Evaluating shoulder pain; diagnostics and its interpretation

Shoulder pain is a very common disorder and a large number of patients consult a physical therapist. If a patient consults a physical therapist, a diagnostic process will start, including history taking (possibly with additional PROMs) and followed by physical examination (possibly followed by additional tests such as ultrasound). Shoulder pain can impact activity limitations and is, in many cases, a treatment goal. Therefore, it is important to objectify these limitations. Our review recommended using the SPADI in English, Norwegian and Turkish. In Dutch however, the SST and the SDQ were recommended. We assessed the measurement properties of the Dutch SPADI and concluded the SPADI-D is valid, reliable and responsive, moreover the measurement error and the minimal clinical important change are known. As PROMs are not yet completely implemented in clinical care and reasons for not using them are mainly time-based, we assessed if it was possible to replace the SPADI-D with one question. This substitute question proved to be valid and responsive but not predictive for recovery.
After history taking and the use of PROMs, physical examination will be performed. Physical tests are not completely capable in confirming or rejecting a diagnosis. Therefore, ultrasound is used by physical therapists. Ultrasound is widely used by radiologists and is valid and reliable for e.g. a full thickness tear. We assessed the inter professional agreement between the radiologist and the physical therapist for full thickness tear, partial thickness tear, bursitis and calcification. The agreement was fair (k=0.36). We concluded ultrasound should not yet be implemented in the diagnostic process yet and, if used, physical therapists should be aware of the differences in interpretation.
We then assessed the effectiveness of the following treatments (physical therapy, surgery and watchful waiting) on all traditional labels. The ‘full thickness tear’, ‘biceps tendon tear’ and ‘SLAP- lesion’ were labelled to: ‘referral to secondary care’. Here, it is important that the patient is referred to a medical doctor for additional diagnostic tests and/or to discuss operative possibilities. ‘Calcification’, ‘tendinopathy’ and ‘partial tear’ of the rotator cuff, ‘subacromial impingement’ and ‘bursitis’ were labelled as an ‘indication for physiotherapy’. All others (‘arthritis/ arthrosis of the AC-joint’, ‘calcification’ and ‘tendinopathy’ of the biceps and ‘no pathology’) were labelled as ‘watchful waiting’. We recoded all traditional labels into these new treatment related categories. The overall agreement was moderate (k= 0.60). Although this option might be promising, more research is needed.