Fear of movement and emotional distress as prognostic factors for disability in patients with shoulder pain: a prospective cohort study.

BACKGROUND: Shoulder pain is a prevalent and often long-lasting musculoskeletal disorder. The overall prognosis of shoulder pain is highly variable with 40-50% of patients reporting persistent pain 6-12 months after consulting a clinician. The evidence for psychological prognostic factors for patients with shoulder pain is inconsistent. Therefore, the objective of this study was to investigate the association between fear of movement and emotional distress at presentation and self-reported disability over one year of follow-up. METHODS: This is a prospective cohort study of consecutive patients referred to secondary outpatient care due to shoulder pain. Consenting patients underwent a physical examination and completed a comprehensive questionnaire at baseline, three months-, and one-year follow-up. Associations between baseline fear of movement (0-10) or emotional distress (1-4), respectively, and patient reported disability measured using Quick Disability of the Arm and Shoulder (QuickDASH, 0-100) over one year were analyzed with linear mixed-effects models (LMM) for repeated measures (baseline, 3 months and 1 year), adjusting for established prognostic factors. RESULTS: A total of 138 patients were recruited between March 2015 and January 2018, with response rates of 84.7% (n = 117) and 79.7% (n = 100) at three months and one year, respectively. Adjusted associations revealed that for every point increase in baseline fear of movement, the QuickDASH score increased (worsened) by 1.10 points (95% CI 0.2-2.0) over the follow-up year. For every point increase in baseline emotional distress, the QuickDASH score increased by 19.9 points (95% CI 13.9-25.9) from baseline over the follow-up year. CONCLUSION: Higher fear of movement and emotional distress scores at baseline were significantly associated with higher disability over one year in patients with shoulder pain referred to secondary care. Our study indicates that these psychological factors affect prognosis and should be considered by clinicians and researchers working with patients with shoulder pain.

Active digital pedagogies as a substitute for clinical placement during the COVID-19 pandemic: the case of physiotherapy education.

BACKGROUND: In March 2020, campuses at Norwegian academic institutions were closed due to the COVID-19 pandemic. All in-person teaching had to be replaced by digital alternatives. The closure also affected clinical placements in physiotherapy programs, which in some cases had to be replaced by online alternatives without patient contact. The aim of this study is to evaluate the benefits and challenges of using digital pedagogies to accomplish the learning outcomes of clinical placements. METHODS: Forty-four final-year physiotherapy students at Oslo Metropolitan University had their clinical placement substituted by an online alternative centered around two main educational activities conducted online in small groups: 1) clinical case seminars and 2) digital lectures followed by webinars where students discussed and solved tasks related to the lectures. Additionally, as a part of this alternative placement, students had to conduct a physiotherapy assessment of a family member/housemate and summarize the findings in an anonymized medical record. At the end of the placement, all students wrote a short essay reflecting on their learning process. Students' written reflections were anonymized and subjected to a qualitative analysis. RESULTS: Forty-three out of 44 participating students completed their essays. Although students expressed disappointment in missing out on clinical placement, they were surprised by how much learning the online alternative provided. The most valued activities were clinical case seminars where clinical cases previously experienced by the students were discussed. The seminars appeared to facilitate students' engagement in professional discussions and to enhance their clinical reasoning skills. Seminars also seemed to strengthen students' belief in their own and their fellow students' capabilities. Group discussions focusing on topics related to digital lectures were also appreciated. Interestingly, the activity that most closely mimicked a clinical setting - physiotherapy assessment of family member/housemate - was rarely mentioned in the students' essays. As expected, students most regret not meeting real patients and missing out on the new clinical experiences such encounters would provide. CONCLUSIONS: Despite lack of direct patient contact, students in physiotherapy education evaluated that an online alternative placement was highly clinically relevant. Peer-to-peer discussions of clinical cases appeared to be especially valued. The fact that students themselves had to take the main responsibility for preparing the seminars and leading the discussions was an important pedagogical aspect of the online alternative. The findings indicate that in learning of clinical skills, physiotherapy students take benefit of autonomous, student-centered interventions. Further research should investigate how digital technology-enhanced learning can be used to improve quality of ordinary clinical placement, in physiotherapy- and health education.

Digital learning designs in physiotherapy education: a systematic review and meta-analysis.

