Background. Understanding of attitudes, knowledge, and behavior related to evidence-based practice (ESP) and use of evidence-based clinical practice guidelines in primary care physical therapy is limited. Objectives. The objectives of this study were: (1) to investigate self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guideline use among physical therapists in primary care and (2) to explore associations of self-reported use of guidelines with these social cognitive factors along with demographic and workplace characteristics. Design. This was a cross-sectional survey. Methods. A web-based survey of 419 physical therapists in primary care in western Sweden was performed. Multiple logistic regression analysis was performed to examine factors associated with guideline use. Results. The response rate was 64.7%. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. Approximately two thirds reported confidence in finding and using evidence. One third reported being aware of guidelines. Thirteen percent knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. The most important barriers to using guidelines were lack of time, poor availability, and limited access to guidelines. Young age and brief work experience were associated with positive attitudes toward EBP. A postgraduate degree was associated with higher application of EBP. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. Limitations. Data were self-reported, which may have increased the risk of social.desirability bias. Conclusions. Use of guidelines was not as frequent as could be expected in view of the positive attitudes toward EBP and guidelines among physical therapists. Awareness of and perceived access to guidelines were limited. The identified determinants can be addressed when developing guideline implementation strategies.

Background: Patient preferences are suggested to be incorporated in clinical decision making, but little is known about preferences for physiotherapy treatment of patients with musculoskeletal pain. This study aimed to explore preferences regarding physiotherapy treatment and participation in decision making, of patients who seek primary care physiotherapy for pain in the back, neck or shoulder.

Methods: A qualitative study set in an urban physiotherapy clinic in Sweden. Individual, semi-structured interviews were conducted with a purposeful sample of 20 individuals who sought physiotherapy for back, neck or shoulder pain. The interviews were digitally recorded, transcribed verbatim and analysed with qualitative content analysis.

Results: An overarching theme, embracing six categories, was conceptualised: Trust in the physiotherapist fosters active engagement in therapy. Most informants preferred active treatment strategies such as exercise and advice for self-management, allowing them to actively engage in their therapy. Some preferred passive treatments, primarily acupuncture (because they had heard that it works well) or massage therapy (because “it feels good”). Preferences were consistent across the three musculoskeletal conditions. Key influencers on treatment preferences were previous experiences and media. All informants wanted to be involved in the clinical decision making, but to varying extents. Some expressed a preference for an active role and wanting to share decisions while others were content with a passive role. Expectations for a professional management were reflected in trust and confidence in physiotherapists’ skills and competence, expectations for good outcomes, and believing that treatment methods should be evidence-based.

Conclusions: Trust in the physiotherapist’s ability to choose appropriate treatment and confidence in the professional skills and competence of physiotherapists, as well as a desire to participate in clinical decision making, fostered active engagement in physiotherapy. Preferences for particular interventions were subordinate, although a preference for active treatments dominated. Preferences for active engagement need to be embraced by the physiotherapist. Awareness of these preferences can facilitate clinical decision making and contribute to increased quality of care for patients with musculoskeletal pain.

BACKGROUND:

Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden.

METHODS:

An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson's χ2 test and approximative z-test.

RESULTS:

168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes.

CONCLUSIONS:

A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.

Rationale, aims and objectives

Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables.

Methods

419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire.

Results

The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1–16). The most common treatment interventions across the three conditions were advice on posture (reported by 82–94%), advice to stay active (86–92%), and different types of exercise (65–92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29–96%. Modalities such as laser therapy and ultrasound were sparingly used (<5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience.

Conclusions

Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent.

Background: A specific exercise strategy focusing on eccentric exercises, for treating sbacromial pain has in a previous study been found effective at three-month followup.

The aim of the present study was to investigate if the positive short-term results were maintained after one year. A further aim was to examine if baseline clinical score, rotator cuff status and radiological findings influenced the choice of surgery.

Methods: 97 patients on the waiting-list for arthroscopic subacromial decompression were in the first study randomized to a three-month specific exercise strategy or unspecific exercises (controls). Patients were examined with radiology, ultrasound and assessed with clinical scores: primary Constant-Murley score. After three months of exercises the patients were asked if they still wanted surgery and this option was available until the one-year follow-up. All patients were re-assessed with clinical scores one year after inclusion or one year after surgical intervention and the number of patients that had chosen surgery in each group was compared. The baseline Constant-Murley score and the status of subacromial structures were analyzed in relation to patient's choice of surgery.

