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Objectives: This study compares the prevalence of radiological osteoarthritis (OA) in patients with type 1 diabetes mellitus (DM1) for > 45 years and controls, and explores the association with shoulder pain and glycaemic burden in patients with DM1.Method: The Dialong study is a cross-sectional, observational study with 30 years of historical data on long-term glycaemic control. We included 102 patients with DM1 and 73 diabetes-free controls. Demographic data, worst shoulder pain last week [numeric rating scale (NRS) 0-10], pain on abduction at examination (NRS 0-10), and current and historical glycosylated haemoglobin (HbA1c) levels were collected. Standardized shoulder X-rays were taken and interpreted for OA applying the Kellgren-Lawrence classification.Results: In the diabetes group (49% women), the mean ± sd duration of DM1 was 50.6 ± 4.8 years, mean 30 year HbA1c 7.4%, and age 61.9 ± 7.1 years. The mean age of controls (57% women) was 62.6 ± 7.0 years. Radiological glenohumeral OA was found in 36 diabetes patients (35%) and 10 controls (14%) [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.6 to 7.5; p = 0.002]. Few persons had moderate and severe OA [6.9% vs 1.3%, OR 5.3 (95% Cl 0.6 to 44.1); p = 0.1]. Fifteen diabetes patients had painful OA versus two controls (adjusted OR 5.4, 95% CI 0.6 to 47.9; p = 0.13). There was no association between OA and long-term glycaemic burden (mean 30 year HbA1c) in the diabetes group (p > 0.2).Conclusions: Radiological glenohumeral OA was more common in patients with DM1 than in controls for mild, but not moderate and severe OA. The radiological findings were not associated with shoulder pain or long-term glycaemic burden. [ABSTRACT FROM AUTHOR]

Background: Instruments designed to measure the subjective impact of painful shoulder conditions have become essential in shoulder research. The Shoulder Pain and Disability Index (SPADI) is one of the most extensively used scales of this type. The objective of this study was to investigate reproducibility and responsiveness of the SPADI in patients with adhesive capsulitis.Methods: SPADI test-retest reproducibility was estimated by the "intraclass correlation coefficient" (ICC) and the "smallest detectable difference" (SDD). Responsiveness was assessed by exploring baseline and follow-up data recorded in a recently reported clinical trial regarding hydrodilatation and corticosteroid injections in 76 patients with adhesive capsulitis. "Standardized response mean" (SRM) and "reliable change proportion" (RCP) for SPADI were compared with corresponding figures for shoulder range-of-motion (ROM). The relationship between SPADI and ROM change scores was investigated through correlation and linear regression analyses.Results: Results for test-retest reproducibility indicated a smallest detectable difference of 17 points on the 0-100 scale, and an intraclass correlation coefficient of 0.89. The SPADI was generally more responsive than ROM. Weak to moderately strong associations were identified between SPADI and ROM change scores. According to the regression model, the three variables baseline SPADI, baseline active ROM and change in active ROM together explained 60% of the variance in SPADI improvement.Conclusion: This study supports the use of SPADI as an outcome measure in similar settings. [ABSTRACT FROM AUTHOR]

Background: Self-report questionnaires play an important role as outcome measures in shoulder research. Having an estimate of the measurement error of these questionnaires is of importance when assessing follow-up results after treatment and when planning intervention studies. The aim of this study was to cross-culturally adapt the Norwegian version of the OSS and WORC questionnaire and examine and compare agreement, reliability and construct validity of the disease-specific shoulder questionnaire WORC with two commonly used shoulder questionnaires, SPADI and OSS, in patients with rotator cuff disease.Methods: 74 patients with rotator cuff disease were recruited from the outpatient clinic of the Physical Medicine and Rehabilitation Department at Ullevaal University Hospital in Oslo, Norway. A test-retest design was used, and the questionnaires were filled out by the patients at the clinic, with a one week interval between test administrations. Agreement (repeatability coefficient), reliability (ICC) and construct validity were examined and compared for WORC, SPADI and OSS.Results: Reliability analysis was restricted to the 55 patients (51 +/- 10 yrs) who reported no change between test administrations according to scoring on a global scale. The agreement, reliability and construct validity was moderate for all three questionnaires with ICC ranging from 0.83 to 0.85, repeatability coefficient from 16.1 to 19.7 and Spearman rank correlations between total scores from r = 0.57 to 0.69. There was a lower degree of floor and ceiling effects in SPADI compared to WORC and OSS.Conclusion: We conclude that the agreement and reliability of the three shoulder questionnaires examined, WORC index, SPADI and OSS are acceptable and that differences between scores were small. The Norwegian version of the questionnaires is acceptable for assessing Norwegian-speaking patients with rotator cuff disease. The moderate agreement and construct validity should be taken into consideration when assessing follow-up results after treatment and in the planning of prospective studies. [ABSTRACT FROM AUTHOR]

Background: Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated.Methods: In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial.Results: The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0-100 scale. T-tests did not demonstrate any significant between-group differences in range of motion.Conclusion: This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone.Trial Registration: The study is registered in Current Controlled Trials with the registration number ISRCTN90567697. [ABSTRACT FROM AUTHOR]

Objectives: The etiology of fibromyalgia (FM) is disputed, and there is no established cure. Quantitative data on how this may affect patients' healthcare experiences are scarce. The present study aims to investigate FM patients' pain-related healthcare experiences and explore factors associated with high satisfaction and pain relief., Methods: An anonymous, online, and patient-administered survey was developed and distributed to members of the Norwegian Fibromyalgia Association. It addressed their pain-related healthcare experiences from both primary and specialist care. Odds ratios for healthcare satisfaction and pain relief were estimated by binary logistic regression. Directed acyclic graphs guided the multivariable analyses., Results: The patients ( n = 1,626, mean age: 51 years) were primarily women (95%) with a 21.8-year mean pain duration and 12.7 years in pain before diagnosis. One-third did not understand why they had pain, and 56.6% did not know how to get better. More than half had not received satisfactory information on their pain cause from a physician, and guidance on how to improve was reported below medium. Patients regretted a lack of medical specialized competence on muscle pain and reported many unmet needs, including regular follow-up and pain assessment. Physician-mediated pain relief was low, and guideline adherence was deficient. Only 14.8% were satisfied with non-physician health providers evaluating and treating their pain, and 21.5% were satisfied (46.9% dissatisfied) with their global pain-related healthcare. Patients' knowledge of their condition, physicians' pain competence and provision of information and guidance, agreement in explanations and advice, and the absence of unmet needs significantly increased the odds of both healthcare satisfaction and pain relief., Conclusions: Our survey describes deficiencies in FM patients' pain-related healthcare and suggests areas for improvement to increase healthcare satisfaction and pain relief. (REC# 2019/845, 09.05.19)., (© 2024 the author(s), published by De Gruyter.)

