Ramon P. G. Ottenheijm

Accuracy of diagnostic ultrasound in patients with suspected subacromial disorders: a systematic review and meta-analysis

OBJECTIVE To determine the diagnostic accuracy of ultrasound for detecting subacromial disorders in patients presenting in primary and secondary care settings. DATA SOURCES Medline and Embase were searched on June 9, 2010. In addition, the reference list of 1 systematic review and all included articles were searched to identify relevant studies. STUDY SELECTION Two reviewers independently selected the articles evaluating the accuracy of ultrasound for detecting subacromial disorders from the title and abstracts retrieved by the literature search. Selection criteria were ultrasound frequency greater than or equal to 7.5MHz as index test, surgery, magnetic resonance imaging and/or radiography as reference standards, and subacromial disorders as target conditions. DATA EXTRACTION Two reviewers independently extracted the data on study characteristics and results to construct 2 by 2 tables and performed a methodologic quality assessment. DATA SYNTHESIS Twenty-three studies were included: 22 reported on full-thickness rotator cuff tears, 15 on partial-thickness tears, 3 on subacromial bursitis, 2 on tendinopathy, and 2 on calcifying tendonitis, respectively. For full-thickness tears, pooled sensitivity of ultrasound was .95 (95% confidence interval, .90-.97), and specificity .96 (.93-.98). For partial-thickness tears, pooled sensitivity was .72 (.58-.83), and specificity .93 (.89-.96). Statistical pooling was not possible for the other disorders. For subacromial bursitis, sensitivity ranged from .79 to .81, and specificity from .94 to .98. For tendinopathy, sensitivity ranged from .67 to .93, specificity from .88 to 1.00. Sensitivity for calcifying tendonitis was 1.00 in both studies, with specificity ranging from .85 to .98. CONCLUSIONS We strongly recommend ultrasound in patients for whom conservative treatment fails, to rule in or out full-thickness tears, to rule in partial-thickness tears, and to a lesser extent to diagnose tendinopathy, subacromial bursitis, and calcifying tendonitis. These results can help physicians tailor treatment.

Physical activity, body composition and bone density in ballet dancers

The main purpose of the present study was to examine factors that affect bone mineral density (BMD) in female ballet dancers. Training history, Ca intake, body composition, total body BMD (TBMD) and site-specific BMD, and bone mineral content were described in twenty-four female ballet dancers (mean age 22.6 (SD 4.5) years). Training history was determined by questionnaires, Ca intake by 7 d dietary record, BMD and bone mineral content by dual-energy X-ray absorptiometry (DXA), total body water by 2H dilution, extracellular water by bromide dilution, body fat by underwater weighing (UWW; two-component model), DXA, and the four-component (4C) model. Dancers had a significantly lower body mass index (BMI 18.9 (SD 1.0) kg/m2) than controls (21.3 (SD 1.9) kg/m2), with significantly lower percentage body fat (17.4 (SD 3.9) v. 24.4 (SD 5.1)) but comparable fat-free mass. Mean TBMD (1.147 (SD 0.069) g/cm2) was significantly higher (6%) compared with that of a reference population. These high values could be attributed to the high BMD of legs and pelvis, the weight-bearing sites of the dancers body. No relationship was found between age, start of ballet classes, period (years) of dancing, Ca intake, and BMD (total and site-specific). However, TBMD was positively related to BMI, and negatively related to the age of menarche. BMD of the legs was significantly related to BMI, and negatively related to the age of menarche. BMD of the legs was significantly related to daily period (h) of training. Depending on the method used the percentage body fat ranged from 16.4 (by DXA) to 18.3 by the 4C model. These differences were significantly related to the TBMD. Percentage body fat by the different methods was not significantly different, except for DXA and 4C model. The present study showed that, despite the factors that have a negative effect on BMD, such as low body mass and late menarche, BMD in female ballet dancers was relatively high. These high values were probably caused by high levels of weight-bearing physical activity.

The Maastricht Ultrasound Shoulder pain trial (MUST): Ultrasound imaging as a diagnostic triage tool to improve management of patients with non-chronic shoulder pain in primary care

