Terminology and diagnostic criteria used in studies investigating patients with subacromial pain syndrome from 1972 to 2019: a scoping review.

INTRODUCTION: There is no recognised terminology, nor diagnostic criteria, for patients with subacromial pain syndrome (SAPS). This is likely to cause heterogeneity across patient populations. This could be a driver of misconceptions and misinterpretations of scientific results. We aimed to map the literature regarding terminology and diagnostic criteria used in studies investigating SAPS. MATERIALS AND METHODS: Electronic databases were searched from inception to June 2020. Original peer-reviewed studies investigating SAPS (also known as subacromial impingement or rotator cuff tendinopathy/impingement/syndrome) were eligible for inclusion. Studies containing secondary analyses, reviews, pilot studies and studies with less than 10 participants were excluded. RESULTS: 11 056 records were identified. 902 were retrieved for full-text screening. 535 were included. 27 unique terms were identified. Mechanistic terms containing 'impingement' are used less than before, while SAPS is used increasingly. For diagnoses, combinations of Hawkin's, Neer's, Jobe's, painful arc, injection test and isometric shoulder strength tests were the most often used, though this varied considerably across studies. 146 different test combinations were identified. 9% of the studies included patients with full-thickness supraspinatus tears and 46% did not. CONCLUSION: The terminology varied considerably across studies and time. The diagnostic criteria were often based on a cluster of physical examination tests. Imaging was primarily used to exclude other pathologies but was not used consistently. Patients with full-thickness supraspinatus tears were most often excluded. In summary, studies investigating SAPS are heterogeneous to an extent that makes it difficult, and often impossible, to compare studies.

Level of pain catastrophising determines if patients with long-standing subacromial impingement benefit from more resistance exercise: predefined secondary analyses from a pragmatic randomised controlled trial (the SExSI Trial).

OBJECTIVE: The primary aim was to investigate the effectiveness of adding more resistance exercise to usual care on pain mechanisms (including temporal summation, conditioned pain modulation (CPM) and local pain sensitivity) and pain catastrophising in people with subacromial impingement at 16 weeks follow-up. Second, to investigate the modifying effect of pain mechanisms and pain catastrophising on the interventions' effectiveness in improving shoulder strength and disability METHODS: 200 consecutive patients were randomly allocated to usual exercise-based care or the same plus additional elastic band exercise to increase total exercise dose. Completed add-on exercise dose was captured using an elastic band sensor. Outcome measures recorded at baseline, 5 weeks, 10 weeks and 16 (primary end point) weeks included temporal summation of pain (TSP) and CPM assessed at the lower leg, pressure pain threshold at the deltoid muscle (PPT-deltoid), pain catastrophising and the Shoulder Pain and Disability Index. RESULTS: Additional elastic band exercise was not superior to usual exercise-based care in improving pain mechanisms (TSP, CPM and PPT-deltoid) or pain catastrophising after 16 weeks. Interaction analyses showed that pain catastrophising (median split) modified the effectiveness of additional exercises (effect size 14 points, 95% CI 2 to 25), with superior results in the additional exercise group compared with the usual care group in patients with less pain catastrophising. CONCLUSION: Additional resistance exercise added to usual care was not superior to usual care alone in improving pain mechanisms or pain catastrophising. Additional exercise was, however, superior in improving self-reported disability in patients with lower levels of pain catastrophising at baseline. TRIAL REGISTRATION NUMBER: NCT02747251.

Validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) using modern test theory across different cultures and languages: a cross-sectional study of 452 male athletes with groin pain.

