Ida Svege

Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A RANDOMISED CONTROLLED STUDY OF 103 PATIENTS WITH ONE-YEAR FOLLOW-UP

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p - 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8 degrees , p = 0.003) and for reduction in pain (difference on a visual analogue scale -1.7 cm, p < 0.0005).

Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up.

BACKGROUND There is limited Level-I evidence that compares operative and nonoperative treatment of rotator cuff tears. We compared outcomes of patients treated with primary tendon repair with outcomes of those treated with physiotherapy and optional secondary tendon repair if needed. METHODS A single-center, pragmatic, randomized controlled study with follow-ups after six months and one, two, and five years was conducted in a secondary-care institution. One hundred and three patients with a rotator cuff tear not exceeding 3 cm were randomized to primary tendon repair (n = 52) or physiotherapy (n = 51). The primary outcome measure was the Constant score. Secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score; the physical component summary measure of the Short Form 36 Health Survey; the measurement of pain, strength, and shoulder motion; patient satisfaction; and findings from magnetic resonance imaging and sonography. Analysis was by intention to treat. RESULTS The five-year follow-up rate was 98%. Twelve of the fifty-one patients in the physiotherapy group were treated with secondary tendon repair. The results from primary tendon repair were superior to those from physiotherapy plus secondary repair, with between-group mean differences of 5.3 points on the Constant score (p = 0.05), 9.0 points on the American Shoulder and Elbow Surgeons score (p < 0.001), 1.1 cm on a 10-cm visual analog scale for pain (p < 0.001), and 1.0 cm on a 10-cm visual analog scale for patient satisfaction (p = 0.03). In 37% of tears treated with physiotherapy only, there were increasing tear sizes on ultrasound of >5 mm, over five years, associated with an inferior outcome. CONCLUSIONS Although primary repair of small and medium-sized rotator cuff tears was associated with better outcome than physiotherapy treatment, the differences were small and may be below clinical importance. In the physiotherapy treatment group, there were increasing tear sizes and inferior outcomes in one-third of patients who did not undergo repair.

Reliability and validity of the Physical Activity Scale for the Elderly (PASE) in patients with hip osteoarthritis

BackgroundPhysical activity (PA) is beneficial in reducing pain and improving function in lower limb osteoarthritis (OA), and is recommended as a first line treatment. Self-administered questionnaires are used to assess PA, but knowledge about reliability and validity of these PA questionnaires are limited, in particular for patients with OA. The purpose of this study was to evaluate the reliability and validity of the Physical Activity Scale for the Elderly (PASE) in patients with hip OA.MethodsForty patients with hip OA (20 men and 20 women, mean age 61.3 ± 10 years) were included. For test-retest reliability PASE was administered twice with a mean time between tests of 9 ± 4 days. Intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were calculated for the total score and for the particular items assessing different PA intensity levels. In addition a Bland-Altman analysis for the total PASE score was performed. Construct validity was evaluated by comparing the PASE results with the Actigraph GT1M accelerometer and the International Physical Activity Questionnaire (IPAQ), using the Spearman rank correlation coefficient.ResultsICC for the total PASE score was 0.78, with relatively large error of measurement; SEM = 31 and MDC = 87. ICC for the intensity items was 0.20 for moderate PA intensity, 0.46 for light PA intensity and to 0.68 for vigorous PA intensity. The Spearman rank correlation coefficient between the Actigraph GT1M total counts per minute and the total PASE score was 0.30 (p = 0.089), and ranging from 0.20-0.38 for the different PA intensity categories. The Spearman rank correlation between IPAQ and PASE was 0.61 (p = 0.001) for the total scores.ConclusionsIn patients with hip OA the test-retest reliability of the total PASE score was moderate, with acceptable ICC, but with large measurement errors. The construct validity of the PASE was poor when compared to the Actigraph GT1M accelerometer. Test-retest reliability and construct validity revealed that the PASE was unable to assess PA intensity levels. PASE is not recommended as a valid tool to examine PA level for patients with hip OA.

Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised trial

Background Exercise treatment is recommended for all patients with hip osteoarthritis (OA), but its effect on the long-term need for total hip replacement (THR) is unknown. Methods We conducted a long-term follow-up of a randomised trial investigating the efficacy of exercise therapy and patient education versus patient education only on the 6-year cumulative survival of the native hip to THR in 109 patients with symptomatic and radiographic hip OA. Results regarding the primary outcome measure of the trial, self-reported pain at 16 months follow-up, have been reported previously. Results There were no group differences at baseline. The response rate at follow-up was 94%. 22 patients in the group receiving both exercise therapy and patient education and 31 patients in the group receiving patient education only underwent THR during the follow-up period, giving a 6-year cumulative survival of the native hip of 41% and 25%, respectively (p=0.034). The HR for survival of the native hip was 0.56 (CI 0.32 to 0.96) for the exercise therapy group compared with the control group. Median time to THR was 5.4 and 3.5 years, respectively. The exercise therapy group had better self-reported hip function prior to THR or end of study, but no significant differences were found for pain and stiffness. Conclusions Our findings in this explanatory study suggest that exercise therapy in addition to patient education can reduce the need for THR by 44% in patients with hip OA. ClinicalTrials.gov number NCT00319423 (original project protocol) and NCT01338532 (additional protocol for long-term follow-up).

Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence

Background Femoroacetabular impingement (FAI) and associated pathologies are associated with pain and reduced quality of life. Physical impairments can be associated with worse symptoms and may be an important target of rehabilitation programmes in this patient group. Knowledge regarding physical impairments in people with symptomatic FAI is limited. Hypothesis In adults aged 18–50 years with symptomatic FAI: (1) to identify physical impairments in range of motion (ROM), hip muscle function and functional tasks; (2) to compare physical impairments with healthy controls; and (3) to evaluate the effects of interventions targeting physical impairments. Study design Systematic review. Methods A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The modified Downs and Black checklist was used for quality appraisal. Studies of adults aged 18–50 years with symptomatic FAI that examined ROM, hip muscle function and functional tasks were included. Standardised mean differences were calculated where possible or best evidence synthesis and study conclusions were presented. Results Twenty-two studies fulfilled all inclusion criteria. Methodological quality was varied. Results for hip joint ROM differences between people with symptomatic FAI compared and control subjects were varied. People with symptomatic FAI demonstrated some deficits in hip muscle strength and reduced balance on one leg when compared with control subjects. For hip joint ROM and hip muscle strength results for within-group differences between preintervention and postintervention time points were limited and inconclusive. No randomised controlled trials evaluated the effect of different types of interventions for symptomatic patients with symptomatic FAI. Conclusions People with symptomatic FAI demonstrate impairments in some hip muscle strength and single leg balance. This information may assist therapists in providing targeted rehabilitation programmes for people with FAI and associated pathology. Further research is needed to determine whether symptomatic FAI affects other aspects of functional performance; and to evaluate whether targeted interventions are effective in symptomatic FAI. Clinical relevance This information may assist therapists in providing targeted rehabilitation programmes for people with symptomatic FAI.

Reliability and validity of the Norwegian version of the Disabilities of the Arm, Shoulder and Hand questionnaire in patients with shoulder impingement syndrome

BackgroundPatient-rated outcome measures (PROMs) are an important part of clinical decision-making in rehabilitation of patients with shoulder pain. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire was designed to measure physical disability and symptoms in patients with musculoskeletal disorders of the upper extremity and is one the most commonly used outcome measures for patients with shoulder pain. The purpose of this study was to investigate the reliability and validity of the Norwegian version of the DASH in patients with shoulder impingement syndrome.MethodsSixty-three patients diagnosed with shoulder impingement syndrome at an orthopaedic outpatient clinic were included in the study. Internal consistency of the DASH was evaluated by the Cronbach’s alpha and item-to-total correlations. Test-retest reliability was analyzed by the intraclass correlation coefficient (ICC) and limits of agreement (LoA) according to the Bland Altman method. Standard error of measurement (SEM) and minimally detectable change (MDC) were calculated for the total DASH score. Construct validity was evaluated by testing six a priori hypotheses for the Pearson’s correlation coefficient between the DASH and the Shoulder Pain and Disability Index (SPADI), the 36-item Short Form Health Survey (SF-36) and a Numeric Pain Rating Scale (NPRS).ResultsReliability: Cronbach’s alpha of the DASH was 0.93 and item-to-total correlations ranged from 0.36 to 0.81. ICC was 0.89. The 95 percent LoA was calculated to be between -11.9 and 14.1. SEM was 4.7 and MDC 13.1. Construct validity: Eighty-three percent of the a priori hypotheses of correlation were confirmed. The DASH showed a high positive correlation of 0.75 with the SPADI, a negative moderate correlation of -0.48 to -0.62 with physical functioning, bodily pain and physical component summary of the SF-36 and a moderate positive correlation of 0.58 with the NPRS. DASH correlated higher with the physical component summary than with the mental component summary of the SF-36.ConclusionsThe Norwegian version of the DASH is a reliable and valid outcome measure for patients with shoulder impingement syndrome.

