Application of the Staged Approach for Rehabilitation Classification System and Associated Improvements in Patient-Reported Outcomes Following Rehabilitation for Shoulder Pain.

OBJECTIVE: The Staged Approach for Rehabilitation Classification for the Shoulder (STAR-Shoulder) has been proposed as a model to guide management and improve outcomes for patients with shoulder pain; however, the effect of its utilization on patient outcomes has not been established. Therefore, the primary purpose of this study was to determine whether patient outcomes were improved if care was matched to the STAR-Shoulder system compared with unmatched care. METHODS: Collected and reviewed demographic, examination, and intervention data for all patients receiving physical therapist treatment for shoulder pain during a 1-year period within a single health care system. Outcome variables included the numeric pain rating scale, the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), and the number of visits. Clinical records from patients receiving care at the discretion of the therapist were systematically audited to determine whether care provided was considered matched or unmatched. RESULTS: A total of 692 patient records were examined. The interrater reliability of classifying care as matched or unmatched was substantial (κ = 0.6; 95% CI = 0.4 to 0.9), with 82% agreement. Changes in patient outcome scores were significantly better for those patients whose care matched the STAR-Shoulder system for pain changes (mean difference = -1.2; 95% CI = 0.8 to 1.6; effect size [d] = 0.5) and QuickDASH score (mean difference = 12.7; 95% CI = 9.9 to 15.5; d = 0.7). No difference was noted for number of visits. CONCLUSION: The STAR-Shoulder system appears to be a meaningful way to classify patients and guide intervention to improve patient outcomes. IMPACT: Application of the STAR-Shoulder system to help align physical therapist interventions more closely with tissue irritability and physical impairments appears to improve patient outcomes. These findings support this model as a promising approach to advance evidence-based practice for shoulder pain.

Reliability and Concurrent Validity of Shoulder Tissue Irritability Classification.

OBJECTIVE: Rating tissue irritability has been recommended to aid decision making in several recent clinical practice guidelines. An explicit method for rating tissue irritability was proposed as part of the Staged Algorithm for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder), but the reliability and validity of this classification are unknown. The purpose of this study was to examine the reliability and concurrent validity of shoulder tissue irritability ratings as part of a system designed to guide appropriate treatment strategy and intensity. METHODS: A clinical measurement, prospective repeated-measures cross-sectional design was used. The 101 consecutive participants with primary complaints of shoulder pain were assessed by pairs of blinded raters (24 raters in total) and rated for tissue irritability. Patients completed 3 patient-reported outcome (PRO) measures reflecting both pain and disability, and these scores were compared with ratings of tissue irritability. Paired ratings of irritability were analyzed for reliability with prevalence-adjusted, bias-adjusted Kappa for ordinal scales. Analysis of variance was used to compare PRO measures across different levels of irritability. Receiver operating characteristic curve analysis was utilized to derive cut-off scores for 3 PRO instruments. RESULTS: Interrater reliability was 0.69 (95% CI = 0.59-0.78), with 67% agreement. All PRO measures were significantly different among 3 levels of tissue irritability. CONCLUSION: There appears to be acceptable reliability and a strong relationship between PRO measures and therapist-rated tissue irritability, supporting the use of the STAR-Shoulder irritability rating system. IMPACT: Several clinical practice guidelines have recommended that clinicians rate tissue irritability as part of their examination. This study provides important new information supporting the reliability and validity of the STAR-Shoulder tissue irritability rating system.

Diagnostic performance of the 2012 EULAR/ACR classification criteria for polymyalgia rheumatica in Korean patients.

