FOTO - Focus on Therapeutic Outcomes | Shoulder Pain Archives

Risk of Persistent Shoulder Pain

Selena Horner — Thu, 21 Mar 2019 10:00:00 +0000

We spend a lot of time performing thorough assessments. Are we missing something really, really important that can help with prognosis?

The research continues to strongly indicate exactly what FOTO team takes into consideration in the risk adjustment process. When a patient begins services, the amount of perceived disability matters with regard to the outcome of care. The level of functional ability is a very strong predictor. The research below indicates it was the highest predictor of outcome.

The next findings are interesting. How often do you ask if the patient believes services will be beneficial and that their condition will improve? This proves to be a powerful question. Patients who expected services to be beneficial had better outcomes.

Pain self-efficacy also proved to be valuable. Although the patients were experiencing pain, their belief about their ability to complete tasks while in pain provided insight into outcomes. Those who had high pain self-efficacy beliefs tended to attain better outcomes.

The findings suggest that gaining information from patients about expectations and pain self-efficacy are helpful pieces of information to help in providing care or making care decisions. FOTO does have self-efficacy measures included as optional assessments for you to include when gaining baseline information.

The abstract is included below for you to review.

Self-efficacy and risk of persistent shoulder pain:results of a Classification and Regression Tree (CART) analysis.

Chester R¹, Khondoker M², Shepstone L², Lewis JS³, Jerosch-Herold C¹.

Abstract

OBJECTIVES:

To (i) identify predictors of outcome for the physiotherapy management of shoulder pain and (ii) enable clinicians to subgroup people into risk groups for persistent shoulder pain and disability.

METHODS:

1030 people aged ≥18 years, referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited. 810 provided data at 6 months for 4 outcomes: Shoulder Pain and Disability Index (SPADI) (total score, pain subscale, disability subscale) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH). 34 potential prognostic factors were used in this analysis.

RESULTS:

Four classification trees (prognostic pathways or decision trees) were created, one for each outcome. The most important predictor was baseline pain and/or disability: higher or lower baseline levels were associated with higher or lower levels at follow-up for all outcomes. One additional baseline factor split participants into four subgroups. For the SPADI trees, high pain self-efficacy reduced the likelihood of continued pain and disability. Notably, participants with low baseline pain but concomitant low pain self-efficacy had similar outcomes to patients with high baseline pain and high pain self-efficacy. Cut-off points for defining high and low pain self-efficacy differed according to baseline pain and disability. In the QuickDASH tree, the association between moderate baseline pain and disability with outcome was influenced by patient expectation: participants who expected to recover because of physiotherapy did better than those who expected no benefit.

CONCLUSIONS:

Patient expectation and pain self-efficacy are associated with clinical outcome. These clinical elements should be included at the first assessment and a low pain self-efficacy response considered as a target for treatment intervention.

Br J Sports Med. 2019 Jan 9. pii: bjsports-2018-099450. doi: 10.1136/bjsports-2018-099450. [Epub ahead of print]

See what happens after a patient takes an assessment!

FOTO helps you know prognosis!

The post Risk of Persistent Shoulder Pain appeared first on FOTO Patient Outcomes.

What Factors Are Associated With Disability After Upper Extremity Injuries?

Selena Horner — Mon, 19 Nov 2018 11:00:00 +0000

I sometimes wonder if being able to quickly predict outcomes of care will be of high importance as payment models change.

It seems that it is hugely valuable to be able to quickly know if a patient is a good fit for services. By good fit, I guess I’m being somewhat vague because I don’t really know how to be politically correct as I think of how to word my thoughts. Does every patient deserve a chance to improve? If yes, how much of a chance should be granted?

Years ago, I used to believe it was reasonable to give everyone a chance. Now I am beginning to think differently. The pressure to gain outcomes is becoming stronger and stronger. And as we are evaluated for attaining outcomes, there isn’t any pressure on patients nor on the payer to be of assistance in helping achieve the final outcome. We should all be in this together. It doesn’t seem to me that everyone involved has the same amount of skin in the game – and onus is left to the clinicians. This bothers me. It feels like we will become quickly judgmental in determining who should receive services when if we had a bit more time and visits the person just might attain anticipated improvement.

So, as I see more and more research trying to determine prognostic factors, a bulk of the factors reside within the patient and are not related to the physical impairments we are able to observe and measure. It seems that the psychological component plays a major role with regard to how much functional improvement will happen. This means we need to be very intentional with our words and very astute. I wonder if we will be more direct in discussing the factors affecting the patient’s outcomes with the patient. We may need to do more frequent assessment with patient reported outcome measures to determine if the patient is having psychological changes that favor better outcomes. We may also need to determine what amount of time or number of visits are adequate to capture if the patient is demonstrating psychological changes.