Objective: To compare treatment effects between ultrasound guided lavage with corticosteroid injection and sham lavage with and without corticosteroid injection in patients with calcific tendinopathy of the shoulder., Design: Pragmatic, three arm, parallel group, double blinded, sham controlled, randomised, superiority trial with repeated measurements over 24 months., Setting: Six hospitals in Norway and Sweden., Participants: 220 adults with calcific tendinopathy of the shoulder, persistent for at least three months., Interventions: Ultrasound guided deposit lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (lavage+steroid); sham lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (sham lavage+steroid); or sham lavage plus subacromial injection of 10 mL 1% lidocaine hydrochloride (sham). All patients received a physiotherapeutic treatment regimen consisting of four home exercises., Main Outcome Measures: The primary outcome was the result on the 48 point scale (0=worst; 48=best) of the Oxford Shoulder Score (OSS) at four month follow-up. Secondary outcomes included measurements on the short form of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) and of pain intensity up to 24 months. The influence of the size of the deposit at baseline and of the persistence or disappearance of the deposit was investigated., Results: Data from 218 (99%) participants were included in the primary analysis. Differences between groups on the OSS at four months were not significant: lavage+steroid versus sham 0.2 (95% confidence interval -2.3 to 2.8; P=1.0); sham lavage+steroid versus sham 2.0 (-0.5 to 4.6; P=0.35); lavage+steroid versus sham lavage+steroid -1.8 (-4.3 to 0.7; P=0.47). After four months, 143 patients with insufficient treatment effect received supplementary treatment. At 24 months, none of the study procedures was superior to sham. No serious adverse events were reported., Conclusions: This study found no benefit for ultrasound guided lavage with a corticosteroid injection or for sham lavage with a corticosteroid injection compared with sham treatment in patients with calcific rotator cuff tendinopathy of the shoulder., Trial Registration: NCT02419040EudraCT 2015-002343-34; Ethical committee Norway 2015-002343-34; Ethical committee Sweden 2015/79-31; Clinicaltrials.gov NCT02419040., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: support from the Bergersen Foundation, Aase Bye and Trygve J.B. Hoffs foundation, Smith and Nephew, and the Medical Research Council of Southeast Sweden; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Greater Trochanteric Pain Syndrome (GTPS) is a common chronic musculoskeletal condition that may affect physical function, quality of life and sleep. The Victorian Institute of Sport Assessment-Gluteal questionnaire (VISA-G) has been developed as a Patient-Reported Outcome Measurement (PROM) to address pain, everyday activities, physical activities, and difficulty with weight bearing activities. The aim of the study was to test the reliability, validity and floor and ceiling effects of the Norwegian version of the VISA-G (VISA-G-Norwegian) in a population with GTPS in a specialist health care setting., Methods: This psychometric evaluation of the VISA-G-Norwegian questionnaire were conducted with a prospective observational design. The VISA-G was translated into Norwegian following recommended guidelines. A subgroup repeated the VISA-G-Norwegian a week after the initial submission. For the reliability, the Intraclass Correlation Coefficient (ICC 2.1 ), Standard Error of the Measurement (SEM) and the Smallest Detectable Change (SDC 95% ) were calculated. Internal consistency was measured using a Cronbach´s alpha. Floor and ceiling effects were evaluated, and construct validity was assessed with three a priori hypotheses., Results: 78 participants were included in the study of which 47 stable participants undertook the test-retest reliability arm of the study. The ICC 2.1 for the total score was 0.85 (95% CI 0.68, 0.92), SEM was 6.6 points and SDC 95% 18.4 points. Cronbach`s alpha was 0.77 (95% CI 0.69, 0.84). No floor or ceiling effects were found in the total score, but ceiling effect was found in three of the eight items. For construct validity, one of the three hypotheses were confirmed. VISA-G-Norwegian correlated to the modified Harris Hip Score (mHHS), Oswestry Disability Questionnaire (ODI) and Numeric Pain Rating Scale (NPRS), 0.64, -0.75 and - 0.63 respectively., Conclusion: The VISA-G-Norwegian has acceptable reliability and validity, despite ceiling effect of individual items. The large SDC 95% should be considered when measuring change in similar cohorts with GTPS. For a potential future version, it would be recommended to consider response options for questions with ceiling effect and the comprehensibility of question eight., Trial Registration: Registered at ClinicalTrials.gov the 28/02/2020 (NCT04289922)., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Patellofemoral pain (PFP) is commonly described and approached in biomechanical terms despite strong evidence that psychosocial factors such as kinesiophobia, emotional distress, and self-efficacy are important in long-standing musculoskeletal pain., Purpose: To describe levels of self-efficacy, emotional distress, kinesiophobia, and widespread pain in a cohort with long-standing PFP and determine their association with measures of pain, function, and health-related quality of life., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Included were 112 patients with PFP (age range, 16-40 years) who had been recruited to a randomized controlled trial. Seven baseline factors (patient sex, pain duration, number of pain sites throughout the body, kinesiophobia [Tampa Scale of Kinesiophobia], emotional distress [Hopkins Symptom Checklist], self-efficacy, and knee extension strength) were investigated for associations with the following outcomes: symptoms of PFP (Anterior Knee Pain Scale), pain (worst and usual), and health-related quality of life (5-level EuroQol-5 Dimensions [EQ-5D-5L]). We used bivariate models and multivariable linear regression models with a stepwise backward removal method to find associations with the outcomes. Internal validation was conducted, and adjusted coefficients after shrinkage are presented., Results: Of the study patients, 28% reported emotional distress (Hopkins Symptom Checklist ≥1.75), 69% reported multiple pain sites, and 33% had widespread pain. The kinesiophobia score was elevated, with a mean score of 35.4 ± 8.2. Self-efficacy was strongly associated with better function (Anterior Knee Pain Scale) and health-related quality of life (EQ-5D-5L) as well as lower pain scores in bivariate and multivariable models. Self-efficacy and emotional distress explained 50% of the variance in health-related quality of life (EQ-5D-5L)., Conclusion: Our findings support other studies of PFP suggesting elevated levels of kinesiophobia and emotional distress and higher rates of widespread pain compared with the general population or pain-free controls. Higher self-efficacy was associated with better function and health-related quality of life. Together with emotional distress, it explained half the variance of health-related life quality. The results underline the importance of approaching these patients in a biopsychosocial model., Registration: NCT02114294 (ClinicalTrials.gov identifier)., Competing Interests: The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Introduction: Research suggests that current care for shoulder pain is not in line with the best available evidence. This project aims to assess the effectiveness, cost-effectiveness and the implementation of an evidence-based guideline for shoulder pain in general practice in Norway., Methods and Analysis: A stepped-wedge, cluster-randomised trial with a hybrid design assessing clinical effectiveness, cost-effectiveness and the effect of the implementation strategy of a guideline-based intervention in general practice. We will recruit at least 36 general practitioners (GPs) and randomise the time of cross-over from treatment as usual to the implemented intervention. The intervention includes an educational outreach visit to the GPs, a computerised decision tool for GPs and a self-management application for patients. We will measure outcomes at patient and GP levels using self-report questionnaires, focus group interviews and register based data. The primary outcome measure is the patient-reported Shoulder Pain and Disability Index measured at 12 weeks. Secondary outcomes include the EuroQol Quality of Life Measure (EQ5D-5L), direct and indirect costs, patient's global perceived effect of treatment outcome, Pain Self-Efficacy and Brief Illness Perception Questionnaire. We will evaluate the implementation process with focus on adherence to guideline treatment. We will do a cost-minimisation analysis based on direct and selected indirect costs and a cost-utility analysis based on EQ5D-5L. We will use mixed effect models to analyse primary and secondary outcomes., Ethics and Dissemination: Ethics approval was granted by the Regional Committee for Medical and Health Research Ethics-South East Norway (ref. no: 2019/104). Trial results will be submitted for publication in a peer-reviewed medical journal in accordance with Consolidated Standards of Reporting Trials., Trial Registration Number: NCT04806191., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To determine the reliability, validity, responsiveness, and interpretability of the Norwegian Anterior Knee Pain Scale (AKPS) in patients with patellofemoral pain (PFP)., Methods: The AKPS was translated into Norwegian. One hundred and twelve patients with PFP participated in a randomized controlled trial. Fifty stable patients completed the AKPS at a one-week interval for test-retest reliability. Smallest detectable change (SDC) and floor/ceiling effects were evaluated. Validity and responsiveness were assessed using hypothesis testing for correlations with other scores and known-group validity. Minimal important change (MIC) and responsiveness were evaluated at three months., Results: Intraclass correlation coefficient (ICC agreement ) for sum score was 0.83. Smallest detectable change was 13. No floor/ceiling effects were found for total score, but ceiling effects were found on eight of 13 individual items. Hypothesis testing for construct validity and responsiveness was largely confirmed but correlations were moderate to low. The MIC was 11. Area under receiver operating characteristic curve was 0.66 (95% CI 0.56-0.77) indicating moderate responsiveness., Conclusions: The Norwegian AKPS had comparable measurement properties to other versions, with acceptable reliability and construct validity. We found moderate responsiveness which may be related to ceiling effects on several items.Implications for rehabilitationThe Anterior Knee Pain Scale (AKPS) is a commonly used outcome measure in patellofemoral pain, having acceptable reliability and moderate responsiveness.A change in AKPS total score of 11 points would be considered important by the patient, although changes up to 13 points may be due to measurement error.The AKPS has limitations including ceiling effects on most individual items in this patient population, and low correlation between pain and AKPS that questions the validity of the score. A revision of the score should be considered.

