Musculoskeletal conditions involving the shoulder are common and, because of the importance of the upper limb and hand in daily function, symptoms in this region are commonly associated with functional impairment in athletic and non-athletic populations. Deriving a definitive diagnosis as to the cause of shoulder symptoms is fraught with difficulty. Limitations have been recognised for imaging and for orthopaedic special tests. 1 solution is to partially base management on the response to tests aimed at reducing the severity of the patient's perception of symptoms. 1 (of many) such tests is the Shoulder Symptom Modification Procedure (SSMP). The reliability of this procedure is unknown.
37 clinician participants independently watched the videos of 11 patient participants undergoing the SSMP and recorded each patient's response as improved (partially or completely), no change or worse. Inter-rater reliability was assessed by Krippendorff's α, which ranges from 0 to 1.
Krippendorff's α was found to range from 0.762 to 1.000, indicating moderate to substantial reliability. In addition, short (3-hour) and longer (1-day) durations of training were associated with similar levels of reliability across the techniques.
Deriving a definitive structural diagnosis for a person presenting with a musculoskeletal condition involving the shoulder is difficult. The findings of the present study suggest that the SSMP demonstrates a high level of reliability. More research is needed to better understand the relevance of such procedures.
ISRCTN95412360.
Deriving a definitive structural diagnosis for musculoskeletal conditions involving the shoulder is difficult.
Symptom improvement/correction/modification tests have been suggested by clinicians as one method of developing a management programme.
This study demonstrated inter-rater reliability of the Shoulder Symptom Modification Procedure.
A graduated exercise programme is the most common form of management, for people with the majority of musculoskeletal conditions involving the shoulder.
If future research demonstrates that techniques used in the Shoulder Symptom Modification Procedure confer additional benefit when incorporated into a graduated shoulder exercise programme over exercises alone, then methods such as these may have a role in the management of musculoskeletal conditions involving the shoulder.
As a group, musculoskeletal conditions are associated with the second highest number of ‘years lived with disability’.
To understand the basis of the presenting shoulder symptoms, clinicians typically perform a clinical examination, which usually includes: taking a history, collecting disability and impairment data and performing special orthopaedic tests that have been designed to incriminate pathology, such as that involving the rotator cuff tendons, subacromial bursa or glenoid labrum, or to rule in conditions, such as subacromial impingement syndrome.
Although orthopaedic tests are commonly used,
The findings of these clinical and radiological investigations have challenged the basis on which a structural diagnosis may be achieved.
The first stage of the SSMP is for the patient to identify the movements, activities or postures that reproduce symptoms. This may include symptoms experienced while sitting at a desk, lifting a pan or kettle, dressing, swimming, performing weight-bearing activities such as push-ups and in high-powered explosive activities commonplace in sport. Pain is the most commonly reported symptom, but symptoms may also include reduction in movement, instability and symptoms that may be associated with neurovascular compromise. Once defined, the component parts of the SSMP are then applied while the patient performs the symptom-provoking movements, activities or postures to determine if an immediate change is achievable. This type of ‘real-time’ process has been recommended previously,
The SSMP comprises three main sections. The first section aims to assess the relationship between thoracic posture and symptoms, the second aims to evaluate the effect of scapular position on symptoms and the third aims to assess the effect of the relationship between the humeral head and scapula on symptoms. In reality, the assessment procedures do not isolate one structure. For example, reducing the thoracic kyphosis also relatively posteriorly tilts the scapula, changes length-tension relationships of muscles, tendons and related soft tissues and may influence joint biomechanics. As all procedures involve touch, another reason for perceiving a change in symptoms may be the experience of this sensation.
The SSMP assessment form is detailed in
The Shoulder Symptom Modification Procedure assessment form.
