Background
Methods
Study design, setting and key dates
Participants
Inclusion: ▪ Patients with (local) shoulder pain in the presence of an atraumatic (ultrasonographically detected) partial thickness tear ▪ Clinical signs of ‘shoulder impingement’ (e.g. painful arc, positive impingement tests) ▪ Adults (≥ 18 years) ▪ No restrictions on sex ▪ Agreement on conservative treatment ▪ Ability to speak and comprehend the German language ▪ Agreement to participate (signed informed consent) ▪ Anticipated availability for follow-up (living in area of Hamburg) ▪ Agreement to physiotherapy in a collaborating practice Exclusion: ▪ Presence of a full thickness tear at the affected shoulder ▪ Previous substantial shoulder trauma (e.g. shoulder dislocation, fractures) ▪ Previous surgery for the affected shoulder ▪ Previous surgery in the shoulder area that may be causal of or contributory to the current problem (e.g. surgery for breast cancer) ▪ Clinically relevant glenohumeral degeneration or disease (e.g. frozen shoulder) ▪ Current glenohumeral septic arthritis ▪ Clinically relevant acromioclavicular arthritis (e.g. local tenderness, positive provocation tests) ▪ Clinically relevant calcific tendinitis ▪ Ultrasonographic evidence of long head of biceps (LHB) tendon subluxation/ dislocation ▪ Referred pain from the cervical spine region ▪ Multisite musculoskeletal pain ▪ Systemic disorders, diseases or comorbidities as potential sources of (the current) shoulder pain (e.g. breast cancer, rheumatoid disease, inherited disorders (e.g. Marfan syndrome, Ehlers-Danlos syndrome)), or as impairing treatment (e.g. cancer, cardiac insufficiencies) ▪ Neurological disorders or deficits as potential sources of (the current) shoulder pain or impairing assessment and treatment (e.g. hemiplegic shoulder) ▪ Worker’s compensation claims ▪ Unwillingness or inability to give informed consent (e.g. cognitive or intellectual impairments) |
Treatment
Outcomes
Prognostic factors
No | Predictor variable | Measure / measurement system |
---|---|---|
1 | Age | Age at initial presentation (years) |
2 | Sex | Sex (female, male) |
3 | Physical demands | ”Before you had your current shoulder problem, did a typical week include one or more of the following activities (yes, no): ▪ Repetitive or prolonged use of the affected arm for strength effort (e.g. lifting, carrying or moving heavy loads, athletic sports, strength-demanding skilled manual work) ▪ Repetitive or prolonged use of the arm above shoulder height (e.g. overhead work, overhead sports, throwing sports, work as a hairdresser)?” |
4 | Disability | |
5 | Pain | “What is the worst amount of pain that you have experienced within the past week?” (100 mm visual analogue scale VAS) |
6 | History of shoulder pain (incl. Previous treatment) | “Prior to the current episode, have you ever seen a medical doctor or therapist for pain in this shoulder?” (yes, no) |
7 | Symptom duration | “For how long have you been having your current shoulder complaints?” (weeks) |
8 | Diabetes | “Do you have diabetes?” (yes, no) |
9 | Smoking | “Are you a smoker? Please tick “yes” if you regularly smoke at least once a week any amount of tobacco” (yes, no) |
10 | Pain catastrophizing |
Sample size
Missing data
Statistical analysis methods
No | Candidate model | N* factors | Main characteristic | AICC | ∆AICC† | SEE | R2ADJ§ |
---|---|---|---|---|---|---|---|
1 | Age + sex + physical demands + disability (WORC) + pain + history of shoulder pain + symptom duration + smoking + pain catastrophizing (PCS) (+ diabetes removed‡) | 9 | Full model (all factors) | 891 | 11 | 313 | 0.12 |
