What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey.

OBJECTIVE: Despite usually being considered necessary, the rehabilitation regime that optimises outcomes for patients following release procedures for frozen shoulder has not been established and no accepted best practice guidelines currently exist. The purpose of this study was to gain insight into what physiotherapists considered best practice and factors they considered likely to affect patient outcome. METHODS: A cross-sectional, self-administered online questionnaire was developed and distributed to UK based Physiotherapists, undergraduate students and support workers via email, social media and professional networks. RESULTS: 260 eligible and fully completed surveys were received. Clear preference for early (within 72 h), frequent (2-3 times per week or weekly) and prolonged (greater than 6 weeks) treatment delivered in a 1:1 setting was expressed. 99% were highly likely/likely to advocate education and advice, range of movement exercises (99.6%), stretching (73.5%) and strengthening (61.9%). More passive modalities (manual therapy, massage, electrotherapy, acupuncture) were highly unlikely/unlikely to be used and lack of manual therapy and insufficient contact with a physiotherapist were the reasons deemed least likely to affect outcome. Most clinicians (89.2%) were likely to prescribe exercises that patients reported as painful but persistent pain and poor adherence by patients to exercises were the top reasons given for poor outcome along with psychological and psychosocial patient characteristics. CONCLUSION: Physiotherapists consistently advocate early, frequent, prolonged, 1:1 treatment following release procedures for frozen shoulder. Most patients are discharged whilst still experiencing symptoms, particularly pain. Further work is needed to establish high value pathways for this patient group.

Utilisation of outcome measures in the management of non-specific neck pain: A national survey of current physiotherapy practice in the UK.

BACKGROUND: Routine utilisation of outcome measures (OMs) is an integral part of physiotherapy rehabilitation when managing non-specific neck pain (NSNP). Numerous relevant OMs exist; however, the extent to which OMs are used by physiotherapists in the UK for NSNP is unknown. OBJECTIVE: To determine current utilisation patterns of OMs in UK physiotherapy practice when managing NSNP. METHODS: An online web-based survey instrument was developed and physiotherapists were invited to participate if they were currently practicing in the UK and had some experience of managing patients with neck pain. Logistic regression analyses using the generalised linear models was carried out to identify characteristics associated with OMs utilisation. RESULTS: A total of 2101 surveys were completed. One-third of the respondents reported not using OMs when managing NSNP. Lack of time and clear guidance about the suitability of available OMs were the most commonly reported reasons. A majority of the two-thirds of those who reported using OMs were consistently using pain and range of motion rating measures. Physical/functional limitations, psychological distress, and quality of life constructs, which are frequently associated with NSNP, were rarely measured. Years of practice (p = 0.000), nation (p = 0.019) and proportion of patients with neck pain (p = 0.034) variables were found to be independently associated with frequent use of OMs. CONCLUSION: This survey established the poor integration of OMs in the UK when managing NSNP. Further attention is required to identify or develop OMs which are feasible for use in busy clinical practice and to market them more effectively to physiotherapists.

Predictors of the effects of treatment for shoulder pain: protocol of an individual participant data meta-analysis.

BACKGROUND: Shoulder pain is one of the most common presentations of musculoskeletal pain with a 1-month population prevalence of between 7 and 26%. The overall prognosis of shoulder pain is highly variable with 40% of patients reporting persistent pain 1 year after consulting their primary care clinician. Despite evidence for prognostic value of a range of patient and disease characteristics, it is not clear whether these factors also predict (moderate) the effect of specific treatments (such as corticosteroid injection, exercise, or surgery). OBJECTIVES: This study aims to identify predictors of treatment effect (i.e. treatment moderators or effect modifiers) by investigating the association between a number of pre-defined individual-level factors and the effects of commonly used treatments on shoulder pain and disability outcomes. METHODS: This will be a meta-analysis using individual participant data (IPD). Eligible trials investigating the effectiveness of advice and analgesics, corticosteroid injection, physiotherapy-led exercise, psychological interventions, and/or surgical treatment in patients with shoulder conditions will be identified from systematic reviews and an updated systematic search for trials, and risk of bias will be assessed. Authors of all eligible trials will be approached for data sharing. Outcomes measured will be shoulder pain and disability, and our previous work has identified candidate predictors. The main analysis will be conducted using hierarchical one-stage IPD meta-analysis models, examining the effect of treatment-predictor interaction on outcome for each of the candidate predictors and describing relevant subgroup effects where significant interaction effects are detected. Random effects will be used to account for clustering and heterogeneity. Sensitivity analyses will be based on (i) exclusion of trials at high risk of bias, (ii) use of restricted cubic splines to model potential non-linear associations for candidate predictors measured on a continuous scale, and (iii) the use of a two-stage IPD meta-analysis framework. DISCUSSION: Our study will collate, appraise, and synthesise IPD from multiple studies to examine potential predictors of treatment effect in order to assess the potential for better and more efficient targeting of specific treatments for individuals with shoulder pain. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018088298.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.