It is important for clinicians to appreciate that the SSMP is not a stand-alone procedure and if the SSMP does not change symptoms or only partially alleviates them, other rehabilitation based on the clinician's clinical reasoning and the patient's acceptance of that management need to be considered, such as advice, education, rotator cuff rehabilitation exercises,
Although in clinical use,
Ethical approval for the investigation was granted by the Faculty of Education and Health Sciences Research Ethics Committee, University of Limerick, Ireland (2015_12_13_EHS), and from the Health and Human Sciences Ethics Committee, University of Hertfordshire, UK. The investigation was registered—
A sample of convenience of 11 people with unilateral shoulder pain, recruited from community and clinical settings, consented to participate in the investigation. They were provided with participant information documentation and informed of their rights, including the right to withdraw from the investigation at any stage, without having to explain this decision. Prior to participation, all patients signed consent documentation, after which they provided demographic data and a rating of their present pain on a 0–10 scale (0, no pain; 10, worst imaginable pain). Once the videos were filmed, the patient participants' involvement in the study was complete.
A sample of convenience of 40 clinicians from physiotherapy and osteopathy were approached to participate in the investigation.
Clinician participants worked in variety of health settings, including the public and private sectors and in primary and secondary care. They had varied training in the SSMP. Some had previous experience with the SSMP and were using it in current clinical practice, while others were new to the procedure. A number of clinicians had participated in previous training (∼1 day) and to varying extents had incorporated the SSMP into their clinical practice. Others were recruited for the purpose of the investigation and received short training (3 hours duration). As such, clinician participants were not randomised into these long and short training subgroups. The clinicians were given consent documentation, and were made aware of their rights, including the right to withdraw from the study at any stage. Those providing consent also provided demographic data.
Video analysis has been used in previous musculoskeletal conditions to investigate the reliability of assessing posture and movement,
Video filming occurred in a clinical research room at the University of Limerick, Ireland. Videos were made of one of the investigators (JSL) conducting the SSMP on the 11 patient participants. All videos were filmed on the same day. The videos were filmed and audio recordings were made using two JVC Everio Camcorders (Model No. GZ-MS210BEK) cameras (Yokohama, Japan), mounted on extendable tripods positioned ∼1.5 m from the patient participants. To standardise the position, patients were instructed to stand on a cross taped to the floor in front of the cameras. To reduce distortion, the cameras were positioned as close to perpendicular to the patients as possible. Initially, the patient participants were requested to identify and demonstrate the movement that reproduced their symptoms. Following this, the SSMP assessment procedures were performed and the patients' responses filmed, and the patients were asked whether the symptoms were the same, worse or better. At the end of data collection, 167 unique video recordings were available for analysis. The video recordings were initially edited using Adobe Creative Cloud Premier Pro (
Clinician participants were provided with a unique log in and password to the server and independently watched the video clips and completed the data collection documentation. Each video was assigned a separate table on the documentation sheet and after watching each video, the clinician participants were required to record if the SSMP technique had produced no change, made the patient worse or resulted in either partial or complete improvement. The clinicians were informed that responses were to be informed by the responses provided by the patients and not by their own interpretations. Owing to technical constraints, the order of the video clips was not randomised and the clinician participants could choose to watch the video clips in any order. They were encouraged to carry out the task in their own time and in a quiet place without interruptions, and to take breaks as necessary. Clinicians were instructed that ideally they should only watch the video on one occasion but were permitted to watch on two occasions if they were unsure of the patient's responses. Confirmation of this type would occur in clinical practice in such cases of uncertainty. Clinician participants were instructed that they should record:
‘no-change’ if the patient reported that the technique had not changed their symptoms, ‘worse’ if the patient reported that the technique had increased their symptoms, ‘partial improvement’ if the patient reported that the technique had partially improved their symptoms, which was defined as anything between 1% and 99% improvement, and ‘complete improvement’ if the patient reported that the technique had completely alleviated their symptoms (ie, 100% improvement).
To reduce bias, clinicians' scores were entered into a database by a research assistant who was unaware of the purpose of the investigation. Once the data sheet was complete, the clinicians' involvement in the study was complete. At the end of the data collection period, to protect patient confidentiality, the videos were removed from the secure server and destroyed.
