Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance

Background: Physical examination tests of the shoulder (PETS) are clinical examination maneuvers designed to aid the assessment of shoulder complaints. Despite more than 180 PETS described in the literature, evidence of their validity and usefulness in diagnosing the shoulder is questioned. Methods: This meta-analysis aims to use diagnostic odds ratio (DOR) to evaluate how much PETS shift overall probability and to rank the test performance of single PETS in order to aid the clinician’s choice of which tests to use. This study adheres to the principles outlined in the Cochrane guidelines and the PRISMA statement. A fixed effect model was used to assess the overall diagnostic validity of PETS by pooling DOR for different PETS with similar biomechanical rationale when possible. Single PETS were assessed and ranked by DOR. Clinical performance was assessed by sensitivity, specificity, accuracy and likelihood ratio. Results: Six thousand nine-hundred abstracts and 202 full-text articles were assessed for eligibility; 20 articles were eligible and data from 11 articles could be included in the meta-analysis. All PETS for SLAP (superior labral anterior posterior) lesions pooled gave a DOR of 1.38 [1.13, 1.69]. The Supraspinatus test for any full thickness rotator cuff tear obtained the highest DOR of 9.24 (sensitivity was 0.74, specificity 0.77). Compression-Rotation test obtained the highest DOR (6.36) among single PETS for SLAP lesions (sensitivity 0.43, specificity 0.89) and Hawkins test obtained the highest DOR (2.86) for impingement syndrome (sensitivity 0.58, specificity 0.67). No single PETS showed superior clinical test performance. Conclusions: The clinical performance of single PETS is limited. However, when the different PETS for SLAP lesions were pooled, we found a statistical significant change in post-test probability indicating an overall statistical validity. We suggest that clinicians choose their PETS among those with the highest pooled DOR and to assess validity to their own specific clinical settings, review the inclusion criteria of the included primary studies. We further propose that future studies on the validity of PETS use randomized research designs rather than the accuracy design relying less on well-established gold standard reference tests and efficient treatment options

Effects and experiences of inpatient multimodal occupational rehabilitation among individuals with musculoskeletal- and common mental health disorders