BKGROUND: No studies have tested the validity of the Copenhagen Hip and Groin Outcome Score (HAGOS) using modern test theory, across different cultures and languages. OBJECTIVE: To validate the Danish, English and Norwegian versions of HAGOS and its six subscales (Symptoms (S, Item 1-7), Pain (P, Item 1-10), activities of daily living (Item 1-5), Sport and recreation (Sport/rec, Item 1-8), Participation in physical activity (item 1-2) and quality of life (item 1-5)) by evaluating differential item functioning (DIF) and measurement invariance across the three language versions in male multidirectional team athletes with groin pain. Second, to modify subscales depending on goodness-of-fit to the item response theory models and calculate conversion tables if language DIF was observed. METHODS: We included individual responses to the Danish (n=157), English (n=146) and Norwegian (n=149) language versions of HAGOS from 452 athletes (median age 24 years old, range 20-28) with groin pain. Overall fit, model fit, individual item fit, local response dependence and measurement invariance was examined using confirmatory factor analysis and graphical Rasch models. RESULTS: The removal of seven misfitting items (S2, P1, P2, A4, SP1, SP5, Q3) resulted in 6 HAGOS subscales with acceptable psychometric properties. For the Symptoms, Pain and Sports subscales evidence of DIF was disclosed between the three different language-versions of HAGOS and conversion tables were created. CONCLUSIONS: A revised HAGOS derived using modern test theory provides valid measurements for male multidirectional athletes with groin pain across different cultures and languages. Conversion tables must be applied to compare HAGOS scores from Danish, Norwegian and English language versions.

Past-season, pre-season and in-season risk assessment of groin problems in male football players: a prospective full-season study.

OBJECTIVE: We assessed past-season, pre-season and in-season risk factors to investigate their association with an in-season groin problem in male amateur football players. METHODS: Past-season groin-pain information and pre-season short-lever and long-lever adductor squeeze strength were obtained at baseline, together with anthropometrics (weight, lower limb lever length) and player age. In-season hip-related and groin-related sporting function was monitored every 4 weeks using the Sports and Recreation (Sport) subscale from the Hip And Groin Outcome Score questionnaire (HAGOS (Sport)). Groin problems, including time-loss groin injuries and groin pain irrespective of time loss, were collected over a 39-week competitive in-season. We estimated relative risk (RR), and 95% credibility interval (ICr) from logistic regressions fitted in a Bayesian framework. RESULTS: Players (n=245) suffering from groin pain during the past-season had 2.4 times higher risk of experiencing a groin problem in the new season (2.40 RR; 95% ICr 1.5 to 3.7). This risk was reduced by 35% (0.65 RR; 95% ICr 0.42 to 0.99) per unit (N·m/kg) increase in the long-lever adductor squeeze test. Player age, short-lever squeeze test and the HAGOS (Sport) scores were not associated with the risk of a groin problem. CONCLUSIONS: Past-season groin pain increased the risk of a groin problem in the new in-season. This risk was reduced by higher pre-season long-lever adductor squeeze strength. Past-season groin-pain information and long-lever adductor squeeze strength can be quickly obtained during pre-season to identify players with an elevated risk of in-season groin problems. This may be key to reduce these problems in the new season.

Does the Spraino low-friction shoe patch prevent lateral ankle sprain injury in indoor sports? A pilot randomised controlled trial with 510 participants with previous ankle injuries.

BACKGROUND: Lateral ankle sprains are common in indoor sports. High shoe-surface friction is considered a risk factor for non-contact lateral ankle sprains. Spraino is a novel low-friction patch that can be attached to the outside of sports shoes to minimise friction at the lateral edge, which could mitigate the risk of such injury. We aimed to determine preliminary effectiveness (incidence rate and severity) and safety (harms) of Spraino to prevent lateral ankle sprains among indoor sport athletes. METHODS: In this exploratory, parallel-group, two-arm pilot randomised controlled trial, 510 subelite indoor sport athletes with a previous lateral ankle sprain were randomly allocated (1:1) to Spraino or 'do-as-usual'. Allocation was concealed and the trial was outcome assessor blinded. Match and training exposure, number of injuries and associated time loss were captured weekly via text messages. Information on harms, fear-of-injury and ankle pain was also documented. RESULTS: 480 participants completed the trial. They reported a total of 151 lateral ankle sprains, of which 96 were categorised as non-contact, and 50 as severe. All outcomes favoured Spraino with incidence rate ratios of 0.87 (95% CI 0.62 to 1.23) for all lateral ankle sprains; 0.64 (95% CI 0.42 to 0.98) for non-contact lateral ankle sprains; and 0.47 (95% CI 0.25 to 0.88) for severe lateral ankle sprains. Time loss per injury was also lower in the Spraino group (1.8 vs 2.8 weeks, p=0.014). Six participants reported minor harms because of Spraino. CONCLUSION: Compared with usual care, athletes allocated to Spraino had a lower risk of lateral ankle sprains and less time loss, with only few reported minor harms. TRIAL REGISTRATION NUMBER: NCT03311490.