The focus of the analysis of the data was on inter-rater reliability. No attempt was made to assess intrarater reliability, for the following reasons:
intrarater reliability can be assumed to be at least as good as inter-rater reliability, and as the primary practical concern is to assess the lower limit of reliability, a separate assessment of intrarater reliability is of little interest; a repeated assessment of the same videotaped technique by the same clinician would have little relevance to clinical practice; given that the SSMP aims to improve symptoms, if the technique had been videotaped twice, the technique itself might have altered, such that a subsequent test of the same procedure would not be testing the same response, violating a core assumption when assessing intrarater reliability. asking participating clinicians to produce assessments within and between patients would have been onerous and might have discouraged their participation.
Description of techniques
Technique | Description |
---|---|
Thoracic extension | The patient is asked to place a finger (typically from the asymptomatic upper limb) on the sternum and while still maintaining contact with the sternum, gently ‘lift’ the finger superiorly, aiming to extend the thoracic kyphosis |
Scapular elevation | The therapist gently places one hand over the lateral border of the scapular and elevates (ie, upwardly rotates) the scapula ∼1–2 cm using the other hand on top of the shoulder girdle as a guide. This then becomes the new ‘starting position’ for shoulder movement. The scapula is free to move during arm movement but starts and returns in the elevated position |
Scapular depression | The opposite direction to scapular elevation |
Scapular retraction | The therapist gently places one hand over the lateral border of the scapular and retracts the scapula ∼1–2 cm using the other hand on top of the shoulder girdle as a guide. This then becomes the new ‘starting position’ for shoulder movement. The scapula is free to move during arm movement but starts and returns to the new retracted position |
Scapular posterior tilt | The therapist gently places one hand over the lateral border of the scapular and the thumb over the inferior angle of the scapula. The other hand on top of the shoulder girdle gently displaces the superior aspect of the scapula (and other structures) posteriorly. This then becomes the new ‘starting position’ for shoulder movement. The scapula is free to move during arm movement but starts and returns to the new posterior tilted position |
Combinations | If a number of scapular positions are found to be partially reduce symptoms, they can be combined to determine if further improvement if achieved (eg, elevation and posterior tilt; retraction, depression and posterior tilt) |
Depression—flexion | In sitting or standing, the patient's shoulder is flexed as close to 90° flexion as possible (maybe in less or more range, depending on symptoms), the elbow is flexed (ie, shortened lever arm). The therapist places his/her hand on the posterior surface of the distal end of the humerus, 2–3 cm proximal to the point of the elbow. The patient is then asked to push the elbow towards the ground with the therapist resisting isometrically for 5–6 s. The contraction is repeated 3–4 times and the arm gently lowered to the side and the provocative movement retested |
Depression—abduction | The same as for depression—flexion but the starting position is with the shoulder in the plane of the scapula or closer to anatomical abduction if appropriate |
Depression—flexion (supine) | This technique is the same as depression—flexion but is performed in supine and in addition to the muscle contraction procedure, a series of inferiorly directed gliding pressures are applied to the region of the humeral head. Following the technique, the provocative movement is retested |
Depression—abduction (supine) | The same as for depression—flexion (supine), but the starting position is with the shoulder in the plane of the scapula or closer to anatomical abduction if appropriate |
