee Pain, is a common cause of recurrent or chronic knee pain. The etiology is considered to be multifactorial but is not completely understood. At the current time the leading theory is that pathomechanics in the patellofemoral joint leads to PFPS. Traditionally, conservative treatment has focused on improving strength and timing in the quadriceps muscles. In recent years, evidence has been accumulating to support the importance of hip control and strengthening in PFPS. Two recent studies have shown promising results for hip strengthening as an isolated treatment for PFPS. The aim of this randomised controlled trial (RCT) is to compare isolated hip strengthening to traditional quadriceps-based training and a control group with free physical activity.

METHODS/DESIGN

An observer-blinded RCT will be performed. We intend to include 150 patients aged 16-40 years, referred from primary care practitioners to the department of Physical Medicine and Rehabilitation in Kristiansand, Norway for PFPS with more than three months duration. Patients meeting the inclusion criteria will be randomised using opaque sequentially numbered sealed envelopes to one of three groups: isolated hip strengthening, quadriceps based training, or a control group (free physical activity). All groups will receive standardized information about PFPS formulated with the intention to minimize fear avoidance and encourage self-mastery of symptoms. Standardized exercises will be performed under supervision of a study physiotherapist once per week in addition to home training two times per week for a total of six weeks. The primary outcome measure will be the Anterior Knee Pain Score (AKPS) at three and 12 months. Secondary outcome measures will include Visual analogue scale (VAS) for pain, hip abductor and quadriceps strength, the generic EuroQol (EQ-5D), Hopkins Symptom Checklist (HSCL), Knee self-efficacy score and Tampa score for Kinesiophobia.

DISCUSSION

This trial will help to elucidate the role of hip and quadriceps strengthening in the treatment of PFPS. Information as to the role of anxiety and depression, kinesiophobia and self-efficacy will be collected, also as regards prognosis and response to exercise therapy.

TRIAL REGISTRATION

ClinicalTrials.gov reference: NCT02114294.

Identification of relevant International Classification of Functioning, Disability and Health categories in patients with shoulder pain: a cross-sectional study

OBJECTIVE

To identify the most common problems in patients with shoulder pain, using the International Classification of Functioning, Disability and Health (ICF) as a reference.

DESIGN

A cross-sectional study.

SUBJECTS

Outpatients at a hospital with shoulder pain lasting longer than 3 months.

METHODS

Patients were interviewed with an extended version of the ICF Checklist version 2.1a. Patients' problems in functioning, and the magnitude of the problem, were registered separately for each category. Categories identified as a problem in at least 5% of patients were reported. To describe the population, age, diagnosis, work participation and the Shoulder Pain and Disability Index (SPADI) were recorded.

RESULTS

A total of 165 patients with a mean age of 46.5 years (standard deviation 12.5) and a SPADI score of 47.4 (standard deviation 21.1) were included. Of the participants, 92.8% were either employed or students, 35.2% of whom were on sick leave. The primary result was the identification of 61 condition-specific second-level ICF categories: 19 in the body functions and structures component, 34 in activities and participation, and 8 in environmental factors.

CONCLUSION

The findings provide a comprehensive picture from the patient-perspective of the disability associated with shoulder pain. The findings may enhance multidisciplinary communication in clinical settings.

The reliability, validity, interpretability, and responsiveness of the Norwegian version of the Anterior Knee Pain Scale in patellofemoral pain

PURPOSE

To determine the reliability, validity, responsiveness, and interpretability of the Norwegian Anterior Knee Pain Scale (AKPS) in patients with patellofemoral pain (PFP).

METHODS

The AKPS was translated into Norwegian. One hundred and twelve patients with PFP participated in a randomized controlled trial. Fifty stable patients completed the AKPS at a one-week interval for test-retest reliability. Smallest detectable change (SDC) and floor/ceiling effects were evaluated. Validity and responsiveness were assessed using hypothesis testing for correlations with other scores and known-group validity. Minimal important change (MIC) and responsiveness were evaluated at three months.

RESULTS

Intraclass correlation coefficient (ICC_agreement) for sum score was 0.83. Smallest detectable change was 13. No floor/ceiling effects were found for total score, but ceiling effects were found on eight of 13 individual items. Hypothesis testing for construct validity and responsiveness was largely confirmed but correlations were moderate to low. The MIC was 11. Area under receiver operating characteristic curve was 0.66 (95% CI 0.56-0.77) indicating moderate responsiveness.

