Kajsa Johansson

Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study

Objective To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression. Design Randomised, participant and single assessor blinded, controlled study. Setting Department of orthopaedics in a Swedish university hospital. Participants 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists. Interventions The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks. Main outcome measures The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients’ global impression of change because of treatment and decision regarding surgery. Results Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients’ global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001). Conclusion A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study. Trial registration Clinical trials NCT01037673

The influence of age, delay of repair, and tendon involvement in acute rotator cuff tears: Structural and clinical outcomes after repair of 42 shoulders

Background and purpose Few authors have considered the outcome after acute traumatic rotator cuff tears in previously asymptomatic patients. We investigated whether delay of surgery, age at repair, and the number of cuff tendons involved affect the structural and clinical outcome. Patients and methods 42 patients with pseudoparalysis after trauma and no previous history of shoulder symptoms were included. A full-thickness tear in at least 1 of the rotator cuff tendons was diagnosed in all patients. Mean time to surgery was 38 (6–91) days. Follow-up at a mean of 39 (12–108) months after surgery included ultrasound, plain radiographs, Constant-Murley score, DASH score, and western Ontario rotator cuff (WORC) score. Results At follow-up, 4 patients had a full-thickness tear and 9 had a partial-thickness tear in the repaired shoulder. No correlation between the structural or clinical outcome and the time to repair within 3 months was found. The patients with a tendon defect at follow-up had a statistically significantly lower Constant-Murley score and WORC index in the injured shoulder and were significantly older than those with intact tendons. The outcomes were similar irrespective of the number of tendons repaired. Interpretation A delay of 3 months to repair had no effect on outcome. The patients with cuff defects at follow-up were older and they had a worse clinical outcome. Multi-tendon injury did not generate worse outcomes than single-tendon tears at follow-up.

SUPERVISED STRENGTHENING EXERCISES VERSUS HOME-BASED MOVEMENT EXERCISES AFTER ARTHROSCOPIC ACROMIOPLASTY: A RANDOMIZED CLINICAL TRIAL

OBJECTIVE To evaluate and compare the efficacy of 2 rehabilitation strategies after arthroscopic acromioplasty: supervised physical therapy focusing on strengthening exercises of the rotator cuff and scapula stabilizers (PT-group) vs home-based movement exercises (H-group). DESIGN A randomized, single-blinded, clinically controlled study. PATIENTS Thirty-six patients entered the study. Thirteen in the PT-group and 16 in the H-group fulfilled all the assessments. METHODS For 12 weeks following surgery, patients performed either supervised physical therapy or home exercises. Follow-ups were conducted periodically for 6 months after surgery to evaluate shoulder function, pain (Constant-Murley (CM) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores), and health-related quality of life. RESULTS The PT-group exhibited significantly greater improvements in CM (p =0.02) and DASH (p=0.05) scores. After treatment, the between-group mean difference in CM scores was 14.2 p (95% confidence interval 2-26). At the 6-month follow-up, the between-group mean difference in DASH scores was 13.4 p (95% confidence interval 0.1-23). CONCLUSION PT-supervised rehabilitation with strengthening exercises of the rotator cuff and scapula stabilizers seems to be superior to home exercises focusing on mobility for improving shoulder function after arthroscopic acromioplasty.

Determinants of Guideline Use in Primary Care Physical Therapy: A Cross-Sectional Survey of Attitudes, Knowledge, and Behavior

Background Understanding of attitudes, knowledge, and behavior related to evidence-based practice (EBP) and use of evidence-based clinical practice guidelines in primary care physical therapy is limited. Objectives The objectives of this study were: (1) to investigate self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guideline use among physical therapists in primary care and (2) to explore associations of self-reported use of guidelines with these social cognitive factors along with demographic and workplace characteristics. Design This was a cross-sectional survey. Methods A web-based survey of 419 physical therapists in primary care in western Sweden was performed. Multiple logistic regression analysis was performed to examine factors associated with guideline use. Results The response rate was 64.7%. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. Approximately two thirds reported confidence in finding and using evidence. One third reported being aware of guidelines. Thirteen percent knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. The most important barriers to using guidelines were lack of time, poor availability, and limited access to guidelines. Young age and brief work experience were associated with positive attitudes toward EBP. A postgraduate degree was associated with higher application of EBP. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. Limitations Data were self-reported, which may have increased the risk of social desirability bias. Conclusions Use of guidelines was not as frequent as could be expected in view of the positive attitudes toward EBP and guidelines among physical therapists. Awareness of and perceived access to guidelines were limited. The identified determinants can be addressed when developing guideline implementation strategies.

Intra- and interexaminer reliability of four manual shoulder maneuvers used to identify subacromial pain

Shoulder pain is a diagnostic challenge and the physical clinical examination of the shoulder is crucial. It is important that the diagnostic tests used are valid as well as reliable. The objective of the study was to assess intra- and interexaminer reliability for four manual shoulder maneuvers; the Neer impingement sign, the Hawkins-Kennedy impingement test, the Patte maneuver, the Jobe supraspinatus test. These maneuvers are frequently used in clinical practice to examine patients with shoulder complaints in which subacromial pain is highly suspected. Thirty-three participants with shoulder pain were included consecutively. Within a week from inclusion, the four maneuvers were performed by a physiotherapist. The procedure was standardized in order to increase reproducibility. After a week, the maneuvers were performed again by the same physical therapist (test-retest) and by another physical therapist (test for interexaminer reliability). All four maneuvers have an almost perfect agreement (Kappa coefficients 0.91-1.00), if performed with suggested standardizations. Neer impingement sign, Hawkins-Kennedy impingement test, Patte maneuver as well as Jobe supraspinatus test, are highly reproducible and therefore reliable to use in clinical practice to identify patients with subacromial pain with an impingement phenomenon, but the maneuvers are limited as structural discriminators.