Eccentric flexion | In sitting or standing with the shoulder flexed just before the onset of symptoms, the hand loosely grips an elastic rubber resistance tube, which is firmly suspended from above (ie, over the top of a door). With the arm in the same position, tension is applied to the tube and then the hand firmly holds the tube. Following this, the patient is instructed to extend the shoulder ∼20–30° hold isometrically for 5–6 s and then slowly return to the starting position (ie, concentric, isometric and eccentric contractions). This is repeated 3–4 times, the tube released and the provocative movement retested |
Eccentric abduction | The same as for eccentric flexion but the starting position is with the shoulder in the plane of the scapula or closer to anatomical abduction if appropriate |
External rotation | If the provocative movement is shoulder flexion or abduction, the movements are performed with increased shoulder external rotator activity. This could be achieved by using the resistance of an elastic rubber band, the therapists hand or pushing against a wall using a towel, plastic bag or polishing cloth to reduce resistance |
Internal rotation | The same as for external rotation with resistance aimed at increasing an internal rotation force. In addition to the suggestions above, internal rotation resistance can be achieved by asking the patient to flex the shoulders while applying pressure to a ball the size of a soccer or basketball |
AP|AP with inclination | Using a mobilisation belt, heavy resistance elastic rubber band, or a neoprene strap placed over the region corresponding to the anatomical location of the humeral head a posteriorly directed force is applied by the therapist with the therapists other hand stabilising the scapula. While the pressure is applied, the provocative movement is retested. This may be shoulder abduction-external rotation as may occur in someone with an anteriorly unstable shoulder. Care needs to be taken. In addition to trialling different amounts of posteriorly directed force, the therapist can apply a posteriorly directed force with a superior inclination to assess if this combination more effectively reduces symptoms |
PA|PA with inclination | The same as for AP|AP with inclination, but with the pressure applied to produce an anteriorly directed force |
AP, anterior to posterior; PA, posterior to anterior.
The inter-rater reliability of clinicians' assessment of the response to SSMP procedures was calculated by analysing the responses provided by the clinicians (no change, worse, partial improvement, complete improvement) using Krippendorff's α.
There do not appear to be formal methods of calculating sample size for reliability studies with ordinal outcomes and multiple raters. However, methods for continuous outcomes, such as those described by Walter
Eleven patient participants consented to participate. Each presented with unilateral shoulder pain and was naïve to the SSMP procedure. The mean age was 53.7 years. Seven were men and six had symptoms involving the right shoulder. Patient participant demographic information is detailed in
Patient participant information
Patient | Sex | Age (years) | Height (cm) | Weight (kg) | Symptomatic side | Duration (months) | Pain score | Onset | Previous treatment |
---|---|---|---|---|---|---|---|---|---|
1 | M | 51 | 168 | 92 | L | 9 | 3 | Changing swimming technique | PT |
2 | M | 68 | 168 | 79 | L | 12 | 4 | Fall onto shoulder | CS inj (×3), PT |
3 | M | 27 | 180 | 78 | L | 36 | 5 | Dislocation | CS inj (×3), PT |
4 | F | 69 | 166 | 68 | R | 3 | 8 | Insidious | CS inj |
5 | M | 54 | 182 | 80 | R | 12 | 6 | Frozen shoulder (IDDM) | CS inj, PT |
6 | M | 69 | 170 | 90 | R | 18 | 7 | Insidious | Acupuncture |
7 | F | 48 | 180 | 76 | R | 72 | 4 | Insidious | None |
8 | F | 50 | 159 | 91 | R | 14 | 5 | Insidious | NSAIDs |
9 | F | 60 | 153 | 80 | L | 8 | 5 | Insidious | CS inj |
10 | M | 28 | 172 | 99 | L | 1.5 | 4 | Trauma (rugby tackle) | PT |
11 | M | 67 | 170 | 83 | R | 36 | 3 | Insidious | PT |
Mean | 53.7 | 169.8 | 83.3 | 20.1 | 4.9 | ||||
SD | 15.2 | 8.8 | 8.8 | 20.7 | 1.6 |
Duration (duration of symptoms of this episode), pain score (verbal: 0, no pain; 10, worst imaginable pain).
CS inj, corticosteroid injection; F, female; IDDM, insulin-dependent diabetes mellitus; L, left; M, male; PT, physiotherapy; R, right.