Groin problems from pre- to in-season: a prospective study on 386 male Spanish footballers.

This study investigated the weekly prevalence of groin problems over a 3-week football pre-season, compared to a 39-week competitive in-season. We registered time-loss groin injuries, and self-reported weekly groin-pain in 17 amateur male football teams (386 players). The average weekly prevalence of groin problems (prevalence ratio (PR)) was 1.8 times higher (95% CI 1.6 to 2.0) during pre-season (21%) compared to in-season (12%). We found a higher weekly prevalence (PR 1.8; 95% CI 1.6 to 2.1) of groin problems without time loss, during the pre-season (19%) compared to the in-season (10%), but no significant difference in the weekly prevalence of groin problems with time loss (PR 1.5; 95% CI 1.0 to 2.4). Attention should be given to optimal load progression, and early implementation of preventive measures during the football pre-season to reduce the prevalence of groin problems in both pre- and in-season.

Prevalence and severity of groin problems in Spanish football: A prospective study beyond the time-loss approach.

The time-loss definition of injury is commonly adopted in epidemiological groin-injury studies in football, with a significant risk of underestimating the impact of these injuries. This study investigated the extent of groin problems, beyond the time-loss approach, over a full Spanish football season. Players from 17 amateur male teams were followed over 39 consecutive weeks. Groin-injury time loss and self-reported groin pain, irrespective of time loss, were combined to calculate the average weekly prevalence of all groin problems with or without time loss. A subscale measuring hip- and groin-related sporting function from the Copenhagen Hip and Groin Outcome Score questionnaire (HAGOS, Sport/Rec) was registered every 4 weeks. In total, 407 players participated in the study. The average (range) weekly prevalence of all groin problems was 11.7% (7.2%-20.8%); 1.3% with time loss (0.0%-3.2%) and 10.4% without time loss (6.3%-17.6%). Players with groin problems reported lower scores (mean difference) on the HAGOS, Sport/Rec subscale compared with players without (-19.5 [95% CI: -20.7 to -18.4]), while there was no difference between players reporting groin problems with and without time loss (4.0 [95% CI: -1.1 to 9.1]). The traditional time-loss measure only captured 10% of all groin problems. Hip- and groin-related sporting function was not different between players reporting groin problems with or without time loss, suggesting the reason for continuing to play is not only related to the severity of symptoms. These findings question the judicious use of the time-loss approach in overuse conditions, such as groin pain in footballers.

Rasch validation of the Danish version of the shoulder pain and disability index (SPADI) in patients with rotator cuff-related disorders.

PURPOSE: The psychometric properties of the shoulder pain and disability index (SPADI) have been extensively evaluated using classical test theory, but very few studies have applied Rasch analysis. The purpose of this study was to validate the Danish version using Rasch analysis. METHODS: Responses to the SPADI from 229 patients (48% female, mean age 54.5) were included in the Rasch analysis. Overall fit, individual item fit, local response dependence, dimensionality, targeting, reliability, and differential item functioning (DIF) were examined. RESULTS: After iterative analyses, good fit to the Rasch model was observed, with acceptable targeting and uni-dimensionality. SPADI should be reported as two separate subscales: Pain and Functional Disability. The pain subscale initially demonstrated misfit due to local dependence and DIF, but a log linear Rasch model showed good fit to the Rasch model with acceptable targeting and uni-dimensionality. A six-item version of the disability subscale exhibited adequate fit in the Danish version. The same items were also found to fit the Rasch model in the English version. CONCLUSIONS: The measurement properties of the Danish SPADI are similar to those of the English version. SPADI should be reported as two separate subscales. For the pain subscale, DIF with respect to age was disclosed, but the impact was small. The eight-item disability subscale did not fit the Rasch model. A six-item version of the disability subscale exhibited adequate fit in the Danish version. The same items were also found to fit the Rasch model in the English version.

Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes.

OBJECTIVE: To investigate the effect of FIFA injury prevention programmes in football (FIFA 11 and FIFA 11+). DESIGN: Systematic review and meta-analysis. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials comparing the FIFA injury prevention programmes with a control (no or sham intervention) among football players. DATA SOURCES: MEDLINE via PubMed, EMBASE via OVID, CINAHL via Ebsco, Web of Science, SportDiscus and Cochrane Central Register of Controlled Trials, from 2004 to 14 March 2016. RESULTS: 6 cluster-randomised controlled trials had assessed the effect of FIFA injury prevention programmes compared with controls on the overall football injury incidence in recreational/subelite football. These studies included 2 specific exercise-based injury prevention programmes: FIFA 11 (2 studies) and FIFA 11+ (4 studies). The primary analysis showed a reduction in the overall injury risk ratio of 0.75 (95% CI 0.57 to 0.98), p=0.04, in favour of the FIFA injury prevention programmes. Secondary analyses revealed that when pooling the 4 studies applying the FIFA 11+ prevention programme, a reduction in the overall injury risk ratio (incidence rate ratio (IRR) 0.61; 95% CI 0.48 to 0.77, p<0.001) was present in favour of the FIFA 11+ prevention programme. No reduction was present when pooling the 2 studies including the FIFA 11 prevention programme (IRR 0.99; 95% CI 0.80 to 1.23, p=0.940). CONCLUSIONS: An injury-preventing effect of the FIFA injury prevention programmes compared with controls was shown in football. This effect was induced by the FIFA 11+ prevention programme which has a substantial injury-preventing effect by reducing football injuries by 39%, whereas a preventive effect of the FIFA 11 prevention programme could not be documented. TRIAL REGISTRATION NUMBER: PROSPERO CRD42015024120.

Digital mapping of shoulder pain in patients with shoulder disorders: a reliability study.

INTRODUCTION: Digital body mapping can be used to document and quantify the area and location (distribution) of pain and discomfort and support assessment, monitoring, and treatment in clinical populations. This study determines the test-retest reliability of drawings detailing pain and pins and needles using digital body charts and their relationship to pain intensity and patient-reported shoulder function. METHODS: Sixty-two participants with shoulder disorder completed pain and pins and needles drawings with test-retest interval of 30 minutes. Pain intensity in the last week and the patient-reported shoulder function questionnaires were completed. Area and radiating extent were determined using customized software. To assess relative and absolute test-retest reliability, the intraclass correlation coefficient (ICC3,1), standard error of measurement (SEM) and minimal detectable change (MDC95) were calculated. Regression analysis evaluated relation between area and radiating extent of pain and pins and needles with patient-reported function questionnaires. RESULTS: Relative reliability for pain area and radiating extent was excellent (>0.90). Absolute reliability (SEM and MDC95) values for the pain area and radiating extent were 0.20%/34 pixels and 0.57%/94 pixels. Absolute reliability improves for smaller pain areas. Regression analysis revealed the area and radiation extent for both pain and pins and needles are independent constructs to the patient-reported function outcome when adjusted for pain intensity. CONCLUSIONS: Digital body mapping assessing pain area and radiation extent in patients with shoulder disorders are reliable. The magnitude of absolute reliability suggests other sources of variability on repeat testing in this population. Pain area and radiation extent appear to be independent constructs.

Self-management including exercise, education and activity modification compared to usual care for adolescents with Osgood-Schlatter (the SOGOOD trial): protocol of a randomized controlled superiority trial.