Results: The positive short-term effect (improved shoulder function and pain) of the specific exercises was maintained after one-year. Compared to the three-month followup all patients had improved significantly (p < 0.0001) in Constant-Murley score. The number of patients that had chosen surgery in the control exercise group (63%) was significantly larger (p < 0.0001) than in the specific exercise group (24%). Patients that had chosen surgery had a significantly lower baseline Constant-Murley score and significantly more often a full-thickness tear. Patients with partial-thickness tears did not differ from those with intact cuff tendons.

Conclusions: The positive short-term outcomes after specific exercises were maintained after one year and reduced the need of surgery significantly more than the unspecific control exercises. Patients with low baseline clinical score and/or a full-thickness tear significantly more often chose surgery.

Level of evidence: I, Randomized controlled trail according to Consort statement.

Background and purpose A programme based on eccentric exercises for treating subacromial pain was in a previous study found effective at 3-month follow-up. The purposes of the present study were to investigate whether the results were maintained after 1 year and whether the baseline Constant-Murley score, rotator cuff status and radiological findings influenced the outcome. Patients and methods 97 patients on the waiting list for arthroscopic subacromial decompression had been randomised to a specific exercise programme or unspecific exercises (controls). After 3 months of exercises, the patients were asked whether they still wanted surgery and this option was available until a 1-year follow-up. 1 year after inclusion or 1 year after surgery, the number of patients who decided to have surgery in each group was compared. The choice of surgery was related to the baseline Constant-Murley score, ultrasound and radiographs taken at inclusion. Results All patients had improved significantly (pless than0.0001) in the Constant-Murley score at the 1-year follow-up. Significantly more patients in the control group decided to have surgery (63%) than those in the specific exercise group (24%; pless than0.0001). Patients who decided to have surgery had a significantly lower baseline Constant-Murley score and more often a full-thickness tear. Patients with partial tears did not differ from those with intact tendons. Interpretation The positive short-term results of specific exercises were maintained after 1 year, and this exercise strategy reduces the need for surgery. Full-thickness tear and a low baseline Constant-Murley score appear to be a predictive marker for a less good outcome.

Background and purpose Few authors have considered the outcome after acute traumatic rotator cuff tears in previously asymptomatic patients. We investigated whether delay of surgery, age at repair, and the number of cuff tendons involved affect the structural and clinical outcome. Patients and methods 42 patients with pseudoparalysis after trauma and no previous history of shoulder symptoms were included. A full-thickness tear in at least 1 of the rotator cuff tendons was diagnosed in all patients. Mean time to surgery was 38 (6-91) days. Follow-up at a mean of 39 (12-108) months after surgery included ultrasound, plain radiographs, Constant-Murley score, DASH score, and western Ontario rotator cuff (WORC) score. Results At follow-up, 4 patients had a full-thickness tear and 9 had a partial-thickness tear in the repaired shoulder. No correlation between the structural or clinical outcome and the time to repair within 3 months was found. The patients with a tendon defect at follow-up had a statistically significantly lower Constant-Murley score and WORC index in the injured shoulder and were significantly older than those with intact tendons. The outcomes were similar irrespective of the number of tendons repaired. Interpretation A delay of 3 months to repair had no effect on outcome. The patients with cuff defects at follow-up were older and they had a worse clinical outcome. Multi-tendon injury did not generate worse outcomes than single-tendon tears at follow-up.

Rationale, Aims, and Objectives

To provide best available care, the practitioners in primary health care (PHC) must have adequate knowledge about effective interventions. The implementation of such interventions is challenging. A structured implementation strategy developed by researchers at Linköping University, Sweden, was used for the implementation of an evidence‐based assessment and treatment programme for patients with subacromial pain among physiotherapists in PHC. To further develop strategies for implementation of evidence‐based practices, it was deemed important to study the implementation from the practitioners' perspective. The aim of this study was to explore the practitioners' experiences from the implementation.

Methods

A qualitative design with focus group discussions was applied. The implementation in terms of perceptions of process and outcome was evaluated by focus group discussions with, in total, 16 physiotherapists in the target group. Data were analysed using the method qualitative content analysis.