Of the 40 clinicians approached (as a sample of convenience) to participate in the investigation, 37 (92.5%) provided responses. Of the three who did not respond, two cited insufficient time as being the reason for not completing the data sheets; the reason for the other clinician is unknown. There were 20 female and 17 male clinician participants (36 physiotherapists and 1 osteopath). Eighteen had participated in a short (∼3 hours) training programme to explain and practice the SSMP. Nineteen had participated in a longer training programme (∼1 day). Clinician participant demographic information is detailed in
Clinician participant information
Clinician | Sex | Age (years) | Occupation | Years working | Number of people with shoulder pain treated each week | SSMP 3-hour training (n=18) | SSMP 1-day training (n=19) |
---|---|---|---|---|---|---|---|
1 | F | 27 | PT | 0.6 | 25 | Y | |
2 | M | 55 | PT | 27 | 45 | Y | |
3 | M | 49 | PT | 23 | 4 | Y | |
4 | F | 27 | PT | 5 | 25 | Y | |
5 | F | 45 | PT | 24 | 6 | Y | |
6 | F | 26 | PT | 3.5 | 20 | Y | |
7 | F | 51 | PT | 26 | 6 | Y | |
8 | M | 28 | PT | 2 | 13 | Y | |
9 | F | 34 | PT | 10 | 6 | Y | |
10 | F | 31 | PT | 8 | 16 | Y | |
11 | F | 27 | PT | 1.5 | 15 | Y | |
12 | M | 44 | PT | 4 | 10 | Y | |
13 | F | 40 | PT | 19 | 8 | Y | |
14 | F | 46 | PT | 23 | 10 | Y | |
15 | F | 36 | PT | 14 | 5 | Y | |
16 | F | 25 | PT | 4 | 26 | Y | |
17 | M | 27 | PT | 7 | 20 | Y | |
18 | M | 28 | PT | 7 | 25 | Y | |
19 | M | 42 | PT | 12 | 5 | Y | |
20 | M | 50 | PT | 21 | 30 | Y | |
21 | M | 51 | PT | 24 | 10 | Y | |
22 | M | 29 | PT | 4.5 | 10 | Y | |
23 | M | 28 | PT | 4 | 20 | Y | |
24 | F | 34 | PT | 6 | 10 | Y | |
25 | F | 34 | PT | 7 | 20 | Y | |
26 | M | 30 | PT | 8 | 12 | Y | |
27 | M | 52 | PT | 21 | 5 | Y | |
28 | F | 54 | PT | 26 | 6 | Y | |
29 | F | 53 | PT | 6 | 15 | Y | |
30 | M | 26 | PT | 5 | 20 | Y | |
31 | F | 25 | PT | 3 | 20 | Y | |
32 | F | 49 | PT | 29 | 5 | Y | |
33 | M | 42 | PT | 17 | 10 | Y | |
34 | M | 28 | Osteopath | 1 | 12 | Y | |
35 | F | 29 | PT | 8 | 18 | Y | |
36 | M | 33 | PT | 8 | 10 | Y | |
37 | F | 28 | PT | 6 | 10 | Y | |
Mean | 36.8 | 11.5 | 14.4 | ||||
Range | 25–55 | 0.6–29 | 4–45 | ||||
SD | 10.3 | 8.9 | 8.8 |
In total, 19 procedures and combinations were tested, representing isolated procedures (eg, scapular elevation) and, when indicated, procedures tested in combination (eg, thoracic extension and scapular posterior tilt). The responses to the procedures are detailed in
Patient participant response to SSMP techniques
Responses to technique | |||||
---|---|---|---|---|---|
Technique | Number of patients | Worse | No change | Partial | Complete |
AP pressure | 10 | 3 | 0 | 6 | 1 |
Eccentric abduction | 7 | 0 | 1 | 6 | 0 |