BACKGROUND: Osgood-Schlatter is the most frequent growth-related injury affecting about 10% of physically active adolescents. It can cause long-term pain and limitations in sports and physical activity, with potential sequela well into adulthood. The management of Osgood-Schlatter is very heterogeneous. Recent systematic reviews have found low level evidence for surgical intervention and injection therapies, and an absence of studies on conservative management. Recently, a novel self-management approach with exercise, education, and activity modification, demonstrated favorable outcomes for adolescents with patellofemoral pain and Osgood-Schlatter in prospective cohort studies. AIM: The aim of this trial is to assess the effectiveness of the novel self-management approach compared to usual care in improving self-reported knee-related function in sport (measured using the KOOS-child 'Sport/play' subscale) after a 5-month period. METHODS: This trial is a pragmatic, assessor-blinded, randomized controlled trial with a two-group parallel arm design, including participants aged 10-16 years diagnosed with Osgood-Schlatter. Participants will receive 3 months of treatment, consisting of either usual care or the self-management approach including exercise, education, and activity modification, followed by 2 months of self-management. Primary endpoint is the KOOS-child 'Sport/play' score at 5 months. This protocol details the planned methods and procedures. DISCUSSION: The novel approach has already shown promise in previous cohort studies. This trial will potentially provide much-needed level 1 evidence for the effectiveness of the self-management approach, representing a crucial step towards addressing the long-term pain and limitations associated with Osgood-Schlatter. TRIAL REGISTRATION: Clinicaltrials.gov: NCT05174182. Prospectively registered December 30th 2021. Date of first recruitment: January 3rd 2022. Target sample size: 130 participants.

Unravelling interacting barriers and facilitators to adherence and delivery of exercise-based care in the treatment of Subacromial Pain Syndrome - an exploratory qualitative study.

PURPOSE: Subacromial Pain Syndrome (SAPS) is a common persistent pain condition. Exercise-based care is first-line recommendation, but an insufficient exercise dose hampers effectiveness. This study explores individual and contextual barriers and facilitators for delivery of and adherence to exercise-based care in people with SAPS. MATERIALS AND METHODS: Participants in this exploratory qualitative study were involved in the management of SAPS in Denmark. Triangular interviews and analyses were conducted within 3 themes (delivery of recommended services, adherence to recommendations, and frames of the clinical pathways) using the Theoretical Domains Framework (TDF) and the Behavioural Change Wheel model (BCW) to map barriers and facilitators into the Capability, Opportunity, Motivation and Behaviour (COM-B) model. RESULTS: From interviews with 10 persons with SAPS and 37 healthcare practitioners and double-deductive analyses, 30 subjects of target behaviour within 13 TDF domains emerged across perspectives and COM-B components. Central barriers to delivery and adherence were inconsistencies in diagnostic terminology, cross-professional disagreements, beliefs, and expectations towards pathway services. CONCLUSION: We identified interrelated individual and contextual barriers to delivery and adherence across all aspects of the BCW, underpinning the complexity of the subject. Findings support that effectiveness of exercise-based care is linked to contextual barriers to delivery and adherence.

Exercise-based care is the recommended first-line care for Subacromial Pain Syndrome (SAPS), but an insufficient exercise dose hampers effectiveness.Inconsistencies in terminology and care, diverging beliefs and cross-professional disagreements, and varying expectations of pathway services are the main challenges to delivery of and adherence to recommended exercise-based care.Easy access to key information, examination and treatment suggestions, a person-centred approach, and alignment in patient information between HCPs facilitate adherence to clinical recommendations.

Using the app "Injurymap" to provide exercise rehabilitation for people with acute lateral ankle sprains seen at the Hospital Emergency Department-A mixed-method pilot study.

BACKGROUND: Acute lateral ankle sprains (LAS) account for 4-5% of all Emergency Department (ED) visits. Few patients receive the recommended care of exercise rehabilitation. A simple solution is an exercise app for mobile devices, which can deliver tailored and real-time adaptive exercise programs. PURPOSE: The purpose of this pilot study was to investigate the use and preliminary effect of an app-based exercise program in patients with LAS seen in the Emergency Department at a public hospital. MATERIALS AND METHODS: We used an app that delivers evidence-based exercise rehabilitation for LAS using algorithm-controlled progression. Participants were recruited from the ED and followed for four months. Data on app-use and preliminary effect were collected continuously through the exercise app and weekly text-messages. Baseline and follow-up data were collected though an online questionnaire. Semi-structured interviews were performed after participants stopped using the app. Results: Health care professionals provided 485 patients with study information and exercise equipment. Of those, 60 participants chose to enroll in the study and 43 became active users. The active users completed a median of 7 exercise sessions. Most of the active users were very satisfied or satisfied (79%-93%) with the app and 95.7% would recommend it to others. The interviews showed that ankle sprains were considered an innocuous injury that would recover by itself. Several app users expressed they felt insufficiently informed from the ED health care professionals. Only 39% felt recovered when they stopped exercising, and 33% experienced a recurrent sprain in the study period. Conclusion: In this study, only few patients with LAS became active app users after receiving information in the ED about a free app-based rehabilitation program. We speculate the reason for this could be the perception that LAS is an innocuous injury. Most of the patients starting training were satisfied with the app, although few completed enough exercise sessions to realistically impact clinical recovery. Interestingly more than half of the participants did not feel fully recovered when they stopped exercising and one third experienced a recurrent sprain. TRIAL-IDENTIFIERS: https://clinicaltrials.gov/ct2/show/NCT03550274, preprint (open access): https://www.medrxiv.org/content/10.1101/2022.01.31.22269313v1.