Sammendrag (Summary in Norwegian) Bakgrunn: Arbeidsrettede rehabiliteringsopphold har vært utbredt praksis i flere nordiske land, sannsynligvis med røtter tilbake til den europeiske kurbadtradisjonen og behandling av tuberkulosepasienter. Dagens arbeidsrettede rehabiliteringsinstitusjoner er fremdeles oftest plassert i geografisk isolerte og naturskjønne omgivelser. Som for tidligere tiders kurbad, er det god tilgang til natur, frisk luft og muligheter for fysisk aktivitet. Til tross for en lang klinisk tradisjon med ressurskrevende behandling har imidlertid kunnskap om effektene av denne typen arbeidsrettet rehabilitering manglet. Da Hysnes Helsefort ble opprettet i 2010, initierte Helse Midt-Norge et forskningsprosjekt for å undersøke effektene av arbeidsrettet rehabilitering på Hysnes Helsefort i et samarbeid mellom St. Olavs Hospital og NTNU. Rehabiliteringstilnærmingen ved Hysnes Helsefort var tverrfaglig og multimodal med bruk av ulike elementer som fysisk aktivitet/trening, gruppebasert og individbasert undervisning/refleksjon, involvering av familie/nettverk og koordinering/utarbeiding av en plan for retur til arbeid. I tillegg ble ACT (Acceptance and Commitment Therapy), en ny type verdibasert kognitiv atferdsterapi, innlemmet i alle deler av rehabiliteringen. For å kunne måle effektene av intervensjonene med solide vitenskapelige metoder opprettet St. Olavs hospital også et 6 uker langt poliklinisk mestringstilbud (ACT i gruppe) for sammenligning. Deltakere ble fordelt tilfeldig (randomisert) til inneliggende rehabilitering på Hysnes eller poliklinisk ACT gruppe gjennomført ved klinikk for fysikalsk medisin og rehabilitering. Metode: Denne avhandlingen er basert på resultatene fra to randomiserte studier gjennomført ved Hysnes Helsefort i perioden 2012-2014. Deltakerne ble invitert via NAV og var sykmeldte (>50%) med vanlige muskelskjelett- og/eller psykiske helseplager. Den ene studien undersøkte effektene av et kort opphold på Hysnes (4+4 dager, hvor deltakerne hadde to uker hjemme imellom). Den andre studien undersøkte effektene av et 3,5 ukers arbeidsrettet rehabiliteringsopphold, vanlig lengde for slik rehabilitering i Norge. NAVs registre ble brukt for å undersøke effektene på sykefravær. Helserelaterte utfallsmål ble målt med validerte spørreskjema. Siden ACT var en helt ny tilnærming innen arbeidsrettet rehabilitering ønsket vi også å undersøke om og hvordan deltakernes erfaringer reflekterte ACT prosessene. Jeg gjennomførte derfor 5 fokusgruppe-intervju med til sammen 22 deltakere på slutten av det 3,5 uker lange oppholdet. Resultater: Deltakere i det lange oppholdet på Hysnes Helsefort hadde (i median) 32 færre utbetalte sykefraværsdager i løpet av et år sammenliknet med poliklinisk ACT-gruppe. Helsen bedret seg i begge grupper. Det var imidlertid ingen klinisk viktige forskjeller mellom gruppene (Paper I). Gjennom analyse av fokusgruppeintervjuene fant vi at deltakernes erfaringer i det lange oppholdet reflekterte alle relevante prosesser i ACT rettet mot å øke deltakernes psykologiske fleksibilitet. Det var imidlertid variasjon. Spesifikke ACT prosesser relatert til økt selvbevissthet var ikke tydelig gjenkjennbare i deltakernes erfaringer. Litt overraskende var det at ingen av deltakerne nevnte konkrete planer om retur til arbeidet. De snakket isteden om verdibaserte endringer hvor arbeid var nevnt som en del av en større endringsprosess som ville ta lang tid og kreve mye av dem (Paper II) Reduksjon av fryktunngåelse, målt med FABQ (fear avoidance beliefs questionnaire score), er en annen mulig mekanisme for økt arbeidsdeltakelse. I min siste studie (Paper III) slo vi sammen data fra de to randomiserte studiene for bedre å kunne bedømme hvilken påvirkning intervensjonene hadde. Vi fant ingen effekt på endringer i FABQ ved sammenlikning av deltakerne i de to intervensjonsgruppene på Hysnes og deltakere som fikk poliklinisk ACTgruppe. For alle deltakere var reduksjon i FABQ eller konstant lav FABQ gjennom rehabiliteringsperioden likevel assosiert med mindre sykefravær. Et interessant nytt funn var at assosiasjonen mellom lav FABQ og lite sykefravær var sterkest for deltakerne som var sykmeldt for psykiske helseplager. Konklusjon: Forskningen jeg har presentert i denne avhandlingen gir støtte til dagens praksis med 3,5 ukes arbeidsrettet tverrfaglig inneliggende multikomponent rehabilitering for personer med vanlige muskel-skjelettplager og psykiske lidelser. Mekanismene for effekten av det lange oppholdet er imidlertid ikke klarlagt (det korte oppholdet hadde ingen effekt på sykefraværet). Deltakerne følges videre, i første omgang med en 2-års oppfølging hvor helseøkonomiske analyser vil inngå. Videre forskning basert på Hysnes-data vil bidra til å øke kunnskapsgrunnlaget, og vil derigjennom kunne gi bedre grunnlag for politiske prioriteringer

Sick-listed persons’ experiences with taking part in an in-patient occupational rehabilitation program based on Acceptance and Commitment Therapy: a qualitative focus group interview study

