D.A.W.M. van der Windt

Shoulder disorders in general practice: incidence, patient characteristics, and management.

OBJECTIVES--To study the incidence and management of intrinsic shoulder disorders in Dutch general practice, and to evaluate which patient characteristics are associated with specific diagnostic categories. METHODS--In 11 general practices (35,150 registered patients) all consultations concerning shoulder complaints were registered during a period of one year. Patients with an intrinsic shoulder disorder who had not consulted their general practitioner for the complaint during the preceding year (incident cases) were asked to participate in an observational study. Participants completed a questionnaire regarding the nature and severity of their complaints. The general practitioners recorded data on diagnosis and therapy. RESULTS--The cumulative incidence of shoulder complaints in general practice was estimated to be 11.2/1000 patients/year (95% confidence limits 10.1 to 12.3). Rotator cuff tendinitis was the most frequently recorded disorder (29%). There were 349 incident cases enrolled in the observational study. Patient characteristics showed small variations between different diagnostic categories. Age, duration of symptoms, precipitating cause and restriction of movement seemed to be discriminating factors. Twenty two percent of all participants received injections during the first consultation; most (85%) were diagnosed as having bursitis. The majority of patients with tendinitis (53%) were referred for physiotherapy. CONCLUSION--With respect to diagnosis and treatment, the practitioners generally appeared to follow the guidelines issued by the Dutch College of General Practitioners. Although the patient characteristics of specific disorders showed some similarities with the clinical pictures described in the literature, further research is required to demonstrate whether the proposed syndromes indeed constitute separate disorders with a different underlying pathology, requiring different treatment strategies.

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.

Prognosis Research Strategy (PROGRESS) 3: Prognostic Model Research

In this article, the third in the PROGRESS series on prognostic factor research, Sara Schroter and colleagues review how prognostic models are developed and validated, and then address how prognostic models are assessed for their impact on practice and patient outcomes, illustrating these ideas with examples.

Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial

Abstract Objective : To compare the effectiveness of corticosteroid injections with physiotherapy for the treatment of painful stiff shoulder. Design : Randomised trial. Setting : 40 general practices. Subjects : 109 patients consulting general practitioners for shoulder pain were enrolled in the trial. Interventions : Patients were randomly allocated to 6 weeks of treatment either with corticosteroid injections (53) or physiotherapy (56). Main outcome measures : Outcome assessments were carried out 3, 7, 13, 26, and 52 weeks after randomisation; some of the assessments were done by an observer blind to treatment allocation. Primary outcome measures were the success of treatment as measured by scores on scales measuring improvement in the main complaint and pain, and improvement in scores on a scale measuring shoulder disability. Results : At 7 weeks 40 (77%) out of 52 patients treated with injections were considered to be treatment successes compared with 26 (46%) out of 56 treated with physiotherapy (difference between groups 31%, 95% confidence interval 14% to 48%). The difference in improvement favoured those treated with corticosteroids in nearly all outcome measures; these differences were statistically significant. At 26 and 52 weeks differences between the groups were comparatively small. Adverse reactions were generally mild. However, among women receiving treatment with corticosteroids adverse reactions were more troublesome: facial flushing was reported by 9 women and irregular menstrual bleeding by 6, 2 of whom were postmenopausal. Conclusions : The beneficial effects of corticosteroid injections administered by general practitioners for treatment of painful stiff shoulder are superior to those of physiotherapy. The differences between the intervention groups were mainly the result of the comparatively faster relief of symptoms that occurred in patients treated with injections. Adverse reactions were generally mild but doctors should be aware of the potential side effects of injections of triamcinolone, particularly in women.

