Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis

Do therapeutic exercises impact supraspinatus tendon thickness? Secondary analyses of the combined dataset from two randomized controlled trials in patients with rotator cuff-related shoulder pain

BACKGROUND

The mechanistic response of rotator cuff tendons to exercises within the context of rotator cuff-related shoulder pain (RCRSP) remains a significant gap in current research. A greater understanding of this response can shed light on why individuals exhibit varying responses to exercise interventions. It can also provide information on the influence of certain types of exercise on tendons. The primary aim of this article is to explore if changes in supraspinatus tendon thickness (SSTT) ratio differ between exercise interventions (high load vs. low load). The secondary aims are to explore if changes in SSTT ratio differ between ultrasonographic tendinopathy subgroups (reactive vs. degenerative) and if there are associations between tendinopathy subgroups, changes in tendon thickness ratio, and clinical outcomes (disability).

METHODS

This study comprises secondary analyses of the combined dataset from two randomized controlled trials that compared high and low-load exercises in patients with RCRSP. In those trials, different exercise interventions were compared: 1) progressive high-load strengthening exercises and 2) low-load strengthening with or without motor control exercises. In 1 trial, there was also a third group that was not allocated to exercises (education only). Ultrasound-assessed SSTT ratio, derived from comparing symptomatic and asymptomatic sides, served as the primary measure in categorizing participants into tendinopathy subgroups (reactive, normal and degenerative) at baseline.

RESULTS

Data from 159 participants were analyzed. Two-way repeated measures ANOVAs revealed significant Group (P < .001) and Group × Time interaction (P < .001) effects for the SSTT ratio in different tendinopathy subgroups, but no Time effect (P = .63). Following the interventions, SSTT ratio increased in the "Degenerative" subgroup (0.14 [95% confidence interval {CI}: 0.09-0.19]), decreased in the "Reactive" subgroup (-0.11 [95% CI: -0.16 to -0.06]), and remained unchanged in the "Normal" subgroup (-0.01 [95% CI: -0.04 to 0.02]). There was no Time (P = .21), Group (P = .61), or Group × Time interaction (P = .66) effect for the SSTT ratio based on intervention allocation. Results of the linear regression did not highlight any significant association between the tendinopathy subgroup (P = .25) or change in SSTT ratio (P = .40) and change in disability score.

CONCLUSION

Findings from this study suggest that, over time, SSTT in individuals with RCRSP tends to normalize, compared to the contralateral side, regardless of the exercise intervention. Different subgroups of symptomatic tendons behave differently, emphasizing the need to potentially consider tendinopathy subtypes in RCRSP research. Future adequately powered studies should investigate how those different tendinopathy subgroups may predict long-term clinical outcomes.

Will my shoulder pain get better? - secondary analysis of data from a multi-arm randomised controlled trial

OBJECTIVE

To determine whether higher level or improvements over time in pain self-efficacy (PSE) and expectations of intervention effectiveness lead to better outcomes and whether the intervention used to manage rotator cuff related shoulder pain (RCRSP) impacts PSE and expectations over time.

DESIGN

Secondary analysis of data from a randomised controlled trial.

PARTICIPANTS

123 individuals (48 [15] years old; 51% female) with RCRSP.

INTERVENTIONS

Participants randomised into one of three 12-weeks interventions (education; education and motor control exercises; education and strengthening exercises).

MAIN OUTCOME MEASURES

QuickDASH and Western Ontario Rotator Cuff Index (WORC) were administered at baseline and 12 weeks. Pain self-efficacy was assessed at 0 and 6 weeks. Patients' expectations regarding intervention effectiveness were assessed before randomisation and after the first and the last intervention sessions. NparLD were used for the analyses. A time effect indicated a significant change in patients' expectations or PSE over time, while a resolution effect indicated a significant difference in patients' expectations or PSE between those whose symptoms resolved and those whose did not.

RESULTS

Patients' expectations (-3 to 3) increased over time (0.33/3 [0.19 to 0.77]). Overall expectations were higher for those who experienced symptom resolution based on the WORC (0.19/3 [0.05 to 0.33]). PSE increased over time (5.5/60 [3.6 to 7.4]). Overall PSE was higher for those who experienced symptom resolution based on the WORC (7.0 [3.9 to 10.1]) and the QuickDASH (4.9 [1.7 to 8.2]).

CONCLUSION

Clinicians should consider monitoring PSE and patients' expectations as they are important indicators of outcome. CONTRIBUTION OF THE PAPER.

Predictors for the Knee Extension Strength at 2 Yrs After Total Knee Arthroplasty Using Regression Tree Analysis

OBJECTIVE

The aim of the study is to clarify the interactive combinations of clinical factors associated with knee extension strength 2 yrs after total knee arthroplasty.

DESIGN

A retrospective cohort study was conducted on 264 patients who underwent total knee arthroplasty. Knee extension strength was assessed preoperatively, 3 wks, and 2 yrs after total knee arthroplasty. Physical functions were measured with 10-m walking test, Timed Up and Go test, one-leg standing time, isometric knee flexion strength, knee joint stability, knee pain, femora-tibial angle, and passive knee extension and flexion angle before surgery as a baseline and 3 wks after total knee arthroplasty as acute phase. Regression tree analysis was conducted to clarify the interactive combinations that accurately predict the knee extension strength 2 yrs after total knee arthroplasty.

RESULTS

Operational side knee extension strength (>1.00 Nm/kg) at acute phase was the primal predictor for the highest knee extension strength at 2 yrs after total knee arthroplasty. Acute phase Timed Up and Go test (≤10.13 secs) and baseline 10-m walking test (≤11.72 secs) was the second predictor. Acute phase nonoperative side knee extension strength (>0.90 Nm/kg) was also selected as the predictor.

CONCLUSIONS

This study demonstrated that knee extension strength or Timed Up and Go test in the acute phase and 10-m walking test before total knee arthroplasty are useful for estimating the knee extension strength after total knee arthroplasty. The results will help determine specific postoperative rehabilitation goals and training options.

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM): short term effects of a randomised controlled trial in primary care

PURPOSE

To evaluate short-term effects of the PREVention of Sickness Absence for Musculoskeletal disorders (PREVSAM) model on sickness absence and patient-reported health outcomes.

METHODS

Patients with musculoskeletal disorders were randomised to rehabilitation according to PREVSAM or treatment as usual (TAU) in primary care. Sickness absence and patient-reported health outcomes were evaluated after three months in 254 participants.

RESULTS

The proportion of participants remaining in full- or part-time work were 86% in PREVSAM vs 78% in TAU (p = 0.097). The PREVSAM group had approximately four fewer sickness benefit days during three months from baseline (p range 0.078-0.126). No statistically significant difference was found in self-reported sickness absence days (PREVSAM 12.4 vs TAU 14.5; p = 0.634), nor were statistically significant differences between groups found in patient-reported health outcomes. Both groups showed significant improvements from baseline to three months, except for self-efficacy, and only the PREVSAM group showed significantly reduced depression symptoms.

CONCLUSIONS

The findings suggest that for sickness absence, the PREVSAM model may have an advantage over TAU, although the difference did not reach statistical significance at the p < 0.05 level, and similar positive effects on patient-reported health outcomes were found in both groups. Long-term effects must be evaluated before firm conclusions can be drawn.

One-year effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a secondary analysis from a randomised controlled trial

OBJECTIVES

To investigate the long-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms.

METHODS

A secondary analysis of a superiority, parallel-group, randomised trial (balanced block randomisation 1:1, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times in total). The 1-year between-group difference in change in self-reported function was measured using the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best). Secondary outcomes were self-reported measures including changes in shoulder-related symptoms, function, emotions and lifestyle, quality of life, patient-perceived effect, treatment utility and adverse events. A blinded analyst conducted the analyses using linear mixed model repeated measurements analysis.

RESULTS

One-year data were available in 86 out of 100 participants (79% women, mean age 37.8 years) (LIGHT 84%, HEAVY 88%). The mean WOSI score between-group difference favoured HEAVY (-92.9, 95% CI -257.4 to 71.5, p=0.268) but was not statistically significant. The secondary outcomes were mostly inconclusive, but patients in HEAVY had larger improvement in the WOSI emotions subdomain (-36.3; 95% CI -65.4 to -7.3, p=0.014). Patient-perceived effect favoured HEAVY anchored in WOSI-emotions (55% vs 31%, p=0.027) and WOSI-lifestyle (50% vs 29%, p=0.042).

CONCLUSION

High-load shoulder strengthening exercise was not superior to low-load strengthening exercise in improving self-reported function at 1 year. High-load strengthening exercise may be more effective in improving patient emotions about shoulder pain and function, but more robust data are needed to support these findings.

TRIAL REGISTRATION NUMBER

NCT03869307.

Linking patient reported shoulder outcomes to the international classification of functioning, disability and health

PURPOSE

To link the items from shoulder-specific Patient Reported Outcome Measures (PROMs) to the International Classification of Functioning, Disability and Health (ICF) domains and categories, and to determine if the items fit into the ICF framework.

