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Patients with subacromial pain: Diagnosis, treatment and outcome in primary care
Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [sv]

Syftet med avhandlingen var att beskriva diagnostiken och utvärdera handläggningen i primärvård av patienter med subacromial smärta.

Avhandlingen omfattar fyra studier.

I den första studien användes ett frågeformulär och resultaten beskriver hur distriktsläkare och distriktssjukgymnaster i ett svenskt län diagnosticerar och handlägger primärvårdspatienter med subacromial smärta.

Den andra studien beskriver distriktsläkares och distriktssjukgymnasters tilltro till effekten av olika behandlingsmetoder för dessa patienter. Med utgångspunkt från de tilltrodda behandlingsmetoderna genomfördes en systematisk litteraturöversikt.

Den tredje studien utvärderar intra- och interbedömar reliabilitet för ett styrketest som ingår i ett utvärderingsinstrument ‘the Constant-Murley shoulder assessment’.

Den avslutande studien är en randomiserad klinisk studie som utvärderar och jämför effekten av två behandlingsstrategier, akupunktur och ultraljud, båda i kombination med hemträning.

Distriktsläkare och distriktssjukgymnaster visade sig använda en likartad diagnostik. Det troligaste valet av behandling för distriktsläkare var antiinflammatoriska läkemedel och kortisoninjektion i den subacromiala bursan och för distriktssjukgymnaster rörelseträning samt ergonomiska åtgärder.

Dock var de flesta behandlingsalternativen troliga val, vilket tolkas som en osäkerhet om behandlingarnas effekt.

Med utgångspunkt från de behandlingsmetoder som distriktsläkare och distriktssjukgymnaster tilltrodde som effektiva för patienter med subacromial smärta, genomfördes en systematisk kritisk litteraturöversikt. Fyrtio studier inkluderades och deras evidensnivå utvärderades. Endast kortisoninjektion i den subacromiala bursan visade sig ha definitiva bevis för effekt. Akupunktur visade sig ha troliga bevis för effekt och ultraljudsbehandling konkluderades som ineffektivt för patienter med subacromial smärta. Det förelåg en låg grad av samstämmighet mellan tilltro och tillgängliga vetenskapliga bevis.

En digital dynamometer kan ersätta den konventionella fjädervågen i det standardiserade styrketestet. En nästan perfekt överensstämmelse vad gäller både intra- och interbedömarreliabilitet vid test av unga skulderfriska personer, oberoende av om en ”håll emot-” eller ”dragteknik” användes eller om medel- eller maxvärden användes vid beräkningen av överensstämmelse.

I den randomiserade kliniska studien inkluderades 85 patienter. Tre utvärderingsinstrument, kombinerade i resultatanalysen, utvärderade förändringen under en uppföljningsperiod på 12 månader tillsammans med patienternas subjektiva skattning av resultatet.

Resultaten visade att akupunktur i kombination med hemträning är att föredra. Båda behandlingsgrupperna förbättrades signifikant och fortsatte förbättras över tid oberoende av behandling. De flesta patienter uppnådde ett tillfredställande behandlingsresultat efter 12 månader. Åtminstone tre fjärdedelar i varje behandlingsgrupp skattade sig mycket förbättrade eller helt återställda. Detta tolkas som en behandlingseffekt i kombination med naturalförloppet.

Avhandlingen har beskrivit handläggningen i primärvård av patienter med subacromial smärta och har bidragit med vetenskapliga bevis för distriktsläkare att behandla med kortisoninjektion i subacromiala bursan och för distriktssjukgymnaster att behandla med akupunktur kombinerat med hemträning.

Abstract [en]

The aim of the thesis was to describe the diagnostic approach and evaluate primary care management of patients with subacromial pain.

The thesis includes four different studies, a questionnaire study describing attitudes among general practitioners and physiotherapists in a Swedish county toward the diagnostic approach and management of primary care patients with subacromial pain; a combination of a systematic review and general practitioners and physiotherapists beliefs in interventions for patients with subacromial pain; a study of intra- and inter-observer reliability for the strength test in the Constant-Murley shoulder assessment; and a randomised clinical trial to evaluate and compare the efficacy of two treatment strategies for patients with subacromial pain, acupuncture combined with home exercises and continuous ultrasound combined with home exercises.

In the questionnaire study we described that general practitioners and physiotherapists have a uniform diagnostic approach. The most probable choice of treatment was non-steroidal anti-inflammatory drugs and corticosteroid injection into the subacromial bursa for general practitioners and movement exercises together with ergonomics/adjustments at work for physiotherapists, but most treatments were probable choices, reflecting an uncertainty about their effectiveness.

The treatments trusted by general practitioners and physiotherapists were systematically reviewed. Forty studies were included and the level of evidence was summarised. Only corticosteroid injections into the subacromial bursa, had definitive evidence for efficacy. Acupuncture had tentative evidence for efficacy and therapeutic ultrasound was concluded as ineffective for patients with subacromial pain. The association between trusted treatments and available scientific evidence was weak.

