Elsevier

Journal of Hand Therapy

Volume 30, Issue 2, April–June 2017, Pages 200-207
Journal of Hand Therapy

Scientific/Clinical Article
Factors influencing final outcomes in patients with shoulder pain: A retrospective review

https://doi.org/10.1016/j.jht.2017.04.004Get rights and content

Abstract

Study Design

Retrospective cohort.

Introduction

Rehabilitation interventions are commonly prescribed for patients with shoulder pain, but it is unclear what factors may help clinicians' prognosis for final outcomes.

Purpose of the Study

The purpose of this study is to determine what factors are the best predictors of improved patient-reported outcomes at discharge in patients with shoulder pain.

Methods

Retrospective chart review of 128 patients presenting with shoulder pain to an outpatient physical therapy clinic. Chart review captured data regarding patient demographics, treatment interventions, patient history, and patient-reported outcome scores. The primary dependent variable was the overall change score of the QuickDASH (initial to discharge). Thirty-eight predictor variables were entered into a forward stepwise multivariate linear regression model to determine which variables and to what degree contributed to the dependent variable.

Results

The linear regression model identified 5 predictor variables that yielded an R = 0.74 and adjusted R2 = 0.538 (P < .001). The 5 predictor variables identified in order of explained variance are QuickDASH change at the fifth visit, a total number of visits, initial QuickDASH score, scapular retraction exercise, and age.

Discussion

Early change scores, equal to minimal detectable change scores on patient-reported outcomes appear to be strong indicators that patients with shoulder pain are on a positive trajectory to benefit from rehabilitation.

Conclusion

Using patient-reported outcomes throughout care, not just at the start and end of care, will provide therapist feedback regarding patient's progress and indicate treatment effectiveness.

Levels of Evidence

4.

Introduction

Shoulder pain is a common and debilitating diagnosis in health care with a 1-year prevalence reaching up to 47% in the adult population.1 It is second, only to low back pain in prevalence of musculoskeletal conditions for those seeking care.2 Shoulder pain is often associated with unfavorable outcomes with roughly 40%-50% of all new episodes of shoulder pain patients presenting to a primary care setting, who still report symptoms 6-12 months later.3, 4, 5

Research to determine which interventions and factors contribute to positive outcomes with rehabilitation intervention is growing but is inconsistent. A systematic search of the literature identified 16 studies that focused on the prognosis of shoulder disorders; only 6 were designated as of “high quality.”6 Strong evidence exists that high pain intensity and middle age (45-54 years) are associated with poor outcomes. There is moderate evidence that prognostic factors for shoulder pain such as long duration of complaints and high disability score at baseline predict a poor outcome in primary care.6, 7, 8 Many prognostic factors were considered in these 16 studies such as sex, mechanism of injury, psychological factors, work demands, anatomical factors, and impairments of motion and strength.6 However, the vast majority of the prognostic factors were identified only at baseline.

There is compelling evidence in the literature indicating exercise and patient education decreases pain and improves function at short- and long-term follow-up for patients with impingement syndrome.9, 10 Additional interventions such as mobilization, modalities, and stretching interventions are commonly used to treat shoulder impingement syndrome with limited evidence to support their use.11 Clinicians are often faced with questions relating to identifying prognostic factors that will determine a patient's positive outcome. Treatment approaches may vary based on the presence or absence of a number of prognostic factors. There are many factors related to history, comorbidities, psychological state, physical impairments, work demands, physical examination findings, and patient self-report perceptions of function that can contribute to a patient's outcome. It is not known how much each of these items is weighted in contributing to a patient's prognosis.

The role of early response to rehabilitation has demonstrated limited evidence in predicting long-term outcomes. Researchers investigated the effects of early self-reported changes in levels of disability and pain levels in patients with acute back pain seeking chiropractic care.12 Axen et al,12 found that improvement in pain and disability after visit 2 increased the odds of a positive treatment outcome by an 2.9 odds ratio compared with patients with no improvement. This response was further investigated in 2422 patients presenting with multiple musculoskeletal conditions to chiropractors in the United Kingdom over an 8-year period.13 The best predictor of a positive outcome at the tenth visit in those patients with persistent musculoskeletal pain was self-reported improvement by the fifth visit. These authors suggested that early changes may be more important as predictors in musculoskeletal conditions than variables measured at baseline.13

It is hoped that the acquired knowledge of the prognostic factors that contribute to the successful outcomes of patients with shoulder pain will help provide more informed clinical decision-making among health care practitioners. The gained information can be provided to patients regarding their plan of care and opportunity for a successful outcome. Based on the previous research, we sought to be as inclusive as possible in retrospectively examining the charts plus our own clinical observations led us to incorporate the early treatment interventions and change scores of patient-self reports as prognostic factors accounting for the large number of factors used in this study. The objective of this study was to determine what factors are associated with a positive outcome in patients with shoulder pain presenting to a physical therapy clinic in a general orthopedic practice population. Specifically, we sought to identify which early interventions, historical presentations, and demographic variables are most associated with contributing to a positive outcome in patients presenting with shoulder pain.

Section snippets

Methods

We conducted a retrospective study involving patients presenting to a single outpatient physical therapy clinic with shoulder pain between the years 2008 and 2010. The outpatient clinic was located in the southern region of the United States representing a typical general outpatient orthopedic clinic seeking care for shoulder pain. This clinic had instituted patient-reported outcome data collection as a standard operating procedure in the fall of 2006. This clinic used the QuickDASH to track

Results

The multivariate linear regression analysis revealed a model with an adjusted R2 = 0.538 (P < .001) accounting for 5 variables entered into the equation (Table 2). The 5 variables in order were QuickDASH change score at 5 visits, total visits, initial QuickDASH score, RROM scapular retraction, and age. The resulting regression equation was able to account for approximately half of the variance of the change in perceived level of disability measured by the QuickDASH in patients with shoulder

Discussion

The objective of this study was to determine what factors are associated with a positive outcome in patients with shoulder pain presenting to a physical therapy clinic in a general orthopedic practice population. With the recent emphasis on value-based health care24, 25 and estimating final outcomes through the use of G-codes,26 clinicians need to establish and refine reasonable predictors for patient outcomes. The present study predicts short-term outcomes, as indicated by patient

Acknowledgments

The authors would like to acknowledge Daniel Brown, DPT, and Peter J. Gagnon, DPT, who were physical therapy students who assisted in reviewing the charts. They also like to thank Terry Brown, DPT, for allowing us to use ProActive Therapy patients for this study. The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the

Quiz: #488

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.

  • #1.

    The study design is

    • a.

      RCTs

    • b.

      prospective cohort

    • c.

      retrospective cohort

    • d.

      case series

  • #2.

    The primary purpose of the study was to identify the best__________________ for patients with shoulder pain

    • a.

      predictors of outcomes

    • b.

      practices

    • c.

      evaluation techniques

    • d.

      exrercises

  • #3.

    The primary dependent variable was

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