Results

The components of the strategy were viewed positively, and the applicability and evidence base behind the programme were appreciated. The programme was perceived to be adopted, and the practitioners described a changed behaviour and increased confidence in handling patients with subacromial pain. Both patient‐ and provider‐related challenges to the implementation were mentioned.

Conclusions

The practitioners' experiences from the implementation were mainly positive. A strategy with collaboration between academy and practice, and with education and implementation teams as facilitators, resulted in changes in practice. Critical voices concerned interprofessional collaboration and that the programme was focused explicitly on the shoulder, not including other components of physical function.

OBJECTIVE: To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.

DESIGN: Randomised, participant and single assessor blinded, controlled study.

SETTING: Department of orthopaedics in a Swedish university hospital.

PARTICIPANTS: 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists.

INTERVENTIONS: The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks.

MAIN OUTCOME MEASURES: The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients' global impression of change because of treatment and decision regarding surgery.

RESULTS: Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients' global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001).

CONCLUSION: A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.

TRIAL REGISTRATION: Clinical trials NCT01037673.

STUDY QUESTION Can a specific exercise strategy improve shoulder function and pain in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression? SUMMARY ANSWER Compared with a control exercise group, patients in the specific exercise group had significantly greater improvements in shoulder function and pain and fewer patients needed surgery at the three month assessment. WHAT IS KNOWN AND WHAT THIS PAPER ADDS Different exercise programmes are used as first line treatment in patients with subacromial impingement syndrome, but conclusive evidence to support the efficacy for these programmes is lacking. This specific exercise strategy proved effective in improving shoulder function and pain in patients in whom earlier conservative treatment had failed.

Study question

Can a specific exercise strategy improve shoulder function and pain in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression?

Summary answer

Compared with a control exercise group, patients in the specific exercise group had significantly greater improvements in shoulder function and pain and fewer patients needed surgery at the three month assessment.

What is known and what this paper adds

Different exercise programmes are used as first line treatment in patients with subacromial impingement syndrome, but conclusive evidence to support the efficacy for these programmes is lacking. This specific exercise strategy proved effective in improving shoulder function and pain in patients in whom earlier conservative treatment had failed.

Objective: The purpose of this study was to determine the minimal important change (MIC) of improvement in the Constant‐Murley score (CM score) in patients with longstanding subacromial pain and in subgroups of patients with subacromial pain with and without rotator cuff ruptures.

Method: The MIC was estimated by using the visual anchor‐based MIC distribution method, which integrates an anchor‐ and distribution‐based approach: the optimal cut‐off point of the receiver operator characteristic curve (MIC ROC) and the 95% limit cut‐ off point (MIC 95%limit). The study population consisted of 93 patients included in a randomized clinical trial evaluating the effect of a specific exercise strategy in patients with longstanding subacromial pain.

Results: The MIC ROC was found at a mean change of 17 points in the CM score. The MIC 95% limit was found at a mean change of 24 points. In the subgroup analysis the MIC ROC was found at a mean change of 19 points and the MIC 95% limit at 18 points in patients with an intact rotator cuff. In patients with rotator cuff ruptures the MIC ROC was found at a mean change of 15 points and the MIC 95% limit at 30 points.

Conclusion: The CM score is able to detect the minimal important change in individual patients with long‐standing subacromial pain when the rotator cuff is intact. In all patients with longstanding subacromial pain, the MIC value was dependent on the subgroup as well as the choice of statistical analysis. The estimated MIC values could be used as an indication for relevant changes in the CM score in clinical practice and guide the clinician in how to interpret the results of specific treatments for patients with longstanding subacromial pain.

Objective: To evaluate and compare the efficacy of 2 rehabilitation strategies after arthroscopic acromioplasty: supervised physical therapy focusing on strengthening exercises of the rotator cuff and scapula stabilizers (PT-group) vs home-based movement exercises (H-group). Design: A randomized, single-blinded, clinically controlled study. Patients: Thirty-six patients entered the study. Thirteen in the PT-group and 16 in the H-group fulfilled all the assessments. Methods: For 12 weeks following surgery, patients performed either supervised physical therapy or home exercises. Follow-ups were conducted periodically for 6 months after surgery to evaluate shoulder function, pain (Constant-Murley (CM) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores), and health-related quality of life. Results: The PT-group exhibited significantly greater improvements in CM (p  =0.02) and DASH (p = 0.05) scores. After treatment, the between-group mean difference in CM scores was 14.2 p (95% confidence interval 2-26). At the 6-month follow-up, the between-group mean difference in DASH scores was 13.4 p (95% confidence interval 0.1-23). Conclusion: PT-supervised rehabilitation with strengthening exercises of the rotator cuff and scapula stabilizers seems to be superior to home exercises focusing on mobility for improving shoulder function after arthroscopic acromioplasty.