Objectives Recommendations for referral of patients with shoulder pain from primary to specialist care are mainly clinical. Several patients are referred without meeting these criteria for referral, whereas some are referred for a second opinion although surgery is not recommended. The aims of this study were to describe a shoulder pain cohort in specialist healthcare according to demographic data, clinical, and psychological factors; evaluate changes in pain and disability, distress and main symptoms from baseline to six-month follow-up; and to assess predictors of pain and disability, changes in the main symptoms and sick-leave at six-months. Results were compared to previous randomised trials conducted at the same clinic in patients with subacromial shoulder pain. Methods This prospective study included 167 patients from an outpatient clinic in specialist healthcare with shoulder pain for more than 6 weeks. Clinical (pain duration, intensity, pain sites), sociodemographic (age, gender, educational level, work status) and psychological variables (emotional distress (HSCL-10), fear of pain, screening of "yellow flags", health-related quality of life) were collected. Shoulder pain and disability (SPADI-score) were assessed and the patients were asked about their outcome expectation and to predict their status of their shoulder problem the next month. They underwent a clinical interview, a clinical assessment of shoulder function and orthopaedic tests for diagnostic purposes. After six months they received a questionnaire with main variables. Results Of the 167 patients (55% women), 50% had symptoms for more than 12 months and 37 (22%) were on sick-leave. Characteristics were in general comparable to patients previously included in clinical trials at the same department. The SPADI-score was 46 (23) points. Mean emotional distress was within the normal range (1.7 (SD 0.6)). More than 80% had received treatment before, mainly physiotherapy in addition to the GPs treatment. One hundred and thirty-seven patients (82%) were re-referred to physiotherapy, 74 (44%) in the outpatient clinic specialist healthcare, and 63 (38%) in primary care. One hundred and eighteen (71%) answered the follow-up questionnaire. Mean change in SPADI-score was 10.5 points (95% CI (6.5-14.5)), and 29% of the patients improved more than the smallest detectable difference (SDD). The percentage sick-listed was 19.5%, and mean change in main symptoms (-9 to +9) was 3.4 (SD 3.9). The subgroup of patients receiving physiotherapy in outpatient specialist care did not show any significant change in the main variables. The prediction models suggested that a lower level of education, more fear of pain and a high baseline SPADI-score, predicted a higher SPADI-score at follow-up. A high baseline HSCL-10 score was the only significant predictor for a high HSCL-10 score. At follow-up, less pain at rest predicted more change in main symptoms and more yellow flags (a higher score on the Örebro screening test) predicted sick-leave. Conclusions Within the limitations of a cohort study, patients with persistent shoulder pain referred to an outpatient specialist clinic had similar baseline characteristics but shorter treatment duration, inferior clinical results and predictors somewhat different compared with previous clinical trials conducted at the same clinic. The study raises some questions about the effectiveness of the routines in daily clinical practice, the selection of patients, the treatment duration and content.

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 R 2 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.

Objective: Extended follow-up of a randomized trial comparing hip-focused exercise, knee-focused exercise, and free physical activity in patellofemoral pain (PFP)., Methods: A single-blind randomized controlled trial included 112 patients aged 16-40 years (mean 27.6 years) with a clinical diagnosis of PFP ≥3 months (mean 39 months) and pain ≥3/10 on a Visual Analog Scale. Patients were randomized to a 6-week exercise-based intervention consisting of either isolated hip-focused exercises (n = 39), traditional knee-focused exercise (n = 37), or free physical activity (n = 36). All patients received the same patient education. The primary outcome measure was the Anterior Knee Pain Scale (AKPS, 0-100). Secondary outcomes were usual and worst pain, Tampa Scale of Kinesiophobia, Knee Self-Efficacy Score, Euro-Qol (EQ-5D-5L), step-down test, and isometric strength. Blinded observers assessed outcomes at baseline, 3, and 12 months. The study was designed to detect a difference in AKPS >10 at 12 months., Results: After 1 year, there were no significant between-group differences in any primary or secondary outcomes. Between-group differences for AKPS were as follows: knee versus free physical activity -4.3 (95% CI -12.3 to 3.7); hip versus free physical activity -1.1 (95% CI -8.9 to 6.7); and hip versus Knee 3.2 (95% CI -4.6 to 11.0). The cohort as a whole improved significantly at 3 and 12 months compared to baseline for all measures except for knee extension strength., Conclusion: After 1 year, there was no difference in effectiveness of knee exercise, hip exercise, or free physical activity, when combined with patient education in PFP., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Identification of factors predictive of outcome and change is important to improve treatment for patellofemoral pain (PFP). Few studies have examined the predictive value of psychological factors in PFP, although they have been reported to be important predictors in other musculoskeletal pain conditions., Purpose: To evaluate predictors of pain, function, and change 1 year after an exercise-based intervention in PFP., Study Design: Cohort study; Level of evidence, 3., Methods: In sum, 112 patients were recruited to a randomized controlled trial; 98 attended 1-year follow-up. There were no between-group differences in the trial; thus, the material was analyzed as 1 cohort. Nine baseline factors-sex, bilateral pain, worst pain, pain duration, Anterior Knee Pain Scale (AKPS), kinesiophobia, anxiety and depression, self-efficacy, and number of pain sites throughout the body-were investigated for their predictive ability on outcome at 1 year (AKPS, worst pain) and for change at 1 year (global change score, change in AKPS, and change in worst pain). Multivariable linear regression models with stepwise backward removal method were used to find predictors of poor outcome., Results: Number of pain sites at baseline was a significant predictor of worse outcome for AKPS ( B = -2.7; 95% CI, -4.0 to -1.3; P < .01), worst pain ( B = 0.5; 95% CI, 0.2-0.8; P < .01), global change ( B = -0.8; 95% CI, -1.2 to -0.5; P < .01), change in AKPS ( B = -2.7; 95% CI, -4.0 to -1.3; P < .01), and change in worst pain ( B = 0.5, 95% CI, 0.2-0.8; P < .01) at 1 year. Baseline scores for AKPS and worst pain predicted respective 1-year levels and change scores ( P < .01). Lower self-efficacy and male sex predicted less global change ( P < .01). Longer pain duration predicted final score and change score for worst pain ( P < .01). The predictive models had reasonable fit with adjusted R 2 from 0.22 to 0.35., Conclusion: Higher number of pain sites throughout the body was a consistent predictor of poor outcome and less change at 1 year. Baseline levels for AKPS and worst pain predicted respective final scores and change scores., Registration: NCT02114294 ( ClinicalTrials.gov identifier).

