Virtual performance measure in osteoarthritis: An innovative transformation of patient care.

Objectives: The purpose of this study was to develop and establish reliability and validity of a virtual performance measure (VPM) score that encompassed 10 videos in patients with osteoarthritis of the knee joint. Patients' experience and satisfaction were documented. Design: Forty videos were chosen for 10 functional tasks, with four videos showing increasing difficulty for each task. Patients were requested to choose the video that best reflected their own situation. Clinical and radiological findings and self-report and performance measures were completed. Results: Data of 100 patients, 70 (70%) females, mean age: 65 â€‹± â€‹9 were examined. The Cronbach's alpha coefficient that examined internal consistency of the VPM score was 0.92. The intraclass correlation value of 0.82 was obtained for test-retest reliability. Factor analysis showed three distinct domains. There was moderate correlations between the VPM score and the self-report and actual performance measures ranging from r â€‹= â€‹0.46 to 0.66. The VPM summated score of 10 activities was able to differentiate between candidates and non-candidates for knee arthroplasty, with the area under the curve value of 0.90 indicating excellent predictive validity. The overall patient experience and satisfaction was positive with 67% of participants feeling that virtual care could have an impact on minimizing physical presence in the clinic or hospital. Conclusions: The VPM is a reliable and valid outcome measure in patients with osteoarthritis of the knee joint. This digital tool has the potential to transform osteoarthritis care by providing a valid remote measurement of real-life functional limitations and reduce the burden of time consuming in-person tests.

Risk Stratification in a Tertiary Care Spine Centre: Comparison Between STarTBack and OSPRO-YF Screening Tools.

Purpose: STarT Back Screening Tool and OSPRO-YF scales have been reported to be accurate tools for estimating risk for the development of persistent pain or prolonged disability in primary care settings. We performed a comparison of construct convergent and known-group validity and ceiling floor effect (CFE) of these tools using a common sample of patients seen at a tertiary care spine centre. Methods: This was a cross-sectional study of patients with and without a work-related back injury. The Hospital Anxiety and Depression Scale (HADS) was used as the reference outcome measure for convergent validity. For known-group validity, we examined the ability of the scales to differentiate between different levels of compensation, presence of non-organic signs, and work status. The CFE values were calculated. Results: Fifty consecutive injured workers were included along with 50 patients without an active compensation claim related to their low back pain. STarTBack and OSPRO-YF had moderate to high associations with the depression component of the HADS (0.69 to 0.77 respectively) with a statistically significant difference in favour of the OSPRO-YF. STarTBack's risk stratification categories were able to differentiate patients with a compensable injury, non-organic signs, and inability to work (p values ranging from 0.002 to < 0.001). The physical activity and work fear-avoidance beliefs constructs of the OSPRO-YF consistently outperformed other yellow flag constructs (p values ranging from 0.008 to < 0.001). The psychological sub-score of STarTBack showed a ceiling effect. There was a floor effect for the negative affect domain of OSPRO-YF. Neither total score had a floor or ceiling effect. Conclusions: STarTBack and OSPRO-YF are short screening tools with acceptable convergent and known-group construct validity and no floor or ceiling effect of their total score. Both tools could assist with the identification, evaluation, and management of psychological distress in patients presenting to tertiary care spine centres.

Objectif : l'outil de dépistage STarT Back et les échelles OSPRO-YF sont considérés comme des mécanismes précis pour estimer le risque d'apparition d'une douleur persistante ou d'une invalidité prolongée en soins primaires. Les chercheurs ont comparé la validité convergente de construit, la validité des groupes connus et l'effet plafond-plancher (EPP) de ces outils auprès d'un échantillon commun de patients suivis dans un centre tertiaire du rachis. Méthodologie : étude transversale de patients atteints ou non d'une blessure dorsale liée au travail. Les chercheurs ont utilisé l'échelle HADS (anxiété et dépression à l'hôpital) comme mesure de référence des résultats pour déterminer la validité convergente. Pour ce qui est de la validité des groupes connus, ils ont examiné la capacité des échelles à distinguer les divers taux d'indemnisation, la présence de signes non organiques et la situation d'emploi et ont calculé les valeurs de l'EPP. Résultats : cinquante (50) travailleurs blessés consécutifs ont participé à l'étude, de même que 50 patients n'ayant pas de réclamation d'indemnisation active liée à leur douleur lombaire. Les outils STarTBack et OSPRO-YF étaient dotés d'associations modérées à élevées avec l'élément « depression ¼ de l'échelle HADS (0,69 à 0,77. respectivement), et la différence en faveur de l'échelle OSPRO-YF était statistiquement significative. Les catégories de stratification du risque de l'outil STarTBack pouvaient distinguer les patients atteints d'une blessure justifiant une indemnisation, les signes non organiques et l'incapacité de travailler (valeurs p de 0,002 à < 0,001). Les construits de l'activité physique et des comportements d'appréhension ou d'évitement de l'échelle OSPRO-YF étaient constamment supérieurs aux autres construits de drapeau jaune (valeurs p de 0,008 à < 0,001). Le sous-score psychologique de l'outil STarTBack avait un effet plafond, tandis que le domaine d'affect négatif de l'échelle OSPRO-YF avait un effet plancher. Aucun des scores totaux n'avait d'effet plancher ou plafond. Conclusions : STarTBack et OSPRO-YF sont de courts outils de dépistage à la validité de construit convergente et de groupes connus et dont le score total n'a ni effet plancher ni effet plafond. Les deux outils pourraient contribuer à déterminer, à évaluer et à prendre en charge la détresse psychologique chez les parents qui consultent dans un centre tertiaire du rachis.

