Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Psychosocial Factors and Musculoskeletal Symptoms in Office Workers: Validating the Maastricht Upper Extremity Questionnaire

Background

Complaints of the arm, neck, and shoulder (CANS) in the workplace are becoming more prevalent among employees. The Maastricht Upper Extremity Questionnaire (MUEQ) validates upper extremity complaints in 7 domains-including workstation, body posture, break time, job control, job demands, work environment, and social support. The aim of the present study was to translate, adapt, and validate the Persian Version of MUEQ among Iranian office workers.

Methods

The psychometric evaluation of the Persian version of the MUEQ employed a comprehensive methodological approach comprising face and content validity assessments, confirmatory factor analysis (CFA), and Cronbach's alpha. A panel of 10 experts assessed the face and content validity of the instrument. In the second phase, through a cross-sectional study, the validity and reliability of the questionnaire were measured by CFA and Cronbach's alpha in a sample of 420 people from the target population in Tehran, Iran.

Results

The mean age of the participants was 41.40 ± 7.80 years. Examination of upper limb complaints showed that neck pain was the most common complaint among office workers, with a prevalence of 65%. The CFA results confirmed the questionnaire's structure, with 59 items grouped into 7 subscales, and with fit indices-comparative fit index, 0. 87; root mean square error of approximation, 0.08; goodness of fit index, 0.9. The questionnaire demonstrated strong internal consistency, as all items exhibited Cronbach's alpha values of ≥0.9.

Conclusion

The psychometric evaluation of the Persian version of the MUEQ showed that it is a valid and reliable tool for evaluating psychosocial factors in the work environment. Identifying psychosocial factors influential in musculoskeletal problems will lead to better planning to change behavior and design constructive interventions to improve behavior. By addressing psychosocial determinants of musculoskeletal issues at both the individual and organizational levels, we can enhance employees' awareness, self-efficacy, and ability to manage their musculoskeletal health and make informed decisions about their well-being.

Measurement properties of the Dutch versions of QuickDASH and PRWHE in patients with complaints of hand, wrist, forearm and elbow

BACKGROUND

The shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Patient Rated Wrist/Hand Evaluation (PRWHE) are commonly used questionnaires to assess patient-reported hand function. Information about the measurement properties of the Dutch versions is scarce.

OBJECTIVE

To gain insight into the measurement properties of the Dutch language versions of the QuickDASH and the PRWHE in patients with (non)specific complaints of the hand, wrist, forearm and elbow.

METHODS

Internal consistency, construct validity, test-retest reliability, responsiveness, and floor and ceiling effects were assessed according to COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) recommendations.

RESULTS

Questionnaires were filled out by 132 patients. Internal consistency of QuickDASH (Cronbach's α= 0.92) and PRWHE (Cronbach's α= 0.97) was high. Predefined hypotheses for construct validity were not confirmed for 75% for both QuickDASH and PRWHE (accordance with 62% of predefined hypotheses for both questionnaires). Test-retest reliability of QuickDASH (ICC = 0.90) and PRWHE (ICC = 0.87) was good. Both QuickDASH (AUC = 0.84) and PRWHE (AUC = 0.80) showed good responsiveness. No floor or ceiling effects were present.

CONCLUSIONS

Measurement properties of the Dutch language versions of the QuickDASH and the PRWHE, applied to patients with (non)specific complaints of the hand, wrist, forearm and elbow, were very similar. Test-retest reliability and responsiveness were good for both QuickDASH and PRWHE. Construct validity could not be demonstrated sufficiently.

Musculoskeletal complaints, physical work demands, and functional capacity in individuals with a brachial plexus injury: An exploratory study

BACKGROUND

Musculoskeletal complaints (MSCs) may be more common in individuals with brachial plexus injury (BPI), whose physical work demands exceed their functional capacity (FC).

OBJECTIVES

(a) To assess the concurrent validity of five methods for measuring upper extremity work demands and the Dictionary of Occupational Titles (DOT). (b) To explore the relations between MSCs, physical work demands, and FC in individuals with BPI.

METHODS

This study had a descriptive correlational design. Physical work demands of 16 individuals with BPI (12 males, 6 one-handed workers) were assessed during work using five assessment methods and the DOT. Spearman correlation coefficients between work demand methods were determined. FC was assessed using the functional capacity evaluation one-handed (FCE-OH). A questionnaire was used to examine MSCs. The relationship between MSCs, physical work demands and FC was analyzed visually, using Spearman correlation coefficients, and by comparing FCE-OH results to FCE reference values.

RESULTS

Spearman correlation coefficients for the DOT and four out of five assessment methods for determining work demands on upper extremities were significant and moderate (four combinations: r = 0.65-0.79) to strong (five combinations: r = 0.81-0.94). Correlations of the fifth method with the other methods were weak to fair. No significant relationships were found between MSCs, physical work demands and FCE-OH results.

CONCLUSION

The relationships between MSCs, physical work demands, and FC are evidently complex and require further investigation. In this small sample the concurrent validity of the DOT and four methods for determining work demands on upper extremities was moderate to good.

Inter- and intra-rater-reliability of a clinical framework for spine-related neck-arm pain

OBJECTIVE

A mechanism-based clinical framework for spine-related pain differentiates (i) somatic referred pain, ii) heightened nerve mechanosensitivity, iii) radicular pain, iv) radiculopathy and mixed-pain. This study aimed to determine the reliability of proposed framework.

METHOD

Fifty-one people with unilateral spine-related neck-arm pain were assessed and categorized by examiner-1. The classifications were compared to those made by two other examiners, based on written documentation of examiner-1. Cohens kappa was calculated between examiner-pairs; Fleiss Kappa among all examiners to assess agreement in classifying subgroups and entire framework.

RESULT

Inter-rater-reliability showed moderate to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI 0.87-1.0) to 1.0 (95% CI: 1.0-1.0), radicular pain: 0.46 (95% CI: 0.19-0.69) to 0.62 (95% CI: 0.42-0.81), radiculopathy: 0.65 (95% CI: 0.43-0.84) to 0.80 (95% CI: 0.63-0.96) mixed-pain: 0.54 (95% CI: 0.21-0.81) to 0.75 (95% CI: 0.48-0.94). There was almost perfect to moderate reliability among all examiners (somatic: no variation, mechanosensitivity: 0.97 (95% CI: 0.82-1.0), radicular pain: 0.56 (95% CI: 0.40-0.71), radiculopathy: 0.74 (95% CI: 0.58-0.90), mixed-pain: 0.63 (95% CI: 0.47-0.79), entire framework: 0.64 (95% CI: 0.57-0.71)). Intra-rater-reliability showed substantial to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI: 0.87-1.0), radicular pain: 0.76 (95% CI: 0.57-0.92), radiculopathy: 0.84 (95% CI: 0.67-0.96), mixed-pain: 0.83 (95% CI: 0.60-1.0), entire framework: 0.80 (95% CI: 0.61-0.92).

CONCLUSION

Moderate to almost perfect reliability in subgrouping people with spine-related neck-arm pain and substantial reliability for entire framework support this classification's reliability.

Prevalence and factors associated with musculoskeletal complaints and disability in individuals with brachial plexus injury: a cross-sectional study

PURPOSE

(1) To determine the prevalence of musculoskeletal complaints (MSCs) in the non-affected bodily structures in individuals with brachial plexus injury (BPI) and (2) to analyse factors associated with MSCs and disability.

METHODS

Survey among individuals with BPI and a control group. Multivariable logistic and linear regression analyses were used to identify factors associated with MSCs or disability.

RESULTS

Forty-nine percent of individuals (34/70) with BPI experienced MSC, which was not significantly different from controls (35%, n = 40/113). Complaints were most often located in high back (OR  =  3.6) or non-affected limb (OR  =  2.2) or neck (OR  =  2.1). Greater disability was associated with the presence of MSC in individuals with BPI (OR  =  1.1, 95% confidence interval (95% CI) = 1.0; 1.1). Those with no or a low level of education (B = -10.2, 95% CI = -19.6; -1.4), a history of nerve surgery (B = 11.1, 95% CI = -0.2; 20.9), and moderately affected active range of motion (AROM) of the affected limb (B = 20.7, 95% CI  =  8.8; 31.0) experienced most disability. Individuals with severely affected AROM showed a wide range of experienced disability.