MATERIALS AND METHODS

The Brazilian versions of the Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST) and Western Ontario Rotator Cuff Index (WORC) were linked to the ICF by two researchers independently. Agreement between raters was determined by calculating the Kappa Index.

RESULTS

Fifty-eight items from the PROMs were linked to eight domains and 27 categories of ICF. The PROMs covered components of body functions, activities, and participation. Components of body structure and environmental factors were not covered by any of the PROMs. ​There was substantial agreement between raters when linking the OSS (Kappa index = 0.66), SPADI (Kappa index = 0.92), SST (Kappa index = 0.72) and WORC (Kappa index = 0.71).

CONCLUSIONS

WORC and SST were the PROMs that covered the highest number of ICF domains (seven and six, respectively). However, SST is short and may be less time consuming in a clinical assessment. Clinicians can benefit from this study to decide which shoulder-specific PROM may be more adequate according to the clinical demand.Implications For RehabilitationWestern Ontario Rotator Cuff Index was the shoulder-specific Patient Reported Outcome Measure (PROM) that best showed a broader view of functionality through the International Classification of Functioning, Disability and Health (ICF) domains that can influence shoulder pain and disability.Simple Shoulder Test seems to be the most recommended shoulder-specific PROM considering the number of domains covered by the ICF and the clinical evaluation time consumption.Shoulder Pain and Disability Index fails to provide a broader view of functioning through other ICF domains that may influence shoulder pain and disability.

Scapular muscle dynamic stiffness of asymptomatic subjects and subjects with chronic shoulder pain, at rest and isometric contraction conditions

Muscle stiffness had a crucial role in joint stability, particularly, at the shoulder complex. Although changes in upper trapezius muscle stiffness have been described for shoulder pain, contradictory findings have been obtained. Also, existing data regarding scapular muscles are, majorly, about trapezius. Myotonometry is a method used to assess stiffness; however, the reliability values of scapular muscle stiffness through this method have not been assessed in shoulder pain conditions. The present study aims to compare scapular muscles' stiffness (trapezius, serratus anterior, and levator scapulae) between subjects with and without chronic shoulder pain and to evaluate the related test-retest reliability. Twenty-two symptomatic and twenty-two asymptomatic subjects participated in a cross-sectional study. The dynamic muscular stiffness of scapular muscles, at rest and during an isometric contraction, was measured bilaterally with myotonometry, in two moments. The differences in bilateral averaged values between symptomatic and asymptomatic subjects and the effect of the group (group presenting pain in the dominant or non-dominant side, and asymptomatic group) and of the limb (unilateral painful or asymptomatic limb, and bilateral asymptomatic limbs) were investigated. Test-retest intra-rater reliability was determined. An effect of the group was observed at rest, for middle trapezius stiffness, and during contraction, for middle and lower trapezius stiffness. For middle trapezius, increased values were observed in the group presenting pain in non-dominant side comparing to both groups or to group presenting pain in dominant side. The intraclass correlation coefficient, majorly, ranged between 0.775 and 0.989. Participants with pain in the non-dominant side presented an increased middle trapezius' stiffness. Globally, high reliability was observed for scapular muscles dynamic stiffness.

Interaction of Biomechanical, Anthropometric, and Demographic Factors Associated with Patellofemoral Pain in Rearfoot Strike Runners: A Classification and Regression Tree Approach

BACKGROUND

Patellofemoral pain (PFP) is among the most common injuries in runners. While multiple risk factors for patellofemoral pain have been investigated, the interactions of variables contributing to this condition have not been explored. This study aimed to classify runners with patellofemoral pain using a combination of factors including biomechanical, anthropometric, and demographic factors through a Classification and Regression Tree analysis.

RESULTS

Thirty-eight runners with PFP and 38 healthy controls (CON) were selected with mean (standard deviation) age 33 (16) years old and body mass index 22.3 (2.6) kg/m2. Each ran at self-selected speed, but no between-group difference was identified (PFP = 2.54 (0.2) m/s x CON = 2.55 (0.1) m/s, P = .660). Runners with patellofemoral pain had different patterns of interactions involving braking ground reaction force impulse, contact time, vertical average loading rate, and age. The classification and regression tree model classified 84.2% of runners with patellofemoral pain, and 78.9% of healthy controls. The prevalence ratios ranged from 0.06 (95% confidence interval: 0.02-0.23) to 9.86 (95% confidence interval: 1.16-83.34). The strongest model identified runners with patellofemoral pain as having higher braking ground reaction force impulse, lower contact times, higher vertical average loading rate, and older age. The receiver operating characteristic curve demonstrated high accuracy at 0.83 (95% confidence interval: 0.74-0.93; standard error: 0.04; P < .001).

CONCLUSIONS

The classification and regression tree model identified an influence of multiple factors associated with patellofemoral pain in runners. Future studies may clarify whether addressing modifiable biomechanical factors may address this form of injury.

The Swedish version of the pain self-efficacy questionnaire short form, PSEQ-2SV: Cultural adaptation and psychometric evaluation in a population of patients with musculoskeletal disorders

OBJECTIVES

Measuring pain self-efficacy is suggested as relevant in patients with musculoskeletal disorders (MSDs) in a primary care setting. However, there is no pain self-efficacy questionnaire (PSEQ) available in Swedish. The aim of this study was to translate and culturally adapt PSEQ-2 to Swedish and evaluate reliability and validity in a population of patients with MSDs.

METHODS

A translation and cultural adaptation together with psychometric evaluation of reliability and validity were performed according to guidelines with three groups of participants with MSDs. First, a convenient sample of 25 individuals were interviewed in the translation process. Next, 61 participants completed the test-retest survey via social media or QR codes in waiting rooms in rehabilitation clinics. Finally, to evaluate construct validity questionnaires were obtained from 132 participants with MSDs in an ongoing randomized controlled trial.

RESULTS

The Swedish version of PSEQ-2 showed adequate face and content validity. The results of 0.805 on Cohen's weighted kappa indicate that the reliability of PSEQ-2SV in a group of adults with MSDs is on the border between substantial and almost perfect. The point estimate regarding relative rank variance, measuring the individual variation within the group, and relative concentration, the systematic change in how the assessments are concentrated on the scale's categories, shows minor systematic differences and some random differences not neglectable. The construct validity of pre-defined hypotheses was met to some degree.

CONCLUSION

The PSEQ-2SV has been accurately linguistically translated and tested for reliability and validity, in a population of MSDs, and is deemed to be able to be used in the clinic and in research. As there were some concerns regarding measurement error and systematic bias, more research could be of value.

"Restoring That Faith in My Shoulder": A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff-Related Shoulder Pain

OBJECTIVE

Rotator cuff-related shoulder pain (RCRSP) is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for RCRSP. However, the causal mechanisms underpinning the benefits of exercise for RCRSP are not well understood. Moreover, how individuals with lived experience of RCRSP believe exercise helped or did not help them is unknown. This study aimed to gain insights into how individuals with RCRSP believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs.

METHODS

This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semi-structured interview. The data were coded by 2 members of the research team (J.K.P. and N.C.) and verified by a third (B.S.). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations.

RESULTS

Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psychoemotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress.

CONCLUSION

Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with RCRSP was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself.

IMPACT

Exercise is a recommended first-line intervention to manage RCRSP. The results of this study suggest that a positive experience and outcome with exercise for RCRSP is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context that an exercise program is prescribed and delivered within should be considered by clinicians.

Shoulder pain: Is the outcome of manual therapy, acupuncture and electrotherapy different for people with high compared to low pain self-efficacy? An analysis of effect moderation

Background

High baseline pain self-efficacy (PSE) predicts a better outcome for people attending physiotherapy for musculoskeletal shoulder pain. A potential contributing factor is that PSE moderates the relationship between some treatment modalities and outcome. Our aim was to investigate whether there is a difference in outcome between participants with high compared to low PSE receiving manual therapy, acupuncture, and electrotherapy.

Methods

Participants were stratified into high or low baseline (i) PSE, (ii) shoulder pain and disability index (SPADI), and (iii) did or did not receive the treatment. Whether the effect of treatment differs for people with high compared to low PSE was assessed using the 95% confidence interval of the difference of difference (DoD) at a 5% significance level (p < 0.05).

Results

Six-month SPADI scores were consistently lower (less pain and disability) for those who did not receive passive treatments compared to those who did (statistically significant less pain and disability in 7 of 24 models). However, DoD was statistically insignificant.

Conclusion

PSE did not moderate the relationship between treatment and outcome. However, participants who received passive treatment experienced equal or more pain and disability at 6 months compared to those who did not. Results are subject to confounding by indication but do indicate the need for further appropriately designed research.

Level of Evidence

Level of evidence II-b.

Risk profiles for smoke behavior in COVID-19: a classification and regression tree analysis approach

BACKGROUND

COVID-19 pandemic emerged worldwide at the end of 2019, causing a severe global public health threat, and smoking is closely related to COVID-19. Previous studies have reported changes in smoking behavior and influencing factors during the COVID-19 period, but none of them explored the main influencing factor and high-risk populations for smoking behavior during this period.