Assessing Appropriateness for Shoulder Arthroplasty Using a Shared Decision-Making Process.

Purpose: The primary purpose of this study was to validate an appropriateness decision-aid tool as a part of engaging patients with glenohumeral arthritis in their surgical management. The associations between the final decision to have surgery and patient characteristics were examined. Materials and Methods: This was an observational study. The demographics, overall health, patient-specific risk profile, expectations, and health-related quality of life were documented. Visual analog scale and the American Shoulder & Elbow Surgeon (ASES) measured pain and functional disability, respectively. Clinical and imaging examination documented clinical findings and extent of degenerative arthritis and cuff tear arthropathy. Appropriateness for arthroplasty surgery was documented by a 5-item Likert response survey and the final decision was documented as ready, not-ready, and would like to further discuss. Results: Eighty patients, 38 women (47.5%), mean age: 72(8) participated in the study. The appropriateness decision aid showed excellent discriminate validity (area under the receiver operating characteristic curve value of 0.93) in differentiating between patients who were "ready" and those who were "not-ready" to have surgery. Gender (P = 0.037), overall health (P = .024), strength in external rotation (P = .002), pain severity (P = .001), ASES score (P < .0001), and expectations (P = .024) were contributing factors to the decision to have surgery. Imaging findings did not play a significant role in the final decision to have surgery. Conclusions: A 5-item tool showed excellent validity in differentiating patients who were ready to have surgery versus those who were not. Patient's gender, expectations, strength, and self-reported outcomes were important factors in reaching the final decision.

Detection of Low Back Physiotherapy Exercises With Inertial Sensors and Machine Learning: Algorithm Development and Validation.

BACKGROUND: Physiotherapy is a critical element in the successful conservative management of low back pain (LBP). A gold standard for quantitatively measuring physiotherapy participation is crucial to understanding physiotherapy adherence in managing recovery from LBP. OBJECTIVE: This study aimed to develop and evaluate a system with wearable inertial sensors to objectively detect the performance of unsupervised exercises for LBP comprising movement in multiple planes and sitting postures. METHODS: A quantitative classification design was used within a machine learning framework to detect exercise performance and posture in a cohort of healthy participants. A set of 8 inertial sensors were placed on the participants, and data were acquired as they performed 7 McKenzie low back exercises and 3 sitting posture positions. Engineered time series features were extracted from the data and used to train 9 models by using a 6-fold cross-validation approach, from which the best 2 models were selected for further study. In addition, a convolutional neural network was trained directly on the time series data. A feature importance analysis was performed to identify sensor locations and channels that contributed the most to the models. Finally, a subset of sensor locations and channels was included in a hyperparameter grid search to identify the optimal sensor configuration and best performing algorithms for exercise and posture classification. The final models were evaluated using the F1 score in a 10-fold cross-validation approach. RESULTS: In total, 19 healthy adults with no history of LBP each completed at least one full session of exercises and postures. Random forest and XGBoost (extreme gradient boosting) models performed the best out of the initial set of 9 engineered feature models. The optimal hardware configuration was identified as a 3-sensor setup-lower back, left thigh, and right ankle sensors with acceleration, gyroscope, and magnetometer channels. The XGBoost model achieved the highest exercise (F1 score: mean 0.94, SD 0.03) and posture (F1 score: mean 0.90, SD 0.11) classification scores. The convolutional neural network achieved similar results with the same sensor locations, using only the accelerometer and gyroscope channels for exercise classification (F1 score: mean 0.94, SD 0.02) and the accelerometer channel alone for posture classification (F1 score: mean 0.88, SD 0.07). CONCLUSIONS: This study demonstrates the potential of a 3-sensor lower body wearable solution (eg, smart pants) that can identify exercises in multiple planes and proper sitting postures, which is suitable for the treatment of LBP. This technology has the potential to improve the effectiveness of LBP rehabilitation by facilitating quantitative feedback, early problem diagnosis, and possible remote monitoring.

Validation of the Subgroups for Targeted Treatment for Back (STarT Back) screening tool at a tertiary care centre.

BACKGROUND: The Subgroups for Targeted Treatment for Back (STarT Back) tool is a screening questionnaire developed to identify modifiable risk factors for back pain disability in primary care. Given the ability of this tool to assist with early identification of patients at high risk, we examined its concurrent convergent and known-group construct validity in tertiary care. METHODS: This was a case-control study of adult (age > 18 yr) patients with and without an active work-related compensation claim recruited from an academic health centre between August 2017 and May 2019. Patients in the study group were assessed by a physiotherapist and an orthopedic surgeon in a spine specialty program designed to assess and treat workplace injuries. The control group included patients referred to an orthopedic spine surgeon in a publicly funded specialty clinic where an advanced practice physiotherapist determined the need for surgical consultation. We used the Roland-Morris Disability Questionnaire (RMDQ) and the Hospital Anxiety and Depression Scale (HADS) to determine the convergent and known-group construct validity of the STarT Back tool. RESULTS: Fifty case and 50 control participants were included. We observed moderate to high association between the STarT Back total score, psychosocial subscore and risk categories and the RMDQ and HADS scores in the expected direction (p < 0.001). A significant association was observed between risk group allocation and depression (area under the curve values > 80), having a compensable injury and work status (p = 0.002-0.001). CONCLUSION: The STarT Back tool was able to differentiate between patients with and without a compensable injury and patients with different levels of work status. The tool has acceptable convergent and known-group construct validity and can assist in clinical decision-making in a tertiary care setting where adjunct psychologic management may be indicated.