AIM: This prospective study aimed to evaluate the diagnostic performance of the 2012 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) classification criteria for polymyalgia rheumatica (PMR) compared to that of previous classification/diagnostic criteria in the Korean population. METHOD: We consecutively included 77 patients aged ≥50 years presenting with bilateral shoulder pain and elevated acute-phase reactants. All patients were evaluated for fulfillment of each of the 5 different criteria for PMR (Chuang et al, Bird, Jones and Hazleman, Healey, and the EULAR/ACR criteria). At baseline, bilateral ultrasound (US) examinations of the shoulders and hips were performed. Final diagnosis was made by an experienced rheumatologist at the 12-month follow-up. The area under the curve (AUC), sensitivity, and specificity of criteria sets were assessed. RESULTS: At the end of follow-up, 38 and 39 patients were diagnosed with PMR and non-PMR including rheumatoid arthritis (RA, n = 20), respectively. The EULAR/ACR classification criteria with US showed the best discriminating capacity (AUC 0.843). Adding US to EULAR/ACR criteria increased specificity from 74.4% to 89.7%, but decreased sensitivity from 89.5% to 78.9%. The two US items of the EULAR/ACR criteria were significantly more frequent in patients with PMR than in controls. However, the second criterion consisting of both shoulders inflamed were similar between PMR (60.5%) and RA (60.0%) groups. CONCLUSION: The 2012 EULAR/ACR classification criteria for PMR performed best in classifying PMR from other inflammatory and non-inflammatory disorders with shoulder pain in Asian populations.

Biopsychosocial Influences on Shoulder Pain: Analyzing the Temporal Ordering of Postoperative Recovery.

Shoulder surgery is a primary intervention for shoulder pain, yet many individuals experience persistent postoperative pain. Previously, we found individuals categorized as having a high-risk phenotype (comprised of COMT variation and pain catastrophizing) had approximately double the chance of not reaching a 12-month pain recovery criterion. As a means to better understand the development of persistent postoperative shoulder pain, this study advanced our previous work by examining temporal ordering of postoperative shoulder recovery based on potential mediating factors, and expansion of outcomes to include movement-evoked pain and shoulder active range of motion. Before surgery, individuals were categorized as either high-risk (high pain catastrophizing, COMT-genotype linked to low enzyme activity [n = 41]) or low-risk (low pain catastrophizing, COMT-genotype linked to normal enzyme activity [n = 107]). We then compared potential mediating variables at 3, 6, and 12 months postoperatively 1) endogenous pain modulation defined by a conditioned pain modulation paradigm; and 2) and emotion factors such as anxiety, fear of movement, and depressive symptoms. At 3 months, the high-risk subgroup had higher fear and movement-evoked pain, and causal mediation analysis confirmed the direct effect of risk subgroup on 12-month movement evoked pain. However, baseline to 12-month change in depressive symptoms were found to mediate 53% of the total effect of risk subgroup on 12-month movement-evoked pain. This study introduces potential temporal components and relationships to the development of persistent postoperative shoulder pain, which future studies will confirm and assess for potential therapeutic targets. PERSPECTIVE: This study expands upon postoperative shoulder recovery measures to include movement-evoked pain and depressive symptoms, and provides preliminary indication of temporal ordering to postoperative shoulder recovery for a preidentified high-risk subgroup. Future studies will distinguish temporal components of shoulder surgery that may optimize treatment targets of postoperative recovery.

A prospective study of patients with shoulder pain and Mechanical Diagnosis and Therapy (MDT).

Objectives: A prospective observational cohort study was conducted to (1) determine the prevalence of Mechanical Diagnosis and Therapy (MDT) syndromes for patients with shoulder impairments and (2) report the interaction between MDT classification and clinical outcomes, including pain intensity and disability, at discharge.Methods: Clinical outcome measures were completed at intake and discharge by 115 patients. A two-way mixed model analysis of variance with subsequent pairwise comparisons was done to examine differences in clinical outcomes between the following MDT classifications: Shoulder Derangement, Shoulder Dysfunction, and Other.Results: The primary findings were that (1) 44.3 (35.3, 53.4), 40.0 (31.0, 48.9), and 15.6 (9.0, 22.3) percent of patients' conditions were classified as Shoulder Derangement, Shoulder Dysfunction, and Other, respectively, (2) all groups managed via MDT methods made clinically significant improvements in disability and pain intensity at discharge, (3) a statistically significant difference in pain intensity at discharge was observed between the Shoulder Derangement and the Shoulder Dysfunction classifications (p = 0.01), and (4) patients with the Shoulder Derangement classification were discharged, on average, 35.3 days earlier than the Shoulder Dysfunction classification and 28.3 days earlier than the Other classification.Discussion: This study confirms previous reports that the Shoulder Derangement and Shoulder Dysfunction classifications are common and represent distinct clinical trajectories when assessed and managed via MDT methods.