Eccentric flexion | 3 | 0 | 1 | 2 | 0 |
AP pressure with superior translation | 4 | 0 | 1 | 2 | 1 |
External rotation in flexion | 3 | 0 | 2 | 1 | 0 |
External rotation in abduction | 7 | 1 | 1 | 3 | 2 |
Internal rotation in flexion | 4 | 1 | 1 | 2 | 0 |
Internal rotation in abduction | 6 | 1 | 1 | 2 | 2 |
Depression in flexion | 3 | 0 | 0 | 3 | 0 |
Depression in abduction | 8 | 0 | 1 | 4 | 3 |
PA pressure | 8 | 0 | 2 | 3 | 3 |
Scapular elevation | 11 | 0 | 4 | 4 | 3 |
Scapular elevation and posterior tilt | 3 | 0 | 0 | 2 | 1 |
Scapular elevation, retraction and posterior tilt | 3 | 0 | 0 | 3 | 0 |
Scapular depression | 11 | 3 | 3 | 5 | 0 |
Scapular posterior tilt | 11 | 2 | 1 | 6 | 2 |
Scapular protraction | 10 | 2 | 3 | 5 | 0 |
Scapular retraction | 11 | 1 | 2 | 7 | 1 |
Thoracic extension | 11 | 0 | 5 | 5 | 1 |
Total | 134 | 14 (10.4%) | 29 (21.6%) | 71 (53.0%) | 20 (14.9%) |
AP, anterior to posterior; ER, external rotation; IR, internal rotation; PA, posterior to anterior.
Intertester reliability, whole cohort of clinicians
Movement | α | 95% CI | Probability of not attaining 0.800 | Number of patients | Missing ratings |
---|---|---|---|---|---|
AP pressure | 0.846 | 0.802 to 0.888 | 0.020 | 10 | 6/370 |
Eccentric abduction | 0.821 | 0.717 to 0.914 | 0.334 | 7 | 0/259 |
Eccentric flexion | 0.928 | 0.878 to 0.970 | <0.001 | 3 | 0/111 |
AP pressure with superior translation | 0.783 | 0.702 to 0.857 | 0.647 | 4 | 4/148 |
External rotation in flexion | 0.874 | 0.806 to 0.935 | 0.018 | 3 | 0/111 |
External rotation in abduction | 0.826 | 0.775 to 0.873 | 0.147 | 7 | 5/259 |
Depression in flexion | NC | NC | NC | 3 | 1/111 |
Internal rotation in flexion | 0.762 | 0.690 to 0.828 | 0.863 | 4 | 0/148 |
Internal rotation in abduction | 0.894 | 0.863 to 0.922 | <0.001 | 6 | 1/222 |
Depression in flexion | NC | NC | NC | 3 | 1/111 |
Depression in abduction | 0.915 | 0.861 to 0.958 | <0.001 | 8 | 1/296 |
PA pressure | 0.837 | 0.772 to 0.894 | 0.129 | 8 | 3/296 |
Scapular elevation | 0.905 | 0.854 to 0.946 | <0.001 | 11 | 0/407 |
Scapular elevation, posterior tilt | 0.920 | 0.839 to 1.00 | 0.009 | 3 | 0/111 |
Scapular elevation, retraction, posterior tilt | NC | NC | NC | 3 | 0/111 |
Scapular depression | 0.838 | 0.761 to 0.907 | 0.160 | 11 | 1/407 |
Scapular posterior tilt | 0.911 | 0.876 to 0.944 | <0.001 | 11 | 2/407 |
Scapular protraction | 0.928 | 0.874 to 0.973 | 0.001 | 10 | 0/370 |
Scapular retraction | 0.851 | 0.790 to 0.908 | 0.051 | 11 | 0/407 |
Thoracic extension | 0.921 | 0.853 to 0.976 | <0.001 | 11 | 0/407 |
The NC values were due to insufficient variation in the rating to perform calculation.
AP, anterior to posterior; NC, not calculable; PA, posterior to anterior.
