At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears.

BACKGROUND: Tendon repair and physiotherapy are frequently used treatment methods for small and medium-sized rotator cuff tears. In 2 previous publications of the 1 and 5-year results of this study, we reported significant but small between-group differences in favor of tendon repair. Long-term results are needed to assess whether the results in both groups remain stable over time. METHODS: In this study, 103 patients with a rotator cuff tear not exceeding 3 cm were randomly assigned to primary tendon repair or physiotherapy with optional secondary repair. Blinded follow-up was performed after 6 months and 1, 2, 5, and 10 years. Outcome measures included the Constant score; the self-report section of the American Shoulder and Elbow Surgeons score; the measurement of shoulder pain, motion, and strength; and patient satisfaction. Magnetic resonance imaging (MRI) was performed on surgically treated shoulders after 1 year, and ultrasound was performed on all shoulders after 5 and 10 years. The main analysis was by 1-way analysis of covariance and by intention to treat. RESULTS: Ninety-one of 103 patients attended the last follow-up. After 10 years, the results were better for primary tendon repair, by 9.6 points on the Constant score (p = 0.002), 15.7 points on the American Shoulder and Elbow Surgeons score (p < 0.001), 1.8 cm on a 10-cm visual analog scale for pain (p < 0.001), 19.6° for pain-free abduction (p = 0.007), and 14.3° for pain-free flexion (p = 0.01). Fourteen patients had crossed over from physiotherapy to secondary surgery and had an outcome on the Constant score that was 10.0 points inferior compared with that of the primary tendon repair group (p = 0.03). CONCLUSIONS: At 10 years, the differences in outcome between primary tendon repair and physiotherapy for small and medium-sized rotator cuff tears had increased, with better results for primary tendon repair. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Responsiveness and minimal important change of the Norwegian version of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) in patients with subacromial pain syndrome.

BACKGROUND: The Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) is a valid and reliable patient-reported outcome measure (PROM). It was designed to measure physical disability and symptoms in patients with musculoskeletal disorders of the upper extremity, and is one of the most commonly used PROMs for patients with shoulder pain. The aim of this study was to examine responsiveness, the smallest detectable change (SDC) and the minimal important change (MIC) of the DASH, in line with international (COSMIN) recommendations. METHODS: The study sample consisted of 50 patients with subacromial pain syndrome, undergoing physical therapy for 3-4 months. Responsiveness to change was examined by calculating area under the receiver operating characteristic curves (AUC) and testing a priori-formulated hypothesis regarding correlations with changes in other instruments that measuring the same construct. The SDC was calculated using a test re-test protocol, and the MIC was calculated by the anchor-based MIC distribution. MIC values for patients with low and high baseline scores were also calculated. RESULTS: DASH appeared to be responsive, as it was able to distinguish patients who reported to be improved from those unchanged (AUC 0.77). All of the hypotheses were accepted. The SDC was 11.8, and the MIC was 4.4. CONCLUSION: This study shows that the Norwegian version of the DASH has good responsiveness to change and may thus be recommended to measure outcome in patients with shoulder pain in Norway.

Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up.

BACKGROUND: There is limited Level-I evidence that compares operative and nonoperative treatment of rotator cuff tears. We compared outcomes of patients treated with primary tendon repair with outcomes of those treated with physiotherapy and optional secondary tendon repair if needed. METHODS: A single-center, pragmatic, randomized controlled study with follow-ups after six months and one, two, and five years was conducted in a secondary-care institution. One hundred and three patients with a rotator cuff tear not exceeding 3 cm were randomized to primary tendon repair (n = 52) or physiotherapy (n = 51). The primary outcome measure was the Constant score. Secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score; the physical component summary measure of the Short Form 36 Health Survey; the measurement of pain, strength, and shoulder motion; patient satisfaction; and findings from magnetic resonance imaging and sonography. Analysis was by intention to treat. RESULTS: The five-year follow-up rate was 98%. Twelve of the fifty-one patients in the physiotherapy group were treated with secondary tendon repair. The results from primary tendon repair were superior to those from physiotherapy plus secondary repair, with between-group mean differences of 5.3 points on the Constant score (p = 0.05), 9.0 points on the American Shoulder and Elbow Surgeons score (p < 0.001), 1.1 cm on a 10-cm visual analog scale for pain (p < 0.001), and 1.0 cm on a 10-cm visual analog scale for patient satisfaction (p = 0.03). In 37% of tears treated with physiotherapy only, there were increasing tear sizes on ultrasound of >5 mm, over five years, associated with an inferior outcome. CONCLUSIONS: Although primary repair of small and medium-sized rotator cuff tears was associated with better outcome than physiotherapy treatment, the differences were small and may be below clinical importance. In the physiotherapy treatment group, there were increasing tear sizes and inferior outcomes in one-third of patients who did not undergo repair.