Assessing shoulder disability in orthopaedic specialist care: Introducing the Copenhagen Shoulder Abduction Rating (C-SAR).

BACKGROUND: Differences in shoulder-disability among common shoulder-disorders in orthopaedic specialist care is unknown. Furthermore, rating of shoulder-disability using patient-reported outcomes is time-consuming, and a faster approach is needed. OBJECTIVES: First, compare shoulder-disability among common shoulder-disorders. Secondly, rate shoulder-disability according to the new and quick Copenhagen Shoulder Abduction Rating (C-SAR) and investigate criterion validity of C-SAR. METHODS: Cross-sectional study including 325 consecutive patients with shoulder-disorders in orthopaedic specialist care. We assessed shoulder abduction range-of-motion and pain during testing (NRS:0-10), and shoulder-disability using Shoulder Pain and Disability Index (SPADI) subscales. Patients were sub-grouped using C-SAR, which is based on shoulder abduction range-of-motion and pain during testing: Severe (range-of-motion ≤90°), Medium (range-of-motion >90°, NRS:>5), Mild (range-of-motion >90°, NRS:≤5). Shoulder-disability was compared among diagnostic categories and C-SAR subgroups using ANCOVA-models. RESULTS: Most patients were diagnosed with either subacromial impingement (n = 211) or full-thickness/complete rotator-cuff tear (n = 18), but adhesive capsulitis (n = 22) was the diagnostic category related to worst SPADI scores. Data for C-SAR subgrouping were available from 187/229 (82%) patients with rotator-cuff related disorders (subacromial impingement or rotator-cuff tears). C-SAR subgrouping was not feasible for patient with adhesive capsulitis or glenohumeral injury. Differences in shoulder-disability between Mild (n = 67) and Medium (n = 56) C-SAR subgroups were large for both SPADI-subscales (ES: 1.0, p < .0001). Only SPADI-function differed significantly between Severe (n = 64) and Medium C-SAR subgroups (ES: 0.4, p = .017). CONCLUSION: In orthopaedic specialist care, adhesive capsulitis relates to highest level of shoulder-disability, while C-SAR is a promising test to rate shoulder-disability for most patients, namely those with rotator-cuff related disorders.

Maintenance of physical activity after cardiac rehabilitation (FAIR): study protocol for a feasibility trial.

INTRODUCTION: To enhance health and prevent secondary consequences for patients with cardiovascular disease (CVD), maintenance of an active lifestyle following participation in cardiac rehabilitation (CR) is important. However, levels of physical activity often decrease after completion of a structured CR programme. Models that support long-term behaviour change with a sustained level of physical activity are imperative. The aim of this study is to evaluate the feasibility of a mobile health intervention based on the Health Action Process Approach theoretical model of behaviour change in patients with CVD for 3 months after completion of a CR programme. METHODS AND ANALYSIS: In a feasibility trial design, we will recruit 40 participants from CR programmes at Slagelse Hospital, the City of Slagelse (municipality), or Holbæk Hospital. After completing the standard structured CR programme, each participant will create an action plan for physical activity together with a physiotherapist. Following that, participants are sent 2 weekly text messages for 3 months. The first text message prompts physical activity, and the second will check if the action plan has been followed. If requested by participants, a coordinator will call and guide the physical activities behaviour. The feasibility of this maintenance intervention is evaluated based on predefined progression criteria. Physical activity is measured with accelerometers at baseline and at 3 months follow-up. ETHICS AND DISSEMINATION: Study approval was waived (EMN-2021-00020) by the Research Ethics Committee of Region Zealand, Denmark. Study results will be made public and findings disseminated to patients, health professionals, decision-makers, researchers and the public. TRIAL REGISTRATION NUMBER: NCT05011994.

