Shoulder pain in primary care:Diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain

BACKGROUND: Despite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort. METHODS: Consecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (Xylocaine(TM)) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O’Brien’s test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests. RESULTS: Twenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84). CONCLUSIONS: In this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort

Shoulder pain patients in primary care - Part 1: Clinical outcomes over 12 months following standardized diagnostic workup, corticosteroid injections, and community-based care

Objective: Measure changes in pain and disability of primary care shoulder pain patients over a 12-month period. Design: A non-randomized audit with repeated measures of pain and disability at 3 weeks, 3, 6 and 12 months. Patients: Of 208 patients, 161 agreed to participate with 96.9%, 98.1%, 86.3%, 83.9% follow-up at 3 weeks, at 3, 6 and 12 months, respectively. Mean age was 44 years, mean symptom duration 3.6 months. Methods: Patients were treated with protocol driven corticosteroid injection and community based care. Primary outcome measure was the Shoulder Pain and Disability index (SPADI) questionnaire. Based on the SPADI and minimal clinically important difference (MCID), outcomes were categorized into: total recovery, 90% or more improved, better, unchanged and worse. Results: There was significant reduction of pain and disability at 3 weeks (

A prospective study of shoulder pain in primary care: Prevalence of imaged pathology and response to guided diagnostic blocks

<p>Abstract</p> <p>Background</p> <p>The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ).</p> <p>Methods</p> <p>Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks.</p> <p>Results</p> <p>In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; <it>p </it>< 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; <it>p </it>< 0.01) and an intact rotator cuff (OR 1.3; <it>p </it>< 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (<it>p </it>≤ 0.05).</p> <p>Conclusions</p> <p>Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.</p

Diagnosis of shoulder pain in primary care

Shoulder pain is a common and disabling complaint that is associated with high morbidity and significant associated health care costs. Shoulder pain is a common reason for primary care medical consultation, however the clinical diagnosis of shoulder pain is complicated by the similar presentations of different shoulder conditions and a lack of validated clinical examination tests and diagnostic criteria in primary care populations. Radiological imaging is also widely available and is increasingly being utilized to aid in the diagnostic process however the relevance of imaging to symptoms of shoulder pain remains unclear. The difficulties associated with the diagnosis of shoulder pain frequently result in delayed diagnosis and delays in the implementation of appropriate management. An improvement in the ability to accurately diagnose painful shoulder conditions would assist in optimising patient outcomes in primary health care. The aim of this thesis was to evaluate the diagnostic accuracy of a clinical examination for identifying a predominant subacromial, acromioclavicular joint (ACJ) and glenohumeral joint (GHJ) pain source, and to assess the added value of diagnostic imaging findings for identifying symptomatic pathology affecting these structures. The diagnostic accuracy of clinical examination findings for detecting the presence of rotator cuff tears that may require early referral for specialist evaluation was also assessed. A review of the literature highlighted the poor specificity of many commonly used clinical tests, a lack of information regarding the relationship between imaged pathology and symptoms with little information to guide decisions regarding the use of diagnostic imaging investigations for shoulder pain. This project consisted of a reliability study in which the reliability of clinical examination tests was first evaluated, followed by a diagnostic accuracy study in which consecutive patients with shoulder pain were recruited from primary health care physiotherapy and medical practices. All participants received a clinical examination and a series of diagnostic imaging investigations (x-ray and diagnostic ultrasound scan) (index tests) followed by a diagnostic injection of local anaesthetic (diagnostic block) into the subacromial bursa (SAB) and ACJ (reference standard tests). Those not reporting at least 80% reduction in pain (positive anaesthetic response (PAR)) following the SAB or ACJ diagnostic block also received a GHJ diagnostic block performed as part of a magnetic resonance arthrogram (MRA) investigation. Results of the clinical examination and diagnostic imaging investigations (index tests) were compared with results of the reference standard tests to estimate the ability of these clinical examination and imaging findings to accurately identify a predominant subacromial, ACJ or GHJ pain source and to detect the presence of rotator cuff tears. Combinations of clinical features were identified with the ability to accurately rule-in a PAR following SAB and ACJ diagnostic block. When only a small number of these clinical features were present, confirmation of supraspinatus or ACJ pathology on ultrasound improved the ability to rule-in a PAR following SAB and ACJ diagnostic block respectively. Overall the added diagnostic value of imaging findings for predicting an 80% PAR was limited due to the low prevalence of specific imaging findings, resulting in identification of only a small additional number of cases in whom a PAR could be predicted. Additional diagnostic investigations such as clinically-administered diagnostic injections of local anaesthetic may provide more information regarding the likelihood of a predominant subacromial or ACJ pain source in a larger proportion of patients. Analysis of diagnostic accuracy of clinical examination and imaging findings for predicting a PAR following GHJ diagnostic block was beyond the scope of this thesis but will be the subject of ongoing analysis. Clinical examination predictors of a large or multi-tendon rotator cuff were also identified that were able to accurately identify the presence of a large or multi-tendon rotator cuff tear that may require specialist evaluation. In conclusion, the ability to accurately diagnose painful subacromial and ACJ disorders in primary care begins with information gathered from the clinical examination however, for many patients the accurate diagnosis of these disorders may also require additional diagnostic investigations including diagnostic imaging or diagnostic injections. Combinations of clinical examination findings alone are likely to be sufficient to identify a large or multi-tendon rotator cuff tear that may require specialist evaluation. Results of this research may provide a framework that can be used by primary care practitioners to guide diagnostic processes for painful shoulder disorders, enabling more accurate and efficient identification of these conditions. This has the potential to reduce health care costs, reduce the burden on secondary care services, enable more timely application of appropriate treatment interventions and improve outcomes for patients suffering from shoulder pain

Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain.

The diagnosis of subacromial pathology is limited by the poor accuracy of clinical tests for specific pathologies. The aim of this study was to estimate the diagnostic accuracy of clinical examination and imaging features for identifying subacromial pain (SAP) defined by a positive response to diagnostic injection, and to evaluate the influence of imaging findings on the clinical diagnosis of SAP.In a prospective, diagnostic accuracy design, 208 consecutive patients presenting to their primary healthcare practitioner for the first time with a new episode of shoulder pain were recruited. All participants underwent a standardized clinical examination, shoulder x-ray series and diagnostic ultrasound scan. Results were compared with the response to a diagnostic block of xylocaineTM injected into the SAB under ultrasound guidance using ≥80% post-injection reduction in pain intensity as the positive anaesthetic response (PAR) criterion. Diagnostic accuracy statistics were calculated for combinations of clinical and imaging variables demonstrating the highest likelihood of a PAR. A PAR was reported by 34% of participants. In participants with no loss of passive external rotation, combinations of three clinical variables (anterior shoulder pain, strain injury, absence of symptoms at end-range external rotation (in abduction)) demonstrated 100% specificity for a PAR when all three were positive (LR+ infinity; 95%CI 2.9, infinity). A full-thickness supraspinatus tear on ultrasound increased the likelihood of a PAR irrespective of age (specificity 98% (95%CI 94, 100); LR+ 6.2; 95% CI 1.5, 25.7)). Imaging did not improve the ability to rule-out a PAR.Combinations of clinical examination findings and a full-thickness supraspinatus tear on ultrasound scan can help confirm, but not exclude, the presence of subacromial pain. Other imaging findings were of limited value for diagnosing SAP

Diagnostic accuracy of clinical examination features for identifying large rotator cuff tears in primary health care

