Ole Marius Ekeberg

Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study

Objective To compare the effectiveness of ultrasound guided corticosteroid injection in the subacromial bursa with systemic corticosteroid injection in patients with rotator cuff disease. Design Double blind randomised clinical trial. Setting Outpatient clinic of a physical medicine and rehabilitation department in Oslo, Norway. Patients 106 patients with rotator cuff disease lasting at least three months. Interventions Ultrasound guided corticosteroid and lidocaine injection in the subacromial bursa and lidocaine injection in the gluteal region (local group); corticosteroid and lidocaine injection in the gluteal region and ultrasound guided lidocaine injection in the subacromial bursa (systemic group). Main outcome measures Difference in improvement in the overall shoulder pain and disability index score after six weeks. Results Six weeks after the intervention, the mean difference in improvement in overall shoulder pain and disability index score between the local group and the systemic group was −5.2 (95% confidence interval −13.9 to 3.5); it was −4.1 (−12.3 to 4.1, P=0.32) after adjustment for baseline score. A small but statistically significant difference in improvement between groups occurred in favour of the local group for two secondary outcome measures: the Western Ontario rotator cuff index (8.1, 0.7 to 15.6) and change in main complaint (2.0, 0 to 4). Conclusions No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease. Trial registration Clinical trials NCT00640575.

Agreement, reliability and validity in 3 shoulder questionnaires in patients with rotator cuff disease

BackgroundSelf-report questionnaires play an important role as outcome measures in shoulder research. Having an estimate of the measurement error of these questionnaires is of importance when assessing follow-up results after treatment and when planning intervention studies. The aim of this study was to cross-culturally adapt the Norwegian version of the OSS and WORC questionnaire and examine and compare agreement, reliability and construct validity of the disease-specific shoulder questionnaire WORC with two commonly used shoulder questionnaires, SPADI and OSS, in patients with rotator cuff disease.Methods74 patients with rotator cuff disease were recruited from the outpatient clinic of the Physical Medicine and Rehabilitation Department at Ullevaal University Hospital in Oslo, Norway. A test-retest design was used, and the questionnaires were filled out by the patients at the clinic, with a one week interval between test administrations. Agreement (repeatability coefficient), reliability (ICC) and construct validity were examined and compared for WORC, SPADI and OSS.ResultsReliability analysis was restricted to the 55 patients (51 ± 10 yrs) who reported no change between test administrations according to scoring on a global scale. The agreement, reliability and construct validity was moderate for all three questionnaires with ICC ranging from 0.83 to 0.85, repeatability coefficient from 16.1 to 19.7 and Spearman rank correlations between total scores from r = 0.57 to 0.69. There was a lower degree of floor and ceiling effects in SPADI compared to WORC and OSS.ConclusionWe conclude that the agreement and reliability of the three shoulder questionnaires examined, WORC index, SPADI and OSS are acceptable and that differences between scores were small. The Norwegian version of the questionnaires is acceptable for assessing Norwegian-speaking patients with rotator cuff disease. The moderate agreement and construct validity should be taken into consideration when assessing follow-up results after treatment and in the planning of prospective studies.

Radial extracorporeal shockwave treatment compared with supervised exercises in patients with subacromial pain syndrome: single blind randomised study

Objective To compare the effectiveness of radial extracorporeal shockwave treatment with that of supervised exercises in patients with shoulder pain. Design Single blind randomised study. Setting Outpatient clinic of physical medicine and rehabilitation department in Oslo, Norway. Participants 104 patients with subacromial shoulder pain lasting at least three months. Interventions Radial extracorporeal shockwave treatment: one session weekly for four to six weeks. Supervised exercises: two 45 minute sessions weekly for up to 12 weeks. Primary outcome measure Shoulder pain and disability index. Results A treatment effect in favour of supervised exercises at 6, 12, and 18 weeks was found. The adjusted treatment effect was −8.4 (95% confidence interval −16.5 to −0.6) points. A significantly higher proportion of patients in the group treated with supervised exercises improved—odds ratio 3.2 (1.3 to 7.8). More patients in the shockwave treatment group had additional treatment between 12 and 18 weeks—odds ratio 5.5 (1.3 to 26.4). Conclusion Supervised exercises were more effective than radial extracorporeal shockwave treatment for short term improvement in patients with subacromial shoulder pain. Trial registration Clinical trials NCT00653081.

