Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review

Clinical examination tests for adductor- and pubic-related groin pain in athletes with longstanding groin pain: Inter-examiner reliability and prevalence of positive tests

OBJECTIVES

Evaluate the inter-examiner reliability of pain provocation tests for hip adductors (palpation, stretch and resistance) and for pubic symphysis (palpation) in athletes with longstanding groin pain, and to determine the prevalence of positive tests.

DESIGN

Inter-examiner reliability.

SETTING

Orthopaedic and sports medicine hospital.

PARTICIPANTS

Male athletes with longstanding groin pain.

MAIN OUTCOME MEASURES

Inter-examiner reliability, absolute/positive/negative agreement, and the mean prevalence of positive tests for athletes classified with adductor- and pubic-related groin pain were calculated.

RESULTS

We included 44 male athletes with longstanding groin pain (61 symptomatic sides). The mean age was 29 years (±6) and 70% were soccer players. Inter-examiner reliability was slight to moderate for adductor palpation (Cohen's Kappa statistic(κ)) = 0.02-0.54) and pubic palpation (κ = 0.37-0.45); moderate for the adductor stretch test (κ = 0.50), and fair to substantial for adductor resistance tests (κ = 0.22-0.74). Palpation pain was most prevalent at the adductor longus origin (94%) in athletes classified with adductor-related groin pain.

CONCLUSION

The inter-examiner reliability of palpation tests varied from slight to moderate. The adductor stretch test had a moderate reliability, and adductor resistance tests a fair to substantial reliability. Adductor longus origin is the main site for palpation pain. Adductor palpation tests not related to the adductor longus have limited inter-examiner reliability. The adductor stretch test did not assist in classifying adductor-related groin pain.

Diagnosing the direction of shoulder instability in rugby players

The muscular characteristics of rugby players may make diagnosing the direction of shoulder instability and labral pathology challenging. This study aimed to assess the accuracy of clinical examination and specifically instability tests, in diagnosing the direction of shoulder instability in rugby players. One-hundred-and-forty rugby players, who had undergone a shoulder stabilization procedure, over a 55-month period, were included in this study. The mean age was 21.5 years with 137 males. Data collected included clinical examination and intraoperative findings. The two were compared to calculate the diagnostic accuracy of special tests for instability. The Anterior Apprehension Test had good sensitivity (82.7%), specificity (100%) and PPV (100%) but poor NPV (55.8%). All posterior instability tests demonstrated a sensitivity of over 85%, but all had a specificity of 25% or less. In 83.6% of cases the direction of instability was correctly identified from history and examination. Anterior instability was correctly diagnosed in 78.9% of cases and posterior in 100.0%. The poor NPV of the anterior apprehension test suggests that clinicians should be suspicious of anterior instability in rugby shoulders even in the light of negative examination findings. Positive posterior instability tests are highly suggestive of posterior instability in rugby players.

Reliability and Concurrent Validity of a Markerless, Single Camera, Portable 3D Motion Capture System for Assessment of Glenohumeral Mobility

Introduction

Recent technological advancements have enabled medical, sport, and fitness professionals to utilize digital tools that assist with conducting movement examinations and screenings. One such advancement has been the implementation of a single camera, markerless, and portable 3D motion capture system designed to obtain ROM measurements for multiple body parts simultaneously. However, the reliability and validity of a markerless 3D motion capture system that uses a single camera has not been established.

Purpose

The purpose of this study was to investigate the reliability and concurrent validity of this 3D motion capture system compared to a goniometer in assessing ROM of the glenohumeral joint.

Study Design

Quasi-experimental reliability, convenience sampling.

Methods/materials

Forty healthy volunteers (mean ± SD, age 27.4 ± 12.4 years, height 173.4 ± 11.1 cm, weight 72.1 ± 16.2 kg) participated in this study. Intrarater reliability was analyzed by ICC(2,k) with a 95% CI using two repeated trials for each shoulder movement (flexion, abduction, external rotation, internal rotation) that were recorded simultaneously via two methods: a standard goniometer and a 3D motion capture system. Concurrent validity was analyzed using Pearson Correlation Coefficient (r).

Results

The intrarater reliability between the two instruments for glenohumeral motions yielded an overall ICC of 0.82 (95% CI: 0.74-0.88) indicating good reliability for both instruments.The 3D motion capture system demonstrated strong correlations with goniometry for shoulder flexion (r = 0.67), abduction (r = 0.63), and external rotation (r = 0.76), and very strong correlation for shoulder internal rotation (r = 0.84).

Conclusion

Results from this study indicated that a markerless, single camera, portable 3D motion capture system can be a reliable and valid tool to assess glenohumeral joint ROM in comparison to a standard goniometer.

Level of Evidence

3.

Physical Therapists Use of Diagnostic Ultrasound Imaging in Clinical Practice: A Review of Case Reports

Objective

Ultrasound diagnostic imaging (USI) is widely utilized in sports medicine, orthopaedics, and rehabilitation. Its use in physical therapy clinical practice is increasing. This review summarizes published patient case reports describing USI in physical therapist practice.

Design

Comprehensive literature review.

Literature Search

PubMed was searched using the keywords "physical therapy" AND "ultrasound" AND "case report" AND "imaging". In addition, citation indexes and specific journals were searched.

Study Selection Criteria

Papers were included if the patient was attending physical therapy, USI was necessary for patient management, the full text was retrievable, and the paper was written in English. Papers were excluded if USI was only used for interventions, such as biofeedback, or if the USI was incidental to physical therapy patient/client management.

Data Synthesis

Categories of data extracted included: 1) Patient presentation; 2) Setting; 3) Clinical indications; 4) Who performed USI; 5) Anatomical region; 6) Methods of USI; 7) Additional imaging; 8) Final diagnosis; and 9) Case outcome.

Results

Of the 172 papers reviewed for inclusion, 42 were evaluated. Most common anatomical regions scanned were the foot and lower leg (23%), thigh and knee (19%), shoulder and shoulder girdle (16%), lumbopelvic region (14%), and elbow/wrist and hand (12%). Fifty-eight percent of the cases were deemed static, while 14% reported using dynamic imaging. The most common indication for USI was a differential diagnosis list that included serious pathologies. Case studies often had more than one indication. Thirty-three cases (77%) resulted in confirmation of a diagnosis, while 29 case reports (67%) documented significant changes in physical therapy intervention strategies due to the USI, and 25 case reports (63%) resulted in referral.

Conclusion

This review of cases provides details on unique ways USI can be used during physical therapy patient care, including aspects that reflect the unique professional framework.

Clinical examination for athletes with inguinal-related groin pain: interexaminer reliability and prevalence of positive tests

Objectives

To evaluate the interexaminer reliability of abdominal palpation and resistance tests in athletes with longstanding groin pain, and to identify the prevalence of positive clinical tests in athletes classified with inguinal-related groin pain.