A digital dynamometer can replace the conventional spring-balance in the standardised strength test. An almost perfect agreement was found for intra- and inter-observer reliability in young shoulder-healthy persons, regardless of whether a 'resisted-force' or a 'pull-force' was used or if calculated with mean or maximum values.

Eighty-five patients were included in the randomised clinical trial. Three shoulder scores, combined in the analysis, measure change during a 12 months follow-up together with a ‘patient self-evaluation’ of the experienced result. The results favoured acupuncture combined with home exercises. Both groups improved significantly and continued to improve over time independent of treatment and most of the patients reached a satisfactory result at 12 months. At least three fourths of the patients, in each treatment group, reported large improvements or felt completely recovered. This is interpreted as a combination of treatment effect and the natural course.

This thesis has described the primary care management of patients with subacromial pain and provided scientific evidence for general practitioners to use corticosteroid injection and for physiotherapists to use acupuncture combined with home exercises, when treating these patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2004. , 84 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 834
Keyword [en]
evidence based medicine, general practitioners, physiotherapy, rotator cuff, shoulder impingement syndrome
National Category
Family Medicine
Identifiers
URN: urn:nbn:se:liu:diva-8648ISBN: 91-7373-803-4 (print)OAI: oai:DiVA.org:liu-8648DiVA: diva2:23390
Public defence
2004-02-27, Aulan, Hälsans hus, Hälsouniversitetet, Linköping, 09:00 (English)
Opponent
Supervisors
Note
On the day of the defence date the status on article III was Accepted and article IV was Submitted.Available from: 2007-04-05 Created: 2007-04-05 Last updated: 2012-01-25Bibliographically approved
List of papers
1. Attitudes toward management of patients with subacromial pain in Swedish primary care
Open this publication in new window or tab >>Attitudes toward management of patients with subacromial pain in Swedish primary care
1999 (English)In: Family Practice, ISSN 0263-2136, Vol. 16, no 3, 233-237 p.Article in journal (Refereed) Published
Abstract [en]

Objective. We aimed to describe the attitudes among GPs and physiotherapists toward the diagnostic approach and management of patients with a common shoulder disorder.

Method. A questionnaire was sent out to 188 GPs and 71 physiotherapists. The total response rate was 71.8%. The questions were based on a written case simulation with cues about history and symptoms.

Results. The results showed a unanimous opinion of the diagnosis. Rotator cuff tendinitis was marked as the most probable. The two groups showed similarities in the way that they would examine the patient. The GPs referred the patients to the physiotherapists significantly more often than the other way around. The most probable choice of treatment made by the GPs was non-steroidal anti-inflammatory drugs (NSAIDs) and by the physiotherapists, movement exercises together with ergonomics. Most treatment alternatives had at least 20% of the responders marking a neutral attitude, and few treatments were disregarded.

Conclusions. We conclude that in Swedish primary care GPs and physiotherapists have a uniform diagnostic approach towards patients with subacromial pain, but their choice of treatment reflects an uncertainty about the effectiveness of conservative treatments. The questioned pathogenesis of the suggested diagnosis and lack of research regarding the efficacy of conservative treatments could explain this uncertainty.

Keyword
Conservative treatment, general practice, questionnaire, shoulder problems, written case simulation
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14390 (URN)
Note
Original Publication: Kajsa Johansson, Lars Adolfsson and Mats Foldevi, Attitudes toward management of patients with subacromial pain in Swedish primary care, 1999, Family Practice, (16), 3, 233-237. http://fampra.oxfordjournals.org/cgi/content/abstract/16/3/233 Copyright: Oxford University Press http://fampra.oxfordjournals.org/ Available from: 2007-04-05 Created: 2007-04-05 Last updated: 2009-11-22
2. A combination of systematic review and clinicians’ beliefs in interventions for subacromial pain
Open this publication in new window or tab >>A combination of systematic review and clinicians’ beliefs in interventions for subacromial pain
2002 (English)In: British Journal of General Practice, ISSN 0960-1643, Vol. 52, no 475, 145-152 p.Article in journal (Refereed) Published
Abstract [en]

