Shoulder patients in primary and specialist health care. A cross-sectional study

Objectives Shoulder pain is a prevalent problem and has a considerable impact on the use of primary and specialist health care in Norway. It is important to improve short-term recovery and reduce long-term consequences regarding pain and disability, the high costs of treatment and the amount of sick-leave. Treatment for non-specific shoulder pain is mainly non-operative. The aims of this study were to investigate if there are differences in main characteristics, pain and disability (SPADI-score) and psycho-social factors between patients in primary and specialist health care. Methods This cross-sectional study included patients consulting physiotherapy in primary health care and patients at an outpatient clinic in specialist health care. Well-known and tested questionnaires for these populations were used and variables were divided into clinical, sociodemographic, psycho-social, and shoulder pain and disability. Descriptive statistics were applied. Two-sample t-test and linear regression were used for continuous data whereas chi-square tests and logistic regression were applied to test differences in categorical data between the two study populations. Results Two hundred and 36 patients were recruited from primary health care (FYSIOPRIM, Physiotherapy In Primary Care) and 167 from specialist health care. Patients in primary health care reported less regular use of pain medication (30.7 vs. 61.3%) and fewer patients had symptom duration >12 months (41.9 vs. 51.0%). Furthermore, they reported lower pain intensity, less shoulder pain and disability (SPADI-score), lower scores on psycho-social factors, but higher on expectations of recovery. Conclusions Patients with shoulder pain treated in primary health care and in specialist health care are different according to factors such as duration of symptoms, pain and disability, and some of the psycho-social variables. However, the differences are small and the variations within the two study samples is large. Patients treated in primary health care seemed to be less affected and to have higher expectations concerning their recovery. However, based on our results we may question why many patients are referred to specialist health care rather than continuing treatment in primary health care

Associations between shoulder pain and functioning on the ICF Checklist and the Disabilities of the Arm, Shoulder and Hand scale – a cross-sectional study

Purpose: The association between patients’ shoulder pain and functioning according to the International Classification of Functioning, Disability, and Health (ICF), and outcome on a condition specific patient reported outcome measure (PROM), has not been studied. The aim was to investigate how the most common problems on the ICF checklist were associated with shoulder function and disability. Materials and methods: In a cross-sectional design 164 patients ≥ 18 years with chronic shoulder pain were included. The ICF checklist, the Disability of the Arm, Shoulder, and Hand (DASH) outcome measure and the Self-Report Comorbidity Questionnaire were used. A hierarchical regression model tested categories for functioning on the ICF checklist associated with disability on the DASH. Results: Mean age was 46.5 years, 54% were women. 85% had had the shoulder pain longer than 6 months. Mean DASH score was 33.2 points (SD 17.1). Adjusted R2 was 0.67. Older age, being woman and having a lower education explained 22% of the variance on the DASH. The body functions bodily pain, mobility of joints and energy and drive function explained 30% of the variance, and the activities and participation problems lifting and carrying objects, washing oneself and recreation and leisure explained an additional 13%. Conclusions: The shoulder disability was multi-dimensional and comprised body functions and activities and participation. And 67% of the variance in the DASH score was explained. Implications for rehabilitation Persistent shoulder pain results in multi-dimensional disability calling for a broader assessment of function. A biopsychosocial approach to shoulder pain and disability is recommended. Functioning assessed on the ICF checklist can be applied in the assessment of chronic shoulder pain as it contributes to the understanding of self-reported disability on a region specific outcome measure

Visual trajectory pattern as prognostic factors for neck pain

Background A novel approach capturing both temporal variation and pain intensity of neck pain is by visual trajectory patterns. Recently, both previous and expected visual trajectory patterns were identified as stronger predictors of outcome than traditional measures of pain history and psychological distress. Our aim was to examine patient characteristics within the various previous and expected patterns, relationship between the two patterns and predictive value of a variable combining the previous and expected patterns. Methods Patients with neck pain (n = 932) consulting chiropractors were included. Baseline measures included pain intensity, disability, psychological variables and symptom history and expectations. Participants reported global perceived effect after 12 weeks. Analyses included descriptive statistics and logistic regression. Results Pain intensity, disability, psychological and worse outcome expectations increased from a single pain episode to severe ongoing pain of previous and expected patterns. Having a severe pain history was associated with poor prognosis, particularly if combined with negative expectations. The variable combining previous and expected patterns had a discriminative ability similar to that of other predictors AUC = 0.64 (95% CI = 0.60–0–67) versus AUC = 0.66 (95% CI = 0.62–0.70). The model with highest discriminative ability was achieved when adding the combined patterns to other predictors AUC = 0.70 (95% CI = 0.66–0.73). Conclusion The study indicates that pain expectations are formed by pain history. The patients’ expectations were similar to or more optimistic compared with their pain history. The prognostic ability of the model including a simplified combination of previous and expected patterns, together with a few other predictors, suggests that the trajectory patterns might have potential for clinical use. Significance The dynamic nature of neck pain can be captured by visual illustrations of trajectory patterns. We report, that trajectory patterns of pain history and future expectations to some extent are related. The patterns also reflect a difference in severity assessed by higher degree of symptoms and distress. Moreover, the visual trajectory patterns predict outcome at 12‐weeks. Since the patterns are easily applicable, they might have potential as a clinical tool

The clinical course of neck pain: Are trajectory patterns stable over a 1-year period?