BACKGROUND: Digital learning designs have the potential to support teaching and learning within higher education. However, the research on digital learning designs within physiotherapy education is limited. This study aims to identify and investigate the effectiveness of digital learning designs in physiotherapy education. METHODS: The study was designed as a systematic review and meta-analysis of randomized and non-randomized trials. A search of eight databases on digital learning designs and technology was conducted. Study selection, methodology and quality assessment were performed independently by three reviewers. The included studies were mapped according to the types of digital interventions and studies. For similar interventions, the learning effects were calculated using meta-analyses. RESULTS: Altogether, 22 studies were included in the review (17 randomized controlled trials and five cohort studies). A blended learning design was used in 21 studies, a flipped classroom model in five and a distance learning design in one. Altogether, 10 of the 22 articles were included in meta-analyses, which showed statistically significant effects for flipped classrooms on knowledge acquisition (standardized mean difference [SMD]: 0.41; 95% confidence interval [CI]: 0.20, 0.62), for interactive websites or applications (apps) on practical skills (SMD: 1.07; 95% CI: 0.71,1.43) and for students self-produced videos on a practical skill in a cervical spine scenario (SMD: 0.49; 95% CI: 0.06, 0.93). Overall, the effects indicated that blended learning designs are equally as or more effective than traditional classroom teaching to achieve learning outcomes. Distance learning showed no significant differences compared to traditional classroom teaching. CONCLUSIONS: The current findings from physiotherapy education indicate that digital learning designs in the form of blended learning and distance learning were equally or more effective compared to traditional teaching. The meta-analyses revealed significant effects on student learning in favour of the interventions using flipped classrooms, interactive websites/apps and students self-produced videos. However, these results must be confirmed in larger controlled trials. Further, research should investigate how digital learning designs can facilitate students' learning of practical skills and behaviour, learning retention and approaches to studying as well as references for teaching and learning in digital learning environments.

Learning with technology in physiotherapy education: design, implementation and evaluation of a flipped classroom teaching approach.

BACKGROUND: The purpose of the study was to describe the design, implementation and evaluation of a flipped classroom teaching approach in physiotherapy education. The flipped classroom is a blended learning approach in which students receive digital lectures as homework, while active learning activities are used in the classroom. Flipped classroom teaching enables a learning environment that aims to develop higher-order cognitive skills. METHODS: The study design was a historically controlled, prospective, cohort study. An eight week theoretical course on musculoskeletal disorders was redesigned, moving from a conventional approach to a flipped classroom model. Pre-class learning material consisted of about 12 h of video lectures and other digital learning resources that were split up over the duration of the course. In-class activities consisted of seven full-day seminars where students worked in groups in order to solve problem-based assignments. The assignments were designed to reflect authentic clinical problems and required critical thinking and reasoning. Outcomes were measured with course-grades and compared with historical controls of conventional teaching, using descriptive statistics. Self-perceived learning outcomes and students' experiences were also collected in a survey. RESULTS: Fifty-one students passed the course exam, two failed and one did not attend (n = 54). The share of students with Excellent, Very good and Good (ABC) performances increased by more than 10% relative to any previous year. In addition, Satisfactory, Sufficient and Failed performances (DEF) decreased by more than 10%. Almost two thirds of the students preferred the flipped classroom approach as compared with conventional teaching. Interaction with peers and educators, and flexibility, were the most positive factors that were reported by students. Long seminars, time-constraints and low motivation with respect to preparation and educators' roles were the most common complaints. CONCLUSIONS: A flipped classroom approach in physiotherapy education resulted in improved student performances in this professional programme, when compared with conventional teaching. Students responded positively to the collaborative learning environment, especially with respect to the associated autonomy and flexibility. There were indicators that all groups did not work optimally and that accountability to other group members did not always ensure pre-classroom preparations.

Emotional distress was associated with persistent shoulder pain after physiotherapy: a prospective cohort study.

BACKGROUND: There is a paucity of research on the association between psychological factors and persistent shoulder pain. The aim of this study was to investigate whether emotional distress was associated with pain intensity and self-reported disability after physiotherapy treatment in patients with shoulder pain. METHODS: Data from 145 patients treated at physiotherapy outpatient clinics aged ≥18 years with self-reported pain in the shoulder or arm, and movement activity problems related to the upper-extremity, were included. Outcome measures were pain intensity measured by Numeric Pain Rating Scale and disability measured by Patient Specific Functional Scale. Demographic and clinical characteristics, including emotional distress measured by Hopkins Symptom Checklist - 25, were obtained at study onset. Association between characteristics at study onset and pain and disability after physiotherapy treatment were analysed using multiple linear regression and a backward manual elimination method. The final models were adjusted for age and sex. RESULTS: Higher emotional distress at study onset (B 1.06, 95% CI 0.44 to 1.68) was associated with higher pain intensity after the physiotherapy treatment (P = 0.001). Emotional distress was not associated with self-reported disability after the physiotherapy treatment. CONCLUSION: This study found that emotional distress at study onset was associated with shoulder pain intensity after physiotherapy treatment, but not with disability. The findings indicate that emotional distress should be included in the initial physiotherapy examination of shoulder pain.