Arthroscopic Versus Mini-open Rotator Cuff Repair: A Randomized Trial and Meta-analysis.

BACKGROUND: Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair. PURPOSE: This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials. RESULTS: From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, -0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, -0.06 [95% CI, -0.34 to 0.22]). CONCLUSION: Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements. TRIAL REGISTRATION: NCT00128076.

Adherence Patterns and Dose Response of Physiotherapy for Rotator Cuff Pathology: Longitudinal Cohort Study.

BACKGROUND: Physiotherapy is considered to be essential for the successful operative and nonoperative management of rotator cuff pathology; however, the extent to which patients adhere to assigned physiotherapy activities and how this impacts recovery is unknown. OBJECTIVE: The purpose of this study was to measure the rate and patterns of participation in physiotherapy for rotator cuff disorders, assess the dose response between physiotherapy activity and recovery, and explore patient factors predictive of physiotherapy participation. METHODS: We report a prospective longitudinal study of 42 patients undergoing physiotherapy for symptomatic rotator cuff pathology. The patients were issued a smartwatch that recorded inertial sensor data while they performed physiotherapy exercises both in the clinic and in the home setting. A machine learning approach was used to assess total physiotherapy participation from smartwatch inertial data. Primary outcomes were the Disabilities of the Arm Shoulder and Hand and numeric pain rating scale assessed every 4 weeks until 12 weeks follow-up. The relationships between participation, outcomes, and clinical patient variables were assessed in univariable analyses. RESULTS: Mean physiotherapy exercise participation in clinic and at home were 11 minutes per week and 33 minutes per week, respectively, with patients participating in physiotherapy on 41% of days assigned to treatment. Home physiotherapy participation decreased significantly over time (P=.03). There was a statistically significant and clinically meaningful relationship between cumulative physiotherapy participation and recovery demonstrated by pain scores at 8 weeks (P=.02) and 12 weeks (P=.05) and disability scores at 8 weeks (P=.04) and 12 weeks (P=.04). Low patient expectations and self-efficacy were associated with low rates of physiotherapy participation. CONCLUSIONS: There was a low rate of participation in home shoulder physiotherapy exercise, and a statistically and clinically significant dose response of physiotherapy on treatment outcome in patients with rotator cuff pathology. The findings highlight the opportunity to develop novel methods and strategies to improve the participation in and efficacy of physiotherapy exercises for rotator cuff disorders. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/17841.

Psychometric Properties of the OSPRO-YF Screening Tool in Patients with Shoulder Pathology.

Purpose: The Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) is a screening tool that incorporates many important psychosocial domains into one questionnaire to reduce the burden of completing multiple questionnaires. The objectives of this study were to examine the reliability and validity of the 10-item version of the OSPRO-YF with patients with shoulder conditions. Method: The study group consisted of injured workers with an active compensation claim for a shoulder injury. The control group consisted of patients with a complaint of shoulder pain but without a work-related shoulder injury. We examined reliability (internal consistency, test-retest) and validity (factorial, convergent, known groups). The Hospital Anxiety and Depression Scale; the Quick Disabilities of Arm, Shoulder and Hand; and the short Örebro Musculoskeletal Pain Screening Questionnaire were used for comparison. Results: Eighty patients had an active compensation claim, and 160 were in the control group. The intra-class correlation coefficient values for two observations of the domain scores varied from 0.91 to 0.94. The test-retest reliability of the dichotomous constructs was moderate to perfect for 8 of 11 constructs. The 10-item OSPRO-YF questionnaire had three distinct domains, as conceptualized by the developers: mood, fear avoidance, and positive affect-coping. The Cronbach's a coefficients for these domains were 0.88, 0.94, and 0.94, respectively. The associations between the psychological constructs and domains and the similar theoretically derived scales were moderate to high and in the expected direction. Of the 11 constructs of the OSPRO-YF, 10 differentiated between patients with and without a work-related injury (p-values ranging from 0.028 to < 0.001). Conclusions: The 10-item OSPRO-YF reduces the burden of using multiple questionnaires and has acceptable test-retest and internal consistency reliability and factorial, convergent, and known-groups validity.

Objectif : l'Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO­YF) est un outil de dépistage qui regroupe plusieurs volets psychosociaux importants dans un seul questionnaire pour réduire le désagrément de remplir de multiples questionnaires. La présente étude visait à examiner la fiabilité et la validité de la version en dix questions de l'OSPRO­YF chez les patients ayant des problèmes d'épaule. Méthodologie : le groupe d'étude se composait de travailleurs ayant une réclamation d'indemnisation active à cause d'une blessure à l'épaule. Le groupe témoin incluait des patients qui se plaignaient de douleur à l'épaule, mais d'origine non professionnelle. Les chercheurs ont examiné la fiabilité (cohérence interne, test­retest) et la validité (factorielle, convergente et groupes connus) de l'outil. L'échelle d'anxiété et de dépression à l'hôpital, le questionnaire rapide des incapacités du bras, de l'épaule et de la main et le questionnaire court de dépistage de la douleur musculosquelettique Örebro ont été utilisés à des fins comparatives. Résultats : au total, 80 patients avaient une réclamation d'indemnisation active et 160 faisaient partie du groupe témoin. Les valeurs du coefficient de corrélation intraclasse de deux observations se situaient entre 0,91 et 0,94. La fiabilité test­retest des construits dichotomiques était de modérée à parfaite pour huit des 11 construits. Le questionnaire OSPRO­YF en dix questions se divisait en trois volets distincts conceptualisés par les développeurs : humeur, évitement de la peur et affect positif ou adaptation. Les coefficients alpha de Cronbach de ces volets s'établissaient à 0,88, 0,94 et 0,94, respectivement. Les associations entre les construits psychologiques, les volets et les échelles semblables dérivées théoriquement étaient modérées à élevées et se situaient dans l'orientation prévue. Dix des 11 construits du questionnaire OSPRO­YF pouvaient distinguer les patients ayant ou non une blessure professionnelle (valeurs p entre 0,028 et < 0,001). Conclusions : l'OSPRO­YF en dix questions réduit le désagrément lié à l'utilisation de multiples questionnaires et présente une fiabilité test­retest et une cohérence interne acceptables, de même qu'une fiabilité factorielle, convergente et de groupe connu.