Long-Term Effect of Exercise Therapy and Patient Education on Impairments and Activity Limitations in People With Hip Osteoarthritis: Secondary Outcome Analysis of a Randomized Clinical Trial

Background The effect of exercise on specific impairments and activity limitations in people with hip osteoarthritis (OA) is limited. Objective The study objective was to evaluate the long-term effect of exercise therapy and patient education on range of motion (ROM), muscle strength, physical fitness, walking capacity, and pain during walking in people with hip OA. Design This was a secondary outcome analysis of a randomized clinical trial. Setting The setting was a university hospital. Participants One hundred nine people with clinically and radiographically evident hip OA were randomly allocated to receive both exercise therapy and patient education (exercise group) or patient education only (control group). Intervention All participants attended a patient education program consisting of 3 group meetings led by 2 physical therapists. Two other physical therapists were responsible for providing the exercise therapy program, consisting of 2 or 3 weekly sessions of strengthening, functional, and stretching exercises over 12 weeks. Both interventions were conducted at a sports medicine clinic. Measurements Outcome measures included ROM, isokinetic muscle strength, predicted maximal oxygen consumption determined with the Astrand bicycle ergometer test, and distance and pain during the Six-Minute Walk Test (6MWT). Follow-up assessments were conducted 4, 10, and 29 months after enrollment by 5 physical therapists who were unaware of group allocations. Results No significant group differences were found for ROM, muscle strength, predicted maximal oxygen consumption, or distance during the 6MWT over the follow-up period, but the exercise group had less pain during the 6MWT than the control group at 10 months (mean difference=−8.5 mm; 95% confidence interval=−16.1, −0.9) and 29 months (mean difference=−9.3 mm; 95% confidence interval=−18.1, −0.6). Limitations Limitations of the study were reduced statistical power and 53% rate of adherence to the exercise therapy program. Conclusions The previously described effect of exercise on self-reported function was not reflected by beneficial results for ROM, muscle strength, physical fitness, and walking capacity, but exercise in addition to patient education resulted in less pain during walking in the long term.

Development and Reliability of a Clinician-rated Instrument to Evaluate Function in Individuals with Shoulder Pain: A Preliminary Study

Background and Purpose Subacromial impingement syndrome (SIS) is a common and disabling condition in the population. Interventions are often evaluated with patient-rated outcome measures. The purpose of this study was to develop a simple clinician-rated measure to detect difficulties in the execution of movement-related tasks among patients with subacromial impingement syndrome. Method The steps in the scale development included a review of the clinical literature of shoulder pain to identify condition-specific questionnaires, pilot testing, clinical testing and scale construction. Twenty-one eligible items from thirteen questionnaires were extracted and included in a pilot test. All items were scored on a five-point ordinal scale ranging from 1 (no difficulty) to 5 (cannot perform). Fourteen items were excluded after pilot testing because of difficulties in standardization or other practical considerations. The remaining seven items were included in a clinical test-retest study with outpatients at a hospital. Of these, four were excluded because of psychometric reasons. From the remaining three items, a measure named Shoulder Activity Scale (summed score ranging from 3 to 15) was developed. Results A total of 33 men and 30 women were included in the clinical study; age range 27–80 years. The intraclass correlation coefficient results for inter-rater reliability and test-retest reliability were 0.80 (95% CI = 0.51–0.90) and 0.74 (95% CI = 0.58–0.84), respectively. The standard error of measurement and minimal detectable change were 1.19 and 3.32, respectively. The scale was linked to the International Classification of Functioning, Disability and Health second level categories lifting and carrying objects (d430), dressing (d540), hand and arm use (d445) and control of voluntary movement (b760). Conclusion The Shoulder Activity Scale showed acceptable reliability in a sample of outpatients at a hospital, rated by clinicians experienced in shoulder rehabilitation. The validity of the scale should be investigated in future studies before application to common practice.