Shoulder pain assessment in elite wheelchair basketball players / Evaluación de dolor de hombro en jugadores de baloncesto en silla de ruedas de élite / Avaliação da dor no ombro em jogadores de elite de basquete em cadeira de rodas

Objective: The aim of this study was to evaluate shoulder pain in a sample of elite wheelchair basketball players during their preparation for a major competition. Method: Seventeen male wheelchair basketball players, between 16 and 43 years of age, were studied during their athletic preparation for a wheelchair basketball championship. The shoulder pain questionnaire, impingement tests and shoulder range of motion were evaluated during a training camp. Spearman's rank correlation coefficient was used to analyze the relationship between shoulder pain and range of motion indicating the value of the effect size. Results: Shoulder pain was evident in 52.9% of the sample and was significant and negatively correlated with range of motion, while 35.3% related to impingement tests player's reported pain. The correlation was moderate to high. Conclusions: In conclusion, the use of shoulder pain questionnaire, goniometric measurements and clinical test could be a useful approach for monitoring the shoulder injuries of wheelchair basketball players to explore the possible consequences of performing repetitive movements

Objetivo: El objetivo de este estudio fue evaluar el dolor de hombro en jugadores de baloncesto en silla de ruedas de élite durante su preparación para una competencia de alto nivel. Método: Diecisiete jugadores masculinos de baloncesto en silla de ruedas, entre 16 y 43 años, fueron evaluados con el cuestionario para el dolor de hombro en jugadores de baloncesto en silla de ruedas, las pruebas clínicas y el rango de movimiento del hombro durante la preparación para un campeonato. El coeficiente de correlación de Spearman se utilizó para analizar la correlación entre el dolor de hombro y el rango de movimiento, indicando el valor del tamaño del efecto. Resultados: El dolor de hombro fue evidente en el 52.9% de la muestra, siendo significativo. En tanto que, hubo una correlación negativa entre el dolor de hombro y el rango de movimiento, mientras que el 35.3% reportó dolor de acuerdo con las pruebas clínicas. La correlación fue de moderada a alta. Conclusiones: La utilización del cuestionario, las mediciones goniométricas y las pruebas clínicas podrían ser herramientas adecuadas para monitorear la condición del hombro en los jugadores de baloncesto en silla de ruedas, y así explorar las posibles consecuencias de los movimientos repetitivos

Objetivo: O objetivo deste estudo foi avaliar a dor no ombro em uma amostra de jogadores de elite de basquete em cadeira de rodas durante sua preparação para uma competição de alto nível. Método: Dezessete jogadores de basquete em cadeira de rodas do sexo masculino, entre 16 e 43 anos de idade, foram avaliados com o questionário de dor no ombro, testes clínicos de impacto e amplitude articular durante o treinamento para um campeonato. O coeficiente de correlação de Spearman foi utilizado para analisar a relação entre dor no ombro e amplitude de movimento que indica o valor do tamanho do efeito. Resultados: A dor no ombro foi evidente em 52,9% da amostra e foi significativa e negativamente correlacionada com a amplitude de movimento, enquanto 35,3% teve uma correlação de moderada a alta em relação à dor durante os testes de impacto. Conclusões: Em conclusão, o uso de questionário de dor no ombro, medições goniométricas e teste clínico poderia ser uma abordagem útil para monitorar as lesões no ombro de jogadores de basquete em cadeira de rodas para explorar as possíveis consequências da realização de movimentos repetitivos

Multigroup latent class model of musculoskeletal pain combinations in children/adolescents: identifying high-risk groups by gender and age.