PURPOSE: Shoulder pain is a common disorder. Despite growing evidence of the importance of physiotherapy, in particular active exercise therapy, little data is available to guide treatment. The aim of this project was to contribute to the development of an internationally accepted assessment and treatment algorithm for patients with shoulder pain.

METHODS: Nine physiotherapists with expertise in the treatment of shoulder dysfunction met in Sweden 2012 to begin the process of developing a treatment algorithm. A questionnaire was completed prior to the meeting to guide discussions. Virtual conferences were thereafter the platform to reach consensus.

RESULTS: Consensus was achieved on a clinical reasoning algorithm to guide the assessment and treatment for patients presenting with local shoulder pain, without significant passive range of motion deficits and no symptoms or signs of instability. The algorithm emphasises that physiotherapy treatment decisions should be based on physical assessment findings and not structural pathology, that active exercises should be the primary treatment approach, and that regular re-assessment is performed to ensure that all clinical features contributing to the presenting shoulder pain are addressed. Consensus was also achieved on a set of guiding principles for implementing exercise therapy for shoulder pain, namely, a limited number of exercises, performed with appropriate scapulo-humeral coordination and humeral head alignment, in a graduated manner without provoking the presenting shoulder pain.

CONCLUSION: The assessment and treatment algorithm presented could contribute to a more formal, extensive process aimed at achieving international agreement on an algorithm to guide physiotherapy treatment for shoulder pain.

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.

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.

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.

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.

bjective. To compare the efficacy of subacromial corticosteroids injected by a GP with physiotherapy combining acupuncture and home exercises as treatments for SIS. less thanbrgreater than less thanbrgreater thanMethods. A randomized clinical trial was performed in primary health care. Patients diagnosed with SIS were randomized to either subacromial corticosteroid injection (s) or 10 acupuncture treatments combined with home- exercises. The main outcomes were pain and shoulder function (Adolfsson-Lysholm shoulder assessment score). Secondary outcomes were health-related quality of life (HRQL) (EuroQol-five dimension self-report questionnaire) and the patients global assessment of change. All patients were assessed at baseline and after 6 weeks and 3, 6 and 12 months. less thanbrgreater than less thanbrgreater thanResults. One hundred and seventeen patients with SIS were included, of which 91 complied with the study protocol. There were no significant differences between treatments with regard to pain, shoulder function and HRQL in change over time. However, both treatment groups improved significantly from baseline over time. less thanbrgreater than less thanbrgreater thanConclusions. Both subacromial corticosteroid injection and a series of acupuncture treatments combined with home exercises significantly decreased pain and improved shoulder function in patients with SIS, but neither treatment was significantly superior to the other.

Shoulder pain is a diagnostic challenge and the physical clinical examination of the shoulder is crucial. It is important that the diagnostic tests used are valid as well as reliable. The objective of the study was to assess intra- and interexaminer reliability for four Manual Shoulder maneuvers; the Neer impingement sign, the Hawkins-Kennedy impingement test, the Patte maneuver, the Jobe supraspinatus test. These maneuvers are frequently used in clinical practice to examine patients with shoulder complaints in which subacromial pain is highly suspected. Thirty-three participants with shoulder pain were included consecutively. Within a week from inclusion, the four maneuvers were performed by a physiotherapist. The procedure was standardized in order to increase reproducibility. After a week, the maneuvers were performed again by the same physical therapist (test-retest) and by another physical therapist (test for interexaminer reliability). All four maneuvers have an almost perfect agreement (Kappa coefficients 0.91-1.00), if performed with suggested standardizations. Neer impingement sign, Hawkins-Kennedy impingement test, Patte maneuver as well as Jobe supraspinatus test, are highly reproducible and therefore reliable to use in clinical practice to identify patients with subacromial pain with an impingement phenomenon, but the maneuvers are limited as structural discriminators.

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.