Methods

Male athletes (18-40 years) with longstanding groin pain were prospectively recruited between March 2019 and October 2020 at a sports medicine hospital. Two examiners performed history taking and standardised clinical examination (including abdominal palpation, scrotal invagination and abdominal resistance tests) blinded to each other's findings. Interexaminer reliability was calculated using Cohen's Kappa statistic (κ). Examiners classified groin pain using the Doha agreement meeting terminology. A differentiation was made between 'defined inguinal-related groin pain' (according to recommended definition criteria) and 'likely inguinal-related groin pain' (expert-based application of the Doha agreement classification when not all recommended criteria were present).

Results

Overall, 44 athletes were included (61 symptomatic sides). Interexaminer reliability of inguinal palpation pain provocation tests varied from fair to moderate (κ=0.35-0.49). Reliability of posterior wall structure palpation (firm/soft) was slight (κ=0.01), and posterior wall bulging (yes/no) fair (κ=0.29). Reliability for abdominal resistance tests varied from fair to substantial (κ=0.35-0.72). In athletes classified with defined inguinal-related groin pain, recognisable injury pain on palpation during scrotal invagination when athletes performed a Valsalva manoeuvre was the most prevalent positive palpation test (79%). Abdominal resistance tests were positive in 21%-49% of these cases.

Conclusion

The interexaminer reliability for clinical examination tests used to classify inguinal-related groin pain in athletes varies from slight to substantial. There is no single perfect clinical examination test.

Trial registration number

NCT03842826.

Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: A systematic review

BACKGROUND

This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness.

METHODS

Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE.

RESULTS

Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment.

DISCUSSION

Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access.

TRIAL REGISTRATION

The review was registered in the PROSPERO database, CRD42021277624.

Reliability and Validity of Non-radiographic Methods of Forward Head Posture Measurement: A Systematic Review

Forward head posture measurement can be conducted using various methods and instruments. The selection of the appropriate method requires the factors of validity and reliability to be considered. This systematic review reports on the reliability and validity of the non-radiographic methods examined for measuring forward head posture. The review identified relevant studies following a systematic search of electronic databases. The studies were assessed for quality by two independent reviewers using a critical appraisal tool. The studies’ data were extracted and assessed, and the results were synthesized qualitatively using a level of evidence approach. Twenty-one studies met the eligibility criteria and were included in the review. Both reliability and validity were investigated for five studies, whereas reliability only was investigated for 17 studies. In total, 11 methods of forward head posture measurement were evaluated in the retrieved studies. The validity of the methods ranged from low to very high. The reliability of the methods ranged from moderate to excellent. The strongest levels of evidence for reliability support the use of classic photogrammetry. For validity, the evidence is not conclusive. Further studies are required to strengthen the level of evidence on the reliability and validity of the remaining methods. It is recommended that this point be addressed in future research.

Home training with or without joint mobilization compared to no treatment: a randomized controlled trial

[Purpose] To investigate if joint mobilization in patients with subacromial pain syndrome has additional benefits to a home training program on shoulder function and pain, and to compare home training to no physical therapy. [Participants and Methods] Eighty-nine primary care patients (mean age 45 years) with subacromial pain syndrome during an average of 23 weeks. Home training was performed twice a day during a 12 week period. One of the intervention groups received add-on shoulder joint mobilization to the home training. A third group did not receive any physical therapy. Constant-Murley score, pain and active range of motion was evaluated at baseline, 6 weeks, 12 weeks and 6 months. [Results] The total Constant-Murley score revealed no significant differences between groups at any time point. All groups improved over time. The add-on joint mobilization group reached clinical important change at 12 weeks. The subscale pain showed that both intervention groups reported less pain after 12 weeks compared to the reference group. [Conclusion] Home training is not superior to no treatment evaluated with the total Constant-Murley score. However, home training with or without add-on joint mobilization may decrease pain compared to no treatment.

Predicting pain and function outcomes in people consulting with shoulder pain: the PANDA-S clinical cohort and qualitative study protocol

INTRODUCTION

People presenting with shoulder pain considered to be of musculoskeletal origin is common in primary care but diagnosing the cause of the pain is contentious, leading to uncertainty in management. To inform optimal primary care for patients with shoulder pain, the study aims to (1) to investigate the short-term and long-term outcomes (overall prognosis) of shoulder pain, (2) estimate costs of care, (3) develop a prognostic model for predicting individuals' level and risk of pain and disability at 6 months and (4) investigate experiences and opinions of patients and healthcare professionals regarding diagnosis, prognosis and management of shoulder pain.

METHODS AND ANALYSIS

The Prognostic And Diagnostic Assessment of the Shoulder (PANDA-S) study is a longitudinal clinical cohort with linked qualitative study. At least 400 people presenting to general practice and physiotherapy services in the UK will be recruited. Participants will complete questionnaires at baseline, 3, 6, 12, 24 and 36 months. Short-term data will be collected weekly between baseline and 12 weeks via Short Message Serevice (SMS) text or software application. Participants will be offered clinical (physiotherapist) and ultrasound (sonographer) assessments at baseline. Qualitative interviews with ≈15 dyads of patients and their healthcare professional (general practitioner or physiotherapist).Short-term and long-term trajectories of Shoulder Pain and Disability Index (using SPADI) will be described, using latent class growth analysis. Health economic analysis will estimate direct costs of care and indirect costs related to work absence and productivity losses. Multivariable regression analysis will be used to develop a prognostic model predicting future levels of pain and disability at 6 months using penalisation methods to adjust for overfitting. The added predictive value of prespecified physical examination tests and ultrasound findings will be examined. For the qualitative interviews an inductive, exploratory framework will be adopted using thematic analysis to investigate decision making, perspectives of patients and clinicians on the importance of diagnostic and prognostic information when negotiating treatment and referral options.

ETHICS AND DISSEMINATION

The PANDA-S study has ethical approval from Yorkshire and The Humber-Sheffield Research Ethics Committee, UK (18/YH/0346, IRAS Number: 242750). Results will be disseminated through peer-reviewed publications, social and mainstream media, professional conferences, and the patient and public involvement and engagement group supporting this study, and through newsletters, leaflets and posters in participating sites.

TRIAL REGISTRATION NUMBER

ISRCTN46948079.

Interrater reliability of physical examination tests in the acute phase of shoulder injuries

BACKGROUND

The physical examination is one of the cornerstones of the diagnostic process in patients with acute shoulder injuries. The discriminative properties of a given examination test depend both on its validity and reliability. The aim of the present study was to assess the interrater reliability of 13 physical examination manoeuvres for acute rotator cuff tears in patients with acute soft tissue shoulder injuries.

METHODS

In a large walk-in orthopaedic emergency department, 120 consecutive patients ≥40 years of age were included in a diagnostic study. Patients who had follow-up within three weeks of an acute shoulder injury without fracture on radiographs were eligible. Four emergency department physicians participated as examiners. In a subset of 48 patients, the physical examination tests were performed by two physicians, randomly chosen by their work rotation. The physicians were blinded to the findings of each other and the results of the ultrasound screening. The interrater reliability was assessed by Cohen's kappa, intraclass correlation coefficient (ICC), standard error of measurement (SEM) and Bland-Altman plots depending on whether the examination test result was registered as a binary, ordered categorical or continuous numerical variable.