CONCLUSIONS

The Norwegian AKPS had comparable measurement properties to other versions, with acceptable reliability and construct validity. We found moderate responsiveness which may be related to ceiling effects on several items.Implications for rehabilitationThe Anterior Knee Pain Scale (AKPS) is a commonly used outcome measure in patellofemoral pain, having acceptable reliability and moderate responsiveness.A change in AKPS total score of 11 points would be considered important by the patient, although changes up to 13 points may be due to measurement error.The AKPS has limitations including ceiling effects on most individual items in this patient population, and low correlation between pain and AKPS that questions the validity of the score. A revision of the score should be considered.

Long term type 1 diabetes is associated with hand pain, disability and stiffness but not with structural hand osteoarthritis features - The Dialong hand study

OBJECTIVE

To explore whether having long-term type 1 diabetes (>45 years) is associated with a higher prevalence of radiographic hand OA, erosive hand OA and increased hand pain, disability and stiffness.

METHODS

In total N = 96 persons with type 1 diabetes diagnosed before 1970 were included (mean [SD] age: 62.2 [7.4], mean [SD] HbA1c: 7.43 [0.80] and N = 49 [51%] men). Regular measurements of their HbA1c were obtained till 2015. We included N = 69 healthy controls without any diabetes (mean [SD] age: 63.0 [7.0], mean [SD] HbA1c: 5.41 [0.32], N = 29 [42%] men). The groups were compared for radiographic hand OA (Kellgren-Lawrence grade ≥2 in ≥1 joint) and erosive hand OA (central erosions in ≥1 joint), Australian/Canadian index (AUSCAN) for hand pain, disability and stiffness using regression analyses adjusted for age, sex, educational level and waist circumference.

RESULTS

We found no associations between having long term type 1 diabetes and more prevalent radiographic hand OA (OR = 0.83, 95% CI = 0.38-1.81). We found a trend towards higher prevalence of erosive hand OA in diabetes patients (OR = 2.96, 95% CI = 0.82-10.64). Strong and consistent associations were observed between long term type 1 diabetes and increased hand pain (B = 2.78, 95% CI = 1.65-3.91), disability (B = 5.30, 95% CI = 3.48-7.12) and stiffness (B = 2.00, 95% CI = 1.33-2.67). These associations were particularly strong for women and participants below the median age of 61 years.

CONCLUSION

Long-term type 1 diabetes was not associated with radiographic hand OA, but was strongly associated with hand pain, disability and stiffness. The association between diabetes and erosive hand OA warrants further investigation.

Predictors of Pain, Function, and Change in Patellofemoral Pain

BACKGROUND

Identification of factors predictive of outcome and change is important to improve treatment for patellofemoral pain (PFP). Few studies have examined the predictive value of psychological factors in PFP, although they have been reported to be important predictors in other musculoskeletal pain conditions.

PURPOSE

To evaluate predictors of pain, function, and change 1 year after an exercise-based intervention in PFP.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In sum, 112 patients were recruited to a randomized controlled trial; 98 attended 1-year follow-up. There were no between-group differences in the trial; thus, the material was analyzed as 1 cohort. Nine baseline factors-sex, bilateral pain, worst pain, pain duration, Anterior Knee Pain Scale (AKPS), kinesiophobia, anxiety and depression, self-efficacy, and number of pain sites throughout the body-were investigated for their predictive ability on outcome at 1 year (AKPS, worst pain) and for change at 1 year (global change score, change in AKPS, and change in worst pain). Multivariable linear regression models with stepwise backward removal method were used to find predictors of poor outcome.

RESULTS

Number of pain sites at baseline was a significant predictor of worse outcome for AKPS (B = -2.7; 95% CI, -4.0 to -1.3; P < .01), worst pain (B = 0.5; 95% CI, 0.2-0.8; P < .01), global change (B = -0.8; 95% CI, -1.2 to -0.5; P < .01), change in AKPS (B = -2.7; 95% CI, -4.0 to -1.3; P < .01), and change in worst pain (B = 0.5, 95% CI, 0.2-0.8; P < .01) at 1 year. Baseline scores for AKPS and worst pain predicted respective 1-year levels and change scores (P < .01). Lower self-efficacy and male sex predicted less global change (P < .01). Longer pain duration predicted final score and change score for worst pain (P < .01). The predictive models had reasonable fit with adjusted R² from 0.22 to 0.35.

CONCLUSION

Higher number of pain sites throughout the body was a consistent predictor of poor outcome and less change at 1 year. Baseline levels for AKPS and worst pain predicted respective final scores and change scores.

REGISTRATION

NCT02114294 ( ClinicalTrials.gov identifier).

