BACKGROUND: The influence of elevated fear-avoidance beliefs on change in functional status is unclear. OBJECTIVE: The purpose of this study was to determine the influence of fear-avoidance on recovery of functional status during rehabilitation for people with shoulder impairments. DESIGN: A retrospective longitudinal cohort study was conducted. METHODS: Data were collected from 3,362 people with musculoskeletal conditions of the shoulder receiving rehabilitation. At intake and discharge, upper-extremity function was measured using the shoulder Computerized Adaptive Test. Pain intensity was measured using an 11-point numerical rating scale. Completion rate at discharge was 57% for function and 47% for pain intensity. A single-item screen was used to classify patients into groups with low versus elevated fear-avoidance beliefs at intake. A general linear model (GLM) was used to describe how change in function is affected by fear avoidance in 8 disease categories. This study also accounted for within-clinic correlation and controlled for other important predictors of functional change in functional status, including various demographic and health-related variables. The parameters of the GLM and their standard errors were estimated with the weighted generalized estimating equations method. RESULTS: Functional change was predicted by the interaction between fear and disease categories. On further examination of 8 disease categories using GLM adjusted for other confounders, improvement in function was greater for the low fear group than for the elevated fear group among people with muscle, tendon, and soft tissue disorders (Δ=1.37, P<.01) and those with osteopathies, chondropathies, and acquired musculoskeletal deformities (Δ=5.52, P<.02). These differences were below the minimal detectable change. Limitations Information was not available on whether therapists used information on level of fear to implement treatment plans. CONCLUSIONS: The influence of fear-avoidance beliefs on change in functional status varies among specific shoulder impairments.
BACKGROUND: Glenohumeral internal rotation deficit (GIRD) and posterior shoulder tightness have been linked to internal impingement. PURPOSE: To determine if improvements in GIRD and/or decreased posterior shoulder tightness are associated with a resolution of symptoms. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Passive internal rotation and external rotation (ER) range of motion (ROM) at 90 degrees of shoulder abduction and posterior shoulder tightness (cross-chest adduction in side lying) were assessed in 22 patients with internal impingement (11 men, 11 women; age 41 +/- 13 years). Treatment involved stretching and mobilization of the posterior shoulder. The Simple Shoulder Test (SST) was administered on initial evaluation and discharge. Changes in GIRD, ER ROM, and posterior shoulder tightness were compared between patients with complete resolution of symptoms versus patients with residual symptoms using independent t tests. RESULTS: Patients had significant GIRD (35 degrees), loss of ER ROM (23 degrees), and posterior shoulder tightness (35 degrees) on initial evaluation (all P < .01). Physical therapy (7 +/- 2 weeks; range, 3-12 weeks) improved GIRD (26 degrees +/- 14 degrees; P < .01), ER ROM loss (14 degrees +/- 20 degrees), and posterior shoulder tightness (27 degrees +/-19 degrees). The SST improved from 5 +/- 3 to 11 +/- 1 (P < .01). A greater improvement in posterior shoulder tightness was seen in patients with complete resolution of symptoms (n = 12) compared with patients with residual symptoms (35 degrees vs 18 degrees; P < .05). Improvements in GIRD and ER ROM loss were not different between groups (GIRD, 25 degrees vs 28 degrees, P = .57; ER ROM, 14 degrees vs 15 degrees, P = .84). CONCLUSION: Resolution of symptoms after physical therapy treatment for internal impingement was related to correction of posterior shoulder tightness but not correction of GIRD.
BACKGROUND: It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions.
OBJECTIVE: The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation.
DESIGN: This was a prospective single-arm trial.
SETTING: This study was conducted in outpatient physical therapy clinics.
PARTICIPANTS: The participants were individuals who were seen by physical therapists for a primary complaint of shoulder pain.
INTERVENTION AND MEASUREMENTS: Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success.
RESULTS: Data for 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio=5.3).
LIMITATIONS: A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in "overfitting" of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables.
CONCLUSIONS: The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future studies are necessary to validate these findings.
<b>BACKGROUND: </b>Shoulder pain is a common complaint in primary health care and has an unfavourable outcome in many patients. The objectives were to identify predictors for pain and disability (SPADI) and work status in patients with subacromial shoulder pain.<b>METHODS: </b>Secondary analyses of data from a randomized clinical controlled trial were performed. Outcome measures were the absolute values of the combined Shoulder Pain and Disability Index (SPADI) and work status 1 year after treatment with supervised exercises (SE) or radial extracorporeal shockwave therapy (rESWT). Predictors of outcome were investigated using multiple linear regression (SPADI) and logistic regression (work status).<b>RESULTS: </b>104 patients were included. Low education (≤ 12 years), previous shoulder pain, and a high baseline SPADI score predicted poor results with these variables explaining 29.9% of the variance in SPADI score at 1 year. Low education and poor self-reported health status predicted a work status of "not working": Odds Ratio, OR = 4.3(95% CI (1.3 to 14.9)), p = 0.02 for education, and OR = 1.06 (95% CI (1.0 to 1.1)), p = 0.001 for self-reported health status, respectively. Adjustments for age, gender, and treatment group were performed, but did not change the results.<b>CONCLUSION: </b>Education was the most consistent predictor of pain and disability, and work status at 1 year follow-up. Also, baseline SPADI score, previous shoulder pain and self-reported health status predicted outcome.<b>Trial Registration: </b>Clinical trials NCT00653081.
