Nigel Hanchard

Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder: quick reference summary

Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder: quick reference summary Nigel C.A. Hanchard a,∗, Lorna Goodchild b, Jackie Thompson c, Tracey O’Brien d, Dot Davison e, Chris Richardson e a Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough, TS1 3BA, UK b Department of Rehabilitation, James Cook University Hospital, Middlesbrough, UK c Department of Physiotherapy, County Durham and Darlington Foundation Trust, Darlington, UK d Department of Physiotherapy, Langbaurgh Primary Care Trust, Guisborough, UK e Department of Physiotherapy, Middlesbrough Primary Care Trust, Middlesbrough, UK

A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder

Objectives To elucidate the experiences and perceptions of people living with primary frozen shoulder and their priorities for treatment. Design Qualitative study design using semistructured interviews. Setting General practitioner (GP) and musculoskeletal clinics in primary and secondary care in one National Health Service Trust in England. Participants 12 patients diagnosed with primary frozen shoulder were purposively recruited from a GPs surgery, community clinics and hospital clinics. Recruitment targeted the phases of frozen shoulder: pain predominant (n=5), stiffness predominant (n=4) and residual stiffness predominant following hospital treatment (n=2). One participant dropped out. Inclusion criteria: adult, male and female patients of any age, attending the clinics, who had been diagnosed with primary frozen shoulder. Results The most important experiential themes identified by participants were: pain which was severe as well as inexplicable; inconvenience/disability arising from increasing restriction of movement (due to pain initially, gradually giving way to stiffness); confusion/anxiety associated with delay in diagnosis and uncertainty about the implications for the future; and treatment-related aspects. Participants not directly referred to a specialist (whether physiotherapist, physician or surgeon) wanted a faster, better-defined care pathway. Specialist consultation brought more definitive diagnosis, relief from anxiety and usually self-rated improvement. The main treatment priority was improved function, though there was recognition that this might be facilitated by relief of pain or stiffness. There was a general lack of information from clinicians about the condition with over-reliance on verbal communication and very little written information. Conclusions Awareness of frozen shoulder should be increased among non-specialists and the best available information made accessible for patients. Our results also highlight the importance of patient participation in frozen shoulder research.

Assessing Reliability of Measurement of Gait Velocity

Summary Background and Purpose Gait velocity reliability was evaluated using the GAITRite® system to measure healthy subjects at free walking speed. Methods A convenience sample of 60 subjects (mean age 22.3 years) was measured on two separate occasions (24 hours apart) with each subject traversing a 7.5 metre walkway. Instructions to each subject were standardised in an attempt to control for variability of gait. A strict protocol was used to ensure consistency. The mean velocity for the three repetitions on each occasion was recorded. Data were analysed to assess reliability by the Bland and Altman method to evaluate the clinical importance of the error inherent in the data. Results For the measurement of gait velocity, the limits of agreement (0.13 m/s to –0.09 m/s) demonstrated that two measurements taken 24 hours apart, and according to the protocol described, would be within 0.11 m/s of each other in 95% of cases. Conclusion The clinical implications from these results suggest that the relatively small error described by the limits of agreement reflects the accuracy of the measurements. The system would be useful in a busy clinical practice to assess gait parameters.

Manual therapy and exercises for shoulder impingement revisited

Abstract Background: Disorders related to shoulder impingement are consistently classified as the most common diagnostic subgroup of shoulder pain. A variety of interventions for shoulder impingement have been proposed, including manual therapy and exercises. Despite a growing body of evidence on these interventions, their effectiveness has not yet been conclusively established. Objectives: To establish the current state of evidence on the effectiveness of manual therapy and exercises to improve patient-centered outcomes in adults with shoulder impingement. Methods: This systematic review updates a previous systematic review by the same authors. It includes evidence from randomized controlled trials published between October 2008 and September 2012. Comprehensive searches were made of seven relevant electronic databases including MEDLINE, Cochrane CENTRAL, CINAHL, and PEDro, supplemented by further sources. Methodological quality was assessed with the PEDro scale. Results: Nine randomized controlled trials were included and synthesized narratively. The trials varied considerably in methodological quality and reporting quality, as well as in terms of the interventions and comparisons considered, and in the outcome measures used. Clinical heterogeneity precluded meta-analysis. The trials provide limited evidence to support the effectiveness of a diversity of manual therapy and exercise approaches for treating shoulder impingement. Conclusions: This systematic review update provides some further evidence supporting the effectiveness of manual therapy and exercises for shoulder impingement, but methodological deficits/risk of bias warrant cautious interpretation. Further research is needed to establish the optimal manual therapy and exercise techniques and parameters.

Exploring the outcomes in studies of primary frozen shoulder: is there a need for a core outcome set?

PurposeIn our study we explored the need to define a core outcome set for primary frozen shoulder.MethodsWe investigated the outcomes used by studies included in a systematic review of the management of primary frozen shoulder; surveyed which primary outcome measures health care professionals considered important; and re-examined papers previously obtained for a systematic review of patients’ views of interventions for frozen shoulder to investigate their views on outcomes.ResultsThirty-one studies investigated the outcomes range of movement (28 studies), pain (22), function and disability (22), adverse events (13), quality of life (7) and other outcomes (5). Many different types of pain and ranges of movement were measured. Function and disability was measured using fifteen instruments, the content of which varied considerably. Function and disability, pain and range of movement (132, 108 and 104 respondents, respectively) were most often cited by health care professionals as the primary outcome measure that should be used. Searches identified one paper that included patients’ views. Outcomes of importance to patients were pain at night, general pain, reduced mobility (resulting in modification of activities) and the emotional impact of frozen shoulder.ConclusionsWe identified a diverse range of outcomes that have been used or are considered to be important. The development of a core outcome set would improve the design and reporting of studies and availability of data for evidence synthesis. Methods used to develop a core outcome set should be robust, transparent and reflect the views of all stakeholders.