METHODS

We conducted a nationwide survey and obtained 21,916 valid data. Logistic regression was used to examine the relationships between each potential influencing factor (sociodemographic characteristics, perceived social support, depression, anxiety, and self-efficacy) and smoking outcomes. Then, variables related to smoking behavior were included based on the results of the multiple logistic regression, and the classification and regression tree (CART) method was used to determine the high-risk population for increased smoking behavior during COVID-19 and the most profound influencing factors on smoking increase. Finally, we used accuracy to evaluated the performance of the tree.

RESULTS

The strongest predictor of smoking behavior during the COVID-19 period is acceptance degree of passive smoking. The subgroup with a high acceptation degree of passive smoking, have no smokers smoked around, and a length of smoking of ≥ 30 years is identified as the highest smoking risk (34%). The accuracy of classification and regression tree is 87%.

CONCLUSION

The main influencing factor is acceptance degree of passive smoking. More knowledge about the harm of secondhand smoke should be promoted. For high-risk population who smoke, the "mask protection" effect during the COVID-19 pandemic should be fully utilized to encourage smoking cessation.

Exercise into pain in chronic rotator cuff related shoulder pain: a prospective single-group feasibility study

OBJECTIVES

This study evaluated the feasibility of exercising into pain in rotator cuff related shoulder pain (RCRSP), data collection procedures, feedback from physiotherapists and patients, and clinically important changes in patient-reported outcome measures (PROMs).

DESIGN

Unblinded non-randomised single-group study.

SETTING

Physiotherapy clinic in Belgium.

PARTICIPANTS

Twelve patients with unilateral RCRSP for minimum 3 months, aged 18-65 years.

INTERVENTIONS

Twelve weeks of four individualised exercises, with nine physiotherapist-led sessions with pain ratings 4-7 out of 10 on a verbal Numeric Pain Rating Scale for 9 weeks and then pain ratings 0-2 for 3 weeks. Every physiotherapy session included 15 min of manual therapy. Non-supervised exercises were: 2×/week in weeks with physiotherapy session, 3×/week in weeks without physiotherapy session.

OUTCOME MEASURES

Primary: adherence, where patients were considered adherent with 78% (7/9 sessions) attendance for supervised sessions and 81% (22/27 sessions) completion for non-supervised exercises, and Shoulder Pain and Disability Index (SPADI); secondary: fear-avoidance behaviour, fear of pain, physical outcomes (strength, range of motion, scapular dyskinesis); others: ultrasound (US) imaging outcomes (acromionhumeral distance, supraspinatus tendon thickness, occupation ratio), global perceived effect (GPE). PROMs were collected via online survey, except for the GPE (via closed envelope). US measures were taken after physical measures.

RESULTS

Adherence and adverse effects were analysed in patients who had the possibility to attend minimum seven supervised sessions (n=8): 88% of them adhered to supervised sessions, 50% to non-supervised exercises; none of them withdrew from the study, three of them obtained individual clinically important improvements in SPADI score above 20 points. The measurement protocol of physical and ultrasonographic outcomes took around 60 min.

CONCLUSIONS

Adherence to supervised sessions was satisfactory, the adherence to non-supervised exercises must be improved. Data collection procedures were feasible to perform, but some changes are recommended.

TRIAL REGISTRATION NUMBER

NCT04154345.

Pain Control Beliefs Predict Premature Withdrawal From the Labor Market in Workers With Persistent Pain: Prospective Cohort Study With 11-Year Register Follow-up

While a range of work-related psychosocial factors has been associated with various pain disorders and early retirement, less is known about pain cognitions and their influence on premature exit from the labor market. Therefore, as a primary objective, this study investigates associations between pain control beliefs and risk of disability pension among Danish eldercare workers. In 2005, 2257 female eldercare workers with low-back and/or neck/shoulder pain>90 days within the previous 12 months, replied to a survey and were followed for 11 years in a national register of social transfer payments. Using Cox regression, we estimated the risk of disability pension during follow-up from experiencing different levels of "pain control" and "pain influence," controlling for pain intensity and other relevant confounders. In the fully adjusted model for pain control with "high" as reference, hazard ratios of 1.30 (95% CI 1.03-1.64) and 2.09 (95% CI 1.45-3.01) are observed for "moderate" and "low," respectively, while the metric of pain influence shows hazard ratios of 1.43 (95% CI 1.11-1.87) and 2.10 (1.53-2.89), respectively. Pain control beliefs are associated with disability pension among eldercare workers with persistent pain. These results highlight the importance of evaluating not only bodily manifestations of pain, but also individual pain-related cognitions that may influence the experience of pain. PERSPECTIVE: This article addresses the complex experience of pain within an organizational context. We introduce the metrics of "pain control" and "pain influence" among workers with persistent pain, showing that the psychometric properties of these measures are prospectively associated with premature exit from the labor market.

Scapular movement training is not superior to standardized exercises in the treatment of individuals with chronic shoulder pain and scapular dyskinesis: randomized controlled trial

PURPOSE

To investigate whether scapular movement training (SMT) is superior to standardized exercises in improving scapular biomechanics, behavioral, and clinical aspects of individuals with shoulder pain.

METHODS AND METHODS

A total of 64 individuals with chronic shoulder pain were randomly assigned to receive 16 sessions of SMT or SE over 8 weeks. Outcome measures included three-dimensional scapular kinematics, muscle activity of scapulothoracic muscles, pain, disability, fear-avoidance, kinesiophobia, and self-perceived changes. Kinematics and muscle activity were assessed at baseline and after treatment, and self-reported measurements at baseline, 4, 8, and 12 weeks.

RESULTS

SMT significantly (p < 0.05) decreased scapular internal rotation during arm elevation and lowering at sagittal and scapular planes (mean difference [MD]: ranged from 2.8 to 4.1°), and at lower angles of arm elevation and lowering at the frontal plane (MD: 3.4° and 2.4°, respectively), increased upper trapezius (UT) activity (MD: 10.3%) and decreased middle trapezius (MT) (MD: 60.4%) and serratus anterior (MD: 9.9%) activity during arm lowering compared to SE. Both groups significantly improved pain, disability, fear-avoidance, kinesiophobia, and self-perceived changes over 4 weeks, which was sustained over the remaining 8 weeks.

CONCLUSIONS

SMT is not superior to standardized exercises in improving scapular biomechanics, behavioral, and clinical aspects of individuals with shoulder pain.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03528499Implications for rehabilitationScapular movement training (SMT) showed small and likely not clinically relevant changes in scapular kinematics and muscle activity compared to standardized exercises.SMT and standardized exercises presented similar improvements in pain, disability, fear-avoidance beliefs, kinesiophobia, and self-perceived change in health condition immediately following 4-weeks of treatment, which was sustained over the following 8 weeks.The changes in patient-reported outcome measures are unlikely to be associated with changes in scapular kinematics and electromyographic activity.Clinicians should consider other factors than scapular movement during the treatment of patients with shoulder pain.

Psychological factors and symptom duration are associated with exercise-based treatment effect in people with hypermobile shoulders: A secondary analysis of a randomised controlled trial

BACKGROUND

Shoulder symptoms are common in patients with hypermobility spectrum disorders (HSD), but few studies focus on identifying factors associated with treatment effects.

AIM

To identify baseline and clinical characteristics associated with a better outcome 16 weeks after starting an exercise-based treatment in patients with HSD and shoulder symptoms.

DESIGN

Exploratory secondary analysis of data from a randomised controlled trial.

METHOD

Self-reported treatment outcome was reported as change between baseline and follow-up after 16 weeks of high-load or low-load shoulder strengthening. Multiple linear and logistic regressions were used to investigate associations of patient expectations of treatment effect, self-efficacy, fear of movement, and symptom duration with change in shoulder function, shoulder pain, quality of life, and patient reported health change. All regression models were performed firstly with adjustments for covariates (age, sex, body mass index, hand dominance, treatment group, and baseline score of the outcome variable) and secondly with additional adjustments for exposure variables.

RESULTS

Expectations of complete recovery were associated with an increased odds of perceiving an important improvement in physical symptoms after a 16-week exercise-based treatment program. Higher self-efficacy at baseline seemed to be associated with improved shoulder function, shoulder pain and quality of life. A higher fear of movement seemed to be associated with increased shoulder pain and decreased quality of life. A longer symptom duration was associated with decreased quality of life.

CONCLUSION

Expectations of complete recovery, higher self-efficacy, lower fear of movement and shorter symptom duration seem to be important for better treatment outcomes.

Prediction of anorectal malformations with bladder-neck/urethral-prostatic fistula using classification and regression tree analysis

BACKGROUND

The anorectal malformations (ARMs) with bladder-neck/urethral-prostatic fistula in males are the most complex groups in ARMs. It is essential to diagnose them effectively before the primary operation for both surgical modalities and future functional prognosis can be quite different from other types. Our study aimed to develop a classification and regression tree (CART) model for the prediction of ARMs with bladder-neck/urethral-prostatic fistula.