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.

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.

A systematic review of measures of shoulder pain and functioning using the International classification of functioning, disability and health (ICF).

BACKGROUND: Shoulder pain is a common condition with prevalence estimates of 7-26% and the associated disability is multi-faceted. For functional assessments in clinic and research, a number of condition-specific and generic measures are available. With the approval of the ICF, a system is now available for the analysis of health status measures. The aims of this systematic literature review were to identify the most frequently addressed aspects of functioning in assessments of shoulder pain and provide an overview of the content of frequently used measures. METHODS: Meaningful concepts of the identified measures were extracted and linked to the most precise ICF categories. Second-level categories with a relative frequency above 1% and the content of measures with at least 5 citations were reported. RESULTS: A set of 40 second-level ICF categories were identified in 370 single-item measures and 105 multi-item measures, of these, 28 belonged to activities and participation, 11 to body functions and structures and 1 to environmental factors. The most frequently addressed concepts were: pain; movement-related body functions and structures; sleep, hand and arm use, self-care, household tasks, work and employment, and leisure. Concepts of psycho-social functions and environmental factors were less frequently included. The content overview of commonly used condition-specific and generic measures displayed large variations in the number of included concepts. The most wide-ranging measures, the DASH and ASES were linked to 23 and 16 second-level ICF categories, respectively, whereas the Constant were linked to 7 categories and the SST and the SPADI to 6 categories each. CONCLUSIONS: This systematic review displayed that measures used for shoulder pain included more than twice as many concepts of activities and participation than concepts of body functions and structures. Environmental factors were scarcely addressed. The huge differences in the content of the condition-specific multi-item measures demonstrates the importance of clarifying the content to select the most appropriate measure both in research and in clinical work. For clinical situations, we propose use of a wide-ranging condition-specific measure that conceptualizes assessments of shoulder pain from a bio-psycho-social perspective. Further research is needed to assess how patient-reported problems in functioning are captured in the commonly used measures.

"Learning is about being active, but the digital is not really active": physiotherapy teachers' attitudes toward and experiences with digital education.

BACKGROUND: Digital education is expected to transform higher education teaching and learning. Despite high expectations, higher education teachers have been slow to implement active digital learning. OBJECTIVE: The aim of this study was to investigate physiotherapy teachers' attitudes toward and experiences with digital education and what the teachers' considered prerequisites to a digital transformation of teaching and learning in physiotherapy. METHODS: Qualitative in-depth interviews were conducted with 12 teachers in physiotherapy education. The interviews were analyzed using inductive thematic analysis. FINDINGS: The findings illuminate teachers' attitudes toward and experiences with digital education and their views on prerequisites to a digital transformation of teaching and learning in physiotherapy education, presented as four themes: 1) skepticism toward digital education; 2) digital technology as a tool to support the established teaching practice; 3) longing for teacher collaboration; and 4) calling for time to plan and learn, and significant academic leadership. CONCLUSION: This study shows how physiotherapy teachers are skeptical about digital education, primarily viewing it as a threat to established teaching practices. Taken together, the findings demonstrate a potential for digital transformation in physiotherapy education, which can be released by informing the current teaching practices with evidence from research showing how use of digital technology can improve teaching and learning in physiotherapy education.

Contextualizing the lived experiences of patients with low back pain from different countries according to the ICF framework.

OBJECTIVE: To explore perspectives, including social and psychological aspects, of patients seeking manual care for low back pain, in order to understand constructs of functioning that are important across different cultural contexts. The International Classification of Functioning, Disability and Health (ICF) emphasizes the importance of these aspects to describe health-related functioning. DESIGN: Focus group interviews. PATIENTS: Patients from Botswana, Canada and Norway seeking manual care for their low back pain. METHODS: Interviews were conducted in the 3 countries, transcribed verbatim, translated into English, and linked to the ICF according to established rules. RESULTS: Seven focus groups yielded 1,863 meaningful concepts that were linked to ICF categories. The largest proportion of responses linked to the Activities and Participation domain. The most frequently mentioned chapters related to pain and its mental aspects, suggesting that the psychological impact of living with low back pain is important to patients. CONCLUSION: Despite cultural differences, patients seeking manual care for low back pain in Botswana, Canada and Norway reported similar experiences of disability across ICF domains. The relatively high ranking of psychosocial factors highlights their importance for patients, in addition to factors of biological origin, and indicates that the contextual nature of the lived experience of low back pain may not be covered in standard examinations used in manual medicine.