Prognostic Models in Adults Undergoing Physical Therapy for Rotator Cuff Disorders: Systematic Review

Background Rotator cuff–related disorders represent the largest subgroup of shoulder complaints. Despite the availability of various conservative and surgical treatment options, the precise indications for these options remain unclear. Purpose The purpose of this systematic review was to synthesize the available research on prognostic models for predicting outcomes in adults undergoing physical therapy for painful rotator cuff disorders. Data Sources The MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and PEDro databases and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) up to October 2015 were searched. Study Selection The review included primary studies exploring prognostic models in adults undergoing physical therapy, with or without other conservative measures, for painful rotator cuff disorders. Primary outcomes were pain, disability, and adverse events. Inclusion was limited to prospective investigations of prognostic factors elicited at the baseline assessment. Study selection was independently performed by 2 reviewers. Data Extraction A pilot-tested form was used to extract data on key aspects of study design, characteristics, analyses, and results. Risk of bias and applicability were independently assessed by 2 reviewers using the Prediction Study Risk of Bias Assessment tool (PROBAST). Data Synthesis Five studies were included in the review. These studies were extremely heterogeneous in many aspects of design, conduct, and analysis. The findings were analyzed narratively. Limitations All included studies were rated as at high risk of bias, and none of the resulting prognostic models was found to be usable in clinical practice. Conclusions There are no prognostic models ready to inform clinical practice in the context of the review question, highlighting the need for further research on prognostic models for predicting outcomes in adults who undergo physical therapy for painful rotator cuff disorders. The design and conduct of future studies should be receptive to developing methods.

Developing, delivering and documenting rehabilitation in a multi-centre randomised controlled surgical trial: experiences from the ProFHER trial

Objectives A rigorous approach to developing, delivering and documenting rehabilitation within randomised controlled trials of surgical interventions is required to underpin the generation of reliable and usable evidence. This article describes the key processes used to ensure provision of good quality and comparable rehabilitation to all participants of a multi-centre randomised controlled trial comparing surgery with conservative treatment of proximal humeral fractures in adults. Methods These processes included the development of a patient information leaflet on self-care during sling immobilisation, the development of a basic treatment physiotherapy protocol that received input and endorsement by specialist physiotherapists providing patient care, and establishing an expectation for the provision of home exercises. Specially designed forms were also developed to facilitate reliable reporting of the physiotherapy care that patients received. Results All three initiatives were successfully implemented, alongside the measures to optimise the documentation of physiotherapy. Thus, all participating sites that recruited patients provided the sling immobilisation leaflet, all adhered to the physiotherapy protocol and all provided home exercises. There was exemplary completion of the physiotherapy forms that often reflected a complex patient care pathway. These data demonstrated equal and high access to and implementation of physiotherapy between groups, including the performance of home exercises. Conclusion In order to increase the validity and relevance of the evidence from trials of surgical interventions and meet international reporting standards, careful attention to study design, conduct and reporting of the intrinsic rehabilitation components is required. The involvement of rehabilitation specialists is crucial to achieving this. Cite this article: Bone Joint Res 2014;3:335–40.

Predicting the outcome of conservative treatment with physiotherapy in adults with shoulder pain associated with partial-thickness rotator cuff tears – a prognostic model development study

BackgroundRotator cuff disorders represent the commonest type of painful shoulder complaints in clinical practice. Although conservative treatment including physiotherapy is generally recommended as first-line treatment, little is known about the precise treatment indications for subgroups of rotator cuff disorders, particularly people with shoulder pain associated with partial-thickness tears of the rotator cuff, PTTs: “symptomatic PPTs”. The aim of this study was to develop a prognostic model for predicting the outcome of a phase of conservative treatment primarily with physiotherapy in adults with symptomatic PTTs.MethodsA prospective observational cohort study was conducted in an outpatient setting in Germany. Ten baseline factors were selected to evaluate nine pre-defined multivariable candidate prognostic models (each including between two and nine factors) in a cohort of adults with symptomatic atraumatic PTTs undergoing a three-month phase of conservative treatment primarily with physiotherapy. The primary outcome was change in the Western Ontario Rotator Cuff Index. The models were developed using linear regression and an information-theoretic analysis approach: Akaike’s Information Criterion (AICC).ResultsEight candidate models were analyzed using data from 61 participants. Two “best models” were identified: smoking & pain catastrophizing and disability & pain catastrophizing. However, none of the models had a satisfactory performance or precision.ConclusionsWe could not determine a prognostic model with satisfactory performance and precision. Further high-quality prognostic model studies with larger samples are needed, but should be underpinned, and thus preceded, by robust research that enhances knowledge of relevant prognostic factors.Study registrationDRKS00004462. Registered 08 April 2014; retrospectively registered (prior to the analysis).