METHODS

A total of 132 newborns with ARMs were included retrospectively and randomly assigned to the training sample and test sample in a 3:1 ratio. The pouch-perineum distance of ultrasound (PPDU), the pouch-perineum distance of invertogram (PPDI), and the rectum gas above the coccyx (RGAC) on the invertogram were hypothesized can serve as individual predictors. The CART analysis was used to determine the best combination of candidate predictors. The model's performance was assessed by the area under the receiver operating characteristic curve (AUC) and validated in the test sample.

RESULTS

All three individual predictors were included in the CART model to predict the ARMs with bladder-neck/urethral-prostatic fistula in the derivation cohort with the following test characteristics (95% CI): sensitivity 75.6% (60.1 to 86.6); specificity 88.9% (76.7 to 95.4); AUC 0.909 (0.854 to 0.965). The model's predicted accuracy was validated in the test cohort (AUC = 0.883). In all 132 subjects, the AUC of the tree model was significantly superior to that of the best individual index: PPDU (0.901 vs. 0.819; p = 0.005).

CONCLUSIONS

A predictive model that consists of PPDU, PPDI, and RGAC may be useful in predicting ARMs with bladder-neck/urethral-prostatic fistula.

Immediate response to injection is associated with conservative care outcomes at 12 weeks in subacromial shoulder pain

BACKGROUND

Subacromial injection is known to influence pain of subacromial origin, yet its association with conservative care outcomes is unknown. This study investigated whether immediate response to subacromial injection of corticosteroid and local anaesthetic is associated with conservative care outcomes at 12 weeks post injection and/or progression to surgery.

DESIGN

prospective prognostic cohort study.

METHODS

Sixty-four participants with subacromial related shoulder pain attending initial orthopaedic outpatient appointment at an Australian public hospital, received subacromial injection of corticosteroid and local anaesthetic followed by up to 12 weeks of physiotherapy. Immediate response to injection was measured by change in shoulder range of motion (ROM) and pain immediately (within 20 min) before and after injection. The Shoulder Pain and Disability Index (SPADI) was measured at baseline, 6 and 12-weeks.

RESULTS

Backward stepwise linear regression revealed immediate post-injection improvement in pain-free ROM (p = 0.001) and higher baseline symptoms (p = 0.016) were significantly associated with better 12-week SPADI outcomes. Longer symptom duration (p = 0.029) and higher age (p = 0.013) were significantly associated with poorer outcomes. Only 11 individuals progressed to surgery. The resultant model could explain 35% of the variation in change in SPADI at 12 weeks.

CONCLUSION

Improvement in pain-free shoulder ROM immediately post injection is significantly associated with better 12-week conservative care outcomes. This information, derived from within consultation injection responses, could help inform decisions about potential treatment options. Further research with higher numbers and longer-term patient-reported outcomes could further clarify these findings.

REGISTRATION

Australia and New Zealand Clinical Trials Registry 21 May 2012: 12612000532808.

'Thinking about pain in a different way': Patient perspectives of a neuroscience-informed physiotherapy programme for rotator cuff-related shoulder pain

BACKGROUND

Rotator cuff-related shoulder pain (RCRSP) is a common musculoskeletal problem. The multi-factorial contributors to persistent pain are often overlooked during treatment. Pain neuroscience education (PNE) contributes to a holistic approach for patients with persistent pain but has not yet been researched for patients with RCRSP.

OBJECTIVE

To explore the perspectives and experiences of participants with RCRSP who had completed a programme of PNE-informed pragmatic physiotherapy.

DESIGN

A qualitative study using semi-structured interviews.

METHODS

We included a sub-group of five males and five females, aged 46-75 years, with persistent RCRSP of at least three months. They had undertaken a three-month pragmatic physiotherapy integrated with PNE. Individual semi-structured interviews were recorded, transcribed verbatim, and analysed using the General Inductive Approach.

RESULTS

Four themes emanated from the interviews. The first two themes were named 'Patient Beliefs' and overall 'Rapport and Relationship'. Another theme, 'Perspective and Understanding of the Resources', indicated diverse uptake of the resource information. The participants reported developing self-management skills, active coping strategies and a reduction in fear of pain described by the theme: 'Empowerment: My Shoulder into the Future'.

CONCLUSIONS

Participants experienced a change in their beliefs, which were enhanced by an individualised delivery and a strong therapeutic relationship through the course of the physiotherapy care. The participants appeared to value when the physiotherapist listened to and understood their beliefs. This required a shift in the patient-therapist relationship from the physiotherapist being the 'expert' to facilitating the patient's ability to take control of their shoulder health.

A critical appraisal of web-based information on shoulder pain comparing biomedical vs. psychosocial information

BACKGROUND

Websites have become a primary way for patients to access health-related information, which allows patients to not only understand their condition better but also to engage in better decision making with their health care provider. However, this can be a double-edged sword, as information patients access may not be of high quality, easily readable, or could be biased based on website authorship. This study examines the readability and content quality of common websites about shoulder pain, with a specific focus on biomedical vs. psychosocial information.

METHODS

The Flesch reading-ease score (FRES) and Flesch-Kincaid grade level (FKGL) instruments were used to assess website readability. Health on the net code of conduct (HONcode) certification and the DISCERN tool were used to evaluate the reliability and quality of information. Lastly, shoulder-specific content quality and focus was gauged using a Shoulder-specific Website Appraisal Tool (SWAT) created for this study. A systematic search protocol was used to identify popular shoulder injury websites. The websites were identified using 5 search terms (shoulder pain, shoulder muscle pain, shoulder impingement, shoulder rotator cuff pain, and shoulder pain diagnosis) across 5 English-speaking regions (United States, Canada, United Kingdom, Australia, and New Zealand) using the Google search engine. The top 10 websites for each term and region combination were included and combined, yielding 41 original websites for appraisal; several (6) websites were omitted as duplicates, behind paywalls, or nontext (video) for a total of 35 websites appraised.

RESULTS

On average, the FRES shoulder pain websites readability was 55.37, which is categorized as "fairly difficult" to read, and a seventh- or eighth-grade reading level based on the FKGL. For trustworthiness and bias, 57% (20 of 35) of the websites were HONcode certified. The quality of health care information using the DISCERN score averaged 50.92%. Examining shoulder-specific content quality, the average SWAT score was 10.54 out of 14 possible points, with only 1 website reporting information on psychosocial aspects of shoulder pain.

CONCLUSIONS

This study suggests that shoulder pain websites present information that is at too high of a reading level for public consumption, has a strong bias toward biomedical causes of shoulder pain, and would benefit from implementation of website screening tools to improve evidence-based content.

A Machine Learning Approach to Identify Previously Unconsidered Causes for Complications in Aesthetic Breast Augmentation

INTRODUCTION

Primary breast augmentation is one of the most commonly requested aesthetic procedures. Considering the large number of procedures performed in connection with a high demand, it is crucial to prevent complications. For this reason, finding and avoiding possible sources of complications is decisive.

METHODS

Between January 2010 and December 2021, 1625 female patients underwent an aesthetic breast augmentation performed by a single surgeon. The data collected were analyzed through a machine learning technique for binary recursive partitioning. This made it possible to detect unknown sources of a complication and determine a vertex for the various features.

RESULTS

When analyzing the data, for most features a high importance score with low entropy was achieved, concluding a high significance. In addition, reproducibility was demonstrated through detailed testing and training accuracies in the algorithm. With this procedure, in addition to known risks such as a high BMI and round implant shape, a larger than A preoperative bra-cup size (OR: 2.7) and a taller body could also be identified as most significant influencing factors for complications.

DISCUSSION

Preoperative breast size plays an exceptionally important role in the occurrence of complications and should be a factor held in a surgeon's considerations. In addition, this study shows ways to transfer artificial intelligence into plastic surgery to increase medical quality.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Unhappy Shoulder: A Conceptual Review of the Psychosomatics of Shoulder Pain

INTRODUCTION

Chronic pain is a multifaceted disorder genuinely entangled with psychic and psychosomatic symptoms, which are typically involved in the processes of chronification. The impingement syndrome of the shoulder is no exception to this rule, but several studies have shown respective peculiarities among those with pain and impingement of the shoulder. Notably, chronic pain is a lateralized experience, and, similarly, its psychosomatic correlates may be attached to the hemispheres functionally.

AIM

The present review therefore gives an overview of the respective findings, with regard not only to psychopathology, but also to personality factors and psychologic trauma, since the latter are reportedly associated with chronic pain. Moreover, we acknowledge symmetry as a possible pathogenic factor.

METHODS

This narrative review followed the current standards for conducting narrative studies. Based on prior findings, our research strategy included the relevance of psychotraumatologic and symmetrical aspects, as well as comorbidity. We retrieved the relevant literature reporting on the impact of psychopathology as well as personality features on shoulder pain, as published up to January 2022 from the Medline database (1966-2022). Study selecton: We included numerous studies, and considered the contextual relevance of studies referring to the neuropsychosomatics of chronic pain.

RESULTS

Pain-specific fears, depression, and anxiety are important predictors of shoulder pain, and the latter is generally overrepresented in those with trauma and PTSD. Moreover, associations of shoulder pain with psychological variables are stronger as regards surgical therapies as compared to conservative ones. This may point to a specific and possibly trauma-related vulnerability for perioperative maladaptation. Additionally, functional hemispheric lateralization may explain some of those results given that limb pain is a naturally lateralized experience. Not least, psychosocial risk factors are shared between shoulder pain and its physical comorbidities (e.g., hypertension), and the incapacitated state of the shoulder is a massive threat to the function of the human body as a whole.