RESULTS

The median age was 55.5 years, 46% were female. Twenty-seven percent had a rotator cuff full-thickness tear on ultrasound screening; all but one involved the supraspinatus tendon. Cohen's kappa for binary tests ranged from excellent to fair. Excellent agreement (kappa > 0.8) was found for the inability to abduct above 90° and abduction strength. External rotation strength expressed substantial agreement (kappa 0.7). The lowest scores were registered for Hawkins` test and the external rotation lag sign (kappa 0.25 and 0.40, respectively). The ICCs for active range of abduction and external rotation were 0.93 (0.88-0.96) and 0.84 (0.72-0.91), whereas the SEM was 15 and 9, respectively.

CONCLUSIONS

The results indicate that examination manoeuvres assessing abduction and external rotation range of motion and strength are more reliable than manoeuvres assessing pain in patients in the acute phase of traumatic shoulder injury. The poor agreement observed is likely to limit the validity in the present setting of two commonly used tests.

TRIAL REGISTRATION

The Norwegian Regional Ethics Committee South East ( 2015/195 ).

Bilateral ultrasound findings in patients with unilateral subacromial pain syndrome

Background: Subacromial pain syndrome is a common musculoskeletal shoulder problem. The accuracy of clinical tests is low and techniques such as ultrasound and magnetic resonance imaging have been added to set up a diagnosis. Previous researchers have usually only examined the symptomatic shoulder. However, there might be similar findings in the asymptomatic shoulder. Objective:The aim of the present study was to investigate the prevalence of structural abnormalities of both shoulders in patients with clinically diagnosed unilateral subacromial pain syndrome using diagnostic ultrasound. Methods: Bilateral ultrasound examinations were performed in 115 consecutive patients, 54 men and 61 women. The patients were recruited from primary care centers in the area of Stockholm, Sweden. Results: Abnormal ultrasound findings were found in both shoulders and increased with age (p = .0004). Bursitis was the most common ultrasound finding and significantly more prevalent in the symptomatic shoulder compared to the asymptomatic shoulder (90%:74%; p = .0021), though 73% of the bursitis were bilateral. Supraspinatus is the most vulnerable tendon of the rotator cuff in both shoulders. In terms of partial-thickness tears and tendinosis, the tendon was affected more commonly in the symptomatic shoulder compared to the asymptomatic shoulder (30%:14%: 14%; p = .0026) and (24%:10%; p = .0054), respectively, but for calcification no significant difference between the shoulders was found (18%:12%; 0.1988). Conclusion: Ultrasound detected shoulder abnormalities were present in both symptomatic and asymptomatic shoulders. Bursitis and partial-thickness tears were more common in the affected shoulder when compared to the unaffected shoulder. Ultrasound as well as clinical examination findings and patient´s history should be taken into consideration when diagnosing patients with subacromial pain syndrome.

Shoulder Pain and Disability Index: Italian cross-cultural validation in patients with non-specific shoulder pain

BACKGROUND

Health-related patient reported outcome measures are considered essential to determine the impact of disease on the life of individuals. Aim of this study is to culturally adapt the Italian version of the Shoulder Pain and Disability Index (SPADI). The secondary aim is to evaluate psychometric proprieties in patients with non-specific shoulder pain.

METHODS

The current study is an analysis of a sample of 59 adult patients with non-specific shoulder pain. The SPADI was translated and cross-culturally adapted, and then psychometric properties were tested. Participants completed the Shoulder Pain and Disability Index-Italian (SPADI-I), 36-item short form health survey, the Oxford Shoulder Score, the Disability of Arm, Shoulder, and Hand scale and a pain intensity visual analogue scale.

RESULTS

SPADI-I included two domains. Internal consistency analysis showed good values for total (α = 0.84) and subscales (α = 0.94 and α = 0.76). For construct validity, there was good correlation between the visual analogue scale, the Oxford Shoulder Score, the DASH and the SPADI-I total score and subscales. Standard error of measurement and minimally detectable change were calculated.

CONCLUSIONS

The SPADI-I was culturally adapted into Italian. SPADI-I is centred on pain and disability of the shoulder only and can be considered as a useful tool in daily clinical practice for assessing musculoskeletal non-specific shoulder pain because of its good internal consistency and validity. Further studies should focus on other psychometric proprieties such as test re-test reliability, responsiveness and clinical interpretability to improve the available clinimetrics of the tool.

Psychometric properties of chronic low back pain diagnostic classification systems: a systematic review

OBJECTIVES

To identify and critically appraise studies evaluating psychometric properties of functionally oriented diagnostic classification systems for Non-Specific Chronic Low Back Pain (NS-CLBP).

METHODS

This review employed methodology consistent with PRISMA guidelines. Electronic databases and journals: (PubMed, EMBASE, Cochrane, PEDro, CINAHL, Index to chiropractic literature, ProQuest, Physical Therapy, Journal of Physiotherapy, Canadian Physiotherapy and Physiotherapy Theory and Practice) were searched from inception until January 2020. Included studies evaluated the validity and reliability of NS-CLBP diagnostic classification systems in adults. Risk of bias was assessed using a Critical Appraisal Tool.

RESULTS

Twenty-two studies were eligible: Five investigated inter-rater reliability, and 17 studies analyzed validity of O'Sullivan's classification system (OCS, n = 15), motor control impairment (MCI) test battery (n = 1), and Pain Behavior Assessment (PBA, n = 1). Evidence from multiple low risk of bias studies demonstrates that OCS has moderate to excellent inter-rater reliability (kappa > 0.4). Also, two low risk of bias studies support of OCS-MCI subcategory. Three tests within the MCI test battery show acceptable inter- and intra-rater reliability for clinical use (the "sitting knee extension," the "one leg stance," and the "pelvic tilt" tests). Evidence for the reliability and validity of the PBA is limited to one high bias risk study.

CONCLUSIONS

Multiple low risk of bias studies demonstrate strong inter-rater reliability for OCS classification specifically OCS-MCI subcategory. Future studies with low risk of bias are needed to evaluate reliability and validity of the MCI test battery and the PBA.

Clinical Examination and Self-Reported Upper Extremity Impairments in Patients with Long-Standing Type 1 Diabetes Mellitus

AIM

The aims of the current study were (1) to determine the prevalence of upper extremity impairments (UEIs) in patients with type 1 diabetes by clinical investigation; (2) to investigate if self-reported impairments were concordant with clinical findings and if key questions could be identified; and (3) to investigate if answers to our self-reported questionnaire regarding UEIs are reliable.

METHODS

Patients with type 1 diabetes were invited to participate in a cross-sectional study of clinical and self-reported (12 items) UEIs in adjunction to ordinary scheduled clinical visit. Before the visit, a questionnaire on UEIs was filled in twice (test-retest) followed by clinical testing at the planned visit.

RESULTS

In total, 69 patients aged 45 ± 14 years and with diabetes duration 26 ± 15 were included in the study. In the clinical examination, two-thirds (65%) of the patients showed one or more UEI, with failure to perform hand against back as the most common clinical finding (40%) followed by positive Phalen's test (27%), Tinel's test (26%), and Prayer's sign (24%). UEIs observed by clinical examination were often bilateral, and multiple impairments often coexisted. Self-reported shoulder stiffness was associated with impaired shoulder mobility and with Prayer's sign. Self-reported reduced hand strength was associated to lower grip force, Prayer's sign, trigger finger, fibrosis string structures, and reduced thenar strength as well as reduced shoulder mobility. In addition, self-reporting previous surgery of carpal tunnel and trigger finger was associated with several clinical UEIs including shoulder, hand, and finger. The test-retest of the questionnaire showed a high agreement of 80-98% for reported shoulder, hand, and finger impairments.