Background: Occupational medicine has shifted emphasis from disease treatment to disability rehabilitation and management. Hence, newly developed occupational rehabilitation programs are often generic and multicomponent, aiming to influence the sick-listed persons’ perception on return to work, and thereby support the return to work process. The aim of this study was to explore sick-listed persons’ experiences with taking part in an in-patient occupational rehabilitation program based on Acceptance and Commitment Therapy. Methods: Twenty-nine adults on sickness benefit or work assessment allowance due to musculoskeletal and/or common mental health disorders participated in this study. They were interviewed in focus groups at the beginning and at the end of a 3.5 week inpatient group-based occupational rehabilitation program in Central Norway. Key elements in the program were Acceptance and Commitment Therapy (ACT), physical exercise and creating a work-participation plan. The program was mainly group-based including participants with different diagnoses. Data was analyzed according to a phenomenological approach. Results: At the start of the program most participants expressed frustration regarding being sick-listed, external anticipations as well as hindrances towards returning to work, and described hope that the program would provide them with the skills and techniques necessary to cope with health problems and being able to return to work. At the end of the program the participants described that they had embarked upon a long process of increased awareness. This process encompassed four areas; an increased awareness of what was important in life, realizing the strain from external expectations and demands, a need to balance different aspects of life, and return to work as part of a long and complex process. Conclusions: The occupational rehabilitation program induced a perceived meaningful reorientation encompassing several aspects of life. However, the return to work process was described as diffuse and uncertain for most participants. The providers of occupational rehabilitation program should balance this reorientation with specific steps towards return to work. Effect studies and long-term qualitative studies evaluating how this affects long-term work- and health outcomes are underway. Keywords: MeSH, Absenteeism, Occupational health, Rehabilitation, Return to work, Acceptance and commitment therapy, Cognitive behaviour therapy, Musculoskeletal diseases

Two‑Year Follow‑Up of a Randomized Clinical Trial of Inpatient Multimodal Occupational Rehabilitation Vs Outpatient Acceptance and Commitment Therapy for Sick Listed Workers with Musculoskeletal or Common Mental Disorders

Purpose There is a lack of results on long-term effects of return to work interventions. We previously reported that an inpatient multimodal occupational rehabilitation program (I-MORE) was more effective in reducing sickness absence and facilitating return to work (RTW) at 12 months follow-up compared to an outpatient program that consisted mainly of Acceptance and Commitment Therapy (O-ACT). We now report the 2-year outcome data. Methods A randomized clinical trial with parallel groups. Participants were 18–60 years old, sick listed with musculoskeletal, common mental or general/unspecified disorders. I-MORE lasted 3.5 weeks and consisted of ACT, physical training and work-related problem solving. O-ACT consisted mainly of 6 weekly sessions (2.5 h. each) of ACT in groups. Outcomes were cumulated number of days on medical benefits and time until sustainable RTW (1 month without medical benefits) during 2-years of follow-up, measured by registry data. Results For the 166 randomized participants, the median number of days on medical benefits was 159 (IQR 59–342) for I-MORE vs 249 days (IQR 103–379; Mann–Whitney U test, p = 0.07), for O-ACT. At 2 years, 40% in I-MORE received long-term benefits (work assessment allowance) vs 51% in O-ACT. The crude hazard ratio (HR) for sustainable RTW was 1.59 (95% CI 1.04–2.42, p = 0.03) and the adjusted HR 1.77 (95% CI 1.14–2.75, p = 0.01), in favor of I-MORE. Conclusions The 2-year outcomes show that I-MORE had long-term positive effects on increasing work participation for individuals sick listed with musculoskeletal and mental disorders. Further follow-up and economic evaluations should be performed

Kan fysisk aktivitet redusere sykefravær og uføretrygding?