CONCLUSIONS

This review suggests the involvement of psychosomatic and psychotraumatologic factors in shoulder impingement-related chronic pain, but the inconclusiveness and heterogeneity of the literature in the field is possibly suggestive of other determinants such as laterality.

Reliability, validity, and responsiveness of a Canadian French adaptation of the pain self-efficacy questionnaire (PSEQ)

PURPOSE

The objectives of this study were to translate the Pain Self-Efficacy Questionnaire (PSEQ) into Canadian French (PSEQ-F) and to evaluate its validity, reliability and responsiveness in a French-Canadian sample of patients with persistent rotator cuff related shoulder pain (RCRSP).

METHODS

Translation and cross-cultural adaptation of the original English version of the PSEQ into Canadian French were performed according to standard procedures. Thereafter, 78 adults with RCRSP completed the PSEQ-F on three occasions: baseline, 2 days later to evaluate the reliability and 6 weeks later to evaluate responsiveness.

RESULTS

Cross-cultural adaptation was performed without problems with content or language. The PSEQ-F was found to be reliable (Intraclass Correlation Coefficient = 0.96; Minimal Detectable Change = 3 points [5%]), valid (moderate correlations with an abbreviated version of Disability of the Arm, Shoulder and Hand [QuickDASH] and Brief Pain Inventory [BPI] Questionnaires) and responsive (Standardized Response Mean = 0.96; Effect Size = 0.81; Minimal Clinically Important Difference = 6 points [10%]).

CONCLUSION

The PSEQ-F is a reliable, valid and responsive questionnaire that can be used to assess pain self-efficacy in French-speaking individuals with RCRSP. Further studies should use a self-efficacy-specific Global Rating of Change scale to estimate its responsiveness more thoroughly.Implications for rehabilitationHigher levels of pain self-efficacy have been associated with increased odds of symptom resolution in those with persistent rotator cuff related shoulder pain (RCRSP).The Pain Self-Efficacy Questionnaire (PSEQ) has been identified as the most frequently used tool by clinicians to assess pain self-efficacy in patients at risk of developing persistent musculoskeletal pain.The Canadian French version of the PSEQ (PSEQ-F) is a reliable, valid and responsive questionnaire that can be used to assess pain self-efficacy in French-speaking individuals with RCRSP.

Individuals' beliefs about the biopsychosocial factors that contribute to their chronic musculoskeletal pain: protocol for a qualitative study in the UK

INTRODUCTION

Chronic musculoskeletal pain (CMP) is described as pain that persists for longer than 3 months. At present, no research is available that understands why CMP develops and continues from the perspective of the individual. Research is needed to establish if there are any consistent biopsychosocial factors perceived as contributing to CMP and what informs such beliefs. Understanding individual beliefs will inform more effective communication between clinicians and patients about their CMP, as well as informing future research into the epidemiology of CMP. Interpretative phenomenological analysis will be used as a methodological framework as it explores how individuals make sense of their world through personal experiences and perceptions while preserving individual nuance. The aim of this study is to understand individuals' beliefs and perceptions about the biological, psychological and social factors, which contribute to the development and maintenance of their CMP.

METHODS AND ANALYSIS

A qualitative study informed by the Consolidated Criteria for Reporting Qualitative Research using interpretative phenomenological analysis and semistructured interviews. A maximum variation purposive sample of 6-12 adults with CMP will be recruited from the general public in the UK. One semistructured interview will be conducted with each participant via an online video platform with interviews transcribed verbatim. The interview schedule (codesigned with expert patients and informed by existing evidence) identifies three domains of important questions; (1) patient beliefs on why they developed and continue to experience CMP; (2) the relationship between their biopsychosocial experiences and CMP; and (3) the origin of their beliefs. Strategies such as 'member checking' will be employed to ensure trustworthiness.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Research Ethics Office at the University of Birmingham (reference ERN_21-0813). Informed consent will be obtained from all participants. The study findings will be submitted for publication in a peer-reviewed journal and for presentation at conferences.

Short-term effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial

OBJECTIVES

To investigate the short-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms.

METHODS

A superiority, parallel-group, randomised trial (balanced block randomisation, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or shoulder instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times). The primary outcome was the 16-week between-group difference in self-reported function measured with the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best, minimal important difference 252 points). Secondary outcomes were self-reported measures including quality of life and clinical tests including shoulder muscle strength and range of motion. An intention-to-treat analysis with multiple imputation was conducted by a blinded biostatistician using linear regression.

RESULTS

93 of 100 patients (93%) completed the 16-week evaluation. The mean WOSI score between-group difference significantly favoured HEAVY (-174.5 points, 95% CI -341.4 to -7.7, adjusted for age, sex, baseline score, clustering around clinic). The secondary outcomes were inconclusive, but patients in HEAVY were less likely to have a positive shoulder rotation test >180°, and more likely to rate an important improvement in physical symptoms. There were no serious adverse events, but HEAVY was associated with more transient muscle soreness (56% vs 37%) and headaches (40% vs 20%).

CONCLUSION

High-load shoulder strengthening exercise was statistically superior to low-load strengthening exercise for self-reported function at 16 weeks and may be used in primary care to treat patients with HSD and shoulder pain and/or instability to improve shoulder function in the short term. Further studies are needed to confirm the clinical relevance, and patients should be supported to manage associated minor adverse events.

TRIAL REGISTRATION NUMBER

NCT03869307.

Rating the Quality of Smartphone Apps Related to Shoulder Pain: Systematic Search and Evaluation Using the Mobile App Rating Scale

Background

The successful rehabilitation of musculoskeletal pain requires more than medical input alone. Conservative treatment, including physiotherapy and exercise therapy, can be an effective way of decreasing pain associated with musculoskeletal pain. However, face-to-face appointments are currently not feasible. New mobile technologies, such as mobile health technologies in the form of an app for smartphones, can be a solution to this problem. In many cases, these apps are not backed by scientific literature. Therefore, it is important that they are reviewed and quality assessed.

Objective

The aim is to evaluate and measure the quality of apps related to shoulder pain by using the Mobile App Rating Scale.

Methods

This study included 25 free and paid apps—8 from the Apple Store and 17 from the Google Play Store. A total of 5 reviewers were involved in the evaluation process. A descriptive analysis of the Mobile App Rating Scale results provided a general overview of the quality of the apps.

Results

Overall, app quality was generally low, with an average star rating of 1.97 out of 5. The best scores were in the “Functionality” and “Aesthetics” sections, and apps were scored poorer in the “Engagement” and “Information” sections. The apps were also rated poorly in the “Subjective Quality” section.

Conclusions

In general, the apps were well built technically and were aesthetically pleasing. However, the apps failed to provide quality information to users, which resulted in a lack of engagement. Most of the apps were not backed by scientific literature (24/25, 96%), and those that contained scientific references were vastly out-of-date. Future apps would need to address these concerns while taking simple measures to ensure quality control.

The Role of Patient Recovery Expectations in the Outcomes of Physical Therapist Intervention: A Systematic Review

OBJECTIVE

The purpose of this study was to determine the association between baseline patient recovery expectations and outcomes following physical therapy care.

METHODS

PubMed, CINAHL Complete, PEDro, SPORTDiscus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and PsycINFO were searched from inception to February 2021. Concepts represented in the search included physical therapy, patient expectations, patient outcomes, and their relevant synonyms. Two reviewers independently screened studies of article abstracts and full texts. Eligibility criteria included English language studies that evaluated adults seeking physical therapist intervention for any health condition where both patient outcome (recovery) expectations and functional or other outcome measures were reported. Methodologic standards were assessed using the Critical Appraisal Skills Program criteria. Data were extracted using a custom template for this review with planned descriptive reporting of results. Vote counting was used to measure reported outcomes.

RESULTS

Twenty-one studies were included in this review, representing 4879 individuals. Studies were most commonly prospective cohort studies or secondary analyses of controlled trials. Varied expectation, outcome, and statistical measures that generally link patient recovery expectations with self-reported outcomes in musculoskeletal practice were used.

CONCLUSION

Patient recovery expectations are commonly associated with patient outcomes in musculoskeletal physical therapy.

IMPACT

Evidence supports measuring baseline patient expectations as part of a holistic examination process.

Rotator cuff repair vs. nonoperative treatment: a systematic review with meta-analysis

BACKGROUND

Rotator cuff (RC) tears have been widely studied as many treatment strategies have been recommended. However, optimal management for patients with RC tears is still unclear.

PURPOSE

The main aim of this systematic review was to analyze randomized controlled trials using meta-analysis to compare repair to conservative treatments for patients with any type of RC tear.

METHODS

MEDLINE, Cochrane Library (CENTRAL database), PEDro, and Scopus databases were used. Two independent reviewers selected randomized controlled trials that compared surgical to conservative treatments for RC tear patients. The studies included were assessed using Cochrane Risk of Bias 2 tools, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and to summarize the study conclusions.