BackgroundSubacromial disorders are considered to be one of the most common pathologies affecting the shoulder. Optimal therapy for shoulder pain (SP) in primary care is yet unknown, since clinical history and physical examination do not provide decisive evidence as to the patho-anatomical origin of the symptoms. Optimal decision strategies can be furthered by applying ultrasound imaging (US), an accurate method in diagnosing SP, demonstrating a clear relationship between diagnosis and available therapies. Yet, the clinical cost-effectiveness of applying US in the management of SP in primary care has not been studied. The aim of this paper is to describe the design and methods of a trial assessing the cost-effectiveness of ultrasound imaging as a diagnostic triage tool to improve management of primary care patients with non-chronic shoulder pain.Methods/DesignThis randomised controlled trial (RCT) will involve 226 adult patients with suspected subacromial disorders recruited by general practitioners. During a Qualification period of two weeks, patients receive care as usual as advised by the Dutch College of General Practitioners, and patients are referred for US. Patients with insufficient improvement qualify for the RCT. These patients are then randomly assigned to the intervention or the control group. The therapies used in both groups are the same (corticosteroid injections, referral to a physiotherapist or orthopedic surgeon) except that therapies used in the intervention group will be tailored based on the US results. Ultrasound diagnosed disorders include tendinopathy, calcific tendinitis, partial and full thickness tears, and subacromial bursitis. The primary outcome is patient-perceived recovery at 52 weeks, using the Global Perceived Effect questionnaire. Secondary outcomes are disease specific and generic quality of life, cost-effectiveness, and the adherence to the initial applied treatment. Outcome measures will be assessed at baseline, 13, 26, 39 and 52 weeks after inclusion. An economic evaluation will be performed from both a health care and societal perspective with a time horizon of 52 weeks.DiscussionThe results of this trial will give unique evidence regarding the cost-effectiveness of US as a diagnostic triage tool in the management of SP in primary care.

Early student-patient contacts in general practice: An approach based on educational principles

Background: Clinical teaching and learning is generally seen as an educationally sound approach, but the clinical environment does not always offer optimal conditions to facilitate students’ learning processes. Aims: To show how insights on constructing a good learning environment for student-patient contacts in real practice can be translated into an undergraduate clinical general practice programme in Year 3 and to study its feasibility. Method: Literature search, yielding starting points for the development of the new programme and questionnaire evaluation of the programme. Results: Six starting points for a good learning environment for early student-patient contacts: continuing exposure to patients, transformation of experience into knowledge, active role of students, supervision and feedback, time and space for teaching and teacher training were translated into a the new programme. The evaluation showed that the programme was feasible and well received by students and GPs, although some improvements are possible. Conclusion: In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in general practice based on educational principles.

Amenorrhea in ballet dancers in the Netherlands.

The prevalence of amenorrhea was studied among 113 professional and student ballet dancers in the Netherlands (mean age 23.3 yr, SD 4.8). Sixty-one dancers not on oral contraceptives were included in the subsequent analyses. Six cases (prevalence 9.8 percent, 95 percent confidence interval: 2.4-17.2) with secondary amenorrhea (< or = 4 cycles per year; previous menstruation > or = 3 months prior to the study; menarche > or = 1 yr prior to the study) were found. Two dancers had primary amenorrhea (no menarche at the age of > or = 16). There was a negative correlation between the age of menarche and the number of menstrual cycles during the 12 months preceding the study (r = -0.46, P = 0.001). Body composition (four-compartment model), amount of dancing (recorded), resting energy expenditure (ventilated hood), dietary intake (recorded), and indices of eating disorders (Eating Disorders Inventory, EDI) were studied in 15 of the dancers, 5 amenorrheic and 10 eumenorrheic. No significant differences were found between the amenorrheic and eumenorrheic dancers. An explanation for the lower prevalence of amenorrhea in ballet dancers in the Netherlands, compared with U.S. dancers, was not obvious. Relatively low EDI scores (25.8, SD 14.5) in a subsample of 24 dancers could indicate less rigid emphasis on leanness and dieting.

Ultrasound Imaging for Tailored Treatment of Patients With Acute Shoulder Pain

PURPOSE The objective of this study was to assess the frequencies of ultrasound findings in patients with acute rotator cuff disorders in family medicine. METHODS In a prospective observational study, 129 patients aged 18 to 65 years with acute shoulder pain in whom the family physician suspected rotator cuff disease underwent ultrasound imaging. RESULTS Rotator cuff disease was present in 81% of the patients, and 50% of them had multiple disorders. Calcific tendonitis was the most frequently diagnosed specific disorder. An age of 40 years or older was most strongly related to rotator cuff disease. CONCLUSIONS Ultrasound imaging enables family physicians to rationalize treatment in nearly all patients who are aged 40 years and older with acute shoulder pain.

Development of a Prognostic Model for Patients With Shoulder Complaints in Physical Therapist Practice

Background Health care providers need prognostic factors to distinguish between patients who are likely to recover and those who are not likely to recover. Objective The aim of this study was to: (1) describe the clinical course of recovery and (2) identify prognostic factors of recovery in patients with shoulder pain at the 26‐week follow‐up. Design A prospective cohort study was carried out in the Netherlands and included 389 patients who consulted a physical therapist for a new episode of shoulder pain. Method Participants were followed for 26 weeks. Potential predictors of recovery were selected from the literature and, with the addition of 2 new variables (ie, use of diagnostic ultrasound and working alliance), evaluated in the multivariable regression analysis. Multiple imputation was used to handle missing data, and bootstrap methods were used for internal validation. Results The recovery rate was 60% for the total population and 65% for the working population after 26 weeks. Short duration of complaints, lower disability scores, having a paid job, better working alliance, and no feelings of anxiety or depression were associated with recovery. In the working population, only duration of complaints and disability remained in the final model. The area under the receiver operating characteristic curve (AUC) for the final model was 0.67 for the total population and 0.63 for the working population. After internal validation, the AUC was corrected to 0.66 and 0.63, respectively. Limitations External validation of the prognostic model should be done prior to its use in clinical practice. Conclusion The results of this study indicate that several factors can predict recovery.

