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Thoomes-de Graaf M1, Verhagen A2, Scholten-Peeters W3, Karel Y4, Duijn E4, Koes B1, Ottenheijm R5, Dinant GJ5, van den Borne M6, Beumer A6, van Broekhoven J7, Tetteroo E8, Lucas C9
1Erasmus MC University Medical Center Rotterdam, Department of General Practice, Rotterdam, Netherlands, 2Graduate School of Health University of Technology Sydney, Department of Physiotherapy, Sydney, Australia, 3Vrije Universiteit Amsterdam, Department of Human Movement Sciences, Amsterdam, Netherlands, 4Avans University of Applied Science, Research Group Diagnostics, Breda, Netherlands, 5Maastricht University, Department of Family Medicine, Maastricht, Netherlands, 6AMPHIA Hospital, Department of Orthopaedic Surgery, Breda, Netherlands, 7Monné Zorg en Beweging, Physiotherapy, Breda, Netherlands, 8AMPHIA Hospital, Department of Radiology, Breda, Netherlands, 9Academic Medical Centre, University of Amsterdam, Department of Clinical Epidemiology, Amsterdam, Netherlands
Background: Diagnostics of shoulder pain is difficult as physical examination, including specific and widely used tests, alone is not valid to differentiate between various disorders, because of low sensitivity, specificity and reproducibility. Recently, diagnostic musculoskeletal ultrasound (DMUS) is increasingly used by physiotherapists (PTs). DMUS is valid and reproducible when used by radiologists. The performance of DMUS is unknown when applied by PTs.
Purpose: The purpose of this project was to assess the interprofessional agreement between radiologists and PTs. First, we assessed the interprofessional agreement on traditional diagnostic labels (full thickness tear, partial thickness tear, subacromial bursitis and calcification) as the psychometric properties of DMUS when used by radiologists is good. Next, we assessed the agreement when a new stratification approach was used (based upon treatment related categories).
Methods: 1. A cohort study included patients with shoulder pain from primary care physiotherapy. Patients followed the usual diagnostic pathway of which DMUS could be a part. Patients that received DMUS also visited a radiologist within one week for a second one. Patients and radiologists were blinded for the DMUS diagnosis of the PTs. Agreement was assessed using Cohen's kappa statistics. Subgroup analysis was performed on education and experience.
2.First, a literature search was performed to assess which traditional diagnostic labels could be recoded into new treatment related categories(referral to secondary care, corticosteroid injections, physical therapy, watchful waiting). Next, kappa values were calculated for these categories between PTs and radiologists.
Results: 1. A total of 65 patients were enrolled and 13 PTs and 9 radiologists performed DMUS. We found substantial agreement (0.63Κ) between PTs and radiologists on the assessment of full thickness tears. The overall kappa of all four diagnostic categories was 0.36, indicating fair agreement. The more experienced and highly trained PTs showed moderate agreement (0.43Κ) compared to only slight agreement (0.17 and 0.09Κ) for the less experienced and trained PTs with radiologists. 2. Only three categories were extracted, as none of the traditional diagnostic labels were classified into the 'corticosteroid injection' category.Overall, we found moderate agreement to stratify patients into treatment related categories andsubstantial agreement for the category 'referral to secondary care'. Both categories 'watchful waiting' and 'indication for physical therapy' showed moderate agreement between the two professions.
Conclusion(s): At this moment the interprofessional agreement is not high enough to recommend DMUS in clinical care, although training and experience impact the agreement. Clinicians should be careful when using DMUS. Our results indicate that the agreement between radiologists and PTs is moderate to substantial when labelling is based on treatment effectiveness. DMUS might be facilitate PT treatment guidance, especially for the category 'referral to secondary care' as this showed the highest agreement. However, more research is needed, to validate and assess the consequences of this stratification classification for clinical care.
Implications: It is too soon to make solid statements regarding DMUS, clinicians using DMUS should be aware of the (high) likelihood with differences of interpretations of findings with the radiologist and should take this into account when communicating with their patients about the findings.
Keywords: Shoulder pain, diagnostic ultrasound, reliability
Funding acknowledgements: This study was financed by the SIA-RAAK grant serving exclusively for lectureships and knowledge networks at Universities of Applied Sciences.
Purpose: The purpose of this project was to assess the interprofessional agreement between radiologists and PTs. First, we assessed the interprofessional agreement on traditional diagnostic labels (full thickness tear, partial thickness tear, subacromial bursitis and calcification) as the psychometric properties of DMUS when used by radiologists is good. Next, we assessed the agreement when a new stratification approach was used (based upon treatment related categories).
Methods: 1. A cohort study included patients with shoulder pain from primary care physiotherapy. Patients followed the usual diagnostic pathway of which DMUS could be a part. Patients that received DMUS also visited a radiologist within one week for a second one. Patients and radiologists were blinded for the DMUS diagnosis of the PTs. Agreement was assessed using Cohen's kappa statistics. Subgroup analysis was performed on education and experience.
2.First, a literature search was performed to assess which traditional diagnostic labels could be recoded into new treatment related categories(referral to secondary care, corticosteroid injections, physical therapy, watchful waiting). Next, kappa values were calculated for these categories between PTs and radiologists.
Results: 1. A total of 65 patients were enrolled and 13 PTs and 9 radiologists performed DMUS. We found substantial agreement (0.63Κ) between PTs and radiologists on the assessment of full thickness tears. The overall kappa of all four diagnostic categories was 0.36, indicating fair agreement. The more experienced and highly trained PTs showed moderate agreement (0.43Κ) compared to only slight agreement (0.17 and 0.09Κ) for the less experienced and trained PTs with radiologists. 2. Only three categories were extracted, as none of the traditional diagnostic labels were classified into the 'corticosteroid injection' category.Overall, we found moderate agreement to stratify patients into treatment related categories andsubstantial agreement for the category 'referral to secondary care'. Both categories 'watchful waiting' and 'indication for physical therapy' showed moderate agreement between the two professions.
Conclusion(s): At this moment the interprofessional agreement is not high enough to recommend DMUS in clinical care, although training and experience impact the agreement. Clinicians should be careful when using DMUS. Our results indicate that the agreement between radiologists and PTs is moderate to substantial when labelling is based on treatment effectiveness. DMUS might be facilitate PT treatment guidance, especially for the category 'referral to secondary care' as this showed the highest agreement. However, more research is needed, to validate and assess the consequences of this stratification classification for clinical care.
Implications: It is too soon to make solid statements regarding DMUS, clinicians using DMUS should be aware of the (high) likelihood with differences of interpretations of findings with the radiologist and should take this into account when communicating with their patients about the findings.
Keywords: Shoulder pain, diagnostic ultrasound, reliability
Funding acknowledgements: This study was financed by the SIA-RAAK grant serving exclusively for lectureships and knowledge networks at Universities of Applied Sciences.
Topic: Musculoskeletal: upper limb; Disability & rehabilitation; Primary health care
Ethics approval required: Yes
Institution: Erasmus MC
Ethics committee: Medical Ethics Committee of the Erasmus Medical Center in Rotterdam
Ethics number: MEC-2011-414
All authors, affiliations and abstracts have been published as submitted.