Background: The DASH 7 is a recently published activity-related 7-item short form of the disability of the arm, shoulder, and hand (DASH) questionnaire developed to assess shoulder function in patients with subacromial pain. Before implementation in both intervention studies and in clinical practice, it is essential to evaluate its responsiveness. The objective of this study was to determine the minimal important change (MIC) in the DASH 7 questionnaire for patients with subacromial pain after a 3 months exercise intervention in a primary care context.

Methods: In this psychometric study the anchor-based MIC-distribution method was used to establish the MIC. The Patient Global Impression of Change (PGIC) was used as external criterion. Data from a clinical implementation study, aimed to implement a specific exercise strategy for patients with subacromial pain among physiotherapists in primary care, were used. Data from 70 patients were included in the analyses.

Results: The correlation coefficient between Patient Global Impression of Change and the DASH 7 score change was 0.67 and the area under the curve was 0.94 (95% confidence interval: 0.88-1.0). The MIC_ROC for improvement was detected at a mean change in 6.5 points with the sensitivity at 0.98 (98%) and the specificity at 0.78 (78%), and the MIC_{95% limit} for improvement was detected at a mean change of 25.7 points. There were 77% of the patients who reached at least this MIC_ROC and 51% who reached at least the MIC_{95% limit} after 3 months of exercise intervention_.

Conclusion: The DASH 7 is responsive to change over time and can discriminate between patients considered to be improved and patients considered not improved. These MIC values for patients with subacromial pain in the primary care setting can be used in clinical practice and in intervention studies as an indication on the patients clinically important level of score change for improvement.

Background Subacromial pain is a common cause of shoulder dysfunction that negatively affects quality of life. Currently, most outcome measures for shoulder pain are applied to a heterogeneous group of patients. Of these measures, the Disabilities of the Arm, Shoulder, and Hand (DASH) is the most widely recognized test with which to assess patients with subacromial pain. The primary aim of this study was to assess the content validity of DASH for patients with subacromial pain, with a secondary aim to test responsiveness to a modified set of DASH items tailored to these patients. Methods There were 129 patients who reported activities in the Patient-Specific Functional Scale (PSFS). To assess validity, 5 independent physiotherapists matched PSFS activities to the most appropriate DASH item. DASH items identified as being of greatest importance to patients were those corresponding to the highest number of PSFS-matched activities. Calculations were made for responsiveness and internal consistency. Results Physiotherapists matched DASH items to 271 PSFS activities, reaching agreement for almost 80%. Seven DASH items (DASH 7) were identified as being particularly important. Effect size data (Cohen's d) were 0.93 for DASH 7, 0.92 for DASH 30, and 0.85 for QuickDASH; the corresponding Cronbach's α values (for DASH 7, DASH 30, and QuickDASH) were 0.84, 0.94, and 0.86, respectively. Conclusions DASH 7 is a short, patient-centered, and activity-related scale that can measure shoulder function in patients with subacromial pain using a quarter of the original DASH items. DASH 7 demonstrated responsiveness, with a satisfactory level of internal consistency.

Objective: The primary aim was to describe the variability within clinical presentation of patients with subacromial pain in primary care, secondly to investigate associations between clinical presentation and self-reported pain intensity, shoulder function, level of anxiety and depression, and health-related quality of life. Design and setting A cross-sectional study based on data from two clinical studies in primary care, one randomized controlled trial and one implementation study. Three components: active range of motion (AROM), rotator cuff function and scapular kinematics were analyzed to describe variability within clinical presentation and patient-reported measurements were used to investigate the impact on daily life. Participants Patients aged 30-67 years, describing pain for more than two weeks, and positive signs for a minimum of three out of the following five clinical tests: impingement sign according to Neer, impingement test according to Hawkins-Kennedy, Pattes maneuver, Jobe’s test, and painful arc. Results Among the 164 patients included, 24% displayed dysfunction in one, 50% two and 24% in all three components. Limited AROM was seen in 46%, rotator cuff dysfunction in 91% and scapular dyskinesia in 57% of the patients. Conclusions These results reveal a heterogeneity among primary care patients with subacromial pain confirming a large variability regarding the components AROM, rotator cuff function and scapular kinematics. All three components appear unique (not significantly correlated) where a rotator cuff dysfunction is very frequent while limited AROM and scapular dyskinesia are more inconsistent. There are significant, but rather weak, associations between clinical presentation and impact on daily life.