The aim of the study is to determine which treatments for patients with subacromial pain are trusted by general practitioners (GPs) and physiotherapists, and to compare trusted treatments with evidence from a systematic critical review of the scientific literature. A two-step process was used: a questionnaire (written case simulation) and a systematic critical review. The questionnaire was mailed to 18 GPs and 71 physiotherapists in Sweden. The total response rate was 72% (186/259). The following treatments were trusted: ergonomics/adjustments at work, corticosteroids, non-steroidal anti-inflamatory drugs, movement exercises, acupuncture, ultrasound therapy, strengthening exercises, stretching, transcutaneous electric nerve stimulation, and superficial heat or ice therapy. The review, including efficacy studies for the treatments found to be trusted, was conducted using the CINAHL, EMBASE and MEDLINE databases. Evidence for efficacy was recorded in relation to methodological quality and to diagnostic criteria that labelled participants as having subacromial pain or a non-specific shoulder disorder. Forty studies were included. The methodological quality varied and only one treatment had definitive evidence for efficacy for non-specific patients, namely injection of corticosteroids. The trust in corticosteroids, injected in the subacromial bursa, was supported by definitive evidence for short-term efficacy. Acupuncture had tentative evidence for short-term efficacy in patients with subacromial pain. Ultrasound therapy was ineffective for subacromial pain. This is supported by tentative evidence and, together with earlier reviews, this questions both the trust in the treatment and its use. The clinicians' trust in treatments had a weak association with available scientific evidence.

Keyword
SUBACROMIAL, PAIN, PHYSIOTHERAPY, ROTATOR, CUFF, SHOULDER, SYSTEMATIC, REVIEW
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14391 (URN)
Available from: 2007-04-05 Created: 2007-04-05 Last updated: 2009-08-19
3. Intraobserver and interobserver reliability for the strength test in the Constant-Murley shoulder assessment
Open this publication in new window or tab >>Intraobserver and interobserver reliability for the strength test in the Constant-Murley shoulder assessment
2005 (English)In: Journal of Shoulder and Elbow Surgery, ISSN 1058-2746, Vol. 14, no 3, 273-278 p.Article in journal (Refereed) Published
Abstract [en]

This study evaluates the standardized strength test in the Constant-Murley shoulder assessment of adults with healthy shoulders in a randomized, single-blind design. The following questions were to be answered: (1) Can the spring balance and a digital dynamometer both yield the same result? (2) What is the intraobserver and interobserver reliability of the strength test? (3) Is the strength test sensitive to change in technique or affected by calculation with mean or maximum values? Ten subjects were included in a comparison of the Handyscale (digital dynamometer) and the mechanical spring balance for concurrent validity, resulting in intraclass correlation coefficient values ranging from 0.96 to 0.99. For intraobserver and interobserver reliability, 2 observers tested 20 subjects with the Handyscale and retested them after 2 weeks. Regardless of technique during testing, this resulted in almost perfect agreement (intraclass correlation coefficient range, 0.89–0.98). The digital dynamometer can replace the conventional spring balance. The standardized strength test in the Constant-Murley shoulder assessment is reliable in young subjects with healthy shoulders, independent of technique or whether calculated with mean or maximum values.

Keyword
Constant-Murley shoulder asssessment
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14392 (URN)10.1016/j.jse.2004.08.001 (DOI)
Note
Original Publication: Kajsa Johansson and Lars Adolfsson, Intraobserver and interobserver reliability for the strength test in the Constant-Murley shoulder assessment, 2005, Journal of Shoulder and Elbow Surgery, (14), 3, 273-278. http://dx.doi.org/10.1016/j.jse.2004.08.001 Copyright: Elsevier Science B.V., Amsterdam http://www.elsevier.com/ Available from: 2007-04-05 Created: 2007-04-05 Last updated: 2009-11-22
4. Effects of acupuncture versus ultrasound for patients with impingement syndrome: Randomized clinical trial
Open this publication in new window or tab >>Effects of acupuncture versus ultrasound for patients with impingement syndrome: Randomized clinical trial
2005 (English)In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 85, no 6, 490-501 p.Article in journal (Refereed) Published
Abstract [en]

Background and Purpose. There is no definitive evidence for the efficacy of the physical therapy interventions used for patients with impingement syndrome. The purpose of this study was to compare manual acupuncture and continuous ultrasound, both applied in addition to home exercises, for patients diagnosed with impingement syndrome.

Subjects and Methods. Eighty-five patients with clinical signs of impingement syndrome were randomly assigned to either a group that received acupuncture (n=44) or a group that received ultrasound (n=41). Both interventions were given by physical therapists twice a week for 5 weeks in addition to a home exercise program. Scores from 3 shoulder disability measures, combined in the analysis, measured change during a period of 12 months.

Results. Both groups improved, but the acupuncture group had a larger improvement in the combined score.

Discussion and Conclusion. The results suggest that acupuncture is more efficacious than ultrasound when applied in addition to home exercises.

Keyword
Family practice, Home exercise program, Physical therapy, Rotator cuff, Subacromial pain
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14393 (URN)
Note
Original Publication: Kajsa Johansson, Lars Adolfsson and Mats Foldevi, Effects of acupuncture versus ultrasound for patients with impingement syndrome: Randomized clinical trial, 2005, Physical Therapy, (85), 6, 490-501. http://ptjournal.apta.org/cgi/reprint/85/6/490 Copyright2005 Apta American Physical Therapy Association http://www.apta.org/ Available from: 2007-04-05 Created: 2007-04-05 Last updated: 2017-12-13

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