CONCLUSIONS

Clinicians should be aware that almost half of individuals with BPI have MSCs in the non-affected bodily structures, which was associated with increased disability.Implications for rehabilitationMusculoskeletal complaints of the non-affected limb, back and neck are common among individuals with brachial plexus injury, and are associated with more disability.Disability was associated with loss of active range of motion (AROM) in the affected limb, although there was a wide variation in experienced disability among individuals with no or a very limited AROM.

Shoulder Tendinopathies and Occupational Biomechanical Overload: A Critical Appraisal of Available Evidence

BACKGROUND

The aim of this study is to evaluate the association between occupational exposure to biomechanical risk factors and shoulder tendinopathies.

METHODS

We updated recent systematic reviews about specific shoulder disorders and work-related risk factors. MEDLINE was searched up to September 2022. Studies satisfying the following criteria were included: i) the diagnosis was based on physical examination plus imaging data (when available), and ii) the exposure assessment was based on video analysis and/or directly measured.

RESULTS

Five studies met the inclusion criteria: three cross-sectional studies identified from published systematic reviews and two cohort studies retrieved from the update. Two studies investigated shoulder tendinitis, one supraspinatus tendinitis, and the other two rotator cuff syndrome. The diagnosis was based on physical examination, not supported by imaging techniques for all the included studies. In four out of five studies, the exposure was assessed by experienced ergonomists with the support of video recordings. In two studies, the exposure assessment was further supplemented by force gauge measurements or direct measurements of upper arm elevation. Only the combined exposure of working with arms above shoulder level with forceful hand exertion appears to be associated with rotator cuff syndrome: i) a cohort study reported an HR=1.11 (95%CI 1.01-1.22) for each unit increase in forceful repetition rate when the upper arm is flexed ≥45° for ≥29% of the working time; and ii) a cross-sectional study showed an OR=2.43 (95%CI 1.04-5.68) for the combination of upper arm flexion ≥45° for more than 15% of the time with a duty cycle of forceful exertions more than 9% of the time.

CONCLUSIONS

There is moderate evidence of a causal association between shoulder tendinopathy and combined exposures of working above shoulder level with forceful hand exertion. The evidence is insufficient for any single biomechanical exposure on its own. High-quality cohort studies with direct exposure measures and objective diagnostic criteria are needed. The occupational origin of shoulder tendinopathies is still an open question that must be properly answered.

Barriers and facilitators associated with musculoskeletal complaints in individuals with upper limb absence - focus group results and a scoping review

PURPOSE

To guide better prevention and treatment and to develop research priorities, this study aims to create an overview of facilitators and barriers for the development and persistence of musculoskeletal complaints (MSCs) in individuals with upper limb absence (ULA).

METHODS

Exploratory mixed methods design. A focus group (FG) was organized with individuals with ULA about MSCs and associated factors. An inductive approach was employed to the transcript and the studies. A scoping review was performed to systematically identify barriers and facilitators. The International Classification of Functioning, Disability, and Health was used to create an integrated overview of the results.

RESULTS

Eleven participants participated in the FG, eight of them currently sustained or had sustained MSCs in the last year. Ten studies were included in the scoping review. The final overview consisted of 67 associated factors. Participants of the FG predominantly mentioned psychosocial factors, whereas the literature dominantly reported biomechanical factors.

CONCLUSIONS

The extensive overview of 67 factors showed that facilitators and barriers for MSCs are heterogeneous and aids in a better understanding of the complex nature of MSCs. Several biomechanical and psychosocial factors contribute to MSCs, but the association with a prosthesis remains unclear. Implications for rehabilitationMusculoskeletal complaints (MSCs) are highly prevalent in the population with upper limb absence (ULA) and the overview of 67 factors could help in the prevention and treatment of MSCs.Psychosocial factors in the development and persistence of MSCs are underreported in literature, but are important contributors to MSCs according to patients.Wearing a prosthesis does not seem to be protective for the development or persistence of MSCs.Social support, especially from significant others and employers, is essential to help protect MSCs in those with ULA.

Development and feasibility of stratified primary care physiotherapy integrated with eHealth in patients with neck and/or shoulder complaints: results of a mixed methods study

BACKGROUND

Providing individualized care based on the context and preferences of the patient is important. Knowledge on both prognostic risk stratification and blended eHealth care in musculoskeletal conditions is increasing and seems promising. Stratification can be used to match patients to the most optimal content and intensity of treatment as well as mode of treatment delivery (i.e. face-to-face or blended with eHealth). However, research on the integration of stratified and blended eHealth care with corresponding matched treatment options for patients with neck and/or shoulder complaints is lacking.

METHODS

This study was a mixed methods study comprising the development of matched treatment options, followed by an evaluation of the feasibility of the developed Stratified Blended Physiotherapy approach. In the first phase, three focus groups with physiotherapists and physiotherapy experts were conducted. The second phase investigated the feasibility (i.e. satisfaction, usability and experiences) of the Stratified Blended Physiotherapy approach for both physiotherapists and patients in a multicenter single-arm convergent parallel mixed methods feasibility study.

RESULTS

In the first phase, matched treatment options were developed for six patient subgroups. Recommendations for content and intensity of physiotherapy were matched to the patient's risk of persistent disabling pain (using the Keele STarT MSK Tool: low/medium/high risk). In addition, selection of mode of treatment delivery was matched to the patient's suitability for blended care (using the Dutch Blended Physiotherapy Checklist: yes/no). A paper-based workbook and e-Exercise app modules were developed as two different mode of treatment delivery options, to support physiotherapists. Feasibility was evaluated in the second phase. Physiotherapists and patients were mildly satisfied with the new approach. Usability of the physiotherapist dashboard to set up the e-Exercise app was considered 'OK' by physiotherapists. Patients considered the e-Exercise app to be of 'best imaginable' usability. The paper-based workbook was not used.

CONCLUSION

Results of the focus groups led to the development of matched treatment options. Results of the feasibility study showed experiences with integrating stratified and blended eHealth care and have informed amendments to the Stratified Blended Physiotherapy approach for patients with neck and/or shoulder complaints ready to use within a future cluster randomized trial.

Functional capacity of individuals with brachial plexus injury

BACKGROUND

To enable (pain free) functioning, individuals with brachial plexus injury (BPI) may require a higher functional capacity compared to two-handed individuals, because the load on unaffected structures is greater.

OBJECTIVE

This study compared the functional capacity of individuals with BPI and healthy controls and explored differences in the functional capacity of BPI-affected individuals with respect to: those with and without hand function; affected and unaffected sides; with and without musculoskeletal complaints (MSCs).

METHODS

Six functional capacity tests adjusted for one-handed function were performed by 23 BPI-affected individuals and 20 healthy controls. Hand function was assessed through physical examination and the Dutch Musculoskeletal Questionnaire was used to assess MSCs.

RESULTS

Individuals with BPI scored lower for the two-handed tests, compared with the controls (p≤0.01, effect size (r) ≤-0.41 for both tests). However, both groups performed similar in the one-handed tests. On average individuals with BPI met the physical demands to perform sedentary to light physical work. Among BPI-affected individuals, two-handed overhead lifting capacity was higher in those with hand function than in those without hand function (p = 0.02; r = 0.33). Functional capacity tended to be lower for the unaffected side than for the affected side (4 tests; p≤0.05, r≤-0.36). Test results of BPI-affected Individuals with and without MSCs were similar.

CONCLUSION

Individuals with BPI demonstrated lower two-handed functional capacity than healthy controls. Effect sizes were medium. Capacity of their unaffected side was similar to the dominant side of controls. No association was found between MSCs and functional capacity.

Experiences and needs of physiotherapists and exercise therapists regarding the management of working people with complaints of the arm, neck and shoulder (CANS): A focus group study

BACKGROUND

Non-traumatic complaints of the arm, neck and/or shoulder (CANS) are difficult-to-treat musculoskeletal conditions. CANS treatment has varying degrees of success, particularly in the working population.

OBJECTIVES

To evaluate the experiences and needs of physiotherapists (PTs) and exercise therapists (ETs) regarding the treatment of working patients with CANS.

DESIGN

An exploratory qualitative focus group study was conducted.

METHOD

Qualitative data were collected from 27 therapists who were purposefully recruited for their broad range of experience and qualifications. The data was analysed using thematic analysis.