RESULTS

Six trials were included. Pooled results showed improvement in function and pain perception in favor of the repair group at 6 months (mean difference 1.26, 95% CI -2.34, 4.85, P = .49; and -0.59, 95% CI -0.84, -0.33, P < .001, respectively), at 12 months (mean difference 5.25, 95% CI 1.55, 8.95, P = .005, for function; and -0.41, 95% CI -0.70, -0.12, P = .006, for pain) and at 24 months (mean difference 5.57, 95% CI 1.86, 9.29, P = .003, for function; and -0.92, 95% CI -1.31, -0.52, P < .001, for pain) in RC tear patients. However, these differences did not reach the minimum clinically important difference. The certainty of evidence ranged from low to moderate because of imprecision in the studies included.

CONCLUSIONS

Overall analysis showed that in patients with RC tear, repair compared with conservative treatment could result in increased pain reduction and functional improvement at 6, 12, and 24 months. Even if these effects were often statistically significant, their clinical relevance was limited. Moreover, the certainty of body of evidence ranged from low to moderate.

Predicting change in symptoms and function in patients with persistent shoulder pain: a prognostic model development study

BACKGROUND

Persistent shoulder pain causes considerable disruption of the individual's life and imposes high costs on healthcare and society. Well-informed treatment and referral pathways are crucial as unsuccessful interventions and longer duration of symptoms minimizes the likelihood of success in future interventions. Although physiotherapy is generally recommended as first line treatment, no prognostic model or clinical prediction rules exists to help guide the treatment of patients with persistent shoulder pain undergoing physiotherapy. Thus, the objective of this study was to develop a prognostic model to inform clinical decision making and predict change in symptoms and function in patients with persistent shoulder pain.

METHODS

This was a prospective cohort study of 243 patients with persistent shoulder pain referred to outpatient physiotherapy rehabilitation centres. Data was collected at baseline and six-month follow-up. The outcome was change in shoulder symptoms and function as measured by the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) from baseline to 6 months follow up. Potential predictors were included in a multivariable linear regression model which was pruned using modified stepwise backwards elimination.

RESULTS

The final model consisted of seven predictors; baseline QuickDASH score, employment status, educational level, movement impairment classification, self-rated ability to cope with the pain, health-related quality of life and pain catastrophizing. Together these variables explained 33% of the variance in QuickDASH-change scores with a model root mean squared error of 17 points.

CONCLUSION

The final prediction model explained 33% of the variance in QuickDASH change-scores at 6 months. The root mean squared error (model SD) was relatively large meaning that the prediction of individual change scores was quite imprecise. Thus, the clinical utility of the prediction model is limited in its current form. Further work needs be done in order to improve the performance and precision of the model before external validity can be examined along with the potential impact of the model in clinical practice. Two of the included predictors were novel and could be examined in future studies; movement impairment classification based on diagnosis and health-related quality of life.

Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review

Background

Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention.

Methods

This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against.

Results

Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome.

Conclusions

Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.

Monitoring Diagnostic Safety Risks in Emergency Departments: Protocol for a Machine Learning Study

BACKGROUND

Diagnostic decision making, especially in emergency departments, is a highly complex cognitive process that involves uncertainty and susceptibility to errors. A combination of factors, including patient factors (eg, history, behaviors, complexity, and comorbidity), provider-care team factors (eg, cognitive load and information gathering and synthesis), and system factors (eg, health information technology, crowding, shift-based work, and interruptions) may contribute to diagnostic errors. Using electronic triggers to identify records of patients with certain patterns of care, such as escalation of care, has been useful to screen for diagnostic errors. Once errors are identified, sophisticated data analytics and machine learning techniques can be applied to existing electronic health record (EHR) data sets to shed light on potential risk factors influencing diagnostic decision making.

OBJECTIVE

This study aims to identify variables associated with diagnostic errors in emergency departments using large-scale EHR data and machine learning techniques.

METHODS

This study plans to use trigger algorithms within EHR data repositories to generate a large data set of records that are labeled trigger-positive or trigger-negative, depending on whether they meet certain criteria. Samples from both data sets will be validated using medical record reviews, upon which we expect to find a higher number of diagnostic safety events in the trigger-positive subset. Machine learning will be used to evaluate relationships between certain patient factors, provider-care team factors, and system-level risk factors and diagnostic safety signals in the statistically matched groups of trigger-positive and trigger-negative charts.

RESULTS

This federally funded study was approved by the institutional review board of 2 academic medical centers with affiliated community hospitals. Trigger queries are being developed at both organizations, and sample cohorts will be labeled using the triggers. Machine learning techniques such as association rule mining, chi-square automated interaction detection, and classification and regression trees will be used to discover important variables that could be incorporated within future clinical decision support systems to help identify and reduce risks that contribute to diagnostic errors.

CONCLUSIONS

The use of large EHR data sets and machine learning to investigate risk factors (related to the patient, provider-care team, and system-level) in the diagnostic process may help create future mechanisms for monitoring diagnostic safety.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24642.

Shoulder Pain of Spinal Source in the Military: A Case Series

Musculoskeletal injury (MSI) presents the greatest threat to military mission readiness. Atraumatic shoulder pain is a common military MSI that often results in persistent functional limitations. Shoulder orthopedic evaluation presents many diagnostic challenges, due in part to the possibility of a spinal source of symptoms. This case series outlines the use of mechanical diagnosis and therapy to screen the cervical and thoracic spine in active duty (AD) service members (SMs) with a chief complaint of unchanging or worsening shoulder pain. All three SMs previously received shoulder-specific diagnoses from experienced clinicians, yet repeated movements revealed a possible spinal nociceptive driver that guided targeted intervention. Treatment directed only at the cervical spine resulted in a clinically important improvement within an average of 10 days from the initial evaluation, return to duty (RTD) within an average of 32 days, and continued resolution at 3 months. SMs can independently complete the screening process with guidance from healthcare providers, ultimately shaping the treatment strategy and possibly facilitating self-management of future recurrence. This case series demonstrates that identification of shoulder pain of spinal source in the military population may be an important step in facilitating timely RTD. These cases also highlight the use of a standardized, systematic method to screen the cervical and thoracic spine that concurrently reveals the indicated treatment. Further research to determine the prevalence of shoulder pain of spinal source in the AD population and its impact on RTD rates has the potential to reduce the substantial burden of MSI in the military.

A predictive tool for the assessment of right ventricular dysfunction in non-high-risk patients with acute pulmonary embolism

Background

Rapid and accurate identification of right ventricular (RV) dysfunction is essential for decreasing mortality associated with acute pulmonary embolism (PE), particularly for non-high-risk patients without hypotension on admission. This study aimed to develop a rapid and accurate tool for predicting the risk of RV dysfunction in non-high-risk patients with acute PE.

Methods

The medical records of non-high-risk patients with acute PE admitted to Shengjing Hospital of China Medical University between January 2011 and May 2020 were retrospectively analysed. The primary outcome of this study was RV dysfunction within 24 h after admission. The enrolled patients were randomized into training or validation sets as a ratio of 2:1. In the training set, a nomogram was developed, and the consistency was corroborated in the validation set. The areas under the receiver operating characteristic curves (AUCs) and 95% confidence intervals (CIs) were calculated.

Results

A total of 845 patients were enrolled, including 420 men and 425 women with an average age of 60.05 ± 15.43 years. Right ventricular dysfunction was identified in 240 patients (28.40%). The nomogram for RV dysfunction included N-terminal pro-brain natriuretic peptide, cardiac troponin I, and ventricular diameter ratios, which provided AUC values of 0.881 in the training dataset (95% confidence interval (CI): 0.868–0.898, p < 0.001) and 0.839 in the validation set (95% CI: 0.780–0.897, p < 0.001). The predictive tool was published as a web-based calculato (https://gaoyzcmu.shinyapps.io/APERVD/).

Conclusions

The combination of CT and laboratory parameters forms a predictive tool that may facilitate the identification of RV dysfunction in non-high-risk patients with acute PE.

Pain-related beliefs are associated with arm function in persons with frozen shoulder

BACKGROUND

Frozen shoulder is a painful glenohumeral joint condition. Pain-related beliefs are recognized drivers of function in musculoskeletal conditions. This cross-sectional study investigates associations between pain-related beliefs and arm function in frozen shoulder.

METHODS

Pain intensity, arm function (Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH)), pain catastrophizing (Pain Catastrophizing Scale (PCS)), pain-related fear (Tampa Scale for Kinesiophobia (TSK-11)) and pain self-efficacy (Pain Self-Efficacy Questionnaire (PSEQ)) were administered in 85 persons with frozen shoulder. Correlation analyses assessed associations between pain-related beliefs and arm function. Regression analysis calculated the explained variance in arm function by pain-related beliefs.

RESULTS

Pain-related fear, pain catastrophizing and pain self-efficacy were significantly associated with arm function (r = 0.51; r = 0.45 and r = -0.69, all p < .0001, respectively). Thirty-one percent of variance in arm function was explained by control variables, with pain intensity being the only significant one. After adding TSK-11, PCS and PSEQ scores to the model, 26% extra variance in arm function was explained, with significant contributions of pain intensity, pain-related fear and pain self-efficacy (R²= 0.57).

