A.F. de Winter

Occupational risk factors for shoulder pain: a systematic review

OBJECTIVES To systematically evaluate the available evidence on occupational risk factors of shoulder pain. METHODS Relevant reports were identified by a systematic search of Medline, Embase, Psychlit, Cinahl, and Current Contents. The quality of the methods of all selected publications was assessed by two independent reviewers using a standardised checklist. Details were extracted on the study population, exposures (physical load and psychosocial work environment), and results for the association between exposure variables and shoulder pain. RESULTS 29 Studies were included in the review; three case-control studies and 26 cross sectional designs. The median method score was 60% of the maximum attainable score. Potential risk factors related to physical load and included heavy work load, awkward postures, repetitive movements, vibration, and duration of employment. Consistent findings were found for repetitive movements, vibration, and duration of employment (odds ratio (OR) 1.4–46 in studies with method scores ⩾ 60%). Nearly all studies that assessed psychosocial risk factors reported at least one positive association with shoulder pain, but the results were not consistent across studies for either high psychological demands, poor control at work, poor social support, or job dissatisfaction. Studies with a method score ⩾60% reported ORs between 1.3 and 4.0. Substantial heterogeneity across studies for methods used for exposure assessment and data analysis impeded statistical pooling of results. CONCLUSIONS It seems likely that shoulder pain is the result of many factors, including physical load and the psychosocial work environment. The available evidence was not consistent across studies, however, and the associations were generally not strong. Future longitudinal research should evaluate the relative importance of each individual risk factor and the role of potential confounding variables—such as exposure during leisure time—to set priorities for the prevention of shoulder pain in occupational settings.

Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised clinical trials.

Abstract Objective: To assess the effectiveness of physiotherapy for patients with soft tissue shoulder disorders. Design: A systematic computerised literature search of Medline and Embase, supplemented with citation tracking, for relevant trials with random allocation published before 1996. Subjects: Patients treated with physiotherapy for disorders of soft tissue of the shoulder. Main outcome measures: Success rates, mobility, pain, functional status. Results: Six of the 20 assessed trials satisfied at least five of eight validity criteria. Assessment of methods was often hampered by insufficient information on various validity criteria, and trials were often flawed by lack of blinding, high proportions of withdrawals from treatment, and high proportions of missing values. Trial sizes were small: only six trials included intervention groups of more than 25 patients. Ultrasound therapy, evaluated in six trials, was not shown to be effective. Four other trials favoured physiotherapy (laser therapy or manipulation), but the validity of their methods was unsatisfactory. Conclusions: There is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders. Due to small trial sizes and unsatisfactory methods, evidence for the effectiveness of other methods of physiotherapy is inconclusive. For all methods of treatment, trials were too heterogeneous with respect to included patients, index and reference treatments, and follow up to merit valid statistical pooling. Future studies should show whether physiotherapy is superior to treatment with drugs, steroid injections, or a wait and see policy. Key messages Because of the small sample sizes and unsatisfactory methods of most trials, only a few randomised clinical trials of methods of physiotherapy in patients with soft tissue shoulder disorders allow firm conclusions on effectiveness of treatment When compared with placebo or another treatment, ultrasound therapy seems ineffective in patients with shoulder disorders Evidence is insufficient to support the effectiveness of low level laser therapy, heat treatment, cold therapy, electrotherapy, exercise, and mobilisation in such patients Future trials should focus on the effectiveness of exercise and mobilisation in comparison to analgesics, non-steroidal drugs, steroid injections, and advice and a wait and see policy Special attention should also be given to the principles of adequate design and conduct of trials and the standards of reporting

The responsiveness of the Shoulder Disability Questionnaire

Objective—To evaluate the responsiveness of the Shoulder Disability Questionnaire (SDQ). Methods—The study was conducted within the framework of an observational study on shoulder disorders in primary care. After first presentation of their complaints to the general practitioner and after one and six months, participants completed the SDQ, a single question on functional status (FSQ), and an ordinal 11 point scale for the severity of pain (PSS). Responsiveness of the SDQ was evaluated compared with that of the FSQ and PSS, by calculating responsiveness ratios and by plotting receiver operating characteristic (ROC) curves. Recovery according to the patient was used as an external criterion for clinically relevant improvement (complete recovery or much improved on a six point Likert scale was denoted as clinically relevant improvement). Results—A total of 349 consecutive patients with shoulder disorders were enrolled in the observational study. Response rates ranged between 96% and 89%. Responsiveness ratios were slightly higher for the PSS compared with the SDQ (2.53 versus 2.22 at one month, 2.24 versus 1.89 at six months). The area under the ROC curve was 0.84 for both the SDQ and the PSS, and 0.72 for the FSQ. Conclusion—The results of this study confirm the responsiveness of the SDQ, making it a useful instrument to assess functional disability in longitudinal studies.

Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement

OBJECTIVES To assess the interobserver agreement on the diagnostic classification of shoulder disorders, based on history taking and physical examination, and to identify the determinants of diagnostic disagreement. METHODS Consecutive eligible patients with shoulder pain were recruited in various health care settings in the Netherlands. After history taking, two physiotherapists independently performed a physical examination and subsequently the shoulder complaints were classified into one of six diagnostic categories: capsular syndrome (for example, capsulitis, arthritis), acute bursitis, acromioclavicular syndrome, subacromial syndrome (for example, tendinitis, chronic bursitis), rest group (for example, unclear clinical picture, extrinsic causes) and mixed clinical picture. To quantify the interobserver agreement Cohen’s κ was calculated. Multivariate logistic regression analysis was applied to determine which clinical characteristics were determinants of diagnostic disagreement. RESULTS The study population consisted of 201 patients with varying severity and duration of complaints. The κ for the classification of shoulder disorders was 0.45 (95% confidence intervals (CI) 0.37, 0.54). Diagnostic disagreement was associated with bilateral involvement (odds ratio (OR) 1.9; 95% CI 1.0, 3.7), chronic complaints (OR 2.0; 95% CI 1.1, 3.7), and severe pain (OR 2.7; 95% CI 1.3, 5.3). CONCLUSIONS Only moderate agreement was found on the classification of shoulder disorders, which implies that differentiation between the various categories of shoulder disorders is complicated. Especially patients with high pain severity, chronic complaints and bilateral involvement represent a diagnostic challenge for clinicians. As diagnostic classification is a guide for treatment decisions, unsatisfactory reproducibility might affect treatment outcome. To improve the reproducibility, more insight into the reproducibility of clinical findings and the value of additional diagnostic procedures is needed.

NHG-Standaard Schouderklachten

grafie) is bij een eerste episode van niettraumatische schouderklachten niet zinvol, omdat de uitslag het beleid van de huisarts niet beinvloedt. De stapsgewijze behandeling bestaat uit het geven van voorlichting en adviezen, en het zo nodig voorschrijven van analgetica. Bij onvoldoende vermindering van de klachten na een tot twee weken analgeticagebruik overweegt de huisarts op grond van de driedeling en overige bevindingen als tweede stap: – een verlenging van de behandeling met analgetica;