RESULTS

Both PTs and ETs assess CANS extensively by exploring their patients' psychosocial factors, work-related factors, illness beliefs, and working conditions. Therapists apply hands-off treatment interventions, such as coaching the patient to make behavioural changes and providing self-management support. However, therapists experience many difficulties in these areas, resulting in a need to learn more about coaching techniques for behavioural change, engaging in meaningful conversations about the patient's perspective, supporting patients in building a strong social network in the workplace, and creating a professional network for collaboration.

CONCLUSIONS

The treatment of working people with CANS is difficult for PTs and ETs. Therapists express a need to learn more about supporting self-management, applying coaching techniques and engaging in meaningful conversations. Moreover, therapists indicate a need to establish a professional multidisciplinary network to support collaborations with other disciplines to treat working patients with CANS.

Comparison between patient-reported and physician-estimated pain and disability in hand and wrist disorders

Background

Pain and disability are important components of the assessment of hand problems, but it is unknown how physician estimates compare to patient self‐reports.

Objective

To analyse differences between patient‐reported and physician‐estimated pain and disability in patients with hand or wrist disorders and to analyse factors influencing these differences.

Methods

Observational study of patients with hand or wrist disorders seen during multidisciplinary outpatient consultations. Patients, rehabilitation medicine (RM) consultants, RM trainees and plastic surgeons completed visual analogue scales (VASs) to rate the level of self‐reported (patients) or estimated (physicians) pain and disability. Multilevel analyses were performed to evaluate differences in VAS‐pain and VAS‐disability scores between patients and physicians and to evaluate the influences of diagnosis, physician experience and medical specialty.

Results

Complete data were obtained for 250 patients. Levels of pain and disability estimated by physicians were lower compared to patient self‐reports. Ratings differed among medical specialties. Pain was underestimated to a greater extent by plastic surgeons compared to RM consultants. Disability was underestimated to a greater extent by RM consultants compared to plastic surgeons. Estimates of pain and disability did not differ between consultants and trainees in RM. Type of diagnosis did not influence the degree of underestimation of pain and disability.

Conclusions

Physicians underestimate pain and disability compared to self‐reports in patients with hand or wrist disorders. Ratings differ among medical specialties: plastic surgeons underestimate pain more, while RM consultants underestimate disability more. Physician experience and diagnosis do not influence the degree of underestimation of pain and disability.

Health-related physical fitness in patients with complaints of hand, wrist, forearm and elbow: an exploratory study

Objectives

Little is known about the physical fitness of patients with complaints of hand, wrist, forearm and/or elbow and its possible determinants. Aims were to assess health-related physical fitness (HRPF) in these patients, to compare HRPF with reference values of healthy persons, and to explore whether HRPF was correlated with symptom severity, upper limb function (ULF) and physical activity (PA).

Methods

Cardiorespiratory fitness, handgrip strength and body composition, self-reported symptom severity, ULF and PA were assessed in adult outpatients with complaints of hand, wrist, forearm and/or elbow diagnosed as CANS.

Results

Measurements were completed in 25 subjects (8 males) aged 46.1±14.5 years, of which 44% had specific CANS and 56% had non-specific CANS.

Peak oxygen consumption (VO₂peak) of men was 2978±983 mL/min and of women was 1978±265 mL/min. Handgrip strength of men was 47.0±11.1 kgf and of women was 32.4±6.3 kgf. Body mass index (BMI) of men was 24.2±2.6 kg/m² and of women was 27.4±6.1 kg/m².

VO₂peak of the study sample was lower than that of healthy adults (−414±510 mL/min, p<0.001). Handgrip strength and BMI were similar to reference values.

VO₂peak was correlated with PA (r=0.58, p=0.004); BMI was correlated with disability (r=0.48, p=0.022). Other correlations between HRPF and symptom severity and ULF were non-significant.

Conclusions

Patients with CANS have lower cardiorespiratory fitness, but similar handgrip strength and body composition, compared with the healthy population. Cardiorespiratory fitness was correlated with PA and BMI was correlated with disability, no other correlations were observed with symptom severity and ULF.

Imaging of non-specific complaints of the arm, neck, and/or shoulder (CANS): role of the scalene muscles and piercing variants in neurogenic thoracic outlet syndrome

Complaints of the arm, neck and/or shoulder (CANS) are common in the general population (40%) and workers (30%) and have significant economic impact. Twenty-three conditions have been designated as specific CANS. Cases where no cause is identified are reported as non-specific CANS; these cases make up the majority of CANS. Non-specific CANS presentations overlap with clinical entities including cervicobrachial and scalene myofascial syndromes that are associated with neurogenic thoracic outlet syndrome (NTOS). The scalene muscles have been identified as the commonest site of NTOS, although this has been reported to be functional and in conjunction with cervicothoracic junction variants that compromise the brachial plexus lower trunk. Anatomical variants in relation to both the scalene muscles and brachial plexus are not widely recognised in the clinical and imaging literature; however, pass-through and pass-over (or "piercing") variants of the brachial plexus upper trunk and scalene muscles have been well described in the anatomical and anaesthetic literature. In this review, we demonstrate the presence and describe the imaging of scalene muscle pathology and variant muscle-brachial plexus anatomy affecting the upper trunk that are underdiagnosed causes of non-specific CANS presentations and NTOS.

Musculoskeletal Disorder Symptoms in Saudi Allied Dental Professionals: Is there an Underestimation of Related Occupational Risk Factors?

This study aims to examine the prevalence of musculoskeletal disorder (MSD) symptoms in allied dental professionals (ADPs) in Saudi Arabia and risk factors for MSDs. The study also explores ADPs' opinions and attitudes about the effect of MSD symptoms on the quality of life and potential mitigatory measures. This is a prospective cross-sectional study. Participants were 355 licensed dental staff (average age 33.6 ± 8.1 years, 69% women) working as assistants, lab technicians, radiology technicians, or sterilization technicians with at least six months' work experience. The self-administrated questionnaire comprised socio-demographics, work-related factors, and items from the Nordic Musculoskeletal Questionnaire. Multivariate and univariate logistic regressions were conducted to investigate risk factors for MSD symptoms. Overall, 93% of ADPs complained of MSD symptoms in at least one body site in the past 12 months. Factors related to work conditions (e.g., 'keeping an uncomfortable posture for long periods of time', 'lifting heavy objects') and years of experience were proven to be significant risk factor for developing MSDs. The cohort of ADPs showed a high MSD symptoms prevalence. Efforts are imperative in addressing the risk factors of ergonomics and the workplace environment, and more rigorous studies are needed to further investigate risk factors.

Expert opinion on the UK standard of care for haemophilia patients with inhibitors: a modified Delphi consensus study

Background and Aims:

Despite advances in haemophilia care, inhibitor development remains a significant complication. Although viable treatment options exist, there is some divergence of opinion in the appropriate standard approach to care and goals of treatment. The aim of this study was to assess consensus on United Kingdom (UK) standard of care for child and adult haemophilia patients with inhibitors.

Methods:

A modified Delphi study was conducted using a two-round online survey. A haemophilia expert steering committee and published literature informed the Round 1 questionnaire. Invited participants included haematologists, haemophilia nurses and physiotherapists who had treated at least one haemophilia patient with inhibitors in the past 5 years. Consensus for 6-point Likert scale questions was pre-defined as ⩾70% participants selecting 1–2 (disagreement) or 5–6 (agreement).

Results:

In all, 46.7% and 35.9% questions achieved consensus in Rounds 1 (n = 41) and 2 (n = 34), respectively. Consensus was reached on the importance of improving quality of life (QoL) and reaching clinical goals such as bleed prevention, eradication of inhibitors and pain management. There was agreement on criteria constituting adequate/inadequate responses to immune tolerance induction (ITI) and the appropriate factor VIII dose to address suboptimal ITI response. Opinions varied on treatment aims for adults and children/adolescents, when to offer prophylaxis with bypassing agents and expectations of prophylaxis. Consensus was also lacking on appropriate treatment for mild/moderate patients with inhibitors.

Conclusion:

UK healthcare professionals appear to be aligned on the clinical goals and role of ITI when managing haemophilia patients with inhibitors, although novel treatment developments may require reassessment of these goals. Lack of consensus on prophylaxis with bypassing agents and management of mild/moderate cases identifies a need for further research to establish more comprehensive, evidence-based treatment guidance, particularly for those patients who are unable/prefer not to receive non-factor therapies.

