Examining outcome of early physician specialist assessment in injured workers with shoulder complaints.

BACKGROUND: There is minimal research on demographics, type of injury and diagnosis of injured workers with shoulder problems. The purposes of this study were: 1) to document the demographics of patients with shoulder complaints referred to an Early Shoulder Physician Assessment (ESPA) Program and to describe the recommended management, and 2) to examine the relationship between patient characteristics and their subjective complaints of pain and functional difficulty. METHODS: This study involved a retrospective review of electronic files of injured workers mostly seen within the first 16 weeks of injury or recurrence. Measures of functional difficulty and pain were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Numeric Pain Scale (NPS). RESULTS: Files of 550 consecutive patients, 260 females (47%), 290 men (53%) were examined. The average age was 49 (SD = 11, range 22-77), with 28 (5%) patients being 65 years of age or older. Patients who were not working were the most disabled group based on Quick DASH (F = 49.93, p < 0.0001) and NPS (F = 10.24, p = 0.002). Patients who were working full time performing regular duties were the least disabled according to both measures, the QuickDASH (F = 10.24, p = 0.002) and NPS (F = 7.57, p = 0.006). Patients waiting more than 16 weeks were slightly older (53 years of age vs. 49, p = 0.045) than those who met the criteria for early assessment with similar levels of pain and functional difficulty. Biceps pathology had the highest prevalence (37%). Full thickness tear had a prevalence of 14%. Instability, labral lesions and osteoarthritis of glenohumeral joint were uncommon conditions (3, 2 and 1% respectively). Fifty-five patients (10%) were surgical candidates and had higher scores on QuickDASH (F = 7.16, p = 0.008) and NPS (F = 4.24, p = 0.04) compared to those who did not require surgery. CONCLUSIONS: This study provides information on characteristics and prevalence of important variables in injured workers with shoulder problems and highlights the impact of these characteristics on pain and disability.

Management of Acute Work-Related Shoulder Injuries by an Early Shoulder Assessment Program: Efficiency of Imaging Investigations.

Purpose: There has been a significant increase in the number of costly investigations of the shoulder joint over the past decade. The purposes of this study were to (1) describe the diagnostic imaging investigations ordered for injured workers seen at an Early Shoulder Physician Assessment (ESPA) program, (2) evaluate the impact of these investigations on final diagnosis and management, and (3) examine how efficient the program was by determining the appropriateness of referrals and whether costly imaging was justified. Methods: This was a retrospective review of the electronic files of injured workers who had been referred to an early assessment program because they had not progressed in their recovery or return-to-work plan within 16 weeks of the injury or reoccurrence. Results: The data of 750 consecutive patients-337 women (45%) and 413 men (55%), mean age 49 (SD 11) years-were reviewed. A total of 183 patients (24%) had been referred for further investigation. Of these, 90 (49%) were considered candidates for surgery (group 1), 58 (32%) had a change in diagnosis or management (group 2), and 17 (9%) had no change in diagnosis or management (group 3); 18 (10%) patients were lost to follow-up. We noticed a pattern in the type of diagnosis and the groups: full-thickness rotator cuff (RC) tear was the predominant diagnosis (Fisher's exact test [FET]=0.001, p<0.0001) for group 1. No statistically significant differences were found among the groups in the prevalence of labral pathology (FET=0.010, p=0.078), impingement syndrome (FET=0.012, p=0.570), partial-thickness RC tear (FET=0.004, p=0.089), or biceps pathology (FET=0.070, p=0.149). Ultrasound investigations were more prevalent in group 2 (FET=0.004, p=0.047). No pattern was found for use of magnetic resonance imaging and group allocation. However, all magnetic resonance arthrogram investigations (FET=0.007, p=0.027) had been ordered for patients who required labral or instability-related surgery. Conclusions: Of the injured workers we studied, 24% had further investigation, and the type and severity of pathology had affected the type of investigation. For the 165 patients who were included in groups 1-3, the ESPA was 90% efficient, with only 10% of patients not having had a change in diagnosis or management.

Objectif : le nombre d'investigations coûteuses pour blessures à l'épaule a beaucoup augmenté au cours des dix dernières années. La présente étude avait pour objectif de 1) décrire les investigations par imagerie diagnostique prescrites aux travailleurs blessés dans le cadre d'un programme d'évaluation médicale précoce de l'épaule (ÉMPÉ); 2) évaluer l'incidence de ces investigations sur le diagnostic final et la prise en charge; 3) examiner l'efficacité du programme en déterminant le bien-fondé des références et des examens d'imagerie. Méthodes : il s'agissait d'une revue rétrospective des dossiers électroniques de travailleurs blessés qui avaient été dirigés vers un programme d'évaluation précoce en raison d'un manque de progression par rapport à leur plan de rétablissement ou de retour au travail au bout de 16 semaines après la blessure ou une nouvelle blessure. Résultats : on a examiné les données de 750 patients consécutifs, soit 337 femmes (45 %) et 413 hommes (55 %), dont l'âge moyen était de 49 ans (écart-type : 11). En tout, 183 de ces patients (24 %) ont été dirigés vers un autre professionnel pour investigation supplémentaire. Sur ceux-ci, 90 (49 %) ont été considérés comme des candidats à l'intervention chirurgicale (groupe 1), le diagnostic ou la prise en charge a évolué chez 58 (32 %) d'entre eux (groupe 2) et la prise en charge ou le diagnostic a été confirmé chez 17 (9 %) d'entre eux (groupe 3); 18 (10 %) patients n'ont pas été revus. Nous avons remarqué une tendance dans le type de diagnostic et les groupes : le diagnostic de déchirure complète de la coiffe des rotateurs (CR) prédominait (test exact de probabilité de Fisher [TEPF]=0,001, p<0,0001) dans le groupe 1. On n'a constaté aucune différence importante du point de vue statistique dans les groupes pour ce qui est de la prévalence de pathologies du bourrelet (TEPF=0,010, p=0,078), du syndrome de conflit sous-acromial (TEPF=0,012, p=0,570), de la déchirure partielle de la CR (TEPF=0,004, p=0,089) et des pathologies du biceps (TEPF=0,070, p=0,149). Un plus grand nombre d'échographies a été observé dans le groupe 2 (TEPF=0,004, p=0,047). On n'a remarqué aucune tendance du recours à l'imagerie par résonnance magnétique par rapport aux groupes. Toutefois, toutes les arthrographies par résonnance magnétique (TEPF=0,007, p=0,027) ont été prescrites pour des patients qui nécessitaient une intervention relative au bourrelet ou à l'instabilité. Conclusions : parmi les travailleurs blessés que nous avons étudiés, 24 % ont fait l'objet d'une investigation supplémentaire. Le type et la gravité de la pathologie ont influencé le choix du mode d'investigation. Dans le cas des 165 patients des groupes 1 à 3, l'efficacité du programme d'ÉMPÉ s'est élevée à 90 %, le diagnostic ou la prise en charge n'ayant pas évolué que dans 10 % des cas.