CONCLUSION

UEIs are common in type 1 diabetes. Self-reported shoulder stiffness and reduced hand strength might be used to capture patients with UEIs in need of clinical investigation and enhanced preventive and therapeutic strategies, as well as rehabilitative interventions.

An evaluation of two types of exercise classes, containing shoulder exercises or a combination of shoulder and thoracic exercises, for the treatment of nonspecific shoulder pain: A case series

STUDY DESIGN

A case series was carried out.

INTRODUCTION

There is a lack of evidence exploring the effectiveness of group exercise classes for people with nonspecific shoulder pain (NSSP). Also, there is a lack of research that measures potential reductions in thoracic kyphosis after exercise interventions in people with NSSP.

PURPOSE OF THE STUDY

To observe changes in shoulder pain, disability, and thoracic kyphosis in 2 groups of people with NSSP, after 2 different types of group exercise classes.

METHODS

People with NSSP received a 6-week block of exercises classes containing either shoulder exercises alone (shoulder group, n = 20) or a mixture of shoulder and thoracic extension exercises (thoracic group, n = 19). The Disabilities of the Arm, Shoulder and Hand questionnaire for disability and the Numeric Rating Scale for pain were measured at baseline, 6 weeks, and 6 months. Thoracic kyphosis was measured at baseline and 6 weeks using the manual inclinometer.

RESULTS

Significant and clinically meaningful improvements in Numeric Rating Scale and Disabilities of the Arm, Shoulder and Hand were demonstrated in both groups at 6-week and 6-month follow-up (P < .001). Effect sizes ranged from 0.78-1.16 in the shoulder group and 0.85-1.88 in the thoracic group. Thoracic kyphosis did not change beyond measurement error in either group.

DISCUSSION/CONCLUSION

Group exercise classes can improve shoulder pain and disability in people with NSSP. Resting thoracic kyphosis did not change after either exercise intervention, which suggests that the treatment effect was not due to a change in static thoracic spine posture.

Screening of the cervical spine in subacromial shoulder pain: A systematic review

BACKGROUND

Subacromial shoulder pain is a common clinical presentation with much diagnostic uncertainty. Some of this uncertainty relates to the involvement of the cervical spine as a source or contribution to subacromial shoulder pain. Currently, there is no accepted method of screening of the cervical spine in the presence of subacromial shoulder pain, which risks patients receiving misguided and/or ineffective interventions.

OBJECTIVE

To evaluate approaches used to screen the cervical spine in patients with subacromial shoulder pain.

DESIGN

Systematic review of randomized controlled trials.

METHODS

Electronic searches of PEDro and MEDLINE to December 2016 were conducted. Randomized controlled trials evaluating the effectiveness of interventions within the current scope of physiotherapy comprising of adult patients complaining of subacromial shoulder pain were included. Data relating to the method of cervical spine screening were extracted and synthesized categorically.

RESULTS

One hundred and two studies were included. Twenty-six (25.5%) were categorized as "No method of screening undertaken or reported," 49 (48.0%) were categorized as "Localized cervical spine symptoms and/or radiculopathy/radicular pain," nine (8.8%) were categorized as "Cervical examination," two (2.0%) were categorized as "Manual testing," two (2.0%) were categorized as "History of cervical surgery," and 14 (13.7%) were categorized as using "Combined approaches."

CONCLUSION

Examination of the cervical spine in patients with subacromial shoulder pain is variable in randomized controlled trials. In many instances, no or minimal attempts to screen were undertaken or reported. This has potential research and management implications and further research is indicated to facilitate development of this aspect of examination.

Reliability and validity of clinically accessible smartphone applications to measure joint range of motion: A systematic review

Measuring joint range of motion is an important skill for many allied health professionals. While the Universal Goniometer is the most commonly utilised clinical tool for measuring joint range of motion, the evolution of smartphone technology and applications (apps) provides the clinician with more measurement options. However, the reliability and validity of these smartphones and apps is still somewhat uncertain. The aim of this study was to systematically review the literature regarding the intra- and inter-rater reliability and validity of smartphones and apps to measure joint range of motion. Eligible studies were published in English peer-reviewed journals with full text available, involving the assessment of reliability and/or validity of a non-videographic smartphone app to measure joint range of motion in participants >18 years old. An electronic search using PubMed, Medline via Ovid, EMBASE, CINAHL, and SPORTSDiscus was performed. The risk of bias was assessed using a standardised appraisal tool. Twenty-three of the eligible 25 studies exceeded the minimum 60% score to be classified as a low risk of bias, although 3 of the 13 criteria were not achieved in >50% of the studies. Most of the studies demonstrated adequate intra-rater or inter-rater reliability and/or validity for >50% of the range of motion tests across all joints assessed. However, this level of evidence appeared weaker for absolute (e.g. mean difference ± limit of agreement, minimal detectable change) than relative (e.g. intraclass correlation, correlation) measures; and for spinal rotation than spinal extension, flexion and lateral flexion. Our results provide clinicians with sufficient evidence to support the use of smartphones and apps in place of goniometers to measure joint motion. Future research should address some methodological limitations of the literature, especially including the inclusion of absolute and not just relative reliability and validity statistics.

A prospective study of patients with shoulder pain and Mechanical Diagnosis and Therapy (MDT)

Objectives: A prospective observational cohort study was conducted to (1) determine the prevalence of Mechanical Diagnosis and Therapy (MDT) syndromes for patients with shoulder impairments and (2) report the interaction between MDT classification and clinical outcomes, including pain intensity and disability, at discharge.Methods: Clinical outcome measures were completed at intake and discharge by 115 patients. A two-way mixed model analysis of variance with subsequent pairwise comparisons was done to examine differences in clinical outcomes between the following MDT classifications: Shoulder Derangement, Shoulder Dysfunction, and Other.Results: The primary findings were that (1) 44.3 (35.3, 53.4), 40.0 (31.0, 48.9), and 15.6 (9.0, 22.3) percent of patients' conditions were classified as Shoulder Derangement, Shoulder Dysfunction, and Other, respectively, (2) all groups managed via MDT methods made clinically significant improvements in disability and pain intensity at discharge, (3) a statistically significant difference in pain intensity at discharge was observed between the Shoulder Derangement and the Shoulder Dysfunction classifications (p = 0.01), and (4) patients with the Shoulder Derangement classification were discharged, on average, 35.3 days earlier than the Shoulder Dysfunction classification and 28.3 days earlier than the Other classification.Discussion: This study confirms previous reports that the Shoulder Derangement and Shoulder Dysfunction classifications are common and represent distinct clinical trajectories when assessed and managed via MDT methods.