A questionnaire found disease-specific WORC index is not more responsive than SPADI and OSS in rotator cuff disease

OBJECTIVES To compare responsiveness and minimal clinically important change (MCIC) for the disease-specific Western Ontario Rotator Cuff index (WORC) and the two region-specific questionnaires Shoulder Pain and Disability Index (SPADI) and Oxford Shoulder Scale (OSS) in patients with rotator cuff disease receiving corticosteroid injection therapy. STUDY DESIGN AND SETTING One hundred twenty-one patients with rotator cuff disease. Western Ontario Rotator Cuff index, SPADI, and OSS were administered before treatment and at 2 and 6 weeks after corticosteroid injection. Responsiveness was compared between questionnaires using the standardized response mean (SRM), area under the receiver operating characteristic curve, and reliable change proportion (RCP) statistics. Minimal clinically important change estimates were reported. RESULTS The differences between questionnaires were small and not consistent across the different responsiveness indices. Shoulder Pain and Disability Index was significantly more responsive than OSS measured by SRM and RCP at 2 and 6 weeks. Western Ontario Rotator Cuff index was significantly more responsive than OSS in RCP and area under receiver operating characteristic curve at 6 weeks. Shoulder Pain and Disability Index was significantly more responsive than WORC measured by RCP at 2 weeks. Minimal clinically important change was estimated to 5, 275, and 20 points for OSS, WORC, and SPADI, respectively. CONCLUSIONS All questionnaires are suitable for measuring change in patients with rotator cuff disease. Disease-specific WORC index is not more responsive than the region-specific SPADI and OSS in rotator cuff disease.

Supervised Exercises Compared With Radial Extracorporeal Shock-Wave Therapy for Subacromial Shoulder Pain: 1-Year Results of a Single-Blind Randomized Controlled Trial

Background Evidence from a recent randomized controlled trial indicated that supervised exercises (SE) were more effective than radial extracorporeal shock-wave therapy (rESWT) for the treatment of subacromial shoulder pain in the short to medium term. Little knowledge exists about the long-term results of rESWT for subacromial pain. Objective The aim of this study was to evaluate the results of rESWT and SE provided to patients with subacromial shoulder pain after 1 year. Design This was a single-blind randomized controlled trial. Setting The study was conducted in the outpatient clinic of the Physical Medicine and Rehabilitation Department at Oslo University Hospital, Ullevaal, Norway. Patients One hundred four patients with subacromial shoulder pain lasting at least 3 months participated. Patients were randomly assigned to either an rESWT group (n=52) or an SE group (n=52). Intervention The rESWT intervention consisted of one session weekly for 4 to 6 weeks. The SE intervention consisted of two 45-minute sessions per week for up to 12 weeks. Measurements The primary outcome measure was the Shoulder Pain and Disability Index. Secondary outcome measures were questions regarding pain and function and work status. Results After 1 year, an intention-to-treat analysis showed no significant differences between the 2 groups for the primary outcome measure (−7.6 points, 95% confidence interval=−16.6 to 0.5) and pain, function, and medication use. Twenty-nine participants (60%) in the SE group versus 24 participants (52%) in the rESWT group were categorized as clinically improved. Thirty-eight participants in the SE group were at work compared with 30 participants in the rESWT group (odds ratio=1.1, 95% confidence interval=1.0 to 1.2). Fewer patients in the SE group had received additional treatments between 18 weeks and 1 year. Limitations The lack of a placebo control group, the lack of a cost-benefit analysis, and the small sample size were limitations of the study. Conclusion No significant difference was found between the SE and rESWT groups at the 1-year follow-up. More participants in the SE group had returned to work.