BACKGROUND: To investigate the combinations of Musculoskeletal pain (MSP) (neck, shoulder, upper and low back pain) among a sample of Iranian school children. METHODS: The MSP combinations was modeled by latent class analysis (LCA) to find the clusters of high-risk individuals and multigroup LCA taking into account the gender and age (≤ 13 years and ≥ 14 years of age categories). RESULTS: The lowest and highest prevalence of MSP was 14.2% (shoulder pain in boys aged ≥14 years) and 40.4% (low back pain in boys aged ≤13 years), respectively. The likelihood of synchronized neck and low back pain (9.4-17.7%) was highest, while synchronized shoulder and upper back pain (4.5-9.4%) had the lowest probability. The probability of pain at three and four locations was significantly lower in boys aged ≥14 years than in other gender-age categories. The LCA divided the children into minor, moderate, and major pain classes. The likelihood of shoulder and upper back pain in the major pain class was higher in boys than in girls, while the likelihood of neck pain in the moderate pain class and low back pain in the major pain class were higher in children aged ≥14 years than those aged ≤13 years. Gender-age specific clustering indicated a higher likelihood of experiencing major pain in children aged ≤13 years. CONCLUSIONS: The findings highlight the importance of gender- and age-specific data for a more detailed understanding of the MSP combinations in children and adolescents, and identifying high-risk clusters in this regard.

Consistency of commonly used orthopedic special tests of the shoulder when used with the McKenzie system of mechanical diagnosis and therapy.

BACKGROUND: Shoulder Orthopedic Special Tests (OSTs) are used to assist with diagnosis in shoulder disorders. Issues with reliability and validity exist, making their interpretation challenging. Exploring OST results on repeated testing within Mechanical Diagnosis and Therapy (MDT) shoulder classifications may offer insight into the poor performance of these tests. OBJECTIVES: To investigate in patients with shoulder complaints, whether MDT classifications affect the agreement of OST results over the course of treatment. METHODS: An international group of MDT clinicians recruited 105 patients with shoulder problems. Three commonly used OSTs (Empty Can, Hawkins-Kennedy, and Speed's tests) were utilized. Results of the OSTs were collected at sessions 1, 3, 5 and 8, or at discharge from an MDT classification-based treatment. The Kappa statistic was utilized to determine the agreement of the OST results over time for each of the MDT classifications. RESULTS: The overall Kappa values for Empty Can, Hawkins-Kennedy and Speed's tests were 0.28 (SE = 0.07), 0.28 (SE = 0.07) and 0.29 (SE = 0.07), respectively. The highest level of agreement was for Articular Dysfunction for the Empty Can test (0.84, SE = 0.19). For shoulder Derangements, there was no agreement for any of the OSTs (P values > 0.05). CONCLUSION: The lack of agreement when the OSTs were consecutively tested in the presence of the MDT Derangement classification contrasted with the other MDT classifications. The presence of Derangement was responsible for reducing the overall agreement of commonly used OSTs and may explain the poor consistency for OSTs.

The Greek version of Shoulder Pain and Disability Index (SPADI): translation, cultural adaptation, and validation in patients with rotator cuff tear.

BACKGROUND: This study aimed to translate and culturally adapt a Greek version of the Shoulder Pain and Disability Index (SPADI) questionnaire and to validate its usage in Greek patients. MATERIALS AND METHODS: A forward and backward translation was performed, and the final version of the Greek questionnaire was administered to 134 outpatients (mean age 47.4 ± 14.5) with rotator cuff tear under conservative treatment. The questionnaire was re-administered 2-5 days later to assess test-retest reliability. Patients completed the Greek SPADI, the Greek version of the Quick DASH (Disability of the Arm, Shoulder and Hand Questionnaire) and the EuroQoL EQ-5D. 102 of the 134 questionnaires were considered valid. RESULTS: The internal consistencies of the SPADI total and its subscales measured with Cronbach's alpha coefficient were high (0.932 for SPADI-Total, 0.899 for SPADI-Disability, 0.905 for SPADI-Pain). Intraclass correlation coefficients showed excellent test-retest reliability (0.899 for Disability, 0.902 for Pain, and 0.929 for total SPADI). A significantly high positive correlation was found between the SPADI total score and its subscales, and Quick DASH for Pain and Disability. Significant correlations were also found between SPADI scales and EQ-5D variables. There was a moderate positive correlation with the variables "self-reliance" (r = 0.66), "common activities" (r = 0.58), and "pain/discomfort" (r = 0.49), and a weaker correlation with the "mobility" variable (r = 0.20). Factor analysis (PAF method) revealed a bidimensional formation of the SPADI. Eight items (five pain/three disability) weighted the first factor by >0.5, and five disability items weighted the second factor. CONCLUSIONS: The Greek SPADI represents a valid and reliable tool for measuring pain and disability in patients with painful shoulder disorders. LEVEL OF EVIDENCE: Level 3.