Interrater agreement and reliability of clinical tests for assessment of patients with shoulder pain in primary care

Background: There is limited information about the agreement and reliability of clinical shoulder tests. Objectives: To assess the interrater agreement and reliability of clinical shoulder tests in patients with shoulder pain treated in primary care. Methods: Patients with a primary report of shoulder pain underwent a set of 21 clinical shoulder tests twice on the same day, by pairs of independent physical therapists. The outcome parameters were observed and specific interrater agreement for positive and negative scores, and interrater reliability (Cohen's kappa (κ)). Positive and negative interrater agreement values of ≥0.75 were regarded as sufficient for clinical use. For Cohen's κ, the following classification was used: <0.20 poor, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 good, 0.81-1.00 very good reliability. Participating clinics were randomized in two groups; with or without a brief practical session on how to conduct the tests. Results: A total of 113 patients were assessed in 12 physical therapy practices by 36 physical therapists. Positive and negative interrater agreement values were both sufficient for 1 test (the Full Can Test), neither sufficient for 5 tests, and only sufficient for either positive or negative agreement for 15 tests. Interrater reliability was fair for 11 tests, moderate for 9 tests, and good for 1 test (the Full Can Test). An additional brief practical session did not result in better agreement or reliability. Conclusion: Clinicians should be aware that interrater agreement and reliability for most shoulder tests is questionable and their value in clinical practice limited.

The reliability and validity of goniometric elbow measurements in adults: A systematic review of the literature

BACKGROUND

The universal goniometer is a simple measuring tool. With this review we aimed to investigate the reliability and validity of the universal goniometer in measurements of the adults' elbow.

METHODS

Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines were followed and our study protocol was published online at PROSPERO. A literature search was conducted on relevant studies. Methodological quality was assessed using the Quality Appraisal of Diagnostic Reliability (QAREL) scoring system.

RESULTS

Out of 697 studies yielded from our literature search, 12 were included. Six studies were rated as high quality. The intrarater reliability intraclass correlation coefficient ranged from 0.45 to 0.99, the interrater reliability ranged from intraclass correlation coefficient 0.53-0.97. One study providing instructions on goniometric alignment did not find a difference in expert versus non-expert examiners. Another study in which examiners were not instructed found a higher interrater reliability in expert examiners. One study investigating the validity of the goniometer in elbow measurements found a maximum standard error of the mean of 11.5° for total range of motion.

DISCUSSION

Overall, the studies showed high intra- and interrater reliability of the universal goniometer. The reliability of the universal goniometer in non-expert examiners can be increased by clear instructions on goniometric alignment.

Dual energy X-ray absorptiometry positioning protocols in assessing body composition: A systematic review of the literature

OBJECTIVES

To systematically identify and assess methods and protocols used to reduce technical and biological errors in published studies that have investigated reliability of dual energy X-ray absorptiometry (DXA) for assessing body composition.

DESIGN

Systematic review.

METHODS

Systematic searches of five databases were used to identify studies of DXA reliability. Two independent reviewers used a modified critical appraisal tool to assess their methodological quality. Data was extracted and synthesised using a level of evidence approach. Further analysis was then undertaken of methods used to decrease DXA errors (technical and biological) and so enhance DXA reliability.

RESULTS

Twelve studies met eligibility criteria. Four of the articles were deemed high quality. Quality articles considered biological and technical errors when preparing participants for DXA scanning. The Nana positioning protocol was assessed to have a strong level of evidence. The studies providing this evidence indicated very high test-retest reliability (ICC 0.90-1.00 or less than 1% change in mean) of the Nana positioning protocol. The National Health and Nutrition Examination Survey (NHANES) positioning protocol was deemed to have a moderate level of evidence due to lack of high quality studies. However, the available studies found the NHANES positioning protocol had very high test-retest reliability. Evidence is limited and reported reliability has varied in papers where no specific positioning protocol was used or reported.

CONCLUSIONS

Due to the strong level of evidence of excellent test-retest reliability that supports use of the Nana positioning protocol, it is recommended as the first choice for clinicians when using DXA to assess body composition.

Classification of Tendon Matrix Change Using Ultrasound Imaging: A Systematic Review and Meta-analysis

Ultrasound imaging (US) is an accurate and reliable method used to diagnose tendinopathy. This systematic review was aimed at identifying common criteria and parameters used to diagnose tendinopathy, the methodological quality of studies and the predictive value of US. Nineteen studies met the inclusion criteria, with the Achilles, quadriceps and patella tendons being investigated. Overall, there was significant heterogeneity between the criteria used to diagnose tendinopathy utilising US. The methodological quality of included studies was "good." Additionally, meta-analysis revealed that US-identified abnormalities were predictive of future symptoms, and classification of tendinopathy using three US defined parameters indicated a higher relative risk of developing clinical tendinopathy compared with the use of two US-defined parameters. Further research into the development of a standardised US criterion that incorporates both clinical and US findings is required to allow for greater consistency in the diagnosis of tendinopathy.

Reliability of Common Provocative Tests for Shoulder Tendinitis

OBJECTIVE

Accurate and reliable shoulder tendinopathy examination maneuvers are essential for diagnosing and treating shoulder pain; however, studies have reported varying results as to the accuracy of common maneuvers. Thus, data from a large, cross-sectional study were used to systematically quantify the reliability and accuracy of clinical diagnostic tests.

METHODS

Baseline data from the WISTAH cohort study were used to evaluate inter-tester reliability and accuracy of common provocative shoulder examination tests compared with a case definition of shoulder tendinitis.

RESULTS

Inter-tester reliability showed reliable consistency between providers with kappa coefficients between 89.5% and 94.8% for all tests. However, sensitivity was generally poor (3.0% to 60.6%). Specificity was consistently high (96.2% to 99.6%).

CONCLUSION

Common shoulder provocative tests show low sensitivity but high specificity, which implies that the primary utility of examination maneuvers is for their negative predictive values.

Towards an integrated clinical framework for patient with shoulder pain

Background

Shoulder pain (SP) represents a common musculoskeletal condition that requires physical therapy care. Along the years, the usual evaluation strategies based on clinical tests and diagnostic imaging has been challenged. Clinical tests appear unable to clearly identify the structures that generated pain and interpretation of diagnostic imaging is still controversial. The current patho-anatomical diagnostic categories have demonstrated poor reliability and seem inadequate for the SP treatment.

Objectives

The present paper aims to (1) describe the different proposals of clinical approach to SP currently available in the literature; to (2) integrate these proposals in a single framework in order to help the management of SP.

Conclusion

The proposed clinical framework, based on a bio-psychosocial vision of health, integrates symptoms characteristics, pain mechanisms and expectations, preferences and psychosocial factors of patients that may guide physiotherapist to make a diagnostic triage and to choose the right treatment for the individual patient.

Reliability of the Shoulder Symptom Modification Procedure and association of within-session and between-session changes with functional outcomes

Background

Despite being a common problem, there is considerable diagnostic uncertainty with regard to shoulder pain. This uncertainty relates to the reliability and validity of current examination tests. The Shoulder Symptom Modification Procedure (SSMP) has been proposed as an alternative to existing approaches.

Objective

To evaluate interclinician reliability of the SSMP and the association of within-session and between-session changes on clinical outcome at 1 week, and at 1 and 3 months.