Background: Exercise for patellofemoral pain (PFP) is traditionally knee focused, targeting quadriceps muscles. In recent years, hip-focused exercise has gained popularity. Patient education is likely an important factor but is underresearched., Purpose: To compare 3 treatment methods for PFP, each combined with patient education: hip-focused exercise, knee-focused exercise, or free physical activity., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: A single-blind randomized controlled trial was performed with 112 patients who were 16 to 40 years old (mean, 27.6 years) and had a symptom duration >3 months (mean, 39 months) with a clinical diagnosis of PFP and no radiograph or magnetic resonance evidence of other pathology. Patients were randomized to a 6-week intervention consisting of patient education combined with isolated hip-focused exercise (n = 39), traditional knee-focused exercise (n = 37), or free physical activity (n = 36). The primary outcome was Anterior Knee Pain Scale (0-100) at 3 months. Secondary outcomes were visual analog scale for pain, Tampa Scale for Kinesiophobia, Knee Self-efficacy Scale, EuroQol, step-down, and isometric strength., Results: There were no between-group differences in any primary or secondary outcomes at 3 months except for hip abduction strength and knee extension strength. Between-group differences at 3 months for Anterior Knee Pain Scale were as follows: knee versus control, 0.2 (95% CI, -5.5 to 6.0); hip versus control, 1.0 (95% CI, -4.6 to 6.6); and hip versus knee, 0.8 (95% CI, -4.8 to 6.4). The whole cohort of patients improved for all outcomes at 3 months except for knee extension strength., Conclusion: The authors found no difference in short-term effectiveness in combining patient education with knee-focused exercise, hip-focused exercise, or free training for patients with PFP., Registration: NCT02114294 (ClinicalTrials.gov identifier).

Objective: In the present study, we evaluate the intra- and interrater agreement of radiological glenohumeral OA using three different classification systems and estimate the prevalence of radiological and clinical glenohumeral OA in patients with type 1 diabetes mellitus (DM1), for over 45 years and controls (The Dialong study)., Materials and Methods: We included 102 patients with DM1 (49% women, mean age, 61.9 years) and 73 controls (57% women, mean age, 62.6 years). Anterior-posterior shoulder radiographs were interpreted by two observers applying the Kellgren-Lawrence (K-L), Samilson-Prieto (S-P) and Samilson-Prieto Allain (S-PA) classifications., Results: The interrater agreement was moderate (weighted kappa, 0.46 to 0.48) for all classifications and the intrarater agreement mainly substantial (0.48-0.86) for both observers. The agreed prevalence of radiological OA was 26 and 18% (OR 1.6 (0.8 to 3.3), p = 0.22, 44 and 26% (OR 2.2 (1.2 to 4.2), p = 0.02) and 30 and 17% (OR 2.1 (1.0 to 4.5), p = 0.05) for the K-L, S-P and S-PA classifications respectively in the diabetes and control groups. The prevalence of moderate or severe radiological OA was 1 to 6% and clinical OA 1 to 2% with no difference between the groups., Conclusion: The prevalence of radiological glenohumeral OA was higher in the diabetes group with the Samilson-Prieto classification systems, but not associated with clinical OA. The interrater agreement was moderate. We recommend the Samilson-Prieto Allain classification for glenohumeral OA to avoid interpretation of osteophytes < 1 mm as OA in patient groups with a low pre-test likelihood of glenohumeral OA.

Background: Radial Extracorporeal Shock Wave Therapy (rESWT) is increasingly used to treat patients with subacromial pain syndrome despite conflicting evidence of its effectiveness. Better knowledge regarding prognostic factors may contribute to the improvement in treatment and prognosis for the patients., Aim: The first aim of this study was to evaluate the effect of rESWT in addition to supervised exercises in patients with subacromial pain syndrome after one year. The second aim was to identify predictors of pain and disability and work status after one year in this patient group., Design: A randomized, double-blind, sham-controlled trial., Setting: An outpatient shoulder clinic of a University hospital., Methods: Patients aged 25 to 70 years, with subacromial pain syndrome lasting at least three months were included and randomly assigned to receive either rESWT and supervised exercises or sham rESWT and supervised exercises. The Shoulder Pain and Disability Index (SPADI) and work status were assessed after one year., Results: We screened 265 patients and enrolled 143; 74 were allocated to receive sham rESWT and exercises, and 69 were allocated to receive rESWT and exercises. After one year, no differences were found for the SPADI Score (mean difference -1.6, 95% confidence interval (CI) -10.2 to 7.0, P=0.71). Subgroup analysis of patients with calcification in the rotator cuff demonstrated no significant additional effect of rESWT to supervised exercises (mean difference -6.3, 95% CI -22.4 to 9.8, P=0.44). Marital status (single), frequent use of pain medication, not working at baseline, negative outcome expectations, low self-reported general health status and few supervised exercise sessions predicted a poor outcome on SPADI after one year., Conclusions: Radial ESWT was not superior to sham rESWT in addition to supervised exercises in the long term for patients with subacromial pain syndrome. The identified predictors for pain, disability and work should be assessed in future studies and addressed by clinicians in order to improve the effectiveness of supervised exercises., Clinical Rehabilitation Impact: Radial ESWT should not be recommended for patients with subacromial pain syndrome. Clinicians should assess patient`s outcome expectations, and if possible reduce the use of pain medication and sick leave in this patient group.

