Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial.

BACKGROUND: Despite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT. METHODS: The Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic "add-on" trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes). RESULTS: The average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82). CONCLUSIONS: In patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function. TRIAL REGISTRATION: The trial is registered on ClinicalTrials.gov: NCT03353272 (27/11/2017).

The influence of a cognitive behavioural approach on changing patient expectations for conservative care in shoulder pain treatment: a protocol for a pragmatic randomized controlled trial.

BACKGROUND: Despite similar outcomes for surgery and conservative care, the number of surgeries to treat rotator cuff related shoulder pain has increased. Interventions designed to enhance treatment expectations for conservative care have been shown to improve patient expectations, but no studies have yet explored whether such interventions influence patient decisions to pursue surgery. The purpose of this randomized clinical trial is to examine the effect of an intervention designed to improve expectations of conservative care on the decision to have surgery. METHODS: We will test the effectiveness of the Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention which is intended to change expectations regarding conservative care. The PEERC intervention will be evaluated in a randomized, pragmatic "add-on" trial, to better understand the effect the intervention has on outcomes. Ninety-four (94) participants with rotator cuff related shoulder pain referred for physical therapy will be randomized to receive either impairment-based care or impairment-based care plus PEERC. Both groups will receive impairment-based conservative treatment created by compiling the evidence associated with established, effective interventions. Participants assigned to the impairment-based care plus PEERC condition will also receive the PEERC intervention. This intervention, informed by principles of cognitive behavioral therapy, involves three components: (1) strategies to enhance engagement, (2) education and (3) cognitive restructuring and behavioral activation. Outcomes will be assessed at multiple points between enrolment and six months after discharge. The primary outcome is patient reported decision to have surgery and the secondary outcomes are pain, function, expectations and satisfaction with conservative care. DISCUSSION: Rotator cuff related shoulder pain is highly prevalent, and because conservative and surgical treatments have similar outcomes, an intervention that changes expectations about conservative care could alter patient reports of their decision to have surgery and ultimately could lead to lower healthcare costs and decreased risk of surgical complications. TRIAL REGISTRATION: This study is registered as NCT03353272 at ClincialTrials.gov.

Do older adults with shoulder disorders who meet the minimal clinically important difference also present low disability at discharge? An observational study.

BACKGROUND: The choice of outcome success thresholds may influence clinical management, pay-for-performance, and assessment of value-based care. OBJECTIVE: To evaluate outcomes success thresholds in older adults using two different methods: 1) Minimal clinically important differences (MCIDs) of the Quick-DASH and 2) Dichotomization of the Quick-DASH based on low disability rating at discharge DESIGN: An observational design (retrospective database study). SETTING: Dataset of 1109 patients with shoulder disorders. PARTICIPANTS: 297 older adults patients who were diagnosed with rotator cuff related shoulder disorders and were managed through physical therapy treatment. MAIN OUTCOME MEASURES: We categorized and calculated how many patients met 8.0 and 16.0 point changes on the Quick-DASH. To evaluate outcomes success thresholds using dichotomization, patients who discharge score of ≤20 on the Quick-DASH were considered positive responders with successful outcomes. RESULTS: The percentage of positive responders who met the MCID thresholds for the Quick-DASH were 63.3% using MCID of 8.0 points, 39.7% using the MCID of 16.0 points, and 46.12% who met discharge score of ≤ 20 on the Quick-DASH. 39.0% met both MCID of 8.0 points and discharge score of ≤ 20 on the Quick-DASH. Only 28% met both MCID of 16.0 points and discharge score of = 20 on the Quick-DASH. CONCLUSION: Three different success threshold derivations classified patients into three very different assessments of success. Quick-DASH scores of ≤ 20 represent low levels of self-report disability at discharge and can be a stable clinical option for a measure of success to capture whether a treatment results in meaningful improvement.

IMMEDIATE AND SHORT TERM EFFECT OF DRY NEEDLING ON TRICEPS SURAE RANGE OF MOTION AND FUNCTIONAL MOVEMENT: A RANDOMIZED TRIAL.

BACKGROUND: Dry needling (DN) has been established as an effective treatment for myofascial pain, however, there are no studies thus far investigating the benefit to movement and motor control. PURPOSE: The primary purpose of this study was to compare differences in a series of outcomes between dry needling, dry needling and stretching, and stretching only in a sample of healthy males. A secondary purpose was to compare change over time. DESIGN: Blinded, randomized controlled trial. METHODS: Thirty healthy male subjects were randomly assigned to one of three intervention groups: DN, stretching, or combination DN +stretching. Subjects in the DN group and DN+stretch group received DN to a palpated trigger point (TrP) in the triceps surae to elicit local twitch response. Subjects in the stretch group and DN+stretch group were instructed in a home stretching program for gastrocnemius and soleus muscles. All groups were tested for dorsiflexion range of motion and performed functional tasks (overhead deep squat, and Y-Balance test, Lower Quarter) prior to intervention, directly after intervention, and four days post intervention. Group comparisons were performed using a repeated measure Analysis of Variance and a partial eta squared calculation for effect size. For all measures a p-value of < 0.05 was used to determine significance. Cohen's criteria were used to categorize strength of effect size. RESULTS: There were no statistically significant differences among groups for range of motion nor functional measures, with the exception of the deep squat. Proportionally, the DN group improved significantly in deep squat performance (p<0.01) compared to the other groups. Time oriented improvements were seen for the YBT posterior-lateral reach (p = 0.02) only. Between groups effect sizes ranged from 0.02 (small) to 0.17 (large). CONCLUSIONS: Including DN did not markedly influence range of motion nor functional assessment measures, excluding those seen during the overhead deep squat. Effect measures suggest the lack of significant findings may be an issue of statistical power. LEVEL OF EVIDENCE: 1b.