Maximizing Muscle Function in Cuff-Deficient Shoulders: A Rehabilitation Proposal for Reverse Arthroplasty.

PURPOSE: The purpose of this review is to describe the role of altered joint biomechanics in reverse shoulder arthroplasty and to propose a rehabilitation protocol for a cuff-deficient glenohumeral joint based on the current evidence.Methods and Materials: The proposed rehabilitation incorporates the principles of pertinent muscle loading while considering risk factors and surgical complications. RESULTS: In light of altered function of shoulder muscles in reverse arthroplasty, scapular plane abduction should be more often utilized as it better activates deltoid, teres minor, upper trapezius, and serratus anterior. Given the absence of supraspinatus and infraspinatus and reduction of external rotation moment arm of the deltoid in reverse arthroplasty, significant recovery of external rotation may not occur, although an intact teres minor may assist external rotation in the elevated position. CONCLUSION: Improving the efficiency of deltoid function before and after reverse shoulder arthroplasty is a key factor in the rehabilitation of the cuff deficient shoulders. Performing exercises in scapular plane and higher abduction angles activates deltoid and other important muscles more efficiently and optimizes surgical outcomes.

Substantial clinical benefit, responsiveness, and sensitivity to change of three common outcome measures following shoulder arthroplasty.

OBJECTIVES: It is important for clinicians involved in the care of patients with advanced glenohumeral osteoarthritis to determine clinically significant change when using outcome measures. There is little information on the amount of substantial clinical benefit in shoulder outcomes after shoulder arthroplasty. The purpose of this study was twofold: (1) to quantify substantial clinical benefit for the American Shoulder and Elbow Surgery score, the Constant Murley Score, and the Western Ontario Osteoarthritis of the Shoulder index and (2) to provide estimates of responsiveness and sensitivity to change for these measures following shoulder arthroplasty. METHODS: The study involved a secondary analysis of previously collected data. The substantial clinical benefit and responsiveness of the measures were calculated based on external anchors related to change in pain, range of motion, and ability to carry out activities of daily living. The areas under curve and standardized response mean represented responsiveness and sensitivity to change. RESULTS: The data of 159 and 131 patients with complete follow-up at 6 months and 2 years were reviewed. The amount of substantial clinical benefit was dependent on the outcome measure and the external anchor and increased for all measures from 6 months to 2 years. Responsiveness was high (areas under curve > 0.80) at 6 months and further improved at 2 years (areas under curve > 0.88). The standardized response mean values of both time points were over 2.00, indicating high effect sizes. The standardized response means of the Constant Murley Score were statistically significantly higher than the standardized response means of the American Shoulder and Elbow Surgery and Western Ontario Osteoarthritis of the Shoulder. CONCLUSION: Amount of substantial clinical improvement in pain, range of motion, and activities of daily living following shoulder arthroplasty depends on the type of outcome measure used. All three measures, the American Shoulder and Elbow Surgery, absolute and relative Constant Murley Score, and Western Ontario Osteoarthritis of the Shoulder, demonstrated good to excellent accuracy and optimal standardized response means. LEVEL OF EVIDENCE: Level III, Retrospective Cohort study.

Adherence Tracking With Smart Watches for Shoulder Physiotherapy in Rotator Cuff Pathology: Protocol for a Longitudinal Cohort Study.

BACKGROUND: Physiotherapy is essential for the successful rehabilitation of common shoulder injuries and following shoulder surgery. Patients may receive some training and supervision for shoulder physiotherapy through private pay or private insurance, but they are typically responsible for performing most of their physiotherapy independently at home. It is unknown how often patients perform their home exercises and if these exercises are performed correctly without supervision. There are no established tools for measuring this. It is, therefore, unclear if the full benefit of shoulder physiotherapy treatments is being realized. OBJECTIVE: The proposed research will (1) validate a smartwatch and machine learning (ML) approach for evaluating adherence to shoulder exercise participation and technique in a clinical patient population with rotator cuff pathology; (2) quantify the rate of home physiotherapy adherence, determine the effects of adherence on recovery, and identify barriers to successful adherence; and (3) develop and pilot test an ethically conscious adherence-driven rehabilitation program that individualizes patient care based on their capacity to effectively participate in their home physiotherapy. METHODS: This research will be conducted in 2 phases. The first phase is a prospective longitudinal cohort study, involving 120 patients undergoing physiotherapy for rotator cuff pathology. Patients will be issued a smartwatch that will record 9-axis inertial sensor data while they perform physiotherapy exercises both in the clinic and in the home setting. The data collected in the clinic under supervision will be used to train and validate our ML algorithms that classify shoulder physiotherapy exercise. The validated algorithms will then be used to assess home physiotherapy adherence from the inertial data collected at home. Validated outcome measures, including the Disabilities of the Arm, Shoulder, and Hand questionnaire; Numeric Pain Rating Scale; range of motion; shoulder strength; and work status, will be collected pretreatment, monthly through treatment, and at a final follow-up of 12 months. We will then relate improvement in patient outcomes to measured physiotherapy adherence and patient baseline variables in univariate and multivariate analyses. The second phase of this research will involve the evaluation of a novel rehabilitation program in a cohort of 20 patients. The program will promote patient physiotherapy engagement via the developed technology and support adherence-driven care decisions. RESULTS: As of December 2019, 71 patients were screened for enrollment in the noninterventional validation phase of this study; 65 patients met the inclusion and exclusion criteria. Of these, 46 patients consented and 19 declined to participate in the study. Only 2 patients de-enrolled from the study and data collection is ongoing for the remaining 44. CONCLUSIONS: This study will provide new and important insights into shoulder physiotherapy adherence, the relationship between adherence and recovery, barriers to better adherence, and methods for addressing them. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17841.

Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists.

Purpose: The primary purpose of this study was to examine the inter-tester reliability and criterion validity of reduced acromiohumeral distance (AHD; <6 mm) visualized on plain radiographs in detecting rotator cuff (RC) pathology. The secondary objective was to examine the relationship between this radiographic feature and patient demographics and clinical examination. Method: This was a diagnostic study of patients seen in a tertiary care centre. Two advanced-practice physiotherapists measured AHD in two radiographic views. MRI was used as the gold standard. Results: A total of 150 consecutive patients (mean age 59 [SD 11] y, 57 women, 93 men) were included. AHD less than 6 millimetres was highly specific in both views for the presence of tear (99%), tear size (96%-98%), and fatty infiltration in the supraspinatus and infraspinatus muscles (93%-96%). The absence of AHD less than 6 millimetres was associated with a lack of advanced fatty infiltration in the supraspinatus and infraspinatus muscles (92%-100%). Sensitivity values were low for the presence and size of RC tear (21%-55%). We found a statistically significant positive association between the AHD categories and clinically observed muscle wasting and weakness of the RC muscles (p < 0.05). Conclusions: AHD less than 6 millimetres was reliably measured in plain radiographs and was strongly associated with important clinical and imaging features of advanced RC pathology; this may assist with clinical decision making by allowing judicious use of more costly investigations and referral for surgery.

Objectif : la présente étude avait comme objectif primaire d'examiner la fiabilité interévaluateur et la validité critérielle d'un intervalle acromio-huméral réduit (IAH < 6 mm) observé à la radiographie simple pour déceler une pathologie de la coiffe des rotateurs (CR). Son objectif secondaire consistait à examiner la relation entre cette caractéristique radiographique, la démographie des patients et l'examen clinique. Méthodologie : étude diagnostique de patients vus dans un centre de soins tertiaires. Deux physiothérapeutes en pratique avancée ont mesuré l'IAH sur deux vues radiographiques. L'imagerie par résonance magnétique servait de norme de référence. Résultats : au total, 150 patients consécutifs (âge moyen de 59 ans [ÉT 11], 57 femmes, 93 hommes) ont été inclus dans l'étude. Dans les deux vues radiographiques, l'IAH inférieur à 6 mm était hautement spécifique de la présence d'une déchirure (99 %), de la dimension de la déchirure (96 % à 98 %) et d'une infiltration graisseuse dans les muscles supra-épineux et infra-épineux (93 % à 96 %). L'absence d'IAH inférieur à 6 mm s'associait à l'absence d'infiltration graisseuse avancée dans les muscles supra-épineux et infra-épineux (92 % à 100 %). Les valeurs de sensibilité étaient faibles pour ce qui est de la présence et de la dimension d'une déchirure de la CR (21 % à 55 %). On constatait une association statistiquement significative entre les catégories d'IAH et une observation clinique d'amyotrophie et de faiblesse musculaire de la CR (p < 0,05). Conclusion : l'IAH inférieur à 6 mm était mesuré en toute fiabilité sur des radiographies simples et s'associait fortement à des caractéristiques de pathologie avancée de la CR, tant sur le plan de la clinique que de l'imagerie. Ces constatations pourraient contribuer aux prises de décision en favorisant l'utilisation judicieuse d'explorations plus coûteuses et de l'orientation en chirurgie.

Reduced acromiohumeral distance and increased critical shoulder angle: implications for primary care clinicians.

Objectives: The literature indicates that reduced acromiohumeral distance (AHD) and increased critical shoulder angle (CSA) are associated with large and massive rotator cuff (RC) tears which may not be amenable to a successful repair. The purpose of this study was to examine the overall accuracy of these two radiographic features in diagnosing significant RC pathology. Methods: This was a diagnostic study of patients with shoulder pain. To examine the overall accuracy of the measurements, the area under the Receiver Operating Characteristic curves (AUC) were calculated. The validity indices (sensitivity, specificity and likelihood ratios) examined the predictive value of specific cutoff categories of AHD<6 mm and the CSA >35°. Results: Data of 200 consecutive patients; mean age: 59(11), 117 males were used for analysis. There was a weak inverse correlation (r = 0.46) between the AHD and CSA. The AUCs for presence and size of RC tear and different stages of fatty infiltration of supraspinatus and infraspinatus muscles varied from fair to excellent for AHD and poor to good for CSA. Specificity was high for the cutoff categories of both AHD and CSA (>90%). The positive LRs were large for AHD and small to moderate for CSA. Conclusion: The AHD and CSA were reliably measured in the true AP radiographic view. Both radiographic features (AHD<6mm and CSA>35°) were able to confirm the presence of a major RC pathology. However, the AHD<6 mm, an acquired radiologic abnormality secondary to failure of the RC muscles/tendons had better measurement properties. This information is of value to primary care physicians, sports medicine specialists and advanced practice physiotherapists in their clinical decision making.