Stratified care integrated with eHealth versus usual primary care physiotherapy in patients with neck and/or shoulder complaints: protocol for a cluster randomized controlled trial

BACKGROUND

Neck and shoulder complaints are common in primary care physiotherapy. These patients experience pain and disability, resulting in high societal costs due to, for example, healthcare use and work absence. Content and intensity of physiotherapy care can be matched to a patient's risk of persistent disabling pain. Mode of care delivery can be matched to the patient's suitability for blended care (integrating eHealth with physiotherapy sessions). It is hypothesized that combining these two approaches to stratified care (referred to from this point as Stratified Blended Approach) will improve the effectiveness and cost-effectiveness of physiotherapy for patients with neck and/or shoulder complaints compared to usual physiotherapy.

METHODS

This paper presents the protocol of a multicenter, pragmatic, two-arm, parallel-group, cluster randomized controlled trial. A total of 92 physiotherapists will be recruited from Dutch primary care physiotherapy practices. Physiotherapy practices will be randomized to the Stratified Blended Approach arm or usual physiotherapy arm by a computer-generated random sequence table using SPSS (1:1 allocation). Number of physiotherapists (1 or > 1) will be used as a stratification variable. A total of 238 adults consulting with neck and/or shoulder complaints will be recruited to the trial by the physiotherapy practices. In the Stratified Blended Approach arm, physiotherapists will match I) the content and intensity of physiotherapy care to the patient's risk of persistent disabling pain, categorized as low, medium or high (using the Keele STarT MSK Tool) and II) the mode of care delivery to the patient's suitability and willingness to receive blended care. The control arm will receive physiotherapy as usual. Neither physiotherapists nor patients in the control arm will be informed about the Stratified Blended Approach arm. The primary outcome is region-specific pain and disability (combined score of Shoulder Pain and Disability Index & Neck Pain and Disability Scale) over 9 months. Effectiveness will be compared using linear mixed models. An economic evaluation will be performed from the societal and healthcare perspective.

DISCUSSION

The trial will be the first to provide evidence on the effectiveness and cost-effectiveness of the Stratified Blended Approach compared with usual physiotherapy in patients with neck and/or shoulder complaints.

TRIAL REGISTRATION

Netherlands Trial Register: NL8249 . Officially registered since 27 December 2019. Date of first enrollment: 30 September 2020. Study status: ongoing, data collection.

Application and utility of a clinical framework for spinally referred neck-arm pain: A cross-sectional and longitudinal study protocol

BACKGROUND

The clinical presentation of neck-arm pain is heterogeneous with varying underlying pain types (nociceptive/neuropathic/mixed) and pain mechanisms (peripheral/central sensitization). A mechanism-based clinical framework for spinally referred pain has been proposed, which classifies into (1) somatic pain, (2) neural mechanosensitivity, (3) radicular pain, (4) radiculopathy and mixed pain presentations. This study aims to (i) investigate the application of the clinical framework in patients with neck-arm pain, (ii) determine their somatosensory, clinical and psychosocial profile and (iii) observe their clinical course over time.

METHOD

We describe a study protocol. Patients with unilateral neck-arm pain (n = 180) will undergo a clinical examination, after which they will be classified into subgroups according to the proposed clinical framework. Standardized quantitative sensory testing (QST) measurements will be taken in their main pain area and contralateral side. Participants will have to complete questionnaires to assess function (Neck Disability Index), psychosocial factors (Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Depression, anxiety and stress scale), neuropathic pain (Douleur Neuropathique 4 Questions, PainDETECT Questionnaire) and central sensitization features (Central Sensitization Inventory). Follow-ups at three, six and 12 months include the baseline questionnaires. The differences of QST data and questionnaire outcomes between and within groups will be analyzed using (M)AN(C)OVA and/or regression models. Repeated measurement analysis of variance or a linear mixed model will be used to calculate the differences between three, six, and 12 months outcomes. Multiple regression models will be used to analyze potential predictors for the clinical course.

CONCLUSION

The rationale for this study is to assess the usability and utility of the proposed clinical framework as well as to identify possible differing somatosensory and psychosocial phenotypes between the subgroups. This could increase our knowledge of the underlying pain mechanisms. The longitudinal analysis may help to assess possible predictors for pain persistency.

Prevalence and associated factors of playing-related musculoskeletal disorders among music students in Europe. Baseline findings from the Risk of Music Students (RISMUS) longitudinal multicentre study

Musculoskeletal (MSK) conditions among professional musicians and music students are frequent and may have significant physical and psychosocial consequences on their lives and/or on their playing abilities. The Risk of Music Students (RISMUS) research project was set up in 2018 to longitudinally identify factors associated with increased risk of playing-related musculoskeletal disorders (PRMDs) in a large sample of music students enrolled in pan-European institutions. The aim of this cross-sectional study was to describe the prevalence of playing-related musculoskeletal disorders (PRMDs) in this novel population at baseline of the RISMUS project. A further goal was to begin to identify variables that might be associated with the self-reported presence of PRMDs among music students. Eight hundred and fifty students from fifty-six conservatories and music universities in Europe completed a web-based questionnaire on lifestyle and physical activity participation levels, musical practice habits, health history and PRMDs, psychological distress, perfectionism and fatigue. A total of 560 (65%) out of 850 participants self-reported a positive history of painful MSK conditions in the last 12 months, 408 (48%) of whom self-reported PRMDs. Results showed that coming from West Europe, being a first- or a second-year Masters student, having more years of experience and higher rates of perceived exertion after 45 minutes of practice without breaks were factors significantly associated with self-reported presence of PRMDs. According to the authors’ knowledge, a large-scale multicentre study investigating prevalence and associated factors for PRMDs among music students at different stages of their education (from Pre-college to Masters levels) has not been conducted before. The high prevalence of PRMDs among music students, especially those studying at university-level, has been confirmed in this study and associated factors have been identified, highlighting the need for relevant targeted interventions as well as effective prevention and treatment strategies.

Assessment of arm, neck and shoulder complaints and scapular static malposition among computer users

Background:

Musculoskeletal complaints of the arm, neck and/or shoulder not attributed to acute trauma or any systemic disorder (CANS) are characterized by symptoms such as pain, numbness and paresthesia which may reach severe and disabling levels and thus significantly interfere with the performance of work and daily living activities. Computer use at work considerably increased in recent years, being attended with a substantial elevation of the prevalence of CANS among individuals who use computers at work.

Objective:

To investigate biomechanical and psychosocial risk factors, scapular static imbalance and functional impact on work and daily living activities of upper limb complaints among workers who use computers.

Methods:

We analyzed ergonomic and psychosocial risk factors by means of MUEQ-Br, scapular static malposition with the SICK-scapula protocol, and functional impairment in work and daily living activities with DASH. The sample comprised 109 employees of a private institution who use computers at work.

Results:

The average scores on body posture and control over tasks were significantly higher among the symptomatic participants. Scapular malposition did not differ between the symptomatic and asymptomatic participants, but functional impairment did.

Conclusion:

Awkward posture at work and poor control over tasks seem to contribute to the occurrence of CANS among office workers who use computers. Scapular malposition is not systematically present among individuals with CANS, but the opposite is true. Individuals with CANS exhibited functional impairments.

Effects of eccentric exercise in patients with subacromial impingement syndrome: a systematic review and meta-analysis

Background

Subacromial impingement syndrome is a common problem in primary healthcare. It often include tendinopathy. While exercise therapy is effective for this condition, it is not clear which type of exercise is the most effective. Eccentric exercises has proven effective for treating similar tendinopathies in the lower extremities. The aim of this systematic review was therefore to investigate the effects of eccentric exercise on pain and function in patients with subacromial impingement syndrome compared with other exercise regimens or interventions. A secondary aim was to describe the included components of the various eccentric exercise regimens that have been studied.

Methods

Systematic searches of PubMed, Cochrane Library and PEDro by two independent authors. Included studies were assessed using the PEDro scale for quality and the Cochrane scale for clinical relevance by two independent authors. Data were combined in meta-analyses. GRADE was applied to assess the certainty of evidence.

