| dc.description.abstract | Introduction: Shoulder pain is a common, persistent and disabling disease. The restoration of abnormal movement-patterns is often an important goal in the treatment of patients with shoulder pain. The International Classification of Functioning, Disability and Health (ICF) is a conceptual framework and classification that has been developed by the World Health Organisation. The ICF is a common, multi-disciplinary language that allows identification of condition-specific codes (ICF categories), comparison between patient-experiences of functioning and assessment tools and development of new measures.
Aims: The aims of this thesis are to identify the ICF categories that reflect the concepts used in assessment of shoulder pain and identify the ICF categories that reflect problems related to functioning and interactions with the environment in patients with shoulder pain. As an extension of this aim, whether patient experiences of functioning are captured by the present assessment tools is also investigated. Moreover, the ICF categories that reflect the patientexperiences of functioning and the content of the assessment tools are used to create a preliminary list of ICF categories for shoulder pain. Finally, a clinician-rated activity measure to capture abnormal movement patterns in the upper extremities is developed and tested.
Methods: The present work is based on three studies: a literature review of measures, a cross-sectional study with patient interviews and a test-retest study. In addition, the datasets from the literature review of measures and the cross-sectional study with patient interviews constitute the material used for the comparison of the patient-experiences of functioning and the content of measures, and for the development of a preliminary list of ICF categories for shoulder pain. In the literature review, articles that were written in English, published in peerreviewed journals and based on clinical studies that included patients with shoulder pain aged 18 years and older were included. Studies on patients with fractures, joint replacement, complete dislocation, malignant condition, rheumatic diagnosis and stroke were excluded. The measures extracted from the articles were linked to ICF categories according to standardised rules. The frequency of the identified ICF categories was calculated and reported for categories with a frequency of at least 1%. In the cross-sectional study, patients in the outpatient clinic at the Department of Physical Medicine and Rehabilitation, Ullevaal University Hospital, were included. The inclusion and exclusion criteria were similar to those in the literature review. The patients were interviewed with a condition-adapted ICF checklist that contained 154 categories. The presence of a functional problem or environmental factor according to these ICF categories was registered. The ICF categories that were registered with a frequency of at least 5% were reported. The correspondence between these two datasets was investigated using the following criteria: (1) categories included in both datasets with similar rankings, (2) categories included in both datasets with different rankings, and (3) categories included in only one of the datasets. In addition, the match between high frequent patient-derived ICF categories (reported by = 50 %) and the content of frequently cited condition-specific measures (identified with = 10 citations) was investigated. The preliminary list of ICF categories for shoulder pain was constituted from all the ICF categories that were reported in the cross-sectional study with patient interviews and the literature review of measures. Finally, a simple, clinician-rated activity measure was developed and reliability tested. The development process was based on identification of eligible items in the literature, pilot-testing and statistical analyses. The test-retest study was conducted at the Department of Physiotherapy at Martina Hansens Hospital, Baerum. Patients aged 18 years and older with a main diagnosis of subacromial impingement syndrome were included. The exclusion criteria were similar to those from the literature review and the cross-sectional study. Item-reduction was based on item-to-sum correlations. In the further testing of the final scale, inter- and intra-rater reliability were calculated with the Interclass Correlation Coefficient (ICC) and a 95% Confidence Interval (CI). The minimal detectable change was calculated from the standard error. The content of the scale was linked to ICF categories according to the established rules.
Results: In the literature review, 40 ICF categories were identified in 475 measures. Of these, 28 belonged to activities and participation, 11 to body functions and structures and 1 to environmental factors. In the cross-sectional study with patient interviews, 165 patients with a mean age of 46.5 years (SD = 12.5) were included. A total of 61 ICF categories were identified. Of these, 19 covered body functions and structures, 34 activities and participation, and 8 environmental factors. The correspondence between the two datasets was high for activities and participation, and lower for body functions and structures and environmental factors. In particular, patient-derived mental- and muscle body functions and environmental social support were not present in the measures. Moreover, 6 high frequent patient-derived categories are not matched by the content of any of the most frequently selected conditionspecific scales. The American Shoulder and Elbow Surgeons Standardized Form for Assessment of the Shoulder (ASES) and the Disability of the Arm, Shoulder and Hand (DASH) scale match the highest number of high frequent patient-derived categories. The preliminary list of ICF categories for shoulder pain contains a total of 68 second-level ICF categories. Of these more than half belong to activities and participation. In the test-retest study, a total of 63 patients, aged 53.3 (SD = 12.9) and diagnosed with subacromial impingement syndrome, were included. A clinician-rated activity measure, the Shoulder Activity Scale, with 3 items and a summed score ranging from 3 to 15 was developed. The inter-rater reliability and test-retest reliability were ICC = 0.80 (95% CI = 0.51 - 0.90) and ICC = 0.74 (95% CI = 0.58 - 0.84), respectively. The minimal detectable change of the scale was calculated as 3.32. The scale covers the ICF categories lifting and carrying objects (d430), dressing (d540), hand and arm use (d445) and control of voluntary movement (b760).
Conclusions: The patient experiences of shoulder pain are multi-faceted, covering the ICF body functions sensation of pain, movement-related functions and mental functions and the activity and participation functions mobility, self-care, domestic life, interpersonal interactions and relationships, work and leisure activities. Except for social support from immediate family and friends, environmental factors were scarcely represented. The assessments of patients with shoulder pain only partially capture the patient experiences of functioning and there is large variation in the content of condition-specific measures. These findings have implications for clinicians and researchers in the selection of measures. The Shoulder Activity Scale is a simple and reliable measure that fills a gap in the assessment of patients with shoulder pain. Before it is applied in clinical settings, it needs to be validated. For the first time, a preliminary list of ICF categories for shoulder pain is presented. The preliminary list should be further developed with contributions from qualitative patient interviews, an expert survey and a formalised decision process. | en_US |