Patients with Subacromial Pain Diagnosis, Treatment and Outcome in Primary Care
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Linköping University Medical Dissertations No. 834 Patients with Subacromial Pain Diagnosis, treatment and outcome in primary care Kajsa Johansson Primary Care Department of Health and Society Linköpings universitet S-581 83 Linköping, Sweden Linköping 2004 Patients with subacromial pain - diagnosis, treatment and outcome in primary care Kajsa Johansson, 2004 Illustration on the cover and figure 1, Mats Foldevi, 2004 Published articles have been reprinted with the permission of the copyright holder: Paper I © Reprinted with permission of the Oxford University Press Paper II © Reprinted with permission of the Royal College of General Practitioners ISBN 91-7373-803-4 ISSN 0345-0082 Printed in Sweden by Unitryck, Linköping 2004 To my parents, Gunnar and Tuula To Stefan, our daughter Emma and our unborn child The first key to wisdom is constant and frequent questioning, for by doubting we are led to question and by questioning we arrive at the ‘truthʹ Peter Abelard 1079-1142 (a French philosopher) CONTENT ABSTRACT .................................................................................................................. 1 THE THESIS ................................................................................................................ 3 LIST OF PAPERS ........................................................................................................ 5 ABBREVIATIONS AND DEFINITIONS .............................................................. 7 INTRODUCTION....................................................................................................... 9 Pathogenesis and aetiology of subacromial pain ................................................. 9 The diagnostics of subacromial pain .................................................................... 11 Prevalence................................................................................................................... 14 The natural- and clinical course of subacromial pain ....................................... 14 Treatment in primary care....................................................................................... 15 Acupuncture.................................................................................................... 15 Exercise therapy............................................................................................... 16 Ultrasound therapy.......................................................................................... 17 Outcome measures.................................................................................................... 17 Predictors of outcome............................................................................................... 18 Evidence-based medicine........................................................................................ 19 AIMS ........................................................................................................................... 21 Specific aims .............................................................................................................. 21 MATERIALS AND METHODS............................................................................. 23 Materials ..................................................................................................................... 23 Paper I and II........................................................................................................ 23 Paper III................................................................................................................. 24 Paper IV ................................................................................................................ 25 Procedure for inclusion.................................................................................... 25 Ethics ..................................................................................................................... 26 Methods ...................................................................................................................... 28 Paper I ................................................................................................................... 28 Paper II.................................................................................................................. 29 A study of GPs’ and PTs’ trust in existing treatments .................................. 29 Systematic critical review................................................................................ 29 Paper III................................................................................................................. 31 Concurrent validity ......................................................................................... 31 Intra- and inter-observer reliability................................................................. 32 Paper IV ................................................................................................................ 33 Treatments....................................................................................................... 34 Data analysis.............................................................................................................. 35 REVIEW OF RESULTS ............................................................................................ 37 Current management of patients with subacromial pain in primary care (paper I).......................................................................................................................37 Efficacy for trusted treatments in primary care (paper II) ................................ 40 Concurrent validity and intra- and inter-observer reliability of the standardised strength test (paper III).................................................................... 42 Efficacy of acupuncture compared to therapeutic ultrasound, both combined with home exercises (paper IV).............................................................................. 44 GENERAL DISCUSSION ....................................................................................... 49 Results .........................................................................................................................49 Methodological discussion and the results credibility ..................................... 51 Study populations / participants....................................................................... 51 Study designs ....................................................................................................... 53 Outcome measures and analysis in paper IV.................................................. 55 Implications for clinical practice ........................................................................... 56 Future research of interest....................................................................................... 57 CONCLUSIONS ....................................................................................................... 59 SUMMARY IN SWEDISH...................................................................................... 61 DESCRIPTION OF CONTRIBUTION................................................................. 63 ACKNOWLEDGEMENTS...................................................................................... 65 REFERENCES ............................................................................................................ 67 Appendix A ................................................................................................................ 79 Appendix B................................................................................................................. 81 Appendix C ................................................................................................................ 83 The articles are not published electronically due to copyright restrictions PAPER I-IV FIGURES Figure 1 The anatomical structures thought to be involved in subacromial pain ............................................................................................................ 10 Figure 2 Flow-chart of the study sample in paper IV........................................ 27 Figure 3 Pattern of diagnosing for GPs and PTs ................................................ 38 Figure 4 Pattern of physical examinations for GPs and PTs ............................ 38 Figure 5 General practitioners choice of treatment of the case ........................ 39 Figure 6 Physiotherapists choice of treatment of the case ................................ 40 Figure 7 The change in the combined score from baseline to each follow-up for the treatment groups for those adhering to study protocol........ 46 TABLES Table 1 Diagnostic tests used in clinical research for diagnosis of patients with subacromial pain ............................................................................ 12 Table 2 The diagnostic value of different clinical tests for subacromial pain .................................................................................................................... 13 Table 3 Data for the included patients/participants in paper I-IV................. 24 Table 4 Description of the non-responders age and gender, and a summary of the reasons for not responding to the questionnaire..................... 24 Table 5 Reviewers’ conclusions about evidence for trusted treatments and the proposed effect in relation to grade of evidence and methodological quality..........................................................................