OBJECTIVES: Rotator cuff tears are a common and disabling complaint. The early diagnosis of medium and large size rotator cuff tears can enhance the prognosis of the patient. The aim of this study was to identify clinical features with the strongest ability to accurately predict the presence of a medium, large or multitendon (MLM) rotator cuff tear in a primary care cohort. METHODS: Participants were consecutively recruited from primary health care practices (n = 203). All participants underwent a standardized history and physical examination, followed by a standardized X-ray series and diagnostic ultrasound scan. Clinical features associated with the presence of a MLM rotator cuff tear were identified (P<0.200), a logistic multiple regression model was derived for identifying a MLM rotator cuff tear and thereafter diagnostic accuracy was calculated. RESULTS: A MLM rotator cuff tear was identified in 24 participants (11.8%). Constant pain and a painful arc in abduction were the strongest predictors of a MLM tear (adjusted odds ratio 3.04 and 13.97 respectively). Combinations of ten history and physical examination variables demonstrated highest levels of sensitivity when five or fewer were positive [100%, 95% confidence interval (CI): 0.86–1.00; negative likelihood ratio: 0.00, 95% CI: 0.00–0.28], and highest specificity when eight or more were positive (0.91, 95% CI: 0.86–0.95; positive likelihood ratio 4.66, 95% CI: 2.34–8.74). DISCUSSION: Combinations of patient history and physical examination findings were able to accurately detect the presence of a MLM rotator cuff tear. These findings may aid the primary care clinician in more efficient and accurate identification of rotator cuff tears that may require further investigation or orthopedic consultation

Shoulder pain in primary care - Part 2: Predictors of clinical outcome to 12 months

Objective: Identify predictor variables and models for clinical outcomes for primary care shoulder pain patients to 12 months follow-up. Design: A non-randomized audit with measures of pain and disability at 3 weeks, 3, 6 and 12 months. Patients: Of 208 patients, 161 agreed to participate with 96.9, 98.1, 87.0 and 83.9% follow-up at 3 weeks, 3, 6 and 12 months respectively. Treatment consisted of exercise and manual therapy-based physiotherapy and corticosteroid injection under specified selection criteria. Methods: Potentially useful baseline variables were evaluated in univariate logistic regressions with the dependent variables determined by SPADI Questionnaire at 3 weeks, 3, 6 and 12 months. Variables associated (p-value ≤ 0.2) were retained for potential inclusion within multiple logistic regression analyses. Results: Pain not improved by rest, intermittent pain, lower pain intensity with physical tests and absence of subacromial bursa pathology on ultrasound at the 3-week follow-up, constant pain and lower pain intensity with physical tests are predictors of excellent outcomes at the 3-month follow-up. Worse baseline pain and disability, no history of asthma, pain better with rest, better physical functioning, greater fear avoidance, male gender, no history of pain in the opposite shoulder, pain referred below the elbow, sleep disturbed by pain, smaller waist circumference, lower pain intensity with physical tests are factors predictive of excellent outcomes at the 12-month follow-up. Only higher pain intensity with physical tests was associated with a poor clinical outcome. Conclusion: Predictive models for clinical outcomes in primary-care patients with shoulder pain were achieved for excellent clinical outcomes, successfully classifying 70–90% of cases

Culture-broker and medical decoder: contributions of caregivers in American Indian cancer trajectories.

BackgroundCaregivers play a special role in the management and control of cancer-related pain. For American Indians with cancer, caregivers can contribute to patient education, medication compliance, and can facilitate communication between the patient and the provider and the patient and the family.ObjectiveTo identify the role(s) of caregivers of American Indian cancer survivors.MethodsAs a part of a large randomized intervention designed to improve barriers to cancer symptom management, 13 focus groups were held among American Indian cancer survivors and their caregivers at Southwest reservations and urban sites. Focus groups, audiotaped and transcribed, used constant comparative methods in the analysis of caregiver dialogues.ResultsCaregivers are patient educators and provider culture-brokers and their communication strategies use a combination of cultural and conventional strategies in their care of American Indian cancer patients. Cultural communication styles include "talk stories" (storytelling), group (talking circles), and dialogue to manage cancer pain, educate the patient and community, and to protect the patient from stigma, reduce barriers to care, and provide support to patients and families. Active discussion with providers "re-packaged" the patient's reporting/responses to specific clinical measures (pain measure scores) and identified the need for pain medication and compliance-related issues.LimitationsFindings are not generalizable to the American Indian population outside of the sites and focus groups from which data were collected.ConclusionsCaregivers are "cultural brokers" who inform providers of the cultural nuances associated with American Indian patient care. However, caregivers voiced that cultural restriction for not discussing illness openly was a sanction and an important barrier