News from the Education Committee

This week’s topics were tracked on twitter and you can find a collection of excellent articles currently being discussed amongst the twitter savvy crowd. As always, social media provides an amazing resource of current materials and access to specialists in various fields. However, there are also a number of risks in gaining all your opinions from these sources, there is no quality control and often the loudest and most controversial blogger gets all the attention. We need to take care in shaping our clinical opinions and research ideas purely on the popular topics of the day. Like all things, listen to what people have to say, analyse the information based on your own experiences, and form a healthy consensus of opinion amongst your professional colleagues. 


Does physiotherapy diagnosis of shoulder pathology compare to arthroscopic findings? Mary Elizabeth Magarey1, Mark Alan Jones1, Chad E Cook2, Michael George Hayes3 Br J Sports Med.  October 2015

Abstract

Aims To explore the ability of a physiotherapist, using a standardised musculoskeletal physiotherapy assessment protocol, to accurately identify the structures potentially responsible for shoulder symptoms against a standardised arthroscopic shoulder diagnostic assessment, and to determine the physiotherapists’ ability to influence post-test diagnostic accuracy.

Study design Consecutive case-based cohort study.

Subject selection All participants were selected by two orthopaedic surgeons for arthroscopic investigation during a 6-month period.

Setting Private orthopaedic clinic.

Method All consenting participants selected for arthroscopic investigation were examined by the physiotherapist prior to arthroscopy. Presence and priority of impairments/diagnoses were recorded on a standardised form. Inter and intra-rater reliability and diagnostic accuracy were tabulated.

Statistical analysis Proportional agreement on diagnostic incidence (broad) and priority (strict) using 2×2 contingency tables for sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratios were calculated. Post-test probabilities were analysed to determine the influence of a positive or a negative finding.

Results 211 participants, aged 14–79 years were included. Overall prevalence of subacromial pathology was (77%) and, disorders of the passive restraints (29%). For both negative and positive findings, post-test probabilities were not notably altered; although positive findings yielded greater value in the decision-making modelling.

The physiotherapist's ability to identify individual pathology (eg, tendon rupture vs tendinopathy, capsular vs labral) was lower than recognition of pathology within the broader diagnostic category.

Conclusions The physiotherapist's ability to diagnose individual pathologies was inconsistent. Indirectly, this raises the issue of whether signs and symptoms identified under arthroscopic surgery are reflective of a lesion/pathology reflective of a specific tissue.


 

This is an excellent article outlining some of the problems facing our current assessment and diagnosis of shoulder pathology. What seems to be happening in the research field is that there is more and more evidence to suggest we focus our treatment of the patient specific findings rather than on the structural findings. That is to say, just because a structure may appear to be abnormal does not always mean it needs to be treated. 

Rehabilitation following surgical repair of the rotator cuff: a systematic review Sophie Thomsona, b, , , Chris Jukesb, Jeremy Lewisa, b, c. Physiotherapy. September, 2015

Abstract

Background

Surgery to repair rotator cuff (RC) tears is a commonly performed orthopaedic procedure with the aim of reducing pain and improving function. Surgery is followed by rehabilitation and recommendations for postoperative rehabilitation include; exercise therapy, continuous passive motion machines and aquatic therapy. Currently, there is uncertainty in the literature as to what constitutes best postsurgical rehabilitation.

Objective

To systematically review postsurgical research investigations to provide clinical guidance regarding postsurgical management.

Data sources

A keyword search of Medline, Cinahl, Amed, Embase and Cochrane databases from September 1993 to September 2013.

Study selection

Reviewer assessment using inclusion and exclusion criteria of randomised controlled trials.

Data extraction

Data pertaining to research design, intervention and subjects was extracted from included papers by one author. The data was grouped by reference to the objectives of the study and collated in themes.

Data synthesis

Narrative synthesis of the data was used to describe the effects of the intervention. The methodological quality and risk of bias of the included studies was assessed using the standardised Physiotherapy Evidence Database scale. Eleven studies met the inclusion criteria. All the studies were of fair to good methodological quality. No one rehabilitation protocol was found to be superior to another. The findings of this review suggested that following RC repair, patients should expect improvement in pain, ROM and function.