Subacromial impingement syndrome (SAIS), which is associated with pain and a loss of function, has a high occurrence in the physically active population. Not all patients respond positively to treatment. Classifying patients can improve decision-making. The scapular kinematic and clinical impairments can aid in classifying the patients who are more likely to respond to physical therapy treatment. Thirty-three subjects (males, 20–33 years) presenting SAIS were studied to determine altered scapular kinematics and clinical impairments. Three measurements were collected: (1) three-dimensional scapular kinematics during performing functional tasks; (2) impairment outcomes of range of motion and muscle force; and (3) self-reported measurements of pain, satisfaction, and function. All patients received 6-week (2 times per week) physical therapy treatment. Improvement with treatment was determined using the Global Rating of Change Scale. Scapular kinematics and clinical impairments were first identified by t-test in predicting improvement and then combined into a multivariate prediction method. A prediction method with three variables (Flexilevel Scale of Shoulder Function score < 41, muscle power of serratus anterior < 27.4% body weight, degree of scapular internal rotation at 30° shoulder elevation during descending arm phase in unloaded condition < 0.7°) were identified. It appears that scapular kinematics and impairment features can be used to classify subjects with SAIS in addition to self-report. Prospective validation of the proposed prediction method requires further investigation.
This study was designed for patients with the diagnosis subacromial impingement syndrome who were on the waiting list for orthopaedic surgery. They were sent to physiotherapy for training before the operation. The aim of this study was to explore how large the proportion of patients was that did not need surgery when first treated with a supervised exercise programme. The programme emphasizes relearning of normal patterns of movement in arm elevation, reduction of mechanical subacromial stress, specific endurance training to increase nutrition of the collagen tissue and simple advice to prevent recurrence. Ninety-seven patients were included in this follow-up study, selected consecutively at the physiotherapy department. Seventy-two patients completed the training programme; 87% scored excellent or good results and 10 patients were operated on, one of them from the training group. No significant difference was seen in the number of treatments or final results related to age, sex or duration of symptoms. A...
OBJECTIVE: To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake.
DESIGN: Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes.
SETTING: Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel.
PARTICIPANTS: A consecutive sample of 22,019 adult patients (mean age 51.2 y, standard deviation=15.7, range 18-96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge.
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURE: Functional status at discharge.
RESULTS: Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs.
CONCLUSIONS: The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice.
Physical therapy is an intervention commonly used in the treatment of subjects with frozen shoulder symptoms, with limited proven effect. The purpose of this study was to identify the kinematic features of patients with frozen shoulder who are more likely to respond to physical therapy. Thirty-four subjects presenting frozen shoulder syndrome were studied to determine altered shoulder kinematics and functional disability. Subjects received the same standardized treatment with passive mobilization/stretching techniques, physical modalities (i.e. ultrasound, shortwave diathermy and/or electrotherapy) and active exercises twice a week for 3 months. Initially, subjects were asked to perform full active motion in 3 tests: abduction in the scapular plane, hand-to-neck and hand-to-scapula. During the test, shoulder kinematics were measured using a 3-D electromagnetic motion-capturing system. In the initial and follow-up sessions, the self-reported Flexilevel Scale of Shoulder Function (FLEX-SF) was used to determine functional disability from symptoms. Improvement with treatment was determined using percent change in FLEX-SF scores over three months of treatment [(final score−initial score)/initial score×100, >20% improvement and <=20% nonimprovement]. Shoulder kinematics were first analysed for univariate accuracy in predicting improvement and then combined into a multivariate prediction method. A prediction method with two variables (scapular tipping >8.4° during arm elevation, and external rotation >38.9° during hand to neck) were identified. The presence of these two variables (positive likelihood ratio=15.71) increased the probability of improvement with treatment from 41% to 92%. It appears that shoulder kinematics may predict improvement in subjects with frozen shoulder syndrome. Prospective validation of the proposed prediction method is warranted.
The influence of elevated fear-avoidance beliefs on change in functional status is unclear.
OBJECTIVE:
The purpose of this study was to determine the influence of fear-avoidance on recovery of functional status during rehabilitation for people with shoulder impairments.
DESIGN:
A retrospective longitudinal cohort study was conducted.
METHODS:
Data were collected from 3,362 people with musculoskeletal conditions of the shoulder receiving rehabilitation. At intake and discharge, upper-extremity function was measured using the shoulder Computerized Adaptive Test. Pain intensity was measured using an 11-point numerical rating scale. Completion rate at discharge was 57% for function and 47% for pain intensity. A single-item screen was used to classify patients into groups with low versus elevated fear-avoidance beliefs at intake. A general linear model (GLM) was used to describe how change in function is affected by fear avoidance in 8 disease categories. This study also accounted for within-clinic correlation and controlled for other important predictors of functional change in functional status, including various demographic and health-related variables. The parameters of the GLM and their standard errors were estimated with the weighted generalized estimating equations method.
RESULTS:
Functional change was predicted by the interaction between fear and disease categories. On further examination of 8 disease categories using GLM adjusted for other confounders, improvement in function was greater for the low fear group than for the elevated fear group among people with muscle, tendon, and soft tissue disorders (Δ=1.37, P<.01) and those with osteopathies, chondropathies, and acquired musculoskeletal deformities (Δ=5.52, P<.02). These differences were below the minimal detectable change. Limitations Information was not available on whether therapists used information on level of fear to implement treatment plans.
CONCLUSIONS:
The influence of fear-avoidance beliefs on change in functional status varies among specific shoulder impairments.
