Lack of uniformity in diagnostic labeling of shoulder pain: Time for a different approach

Department of General Practice, Erasmus Medical Centre, Rotterdam, PO Box 2040, CA Rotterdam, The Netherlands.
Manual therapy (Impact Factor: 1.76). 07/2008; 13(6):478-83. DOI: 10.1016/j.math.2008.04.005
Source: PubMed

ABSTRACT Diagnostic labels for shoulder pain (e.g., frozen shoulder, impingement syndrome) are widely used in international research and clinical practice. However, about 10 years ago it was shown that the criteria to define those labels were not uniform. Since an ongoing lack of uniformity seriously hampers communication and does not serve patients, we decided to evaluate the uniformity in definitions. Therefore, we compared the selection criteria of different randomised controlled trials (RCTs). This comparison revealed some corresponding criteria, but no uniform definition could be derived for any of the diagnostic labels. Besides the lack of uniformity, the currently used labels have only a fair to moderate interobserver reproducibility and in systematic reviews none of the separate trials using a diagnostic label show a large benefit of treatment. This, altogether, seems sufficient reason to reconsider their use. Therefore, we strongly suggest to abolish the use of these labels and direct future research towards undivided populations with "general" shoulder pain. Possible subgroups with a better prognosis and/or treatment result, based on common characteristics that are easily and validly reproducible, can then be identified within these populations.

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Available from: Jasper M Schellingerhout, Dec 06, 2014
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    • "The causes of mechanical compression or excessive tendon loading are multifaceted. (Schellingerhout et al., 2008; Seitz et al., 2011; Braman et al., 2013) Thoracic spine mobility loss and 'slouched' posture (Theisen et al., 2010; Kalra et al., 2010) has been shown to reduce shoulder motion and decrease subacromial space dimensions. Thoracic spinal manipulative therapy (SMT), a low-amplitude high-velocity spinal thrust, is a treatment used to theoretically improve thoracic motion deficits. "
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    ABSTRACT: The evidence to guide use of spinal manipulative therapy (SMT) for patients with shoulder pain is limited. A validated sham comparator is needed to ascertain the unique effects of SMT. We investigated the plausibility of a thoracic sham-SMT comparator for SMT in patients with shoulder pain. Participants(n=56) with subacromial impingement syndrome were randomized to thoracic SMT or a sham-SMT. An examiner blinded to group assignment took measures pre- and post-treatment of shoulder active range of motion (AROM) and perceived effects of the assigned intervention. Treatment consisted of six upper, middle and lower thoracic SMT or sham-SMT. The sham-SMT was identical to the SMT, except no thrust was applied. Believability as an active treatment was measured post-treatment. Believability as an active treatment was not different between groups (χ2=2.19;p=0.15). Perceptions of effects were not different between groups at pre-treatment (t=0.12;p=0.90) or post-treatment (t=0.40;p=0.69), and demonstrated equivalency with 95% confidence between groups at pre- and post-treatment. There was no significant change in shoulder flexion in either group over time, or in the sham-SMT for internal rotation(p>0.05). The SMT group had an increase of 6.49° in internal rotation over time (p=0.04). The thoracic sham-SMT of this study is a plausible comparator for SMT in patients with shoulder pain. The sham-SMT was believable as an active treatment, perceived as having equal beneficial effects both when verbally described and after familiarization with the treatment, and has an inert effect on shoulder AROM. This comparator can be considered for used in clinical trials investigating thoracic SMT. IRB number HM 13182.
    Manual Therapy 09/2014; 20(1). DOI:10.1016/j.math.2014.08.008 · 1.76 Impact Factor
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    • "The essential categories in this classification system are determined by pain location, patient age, mechanism of injury, and aggravating factors determined via specific provocative tests. The literature indicates that the validity and reliability of shoulder testing based primarily on physical examination are poor [5] [17]. For this reason, the current classification system gives the history precedence over the physical examination. "
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    ABSTRACT: To describe and determine the intertester reliability of a newly developed classification system of shoulder syndrome recognition. Intertester reliability study. Fourteen primary care physiotherapy clinics. Two hundred and fifty-five patients with shoulder pain. Inclusion criterion: presence of shoulder pain aring within the glenohumeral or associated joints and structures. Exclusion criteria: previous shoulder surgery, surgical candidates, recognised malignancy, systemic illness, or concurrent cervical pain and/or radiculopathy. Examiners were 55 physiotherapists who were arranged in pairs; each patient received two independent and blinded assessments, one by each of the paired physiotherapists. This shoulder classification approach contains three main clinical syndromes: Pattern 1 (impingement pain), Pattern 2 (acromioclavicular joint pain) and Pattern 3 (shoulder pain: frozen shoulder, glenohumeral arthritis, massive cuff tear, subscapularis tear, painful laxity, post-traumatic instability, internal derangement). Percentage agreement and Cohen's kappa coefficient. The mean age of patients was 46.6 years (standard deviation 16.3, range 16 to 86), and 57% were male. Physiotherapists agreed on the pattern of shoulder pain for 205 of the 255 shoulders assessed (agreement rate 80%); the kappa coefficient was 0.664 (95% confidence interval 0.622 to 0.706; P<0.001). Of the 205 agreements, Pattern 1 was the most common condition; physiotherapists agreed on this pattern for 139 patients (68%). Both physiotherapists diagnosed Pattern 2 for 20 patients and Pattern 3 for 46 patients. This clearly defined system uses key elements of the history and examination to classify patients with shoulder pain. The kappa coefficient denotes good reproducibility.
    Physiotherapy 03/2012; 98(1):40-6. DOI:10.1016/ · 2.11 Impact Factor
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    • "It is in accord with a recent review, which concluded that, because of a lack of standardised operational definitions for diagnostic labels and the lack of a link between diagnostic labels and specific interventions, it is time for a different approach to the management of shoulder problems based on other than specific structural pathology (Schellingerhout et al 2008). Whether the constellation of signs and symptoms that our respondents suggested is actually of useful diagnostic accuracy should be validated by further research. "
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    ABSTRACT: What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the assessment and management of patients with shoulder pain? Qualitative study using a three-round Delphi procedure. Twenty-six experts in the UK consented to be involved and were contactable, of whom 20 contributed, with 12, 15, and 15 contributing to the different rounds. Clinical reasoning was mostly about diagnostic reasoning, but also involved narrative reasoning. Diagnostic reasoning involved both pattern recognition and hypothetico-deductive reasoning. Diagnostic reasoning emphasised general history items, a constellation of signs and symptoms to identify specific diagnostic categories, and standard physical examination procedures. Narrative reasoning was highlighted by the communication involved in expert history taking, seeing patients in their functional and psychological context, and collaborative reasoning with the patient regarding management. These expert clinicians demonstrated the use of diagnostic pattern recognition, and hypothetico-deductive and narrative clinical reasoning processes. The emphasis was on the history and basic physical examination procedures to make clinical decisions.
    The Australian journal of physiotherapy 02/2008; 54(4):261-6. DOI:10.1016/S0004-9514(08)70005-9 · 3.48 Impact Factor
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