Spanish version of SPADI (shoulder pain and disability index) in musculoskeletal shoulder pain: a new 10-items version after confirmatory factor analysis.

BACKGROUND: The Shoulder Pain and Disability Index (SPADI) is a tool designed to evaluate the impact of shoulder pathology. The aim of this study was to cross culturally adapt a Spanish version of the SPADI for Spanish population with a musculoskeletal shoulder pain, and to determine the psychometric properties of this instrument using confirmatory factor analysis (CFA). METHODS: Cross-cultural adaptation was performed according to the international guidelines. To assess factor structure, a confirmatory factor analysis was done. Internal consistency was measured using Cronbach's alpha. Item-total and inter-item correlations were assessed. Pearson and Spearman correlations were calculated to assess the convergent validity between SPADI and quick-DASH. RESULTS: A new Spanish version of SPADI was achieved. The original SPADI factor structure was tested by CFA, obtaining a poor fit: relative chi-square (χ2/df) 3.16, CFI 0.89, NFI 0.92, and RMSEA 0.10 (90 % CI 0.08 to 0.12). An additional model was tested, after deleting items which have had a poor adjustment in the model (1, 11, and 12), obtaining the best fit: relative chi-square (χ2/df) of 1.94, CFI 0.98, NFI 0.95, GFI 0,95, and RMSEA 0.06 (90 % CI 0.04 to 0.09). The analysis confirmed the bidimensional structure (pain and disability subscales). A correlation Spearman's Rho coefficient of 0.752 (p < 0.0001) and a Cronbach's alpha of 0.90 were obtained. CONCLUSIONS: This study validated a new 10-items version of SPADI for Spanish population with musculoskeletal shoulder pain providing a patient reported outcome measure that could be used in both clinical practice and research.

A Multivariable Prediction Model for the Chronification of Non-traumatic Shoulder Pain: A Systematic Review.

BACKGROUND: Shoulder pain is the third most common musculoskeletal complaint and many patients have an unfavorable outcome with long-term disability. Only 50% of all new episodes of shoulder pain show complete recovery within 6 months. Little is known about factors that contribute to chronicity of shoulder pain, although such information is needed for the management of patients with acute and sub-acute shoulder pain. OBJECTIVE: To systematically review the literature for prognostic factors which are potential predictors for either recovery or chronification in patients with acute and sub-acute non-traumatic shoulder pain. STUDY DESIGN: Systematic review. SETTING: This systematic review examined all studies involving the prognosis of shoulder pain patients. METHODS: This systematic review was reported following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two reviewers independently scored the methodological quality of the selected studies. Due to heterogeneity of studies, a best-evidence synthesis of the available prognostic factors was provided. RESULTS: Nine studies met our inclusion criteria and were included in this systematic review. There is strong evidence that high scores on the Shoulder Pain and Disability Index (SPADI), high scores on shoulder pain severity, and a long duration of complaints are factors that contribute to the chronification of shoulder pain. Moderate evidence was found supportive for other prognostic factors that enhance chronification, like being male, being over 55 years of age, having poor general health, having a gradual onset of complaints, a large amount of sick leave, the perception of high job demand, the perception of low social support, and the amount of visits to a health care professional. Also moderate evidence exists regarding factors that contributed to a reduced possibility of chronification: an active treatment policy and not taking medication on regular basis. LIMITATIONS: The large variability in definitions of shoulder pain, and patient selection bias. In addition, there is a paucity of strong longitudinal prospective studies. CONCLUSION: This systematic review found evidence that high scores on the SPADI questionnaire, more shoulder pain, and a longer duration of complaints are associated with chronification of shoulder pain. In order to reduce chronification, clinicians can use the International Classification of Functioning based model presented here that could aid their decision-making.