Background: Previous studies on shoulder patients have suggested that the prevalence of rotator cuff or bursa abnormalities are weakly related to symptoms and that similar findings are often found in asymptomatic persons. In addition, it is largely unknown whether structural changes identified by magnetic resonance imaging (MRI) affect outcome after treatment for shoulder pain. The purpose of this study was therefore to evaluate the presence of structural changes on MRI in patients with subacromial pain syndrome and to determine to what extent these changes are associated with symptoms and predict outcome after treatment (evaluated by the Shoulder Pain and Disability Index (SPADI))., Methods: A prospective, observational assessment of a subset of shoulder patients who were included in a randomized study was performed. All participants had an MRI of the shoulder. An MRI total score for findings at the AC joint, subacromial bursa and rotator cuff was calculated. Multiple linear regression analysis was applied to examine the relationship between the MRI total score and the outcome measure at baseline and to examine to what extent the MRI total score was associated with the change in the SPADI score from baseline to the one year follow-up., Results: There was a weak, inverse association between the SPADI score at baseline and the MRI total score (β = -3.1, with 95% CI -5.9 to -0.34; p = 0.03), i.e. the SPADI score was higher for patients with a lower MRI total score. There was an association between the change in the SPADI score from baseline to the one year follow-up and the MRI total score (β = 8.1, 95% CI -12.3 to -3.8; p < 0.001), with a poorer outcome for patients with a higher MRI total score. Both tendinosis (p = 0.01) and bursitis (p = 0.04) were associated with a poorer outcome after one year., Conclusions: In this study, MRI findings were significantly associated with the change in the SPADI score from baseline and to one year follow-up, with a poorer outcome after treatment for the patients with higher MRI total score, tendinosis and bursitis on MRI., Trial Registration: Clinicaltrials.gov no NCT01441830 . September 28, 2011.

Background: Subacromial shoulder pain is a common complaint, and radial extracorporeal shock wave therapy (rESWT) is increasingly used to treat this condition. Although many therapists use rESWT in combination with supervised exercises, no studies have evaluated the additional effect of rESWT with supervised exercises for subacromial shoulder pain., Purpose: To assess whether rESWT is more effective than sham rESWT when combined with supervised exercises for improving pain and function in patients with subacromial shoulder pain., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: Patients between 25 and 70 years of age with subacromial shoulder pain with and without calcification in the rotator cuff lasting at least 3 months were assessed for eligibility; 143 patients were recruited. Participants were allocated (1:1) by computer-generated randomization in blocks of 20 to receive either rESWT or sham rESWT in addition to supervised exercises. The rESWT and sham rESWT were performed once a week with additional supervised exercises once a week for the first 4 weeks. The following 8 weeks, the patients received supervised exercises twice a week. The primary outcome was change in the Shoulder Pain and Disability Index (SPADI) after 24 weeks. Patients and outcome assessors were masked to group assignment., Results: At 24 weeks, participants in both the sham group and the rESWT group had improved ( P < .001) in SPADI score compared with baseline (-23.9 points [SD, 23.8 points] and -23.3 points [SD, 25.0 points], respectively), but there were no differences between the groups (mean difference 0.7; 95% CI, -6.9 to 8.3; P = .76). Prespecified subgroup analysis of patients with calcification in rotator cuff showed that the rESWT group had a greater improvement in SPADI score after 24 weeks (mean difference -12.8; 95% CI, -24.8 to -0.8; P = .018)., Conclusion: Radial ESWT offered no additional benefit to supervised exercises in the treatment of subacromial shoulder pain after 24 weeks, except in the subgroup of patients with calcification in the rotator cuff. Registration: NCT01441830 ( ClinicalTrials.gov identifier).

Aims: We aimed to: (i) estimate the prevalence of Dupuytren's disease, trigger finger, carpal tunnel syndrome and frozen shoulder; (ii) assess stiffness of the hand, shoulder and back; and (iii) explore the association of joint stiffness with both long-term HbA 1c and collagen advanced glycation end-products (AGEs) in long-term type 1 diabetes mellitus (T1DM)., Methods: Patients with T1DM from 1970 or earlier attending a specialized diabetes center were included in this cross-sectional controlled study. We collected HbA 1 /HbA 1c measurements from 1980 to 2015 and data on hand and shoulder diagnoses and joint stiffness through interviews, charts, and standardized examination. Skin biopsies were analyzed for collagen AGEs by liquid chromatography-mass spectrometry., Results: Lifetime prevalence of hand and shoulder diagnoses in the diabetes group (n=102) ranged from 37%-76% (frozen shoulder) versus 11%-15% in controls (n=73) (p<0.001). There was an association between joint stiffness and long-term HbA 1c (odds ratio 2.01 [95% CI 1.10-3.7]) and the AGEs methyl-glyoxal-lysine-dimer (odds ratio 1.68 [95% CI 1.03-2.73]) and pentosidine (odds ratio 1.81 [95% CI 1.04-3.16])., Conclusions: Patients with T1DM >45years had a very high prevalence of hand and shoulder diagnoses versus controls. Joint stiffness was associated with collagen AGEs. However, joint biopsies and prospective studies must explore this association further., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To compare the prevalence of shoulder disorders and self-reported shoulder disability in patients with long-term type 1 diabetes mellitus and diabetes-free subjects; and to explore the association between the long-term glycemic burden and shoulder disability in the diabetes group., Design: Cross-sectional study of shoulder diagnoses with 30 years' historical data on glycemic burden in patients with diabetes., Setting: Diabetics center and a university hospital., Participants: Subjects attending the Norwegian Diabetics Center in 2015 with type 1 diabetes since 1970 or earlier were eligible (N=136). One hundred and five patients were included, and 102 (50% women; mean age, 61.9y) completed the study together with 73 diabetes-free subjects (55% women; mean age, 62.5y)., Interventions: Not applicable., Main Outcome Measure: Shoulder diagnoses decided through clinical examination according to scientific diagnostic criteria., Results: Frozen shoulder was diagnosed in 60 (59%) patients with diabetes and 0 diabetes-free subjects, with a lifetime prevalence of 76% in the diabetes group versus 14% in the diabetes-free subjects. Patients with diabetes had higher disability and higher mean QuickDASH scores (23.0±19.9) than diabetes-free subjects (8.9±12.0), with a mean difference of -14.2 (95% confidence interval, -19.3 to -9.0) points (P<.001). We found an association between chronic hyperglycemia and QuickDASH scores, with a 6.16-point increase in QuickDASH scores per unit increase in glycated hemoglobin A 1c (HbA 1c ) (P=.014)., Conclusions: The point prevalence of frozen shoulder in patients with long-lasting type 1 diabetes was 59%, and the lifetime prevalence was 76%. The diabetes group had more shoulder disability than diabetes-free subjects. The historical HbA 1c level was associated with increased shoulder disability., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To explore whether having long-term type 1 diabetes (>45 years) is associated with a higher prevalence of radiographic hand OA, erosive hand OA and increased hand pain, disability and stiffness., Methods: In total N = 96 persons with type 1 diabetes diagnosed before 1970 were included (mean [SD] age: 62.2 [7.4], mean [SD] HbA1c: 7.43 [0.80] and N = 49 [51%] men). Regular measurements of their HbA1c were obtained till 2015. We included N = 69 healthy controls without any diabetes (mean [SD] age: 63.0 [7.0], mean [SD] HbA1c: 5.41 [0.32], N = 29 [42%] men). The groups were compared for radiographic hand OA (Kellgren-Lawrence grade ≥2 in ≥1 joint) and erosive hand OA (central erosions in ≥1 joint), Australian/Canadian index (AUSCAN) for hand pain, disability and stiffness using regression analyses adjusted for age, sex, educational level and waist circumference., Results: We found no associations between having long term type 1 diabetes and more prevalent radiographic hand OA (OR = 0.83, 95% CI = 0.38-1.81). We found a trend towards higher prevalence of erosive hand OA in diabetes patients (OR = 2.96, 95% CI = 0.82-10.64). Strong and consistent associations were observed between long term type 1 diabetes and increased hand pain (B = 2.78, 95% CI = 1.65-3.91), disability (B = 5.30, 95% CI = 3.48-7.12) and stiffness (B = 2.00, 95% CI = 1.33-2.67). These associations were particularly strong for women and participants below the median age of 61 years., Conclusion: Long-term type 1 diabetes was not associated with radiographic hand OA, but was strongly associated with hand pain, disability and stiffness. The association between diabetes and erosive hand OA warrants further investigation.