Reliability and validity of the Norwegian version of the Disabilities of the Arm, Shoulder and Hand questionnaire in patients with shoulder impingement syndrome.

BACKGROUND: Patient-rated outcome measures (PROMs) are an important part of clinical decision-making in rehabilitation of patients with shoulder pain. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire was designed to measure physical disability and symptoms in patients with musculoskeletal disorders of the upper extremity and is one the most commonly used outcome measures for patients with shoulder pain. The purpose of this study was to investigate the reliability and validity of the Norwegian version of the DASH in patients with shoulder impingement syndrome. METHODS: Sixty-three patients diagnosed with shoulder impingement syndrome at an orthopaedic outpatient clinic were included in the study. Internal consistency of the DASH was evaluated by the Cronbach's alpha and item-to-total correlations. Test-retest reliability was analyzed by the intraclass correlation coefficient (ICC) and limits of agreement (LoA) according to the Bland Altman method. Standard error of measurement (SEM) and minimally detectable change (MDC) were calculated for the total DASH score. Construct validity was evaluated by testing six a priori hypotheses for the Pearson's correlation coefficient between the DASH and the Shoulder Pain and Disability Index (SPADI), the 36-item Short Form Health Survey (SF-36) and a Numeric Pain Rating Scale (NPRS). RESULTS: Reliability: Cronbach's alpha of the DASH was 0.93 and item-to-total correlations ranged from 0.36 to 0.81. ICC was 0.89. The 95 percent LoA was calculated to be between -11.9 and 14.1. SEM was 4.7 and MDC 13.1. Construct validity: Eighty-three percent of the a priori hypotheses of correlation were confirmed. The DASH showed a high positive correlation of 0.75 with the SPADI, a negative moderate correlation of -0.48 to -0.62 with physical functioning, bodily pain and physical component summary of the SF-36 and a moderate positive correlation of 0.58 with the NPRS. DASH correlated higher with the physical component summary than with the mental component summary of the SF-36. CONCLUSIONS: The Norwegian version of the DASH is a reliable and valid outcome measure for patients with shoulder impingement syndrome.

Development and reliability of a clinician-rated instrument to evaluate function in individuals with shoulder pain: a preliminary study.

BACKGROUND AND PURPOSE: Subacromial impingement syndrome (SIS) is a common and disabling condition in the population. Interventions are often evaluated with patient-rated outcome measures. The purpose of this study was to develop a simple clinician-rated measure to detect difficulties in the execution of movement-related tasks among patients with subacromial impingement syndrome. METHOD: The steps in the scale development included a review of the clinical literature of shoulder pain to identify condition-specific questionnaires, pilot testing, clinical testing and scale construction. Twenty-one eligible items from thirteen questionnaires were extracted and included in a pilot test. All items were scored on a five-point ordinal scale ranging from 1 (no difficulty) to 5 (cannot perform). Fourteen items were excluded after pilot testing because of difficulties in standardization or other practical considerations. The remaining seven items were included in a clinical test-retest study with outpatients at a hospital. Of these, four were excluded because of psychometric reasons. From the remaining three items, a measure named Shoulder Activity Scale (summed score ranging from 3 to 15) was developed. RESULTS: A total of 33 men and 30 women were included in the clinical study; age range 27-80 years. The intraclass correlation coefficient results for inter-rater reliability and test-retest reliability were 0.80 (95% CI = 0.51-0.90) and 0.74 (95% CI = 0.58-0.84), respectively. The standard error of measurement and minimal detectable change were 1.19 and 3.32, respectively. The scale was linked to the International Classification of Functioning, Disability and Health second level categories lifting and carrying objects (d430), dressing (d540), hand and arm use (d445) and control of voluntary movement (b760). CONCLUSION: The Shoulder Activity Scale showed acceptable reliability in a sample of outpatients at a hospital, rated by clinicians experienced in shoulder rehabilitation. The validity of the scale should be investigated in future studies before application to common practice. © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.