Results

Sixty-eight records were identified. Seven studies (eight articles) were included, six were meta-analysed (n = 281). Included studies were of moderate quality (median PEDro score 7, range 5–8). Post-treatment pain was significantly lower after eccentric exercise compared with other exercise: MD -12.3 (95% CI − 17.8 to − 6.8, I² = 7%, p < 0.001), but this difference was not clinically important. Eccentric exercise provided no significant post-treatment improvement in function compared with other exercise: SMD -0.10 (95% CI − 0.79 to 0.58, I² = 85%, p = 0.76). Painful eccentric exercise showed no significant difference compared to pain-free eccentric exercise. Eccentric training regimes showed both similarities and diversity. Intervention duration of 6–8 weeks was almost as effective as 12 weeks.

Conclusions

Evidence of low certainty suggests that eccentric exercise may provide a small but likely not clinically important reduction in pain compared with other types of exercise in patients with subacromial impingement syndrome. It is uncertain whether eccentric exercise improves function more than other types of exercise (very low certainty of evidence). Methodological limitations of existing studies make these findings susceptible to change in the future.

Trial registration

PROSPERO CRD42019126917, date of registration: 29-03-2019.

Patient-reported outcomes measured with and without dizziness associated with non-specific chronic neck pain: implications for primary care

Background

The aim of this study was to compare health-related quality of life (HRQoL) and disability and fear of movement in patients with non-specific chronic neck pain (NSCNP) associated with dizziness with respect to patients with isolated NSCNP in primary care settings.

Methods

A cross-sectional study was carried out in a primary care center. A total of 120 patients were divided into two groups and analyzed in this study. One group of patients reported dizziness combined with NSCNP (n = 60), and the other reported no dizziness with their NSCNP (n = 60). Patient-reported outcome measurements were HRQoL (primary outcome) and disability and kinesiophobia (secondary outcomes) assessed by the EuroQoL Five Dimensions and Five Levels (EQ-5D-5L), neck disability index (NDI) and Tampa Scale of Kinesiophobia (TSK-11), respectively.

Results

Statistically significant differences (P < 0.05) for a 95% confidence interval (CI) with a large effect size (Cohen d) were found between both groups with greater values of disability (mean difference = 6.30 points; 95% CI [3.84-8.75]; d = 0.94) and kinesiophobia (mean difference = 8.36 points; 95% CI [6.07-10.65]; d = 1.33), and an impairment of HRQoL (mean difference = 16.16 points; 95% CI [11.09-21.23]; d = 1.16), for patients with NSCNP associated with dizziness with respect to patients with isolated NSCNP.

Conclusions

Patients with NSCNP in conjunction with dizziness present higher HRQoL impairment and higher disability and kinesiophobia compared to patients with isolated NSCNP.

Cross-cultural adaptation and psychometric properties of the Dutch version of the Hand Function Sort in patients with complaints of hand and/or wrist

BACKGROUND

Musculoskeletal complaints of arm, neck, and shoulder (CANS) can lead to loss of work productivity. To assess the functional consequences of impairments in work, patient-reported outcomes can be important. The Hand Function Sort (HFS) is a 62-item pictorial questionnaire that focuses on work task performance. The aims of this study were the cross-cultural adaptation of HFS into HFS-Dutch Language Version (HFS-DLV) (Part I) and determining construct validity, internal consistency, test-retest reliability, responsiveness and floor/ceiling effects of HFS-DLV (Part II).

METHODS

I: Translation into Dutch using international guidelines. II: Construct validity was assessed with Spearman's correlation coefficients between the HFS-DLV and the Dutch version of the QuickDASH, PRWHE, PDI, RAND-36, NRS-pain, and work ability score. Internal consistency was assessed using Cronbach's α and reliability by a test-retest procedure. A global rating scale of change was used after 4-8 weeks of hand therapy to determine responsiveness.

RESULTS

I: Forty patients were included, and no items were changed. II: 126 patients with hand, wrist, and/or forearm disorders classified as specific or nonspecific CANS. Six predefined hypotheses (50%) were confirmed. Cronbach's α: 0.98. Test-retest reliability: ICC of 0.922. AUC of 0.752. There were no floor/ceiling effects.

CONCLUSIONS

I: Translation process into the HFS-DLV went according to plan. II: For construct validity, the presumed direction of correlations was correct, but less than 75% of hypotheses were confirmed. Internal consistency was high, suggesting redundancy. Reliability and responsiveness of the HFS-DLV were good. HFS-DLV can be used in research or clinical practice for Dutch patients with CANS, to evaluate self-reported functional work ability.

The impact of different rheumatic diseases on health-related quality of life: a comparison with a selected sample of healthy individuals using SF-36 questionnaire, EQ-5D and SF-6D utility values

Background: Given the high prevalence of rheumatic diseases, there is a need to determine which conditions have the greatest impact on health-related quality of life (HRQoL). The main aim of this study was to explore the HRQoL scores among 14 different rheumatic diseases and to compare them with the results of a selecting sample of healthy controls. Methods: 2633 patients of an ongoing cohort have been enrolled. Rheumatic diseases were classified into five diagnostic groups: inflammatory rheumatic diseases, connective tissue disorders, symptomatic peripheral osteoarthritis, soft tissue disorders, and osteoporosis. For comparison were used 649 healthy controls. The HRQoL was evaluated with the Medical Outcomes Study Short-Form 36 Health Survey (SF-36), the EuroQol five Dimensions (EQ-5D) questionnaire, and the Short-Form six Dimensions (SF-6D) questionnaire. Results: The five major rheumatic disease groups, compared to healthy people, significantly impaired all eight health concepts of the SF-36 (p <0.0001). Similar results were found for EQ-5D and SF-6D. The patients with inflammatory rheumatic diseases have poorer self-reported health status than those without arthritis in all domains of living, but particularly with respect to scales measuring aspects of physical functioning or mobility, role limitation due to physical health problems and usual activities, and bodily pain. Rheumatoid arthritis had the largest negative impact on HRQoL, followed by fibromyalgia, vertebral fractures due to osteoporosis, hip osteoarthritis, and systemic sclerosis. Conclusions: Our results indicate that rheumatic diseases have a clearly detrimental effect on the HRQoL, and physical domain is more impaired than mental and social ones. (www.actabiomedica.it)

Motor imagery performance and tactile acuity in patients with complaints of arms, neck and shoulder

Aim: This study aims to gain more knowledge of the sensorimotor incongruence in patients with chronic nonspecific complaints of arm, neck and shoulder. Method: Seven patients and seven healthy controls performed a left/right judgment task, and tactile acuity was assessed by the two-point discrimination threshold at fingers and shoulders. Results & conclusion: The results suggest a decreased tactile acuity in patients with chronic nonspecific complaints of arm, neck and shoulder and a faster reaction time at the painful arm, which might imply disturbed information processing of sensory and motor feedback. Due to the small sample size and low scores on the pain and disability questionnaires, these conclusions should be interpreted with care. Further research is recommended.

The course of complaints of arm, neck and/or shoulder: a cohort study in a university population participating in work or study

Background

Not much is known about the characteristics, course and prognosis of complaints of arm, neck and/or shoulder that have not been caused by a trauma or systemic disease (CANS), in a screened population. This study aims to: (1) describe personal and complaint characteristics in a screened population; (2) describe the course during one-year follow-up, in terms of the three different domains of functioning of the International Classification of Functioning, Disability and Health (ICF); and (3) to explore prognostic factors for the different domains of functioning at one-year follow-up. Additionally, this study aims to investigate the manifestation of selection effects (i.e. tertiary selection effects), in order to understand their impact on the interpretation of results.

Methods

A cross-sectional survey was conducted in a university population. Survey respondents who fulfilled eligibility criteria were asked to participate in a longitudinal cohort study. The course of CANS was assessed in terms of the three ICF domains of functioning. Possible prognostic factors across the different components of the ICF were selected to investigate their influence on outcome at one-year follow-up. Non-response analyses were performed to investigate the presence of tertiary selection effects.

Results

The results revealed a population with relatively mild complaints at baseline, and a relatively stable course during follow-up. Because of the small change in scores between baseline and follow-up measurements, examination of prognostic factors was not feasible. The results of the non-response analyses revealed some indications for the potential presence of tertiary selection effects, which may imply that the results obtained are a slight overestimation of the true results.