CONCLUSIONS

Attention should be paid towards the negative effect of pain-related fear on outcomes in frozen shoulder and towards building one's pain self-efficacy given its protective value in pain management.

O escore SPADI, idade, nível de escolaridade e gênero são preditivos de autoeficácia em pacientes com dor no ombro?

RESUMO Fatores intrínsecos, como nível de escolaridade, idade e gênero, se relacionam com dor e disfunção, assim como a autoeficácia pode modificar o efeito que a dor e disfunção têm sobre resultados clínicos dos pacientes. Este estudo transversal investigou se o escore no Shoulder Pain and Disability Index (SPADI), idade, nível de escolaridade e gênero são preditivos de autoeficácia em pacientes com dor no ombro e se há diferença nos níveis de dor e incapacidade entre grupos de idade e gênero. Foram analisados dados sociodemográficos e pontuações do SPADI e do Chronic Pain Self- Efficacy Scale (CPSS) de um banco de dados de pacientes atendidos em um ambulatório de fisioterapia público especializado em ombro, um total de 123 pacientes com média de idade de 54 (±11,54), SPADI de 67,56 (±22,54) e CPSS de 182,22 (±61,76). A análise de regressão linear múltipla mostrou o SPADI como único fator preditivo de autoeficácia (β=-1,39 [IC95%=-1,84 a -0,93], p<0,001), explicando 23% de sua variância (r2=0,23). A análise de variância (ANOVA) mostrou que a pontuação do SPADI foi significantemente diferente entre gêneros (diferença média=22,27; p<0,001), mas similar entre grupos de idade (diferença média=7,04; p=0,16). Concluiu-se que os pacientes que se queixaram de dor no ombro em um ambulatório de fisioterapia público especializado em ombro foram a maioria mulheres de meia-idade, que cursaram apenas o ensino fundamental, apresentaram dor e incapacidade importantes e uma alta autoeficácia. Sendo que a pontuação no questionário SPADI foi capaz de prever parcialmente a autoeficácia.

A randomised controlled trial of heavy shoulder strengthening exercise in patients with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome and long-lasting shoulder complaints: study protocol for the Shoulder-MOBILEX study

Background

Four out of five patients with hypermobility spectrum disorder (HSD) or hypermobile Ehlers-Danlos syndrome (hEDS) experience shoulder complaints including persistent pain and instability. Evidence suggests that patients with HSD/hEDS who experience knee and back complaints improve with exercise-based therapy. However, no study has focused on exercise-based treatment for the shoulder in this patient group. The potential benefits of strengthening the shoulder muscles, such as increased muscle-tendon stiffness, may be effective for patients with HSD/hEDS who often display decreased strength and increased shoulder laxity/instability.

The primary aim is to investigate the short-term effectiveness of a 16-week progressive heavy shoulder strengthening programme and general advice (HEAVY) compared with low-load training and general advice (LIGHT), on self-reported shoulder symptoms, function, and quality of life.

Methods

A superiority, parallel group, randomised controlled trial will be conducted with 100 patients from primary care with HSD/hEDS and shoulder complaints (persistent pain and/or instability) for more than 3 months. Participants will be randomised to receive HEAVY (full range of motion, high load) or LIGHT (neutral to midrange of motion, low load) strengthening programme three times weekly with exercises targeting scapular and rotator cuff muscles. HEAVY will be supervised twice weekly, and LIGHT three times during the 16 weeks. The primary outcome will be between-group difference in change from baseline to 16-week follow-up in the Western Ontario Shoulder Instability Index (WOSI, 0-2100 better to worse). Secondary outcomes will include a range of self-reported outcomes covering symptoms, function, and quality of life, besides clinical tests for shoulder strength, laxity/instability, and proprioception. Outcome assessors will be blinded to group allocation. Participants will be kept blind to treatment allocation through minimal information about the intervention content and hypotheses. Primary analyses will be performed by a blinded epidemiologist.

Discussion

If effective, the current heavy shoulder strengthening programme will challenge the general understanding of prescribing low-load exercise interventions for patients with HSD/hEDS and provide a new treatment strategy. The study will address an important and severe condition using transparent, detailed, and high-quality methods to potentially support a future implementation.

Trial registration

ClinicalTrials.gov NCT03869307. Registered on 11 March 2019.

Supplementary information

The online version contains supplementary material available at 10.1186/s13063-020-04892-0.

The inclusion of mobilisation with movement to a standard exercise programme for patients with rotator cuff related pain: a randomised, placebo-controlled protocol trial

Background

Rotator cuff related pain (RCRP) is one of the most common sources of musculoskeletal shoulder pain affecting the general population. Conservative treatment, in the form of exercise, is considered the first line approach, nonetheless, improvements seem to be modest. One therapeutic modality that might be an adjunct to the treatment of this condition is mobilisation with movement (MWM). MWM is a pain-free manual procedure that targets restricted and painful movements, commonly seen in patients with RCRP. The purpose of clinical trial is to determine whether MWM with exercise has benefits over sham MWM with exercise in RCRP.

Methods

A randomised, sham-controlled trial of 70 adults complaining of RCRP will compare the effects of MWM combined with exercise over sham MWM with exercise. Participants will be allocated to one of two groups: exercise and MWM (EG) or exercise and sham MWM (CG). Two weekly individual treatment sessions will be conducted over five weeks. All assessments will be performed by a blinded assessor. Primary outcome measures will be the shoulder pain and disability index (SPADI) and the numeric pain rating scale (NPRS), assessed at baseline, discharge and one-month follow-up. Secondary outcome measures will be active range of motion, self-efficacy and the global rating of change scale. The analyses will be conducted considering a statistically significant p-value ≤0.05. Normality will be assessed with the Kolmogorov-Smirnov test and homogeneity with the Levene’s test. For the primary outcome measures (SPADI and NPRS) and self-efficacy, a 2 × 3 ANOVA with treatment group (EG versus CG) and time (baseline, end of the treatment and follow-up) factors will be performed. Separate 2 × 2 ANOVA will be used for range of motion (baseline and end of the treatment). Global rating scale of change analysis will be conducted using descriptive statistics. Intention-to-treat analysis will be adopted.

Discussion

As there is a paucity of longitudinal studies investigating the use of MWM in patients with RCRP, this study will help to better understand its role together with a structured exercise programme.

Trial registration

Clinical Trials Registry number NCT04175184. November, 2019.

Biopsychosocial Aspects in Individuals with Acute and Chronic Rotator Cuff Related Shoulder Pain: Classification Based on a Decision Tree Analysis

Biopsychosocial aspects seem to influence the clinical condition of rotator cuff related shoulder pain (RCRSP). However, traditional bivariate and linear analyses may not be sufficiently robust to capture the complex relationships among these aspects. This study determined which biopsychosocial aspects would better classify individuals with acute and chronic RCRSP and described how these aspects interact to create biopsychosocial phenotypes in individuals with acute and chronic RCRSP. Individuals with acute (<six months of pain, n = 15) and chronic (≥six months of pain, n = 38) RCRSP were included. Sociodemographic data, biological data related to general clinical health status, to shoulder clinical condition and to sensory function, and psychosocial data were collected. Outcomes were compared between groups and a decision tree was used to classify the individuals with acute and chronic RCRSP into different phenotypes hierarchically organized in nodes. Only conditioned pain modulation was different between the groups. However, the tree combined six biopsychosocial aspects to identify seven distinct phenotypes in individuals with RCRSP: three phenotypes of individuals with acute, and four with chronic RCRSP. While the majority of the individuals with chronic RCRSP have no other previous painful complaint besides the shoulder pain and low efficiency of endogenous pain modulation with no signs of biomechanical related pain, individuals with acute RCRSP are more likely to have preserved endogenous pain modulation and unilateral pain with signs of kinesiophobia.

Age- and Sex-Specific Pediatric Reference Intervals of Serum Electrolytes in Jilin Province of China Using the A Priori Approach

Objectives

The purpose of this study was to establish age- and sex-specific pediatric reference intervals of serum potassium (K), sodium (Na), chlorine (Cl), calcium (Ca), magnesium (Mg), and phosphorus (P) using a direct sampling technique.

Methods

In accordance with the a priori approach, healthy individuals (n = 6,466, aged 1 month to <18 years) were enrolled from five regions in Jilin Province, China, and all analytes were performed in the center laboratory. Reference intervals were divided according to the regression tree and Harris and Boyd’s method, and then they were calculated by the nonparametric rank method. The dynamic changes of reference intervals were evaluated by the lambda-mu-sigma (LMS) method.

Results

Reference intervals of serum Na and Ca were divided into three age-specific partitions. The concentrations of K, Cl, and Mg remained stable with age. However, only dramatic sex-specific changes of P were shown in those 11 to less than 13 years old and 13 to less than 15 years old, with an earlier peak time in females than in males. The correlation between Na and Cl was the strongest among all serum electrolytes (r = 0.31).