Range of shoulder motion in patients with adhesive capsulitis; Intra-tester reproducibility is acceptable for group comparisons

BackgroundMeasurements of range of motion play a key role in shoulder research. The purpose of this study is to investigate intra-observer reproducibility of measurements of active and passive range of motion in patients with adhesive capsulitis.MethodsThe study was carried out in a population consisting of 32 patients with clinical signs of adhesive capsulitis. A specified measurement protocol was used, and range of motion in affected and non-affected shoulders was measured twice for each patient with a one-week interval.ResultsFor most of the investigated individual movements, test-retest differences in range of motion score of more than approximately 15° are not likely to occur as a result of measurement error only. Point-estimates for the intraclass correlation coefficient ranged from 0.61 to 0.93.ConclusionRange of motion of patients with adhesive capsulitis can be measured with acceptable reproducibility in settings where groups are compared. Scores for individual patients should be interpreted with caution.

Factor structure of the Shoulder Pain and Disability Index in patients with adhesive capsulitis.

BackgroundThe Shoulder Pain and Disability Index (SPADI) is a self-administered questionnaire that aims to measure pain and disability associated with shoulder disease. It consists of a pain section and a disability section with 13 items being responded to on visual analogue scales. Few researchers have investigated SPADI validity in specified diagnostic groups, although the selection of an evaluative instrument should be based on evidence of validity in the target patient group. The aim of the present study was to investigate factor structure of the SPADI in a study population of patients with adhesive capsulitis.MethodsThe questionnaire was administered to 191 patients with adhesive capsulitis. Descriptive statistics for items and a comparison of scores for the two subscales were produced. Internal consistency was analyzed by use of the Cronbach alpha and a principal components analysis with varimax rotation was conducted. Study design was cross-sectional.ResultsTwo factors were extracted, but the factor structure failed to support the original division of items into separate pain and disability sections.ConclusionWe found minimal evidence to justify the use of separate subscales for pain and disability. It is our impression that the SPADI should be viewed as essentially unidimensional in patients with adhesive capsulitis.

Clinical, socio-demographic and radiological predictors of short-term outcome in rotator cuff disease

BackgroundShoulder pain is common with rotator cuff disease as the most frequently used clinical diagnosis. There is a wide range of treatment options for this condition, but limited evidence to guide patients and clinicians in the choice of treatment strategy. The purpose of this study was to investigate possible prognostic factors of short-term outcome after corticosteroid injection for rotator cuff disease.MethodsWe performed analyses of data from 104 patients who had participated in a randomized controlled study. Socio-demographic, clinical and radiographic baseline factors were assessed for association with outcome at six-weeks follow-up evaluated by Shoulder Pain and Disability Index (SPADI) and patient perceived outcome. Factors with significant univariate association were entered into multivariate linear and logistic regression analyses.ResultsIn the multivariate analyses; a high SPADI score indicating pain and disability at follow-up was associated with decreasing age, male gender, high baseline pain and disability, being on sick-leave, and using regular pain medication. A successful patient perceived outcome was associated with not being on sick-leave, high active abduction, local corticosteroid injection and previous cortisone injections. Structural findings of rotator cuff tendon pathology on MRI and bursal exudation or thickening on ultrasonography did not contribute to the predictive model.ConclusionsBaseline characteristics were associated with outcome after corticosteroid injection in rotator cuff disease. Sick-leave was the best predictor of poor short-term outcome. Trial registration: Clinical trials NCT00640575

Determinants of the shoulder pain and disability index in patients with subacromial shoulder pain.

OBJECTIVE To examine the influence of determinants on the Shoulder Pain and Disability Index. DESIGN A cross-sectional study. Baseline registrations were applied. PATIENTS Two hundred patients with subacromial shoulder pain lasting at least 3 months. METHODS A questionnaire consisting of possible determinants, 2 independent variables regarding pain and 2 regarding function, and the outcome measurement. Two multiple regression models (one with and one without the independent variables of pain and function) for the Shoulder Pain and Disability Index, the 2 subscales, and the determinants, were performed. RESULTS The included determinants explained 29% of the variance of the Shoulder Pain and Disability Index (25% for pain and 33% for disability subscale) with pain medication, emotional distress, flexion, and the hand-behind-back range accounting for 26%. When pain and function were included, the final model explained 65% of the variance, with gender, education and range of flexion showing significance. CONCLUSION The determinants explained 26% of the variance of the Shoulder Pain and Disability Index, but explained only a minor proportion when pain and function were included. This supports the Shoulder Pain and Disability Index as a shoulder pain and disability questionnaire.