Background: For the treatment of calcific tendinitis of the shoulder a variety of treatment regimes exist. Commonly used treatment measures include medication with oral analgesics, corticosteroid injections, extracorporeal shockwave therapy, ultrasound guided needling and lavage, and surgical treatment. Earlier cohort studies suggest that patients may benefit from these treatments, but there are few randomized studies and conflicting evidence about the effectiveness of the various treatments. In the present study we aim to compare the effectiveness of ultrasound guided needling and lavage (barbotage) together with a steroid injection to sham barbotage with and without an additional steroid injection., Methods: The study will be performed in six secondary-care institutions in Norway and Sweden. It is designed as a pragmatic, randomized, three-arm, parallel group, double-blinded, sham-controlled clinical trial with a 2-year follow-up. It will be performed on 210 patients, aged 30 years or older, presenting with painful arc, positive impingement sign and a calcium deposit > 5 mm. Randomization to one of the three treatment options will be performed by using an online central randomization system. The three treatment groups are barbotage together with a subacromial steroid injection (the barbotage group), sham barbotage together with a subacromial steroid injection (the steroid group) or sham barbotage without a subacromial steroid injection (the placebo group). In the placebo group the steroid injection will be replaced by a short-acting local anaesthetic. Standardized home-based post-treatment physiotherapy will be performed by all patients for 8 weeks. Follow-ups are at 2 and 6 weeks, 4, 8, 12 and 24 months after treatment was given and will be performed with the patients and the outcome assessors blinded for group assignment. Primary outcome will be the Oxford shoulder score at 4 month follow-up. Secondary outcome measures are the QuickDASH upper extremity score, the EQ-5D-5L general health score and visual analogue scales for pain at rest, during activity, and at night., Discussion: The scientific evidence from this placebo-controlled trial will be of importance for future treatment recommendations in patients with calcific tendinitis., Trial Registration: ClinicalTrials.gov: NCT02419040 , registered 10 April 2015 EudraCT: 2015-002343-34, registered 23 September 2015 (retrospectively registered).

Background: Patellofemoral pain syndrome (PFPS), also known as Anterior Knee Pain, is a common cause of recurrent or chronic knee pain. The etiology is considered to be multifactorial but is not completely understood. At the current time the leading theory is that pathomechanics in the patellofemoral joint leads to PFPS. Traditionally, conservative treatment has focused on improving strength and timing in the quadriceps muscles. In recent years, evidence has been accumulating to support the importance of hip control and strengthening in PFPS. Two recent studies have shown promising results for hip strengthening as an isolated treatment for PFPS. The aim of this randomised controlled trial (RCT) is to compare isolated hip strengthening to traditional quadriceps-based training and a control group with free physical activity., Methods/design: An observer-blinded RCT will be performed. We intend to include 150 patients aged 16-40 years, referred from primary care practitioners to the department of Physical Medicine and Rehabilitation in Kristiansand, Norway for PFPS with more than three months duration. Patients meeting the inclusion criteria will be randomised using opaque sequentially numbered sealed envelopes to one of three groups: isolated hip strengthening, quadriceps based training, or a control group (free physical activity). All groups will receive standardized information about PFPS formulated with the intention to minimize fear avoidance and encourage self-mastery of symptoms. Standardized exercises will be performed under supervision of a study physiotherapist once per week in addition to home training two times per week for a total of six weeks. The primary outcome measure will be the Anterior Knee Pain Score (AKPS) at three and 12 months. Secondary outcome measures will include Visual analogue scale (VAS) for pain, hip abductor and quadriceps strength, the generic EuroQol (EQ-5D), Hopkins Symptom Checklist (HSCL), Knee self-efficacy score and Tampa score for Kinesiophobia., Discussion: This trial will help to elucidate the role of hip and quadriceps strengthening in the treatment of PFPS. Information as to the role of anxiety and depression, kinesiophobia and self-efficacy will be collected, also as regards prognosis and response to exercise therapy., Trial Registration: ClinicalTrials.gov reference: NCT02114294.

Background: Shoulder pain is common in the general population. Reports on specific diagnoses in general populations are scarce and only from primary care. The diagnostic distribution of shoulder disorders in secondary care is not reported. Most of the clinical research in the shoulder field is done in hospital settings. The aim of this study was to identify the diagnoses in a 1-year cohort in a hospital-based outpatient clinic using standardized diagnostic criteria and to compare the results with previous studies., Methods: A diagnostic routine was conducted among patients referred to our physical medicine outpatient clinic at Oslo University Hospital. Diagnostic criteria were derived from the literature and supplemented with research criteria., Results: Of 766 patients diagnosed, 55% were women and the mean age was 49 years (range 19-93, SD ± 14). The most common diagnoses were subacromial pain (36%), myalgia (17%) and adhesive capsulitis (11%). Subacromial pain and adhesive capsulitis were most frequent in persons aged 40-60 years. Shoulder myalgia was most frequent in age groups under 40. Labral tears and instability problems (8%) were most frequent in young patients and not present after age 50. Full-thickness rotator cuff tears (8%) and glenohumeral osteoarthritis (4%) were more prevalent after the age of 60. Few differences were observed between sexes. We identified three studies reporting shoulder diagnoses in primary care., Conclusion: Subacromial pain syndrome, myalgia and adhesive capsulitis were the most prevalent diagnoses in our study. However, large differences in prevalence between different studies were found, most likely arising from different use of diagnostic criteria and a difference in populations between primary and secondary care. Of the diagnoses in our cohort, 20% were not reported by the studies from primary care (glenohumeral osteoarthritis, full thickness rotator cuff tears, labral tears and instabilities).

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.