Design

A single-centre reliability study, with prospective follow-up.

Methods

Twenty-six patients with shoulder pain were recruited. Following an initial SSMP-based examination, a second examination was performed by a second physiotherapist, blinded to the results of the first examination. Clinical outcome data were completed after 1 week, 1 month and 3 months via theNumeric Pain Rating Scale and the Shoulder PainandDisability Index. Reliability was evaluated using kappa and associations were evaluated using Spearman’s r.

Results

Inter-rater reliability of the SSMP was moderate (κ=0.47). Association of within-session changes ranged from fair to poor in the short term (r=0.24–0.01) to poor in the mid-term (r=−0.03). The association of between-session changes ranged from substantial to moderate in the short term (r=0.74–0.47) but slight in the mid-term (r=0.22).

Conclusions

Based on this study, we cannot recommend the SSMP as a reliable tool for physical examination of patients with shoulder pain. The importance of within-session and between-session changes remains uncertain.

Consistency of commonly used orthopedic special tests of the shoulder when used with the McKenzie system of mechanical diagnosis and therapy

BACKGROUND

Shoulder Orthopedic Special Tests (OSTs) are used to assist with diagnosis in shoulder disorders. Issues with reliability and validity exist, making their interpretation challenging. Exploring OST results on repeated testing within Mechanical Diagnosis and Therapy (MDT) shoulder classifications may offer insight into the poor performance of these tests.

OBJECTIVES

To investigate in patients with shoulder complaints, whether MDT classifications affect the agreement of OST results over the course of treatment.

METHODS

An international group of MDT clinicians recruited 105 patients with shoulder problems. Three commonly used OSTs (Empty Can, Hawkins-Kennedy, and Speed's tests) were utilized. Results of the OSTs were collected at sessions 1, 3, 5 and 8, or at discharge from an MDT classification-based treatment. The Kappa statistic was utilized to determine the agreement of the OST results over time for each of the MDT classifications.

RESULTS

The overall Kappa values for Empty Can, Hawkins-Kennedy and Speed's tests were 0.28 (SE = 0.07), 0.28 (SE = 0.07) and 0.29 (SE = 0.07), respectively. The highest level of agreement was for Articular Dysfunction for the Empty Can test (0.84, SE = 0.19). For shoulder Derangements, there was no agreement for any of the OSTs (P values > 0.05).

CONCLUSION

The lack of agreement when the OSTs were consecutively tested in the presence of the MDT Derangement classification contrasted with the other MDT classifications. The presence of Derangement was responsible for reducing the overall agreement of commonly used OSTs and may explain the poor consistency for OSTs.

Review article: Best practice management of common shoulder injuries and conditions in the emergency department (part 4 of the musculoskeletal injuries rapid review series)

Shoulder injuries are a commonly presenting complaint to the ED. In the absence of an obvious deformity, they can be difficult to assess and definitively diagnose because of the multiple structures that cause shoulder pain, the acuity and severity of pain and the lack of range of motion in the ED setting. The quality of ED care provided to patients with musculoskeletal shoulder pain is crucial to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common shoulder injuries and conditions in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines published in English-language in the past 12 years that addressed the acute assessment, management, follow-up plan or prognosis were considered for inclusion. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence. The search revealed 1902 articles, of which 73 were included in the review (n = 12 primary articles, n = 49 systematic reviews and n = 12 guidelines). This rapid review provides clinicians who manage shoulder dislocations, fractures and soft tissue injuries in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is strong evidence to support taking a thorough history and physical examination, with cautious use of special tests because of their poor diagnostic accuracy. Key points regarding the diagnosis and management of these injuries are provided.

Three-dimensional kinematics of shoulder laxity examination and the relationship to clinical interpretation

Understanding clinical test kinematics improves utility of exam techniques. The purposes of this study were as follows: (1) determine inter-examiner repeatability of translation magnitude for the Anterior/Posterior Drawer and Sulcus shoulder laxity tests; (2) describe the relationships between glenohumeral joint translations and subjective grades for each laxity test; and (3) describe the relationship of overall glenohumeral joint laxity to a composite subjective score from the three laxity tests. Eleven subjects with shoulder symptomology were examined with three laxity tests. Motion was tracked with electromagnetic sensors affixed to the humerus and scapula via transcortical pins. ICCs were calculated to determine repeatability of translation magnitudes between two examiners for each test. Descriptive statistics and regression analyses were performed for comparisons of single laxity test grades with translation magnitudes and for composite subjective laxity scores and overall translation across all three tests. Inter-examiner ICCs regarding kinematic repeatability were 0.87 for Anterior Drawer, 0.84 for the Sulcus test, and not calculable for the Posterior Drawer. No linear relationships between subjective grades of individual tests and translation magnitudes were found. The relationship of overall translation with the composite subjective score from all laxity tests was r² = 0.75 (r = 0.86). Clinicians from different disciplines are capable of imparting similar translations during laxity tests. Single-test subjective laxity grades demonstrate large ranges of translation between subjects for the same grade. By combining results of three laxity tests, clinicians are capable of identifying the level of overall shoulder joint laxity in patients.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

BACKGROUND

Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient's pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.

METHODS

Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence.

RESULTS

The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference.

CONCLUSION

Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders.

PROSPERO REGISTRATION

CRD42016038882.

Clinimetric properties of lower limb neurological impairment tests for children and young people with a neurological condition: A systematic review

Background

Clinicians and researchers require sound neurological tests to measure changes in neurological impairments necessary for clinical decision-making. Little evidence-based guidance exists for selecting and interpreting an appropriate, paediatric-specific lower limb neurological test aimed at the impairment level.

Objective

To determine the clinimetric evidence underpinning neurological impairment tests currently used in paediatric rehabilitation to evaluate muscle strength, tactile sensitivity, and deep tendon reflexes of the lower limb in children and young people with a neurological condition.

Methods

Thirteen databases were systematically searched in two phases, from the date of database inception to 16 February 2017. Lower limb neurological impairment tests were first identified which evaluated muscle strength, tactile sensitivity or deep tendon reflexes in children or young people under 18 years of age with a neurological condition. Papers containing clinimetric evidence of these tests were then identified. The methodological quality of each paper was critically appraised using standardised tools and clinimetric evidence synthesised for each test.

Results

Thirteen papers were identified, which provided clinimetric evidence on six neurological tests. Muscle strength tests had the greatest volume of clinimetric evidence, however this evidence focused on reliability. Studies were variable in quality with inconsistent results. Clinimetric evidence for tactile sensitivity impairment tests was conflicting and difficult to extrapolate. No clinimetric evidence was found for impairment tests of deep tendon reflexes.

Conclusions

Limited high-quality clinimetric evidence exists for lower limb neurological impairment tests in children and young people with a neurological condition. Results of currently used neurological tests, therefore, should be interpreted with caution. Robust clinimetric evidence on these tests is required for clinicians and researchers to effectively select and evaluate rehabilitation interventions.

Validation of a modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool: A mixed methods study

AIMS AND OBJECTIVES

To develop and validate a modified Situation-Background-Assessment-Recommendation communication tool incorporating components of the Cape Town modified early warning score vital signs chart for reporting early signs of clinical deterioration.