Intraobserver and interobserver agreement of Goutallier classification applied to magnetic resonance images.

BACKGROUND: Fatty infiltration of the muscle bellies is an important prognostic factor in rotator cuff tears. It was described initially in computed tomography examinations, and there is an ongoing debate about whether magnetic resonance (MR) is a reliable method for staging fatty infiltration. This study sought to determine intraobserver and interobserver agreement for Goutallier's classification of fatty infiltration of the rotator cuff as evaluated through MR imaging. MATERIALS AND METHODS: Twenty MR examinations of the shoulder showing full-thickness tear of the supraspinatus tendon, with or without associated lesions, were evaluated by 3 radiologists with experience in musculoskeletal system imaging and 3 fellowship-trained shoulder surgeons. The evaluators classified the fatty infiltration of the supraspinatus muscle according to the guidelines proposed by Goutallier et al. After 8 weeks, they re-evaluated the examinations, without access to their previous reports. Weighted κ index values were determined for intraobserver and interobserver agreement analyses, and intraobserver agreement κ values are reported with 95% confidence intervals (CIs). RESULTS: The mean intraobserver agreement was 0.832 among the orthopedists (CI > 95%) and 0.741 among the radiologists (CI > 95%). Interobserver agreement was 0.8214 (evaluation 1) and 0.7231 (evaluation 2) among the orthopedists (P < .0001) and 0.6627 (evaluation 1) and 0.6067 (evaluation 2) among the radiologists (P < .0001). Intraobserver agreement was not associated with length of experience or frequency of routine evaluations. CONCLUSIONS: When it is applied to MR images of rotator cuff musculature, Goutallier's fatty infiltration staging rubric yielded highly significant intraobserver and interobserver agreement.

The Dutch Shoulder Pain and Disability Index (SPADI): a reliability and validation study.

PURPOSE: To evaluate the reliability and validity of the Dutch Shoulder Pain and Disability Index (SPADI-D). BACKGROUND: The SPADI is recommended and frequently used. However, the validity and reliability of the SPADI-D are unknown. METHODS: The study population consisted of patients consulting a physical therapist for shoulder pain. We assessed construct validity, using known groups, convergent validity (SDQ) and divergent validity (EQ5D) for which the mean difference or Spearman correlations coefficients were calculated. The factor structure was assessed using principal component factor analysis, and we calculated Cronbach's alpha and the ICC to assess the reliability. RESULTS: A total of 356 patients and a randomly selected group of 74 subjects for the reliability analysis were included. There was a significant difference between extreme groups (a high/low level of pain and work absence/presence) in SPADI score. The correlation between the SPADI and the SDQ was 0.69, with the EQ5D mobility-item 0.25 and with the depression-item 0.14. The SPADI consisted of one factor according to principal component factor analysis, which showed high internal consistency (Cronbach's alpha = 0.94 for the total score), and the test-retest reliability was good (ICC = 0.89). CONCLUSION: The Dutch SPADI is a valid and reliable questionnaire for patients in primary care in assessing functional disability.

Identification of relevant International Classification of Functioning, Disability and Health categories in patients with shoulder pain: a cross-sectional study.

OBJECTIVE: To identify the most common problems in patients with shoulder pain, using the International Classification of Functioning, Disability and Health (ICF) as a reference. DESIGN: A cross-sectional study. SUBJECTS: Outpatients at a hospital with shoulder pain lasting longer than 3 months. METHODS: Patients were interviewed with an extended version of the ICF Checklist version 2.1a. Patients' problems in functioning, and the magnitude of the problem, were registered separately for each category. Categories identified as a problem in at least 5% of patients were reported. To describe the population, age, diagnosis, work participation and the Shoulder Pain and Disability Index (SPADI) were recorded. RESULTS: A total of 165 patients with a mean age of 46.5 years (standard deviation 12.5) and a SPADI score of 47.4 (standard deviation 21.1) were included. Of the participants, 92.8% were either employed or students, 35.2% of whom were on sick leave. The primary result was the identification of 61 condition-specific second-level ICF categories: 19 in the body functions and structures component, 34 in activities and participation, and 8 in environmental factors. CONCLUSION: The findings provide a comprehensive picture from the patient-perspective of the disability associated with shoulder pain. The findings may enhance multidisciplinary communication in clinical settings.