Conclusion

The results of this study demonstrate mild complaints at baseline and an overall stable course during one-year follow-up. Since selection effects cannot be ruled out, the true course might possibly be somewhat less favourable than our results suggest.

Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials

OBJECTIVE

To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential eligible studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint, continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be identified.

CONCLUSIONS

Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for CTS.

Three Months of Progressive High-Load Versus Traditional Low-Load Strength Training Among Patients With Rotator Cuff Tendinopathy: Primary Results From the Double-Blind Randomized Controlled RoCTEx Trial

Background:

Progressive high-load exercise (PHLE) has led to positive clinical results in patients with patellar and Achilles tendinopathy. However, its effects on rotator cuff tendinopathy still need to be investigated.

Purpose:

To assess the clinical effects of PHLE versus low-load exercise (LLE) among patients with rotator cuff tendinopathy.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

Patients with rotator cuff tendinopathy were recruited and randomized to 12 weeks of PHLE or LLE, stratified for concomitant administration of corticosteroid injection. The primary outcome measure was change from baseline to 12 weeks in the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, assessed in the intention-to-treat population.

Results:

A total of 100 patients were randomized to PHLE (n = 49) or LLE (n = 51). Mean changes in the DASH questionnaire were 7.11 points (95% CI, 3.07-11.16) and 8.39 points (95% CI, 4.35-12.44) in the PHLE and LLE groups, respectively; this corresponded to a statistically nonsignificant adjusted mean group difference of −1.37 points (95% CI, −6.72 to 3.99; P = .61). Similar nonsignificant results were seen for pain, range of motion, and strength. However, a significant interaction effect was found between the 2 groups and concomitant corticosteroid use (P = .028), with the largest positive change in DASH in favor of PHLE for the group receiving concomitant corticosteroid.

Conclusion:

The study results showed no superior benefit from PHLE over traditional LLE among patients with rotator cuff tendinopathy. Further investigation of the possible interaction between exercise type and corticosteroid injection is needed to establish optimal and potentially synergistic combinations of these 2 factors.

Registration:

NCT01984203 (ClinicalTrials.gov identifier): Rotator Cuff Tendinopathy Exercise Trial (RoCTEx).

Do Patients With Carpal Tunnel Syndrome Benefit From Low-Level Laser Therapy? A Systematic Review of Randomized Controlled Trials

OBJECTIVE

To systematically review the literature on the effectiveness of low-level laser therapy for patients with carpal tunnel syndrome.

DATA SOURCES

The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results of the 2 systematic reviews and 17 RCTs that were included. Strong evidence was found for the effectiveness of low-level laser therapy compared with placebo treatment in the very short term (0 to ≤5wk). After 5 weeks, the positive effects of low-level laser therapy on pain, function, or recovery diminished over time (moderate and conflicting evidence were found at 7- and 12-wk follow-up, respectively).

CONCLUSIONS

In the very short term, low-level laser therapy is more effective as a single intervention than placebo low-level laser therapy in patients with carpal tunnel syndrome, after which the positive effects of low-level laser therapy tend to subside. Evidence in the midterm and long term is sparse.

Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome-A Systematic Review

OBJECTIVE

To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results. Four systematic reviews and 33 RCTs were included. Surgery versus nonsurgical interventions, timing of surgery, and various surgical techniques and postoperative interventions were studied. Corticosteroid injection was more effective than surgery (strong evidence, short-term). Surgery was more effective than splinting or anti-inflammatory drugs plus hand therapy (moderate evidence, midterm and long-term). Manual therapy was more effective than surgical treatment (moderate evidence, short-term and midterm). Within surgery, corticosteroid irrigation of the median nerve before skin closure as additive to CTS release or the direct vision plus tunneling technique was more effective than standard open CTS release (moderate evidence, short-term). Furthermore, short was more effective than long bulky dressings, and a sensory retraining program was more effective than no program after surgery (moderate evidence, short-term). For all other interventions only conflicting, limited, or no evidence was found.

CONCLUSIONS

Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm. There is no unequivocal evidence that suggests one surgical treatment is more effective than the other. Postsurgical, a short- (2-3 days) favored a long-duration (9-14 days) bulky dressing and a sensory retraining program seems to be more effective than no program in short-term. More research regarding the optimal timing of surgery for CTS is needed.

Long-term patterns of chronic complaints of the arms, neck, and shoulders and their determinants--the Doetinchem Cohort Study

Complaints of the arms, neck, and shoulders (CANS) represent a major public health problem but the long-term course is largely unknown. Our objective was to explore the 15-year course of chronic CANS and its determinants in a population-based cohort. During 1993 to 2012, 3050 men and women aged 26 to 65 years at baseline were measured every 5 years, up to 4 times. Complaints of the arms, neck, and shoulders and sociodemographic, lifestyle, mental health, and physical load determinants were obtained by self-reported questionnaires and physical examinations. Information on chronic CANS was used to create patterns of the 15-year course: persistence, recovery, variable, no CANS, and the development of CANS. Only 47% were free of chronic CANS throughout the total 15-year period. The prevalence of other patterns was development (18.3%), persistence (8.5%), recovery (7.5%), and variable (18.7%). In multivariable logistic regression analyses, female gender, age 46 to 55 years, being not employed, former smoking, physical inactivity, an episode of CANS during the past 12 months, and high physical load in daily life (eg, often adopting awkward postures, frequent lifting, carrying, pushing, or pulling) were associated with the development of chronic CANS. Female gender, age 36 to 45 years, being not employed, and awkward postures in daily life were associated with persistent CANS. We conclude that chronic CANS represent a dynamic condition and affect the majority of the general population at least once in 15 years. Determinants associated with chronic CANS, especially physical load in daily life, can be used to develop preventive interventions and give guidance to treatment.

Evaluation of the efficacy of a short-course, personalized self-management and intensive spa therapy intervention as active prevention of musculoskeletal disorders of the upper extremities (Muska): a research protocol for a randomized controlled trial

Background

Musculoskeletal disorders (MSDs) constitute a major occupational health problem in the working population, substantially impacting the quality of life of employees. They also cause considerable economic cost to the healthcare system, with, notably, the reimbursement of treatments and compensation for lost income. MSDs manifest as localized pain or functional difficulty in one or more anatomical areas, such as the cervical spine, shoulder, elbow, hand, and wrist. Although prevalence varies depending on the region considered and the method of assessment, a prevalence of 30% is found in different epidemiological studies. The disease needs to be prevented, not only for medical and economic reasons, but also for legal reasons, owing to the requirement of assessing occupational risks. The strategy envisaged may thus revolve around active, multimodal prevention that has employees fully involved at the heart of their care. Although physical exercise is widely recommended, few studies with a good level of evidence have enabled us to base a complete, well-constructed intervention on exercise that can be offered as secondary prevention in these disorders.

Methods

A prospective, multicenter, comparative (intervention arm vs. control arm), randomized (immediate vs. later treatment) study using Zelen’s design. This study falls under active prevention of MSDs of the upper extremities (UE-MSDs). Participants are workers aged between 18 and 65 years with latent or symptomatic MSDS, with any type of job or workstation, with or without an history of sick leave. The primary aim is to show the superiority at 3 months of a combination of spa therapy, exercise, and self-management workshops for 6 days over usual care in the management of MSDs in terms of employee functional capacity in personal and professional daily life. Secondary aims are to assess the benefit of the intervention in terms of pain, quality of life, and accumulated duration of sick leave.

Discussion

This randomized controlled trial is the first that will aim to evaluate multidisciplinary management of UE-MSDs using nonpharmacological treatment combining exercise, self-management, and spa therapy. The originality of this intervention lies, in its short, intensive format, which is compatible with remaining in work; and in its multidisciplinary approach. This trial has the potential to demonstrate, with a good level of evidence, the benefits of a short course of spa therapy combined with a personalized self-management program on the functional capacity, pain, and quality of life of employees in their daily life.

Trial registration

Clinical trial.gov NCT02702466 retrospectively registered.

Protocol: Version 4 of 9/10/2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1353-8) contains supplementary material, which is available to authorized users.

