Identification of clinical predictors for recovery from shoulder pain following ultrasound guided corticosteroid injection into the subacromial- subdeltoid bursa

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Wells, Brooke
Author ORCID Profiles (clickable)
Master of Osteopathy
Unitec Institute of Technology
Moran, Robert
Mason, Jesse
Masters Thesis
Ngā Upoko Tukutuku (Māori subject headings)
subacromial-subdeltoid (SASD) bursa
SASD bursa
corticosteroid injection (CSI)
Wells, B. (2020). Identification of clinical predictors for recovery from shoulder pain following ultrasound guided corticosteroid injection into the subacromial- subdeltoid bursa. (Unpublished document submitted in partial fulfilment of the requirements for the degree of Master of Osteopathy). Unitec Institute of Technology, Auckland, New Zealand. Retrieved from
INTRODUCTION TO THE THESIS The study reported in this thesis investigates predictors of success following a corticosteroid injection (CSI) into the subacromial-subdeltoid (SASD) bursa of the glenohumeral (GH) joint. Anecdotally, there is a lack of knowledge regarding how patients will respond to a CSI into the SASD bursa, as well as what attributes may suggest whether a patient will or will not recover well following a bursal injection. This thesis therefore aimed to collate outcome measures and investigate if they can predict changes following a SASD bursal CSI. The study is presented as a Manuscript, which is preceded by a Literature Review discussing research pertinent to the area of study undertaken. Research into the impact of shoulder pain is presented in the following Literature Review presented in Chapter I. The epidemiology and economic impact of shoulder pain is explored first, demonstrating a global lack of current research in this field, and the rise in national costs associated with shoulder pain recovery. The next section titled ‘Why Shoulder Pain?’ explains causes of shoulder pain, integrating anatomical, functional, and biomechanical considerations and theories of pain to provide a comprehensive review of shoulder pain. Subacromial impingement syndrome (SIS) is reported to be one of the most common shoulder pathologies causing shoulder pain and therefore will be discussed in depth in the section titled ‘What is Shoulder Pain’. This will provide background information regarding the likely cause of SIS related shoulder pain, followed by the treatment options that may be used prior to a CSI being considered. The section will introduce SIS as a condition, followed by discussion of the process of diagnosis, treatment options, and prognosis. Given the study investigates corticosteroid injections into the SASD bursa, and whether a response could be predicted following an injection, corticosteroids and their use will be discussed in some depth. The section titled ‘Corticosteroid Injections’ introduces the corticosteroid agents used for musculoskeletal (MSK) pathologies, and the methods used to facilitate accuracy of the injection. This is important to discuss because this study observed ultrasound guided CSIs, and there is debate regarding the effectiveness of guided versus non- guided injections. In this same section evidence pertaining to the effectiveness of a CSI will be discussed, presenting data on short-term versus long-term prognosis following an injection, as well as an outline of reported side effects of CSIs. Predictors and outcome measures related to shoulder rehabilitation will be introduced and discussed in the final section of the Literature Review. This discussion may appear tangential to shoulder pain and CSIs, however, because this pertains to the prediction of outcomes of shoulder pain, it is important to present information regarding such predictors and their use in research and clinical practice. Within the ‘Predictor’ section of the Literature Review, the initial stages of development of a clinical prediction rule (CPR) will be described. Although it was not an aim, nor a product, of this thesis to develop a CPR, it is important to demonstrate the steps necessary to create a successful prediction study. The use of predictors in healthcare will be discussed, as well as common predictors of shoulder pain and disability. Additionally, although this is a prediction study, it is important to introduce outcome measures, as some patient reported outcome measures (PROMs) can be used to assess a patient’s current status and predict future outcomes. The PROM subsection begins with a broad discussion on subjective versus objective measurement, followed by a paragraph on common PROMs used for shoulder pain and disability. A more substantial review on the development, validation and use of outcome measures in healthcare and research completes this section. Finally, a Summary of Chapter I highlights the reasoning behind investigating individual predictors and outcome measures that can predict shoulder pain following a CSI into the SASD bursa. Following this, a Methodology section will present how shoulder pain in the context of this thesis should be researched. The study proper will be presented as a Manuscript in Chapter II, reporting the main findings, as well as the appendices for the manuscript which provide additional information relating to the study. The thesis appendices are located in Chapter III, containing information not reported in the manuscript, such as ethics approval, consent forms, participant information and questionnaires.
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