Are severely injured trauma victims in Norway offered advanced pre‐hospital care? National, retrospective, observational cohort

Studies of severely injured patients suggest that advanced pre‐hospital care and/or rapid transportation provides a survival benefit. This benefit depends on the disposition of resources to patients with the greatest need. Norway has 19 Emergency Helicopters (HEMS) staffed by anaesthesiologists on duty 24/7/365. National regulations describe indications for their use, and the use of the national emergency medical dispatch guideline is recommended. We assessed whether severely injured patients had been treated or transported by advanced resources on a national scale.

Surgery was superior to physiotherapy for small and medium-size rotator cuff tears.

Question: In patients with small or medium-size rotator cuff tears, how do surgery and physiotherapy compare? Design: Randomized (allocation concealed), blinded (outcome assessor) controlled trial with 12-month follow-up. Setting: A hospital in Baerum, Norway. Patients: 103 patients (mean age 60 y, 71 % men) with small (<1 cm) or medium-size (1 to 3 cm) tears of the rotator cuff. Inclusion criteria were lateral shoulder pain at rest or with exercise, a painful arc of shoulder motion, positive impingement signs, and a passive range of movement of ≥140° for abduction and flexion. Exclusion criteria included age of < 18 years, tears absolutely requiring surgery, concomitant local or systemic diseases affecting shoulder function, previous tendon surgery on the relevant shoulder, and medical comorbid conditions. Follow-up data were available for all patients. Intervention: Patients were allocated to surgery (n = 52) or physiotherapy (n = 51). Surgery involved mini-open oropen tendon repair. Following diagnostic arthroscopy and a deltoid-splitting approach, an anteroinferior acromioplasty was performed. The deltoid was repaired to the acromion through drill-holes. Patients in the physiotherapy group received outpatient treatment by 1 of 4 physiotherapists. 40-minute sessions were given on the average of twice weekly for 12 weeks, and thereafter at increasing intervals during the next 6 to 12 weeks. Exercises to center the humeral head in the glenoid fossa were done to achieve glenohumeral control, and then progressed to more challenging positions. Additional exercises were given, tailored to specific demands in work, sports, and leisure activities. Patients who did not improve after 15 sessions were reassessed and offered surgery if deemed necessary. Main outcome measures: The primary outcome measure was an assessment of shoulder function with use of the Constant score (range, 0 to 100; higher scores represent better function). Secondary outcomes included the self-report section of the American Shoulder and Elbow Surgeons (ASES) score (range, 0 to 100); the Short Form (SF)-36 (0 to 100 points; higher scores indicate better health condition); Constant subscores on pain-free active shoulder abduction, pain-free active shoulder flexion, and shoulder strength; and ASES subscore on shoulder pain. Main results: Analysis was by intention to treat. 9 patients (18%) in the physiotherapy group showed no improvement after a mean of 24 sessions and underwent secondary surgical treatment. Missing nonoperative follow-up data of these patients after secondary surgical treatment were handled by a last-observation-carried-forward principle, meaning that the last scoring result before secondary surgical treatment was used for analysis. Differences between the surgery and physiotherapy groups on the Constant and ASES scores showed greater improvement from baseline in the surgery group than in the physiotherapy group (Table). Among the subscores, the surgery group patients had larger increases in shoulder abduction and decreases in pain; groups did not differ with regard to shoulder flexion or shoulder strength (Table). The groups were not different with regard to SF-36 scores. Conclusion: In patients with small or medium-size rotator cuff tears, 1-year outcomes were better after surgery than after physiotherapy.