What Are the Most Important Problems in Functioning Among Patients With Shoulder Pain? An Analysis of the Patient-Specific Functional Scale.

OBJECTIVE: The purpose of this study was to identify important functional problems among individuals with shoulder pain using the Patient-Specific Functional Scale (PSFS) and to investigate differences between individuals receiving primary care and individuals receiving secondary care. METHODS: In this cross-sectional study located in a primary and secondary care outpatient clinic, a total of 177 individuals seeking care for shoulder pain (84 from primary care and 93 from secondary care) were recruited. Background variables, pain, physical activity, and PSFS responses were collected using a questionnaire software package. Meaningful concepts were linked from the PSFS responses to the International Classification of Functioning, Disability and Health (ICF) according to established rules. Frequencies for the ICF categories were estimated separately for primary care and secondary care. Differences between primary care and secondary care were investigated by calculating CIs for the sample proportions at ICF chapter level. RESULTS: The primary care sample reported functional problems linked to 226 ICF categories, whereas the secondary care sample reported functional problems linked to 337 ICF categories. Of the linked ICF categories, 87.7% belonged to the Activities and Participation component of the ICF. Seventeen categories were identified in >3% of the individuals; of those, the most frequent categories were recreation and leisure, lifting and carrying objects, doing housework, hand and arm use, and remunerative employment. Categories included in the ICF chapters of self-care and domestic life were significantly more frequent in the secondary care sample, whereas there was a trend that neuromusculoskeletal and movement-related functions were more frequent in primary care. CONCLUSION: The present findings indicate that individuals with shoulder pain report a wide range of functional problems, from basic functions related to mobility to activities related to work and leisure. This study also discovered differences between patients in primary care and secondary care. The large variation in the experiences between people supports the use of an individualized measure in assessments. IMPACT: This study adds new knowledge about problems in functioning among people with shoulder pain and how the individual experience varies between primary care and secondary care settings. Moreover, the content analyses used in this study showed the full potential of the ICF classification and should have potential for further application.

Adherence to self-managed exercises for patients with persistent subacromial pain: the Ad-Shoulder feasibility study.

BACKGROUND: Exercise is recommended for patients with subacromial pain. It has been suggested that good exercise adherence improves clinical outcomes. Despite this, little attention has been paid to the need for behavioural frameworks to enhance adherence to home exercise programmes for patients with subacromial pain. METHODS: A feasibility study with pre-post design was used. Participants aged > 18 years, with subacromial pain, who had received conservative treatment during the past 6 months, were recruited. The Ad-Shoulder intervention consisted of 1-5 individual sessions provided over 3 months and was based on 5 self-management skills, which aimed to enhance the patients' self-efficacy and adherence to self-managed exercises. The primary objectives were assessed according to predefined progression criteria: (1) the recruitment rate (10 patients enrolled within 12 weeks), (2) follow-up rate (≥ 80% on all self-reported measures), (3) objective physical activity measures (≥ 80% of participants would contribute valid data at each time point), (4) adherence with the self-managed exercises (≥ 80% of the participants would adhere to ≥ 80% of the assigned home exercise programme), (5) fidelity of the delivery of the intervention (the therapists delivered the intervention according to the protocol) and (6) adverse events (< 30% would report adverse events (including mild)). The results were reported using descriptive statistics. RESULTS: Eleven patients were recruited during 16 weeks. Ten patients completed the self-reported measures at baseline and week 12. Objective physical activity measures were successfully obtained for 100% (11/11) at baseline, 64% (7/11) at week six and 82% at week 12. Fifty-five percent (6/11) of the participants satisfactorily completed at least 80% of their home exercise programme. All sessions were delivered according to the protocol. None of the patients reported any adverse events. CONCLUSIONS: Objective physical activity data measures at baseline and week 12, follow-up, the physiotherapists' fidelity to the intervention and adverse events met our pre-specified progression criteria. Recruitment and adherence to the self-managed exercise programme were both below the anticipated level. Further intervention development is necessary to understand whether adherence to the self-managed exercises could be enhanced and additional methods of recruitment would need to be considered, including additional recruitment sites, in any planning for a future main trial. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04190836 , Registered December 9, 2019-retrospectively registered.