Patients with shoulder pain referred to specialist care; treatment, predictors of pain and disability, emotional distress, main symptoms and sick-leave: a cohort study with a six-months follow-up

Objectives

Recommendations for referral of patients with shoulder pain from primary to specialist care are mainly clinical. Several patients are referred without meeting these criteria for referral, whereas some are referred for a second opinion although surgery is not recommended. The aims of this study were to describe a shoulder pain cohort in specialist healthcare according to demographic data, clinical, and psychological factors; evaluate changes in pain and disability, distress and main symptoms from baseline to six-month follow-up; and to assess predictors of pain and disability, changes in the main symptoms and sick-leave at six-months. Results were compared to previous randomised trials conducted at the same clinic in patients with subacromial shoulder pain.

Methods

This prospective study included 167 patients from an outpatient clinic in specialist healthcare with shoulder pain for more than 6 weeks. Clinical (pain duration, intensity, pain sites), sociodemographic (age, gender, educational level, work status) and psychological variables (emotional distress (HSCL-10), fear of pain, screening of “yellow flags”, health-related quality of life) were collected. Shoulder pain and disability (SPADI-score) were assessed and the patients were asked about their outcome expectation and to predict their status of their shoulder problem the next month. They underwent a clinical interview, a clinical assessment of shoulder function and orthopaedic tests for diagnostic purposes. After six months they received a questionnaire with main variables.

Results

Of the 167 patients (55% women), 50% had symptoms for more than 12 months and 37 (22%) were on sick-leave. Characteristics were in general comparable to patients previously included in clinical trials at the same department. The SPADI-score was 46 (23) points. Mean emotional distress was within the normal range (1.7 (SD 0.6)). More than 80% had received treatment before, mainly physiotherapy in addition to the GPs treatment. One hundred and thirty-seven patients (82%) were re-referred to physiotherapy, 74 (44%) in the outpatient clinic specialist healthcare, and 63 (38%) in primary care. One hundred and eighteen (71%) answered the follow-up questionnaire. Mean change in SPADI-score was 10.5 points (95% CI (6.5–14.5)), and 29% of the patients improved more than the smallest detectable difference (SDD). The percentage sick-listed was 19.5%, and mean change in main symptoms (−9 to +9) was 3.4 (SD 3.9). The subgroup of patients receiving physiotherapy in outpatient specialist care did not show any significant change in the main variables. The prediction models suggested that a lower level of education, more fear of pain and a high baseline SPADI-score, predicted a higher SPADI-score at follow-up. A high baseline HSCL-10 score was the only significant predictor for a high HSCL-10 score. At follow-up, less pain at rest predicted more change in main symptoms and more yellow flags (a higher score on the Örebro screening test) predicted sick-leave.

Conclusions

Within the limitations of a cohort study, patients with persistent shoulder pain referred to an outpatient specialist clinic had similar baseline characteristics but shorter treatment duration, inferior clinical results and predictors somewhat different compared with previous clinical trials conducted at the same clinic. The study raises some questions about the effectiveness of the routines in daily clinical practice, the selection of patients, the treatment duration and content.

The prevalence of radiological glenohumeral osteoarthritis in long-term type 1 diabetes: the Dialong shoulder study

OBJECTIVES

This study compares the prevalence of radiological osteoarthritis (OA) in patients with type 1 diabetes mellitus (DM1) for > 45 years and controls, and explores the association with shoulder pain and glycaemic burden in patients with DM1.

METHOD

The Dialong study is a cross-sectional, observational study with 30 years of historical data on long-term glycaemic control. We included 102 patients with DM1 and 73 diabetes-free controls. Demographic data, worst shoulder pain last week [numeric rating scale (NRS) 0-10], pain on abduction at examination (NRS 0-10), and current and historical glycosylated haemoglobin (HbA_1c) levels were collected. Standardized shoulder X-rays were taken and interpreted for OA applying the Kellgren-Lawrence classification.

RESULTS

In the diabetes group (49% women), the mean ± sd duration of DM1 was 50.6 ± 4.8 years, mean 30 year HbA_1c 7.4%, and age 61.9 ± 7.1 years. The mean age of controls (57% women) was 62.6 ± 7.0 years. Radiological glenohumeral OA was found in 36 diabetes patients (35%) and 10 controls (14%) [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.6 to 7.5; p = 0.002]. Few persons had moderate and severe OA [6.9% vs 1.3%, OR 5.3 (95% Cl 0.6 to 44.1); p = 0.1]. Fifteen diabetes patients had painful OA versus two controls (adjusted OR 5.4, 95% CI 0.6 to 47.9; p = 0.13). There was no association between OA and long-term glycaemic burden (mean 30 year HbA_1c) in the diabetes group (p > 0.2).