The aim of this study was to establish a method for injecting corticosteroid into the rotator interval under sonographic guidance and to measure the effect on function, pain and range of motion after 4 and 12 weeks. This study involved a multicenter cohort trial and carried out at outpatient clinics of the physical medicine and rehabilitation departments in Oslo and Porsgrunn, Norway. 39 patients with adhesive capsulitis lasting between 3 and 12 months. Sonographic-guided corticosteroid and lidocaine injection into the rotator interval medial to the biceps tendon using 20 mg triamcinolon hexacetat and 3 ml 20 mg/ml xylocain. Change in the shoulder pain and disability index score (SPADI) after 12 weeks. The change in SPADI was 42 points (95 % confidence interval, 33-51). Changes in the secondary outcomes shoved highly statistically significant increase in active and passive range of motion. One ultrasound-guided corticosteroid injection into the rotator interval seems to give significant improvement in SPADI and active range of motion after 12 weeks. The protocol was evaluated by the research faculty at Oslo university hospital, dept of physical medicine. The study was regarded as regular clinical procedure as injections with triamcinolon already is standard treatment. No trial registration was obtained but the protocol presented the local ethics committee without comments.

Background: Evidence from a recent randomized controlled trial indicated that supervised exercises (SE) were more effective than radial extracorporeal shock-wave therapy (rESWT) for the treatment of subacromial shoulder pain in the short to medium term. Little knowledge exists about the long-term results of rESWT for subacromial pain., Objective: The aim of this study was to evaluate the results of rESWT and SE provided to patients with subacromial shoulder pain after 1 year., Design: This was a single-blind randomized controlled trial., Setting: The study was conducted in the outpatient clinic of the Physical Medicine and Rehabilitation Department at Oslo University Hospital, Ullevaal, Norway., Patients: One hundred four patients with subacromial shoulder pain lasting at least 3 months participated. Patients were randomly assigned to either an rESWT group (n=52) or an SE group (n=52)., Intervention: The rESWT intervention consisted of one session weekly for 4 to 6 weeks. The SE intervention consisted of two 45-minute sessions per week for up to 12 weeks., Measurements: The primary outcome measure was the Shoulder Pain and Disability Index. Secondary outcome measures were questions regarding pain and function and work status., Results: After 1 year, an intention-to-treat analysis showed no significant differences between the 2 groups for the primary outcome measure (-7.6 points, 95% confidence interval=-16.6 to 0.5) and pain, function, and medication use. Twenty-nine participants (60%) in the SE group versus 24 participants (52%) in the rESWT group were categorized as clinically improved. Thirty-eight participants in the SE group were at work compared with 30 participants in the rESWT group (odds ratio=1.1, 95% confidence interval=1.0 to 1.2). Fewer patients in the SE group had received additional treatments between 18 weeks and 1 year., Limitations: The lack of a placebo control group, the lack of a cost-benefit analysis, and the small sample size were limitations of the study., Conclusion: No significant difference was found between the SE and rESWT groups at the 1-year follow-up. More participants in the SE group had returned to work.

Background: Shoulder pain (usually non-traumatic) is the third most common cause of consultations for musculoskeletal pain in primary health care. This article discusses challenges within diagnostics and treatment of non-traumatic shoulder pain., Material and Methods: The article is based on literature identified through a non-systematic search in PubMed and the Cochrane library., Results: One clinical test alone is generally not sufficient to make a pathoanatomical diagnosis. The incidence of degenerative changes in the normal population makes it difficult to interpret diagnostic images. MR is mainly indicated as part of a preoperative assessment and upon a specific indication. For diagnosis of the rotator cuff, ultrasound is as good as MR. Clinical studies do not show clear effects of specific treatment. This may be caused by methodological weaknesses of the trials evaluated and that patient characteristics and placebo effects contribute to the diagnosis. Injection with glucocorticoids seems to be well founded in patients with adhesive capsulate (frozen shoulder). With subacromial pain, supervised physical exercise and surgical treatment have similar effects, but there is not sufficient evidence to recommend particular treatments for rupture., Interpretation: Non-traumatic shoulder pain is usually diagnosed adequately from the medical history and a combination of clinical tests; conservative treatment is most often adequate. When diagnostic imaging is required, ultrasound should be the first choice.

Background: Shoulder pain is common with rotator cuff disease as the most frequently used clinical diagnosis. There is a wide range of treatment options for this condition, but limited evidence to guide patients and clinicians in the choice of treatment strategy. The purpose of this study was to investigate possible prognostic factors of short-term outcome after corticosteroid injection for rotator cuff disease., Methods: We performed analyses of data from 104 patients who had participated in a randomized controlled study. Socio-demographic, clinical and radiographic baseline factors were assessed for association with outcome at six-weeks follow-up evaluated by Shoulder Pain and Disability Index (SPADI) and patient perceived outcome. Factors with significant univariate association were entered into multivariate linear and logistic regression analyses., Results: In the multivariate analyses; a high SPADI score indicating pain and disability at follow-up was associated with decreasing age, male gender, high baseline pain and disability, being on sick-leave, and using regular pain medication. A successful patient perceived outcome was associated with not being on sick-leave, high active abduction, local corticosteroid injection and previous cortisone injections. Structural findings of rotator cuff tendon pathology on MRI and bursal exudation or thickening on ultrasonography did not contribute to the predictive model., Conclusions: Baseline characteristics were associated with outcome after corticosteroid injection in rotator cuff disease. Sick-leave was the best predictor of poor short-term outcome., Trial Registration: Clinical trials NCT00640575.

Objectives: To compare responsiveness and minimal clinically important change (MCIC) for the disease-specific Western Ontario Rotator Cuff index (WORC) and the two region-specific questionnaires Shoulder Pain and Disability Index (SPADI) and Oxford Shoulder Scale (OSS) in patients with rotator cuff disease receiving corticosteroid injection therapy., Study Design and Setting: One hundred twenty-one patients with rotator cuff disease. Western Ontario Rotator Cuff index, SPADI, and OSS were administered before treatment and at 2 and 6 weeks after corticosteroid injection. Responsiveness was compared between questionnaires using the standardized response mean (SRM), area under the receiver operating characteristic curve, and reliable change proportion (RCP) statistics. Minimal clinically important change estimates were reported., Results: The differences between questionnaires were small and not consistent across the different responsiveness indices. Shoulder Pain and Disability Index was significantly more responsive than OSS measured by SRM and RCP at 2 and 6 weeks. Western Ontario Rotator Cuff index was significantly more responsive than OSS in RCP and area under receiver operating characteristic curve at 6 weeks. Shoulder Pain and Disability Index was significantly more responsive than WORC measured by RCP at 2 weeks. Minimal clinically important change was estimated to 5, 275, and 20 points for OSS, WORC, and SPADI, respectively., Conclusions: All questionnaires are suitable for measuring change in patients with rotator cuff disease. Disease-specific WORC index is not more responsive than the region-specific SPADI and OSS in rotator cuff disease.