Innledning: Sykefravær og uføretrygding er betydelige folkehelseproblem med store konsekvenser for enkeltindivid, familie og samfunn. Fysisk aktivitet og trening har mange helsegevinster, og anvendes både i forebygging og behandling av ulike plager og kroniske sykdommer. Imidlertid er sammenhengen mellom fysisk aktivitet og sykefravær uavklart. Q Hoveddel: Artikkelen baserer seg på søk i Pubmed. Bare prospektive befolkningsstudier som undersøkte sammenhengen mellom fysisk aktivitet/kapasitet og sykefravær/ uføretrygd ble inkludert. Tolv studier rapporterte at fysisk aktive hadde redusert risiko for sykefravær eller uføretrygd. Tre av disse rapporterte sterkere sammenhenger ved anstrengende aktivitet sammenlignet med moderat aktivitet. Tre studier viste at god aerob kapasitet medførte redusert risiko for sykefravær. En studie rapporterte en positiv sammenheng mellom muskulær styrke og sykefravær. Fysisk aktivitet i jobben økte risikoen for sykefravær, mens fysisk aktivitet på fritiden reduserte risikoen i en studie. Imidlertid var det i ulik grad justert for potensielle konfunderende variabler. Q Avslutning: Prospektive befolkningsstudier indikerer at utholdenhetsevne og fysisk aktivitet i fritiden reduserer risikoen for sykefravær/uføretrygding. Anstrengende aktivitet ser ut til å redusere risiko for sykefravær/uføretrygd i større grad enn moderat og lett aktivitet, som kan skyldes større effekt på helse og på fysisk kapasitet – som kan gi lavere relativ arbeidsbelastning. Rehabilitering og forebyggende tiltak bør derfor vektlegge jevnlig deltakelse i fysisk aktivitet og trening som inkluderer anstrengende fysisk aktivitet. Vi foreslår en modell for hvordan fysisk aktivitet kan redusere sykefravær og uføretrygding

Can physical activity reduce sickness absence and disability pension?

Introduction: High levels of sick leave and disability pension are significant public health problems with serious consequences for individuals, families and society as a whole. Physical activity and exercise training has many health benefits and is used in both the prevention and treatment of various health complaints and chronic diseases. However, the relationship between physical activity and sickness absence is unresolved. Main part: This article is based on searches in PubMed. Only prospective population studies that examined the association between physical activity/capacity and sickness absence/disability pension were included. Twelve studies reported that physically active persons had a reduced risk of absenteeism or disability pension. Three of these reported stronger associations by vigorous activity compared to moderate activity. Three studies showed that good aerobic capacity reduced the risk of sickness absence. A study reported a positive association between muscular strength and absenteeism. Physically active jobs increased risk of sickness absence, while leisure-time physical activity reduced the risk in one study. However, it varied to what extent studies had adjusted for potential confounding variables. Ending: Prospective population studies indicate that endurance capacity and leisure-time physical activity reduces the risk of sickness absence/disability pension. Vigorous activity appears to reduce the risk more than moderate and light activity, which may be due to a greater impact on health and on physical capacity - which can provide lower relative workloads. Hence, rehabilitation and preventive measures should emphasize regular participation in physical activity and exercise training that includes vigorous physical activity. We propose a model of how physical activity can reduce sickness absence and disability pension

The acceptance and commitment therapy model in occupational rehabilitation of musculoskeletal and common mental disorders: a qualitative focus group study

Aims: The aim of this study was to examine whether and how intended processes of behavioural change were reflected in participants’ experiences after an inpatient occupational rehabilitation programme. The programme was transdiagnostic, lasted 3½ weeks and was based on the acceptance and commitment therapy model. Methods: Twenty-two participants (17 women and 5 men) took part in five qualitative focus group interviews after the programme. Analysis was data-driven, categorising participants’ experiences using an initial explorative phenomenological approach. The emerging data-driven categories were re-contextualised within the theoretical framework of the therapy model. Results: The participants referred to experiences within all three intended domains of the model (openness, awareness, and engagement). Our results indicate that the transdiagnostic approach may have facilitated openness, while the attainment of flexible self-awareness was less evident. Participants expressed engagement and behavioural changes linked to personal values, but did not mention actions leading to imminent return to work. Conclusions: The results imply that for implementation in occupational rehabilitation, further development of this model is needed specifically regarding processes related to self-awareness and committed action towards work. These findings are relevant for the interpretation of results from randomised clinical trials on acceptance and commitment therapy in occupational rehabilitation. Implications for rehabilitation Acceptance and commitment therapy seems to be a feasible component in an occupational rehabilitation programme for persons with different diagnoses. A transdiagnostic approach mixing musculoskeletal pain disorders and common mental disorders in the same rehabilitation programme seems to facilitate the process of openness and acceptance. There is a need to further develop and operationalise some of the processes in Acceptance and commitment therapy to accommodate the approach to the occupational rehabilitation context