Background Recent studies with data-driven approaches have established common pain trajectories. It is uncertain whether these trajectory patterns are consistent over time, and if a shorter measurement period will provide accurate trajectories. Methods We included 1,124 patients with non-specific neck pain in chiropractic practice. We classified patients into pre-defined trajectory patterns in each of four quarters of the follow-up year (persistent, episodic, and recovery) based on measures of pain intensity and frequency from weekly SMS. We explored the shifts between patterns and compared patients with stable and shifting patterns on baseline characteristics and clinical findings. Results 785 (70%) patients were in the same pattern in 1st and 4th quarters. Patients with episodic pattern in the 1st quarter shifted to other patterns more frequently than patients in the other patterns. A stable persistent pattern was associated with reduced function and higher scores on psychosocial factors. There was a decreased frequency of patients classified as persistent pattern (75% to 63%) and an increase of patients in recovery pattern (4% to 15%) throughout the four quarters. The frequency of patients classified as episodic remained relatively stable (21% to 24%). Conclusions We found an overall stability of the persistent pattern, and that episodic patterns have more potential for shifts. Shifts mostly occurred between patterns closest in pain variation. The deviation in pattern distribution compared with previous studies suggests that the duration of measurement periods has an impact on the results of the classification. Significance Having persistent pain and having very minor pain is relatively stable over one year, while episodic pain has more potential for shifts. The duration of measurement periods appears to have an impact on the results of the classification. The given criteria resulted in a reduced frequency of episodic pattern due to shorter measurement periods. Our findings contribute to improved understanding and predicting NP using a combination of patient characteristics and trajectory patterns

Shoulder MRI features with clinical correlations in subacromial pain syndrome: a cross-sectional and prognostic study

Abstract Background Previous studies on shoulder patients have suggested that the prevalence of rotator cuff or bursa abnormalities are weakly related to symptoms and that similar findings are often found in asymptomatic persons. In addition, it is largely unknown whether structural changes identified by magnetic resonance imaging (MRI) affect outcome after treatment for shoulder pain. The purpose of this study was therefore to evaluate the presence of structural changes on MRI in patients with subacromial pain syndrome and to determine to what extent these changes are associated with symptoms and predict outcome after treatment (evaluated by the Shoulder Pain and Disability Index (SPADI)). Methods A prospective, observational assessment of a subset of shoulder patients who were included in a randomized study was performed. All participants had an MRI of the shoulder. An MRI total score for findings at the AC joint, subacromial bursa and rotator cuff was calculated. Multiple linear regression analysis was applied to examine the relationship between the MRI total score and the outcome measure at baseline and to examine to what extent the MRI total score was associated with the change in the SPADI score from baseline to the one year follow-up. Results There was a weak, inverse association between the SPADI score at baseline and the MRI total score (β = −3.1, with 95% CI −5.9 to −0.34; p = 0.03), i.e. the SPADI score was higher for patients with a lower MRI total score. There was an association between the change in the SPADI score from baseline to the one year follow-up and the MRI total score (β = 8.1, 95% CI -12.3 to −3.8; p < 0.001), with a poorer outcome for patients with a higher MRI total score. Both tendinosis (p = 0.01) and bursitis (p = 0.04) were associated with a poorer outcome after one year. Conclusions In this study, MRI findings were significantly associated with the change in the SPADI score from baseline and to one year follow-up, with a poorer outcome after treatment for the patients with higher MRI total score, tendinosis and bursitis on MRI. Trial registration Clinicaltrials.gov no NCT01441830 . September 28, 2011

What is success of treatment? Expected outcome scores in cervical radicolopathy patients were much higher than the previously reported cut-off values for success.