BACKGROUND: Acute anterior shoulder dislocation, which is the most common type of dislocation, usually results from an injury. Subsequently, the shoulder is less stable and is more susceptible to re-dislocation or recurrent instability (e.g. subluxation), especially in active young adults. After closed reduction, most of these injuries are treated with immobilisation of the injured arm in a sling or brace for a few weeks, followed by exercises. This is an update of a Cochrane Review first published in 2006 and last updated in 2014. OBJECTIVES: To assess the effects (benefits and harms) of conservative interventions after closed reduction of traumatic anterior dislocation of the shoulder. These might include immobilisation, rehabilitative interventions or both. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro and trial registries. We also searched conference proceedings and reference lists of included studies. Date of last search: May 2018. SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials comparing conservative interventions with no treatment, a different intervention or a variant of the intervention (e.g. a different duration) for treating people after closed reduction of a primary traumatic anterior shoulder dislocation. Inclusion was regardless of age, sex or mechanism of injury. Primary outcomes were re-dislocation, patient-reported shoulder instability measures and return to pre-injury activities. Secondary outcomes included participant satisfaction, health-related quality of life, any instability and adverse events. DATA COLLECTION AND ANALYSIS: Both review authors independently selected studies, assessed risk of bias and extracted data. We contacted study authors for additional information. We pooled results of comparable groups of studies. We assessed risk of bias with the Cochrane 'Risk of bias' tool and the quality of the evidence with the GRADE approach. MAIN RESULTS: We included seven trials (six randomised controlled trials and one quasi-randomised controlled trial) with 704 participants; three of these trials (234 participants) are new to this update. The mean age across the trials was 29 years (range 12 to 90 years), and 82% of the participants were male. All trials compared immobilisation in external rotation (with or without an additional abduction component) versus internal rotation (the traditional method) following closed reduction. No trial evaluated any other interventions or comparisons, such as rehabilitation. All trials provided data for a follow-up of one year or longer; the commonest length was two years or longer.All trials were at some risk of bias, commonly performance and detection biases given the lack of blinding. Two trials were at high risk of selection bias and some trials were affected by attrition bias for some outcomes. We rated the certainty of the evidence as very low for all outcomes.We are uncertain whether immobilisation in external rotation makes a difference to the risk of re-dislocation after 12 months' or longer follow-up compared with immobilisation in internal rotation (55/245 versus 73/243; risk ratio (RR) 0.67, 95% confidence interval (CI) 0.38 to 1.19; 488 participants; 6 studies; I² = 61%; very low certainty evidence). In a moderate-risk population with an illustrative risk of 312 per 1000 people experiencing a dislocation in the internal rotation group, this equates to 103 fewer (95% CI 194 fewer to 60 more) re-dislocations after immobilisation in external rotation. Thus this result covers the possibility of a benefit for each intervention.Individually, the four studies (380 participants) reporting on validated patient-reported outcome measures for shoulder instability at a minimum of 12 months' follow-up found no evidence of a clinically important difference between the two interventions.We are uncertain of the relative effects of the two methods of immobilisation on resumption of pre-injury activities or sports. One study (169 participants) found no evidence of a difference between interventions in the return to pre-injury activity of the affected arm. Two studies (135 participants) found greater return to sports in the external rotation group in a subgroup of participants who had sustained their injury during sports activities.None of the trials reported on participant satisfaction or health-related quality of life.We are uncertain whether there is a difference between the two interventions in the number of participants experiencing instability, defined as either re-dislocation or subluxation (RR 0.84, 95% CI 0.62 to 1.14; 395 participants, 3 studies; very low certainty evidence).Data on adverse events were collected only in an ad hoc way in the seven studies. Reported "transient and resolved adverse events" were nine cases of shoulder stiffness or rigidity in the external rotation group and two cases of axillary rash in the internal rotation group. There were three "important" adverse events: hyperaesthesia and moderate hand pain; eighth cervical dermatome paraesthesia; and major movement restriction between 6 and 12 months. It was unclear to what extent these three events could be attributed to the treatment. AUTHORS' CONCLUSIONS: The available evidence from randomised trials is limited to that comparing immobilisation in external versus internal rotation. Overall, the evidence is insufficient to draw firm conclusions about whether immobilisation in external rotation confers any benefit over immobilisation in internal rotation.Considering that there are several unpublished and ongoing trials evaluating immobilisation in external versus internal rotation, the main priority for research on this question consists of the publication of completed trials and the completion and publication of ongoing trials. Meanwhile, evaluation of other interventions, including rehabilitation, is warranted. There is a need for sufficiently large, good-quality, well-reported randomised controlled trials with long-term follow-up. Future research should aim to determine the optimal immobilisation duration, precise indications for immobilisation, optimal rehabilitation interventions, and the acceptability of these different interventions.