High incidence of lost workdays in patients with subacromial impingement syndrome.

INTRODUCTION: Loss of workdays is the main societal cost related to shoulder disorders with nine lost workdays per six months on average. The most common shoulder disorder is subacromial impingement syndrome (SIS), but it remains unknown if SIS is also a leading cause of shoulder-related loss of worktime. We aimed to investigate the incidence of workdays lost due to SIS during the six months following a SIS diagnosis in specialised care. METHODS: Among 157 consecutive patients diagnosed with SIS in secondary care, 129 (82%) completed a structured six-month follow-up interview. Job status, average working hours and sick leave due to SIS were recorded. Only patients holding a job (n = 58) and patients who lost their job due to SIS (n = 8) were considered to be at risk of losing workdays, leaving 66 patients in the at-risk group. The number of lost workhours due to SIS was calculated and normalised to full-time workdays, and incidences of lost workdays were estimated using Poisson regressions. RESULTS: In total, 1,781 workdays were lost. The mean number of lost workdays per six months was 27 days (95% confidence interval (CI): 18-40) for patients at risk (n = 66), corresponding to 14 days on average (95% CI: 9-21 days) for the entire cohort (n = 129). A total of 33 patients were responsible for all loss of workdays. CONCLUSIONS: We found that an average of 27 workdays (> 5 work weeks) were lost due to SIS during the first six months after the diagnosis in patients who were otherwise fit to work. This is three times higher than the nine days previously reported for shoulder problems in general, indicating that productivity loss in patients diagnosed with SIS is a major concern. FUNDING: none. TRIAL REGISTRATION: not relevant.

Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement: A Pragmatic, Double-Blind Randomized Controlled Trial (SExSI Trial).

BACKGROUND: A strong recommendation against subacromial decompression surgery was issued in 2019. This leaves nonoperative care as the only treatment option, but recent studies suggest that the dose of strengthening exercise is not sufficient in current nonoperative care. At this point, it is unknown if adding more strengthening to current nonoperative care is of clinical value. PURPOSE: To assess the effectiveness of adding a large dose of shoulder strengthening to current nonoperative care for subacromial impingement compared with usual care alone. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In this double-blinded, pragmatic randomized controlled trial, we randomly allocated 200 consecutive patients referred to orthopaedic shoulder specialist care for long-standing shoulder pain (>3 months), aged 18 to 65 years and diagnosed with subacromial impingement using validated criteria, to the intervention group (IG) or control group (CG). Outcome assessors were blinded, and participants were blinded to the study hypothesis as well as to the treatment method in the other group. The CG received usual nonoperative care; the IG underwent the same plus an add-on intervention designed to at least double the total dose of shoulder strengthening. The primary outcome was the Shoulder Pain and Disability Index (SPADI; 0-100) at 4-month follow-up, with 10 points defined as the minimal clinically important difference. Secondary outcomes included shoulder strength, range of motion, health-related quality of life, and the Patient Acceptable Symptom State (PASS). RESULTS: Intention-to-treat and per-protocol analyses showed no significant or clinically relevant between-group differences for any outcome. From baseline to 4-month follow-up, SPADI scores improved in both groups (intention-to-treat analysis; IG, -22.1 points; CG, -22.7 points; between-group mean difference, 0.6 points [95% CI, -5.5 to 6.6]). At 4 months after randomization, only 54% of the IG and 48% of the CG (P = .4127) reached the PASS. No serious adverse events were reported. CONCLUSION: Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes. Moreover, approximately half of all randomized patients did not achieve the PASS after 4 months of nonoperative care, leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem. REGISTRATION: NCT02747251 (ClinicalTrials.gov identifier).