Towards a preventive strategy for complaints of arm, neck and/or shoulder (CANS): the role of help seeking behaviour

Background

When developing an effective early preventive strategy for employees and students with CANS (Complaints of Arm, Neck or Shoulder, not caused by acute trauma or systemic disease), insight in help seeking behaviour and knowledge of factors associated with help seeking behaviour within the target population, is a prerequisite. The aim of this study was to examine whether perceived hindrance is associated with help seeking behaviour, specifically in employees and students identified with CANS. Additionally, the associations of factors related to functioning and participation, work-environment and demographics with help seeking behaviour were explored in these groups.

Methods

A cross-sectional survey was conducted among employees and students of two universities in the South of the Netherlands. The questionnaire included questions to assess (1) demographics, work/study and activity related factors (2) experience of CANS (3) perceived hindrance (4) help seeking behaviour. A subpopulation of the survey, consisting of those employees and students with self-reported CANS, received additional questionnaires to examine the impact of (1) participant characteristics (2) complaint and health related variables (3) functioning and participation (4) work-environment and social support, on help seeking behaviour.

Results

37.3% of the employees and 41.4% of the students reported CANS. Of these, respectively 43.3% and 45.5%, did not seek help and had no intention to seek help either. Employees and students who had not sought help reported less hindrance, less perceived disabilities and shorter duration of complaints, compared those who did seek help. Employees and students within this group who had also no intention to seek help, perceived fewer disabilities and reported shorter duration of complaints.

Conclusion

The absence of help seeking behaviour in respondents with CANS is a bottleneck for implementation of preventive strategies. In employees and students with CANS, help seeking behaviour is primarily determined by factors related to experienced hindrance. Our findings emphasize the need to tailor preventive strategies, in order to optimize screening and participation in early interventions for CANS.

Sick leave in workers with arm, neck and/or shoulder complaints; defining occurrence and discriminative trajectories over a 2-year time period

OBJECTIVES

Impediments due to complaints of non-traumatic arm, neck and/or shoulder (CANS) during work often leads to consultation in primary care. This study examines the occurrence of sick leave among workers with new CANS, and evaluates sick leave trajectories and their characteristics.

METHODS

This prospective 2-year cohort study included workers with a new CANS presenting in general practice. Participants filled out postal questionnaires on sick leave at 6-monthly intervals. Latent class growth mixture modelling was used to identify distinct trajectories of sick leave. Multinomial regression analyses identified characteristics of the subgroups.

RESULTS

During follow-up, of the 533 participants 190 reported at least one episode of sick leave due to CANS. Three sick leave trajectories were distinguished: (1) 'low-risk' trajectory (n=366), with a constant low probability over time; (2) 'intermediate risk' trajectory, with a high probability at first consultation followed by a steep decrease in probability of sick leave (n=122); (3) 'high-risk' trajectory (n=45), with a constant high probability of sick leave. Compared to the 'low-risk' trajectory, the other trajectories were characterised by more functional limitations, less specific diagnoses, more work-related symptoms and low coworker support. Specific for the 'high-risk' subgroup were more recurrent symptoms, more musculoskeletal comorbidity, high score on somatisation and low score on job demands.

CONCLUSIONS

Three trajectories of sick leave were distinguished, graded from favourable to unfavourable. Several complaint-related and work-related factors and somatisation contributed modestly to identify an unfavourable trajectory of sick leave when presenting in primary care with CANS.

DARE Train-the-Trainer Pedagogy Development Using 2-Round Delphi Methodology

The Dispatcher-Assisted first REsponder programme aims to equip the public with skills to perform hands-only cardiopulmonary resuscitation (CPR) and to use an automated external defibrillator (AED). By familiarising them with instructions given by a medical dispatcher during an out-of-hospital cardiac arrest call, they will be prepared and empowered to react in an emergency. We aim to formalise curriculum and standardise the way information is conveyed to the participants. A panel of 20 experts were chosen. Using Delphi methodology, selected issues were classified into open-ended and close-ended questions. Consensus for an item was established at a 70% agreement rate within the panel. Questions that had 60%–69% agreement were edited and sent to the panel for another round of voting. After 2 rounds of voting, 70 consensus statements were agreed upon. These covered the following: focus of CPR; qualities and qualifications of trainers; recognition of agonal breathing; head-tilt-chin lift; landmark for chest compression; performance of CPR when injuries are present; trainers' involvement in training lay people; modesty of female patients during CPR; AED usage; content of trainer's manual; addressing of questions and answers; updates-dissemination to trainers and attendance of refresher courses. Recommendations for pedagogy for trainers of dispatcher-assisted CPR programmes were developed.

Disability Trajectories in Patients With Complaints of Arm, Neck, and Shoulder (CANS) in Primary Care: Prospective Cohort Study

BACKGROUND

Nontraumatic complaints of arm, neck, and shoulder (CANS) represent an important health issue, with a high prevalence in the general working age population and huge economic impact. Nevertheless, only few prospective cohort studies for the outcome of CANS are available.

OBJECTIVES

The purpose of this study was to identify disability trajectories and associated prognostic factors during a 2-year follow-up of patients with a new episode of CANS in primary care.

DESIGN

This was a prospective cohort study.

METHODS

Data of 682 participants were collected through questionnaires at baseline and every 6 months thereafter. Disability was measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Latent class growth mixture (LCGM) modeling was used to identify clinically meaningful groups of patients who were similar in their disability trajectory during follow-up. Multivariate multinomial regression analysis was used to evaluate associations between sociodemographic, complaint-related, physical, and psychosocial variables and the identified disability trajectories.

RESULTS

Three disability trajectories were identified: fast recovery (67.6%), modest recovery (23.6%), and continuous high disability (8.8%). A high level of somatization was the most important baseline predictor of continuous high disability. Furthermore, poor general health, widespread complaints, and medium level of somatization were associated with this trajectory and >3 months complaint duration, musculoskeletal comorbidity, female sex, history of trauma, low educational level, low social support, and high complaint severity were associated with both continuous high disability and modest recovery. Age, kinesiophobia, and catastrophizing showed significant associations only with modest recovery.

LIMITATIONS

Loss to follow-up ranged from 10% to 22% at each follow-up measurement. Disabilities were assessed only with the DASH and not with physical tests. Misclassification by general practitioners regarding specific or nonspecific diagnostic category might have occurred. The decision for optimal LCGM model, resulting in the disability trajectories, remains arbitrary to some extent.

CONCLUSIONS

Three trajectories described the course of disabilities due to CANS. Several prognostic indicators were identified that can easily be recognized in primary care. As some of these prognostic indicators may be amenable for change, their presence in the early stages of CANS may lead to more intensive or additional interventions (eg, psychological or multidisciplinary therapy). Further research focusing on the use of these prognostic indicators in treatment decisions is needed to further substantiate their predictive value.

Discrete Pathophysiology is Uncommon in Patients with Nonspecific Arm Pain

BACKGROUND

Nonspecific symptoms are common in all areas of medicine. Patients and caregivers can be frustrated when an illness cannot be reduced to a discrete pathophysiological process that corresponds with the symptoms. We therefore asked the following questions: 1) Which demographic factors and psychological comorbidities are associated with change from an initial diagnosis of nonspecific arm pain to eventual identification of discrete pathophysiology that corresponds with symptoms? 2) What is the percentage of patients eventually diagnosed with discrete pathophysiology, what are those pathologies, and do they account for the symptoms?

METHODS

We evaluated 634 patients with an isolated diagnosis of nonspecific upper extremity pain to see if discrete pathophysiology was diagnosed on subsequent visits to the same hand surgeon, a different hand surgeon, or any physician within our health system for the same pain.

RESULTS

There were too few patients with discrete pathophysiology at follow-up to address the primary study question. Definite discrete pathophysiology that corresponded with the symptoms was identified in subsequent evaluations by the index surgeon in one patient (0.16% of all patients) and cured with surgery (nodular fasciitis). Subsequent doctors identified possible discrete pathophysiology in one patient and speculative pathophysiology in four patients and the index surgeon identified possible discrete pathophysiology in four patients, but the five discrete diagnoses accounted for only a fraction of the symptoms.

CONCLUSION

Nonspecific diagnoses are not harmful. Prospective randomized research is merited to determine if nonspecific, descriptive diagnoses are better for patients than specific diagnoses that imply pathophysiology in the absence of discrete verifiable pathophysiology.