Associations between shoulder pain and functioning on the ICF checklist and the disabilities of the arm, shoulder, and hand scale - a cross-sectional study.

Purpose: The association between patients' shoulder pain and functioning according to the International Classification of Functioning, Disability, and Health (ICF), and outcome on a condition specific patient reported outcome measure (PROM), has not been studied. The aim was to investigate how the most common problems on the ICF checklist were associated with shoulder function and disability.Materials and methods: In a cross-sectional design 164 patients ≥ 18 years with chronic shoulder pain were included. The ICF checklist, the Disability of the Arm, Shoulder, and Hand (DASH) outcome measure and the Self-Report Comorbidity Questionnaire were used. A hierarchical regression model tested categories for functioning on the ICF checklist associated with disability on the DASH.Results: Mean age was 46.5 years, 54% were women. 85% had had the shoulder pain longer than 6 months. Mean DASH score was 33.2 points (SD 17.1). Adjusted R2 was 0.67. Older age, being woman and having a lower education explained 22% of the variance on the DASH. The body functions bodily pain, mobility of joints and energy and drive function explained 30% of the variance, and the activities and participation problems lifting and carrying objects, washing oneself and recreation and leisure explained an additional 13%.Conclusions: The shoulder disability was multi-dimensional and comprised body functions and activities and participation. And 67% of the variance in the DASH score was explained.Implications for rehabilitationPersistent shoulder pain results in multi-dimensional disability calling for a broader assessment of function.A biopsychosocial approach to shoulder pain and disability is recommended.Functioning assessed on the ICF checklist can be applied in the assessment of chronic shoulder pain as it contributes to the understanding of self-reported disability on a region specific outcome measure.

What Do the OMERACT Shoulder Core Set Candidate Instruments Measure? An Analysis Using the Refined International Classification of Functioning, Disability, and Health Linking Rules.

OBJECTIVE: The objective of this paper is to assess the content and measurement constructs of the candidate instruments for the domains of "pain" and "physical function/activity" in the Outcome Measures in Rheumatology (OMERACT) shoulder core set. The results of this International Classification of Functioning, Disability, and Health (ICF)-based analysis may inform further decisions on which instruments should ultimately be included in the core set. METHODS: The materials for the analysis were the 13 candidate measurement instruments within pain and physical function/activity in the shoulder core domain set, which either passed or received amber ratings (meaning there were some issues with the instrument) in the OMERACT filtering process. The content of the candidate instruments was extracted and linked to the ICF using the refined linking rules. The linking rules enhance the comparability of instruments by providing a comprehensive overview of the content of the instruments, the context in which the measurements take place, the perspectives adopted, and the types of response options. RESULTS: The ICF content analysis showed a large variation in content and measurement constructs in the candidate instruments for the shoulder core outcome measurement set. CONCLUSION: Two of 6 pain instruments include constructs other than pain. Within the physical function/activity domain, 2 candidate instruments matched the domain, 3 included additional content, and 2 included meaningful concepts in the response options, suggesting that they should be omitted as candidate instruments. The analyses show that the content in most existing instruments of shoulder pain and functioning extends across core set domains.

Content reporting of exercise interventions in rotator cuff disease trials: results from application of the Consensus on Exercise Reporting Template (CERT).

BACKGROUND: Exercise interventions are frequently recommended for patients with rotator cuff disease, but poor content reporting in clinical trials of exercise limits interpretation and replication of trials and clinicians' ability to deliver effective exercise protocols. The Consensus on Exercise Reporting Template (CERT) was developed to address this problem. OBJECTIVE: To assess completeness of content reporting of exercise interventions in randomised controlled trials for patients with rotator cuff disease and the inter-rater reliability of the CERT. DESIGN: Critical appraisal. METHODS: Independent pairs of reviewers applied the CERT to all 34 exercise trials from the most recent Cochrane Review evaluating the effect of manual therapy and exercise for patients with rotator cuff disease. We used the CERT Explanation and Elaboration Statement to guide assessment of whether each of the 19-item criteria were clearly described (score 0-19; higher scores indicate better reporting). Percentage agreement and the prevalence and bias adjusted kappa (PABAK) coefficient were used to measure inter-rater reliability. RESULTS: The median CERT score was 5 (range 0-16). Percentage agreement was high for 15 items and acceptable for 4 items. The PABAK coefficient indicated excellent (5 items), substantial (11 items) and moderate (3 items) inter-rater agreement. CONCLUSION: The description of exercise interventions for patients with rotator cuff disease in published trials is poorly reported. Overall, the inter-rater reliability of the CERT is high/acceptable. We strongly encourage journals to mandate use of the CERT for papers reporting trial protocols and results investigating exercise interventions.