Computerized lifestyle intervention in routine primary health care: Evaluation of usage on provider and responder levels

OBJECTIVE The aim of this study was to evaluate the use of a computerized concept for lifestyle intervention in routine primary health care (PHC). METHODS Nine PHC units were equipped with computers providing a lifestyle test and tailored printed advice regarding alcohol consumption and physical activity. Patients were referred by staff, and performed the test anonymously. Data were collected over a period of 1 year. RESULTS During the study period 3,065 tests were completed, representing 5.7% of the individuals visiting the PHC units during the period. There were great differences between the units in the number of tests performed and in the proportion of patients referred. One-fifth of the respondents scored for hazardous alcohol consumption, and one-fourth reported low levels of physical activity. The majority of respondents found the test easy to perform, and a majority of those referred to the test found referral positive. CONCLUSION The computerized test can be used for screening and intervention regarding lifestyle behaviours in PHC. Responders are positive to the test and to referral. PRACTICE IMPLICATIONS A more widespread implementation of computerized lifestyle tests could be a beneficial complement to face-to-face interventions in PHC.

Consensus for physiotherapy for shoulder pain

PurposeShoulder pain is a common disorder. Despite growing evidence of the importance of physiotherapy, in particular active exercise therapy, little data is available to guide treatment. The aim of this project was to contribute to the development of an internationally accepted assessment and treatment algorithm for patients with shoulder pain.MethodsNine physiotherapists with expertise in the treatment of shoulder dysfunction met in Sweden 2012 to begin the process of developing a treatment algorithm. A questionnaire was completed prior to the meeting to guide discussions. Virtual conferences were thereafter the platform to reach consensus.ResultsConsensus was achieved on a clinical reasoning algorithm to guide the assessment and treatment for patients presenting with local shoulder pain, without significant passive range of motion deficits and no symptoms or signs of instability. The algorithm emphasises that physiotherapy treatment decisions should be based on physical assessment findings and not structural pathology, that active exercises should be the primary treatment approach, and that regular re-assessment is performed to ensure that all clinical features contributing to the presenting shoulder pain are addressed. Consensus was also achieved on a set of guiding principles for implementing exercise therapy for shoulder pain, namely, a limited number of exercises, performed with appropriate scapulo-humeral coordination and humeral head alignment, in a graduated manner without provoking the presenting shoulder pain.ConclusionThe assessment and treatment algorithm presented could contribute to a more formal, extensive process aimed at achieving international agreement on an algorithm to guide physiotherapy treatment for shoulder pain.

A specific exercise strategy reduced the need for surgery in subacromial pain patients

Background and purpose A programme based on eccentric exercises for treating subacromial pain was in a previous study found effective at 3-month follow-up. The purposes of the present study were to investigate whether the results were maintained after 1 year and whether the baseline Constant-Murley score, rotator cuff status and radiological findings influenced the outcome. Patients and methods 97 patients on the waiting list for arthroscopic subacromial decompression had been randomised to a specific exercise programme or unspecific exercises (controls). After 3 months of exercises, the patients were asked whether they still wanted surgery and this option was available until a 1-year follow-up. 1 year after inclusion or 1 year after surgery, the number of patients who decided to have surgery in each group was compared. The choice of surgery was related to the baseline Constant-Murley score, ultrasound and radiographs taken at inclusion. Results All patients had improved significantly (p<0.0001) in the Constant-Murley score at the 1-year follow-up. Significantly more patients in the control group decided to have surgery (63%) than those in the specific exercise group (24%; p<0.0001). Patients who decided to have surgery had a significantly lower baseline Constant-Murley score and more often a full-thickness tear. Patients with partial tears did not differ from those with intact tendons. Interpretation The positive short-term results of specific exercises were maintained after 1 year, and this exercise strategy reduces the need for surgery. Full-thickness tear and a low baseline Constant-Murley score appear to be a predictive marker for a less good outcome. Trial registration number Clinical trials NCT01037673.

Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial.

BackgroundClinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden.MethodsAn implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson’s χ2 test and approximative z-test.Results168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes.ConclusionsA tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.

Minimal important changes in the Constant-Murley score in patients with subacromial pain

OBJECTIVE The purpose of this study was to determine the minimal important change (MIC) of improvement in the Constant-Murley score in patients with long-standing subacromial pain and in subgroups of patients with subacromial pain with and without rotator cuff ruptures. METHOD The MIC was estimated by the anchor-based MIC distribution method, which integrates an anchor- and distribution-based approach: the optimal cutoff point of the receiver operating characteristic curve (MICROC) and the 95% limit cutoff point (MIC95% limit). The study population consisted of 93 patients included in a randomized clinical trial evaluating the effect of a specific exercise strategy. RESULTS The MICROC was found at a mean change of 17 points in the Constant-Murley score, which corresponds to a sensitivity of 91% and a specificity of 79%. The MIC95% limit was found at a mean change of 24 points. In the subgroup analysis, the MICROC was found at a mean change of 19 points and the MIC95% limit at 18 points in patients with an intact rotator cuff. In patients with rotator cuff ruptures, the MICROC was found at a mean change of 15 points and the MIC95% limit at 30 points. CONCLUSION The Constant-Murley score is able to detect the MIC in individual patients with long-standing subacromial pain when the rotator cuff is intact. The estimated MIC values could be used as an indication for relevant changes in the Constant-Murley score in clinical practice and guide the clinician in how to interpret the results of specific treatments.