Purpose Treatment success can be defined by asking a patient how they perceive their condition compared to prior to treatment, but it can also be defined by establishing success criteria in advance. We evaluated treatment outcome expectations in patients undergoing surgery or non-operative treatment for cervical radiculopathy. Methods The first 100 consecutive patients from an ongoing randomized controlled trial (NCT03674619) comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy were included. Patient-reported outcome measures and expected outcome and improvement were obtained before treatment. We compared these with previously published cut-off values for success. Arm pain, neck pain and headache were measured by a numeric rating scale. Neck disability index (NDI) was used to record pain-related disability. We applied Wilcoxon signed-rank test to compare the expected outcome scores for the two treatments. Results Patients reported mean NDI of 42.2 (95% CI 39.6–44.7) at baseline. The expected mean NDI one year after the treatment was 4 (95% CI 3.0–5.1). The expected mean reduction in NDI was 38.3 (95% CI 35.8–40.8). Calculated as a percentage change score, the patients expected a mean reduction of 91.2% (95% CI 89.2–93.2). Patient expectations were higher regarding surgical treatment for arm pain, neck pain and working ability, P < 0.001, but not for headache. Conclusions The expected improvement after treatment of cervical radiculopathy was much higher than the previously reported cut-off values for success. Patients with cervical radiculopathy had higher expectations to surgical treatment

Novel approach towards musculoskeletal phenotypes

Background: The multidimensional array of clinical features and prognostic factors makes it difficult to optimize management within the heterogeneity of patients with common musculoskeletal pain. This study aimed to identify phenotypes across prognostic factors and musculoskeletal complaints. Concurrent and external validity were assessed against an established instrument and a new sample, respectively, and treatment outcome was described. Methods: We conducted a longitudinal observational study of 435 patients (aged 18–67 years) seeking treatment for nonspecific complaints in the neck, shoulder, low back or multisite/complex pain in primary health care physiotherapy in Norway. Latent class analysis was used to identify phenotypes based on 11 common prognostic factors within four biopsychosocial domains; pain, beliefs and thoughts, psychological and activity and lifestyle. Results: Five distinct phenotypes were identified. Phenotype 1 (n = 77, 17.7%) and 2 (n = 142, 32.6%) were characterized by the lowest scores across all biopsychosocial domains. Phenotype 2 showed somewhat higher levels of symptoms across the biopsychosocial domains. Phenotype 3 (n = 89, 20.5%) and 4 (n = 78, 17.9%) were more affected across all domains, but phenotype 3 and 4 had opposite patterns in the psychological and pain domains. Phenotype 5 (n = 49, 11.3%) were characterized by worse symptoms across all domains, indicating a complex phenotype. The identified phenotypes had good external and concurrent validity, also differentiating for the phenotypes in function and health-related quality of life outcome at 3-month follow-up. Conclusion: The phenotypes may inform the development of targeted interventions aimed at improving the treatment efficiency in patients with common musculoskeletal disorders. Significance: This observational prospective study identified five distinct and clinically meaningful phenotypes based on biopsychosocial prognostic factors across common musculoskeletal pain. These phenotypes were independent of primary pain location, showed good external validity, and clear variation in treatment outcome. The findings are particularly valuable as they describe the heterogeneity of patients with musculoskeletal pain and points to a need for more targeted interventions in common musculoskeletal disorders to improve treatment outcome

Novel approach towards musculoskeletal phenotypes

Background The multidimensional array of clinical features and prognostic factors makes it difficult to optimize management within the heterogeneity of patients with common musculoskeletal pain. This study aimed to identify phenotypes across prognostic factors and musculoskeletal complaints. Concurrent and external validity were assessed against an established instrument and a new sample, respectively, and treatment outcome was described. Methods We conducted a longitudinal observational study of 435 patients (aged 18–67 years) seeking treatment for nonspecific complaints in the neck, shoulder, low back or multisite/complex pain in primary health care physiotherapy in Norway. Latent class analysis was used to identify phenotypes based on 11 common prognostic factors within four biopsychosocial domains; pain, beliefs and thoughts, psychological and activity and lifestyle. Results Five distinct phenotypes were identified. Phenotype 1 (n = 77, 17.7%) and 2 (n = 142, 32.6%) were characterized by the lowest scores across all biopsychosocial domains. Phenotype 2 showed somewhat higher levels of symptoms across the biopsychosocial domains. Phenotype 3 (n = 89, 20.5%) and 4 (n = 78, 17.9%) were more affected across all domains, but phenotype 3 and 4 had opposite patterns in the psychological and pain domains. Phenotype 5 (n = 49, 11.3%) were characterized by worse symptoms across all domains, indicating a complex phenotype. The identified phenotypes had good external and concurrent validity, also differentiating for the phenotypes in function and health‐related quality of life outcome at 3‐month follow‐up. Conclusion The phenotypes may inform the development of targeted interventions aimed at improving the treatment efficiency in patients with common musculoskeletal disorders. Significance This observational prospective study identified five distinct and clinically meaningful phenotypes based on biopsychosocial prognostic factors across common musculoskeletal pain. These phenotypes were independent of primary pain location, showed good external validity, and clear variation in treatment outcome. The findings are particularly valuable as they describe the heterogeneity of patients with musculoskeletal pain and points to a need for more targeted interventions in common musculoskeletal disorders to improve treatment outcome