Nineteen clinicians had participated in longer training (over 1 day) and 18 clinicians over a shorter period (∼3 hours). The α coefficients for these two subgroups are presented in
Intertester reliability of those participating in long and short training
Short training (n=18) | Long training (n=19) | ||||
---|---|---|---|---|---|
Movement | α | 95% CI | α | 95% CI | Difference (long—short) |
AP pressure | 0.879 | 0.835 to 0.918 | 0.819 | 0.772 to 0.863 | −0.060 |
Eccentric abduction | 0.869 | 0.759 to 0.960 | 0.771 | 0.655 to 0.872 | −0.098 |
Eccentric flexion | 0.860 | 0.788 to 0.921 | 1.000 | 1.000 to 1.000 | 0.140 |
AP pressure with superior translation | 0.816 | 0.722 to 0.895 | 0.745 | 0.650 to 0.828 | −0.071 |
External rotation in flexion | 0.751 | 0.657 to 0.839 | 1.000 | 1.000 to 1.000 | 0.249 |
External rotation in abduction | 0.846 | 0.780 to 0.905 | 0.802 | 0.748 to 0.852 | −0.044 |
Internal rotation in flexion | 0.733 | 0.657 to 0.803 | 0.783 | 0.698 to 0.860 | 0.050 |
Internal rotation in abduction | 0.920 | 0.894 to 0.945 | 0.867 | 0.827 to 0.902 | −0.053 |
Depression in flexion | NC | NC | NC | NC | NC |
Depression in abduction | 0.908 | 0.855 to 0.954 | 0.922 | 0.857 to 0.967 | 0.014 |
PA pressure | 0.800 | 0.723 to 0.868 | 0.871 | 0.808 to 0.922 | 0.071 |
Scapular elevation | 0.868 | 0.794 to 0.929 | 0.937 | 0.908 to 0.964 | 0.069 |
Scapular elevation, posterior tilt | 01.000 | 1.000 to 1.000 | 0.844 | 0.718 to 0.953 | −0.156 |
Scapular elevation, retraction, posterior tilt | NC | NC | NC | NC | NC |
Scapular depression | 0.859 | 0.776 to 0.932 | 0.816 | 0.737 to 0.888 | −0.043 |
Scapular posterior tilt | 0.941 | 0.911 to 0.966 | 0.883 | 0.841 to 0.921 | −0.058 |
Scapular protraction | 0.902 | 0.828 to 0.960 | 0.952 | 0.904 to 0.989 | 0.050 |
Scapular retraction | 0.906 | 0.841 to 0.960 | 0.805 | 0.735 to 0.869 | −0.101 |
Thoracic extension | 0.918 | 0.852 to 0.975 | 0.943 | 0.890 to 0.988 | 0.025 |
NC, not calculable.
Differences in α for raters undergoing either short (S) or long (L) training.
Deriving a definitive structural diagnosis for an individual presenting with shoulder pain is fraught with difficulty. Suggesting care pathways based on the responses to orthopaedic tests and imaging may not correctly represent the mechanisms underlying the presenting symptoms. This is due to a poor correlation between structural changes and symptoms and poor accuracy of the clinical orthopaedic tests themselves. Clinical diagnosis is further challenged by the need to appreciate, for those presenting with pain as the main symptom, whether the symptoms have a peripheral nociceptive driver or occur as the result of altered central pain processing.
Although the number of raters was constant, the number of patients in whom the reliability of the assessment of each technique could be assessed varied from 3 to 11, and the precision of the estimates of α (as represented by the width of the associated 95% CI) varied accordingly. Nonetheless, owing to the large number of raters and the low rate of missing values, a reasonable degree of precision was obtained even for estimates based on just three patients.
In this investigation, reliability was assessed using video analysis playback. This was chosen as pilot work prior to this research clearly demonstrated that the response to a technique could substantially change the ‘baseline’ for the second tester and therefore confound the possibility of determining the reliability of assessment. The use of videotapes ensured that all clinicians were assessing the same response. Before the SSMP should be considered to be a reliable clinical assessment procedure, the findings of this investigation need to be repeated in a larger sample of patients, as well as testing other methods of reliability such as direct observation of patients being assessed clinically.