Ultrasound imaging to tailor the treatment of acute shoulder pain: a randomised controlled trial in general practice.

Objective To determine the clinical effectiveness of ultrasound tailored treatment in patients with acute subacromial disorders. Design Pragmatic randomised controlled trial. Setting Dutch general practice. Participants Patients aged 18–65 years with acute (duration <3 months) unilateral shoulder pain and no previous treatment, in whom the general practitioner suspected a subacromial disorder was enrolled. Interventions All patients underwent ultrasound imaging of the affected shoulder. Patients who were still symptomatic after a qualification period of 2 weeks with standard treatment were randomised to treatment tailored to ultrasound diagnosis (disclosure of the ultrasound diagnosis) or usual care (non-disclosure of the ultrasound diagnosis). Primary outcome measure Patient-perceived recovery using the Global Perceived Effect questionnaire at 1 year. Results 129 patients were included. 18 patients recovered during the 2-week qualification period, resulting in 111 randomised patients; 56 were allocated to ultrasound tailored treatment and 55 to usual care. After 1 year, no statistically significant differences in recovery were found between the ultrasound tailored treatment group (72.5% (37/51)) and the usual care group (60% (30/50), OR 2.24 (95% CI 0.72 to 6.89; p=0.16)). Also, healthcare use was similar. Conclusions This study has shown no clinically significant difference in the primary outcome measure between the ultrasound tailored treatment and usual care groups. Furthermore, there was no overall difference in healthcare resources used between groups. Although no formal cost data are included, one can only assume that the ultrasound examinations are additional costs for the intervention group, which cannot be justified in routine practice based on this trial. Based on this study, no change in current pragmatic guidelines to incorporate early ultrasound imaging can be recommended. Trial registration number NTR2403; Results.

Echografie bij schouderpijn: doen of niet?

SamenvattingOttenheijm RPG. Echografie bij schouderpijn: doen of niet? Huisarts Wet 2016;59(12):551-3. De prognose van schouderpijn is ongunstig. De NHG-Standaard Schouderklachten adviseert echografie te overwegen bij patiënten die ondanks behandeling pijn blijven houden. In deze beschouwing beschrijf ik de plaats van echografie in het diagnostisch proces, met als doel het verbeteren van de prognose. Huisartsen stellen bij voorkeur een specifieke diagnose en hebben verschillende visies op de plaats van echografie: aanvragen tijdens de beginfase van een episode, bij chronische klachten of helemaal niet. Echografie is een accuraat instrument voor het stellen van specifieke diagnoses. Bij de grote meerderheid van patiënten maakt echografie het mogelijk om een specifieke diagnose te stellen. Bij patiënten met een eerste episode lijkt behandeling op basis van een echografische diagnose na één jaar echter niet te leiden tot een betere prognose. Deze bevinding ondersteunt het NHG-advies om in de beginfase van een epis ode geen echografie aan te vragen. Huisartsen kunnen de NHG-Standaard blijven volgen: overweeg alleen dan een echografie wanneer patiënten ondanks behandeling pijn blijven houden.AbstractOttenheijm RPG. Ultrasound imaging for shoulder pain: is it necessary? Huisarts Wet 2016;59(12):551-3. The prognosis of shoulder pain is unfavourable. According to the guidelines of the Dutch College of General Practitioners, ultrasound imaging should be considered if pain is refractory. This review discusses the role of ultrasound in the diagnostic work-up, with a view to improving the prognosis. While general practitioners would prefer to establish a specific diagnosis, the role of ultrasound is not unequivocal – is it necessary, or should it be ordered early in the disorder or only if symptoms become chronic? Although ultrasound is accurate for diagnosing specific disorders and allows a diagnosis to be established in most patients, the prognosis of patients with a first episode of shoulder pain treated on the basis of ultrasound findings does not seem to be improved after 1 year. This supports the College’s recommendation that ultrasound not be ordered in the early phase of an episode and that it should be considered only in patients with refractory pain.

ESWT bij schouderpijn

SamenvattingBij patiënten met schouderpijn wordt huisartsen geadviseerd om beeldvormende diagnostiek, bijvoorbeeld echografie, te overwegen bij een afwijkend ziektebeloop of wanneer de gebruikelijke behandelstappen onvoldoende verbetering geven. Uit de literatuur blijkt dat er dan frequent sprake is van een tendinitis calcarea (kalkdepot in een pees) of tendinopathie (tendinose) van een van de rotatorcuffpezen.