BACKGROUND

Reporting early signs of physiological and clinical deterioration could prevent "failure to rescue" or unexpected intensive care admission, cardiac arrest or death. A structured communication tool incorporating physiological and clinical parameters allows nurses to provide pertinent information about a deteriorating patient in a logical order.

DESIGN

Mixed methods instrument development and validation.

METHODS

We used a sequential three-phase method: cognitive interviews, content validation and inter-rater reliability testing to validate a self-designed communication tool. Participants were purposively selected expert nurses and doctors in government sector hospitals in Cape Town.

RESULTS

Cognitive interviews with five experts prompted most changes to the communication tool: 15/42 (35.71%) items were modified. Content validation of a revised tool was high by a predetermined ≥70% of 18 experts: 4/49 (8.2%) items were modified. Inter-rater reliability testing by two nurses indicated substantial to full agreement (Cohen's kappa .61-1) on 37/45 (82%) items. The one item achieving slight agreement (Cohen's kappa .20) indicated a difference in clinical judgement. The high overall percentage agreement (82%) suggests that the modified items are sound. Overall, 45 items remained on the validated tool.

CONCLUSION

The first modified early warning score-linked Situation-Background-Assessment-Recommendation communication tool developed in South Africa was found to be valid and reliable in a local context.

RELEVANCE TO CLINICAL PRACTICE

Nurses in South Africa can use the validated tool to provide doctors with pertinent information about a deteriorating patient in a logical order to prevent a serious adverse event. Our findings provide a reference for other African countries to develop and validate communication tools for reporting early signs of clinical deterioration.

Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis

Background

Exercise is frequently suggested as a treatment option for patients presenting with symptoms of subacromial impingement syndrome. Some would argue implementing a specific exercise strategy with special focus on correction of kinematic deficits would be superior to general exercise strategy. There is however a lack of evidence comparing such exercise strategies to determine which is the most effective in the treatment of subacromial impingement syndrome. The aim of this review is to evaluate whether implementing specific exercise strategies involving resistive exercises are more effective than a general exercise strategy for the treatment of patients with subacromial impingement syndrome.

Methods

Randomized controlled trials were identified through an electronic search on PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and PEDro. In addition, article reference lists and Clinicaltrials.gov were searched. Studies were considered eligible if they included interventions with resistive specific exercises as compared to general resistance exercise. Four reviewers assessed risk of bias and methodological quality guided by Cochrane recommendations. Results were synthesised qualitatively or quantitatively, where appropriate.

Results

Six randomized controlled trials were included with 231 participants who experienced symptoms of subacromial impingement syndrome. Four studies evaluated the effectiveness of specific scapular exercise strategy and two studies evaluated the effectiveness of specific proprioceptive strategy. Five studies were of moderate quality and one study was of low quality. No consistent statistical significant differences in outcomes between treatment groups were reported in the studies. Standardized mean difference (SMD) for pain was SMD −0.19 (95% CI −0.61, 0.22) and SMD 0.30 (95% CI −0.16, 0.76) for function.

Conclusions

There is insufficient evidence to support or refute the effectiveness of specific resistive exercise strategies in the rehabilitation of subacromial impingement syndrome. More high quality research is needed to accurately assess this. This review provides suggestions on how to improve the methodological design of future studies in this area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1518-0) contains supplementary material, which is available to authorized users.

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.

Ultrasound-detected pathologies cluster into groups with different clinical outcomes: data from 3000 community referrals for shoulder pain

Background

Ultrasound is increasingly used to evaluate shoulder pain, but the benefits of this are unclear. In this study, we examined whether ultrasound-defined pathologies have implications for clinical outcomes.

Methods

We extracted reported pathologies from 3000 ultrasound scans of people with shoulder pain referred from primary care. In latent class analysis (LCA), we identified whether individual pathologies clustered in groups. Optimal group number was determined by the minimum Bayesian information criterion. A questionnaire was sent to all patients scanned over a 12-month period (n = 2322). Data collected included demographics, treatments received, current pain and function. The relationship between pathology-defined groups and clinical outcomes was examined.

Results

LCA revealed four groups: (1) bursitis with limited inflammation elsewhere (n = 1280), (2) bursitis with extensive inflammation (n = 595), (3) rotator cuff tears (n = 558) and (4) limited pathology (n = 567). A total of 777 subjects (33%) completed questionnaires. The median (IQR) duration post-ultrasound scan was 25 (22–29) months. Subsequent injections were most common in groups 1 and 2 (groups 1–4 76%, 67%, 48% and 61%, respectively); surgery was most common in group 3 (groups 1–4 23%, 21%, 28% and 16%, respectively). Shoulder Pain and Disability Index scores were highest in group 3 (median 48 and 30, respectively) and lowest in group 4 (median 32 and 9, respectively). Patients in group 4 who had surgery reported poor outcomes.

Conclusions

In a community-based population, we identified clusters of pathologies on the basis of ultrasound. Our retrospective data suggest that these groups have different treatment pathways and outcomes. This requires replication in a prospective study to determine the value of a pathology-based classification in people with shoulder pain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1235-y) contains supplementary material, which is available to authorized users.

Rotator Cuff Disorders: A Survey of Current Uk Physiotherapy Practice

Background

Shoulder pain is a common problem and disorders of the rotator cuff are considered to be the commonest cause of this pain. Despite this, there is a paucity of high-quality research upon which to base practice. There is a clear need to determine the range of current practice as a basis upon which to inform future research.

Objectives

To describe current physiotherapy practice in relation to the assessment and management of rotator cuff disorders and to gain an insight into the perceived research needs of physiotherapists in the UK.

Methods

An electronic survey was developed and responses were sought in relation to a case report considered to represent a patient with a typical rotator cuff disorder.

Results

A total of 110 surveys were completed. The respondents stated that they would undertake a range of diagnostic tests, offer a wide variety of interventions and offer a broad prediction of prognosis.

Conclusion

Current physiotherapy practice in relation to rotator cuff disorders is variable, which might reflect the lack of high-quality evidence available. There is a clear need for high-quality research to inform physiotherapy practice in this burdensome area.

Validity evidence for two objective structured clinical examination stations to evaluate core skills of the shoulder and knee assessment

BACKGROUND

We developed two objective structured clinical examinations (OSCEs) to educate and evaluate trainees in the evaluation and management of shoulder and knee pain. Our objective was to examine the evidence for validity of these OSCEs.

METHODS

A multidisciplinary team of content experts developed checklists of exam maneuvers and criteria to guide rater observations. Content was proposed by faculty, supplemented by literature review, and finalized using a Delphi process. One faculty simulated the patient, another rated examinee performance. Two faculty independently rated a portion of cases. Percent agreement was calculated and Cohen's kappa corrected for chance agreement on binary outcomes. Examinees' self-assessment was explored by written surveys. Responses were stratified into 3 categories and compared with similarly stratified OSCE scores using Pearson's coefficient.