Intertester reliability of a classification system for shoulder pain.

OBJECTIVE: To describe and determine the intertester reliability of a newly developed classification system of shoulder syndrome recognition. DESIGN: Intertester reliability study. SETTING: Fourteen primary care physiotherapy clinics. PARTICIPANTS: Two hundred and fifty-five patients with shoulder pain. Inclusion criterion: presence of shoulder pain aring within the glenohumeral or associated joints and structures. EXCLUSION CRITERIA: previous shoulder surgery, surgical candidates, recognised malignancy, systemic illness, or concurrent cervical pain and/or radiculopathy. INTERVENTION: Examiners were 55 physiotherapists who were arranged in pairs; each patient received two independent and blinded assessments, one by each of the paired physiotherapists. This shoulder classification approach contains three main clinical syndromes: Pattern 1 (impingement pain), Pattern 2 (acromioclavicular joint pain) and Pattern 3 (shoulder pain: frozen shoulder, glenohumeral arthritis, massive cuff tear, subscapularis tear, painful laxity, post-traumatic instability, internal derangement). MAIN OUTCOME MEASURES: Percentage agreement and Cohen's kappa coefficient. RESULTS: The mean age of patients was 46.6 years (standard deviation 16.3, range 16 to 86), and 57% were male. Physiotherapists agreed on the pattern of shoulder pain for 205 of the 255 shoulders assessed (agreement rate 80%); the kappa coefficient was 0.664 (95% confidence interval 0.622 to 0.706; P<0.001). Of the 205 agreements, Pattern 1 was the most common condition; physiotherapists agreed on this pattern for 139 patients (68%). Both physiotherapists diagnosed Pattern 2 for 20 patients and Pattern 3 for 46 patients. CONCLUSION: This clearly defined system uses key elements of the history and examination to classify patients with shoulder pain. The kappa coefficient denotes good reproducibility.

Classifying post-stroke shoulder pain: can the DN4 be helpful?

The etiology of post-stroke shoulder pain (PSSP) is largely unclear and may involve both nociceptive and neuropathic mechanisms. No gold standard is present for PSSP diagnosis. The neuropathic pain diagnostic questionnaire (DN4), was originally developed to identify neuropathic pain in the clinical context. In this study we used the DN4 to categorize PSSP patients and compared symptoms and signs suggestive of either nociceptive or neuropathic pain. Pain complaints and sensory functions were compared between patients with chronic PSSP scoring at least four (DN4+, n=9) or less than four (DN4-, n=10) on the DN4. Pain was assessed using a numeric rating scale and the McGill pain questionnaire. Sensory functions were assessed using clinical examination and quantitative sensory testing combined with a cold pressor test. Patients classified as DN4+ reported constant pain, higher pain intensity, a higher impact of pain on daily living, more frequent loss of cold sensation, reduced QST thresholds at the unaffected side and increased QST thresholds at the affected side. Notably, several symptoms and signs suggestive of either neuropathic or nociceptive pain corresponded to the subgroups DN4+ and DN4- respectively. However, since the pathophysiological mechanisms remain unclear and none of the sensory signs could be exclusively related to either DN4+ or DN4-, PSSP prognosis and treatment should not be solely based on the DN4. Nonetheless, a thorough assessment of neuropathic and nociceptive pain complaints and somatosensory functions should be included in the diagnostic work-up of PSSP.

Validation of the Dutch version of the Oxford Shoulder Score.