Effectiveness of exercise therapy: A best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinsons disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

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 quality of diagnostic accuracy studies since the STARD statement Has it improved

Objective: To assess whether the quality of reporting of diagnostic accuracy studies has improved since the publication of the Standards for the Reporting of Diagnostic Accuracy studies (STARD statement). Methods: The quality of reporting of diagnostic accuracy studies published in 12 medical journals in 2000 (pre-STARD) and 2004 (post-STARD) was evaluated by two reviewers independently. For each article, the number of reported STARD items was counted (range 0 to 25). Differences in completeness of reporting between articles published in 2000 and 2004 were analyzed, using multilevel analyses. Results: We included 124 articles published in 2000 and 141 articles published in 2004. Mean number of reported STARD items was 11.9 (range 3.5 to 19.5) in 2000 and 13.6 (range 4.0 to 21.0) in 2004, an increase of 1.81 items (95% CI: 0.61 to 3.01). Articles published in 2004 reported the following significantly more often: methods for calculating test reproducibility of the index test (16% vs 35%); distribution of the severity of disease and other diagnoses (23% vs 53%); estimates of variability of diagnostic accuracy between subgroups (39% vs 60%); and a flow diagram (2% vs 12%). Conclusions: The quality of reporting of diagnostic accuracy studies has improved slightly over time, without a more pronounced effect in journals that adopted the STARD statement. As there is still room for improvement, editors should mention the use of the STARD statement as a requirement in their guidelines for authors, and instruct reviewers to check the STARD items. Authors should include a flow diagram in their manuscript.

Effectiveness of physiotherapy for lateral epicondylitis: a systematic review

AIM: To evaluate the available evidence of the effectiveness of physiotherapy for lateral epicondylitis of the elbow. METHOD: Randomised controlled trials (RCTs) identified by a highly sensitive search strategy in six databases in combination with reference checking. Two independent reviewers selected RCTs that included a physiotherapy intervention, patients with lateral epicondylitis, and at least one clinically relevant outcome measure. No language restrictions were made. Methodological quality was independently assessed by two blinded reviewers. A best evidence synthesis, including a quantitative and qualitative analysis, was conducted, weighting the studies with respect to their internal validity, statistical significance, clinical relevance, and statistical power. RESULTS: 23 RCTs were included in the review, evaluating the effects of lasertherapy, ultrasound treatment, electrotherapy, and exercises and mobilisation techniques. Fourteen studies satisfied at least 50% of the internal validity criteria. Except for ultrasound, pooling of data from RCTs was not possible because of insufficient data, or clinical or statistical heterogeneity. The pooled estimate of the treatment effects of two studies on ultrasound compared to placebo ultrasound, showed statistically significant and clinically relevant differences in favour of ultrasound. There is insufficient evidence either to demonstrate benefit or lack of effect of lasertherapy, electrotherapy, exercises and mobilisation techniques for lateral epicondylitis. CONCLUSIONS: Despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions for lateral epicondylitis due to contradicting results, insufficient power, and the low number of studies per intervention. Only for ultrasound, weak evidence for efficacy was found. More better designed, conducted and reported RCTs are needed.

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.

Value of symptoms and additional diagnostic tests for colorectal cancer in primary care: systematic review and meta-analysis.

Objective To summarise available evidence on diagnostic tests that might help primary care physicians to identify patients with an increased risk for colorectal cancer among those consulting for non-acute lower abdominal symptoms. Data sources PubMed, Embase, and reference screening. Study eligibility criteria Studies were selected if the design was a diagnostic study; the patients were adults consulting because of non-acute lower abdominal symptoms; tests included signs, symptoms, blood tests, or faecal tests. Study appraisal and synthesis methods Two reviewers independently assessed quality with a modified version of the QUADAS tool and extracted data. We present diagnostic two by two tables and pooled estimates of sensitivity and specificity. We refrained from pooling when there was considerable clinical or statistical heterogeneity. Results 47 primary diagnostic studies were included. Sensitivity was consistently high for age ≥50 (range 0.81-0.96, median 0.91), a referral guideline (0.80-0.94, 0.92), and immunochemical faeces tests (0.70-1.00, 0.95). Of these, only specificity of the faeces tests was good. Specificity was consistently high for family history (0.75-0.98, 0.91), weight loss (0.72-0.96, 0.89), and iron deficiency anaemia (0.83-0.95, 0.92), but all tests lacked sensitivity. None of these six tests was (sufficiently) studied in primary care. Conclusions Although combinations of symptom and results of immunochemical faeces tests showed good diagnostic performance for colorectal cancer, evidence from primary care is lacking. High quality studies on their role in the diagnostic investigation of colorectal cancer in primary care are urgently needed.