Conclusion

This review concludes that no single rehabilitation protocol is superior to another following RC repair. Studies with larger study populations and longer term follow up are required to investigate this further.

This is an excellent piece of work that has thoroughly reviewed the current evidence base available to health professionals working in the field of shoulder rehabilitation. This paper continues to demonstrate the lack of conclusive evidence for the most effective rehabilitation program. We desperately need to start evaluating the quality of our rehabilitation programs if we are to further our understanding in this area of medicine. 


Assessment of Correlation Between MRI and Arthroscopic Pathologic Findings in the Shoulder Joint. Omid R Momenzadeh, , Mohamad H Gerami, , Sepideh Sefidbakht, , and Sakineh Dehghani, Arch Bone Jt Surg. 2015 Oct 

ABSTRACT

Background:

The objective of this study was to determine the diagnostic value of magnetic resonance imaging for shoulder joint pathologies and then compare the results with arthroscopy, the standard for joint diagnosis.

Methods:

In this cross-sectional study, 80 patients with shoulder joint disorders, who underwent final arthroscopy, were studied. Based on patients’ medical history and physical examinations, shoulder MRI was requested if paraclinical investigations were. If non-surgical therapies failed, arthroscopy of the affected shoulder was done and the same structures were inspected. Subsequently, sensitivity, specificity, and positive and negative predictive values (PPV) and (NPV) of MRI were determined by arthroscopy comparisons.

Results:

The highest sensitivity, specificity, PPV and NPV were found in MRI pathology reports that included: Hill-Sach lesion (0.910), infraspinatus tendon (0.985), supraspinatus tendon (0.930), and biceps tendon (0.954), respectively. Rotator interval (0.250), biceps labrum complex (0.805), subscapularis tendon (0.538) and anterior labrum lesions (0.604) had the lowest sensitivity, specificity, PPV and NPV, respectively.

Conclusion:

The results showed that MRI can be a useful tool in ruling out possible abnormalities in the shoulder and to give clues to the most probable diagnosis. Although knowing some practical skills in order to successfully perform the procedure and experience of the radiologist with suitable feedback by surgeon is necessary.

 

This article is free to access via the journals website. It reads very well and provides a balanced discussion about the ability to use scans in the assessment process. The author provides a very good breakdown of the types of tissue pathology that can be identified from an MRI Scan. The key message for clinicians has to be that we only use scans to confirm a diagnosis and not to make the diagnosis. 


Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial] Andrew J Carr, Cushla D Cooper, Marion K Campbell, Jonathan L Rees, Jane Moser, David J Beard, Ray Fitzpatrick, Alastair Gray, Jill Dawson, Jacqueline Murphy, Hanne Bruhn, David Cooper, and Craig R Ramsay. Health Technology Assessment, No. 19.80


Headline

The study found that in patients aged > 50 years with a degenerative rotator cuff tear there is no difference in clinical effectiveness or cost-effectiveness between open repair and arthroscopic repair at 2 years for the primary outcome (Oxford Shoulder Score) and all other prespecified secondary outcomes.

Abstract

Background:

Uncertainty exists regarding the best management of patients with degenerative tears of the rotator cuff.

Objective:

To evaluate the clinical effectiveness and cost-effectiveness of arthroscopic and open rotator cuff repair in patients aged ≥ 50 years with degenerative rotator cuff tendon tears.

Design:

Two parallel-group randomised controlled trial.

Setting:

Nineteen teaching and district general hospitals in the UK.

Participants:

Patients (n = 273) aged ≥ 50 years with degenerative rotator cuff tendon tears.

Interventions:

Arthroscopic surgery and open rotator cuff repair, with surgeons using their usual and preferred method of arthroscopic or open repair. Follow-up was by telephone questionnaire at 2 and 8 weeks after surgery and by postal questionnaire at 8, 12 and 24 months after randomisation.