BACKGROUND: The Oxford Shoulder Score (OSS) is an internationally-used patient-based outcome score. Up to now, it was not validated in Dutch. The purpose of this study was to produce a Dutch translation of the OSS and to test this version in terms of reliability and validity. METHODS: Translation of the OSS was done according to the guidelines in literature. One hundred and three patients completed the Dutch version of the OSS. Additionally, the Constant-Murley shoulder score, the (Dutch) Simple Shoulder Test (DSST) score, and SF-36 were included into the validation process. Feasibility and patient-burden parameters were also tested. RESULTS: One-hundred and three patients with general shoulder problems age 55 years (min-max: 21-81 +/- 13 yrs), sex ratio 2/3 (f/m) completed the Dutch version of the OSS and the SF-36. Internal consistency tested by the Cronbach's alpha (0.921) was high. Intra-class correlation coefficient was R = .981 (95% confidence interval: .961 - .993) and the mean difference between both tests was 2.7 points (0-8). Construct validity was also tested by the Pearson correlation coefficient and showed a significant correlation (P < .01) between the Dutch version of the OSS and the other scores (DSST 0.61; the Constant-Murley score 0.64 and with most of the SF-36 sub-scores, except for 2 psychometric subscales, namely, mental health (0.15 [P = .123]) and general health (0.10 [P = .316]) CONCLUSION: The instrument proved to be valid by demonstrating significant correlations predicted by standard clinical assessments (DSST and Constant-Murley scores) and a generic patient-based instrument (SF-36). Application and evaluation in clinical trial proved feasible and understandable.

Calcifying tendonitis of the shoulder joint : predictive value of pretreatment sonography for the response to low-dose radiotherapy.

BACKGROUND AND PURPOSE: Calcifying tendonitis is a degenerative inflammatory joint disorder. Pain relief can be successfully achieved with low-dose radiotherapy. It is actually unknown which types of calcifying tendonitis respond to radiotherapy and which do not. The authors tried to get predictive objectives for the response to radiotherapy on the basis of different morphological patterns of calcifications evaluated by X-ray and ultrasound. PATIENTS AND METHODS: Between August 1999 and September 2002, a total of 102 patients with 115 painful shoulder joints underwent low-dose radiotherapy. At the beginning of radiotherapy, every shoulder joint was examined with a radiograph in two planes. In addition, sonography was performed before and during therapy. This examination was repeated 6 and 18 months after irradiation. Radiotherapy consisted of two series with a total dose of 6.0 Gy. 29 joints with calcifying tendonitis could be further divided using the sonographic and radiographic classification according to Farin and Gärtner, respectively. RESULTS: Pain relief was achieved in 94/115 joints (82%) at a follow-up of 18 months (median). A different response to radiotherapy was found using the sonographic classification of Farin: calcifying tendonitis type III (n = 18) responded well in contrast to a significantly worse result in type I (n = 11). The radiologic classification did not provide a predictive value. CONCLUSION: Sonographic classification of calcifying tendonitis is predictive for the outcome after radiotherapy. Especially patients with Farin type III calcification will benefit from low-dose radiotherapy.

A brief fatigue inventory of shoulder health developed by quality function deployment technique.

BACKGROUND: The purpose of this study was to develop a diagnostic outcome instrument that has high reliability and low cost. The scale, called the Shoulder Fatigue Scale-30 Items (SFS-30) risk assessment, was used to determine the severity of patient neck and shoulder discomfort. METHODS: The quality function deployment (QFD) technique was used in designing and developing a simple medical diagnostic scale with high degree of accuracy. RESULTS: Research data can be used to divide the common causes of neck and shoulder discomfort into 6 core categories: occupation, cumulative, psychologic, diseases, diet, and sleep quality. The SFS-30 was validated by using a group of individuals who had been previously diagnosed with different levels of neck and shoulder symptoms. The SFS-30 assessment determined that 78.57% of the participants experienced a neck and shoulder discomfort level above the SFS-30 risk curve and required immediate medical attention. CONCLUSION: The QFD technique can improve the accuracy and reliability of an assessment outcome instrument. This is mainly because the QFD technique is effective in prioritizing and assigning weight to the items in the scale. This research successfully developed a reliable risk assessment scale to diagnose neck and shoulder symptoms using QFD technique. This scale was proven to have high accuracy and closely represents reality.