You’ll find the abstract to the recent study below.

What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review.

Jayakumar P¹, Overbeek CL, Lamb S, Williams M, Funes C, Gwilym S, Ring D, Vranceanu AM.

Abstract

BACKGROUND:

Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.

QUESTIONS/PURPOSES:

(1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients’ upper extremity injuries?

METHODS:

We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the “upper extremity”, “outcome measurement”, and “impairment, psychological, social or symptomatic” variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.

RESULTS:

Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.

CONCLUSIONS:

Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.

Clin Orthop Relat Res. 2018 Nov;476(11):2190-2215. doi: 10.1097/CORR.0000000000000427.

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Predictors of Pain and Functional Outcomes After the Nonoperative Treatment of Rotator Cuff Tears

Selena Horner — Mon, 24 Sep 2018 10:00:00 +0000

It seems that the philosophy of less care (diagnostic tests, injections, medications & surgery) is better care. This current study intrigued me because it looked at the results of nonoperative care for rotator cuff tears.

Although I am not a fan of the SPADI, the positive in the study is that pain and functional ability were considered for each patient. Because the study used the SPADI and used serial testing (reassessment at 3, 6,12 and 18 months), you’ll need to view the full text to see if a minimal clinically important difference occurred. Based on this study, when the SPADI is completed more frequently than initial evaluation and at discharge, the minimal clinically important difference is 18 points.

Since we know that beliefs impact outcomes, it would have been nice to know how much improvement the patient believed would occur. We already know that the patient had diagnostic testing and was informed that a rotator cuff tear was present in the shoulder.

FOTO risk adjusts for factors outside of a clinician’s control. A few factors not taken into consideration by FOTO include marital status, alcohol use and the intensity in which a patient uses his or her shoulder during the day. FOTO has been capturing data on educational level to perform an analysis on the impact of education on outcomes.

We know from work done on patients who have had a cervical whiplash that fatty infiltration into cervical musculature affects their outcomes. This study highlights the same finding. Fatty infiltration into the rotator cuff musculature affected functional outcomes negatively.

You’ll find the abstract to the recent study below.

Predictors of Pain and Functional Outcomes After the Nonoperative Treatment of Rotator Cuff Tears.

Jain NB^1,², Ayers GD³, Fan R³, Kuhn JE², Baumgarten K⁴, Matzkin E⁵, Higgins LD⁵.

Abstract

BACKGROUND:

Optimal patient selection is key to the success of nonoperative treatment for rotator cuff tears.

PURPOSE:

To assess the predictors of pain and functional outcomes in a longitudinal cohort of patients undergoing nonoperative treatment.

STUDY DESIGN:

Cohort study; Level of evidence, 2.

METHODS:

A multicenter cohort of patients with rotator cuff tears undergoing nonoperative treatment was recruited from March 2011 to February 2015. Patients completed a detailed health questionnaire, completed standardized shoulder questionnaires including the Shoulder Pain and Disability Index (SPADI), and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Longitudinal mixed models were used to test predictors of the SPADI score, and interactions with time were assessed.

RESULTS:

In our cohort of 70 patients, being married as compared with being single/divorced/widowed (P = .02), a shorter duration of symptoms (P = .02), daily shoulder use at work that included light or no manual labor versus moderate or heavy manual labor (P = .04), alcohol use of 1 to 2 times per week or more as compared with 2 to 3 times per month or less (P = .007), and absence of fatty infiltration (P = .0009) were significantly associated with decreased SPADI scores (improved shoulder pain and disability) over time. When interactions with time were assessed, having a college level of education or higher compared with less than a college education showed a differential effect over time, with those with a college level of education or more having lower SPADI scores (P = .004). Partial-thickness tear versus full-thickness tear also had an interaction with follow-up duration, such that those with a partial-thickness tear had lower SPADI scores (P = .0002).

CONCLUSION:

Longitudinal predictors of better outcomes of the nonoperative treatment of rotator cuff tears included being married, having at least a college education, shorter duration of symptoms, light or manual labor in daily work, alcohol use of 1 to 2 times per week or more, partial-thickness tear, and absence of fatty infiltration of the rotator cuff. Our results suggest that nonoperative treatment should be performed early for optimal outcomes. These data can be used to select optimal candidates for the nonoperative treatment of rotator cuff tears and to assist with patient education and expectations before treatment.

Orthop J Sports Med. 2018 Aug 3;6(8):2325967118788531. doi: 10.1177/2325967118788531. eCollection 2018 Aug.

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