Measurement Properties of the Return-to-Work Self-Efficacy Scale in Workers with Shoulder Injuries.

Purpose: The objective of this study was to investigate the measurement properties of the Return-To-Work Self-Efficacy (RTWSE) scale in injured Canadian workers. Method: We assessed internal consistency, construct-convergent, and known-groups validity of the RTWSE scale's total score and the pain management and re-injury self-efficacy (PRSE), supervisor support self-efficacy (SSE), and coworkers support self-efficacy (CWSE) domains in workers who had participated in a multidisciplinary rehabilitation program. Disability was measured by using the Disabilities of the Arm, Shoulder and Hand (DASH) scale. Spearman's ρ, odds ratios, and the area under the receiver operating characteristic curve (AUC) were used to examine the strength of the associations. Results: The data of 57 injured workers (43 men [75%], mean age 52 [11] y) were used for analysis. Internal consistency of the domains was satisfactory, with Cronbach's αs of 0.81, 0.87, and 0.92 for the CWSE, PRSE, and SSE, respectively. The PRSE domain correlated with the DASH (r = 0.39) and relevant domains of the RTWSE scale (rs = 0.47-0.78). The PRSE was able to differentiate between working and non-working people (AUC = 0.72). Satisfaction with the actual support received at work and overall job satisfaction correlated significantly with the total score and CWSE and SSE domains (AUCs ≥ 0.70). Conclusions: The RTWSE showed satisfactory internal consistency and construct convergent and known-groups validity in workers with shoulder injuries.

Objectif : explorer les propriétés de mesure de l'échelle d'efficacité personnelle liée au retour au travail (EPRT) chez des travailleurs canadiens blessés. Méthodologie : les chercheurs ont évalué la cohérence interne, la validité du construit convergent et la validité du groupe connu du score total de l'EPRT, ainsi que les domaines de l'efficacité personnelle de la gestion de la douleur et des nouvelles blessures (EPGDNB), de l'efficacité personnelle du soutien du superviseur (EPSS) et de l'efficacité personnelle du soutien des collègues de travail (EPSC) chez les travailleurs qui avaient participé à un programme de réadaptation multidisciplinaire. Les chercheurs ont mesuré l'incapacité à l'aide de l'échelle des incapacités du bras, de l'épaule et de la main (DASH, d'après l'acronyme anglais). Ils ont examiné la force des associations au moyen de la corrélation de Spearman, des rapports de cotes et de l'aire sous la courbe (ASC) de la fonction d'efficacité du récepteur. Résultats : les chercheurs ont analysé les données relatives à 57 travailleurs blessés 43 hommes [75 %], âge moyen de 52 ans [11]). La cohérence interne des domaines était satisfaisante : le coefficient alpha de Cronbach était de 0,81 pour l'EPSC, de 0,87 pour l'EPGDNB et de 0,92 pour l'EPSS. Le domaine de l'EPGDNB était corrélé avec l'échelle DASH (r = 0,39) et les domaines pertinents de l'EPRT (r s = 0,47 à 0,78). L'EPGDNB a pu distinguer les personnes qui travaillent de celles qui ne travaillent pas (ASC = 0,72). La satisfaction à l'égard du soutien réel reçu au travail et à l'égard du travail global avait une corrélation significative avec le score total et avec les domaines d'EPSC et d'EPSS (ASC ≥ 0,70). Conclusion : L'EPRT démontrait une cohérence interne, une validité du construit convergent et une validité des groupes connus satisfaisantes chez les travailleurs victimes d'une blessure à l'épaule.

Outcomes of expedited rotator cuff surgery in injured workers: Impact of pathology on readiness for return to work.

OBJECTIVES: The objectives of this study were to (1) examine the overall recovery and satisfaction following an expedited rotator cuff (RC) decompression or repair at 3-6 months and (2) explore group differences (repair vs. decompression) in demographics, clinical, disability, and psychosocial factors. METHODS: This was a prospective longitudinal study of injured workers whose surgery was expedited. The outcome measures were Quick disabilities of the arm, shoulder, and hand ( QuickDASH), the Hospital Anxiety and Depression Scale (HADS), the readiness for return to work (RRTW) scale, and satisfaction with surgery and overall recovery. RESULTS: Of 118 patients participated in the study, 106 patients, age: 51 (9), 71 males (67%) completed the study. Sixty-four (60%) patients underwent a RC repair and 42 (40%) had RC decompression. Patients improved on average in QuickDASH ( p = 0.004), anxiety ( p = 0.003), and depression scores ( p = 0.004). The majority of patients (75%) were satisfied with surgery. In the decompression group, the pre-contemplation (PC) stage of the RRTW which documents the absence of desire or planning for return to work in the non-working sample ( r = 0.81, p = 0.008) and the uncertain maintenance (UM) stage of the RRTW which explores the worker's struggle to stay at work in the working sample correlated with physical disability as measured by the QuickDASH scores ( r = 0.62, p = 0.0001). In the repair group, the above domains correlated with the depression HADS scores (PC: r = 0.64, p = 0.001 and UM: r = 0.57, p < 0.0001). CONCLUSION: Expedited RC surgery improved physical disability and mental well-being and was associated with a relatively high satisfaction at a maximum of 6 months. The poorer report of readiness for return to work was associated with higher physical disability in the decompression group and higher report of depression in the repair group. These differential associations may emphasize the importance of physical versus psychological management in patients with different levels of pathology.

Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants.

Purpose: The objectives of this survey study were to provide an estimate of the prevalence of neuropathic pain (NP) and to explore the cross-sectional and longitudinal group differences postoperatively. Method: A cohort of consecutive patients who had undergone total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or humeral head replacement (HHR) were surveyed within an average of 3.8 years after surgery. Questionnaires completed at the time of the survey were the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale, the visual analogue scale (VAS) for pain, the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, the Patient Health Questionnaire-9 (PHQ-9), and a satisfaction questionnaire. Results: Of the 141 candidates who were invited to participate in the study, 115 patients participated (85 TSA, 21 HHR, and 9 RSA), for an 82% response rate. Five patients (4%) met the criteria for NP, of whom one had a loosening of the prosthesis and required further surgery. Having NP was associated with greater pain (VAS; p=0.001), greater depression (PHQ-9; p=0.001), more disability (WOOS; p=0.030), and less satisfaction with the surgery (p=0.014). There was no relationship between the presence of NP and patients' age, sex, preoperative pain, range of motion results, or WOOS scores (p>0.05). Conclusions: Persistent pain of neuropathic origin is not common after shoulder arthroplasty, but it is a significant contributor to poor mental and physical well-being and thus warrants further research.

Objectif : la présente étude par sondage visait à évaluer la prévalence de la douleur neuropathique (DN) et à explorer les différences transversales et longitudinales des groupes après l'opération. Méthodologie : la présente étude visait à sonder une cohorte de patients consécutifs qui avaient subi une arthroplastie totale de l'épaule (ATÉ), une arthroplastie inversée de l'épaule (AIÉ) ou un remplacement de la tête de l'humérus (RTH), en moyenne 3,8 ans après l'intervention. Au moment du sondage, les patients ont rempli les questionnaires sur l'échelle autoadministrée de la Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS; évaluation des signes et symptômes de la douleur neuropathique de Leeds), l'échelle visuelle analogique (ÉVA) de la douleur, le score du Western Ontario Osteoarthritis of the Shoulder (arthrose de l'épaule de Western Ontario, ou WOOS), le questionnaire sur la santé du patient-9 (PHQ-9) et un questionnaire sur la satisfaction. Résultats : des 141 candidats qui ont été invités à participer à l'étude, 115 ont obtempéré (85 ATÉ, 21 RTH et 9 AIÉ), ce qui représente un taux de réponse de 82 %. Cinq patients (4 %) respectaient les critères de DN, dont un présentait un descellement de la prothèse qui nécessitait une nouvelle opération. La DN s'associait à plus de douleur (ÉVA, p=0,001), plus de dépression (PHQ-9, p=0,001), plus d'incapacité (WOOS, p = 0,030) et moins de satisfaction envers l'opération (p=0,014). Il n'y avait pas de relation entre la DN du patient et son âge, son sexe, sa douleur préopératoire, son amplitude de mouvements après l'opération ou les scores WOOS (p>0,05). Conclusions : la douleur persistante d'origine neuropathique n'est pas courante après une arthroplastie de l'épaule, mais elle nuit de manière significative au bien-être mental et physique, ce qui justifie la poursuite des recherches sur le sujet.

Impact of symptom bilaterality and hand dominance on patient-reported disability outcomes.

OBJECTIVES: It is not clear if using patients with bilateral symptoms would impact the level of disability reported in orthopaedic research. The purposes of this study were to (1) examine the prevalence of bilateral shoulder symptoms (significant pain, stiffness or weakness affecting function) in patients with rotator cuff impingement syndrome, rotator cuff tear and osteoarthritis of the glenohumeral joint, (2) explore risk factors associated with bilateral shoulder symptoms, and (3) examine the impact of symptom bilaterality and hand dominance on pre- and post-operative patient-oriented disability outcomes. METHODS: This study involved secondary analysis of prospectively collected data of patients who had undergone shoulder surgery and had returned for their 1-year follow-up. Two outcome measures were collected prior to surgery and at 1-year following surgery: the American Shoulder and Elbow Surgeons and the Constant-Murley Score. RESULTS: Data of 772 patients, 376 (49%) females, 396 males (51%); 288 (impingement syndrome), 332 (rotator cuff tear), and 152 (osteoarthritis) were included in the analysis. There was a statistically significant difference in the prevalence of bilateral symptoms being 44%, 28%, and 22% in the osteoarthritis, impingement syndrome, and rotator cuff tear groups, respectively (p < 0.0001). The prevalence of dominant side involvement was 71%, 67%, and 53% in the rotator cuff tear, impingement syndrome, and osteoarthritis groups (p < 0.0001). Older age and female sex were risk factors for development of bilateral symptoms only in patients with rotator cuff tear. Neither symptom bilaterality nor dominant arm involvement had a negative impact on patient-oriented disability outcome measures prior to or after surgery (p > 0.05). CONCLUSION: This study shows that patients with osteoarthritis of the glenohumeral joint have the highest prevalence of bilateral shoulder complaints. The older age and the female sex increased the risk of having bilateral symptoms in patients with rotator cuff tear. Having bilateral shoulder symptoms or dominant side involvement was not associated with higher level of disability prior or after surgery.