RESULTS

A multi-disciplinary cohort of 69 examinees participated. Examinees correctly identified rotator cuff and meniscal disease 88% and 89% of the time, respectively. Inter-rater agreement was moderate for the knee (87%; k = 0.61) and near perfect for the shoulder (97%; k = 0.88). No correlation between stratified self-assessment and OSCE scores were found for either shoulder (0.02) or knee (-0.07).

CONCLUSIONS

Validity evidence supports the continuing use of these OSCEs in educational programs addressing the evaluation and management of shoulder and knee pain. Evidence for validity includes the systematic development of content, rigorous control of the response process, and demonstration of acceptable interrater agreement. Lack of correlation with self-assessment suggests that these OSCEs measure a construct different from learners' self-confidence.

A systematic review of thrust manipulation for non-surgical shoulder conditions

Purpose

Although many conservative management options are available for patients with non-surgical shoulder conditions, there is little evidence of their effectiveness. This review investigated one manual therapy approach, thrust manipulation, as a treatment option.

Methods

A systematic search was conducted of the electronic databases from inception to March 2016: PubMed, PEDro, ICL, CINAHL, and AMED. Two independent reviewers conducted the screening process to determine article eligibility. Inclusion criteria were manuscripts published in peer-reviewed journals with human participants of any age. The intervention included was thrust, or high-velocity low-amplitude, manipulative therapy directed to the shoulder and/or the regions of the cervical or thoracic spine. Studies investigating secondary shoulder pain or lacking diagnostic confirmation procedures were excluded. Methodological quality was assessed using the PEDro scale and the Cochrane risk-of-bias tool.

Results

The initial search rendered 5041 articles. After screening titles and abstracts, 36 articles remained for full-text review. Six articles studying subacromial impingement syndrome met inclusion criteria. Four studies were randomized controlled trials (RCTs) and 2 were uncontrolled clinical studies. Five studies included 1 application of a thoracic spine thrust manipulation and 1 applied 8 treatments incorporating a shoulder joint thrust manipulation. Statistically significant improvements in pain scores were reported in all studies. Three of 4 RCTs compared a thrust manipulation to a sham, and statistical significance in pain reduction was found within the groups but not between them. Clinically meaningful changes in pain were inconsistent; 3 studies reported that scores met minimum clinically important difference, 1 reported scores did not, and 2 were unclear. Four studies found statistically significant improvements in disability; however, 2 were RCTs and did not find statistical significance between the active and sham groups.

Conclusions

No clinical trials of thrust manipulation for non-surgical shoulder conditions other than subacromial impingement syndrome were found. There is limited evidence to support or refute thrust manipulation as a solitary treatment for this condition. Studies consistently reported pain reduction, but active treatments were comparable to shams. High-quality studies of thrust manipulation with safety data, longer treatment periods and follow-up outcomes are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-016-0133-8) contains supplementary material, which is available to authorized users.

Reliability of physical examination tests for the diagnosis of knee disorders: Evidence from a systematic review

Clinicians often rely on physical examination tests to guide them in the diagnostic process of knee disorders. However, reliability of these tests is often overlooked and may influence the consistency of results and overall diagnostic validity. Therefore, the objective of this study was to systematically review evidence on the reliability of physical examination tests for the diagnosis of knee disorders. A structured literature search was conducted in databases up to January 2016. Included studies needed to report reliability measures of at least one physical test for any knee disorder. Methodological quality was evaluated using the QAREL checklist. A qualitative synthesis of the evidence was performed. Thirty-three studies were included with a mean QAREL score of 5.5 ± 0.5. Based on low to moderate quality evidence, the Thessaly test for meniscal injuries reached moderate inter-rater reliability (k = 0.54). Based on moderate to excellent quality evidence, the Lachman for anterior cruciate ligament injuries reached moderate to excellent inter-rater reliability (k = 0.42 to 0.81). Based on low to moderate quality evidence, the Tibiofemoral Crepitus, Joint Line and Patellofemoral Pain/Tenderness, Bony Enlargement and Joint Pain on Movement tests for knee osteoarthritis reached fair to excellent inter-rater reliability (k = 0.29 to 0.93). Based on low to moderate quality evidence, the Lateral Glide, Lateral Tilt, Lateral Pull and Quality of Movement tests for patellofemoral pain reached moderate to good inter-rater reliability (k = 0.49 to 0.73). Many physical tests appear to reach good inter-rater reliability, but this is based on low-quality and conflicting evidence. High-quality research is required to evaluate the reliability of knee physical examination tests.

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

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.

Utility of features of the patient's history in the diagnosis of atraumatic shoulder pain: a systematic review

BACKGROUND

Whereas physical examination tests for shoulder disorders have numeric values that describe the utility of the test and its effect on the probability of having a diagnosis, this information is lacking for elements of the history. The purpose of this study was to conduct a systematic review of the literature to determine numeric data (sensitivity, specificity, predictive values, and likelihood or odds ratios) for elements of the history with regard to diagnoses in patients with chronic atraumatic shoulder pain.

METHODS

We performed a systematic review to extract information from the existing literature regarding the numeric utility of different features of the patient history as they pertain to chronic atraumatic shoulder pain. Data sources were MEDLINE through PubMed (1946-January 2012) and EMBASE through Ovid (1980-January 2012).

RESULTS

Twenty-one studies met inclusion criteria. A diagnosis of rotator cuff tear was more likely with a history of hypercholesterolemia, having a relative with rotator cuff disease, excessive lifting, above-shoulder work, hand-held vibration work, or age older than 60 years. Acromioclavicular arthritis was more likely in weightlifters. Glenohumeral arthritis was more likely if the patient has a history of prior dislocation, age >75 years, or a diagnosis of knee osteoarthritis. Adhesive capsulitis was more likely with a history of diabetes or thyroid disorder. Posterior labral tear was more likely in football players.

CONCLUSIONS

The numeric values for the utility of these history features will help establish numeric probabilities for diagnoses in patients with shoulder pain.

Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review

Purpose The purpose of this review is to systematically explore and summarise the validity and reliability of telerehabilitation (TR)-based physiotherapy assessment for musculoskeletal disorders. Method A comprehensive systematic literature review was conducted using a number of electronic databases: PubMed, EMBASE, PsycINFO, Cochrane Library and CINAHL, published between January 2000 and May 2015. The studies examined the validity, inter- and intra-rater reliabilities of TR-based physiotherapy assessment for musculoskeletal conditions were included. Two independent reviewers used the Quality Appraisal Tool for studies of diagnostic Reliability (QAREL) and the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool to assess the methodological quality of reliability and validity studies respectively. Results A total of 898 hits were achieved, of which 11 articles based on inclusion criteria were reviewed. Nine studies explored the concurrent validity, inter- and intra-rater reliabilities, while two studies examined only the concurrent validity. Reviewed studies were moderate to good in methodological quality. The physiotherapy assessments such as pain, swelling, range of motion, muscle strength, balance, gait and functional assessment demonstrated good concurrent validity. However, the reported concurrent validity of lumbar spine posture, special orthopaedic tests, neurodynamic tests and scar assessments ranged from low to moderate. Conclusion TR-based physiotherapy assessment was technically feasible with overall good concurrent validity and excellent reliability, except for lumbar spine posture, orthopaedic special tests, neurodynamic testa and scar assessment.