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: 1.71). 07/2008; 13(6):478-83. DOI: 10.1016/j.math.2008.04.005
Source: PubMed


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.
    Full-text · Article · Sep 2014 · Manual Therapy
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    • "This lack of standardisation or discrepancy in labelling shoulder pain has been reported previously [50-52]. Differing exclusion as well as inclusion criteria can contribute to heterogeneity between studies seemingly investigating the same subgroup of patients with shoulder pain and hamper effective comparison [50,51]. "
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    ABSTRACT: People suffering from musculoskeletal shoulder pain are frequently referred to physiotherapy. Physiotherapy generally involves a multimodal approach to management that may include; exercise, manual therapy and techniques to reduce pain. At present it is not possible to predict which patients will respond positively to physiotherapy treatment. The purpose of this systematic review was to identify which prognostic factors are associated with the outcome of physiotherapy in the management of musculoskeletal shoulder pain. A comprehensive search was undertaken of Ovid Medline, EMBASE, CINAHL and AMED (from inception to January 2013). Prospective studies of participants with shoulder pain receiving physiotherapy which investigated the association between baseline prognostic factors and change in pain and function over time were included. Study selection, data extraction and appraisal of study quality were undertaken by two independent assessors. Quality criteria were selected from previously published guidelines to form a checklist of 24 items. The study protocol was prospectively registered onto the International Prospective Register of Systematic Reviews. A total of 5023 titles were retrieved and screened for eligibility, 154 articles were assessed as full text and 16 met the inclusion criteria: 11 cohort studies, 3 randomised controlled trials and 2 controlled trials. Results were presented for the 9 studies meeting 13 or more of the 24 quality criteria. Clinical and statistical heterogeneity resulted in qualitative synthesis rather than meta-analysis. Three studies demonstrated that high functional disability at baseline was associated with poor functional outcome (p <= 0.05). Four studies demonstrated a significant association (p <= 0.05) between longer duration of shoulder pain and poorer outcome. Three studies, demonstrated a significant association (p <= 0.05) between increasing age and poorer function; three studies demonstrated no association (p > 0.05). Associations between prognostic factors and outcome were often inconsistent between studies. This may be due to clinical heterogeneity or type II errors. Only two baseline prognostic factors demonstrated a consistent association with outcome in two or more studies; duration of shoulder pain and baseline function. Prior to developing a predictive model for the outcome of physiotherapy treatment for shoulder pain, a large adequately powered prospective cohort study is required in which a broad range of prognostic factors are incorporated.
    Full-text · Article · Jul 2013 · BMC Musculoskeletal Disorders
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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.
    Full-text · Article · Mar 2012 · Physiotherapy
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