Short-term Outcomes of Arthroscopic Debridement and Selected Acromioplasty of Bursal- vs Articular-Sided Partial-Thickness Rotator Cuff Tears of Less Than 50.

BACKGROUND: While it is believed that good results can be achieved by arthroscopic debridement of partial-thickness tears (PTTs) of <50% tendon thickness, few studies have directly compared the treatment of articular- versus bursal-sided PTTs of <50%. PURPOSE: To compare the postoperative outcomes of patients with articular- versus bursal-sided PTTs of <50% tendon thickness that were treated with arthroscopic debridement and selective acromioplasty (for type II or III acromions). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: An analysis was performed with data from 76 consecutive patients diagnosed with a PTT <50% tendon width (Ellman grade II) who had undergone arthroscopic debridement and selective acromioplasty (for type II or III acromions). Outcome measures included the short version of the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons score, and the relative Constant-Murley score, as well as strength of the affected shoulder. A statistical paired t test (preoperative vs 2 years postoperative) and an independent t test were utilized to compare outcomes between patients with bursal- and articular-sided tears. RESULTS: Between 2001 and 2010, there were 40 (53%) articular- and 36 (47%) bursal-sided tears treated with debridement and selective acromioplasty. The mean patient age was 55 years (range, 36-77 years) for the bursal group and 56 years (range, 33-81 years) for the articular group. The mean follow-up was 24 months (range, 22-26 months). Both groups showed significant improvement in the short version of the Western Ontario Rotator Cuff index, American Shoulder and Elbow Surgeons score, and relative Constant-Murley score 2 years after surgery (P < .0001) as well as in strength (P < .0001 for bursal tears, P = .006 for articular tears). There was no statistically significant difference between groups in any of the postoperative outcome measures at 2 years. CONCLUSION: The results of this study demonstrate that good outcomes can be achieved with arthroscopic debridement and selective acromioplasty among patients with articular- or bursal-sided PTT of <50% tendon thickness. No difference was observed between groups at 2-year follow-up.

Abnormal Pain Response After a Compensable Shoulder Injury.

BACKGROUND: The role of psychosocial factors has been established in patients with shoulder abnormalities. However, the prevalence of exaggerated pain behaviors and their association with the characteristics of injured workers have not been well studied. PURPOSE: To examine the prevalence of abnormal pain responses (APRs) in workers with active workers' compensation claims for a shoulder injury and to examine the differences between workers with APRs versus workers without APRs. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An analysis of electronic data files of injured workers was completed. An APR was defined as an exaggerated pain response during a clinical examination, including facial grimacing, shaking, withdrawal, nonanatomic dermatome or myotome disturbances, increased tenderness, regional symptoms, and verbal utterances such as groaning, moaning, or gasping. To control for potential confounders, patients with positive APRs (APR group) were matched with injured workers without APRs (control group) seen in the same clinic and matched for sex, age, and surgical candidacy. RESULTS: Data from 1000 workers who had sustained a shoulder injury at work and who were referred for an early assessment by an orthopaedic surgeon and a physical therapist were reviewed. A total of 86 (9%) injured workers (mean age, 47 ± 11 years; 55 [64%] female) demonstrated APRs and were matched with 86 injured workers without APRs. There were no statistically significant between-group differences in the wait time, mechanism of injury, coexisting comorbidity, type of abnormality, or medication consumption. The APR group reported higher levels of disability (P < .0001) and psychological problems (P < .0001), presented with more inconsistency in range of motion (P = .04), and had more limitations at work (P = .02). CONCLUSION: The presence of an APR after a compensable shoulder injury was associated with higher reports of disability and psychological problems. Patients with positive APRs were more likely to be off work and less likely to perform full duties.

Accuracy of infraspinatus isometric testing in predicting tear size and tendon reparability: comparison with imaging and arthroscopy.

BACKGROUND: The purpose of this study was to examine the accuracy of external rotation in neutral (0° external position) and in shortened position (45° external position) in relation to rotator cuff tear size, tendon reparability, and other clinical, surgical, and imaging findings. METHODS: This was a prospective blinded diagnostic study of consecutive surgical candidates for rotator cuff repair using magnetic resonance imaging and arthroscopic surgery as the "gold standards." The area under a receiver operating characteristic (AUROC) curve was calculated for each position. RESULTS: Eighty-five patients (35 female [41%] and 50 male [59%]; age, 65 years [standard deviation = 10]) were included. Sixty patients (71%) had a minor tear (4 small, 56 moderate), and 25 patients (29%) had a major tear (17 large and 8 massive). Seventy patients (82%) had a full repair, and 15 (18%) patients underwent a partial repair. There were 26 (31%) associated full-thickness tears of the infraspinatus. The isometric strength testing in both positions had good to excellent accuracy (range, 0.80-0.90) for detecting reparability, tear retraction, infraspinatus atrophic changes observed by the clinician, and infraspinatus fatty infiltration on magnetic resonance images. The shortened position had an overall higher accuracy than the neutral position and was more clinically useful for detecting an infraspinatus full-thickness tear (AUROC = 0.84 vs 0.78) and rotator cuff tear size (AUROC = 0.80 vs. 0.75). CONCLUSIONS: The isometric external rotation is an accurate test in diagnosing different aspects of rotator cuff disease and specifically of the infraspinatus muscle. The isometric strength at the shortened position was a better predictor of clinical, surgical, and imaging findings.