A longitudinal study of neck and upper limb musculoskeletal disorders and alternative measures of vibration exposure

OBJECTIVE

To investigate the exposure-response relationships between alternative frequency weightings of hand-transmitted vibration (HTV) and neck and upper limb musculoskeletal disorders (MSDs) in a cohort of HTV workers.

METHODS

In a three-year longitudinal study, the occurrence of neck and upper limb MSDs was investigated in 249 HTV workers and 138 control men. In the HTV workers, MSDs were related to measures of daily vibration exposure expressed in terms of 8-h energy-equivalent frequency-weighted acceleration magnitude [A(8)]. To calculate A(8), the acceleration magnitudes of vibration were weighted by means of four alternative frequency weightings of HTV. The associations between MSDs, individual characteristics, physical work load other than vibration, and psychological strain were also investigated.

RESULTS

The occurrence of upper limb MSDs was greater in the HTV workers than in the controls. After adjustment for potential confounders, the occurrence of elbow/forearm and wrist/hand MSDs increased with the increase in vibration exposure. A measure of model selection did not reveal any substantial difference in the performance of the alternative frequency weightings of HTV for the prediction of neck and upper limb MSDs. In the study population, age, hard physical work load, and poor psychological well-being were associated with both neck and upper limb MSDs.

CONCLUSIONS

In this study, there was evidence for significant exposure-response relationships between HTV exposure and MSDs in the distal sites of the upper limbs. There were no differences in the prediction of neck and upper limb MSDs between measures of daily vibration exposure calculated with alternative frequency weightings of acceleration magnitude.

The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients

BACKGROUND

The goal of this study was to employ a national database to evaluate the association of preoperative injection before shoulder arthroscopy and arthroplasty with the incidence of postoperative infection.

METHODS

A national database of Medicare patients was queried for patients who underwent shoulder arthroscopy or arthroplasty after ipsilateral shoulder injection. Three arthroscopy cohorts were created: arthroscopy within 3 months of injection (n = 3625), arthroscopy between 3 and 12 months after injection (n = 7069), and matched control arthroscopy without prior injection (n = 186,678). Three arthroplasty cohorts were created: arthroplasty within 3 months of injection (n = 636), arthroplasty between 3 and 12 months after injection (n = 1573), and matched control arthroplasty (n = 6211). Infection rates within 3 and 6 months postoperatively were assessed.

RESULTS

The incidence of infection after arthroscopy at 3 months (0.7%; odds ratio [OR], 2.2; P < .0001) and 6 months (1.1%; OR, 1.6; P = .003) was significantly higher in patients who underwent injection within 3 months before arthroscopy compared with controls. The incidence of infection after arthroplasty at 3 months (3.0%; OR, 2.0; P = .007) and 6 months (4.6%; OR, 2.0; P = .001) was significantly higher in patients who underwent injection within 3 months before arthroplasty compared with controls.

CONCLUSIONS

There was a significant increase in postoperative infection in Medicare patients who underwent injection within 3 months before shoulder arthroscopy and arthroplasty. This association was not noted when shoulder arthroscopy or arthroplasty occurred >3 months after injection.

Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All

Synopsis Clear guidelines for the clinical management of individuals with lateral elbow tendinopathy (LET) are hampered by many proposed interventions and the condition's prognosis, ranging from immediate resolution of symptoms following simple advice in some patients to long-lasting problems, regardless of treatment, in others. This is compounded by our lack of understanding of the complexity of the underlying pathophysiology of LET. In this article, we collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation, such as the presence of neck pain, tendon tears, or central sensitization, are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy. A preliminary algorithm, including targeted interventions, for the management of subgroups of patients with LET based on identified prognostic factors is proposed. Further research is needed to evaluate whether such an approach may lead to improved outcomes and more efficient resource allocation. J Orthop Sports Phys Ther 2015;45(11):938-949. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5841.

The Brazilian Portuguese version of the revised Maastricht Upper Extremity Questionnaire (MUEQ-Br revised): translation, cross-cultural adaptation, reliability, and structural validation

BACKGROUND

Complaints of the arm, neck, and shoulders (CANS) have a multifactorial etiology, and, therefore, their assessment should consider both work-related ergonomic and psychosocial aspects. The Maastricht Upper Extremity Questionnaire (MUEQ) is one of a few specific tools available to evaluate the nature and occurrence of CANS in computer-office workers and the impact of psychosocial and ergonomic aspects on work conditions. The purpose of the present study was to perform a translation and cross-cultural adaptation of the MUEQ to Brazilian Portuguese and verify the reliability, internal consistency, and structural validity of the MUEQ in Brazilian computer-office workers.

METHODS

The cross-cultural adaptation consisted of five stages (forward translation of the MUEQ to Brazilian Portuguese, synthesis of the translation, back-translation, expert committee meeting, and the pre-final-version test). In the pre-final-version test, 55 computer-office workers participated. For reproducibility, a sample of 50 workers completed the questionnaire twice within a one-week interval. A sample of 386 workers from the University of São Paulo (mean age = 37.44 years; 95% confidence interval: 36.50-38.38; 216 women and 170 men) participated on the structural validation and internal consistency analysis. Intraclass correlation coefficient was used for the statistical analysis of reproducibility, Cronbach's alpha was used for internal consistency, and confirmatory factor analysis was used for structural validity.

RESULTS

The calculation of internal consistency, reproducibility, and cross validation provided evidence of reliability and lack of redundancy. The psychometric properties of the modified MUEQ-Br revised were assessed using confirmatory factor analysis, which revealed 6 factors and 41 questions. For this model, the comparative fit index (CFI), goodness-of-fit index (GFI), and non-normed fit index (NNFI) each achieved 0.90, and the consistent Akaike information criterion (CAIC), chi-square, expected cross-validation index (ECIV), and root mean square error of approximation (RMSEA) demonstrated better values.

CONCLUSIONS

The results provide a basis for using the 41-item MUEQ-Br revised for the assessment of computer-office workers' perceptions of the psychosocial and ergonomic aspects of CANS and musculoskeletal-complaint characterization.

Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence?

Femoroacetabuler impingement (FAI) is becoming increasingly recognised as a potential pathological entity for individuals with hip pain. Surgery described to correct FAI has risen exponentially in the past 10 years with the use of hip arthroscopy. Unfortunately, the strength of evidence supporting both the examination and treatment of FAI does not appear to accommodate this exponential growth. In fact, the direction currently taken for FAI is similar to previously described paths of other orthopaedic and sports medicine pathologies (eg, shoulder impingement, knee meniscus tear) for which we have learned valuable lessons. The time has come for improved terminology, study design, and focus on delineation of successful treatment variables in the interest of those individuals with clinical indications of FAI so that we can appropriately address their needs.

Progressive high-load strength training compared with general low-load exercises in patients with rotator cuff tendinopathy: study protocol for a randomised controlled trial

Background

Shoulder pain is the third most common musculoskeletal disorder, often affecting people’s daily living and work capacity. The most common shoulder disorder is the subacromial impingement syndrome (SIS) which, among other pathophysiological changes, is often characterised by rotator cuff tendinopathy. Exercise is often considered the primary treatment option for rotator cuff tendinopathy, but there is no consensus on which exercise strategy is the most effective. As eccentric and high-load strength training have been shown to have a positive effect on patella and Achilles tendinopathy, the aim of this trial is to compare the efficacy of progressive high-load exercises with traditional low-load exercises in patients with rotator cuff tendinopathy.

Methods/Design

The current study is a randomised, participant- and assessor-blinded, controlled multicentre trial. A total of 260 patients with rotator cuff tendinopathy will be recruited from three outpatient shoulder departments in Denmark, and randomised to either 12 weeks of progressive high-load strength training or to general low-load exercises. Patients will receive six individually guided exercise sessions with a physiotherapist and perform home-based exercises three times a week. The primary outcome measure will be change from baseline to 12 weeks in the patient-reported outcome Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Discussion

Previous studies of exercise treatment for SIS have not differentiated between subgroups of SIS and have often had methodological flaws, making it difficult to specifically design target treatment for patients diagnosed with SIS. Therefore, it was considered important to focus on a subgroup such as tendinopathy, with a specific tailored intervention strategy based on evidence from other regions of the body, and to clearly describe the intervention in a methodologically strong study.

Trial registration

The trial was registered with Clinicaltrials.gov (NCT01984203) on 31 October 2013.