2 | Smoking + pain catastrophizing (PCS) (+ diabetes removed‡) | 2 | Potential for modification (could be modified (addressed) by some action (e.g. treatment) | 880 | 0 | 314 | 0.11 |
3 | Age + sex | 2 | Factors that cannot be modified | 889 | 9 | 336 | −0.02 |
4 | Age + sex + physical demands + pain + history of shoulder pain + symptom duration + smoking (+ diabetes removed‡) | 7 | Type of assessment: “no questionnaires” | 899 | 19 | 344 | −0.06 |
5 | Disability (WORC) + pain catastrophizing (PCS) | 2 | Type of assessment: “questionnaires” | 880 | 0 | 314 | 0.11 |
6 | Smoking (+ diabetes removed‡) | (1) | Type of factor: “bio(logical) factors” | Excluded from analysis due to removal of diabetes | |||
7 | History of shoulder pain + symptom duration | 2 | Background (patient history) | 889 | 9 | 336 | −0.02 |
8 | Pain + history of shoulder pain + symptom duration | 3 | Further models: pain-related factors (excluding pain catastrophizing) | 889 | 9 | 335 | −0.01 |
9 | Pain + pain catastrophizing (PCS) | 2 | Further models: pain and attitude towards pain | 882 | 2 | 318 | 0.09 |
Model validation and further analyses
Results
Participants
Characteristic (n) | Measurement | Values | ||
---|---|---|---|---|
Continuous prognostic factors | SD | Range | ||
Age (65) | year | 50 | 12 | 24–76 |
Disability (65)* | WORC_1 score | 897 | 380 | 130–1660 |
Pain (64) | mm VAS | 63 | 26 | 7–100 |
Symptom duration (63) | week | 36 | 49 | 1–250 |
Pain catastrophizing (62)*† | PCS score | 15 | 9 | 1–37 |
Categorical prognostic factors | N | % | ||
Sex (65) | female | 25 | 38 | |
male | 40 | 62 | ||
Physical demands (64) | yes | 41 | 64 | |
no | 23 | 36 | ||
History of shoulder pain (64) | yes | 35 | 55 | |
no | 29 | 45 | ||
Diabetes (65) | yes | 4 | 6 | |
no | 61 | 94 | ||
Smoking (64) | yes | 10 | 16 | |
no | 54 | 84 | ||
Additional characteristics | N | % | ||
Affected tendon (65) | 1. supraspinatus | 63 | 97 | |
2. infraspinatus | 1 | 2 | ||
3. supraspinatus + infraspinatus | 1 | 2 | ||
4. any other | 0 | 0 | ||
Dominant arm affected (65) | yes | 46 | 71 | |
no | 19 | 29 | ||
Work status (64) | 5. full-time | 41 | 64 | |
6. part-time | 11 | 17 | ||
7. sick leave | 0 | 0 | ||
8. retired | 10 | 16 | ||
9. not working (other reason) | 2 | 3 |
Treatment
Category | Domain (n = 65) |
N
| % |
---|---|---|---|
Types of exercises | Strengthening exercises focused at rotator cuff muscles | 52 | 80 |
Scapula positioning exercises | 47 | 72 | |
Stabilisation exercises | 41 | 63 | |
Stretching techniques or exercises (shoulder/shoulder girdle) | 36 | 55 | |
Strengthening exercises focused at shoulder girdle muscles | 34 | 52 | |
Humeral head ‘positioning’ exercises | 33 | 51 | |
Coordination exercises | 25 | 38 | |
Inclusion of high load exercises (> 80% RPM†) | 5 | 8 | |
Correction of thoracic spine posture* | 2 | 3 | |
Proprioceptive Neuromuscular Facilitation (PNF)* | 1 | 2 | |
Types of exercise equipment | Use of small equipment (e.g. elastic bands) | 45 | 69 |
Use of training machines (e.g. pulley, pull-down) | 27 | 42 | |
Setting of exercise treatment | Provision and supervision of supplementary home exercises | 42 | 65 |
Types of manual techniques | Soft tissue techniques (shoulder or shoulder girdle) | 56 | 86 |
Manual mobilisation techniques (shoulder) | 51 | 78 | |
Manual mobilisation of thoracic spine* | 9 | 14 | |
Manual mobilisation of ribs* | 2 | 3 | |
Manual mobilisation of cervical spine* | 2 | 3 | |
Supplementary modalities | Heat or cold applications | 14 | 22 |
Therapeutic ultrasound* | 1 | 2 |