Physiotherapy and shoulder pain; Coactive collaboration, supervised exercises in patients on a waiting list for surgery, and cost-of-illness in primary care.

Background: Shoulder pain is a common cause of disability and lost work days. Rotator cuff disease, impingement syndrome or subacromial pain are similar labels used to describe the most common shoulder diagnosis. Similar results after surgery and exercises supervised by physiotherapist are reported in three randomised controlled trials in hospital settings. The content of the supervised exercise programme has not been explored with qualitative scientific methods. The feasibility of the supervised exercise programme in a specialist primary care setting has not been studied. Cost evaluations of different aspects of shoulder treatment are scarce. Aims: The aim of the first study was to explore and define the communication and teaching techniques used by a physiotherapist in the initial part of the supervised exercise programme. The aim of study II was to evaluate the feasibility of this programme in surgical candidates in a local hospital, and the aim of study III was to evaluate the costs and resource allocation for shoulder treatment in primary health care in a small western Swedish county. Methods: Study I is a qualitative explorative study, using observations with video recordings and field notes. A transcription model was developed and qualitative content analysis was applied to analyse the data. Study II is a prospective cohort study including patients with the impingement syndrome referred for surgical evaluation. The patients had physiotherapy using the method of supervised exercises and this treatment approach was also used in study I. Evaluation was un-blinded using a validated clinical outcome measure (the UCLA score). Study III is a cost-of-illness study with a societal perspective. Evaluation of costs and resource use was based on diagnostic codes and electronic patient records. A spreadsheetbased economic model was constructed. The human capital approach was used to calculate costs for sick leave and a supplementary sensitivity analysis estimated uncertainty due to changes in different parameters. Results: The results of study I were presented in three content areas: context, interaction, and professional skills used in a process of motor learning. The term coactive collaboration was defined to describe the process. It was defined as the mutual effort made by physiotherapist and patient to reduce symptoms. This was accomplished in interaction, using verbal and nonverbal communication, including physical contact. In study II, 72 of 97 patients referred for surgery had in average 11 supervised exercise treatments during 8 weeks. Results were classified as excellent or good by 87% of the 72 patients, and they declined surgery. In study III the mean annual total cost for patients with shoulder pain in primary health care was €4139 per patient. Sick leave contributed to 84% of total costs, while physiotherapy treatments accounted for 60% of the healthcare costs or about 10% of total costs. Conclusions: Study I emphasizes the interaction between physiotherapist and patient. This should be further explored in different settings and comparing different treatment approaches in future studies. With the limitation of the design applied in study II, most patients referred for surgery for the impingement syndrome declined surgery after an average of two months of supervised exercises. This may have consequences for sickness absence, health care costs, and for total costs of shoulder pain. In study III physiotherapy accounted for a major part of healthcare costs, but only a minor part of total costs for shoulder pain in primary care