Our findings suggest that clinicians can learn the component techniques of the SSMP and reliably determine if they have influenced the patient's symptoms in a relatively short period of time, and there do not appear to be substantial clinical differences in reliability if training is conducted over a 3 hour period or over the course of 1 day. However, it should be remembered that clinicians were not randomly allocated to the two durations of training, and a conclusive comparison of the two subgroups cannot therefore be made. It is important to emphasise that although the findings of this investigation suggest that the SSMP is a reliable assessment process, there is no evidence to suggest that incorporating the techniques into management positively influences outcome over natural history or other treatment procedures.
In a recent large multicentre cohort study (1030 participants at baseline, 811 participants at 6-month follow-up) investigating prognostic factors for people with shoulder pain, psychosocial factors were identified as the major determinant. Of the range of biomechanical factors included in the investigation, ‘real-time’ improvement in symptoms associated with changes to scapular posture during active shoulder elevation
One of the potential benefits of assessment and management systems such as the SSMP is that demonstrating to a patient that symptoms are modifiable may give the individual confidence to move, due to the reduction or cessation of symptoms, which, in turn, may facilitate adherence to treatment.
When asked if they attribute the cause of presenting symptoms to anything specific, people presenting with shoulder symptoms commonly implicate ‘poor posture’. Although deviations in posture (from an idealised norm) are frequently cited as the cause of shoulder pain and symptoms,
Of importance, the SSMP is not a stand-alone procedure and must be embedded within a complete patient care management programme that includes education, support, advice, consideration of lifestyle and psychosocial factors, general fitness and other local management strategies. If SSMP techniques do not positively influence symptoms, other treatments or interventions may need to be considered. These may include (but are not restricted to) graduated shoulder exercises aimed at the rotator cuff and shoulder muscles.
The findings of this investigation need to be interpreted in the light of certain limitations. Foremost of these is that the clinicians only viewed one physiotherapist performing the SSMP in video format. If the clinician participants had observed other clinicians performing the SSMP procedures, different estimates of reliability might have resulted. The use of videos was necessary owing to the large number of assessors and the need for them to observe the same responses to each technique; however, although not practicable in this study, it would be more clinically realistic to directly observe the clinician and the patient's responses.
The use of a larger sample of patients would have allowed the reliability of the SSMP to be evaluated over a wider range of clinical presentation. There was, however, a relatively large clinician sample, which provided precise estimates of the reliability coefficients. It also allowed the relative influence of short-duration and long-duration training on reliability to be determined, though this was not a randomised comparison and is subject to confounding by other factors. In addition, it is important to emphasise that the findings only relate to the reliability of clinicians'
The purpose of this research was to investigate the intertester reliability of the SSMP. Suggestions to assess the influence of symptom modification in a systematic way have been made
Deriving a definitive structural diagnosis for a person presenting with a musculoskeletal condition involving the shoulder is difficult. Limitations have been recognised for imaging as well as for orthopaedic special tests. One solution is partially to base management on the response to tests aimed at reducing the severity of the patient's perception of symptoms. One (of many) methods is the Shoulder Symptom Modification Procedure. The findings of the present study suggest that the procedure demonstrates a good level of reliability. More research is needed to better understand the relevance and importance of such procedures.
The authors wish to thank the patient and clinician participants who volunteers to participate in this investigation. In addition, the authors thank the IT departments at the University of Limerick, Ireland, and University of Hertfordshire, UK, for their invaluable help.
Follow Jeremy Lewis at
JSL, KM, EB and EJH designed the study protocol. JSL, KM and EB collected the data. JS performed the statistical analysis. All authors read and approved the final manuscript.
JSL conceived the idea behind the SSMP and has presented the concept internationally.
Obtained.
Research Ethics Committee, University of Limerick, Ireland (2015_12_13_EHS), and from the Health and Human Sciences Ethics Committee, University of Hertfordshire, UK.
Not commissioned; externally peer reviewed.
No additional data are available.