Physiotherapists' use of suprascapular nerve blocks: an online survey.

BACKGROUND: There is some evidence to support the use of suprascapular nerve blocks (SSNBs) to manage shoulder pain. Although many patients with shoulder pain are referred to physiotherapy, there are no data describing whether physiotherapists currently use SSNBs for these patients. OBJECTIVE: To explore if physiotherapists who manage musculoskeletal shoulder pain are using SSNBs and identify, of those who responded to an online questionnaire, how commonplace this practice is in the United Kingdom (UK) DESIGN: An online, cross-sectional, questionnaire survey was developed for physiotherapists involved in the management of patients with shoulder pain. METHODS: A snowball sampling method was used to invite physiotherapists to complete the online survey, using email, research advertisements in a professional magazine and via social media. The questionnaire captured respondents' demographic and professional practice characteristics, their knowledge and use of SSNBs and their views and experiences regarding SSNBs as a treatment for shoulder pain. RESULTS: In total, there were 529 responders to the survey. Of these, 492 were eligible and formed the sample for analyses. The majority of responders (290/474; 61%) were from the UK. Of these, the majority (259/282; 92%) were familiar with SSNBs as a method of treatment for shoulder pain, although few (9/149; 6%) reported regularly using SSNBs in their clinical practice. Only 8 of 287 responders from the UK (3%) reported delivering SSNBs to patients. CONCLUSIONS: This survey provides preliminary evidence that the use and delivery of SSNBs by UK physiotherapists is uncommon. Future research is required to investigate the potential value of physiotherapists using this treatment option for their patients with shoulder pain.

A multi-modal recruitment strategy using social media and internet-mediated methods to recruit a multidisciplinary, international sample of clinicians to an online research study.

BACKGROUND: Challenges exist in recruiting an international sample of clinicians and researchers to an online survey. Traditional recruitment methods remain relevant but issues such as narrow geographical reach, high cost and time intensity limit what can be achieved when aiming to recruit an international, multi-disciplinary sample. Internet-mediated and social media approaches to recruitment and engagement offer new, untested ways of capitalizing upon existing professional networks. OBJECTIVE: To develop, use and appraise a multi-modal recruitment strategy for an online, international survey regarding the management of shoulder pain. METHODS: Traditional recruitment methods were combined with internet-mediated recruitment methods to form a multi-modal recruitment strategy. An overview of the development of this three-month recruitment strategy is provided and the value and role of each strand of the recruitment strategy discussed. RESULTS: In response to the multi-modal recruitment strategy, data was received from 565 clinicians and researchers from 31 countries (64% UK). Complete data was received from 387 respondents with no demographic differences between respondents who completed, and those who started but did not complete the survey. Over 30% of responses were received within 1 week, 50% within 4 weeks and 81% within 8 weeks. CONCLUSIONS: This study shows the acceptability and international, multidisciplinary reach of a low cost multi-modal recruitment strategy for an online survey of international clinicians and researchers. Incorporating the use of social media proved to be an effective, time and resource-efficient recruitment strategy for this online survey and appeared to enhance clinician engagement. A multimodal recruitment strategy is worthy of consideration for future online surveys of clinicians and researchers.