Objective: To compare the effectiveness of radial extracorporeal shockwave treatment with that of supervised exercises in patients with shoulder pain., Design: Single blind randomised study., Setting: Outpatient clinic of physical medicine and rehabilitation department in Oslo, Norway., Participants: 104 patients with subacromial shoulder pain lasting at least three months., Interventions: Radial extracorporeal shockwave treatment: one session weekly for four to six weeks. Supervised exercises: two 45 minute sessions weekly for up to 12 weeks. Primary outcome measure Shoulder pain and disability index., Results: A treatment effect in favour of supervised exercises at 6, 12, and 18 weeks was found. The adjusted treatment effect was -8.4 (95% confidence interval -16.5 to -0.6) points. A significantly higher proportion of patients in the group treated with supervised exercises improved-odds ratio 3.2 (1.3 to 7.8). More patients in the shockwave treatment group had additional treatment between 12 and 18 weeks-odds ratio 5.5 (1.3 to 26.4)., Conclusion: Supervised exercises were more effective than radial extracorporeal shockwave treatment for short term improvement in patients with subacromial shoulder pain., Trial Registration: Clinical trials NCT00653081.

Background: Ultrasound-based techniques are frequently used in cardiology, gynecology and radiology. Work-related symptoms are reported for ultrasound operators, but controlled studies have not been published. We wanted to map symptoms and clinical diagnoses in ultrasound operators, compare them to matched controls and evaluate a possible relation between symptoms and exposure., Material and Methods: All ultrasound operators working at Rikshospitalet and Ullevaal University hospitals and matched controls who had other work at the hospitals were invited to participate. They answered questions about pain, well-being at the workplace, physical activity, smoking and validated function scores for the back (Oswestry Disability Index-ODI), shoulder and arm (Quick-DASH), and health- related quality of life (EQ-5D and EQ-VAS, as well as exposure time for ultrasound examinations. All participants underwent a blinded, systematic clinical examination., Results: 81 persons participated (43 women, 38 men); 44 operators and 37 controls. The ultrasound operators reported significantly more work-related pain from the wrist, elbow and shoulder and scored significantly worse on Quick-DASH (difference 6.1 [95 % CI 2.0 to 10.2, p < 0.001) and health-related function (EQ-5D). There was no difference in health-related quality of life (EQ-VAS) or back function (ODI). The number of persons with one or more clinical diagnosis was significantly higher for ultrasound operators (26/44 [59 %]) than controls (7/37 [19 %]), odds ratio 5.2; 95 % CI 2,0 to 14.0, p < 0.001. For subacromial pain the numbers were 11/44 (25 %) and 2/37 (5 %), odds ratio 5,8; CI 1.2 to 28.3, p = 0.034. For the ultrasound operators there was a significant association between exposure > 1000 min/week and Quick-DASH, subacromial pain and lateral epicondylagia., Interpretation: Ultrasound operators reported significantly more shoulder and arm complaints and clinical diagnosis than controls.

Background: The Shoulder Pain and Disability Index (SPADI) is a self-administered questionnaire that aims to measure pain and disability associated with shoulder disease. It consists of a pain section and a disability section with 13 items being responded to on visual analogue scales. Few researchers have investigated SPADI validity in specified diagnostic groups, although the selection of an evaluative instrument should be based on evidence of validity in the target patient group. The aim of the present study was to investigate factor structure of the SPADI in a study population of patients with adhesive capsulitis., Methods: The questionnaire was administered to 191 patients with adhesive capsulitis. Descriptive statistics for items and a comparison of scores for the two subscales were produced. Internal consistency was analyzed by use of the Cronbach alpha and a principal components analysis with varimax rotation was conducted. Study design was cross-sectional., Results: Two factors were extracted, but the factor structure failed to support the original division of items into separate pain and disability sections., Conclusion: We found minimal evidence to justify the use of separate subscales for pain and disability. It is our impression that the SPADI should be viewed as essentially unidimensional in patients with adhesive capsulitis.

Background: Measurements of range of motion play a key role in shoulder research. The purpose of this study is to investigate intra-observer reproducibility of measurements of active and passive range of motion in patients with adhesive capsulitis., Methods: The study was carried out in a population consisting of 32 patients with clinical signs of adhesive capsulitis. A specified measurement protocol was used, and range of motion in affected and non-affected shoulders was measured twice for each patient with a one-week interval., Results: For most of the investigated individual movements, test-retest differences in range of motion score of more than approximately 15 degrees are not likely to occur as a result of measurement error only. Point-estimates for the intraclass correlation coefficient ranged from 0.61 to 0.93., Conclusion: Range of motion of patients with adhesive capsulitis can be measured with acceptable reproducibility in settings where groups are compared. Scores for individual patients should be interpreted with caution.

We evaluated the effectiveness of exercises and manipulation on pain, disability and sick leave in a systematic review of randomized controlled trials including patients with low back pain. Low back pain is commonly a self-limiting illness and most patients are free of symptoms within 14 days. On the basis of 11 studies, no additional benefits from exercises and manipulation were found in patients with acute complaints (0-4 weeks); thus, our results do not support guidelines that prescribe manipulation in the acute stage. One study found reduced disability and sick leave in the subacute stage (4-12 weeks) when patients were told that it was safe to move and this strategy was reinforced by a graded exercise program and visits to the workplace. Seven studies evaluated manipulation; the effectiveness was no better than other treatments or placebo. Based on seven studies in patients with chronic low back pain (> 12 weeks), there is strong evidence that exercises reduce disability and pain, but their effectiveness on sick leave is not documented. Four studies compared different exercise regimens, but found no evidence in favour of one particular method. The effectiveness of manipulation in patients with chronic pain is poorly documented.

Purpose: This prospective study was performed to assess whether CT-diskography (CT-D), diskomanometry (DMM) including recording of the pain response, or the MR signal intensity of the disks are reliable predictors of the outcome of nucleotomy., Material and Methods: Ninety-one patients, 44 females and 47 males aged 18-68 years (mean 37.4) treated at 99 disk levels were included. All had plain CT, MR imaging, CT-D and DMM performed prior to automated percutaneous nucleotomy with the Nucleotomy R system., Results: Sixty-nine (76%) of the patients responded well to treatment within 3 months. Due to recurrences, the success rate at 1 year was reduced to 65%. Except for better results following nucleotomy in patients with similar and identical pain as the presenting complaint provoked at diskography, no association was demonstrated between diskographic parameters, or loss of signal on MR, and the outcome. Better results were also seen in patients with a short history of disk disease, but not in patients with predominantly sciatica and focal hernias compared to those with predominantly low-back pain and diffuse posterior bulges., Conclusion: The results do not justify routine use of diskography prior to nucleotomy in patients with pathologic disks demonstrated by noninvasive methods and localizing sciatic pain.

This study was carried out in order to assess the clinical results after percutaneous automated nucleotomy with regard to predictive factors for the outcome. Selection criteria included patients with predominance of low-back pain, diffuse posterior disk bulges and concomitant spinal stenosis who are not normally accepted for nucleotomy. In all, 142 patients were treated. The overall success rate after an average observation time of 21 months was 56%. The results were not influenced by whether a diffuse posterior bulge or a focal hernia had been treated or not (p = 0.449). Spinal stenosis (p = 0.043) and disk space narrowing exceeding 25% of the expected width (p = 0.017) were associated with a poor outcome. By excluding these categories and patients with symptoms from more than one disk level, the success rate rose to 70%. With this selection, the results were equally good in patients with predominantly low-back pain compared to those with predominantly sciatica (p = 0.490).