Main outcome measures:

The Oxford Shoulder Score (OSS) at 24 months was the primary outcome measure. Magnetic resonance imaging evaluation of the shoulder was made at 12 months after surgery to assess the integrity of the repair.

Results:

The mean OSS improved from 26.3 [standard deviation (SD) 8.2] at baseline to 41.7 (SD 7.9) at 24 months for arthroscopic surgery and from 25.0 (SD 8.0) at baseline to 41.5 (SD 7.9) at 24 months for open surgery. When effect sizes are shown for the intervention, a negative sign indicates that an open procedure is favoured. For the intention-to-treat analysis, there was no statistical difference between the groups, the difference in OSS score at 24 months was –0.76 [95% confidence interval (CI) –2.75 to 1.22; p = 0.452] and the CI excluded the predetermined clinically important difference in the OSS of 3 points. There was also no statistical difference when the groups were compared per protocol (difference in OSS score –0.46, 95% CI –5.30 to 4.39; p = 0.854). The questionnaire response rate was > 86%. At 8 months, 77% of participants reported that shoulder problems were much or slightly better, and at 24 months this increased to 85%. There were no significant differences in mean cost between the arthroscopic group and the open repair group for any of the component resource-use categories, nor for the total follow-up costs at 24 months. The overall treatment cost at 2 years was £2567 (SD £176) for arthroscopic surgery and £2699 (SD £149) for open surgery, according to intention-to-treat analysis. For the per-protocol analysis there was a significant difference in total initial procedure-related costs between the arthroscopic group and the open repair group, with arthroscopic repair being more costly by £371 (95% CI £135 to £607). Total quality-adjusted life-years accrued at 24 months averaged 1.34 (SD 0.05) in the arthroscopic repair group and 1.35 (SD 0.05) in the open repair group, a non-significant difference of 0.01 (95% CI –0.11 to 0.10). The rate of re-tear was not significantly different across the randomised groups (46.4% and 38.6% for arthroscopic and open surgery, respectively). The participants with tears that were impossible to repair had the lowest OSSs, the participants with re-tears had slightly higher OSSs and the participants with healed repairs had the most improved OSSs. These findings were the same when analysed per protocol.

Conclusion:

In patients aged > 50 years with a degenerative rotator cuff tear there is no difference in clinical effectiveness or cost-effectiveness between open repair and arthroscopic repair at 2 years for the primary outcome (OSS) and all other prespecified secondary outcomes. Future work should explore new methods to improve tendon healing and reduce the high rate of re-tears observed in this trial.

Trial registration:

Current Controlled Trials ISRCTN97804283.

Funding:

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 80. See the NIHR Journals Library website for further project information.
 

This paper outlines the amazing work done by Prof Andy Carr and his team at Oxford University. They outline a robust clinical trial evaluating open vs. closed cuff repairs and analyse not only the cost of the procedure but collate the failure rate to the clinical outcome scores. It is fascinating to see from a physiotherapy perspective that the failure to heal does not necessarily mean a worse outcome for the patient. What this project did fail to achieve was to maintain the no surgery arm of the trial due to a poor retention and compliance rate. It also leaves a lot of unanswered questions around rehabilitation protocols, the need for surgery, and the role of centralised pain in this patient cohort.  

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Andre Le Leu

Andre is a Physiotherapy Clinical Specialist who has developed a number of special interest areas over the years. He worked at the Royal National Orthopaedic Hospital alongside former EUSSER President Anju Jaggi, from 2004-2015 where he developed a unusual skill set across complex trauma, arthroplasty, pain, instability, hypermobility, and muscle transfers of the shoulder and elbow. He also worked as a clinical specialist for the peripheral nerve injuries team where he further enhanced his knowledge of brachial plexus and erbs palsy management and rehabilitation. He has extensive lecturing experience throughout the UK and Europe due to his involvement with EUSSER. He has also been involved in a number of peer-reviewed publications and the development of national guidelines for post operative rehabilitation of shoulder and elbow pathologies. He currently works as the Clinical Director at Highgate Physiotherapy Clinic based in North London, UK (@londonshoulder).