Conclusions

Serum electrolyte reference intervals for children and adolescents were established by regression tree, z test, and the LMS method, which provide a more accurate interpretation for diagnosis and prognosis evaluation of clinical pediatric diseases.

Self-efficacy in patients with chronic musculoskeletal conditions discharged from physical therapy service: A cross-sectional study

OBJECTIVES

This study aimed to investigate self-efficacy levels of patients after finishing rehabilitation for chronic musculoskeletal conditions and identify factors related to self-efficacy.

METHOD

Two hundred and eight patients aged >40 years with musculoskeletal disorders were included. Self-efficacy was assessed by the Chronic Pain Self-Efficacy Scale (CPSS), and regression analyses were used to test six predictors of self-efficacy: age, symptom duration, number of physical therapy sessions, postdischarge pain intensity, perceived clinical improvement, and cognitive reassurance. Self-efficacy was compared between patients who reported improvement and worsening of their clinical condition, and a cutoff value for self-efficacy was established using receiver operating characteristic curve analyses to distinguish patients with severe pain from those with mild to moderate pain.

RESULTS

Better perceived clinical improvement (Beta = -0.37, p = 0.000), lower pain intensity (Beta = -0.33, p = 0.000), and a lower number of physical therapy sessions (Beta = -0.12, p = 0.027) were related to greater self-efficacy. No significant associations were observed between self-efficacy and age, symptom duration, and cognitive reassurance. The patients who reported improvement had greater self-efficacy (204.76 ± 52.80) than those who reported worsening of their clinical condition (145.45 ± 44.18; p = 0.000). A CPSS score of 172 points (sensitivity of 0.77; specificity of 0.72) may indicate low self-efficacy.

CONCLUSION

A higher perception of self-efficacy after discharge from physiotherapy is associated with better perceived clinical improvement, lower pain intensity, and a lower number of physical therapy sessions. Therefore, interventions to support patients' exercise-based rehabilitation should include self-efficacy, which may affect the prognosis of patients with chronic conditions.

Disability is associated with catastrophizing and not with pain intensity in patients with low back pain: A retrospective study

OBJECTIVE

Low back pain (LBP) is the leading cause of years lived with disability at a global scale. The development and chronicity of LBP are influenced by multiple factors, and among them is catastrophizing. We are unaware of the impact that catastrophizing may have on pain and disability in our population. We also lack the tools that allow us to determine in which cases catastrophizing should be assessed. The primary objective is to compare the disability and pain intensity values at baseline in low back pain patients with high and low catastrophizing. The secondary objectives are to analyse the correlation between variables and determine disability variance, and develop a prediction model to identify patients with high catastrophizing.

METHOD

This is a retrospective study. We included the baseline data of patients with LBP. A PCS score ≥ 23 was classified as "high catastrophizing."

RESULTS

A total 121 medical sheets were analysed. Patients with high catastrophizing showed greater disability, with no differences in pain intensity. The PCS value explained 20% of the variance of disability, and pain was 1%. A cut-off point of 11 in the RMQ allowed us to identify patients with high and low catastrophizing, with an accuracy of 76.67%.

CONCLUSION

LBP patients with high catastrophizing reported greater disability than those with low catastrophizing, with no differences as to pain intensity. The PCS was the most relevant variable to explain variability in the RMQ. The RMQ allowed us to identify patients with high and low catastrophizing.

Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review

OBJECTIVE

To systematically scope the reported advice and education in physical therapy management of patients with subacromial shoulder pain, and to define key themes of the advice and education.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched MEDLINE, Scopus, Web of Science, and CINAHL, with publication dates from 2007 to September 2019.

STUDY SELECTION CRITERIA

We included quantitative and qualitative research that reported on physical therapy interventions for subacromial shoulder pain.

DATA SYNTHESIS

We performed a qualitative synthesis that identified items included in patient advice and education.

RESULTS

Of 89 original studies included, there were 61 randomized controlled trials; 5 prospective studies; 16 nonrandomized observational intervention studies or case series; and 7 surveys, audits of physical therapy patient records, and focus groups with physical therapists. We identified 7 key themes for advice and education: exercise intensity and pain response, activity modification advice, posture advice, pain self-management advice, pathoanatomical and diagnosis information, behavioral approaches, and pain biology advice.

CONCLUSION

While advice focused predominantly on the local tissue pathology model, 10% of studies included information about pain neuroscience education, psychosocial factors, motor imagery, or behavior change. J Orthop Sports Phys Ther 2020;50(6):285-293. doi:10.2519/jospt.2020.9152.

Is rotator cuff related shoulder pain a multidimensional disorder? An exploratory study

Background and aims

Rotator cuff related shoulder pain has been associated with factors from multiple dimensions such as strength changes, psychosocial measures, comorbidities and level of education. However, to date little research has been undertaken to evaluate which factors explain the greatest variance in pain and disability levels in people with rotator cuff related shoulder pain. The objective of this study was therefore to evaluate which multidimensional examination findings were associated with higher pain and disability in a primary care cohort with rotator cuff related shoulder pain.

Methods

This was an exploratory cross-sectional cohort study. Sixty-seven participants with rotator cuff related shoulder pain were assessed for: pain intensity, disability; demographic, psychological, social and lifestyle characteristics, and isometric strength of shoulder internal and external rotator muscles. Univariable associations between pain intensity/disability and each variable were assessed using linear regression. Variables with univariable associations (p < 0.1) were entered into backwards stepwise multivariable regression models.

Results

The multivariable model for pain intensity included sleep and perceived persistence and explained 46.5% of the variance (37.6% uniquely by sleep, 5.4% uniquely by perceived persistence). The multivariable model for disability included sleep and sex and explained 26.8% of the variance (4.5% shared by predictors, 16.4% uniquely by sleep, 5.9% uniquely by sex).

Conclusions

Rotator cuff-related shoulder pain and disability are associated with sleep disturbance, perceived symptom persistence and sex. Rotator cuff related shoulder pain may be considered a multidimensional disorder.

Implications

Clinicians need to evaluate sleep and perceived symptom persistence in people with rotator cuff related shoulder pain. Future research may examine whether management strategies for RCRSP directed towards these factors afford improved treatment outcomes.

Effect of Psychomotricity in Combination With 3 Months of Active Shoulder Exercises in Individuals With Chronic Shoulder Pain: Primary Results From an Investigator-Blinded, Randomized, Controlled Trial

OBJECTIVE

To evaluate whether psychomotor therapy (PMT) in combination with usual care active exercise (AE) rehabilitation for the shoulder is superior to merely AE.

DESIGN

The trial was a single-center, stratified (by corticosteroid injection [yes or no]), randomized, and controlled superiority trial.

SETTING

Shoulder unit of the orthopedic department at Hospital Lillebaelt, Vejle Hospital.

PARTICIPANTS

Eligible participants (N=87) were adults aged 18-75 years with shoulder complaints lasting for at least 3 months, in addition to a score equal to or below 3 on the Multidimensional Assessment of Interoceptive Awareness score. Furthermore, patients had at least a visual analog scale pain score of 2 at rest, 3 at night, and 5 in activity (range: 0-10).

INTERVENTIONS

Patients were randomized to 12 weeks of AE (control group) or in combination with 5 PMT sessions (intervention group).

MAIN OUTCOME MEASURE

The primary outcome was the patient-reported outcome score Disability of the Arm, Shoulder and Hand questionnaire. The primary endpoint was 12 weeks after baseline.

RESULTS

There was no between-group difference in function between the intervention group and control group.

CONCLUSIONS

Our results showed no additional benefit on patient-reported function and pain from PMT over usual care in patients with long-lasting shoulder pain and low body awareness. This finding suggests that PMT adds no additional benefit to patients' recovery in relation to pain and active function in comparison to standard care.

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T)

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review

Objective:

To examine the predictive, moderating and mediating role of cognitive, emotional and behavioral factors on pain and disability following shoulder treatment.

Data sources:

Electronic databases (PubMed, Web of Science, Embase and PsycINFO) were searched until 14 January 2019.

Study selection:

Studies including persons with musculoskeletal shoulder pain that describe the predictive, moderating or mediating role of baseline cognitive, emotional or behavioral factors on pain or disability following treatment were selected.

Results:

A total of 23 articles, describing 21 studies and involving 3769 participants, were included. Three studies had a high risk of bias. There was no predictive role of baseline depression, anxiety, coping, somatization or distress on pain or disability across types of shoulder treatment. No predictive role of fear-avoidance beliefs was identified in patients receiving physiotherapy, which contrasted to the results found when surgical treatment was applied. Baseline catastrophizing was also not predictive for pain or disability in patients receiving physiotherapy. After conservative medical treatments, results on the predictive role of catastrophizing were inconclusive. Treatment expectations and baseline self-efficacy predicted pain and disability in patients receiving physiotherapy, which was not the case in patients receiving conservative medical treatment. Finally, there was a moderating role for optimism in the relationship between pain catastrophizing and disability in patients receiving physiotherapy.

Conclusion:

There is evidence that expectations of recovery and self-efficacy have a predictive role and optimism a moderating role on pain and/or disability following physiotherapy for musculoskeletal shoulder pain. After surgical treatment, fear-avoidance is a predictor of pain and disability.