The OMERACT Core Domain Set for Clinical Trials of Shoulder Disorders.

OBJECTIVE: To reach consensus on the core domains to be included in a core domain set for clinical trials of shoulder disorders using the Outcome Measures in Rheumatology (OMERACT) Filter 2.1 Core Domain Set process. METHODS: At OMERACT 2018, the OMERACT Shoulder Working Group conducted a workshop that presented the OMERACT 2016 preliminary core domain set and its rationale based upon a systematic review of domains measured in shoulder trials and international Delphi sessions involving patients, clinicians, and researchers, as well as a new systematic review of qualitative studies on the experiences of people with shoulder disorders. After discussions in breakout groups, the OMERACT core domain set for clinical trials of shoulder disorders was presented for endorsement by OMERACT 2018 participants. RESULTS: The qualitative review (n = 8) identified all domains included in the preliminary core set. An additional domain, cognitive dysfunction, was also identified, but confidence that this represents a core domain was very low. The core domain set that was endorsed by the OMERACT participants, with 71% agreement, includes 4 "mandatory" trial domains: pain, function, patient global - shoulder, and adverse events including death; and 4 "important but optional" domains: participation (recreation/work), sleep, emotional well-being, and condition-specific pathophysiological manifestations. Cognitive dysfunction was voted out of the core domain set. CONCLUSION: OMERACT 2018 delegates endorsed a core domain set for clinical trials of shoulder disorders. The next step includes identification of a core outcome measurement set that passes the OMERACT 2.1 Filter for measuring each domain.

Conceptualization and assessment of disability in shoulder-specific measures with reference to the International Classification of Functioning, Disability and Health.

OBJECTIVE: To expand on a previous systematic review of shoulder-specific outcome measures by investigating how concepts of functioning were conceptualized and measured, using International Classification of Functioning, Disability and Health (ICF) constructs as a reference. METHODS: The material consisted of the linked content of 17 condition-specific measures. The distribution of the key concepts of functioning was assessed in relation to the 3 ICF levels: body level (body functions and structures), personal level (activities) and societal level (participation). Based on this cate-gorization, the concepts were further explored; body functions as to whether they were informed by any contextual information, and activities and participation as to whether they measured a person's capacity, capability or performance. RESULTS: Seven measures assessed all 3 levels of functioning, 8 measured 2 levels, and 2 measured a single level. The majority of the 15 measures including body functions assessed a mix of decontextualized and contextualized functions. Of the 13 measures of activities, 7 measured capabilities, 4 performance and 2 used both constructs. In comparison, among the 11 measures of participation, 5 measured capabilities, 2 performance and 4 a mixture of these. No measure used the capacity construct. CONCLUSION: Shoulder-specific outcome measures differ in their choice of measurement levels and measurement constructs. The inconsistent use of the capability and performance constructs to measure activities and participation, raise important questions about the suitability of the measures for their intended use.

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.

Identification of relevant International Classification of Functioning, Disability and Health categories in patients with shoulder pain: a cross-sectional study.

OBJECTIVE: To identify the most common problems in patients with shoulder pain, using the International Classification of Functioning, Disability and Health (ICF) as a reference. DESIGN: A cross-sectional study. SUBJECTS: Outpatients at a hospital with shoulder pain lasting longer than 3 months. METHODS: Patients were interviewed with an extended version of the ICF Checklist version 2.1a. Patients' problems in functioning, and the magnitude of the problem, were registered separately for each category. Categories identified as a problem in at least 5% of patients were reported. To describe the population, age, diagnosis, work participation and the Shoulder Pain and Disability Index (SPADI) were recorded. RESULTS: A total of 165 patients with a mean age of 46.5 years (standard deviation 12.5) and a SPADI score of 47.4 (standard deviation 21.1) were included. Of the participants, 92.8% were either employed or students, 35.2% of whom were on sick leave. The primary result was the identification of 61 condition-specific second-level ICF categories: 19 in the body functions and structures component, 34 in activities and participation, and 8 in environmental factors. CONCLUSION: The findings provide a comprehensive picture from the patient-perspective of the disability associated with shoulder pain. The findings may enhance multidisciplinary communication in clinical settings.