CONCLUSIONS

Radiological glenohumeral OA was more common in patients with DM1 than in controls for mild, but not moderate and severe OA. The radiological findings were not associated with shoulder pain or long-term glycaemic burden.

Ultrasound guided lavage with corticosteroid injection versus sham lavage with and without corticosteroid injection for calcific tendinopathy of shoulder: randomised double blinded multi-arm study

OBJECTIVE

To compare treatment effects between ultrasound guided lavage with corticosteroid injection and sham lavage with and without corticosteroid injection in patients with calcific tendinopathy of the shoulder.

DESIGN

Pragmatic, three arm, parallel group, double blinded, sham controlled, randomised, superiority trial with repeated measurements over 24 months.

SETTING

Six hospitals in Norway and Sweden.

PARTICIPANTS

220 adults with calcific tendinopathy of the shoulder, persistent for at least three months.

INTERVENTIONS

Ultrasound guided deposit lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (lavage+steroid); sham lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (sham lavage+steroid); or sham lavage plus subacromial injection of 10 mL 1% lidocaine hydrochloride (sham). All patients received a physiotherapeutic treatment regimen consisting of four home exercises.

MAIN OUTCOME MEASURES

The primary outcome was the result on the 48 point scale (0=worst; 48=best) of the Oxford Shoulder Score (OSS) at four month follow-up. Secondary outcomes included measurements on the short form of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) and of pain intensity up to 24 months. The influence of the size of the deposit at baseline and of the persistence or disappearance of the deposit was investigated.

RESULTS

Data from 218 (99%) participants were included in the primary analysis. Differences between groups on the OSS at four months were not significant: lavage+steroid versus sham 0.2 (95% confidence interval -2.3 to 2.8; P=1.0); sham lavage+steroid versus sham 2.0 (-0.5 to 4.6; P=0.35); lavage+steroid versus sham lavage+steroid -1.8 (-4.3 to 0.7; P=0.47). After four months, 143 patients with insufficient treatment effect received supplementary treatment. At 24 months, none of the study procedures was superior to sham. No serious adverse events were reported.

CONCLUSIONS

This study found no benefit for ultrasound guided lavage with a corticosteroid injection or for sham lavage with a corticosteroid injection compared with sham treatment in patients with calcific rotator cuff tendinopathy of the shoulder.

TRIAL REGISTRATION

NCT02419040EudraCT 2015-002343-34; Ethical committee Norway 2015-002343-34; Ethical committee Sweden 2015/79-31; Clinicaltrials.gov NCT02419040.

CT-diskography, diskomanometry and MR imaging as predictors of the outcome of lumbar percutaneous automated nucleotomy

PURPOSE

This prospective study was performed to assess whether CT-diskography (CT-D), diskomanometry (DMM) including recording of the pain response, or the MR signal intensity of the disks are reliable predictors of the outcome of nucleotomy.

MATERIAL AND METHODS

Ninety-one patients, 44 females and 47 males aged 18-68 years (mean 37.4) treated at 99 disk levels were included. All had plain CT, MR imaging, CT-D and DMM performed prior to automated percutaneous nucleotomy with the Nucleotomy R system.

RESULTS

Sixty-nine (76%) of the patients responded well to treatment within 3 months. Due to recurrences, the success rate at 1 year was reduced to 65%. Except for better results following nucleotomy in patients with similar and identical pain as the presenting complaint provoked at diskography, no association was demonstrated between diskographic parameters, or loss of signal on MR, and the outcome. Better results were also seen in patients with a short history of disk disease, but not in patients with predominantly sciatica and focal hernias compared to those with predominantly low-back pain and diffuse posterior bulges.

CONCLUSION

The results do not justify routine use of diskography prior to nucleotomy in patients with pathologic disks demonstrated by noninvasive methods and localizing sciatic pain.

Clinical results after percutaneous automated lumbar nucleotomy. A follow-up study

This study was carried out in order to assess the clinical results after percutaneous automated nucleotomy with regard to predictive factors for the outcome. Selection criteria included patients with predominance of low-back pain, diffuse posterior disk bulges and concomitant spinal stenosis who are not normally accepted for nucleotomy. In all, 142 patients were treated. The overall success rate after an average observation time of 21 months was 56%. The results were not influenced by whether a diffuse posterior bulge or a focal hernia had been treated or not (p = 0.449). Spinal stenosis (p = 0.043) and disk space narrowing exceeding 25% of the expected width (p = 0.017) were associated with a poor outcome. By excluding these categories and patients with symptoms from more than one disk level, the success rate rose to 70%. With this selection, the results were equally good in patients with predominantly low-back pain compared to those with predominantly sciatica (p = 0.490).