Shoulder injuries
A model where MCDM analysis could be applied to illustrate the benefit is shoulder soft tissue injuries and lesions, which are prevalent and costly.12,25-28 Treatment may consist of physiotherapy, (including manual therapy and exercise), medication, and for more serious conditions, surgery. Given that the healing of chronic shoulder problems often seems slow, surgery offers patients a more immediate solution; however, this is not always the most efficacious option. Currently, shoulder health care, including outcome reporting, is highly variable. 29 Perhaps most importantly, for clinicians providing such primary health care, judging the appropriate circumstance and timeframe for imaging and/or surgery is challenging.
When considering shoulder injury treatment pathways, the shoulder presents some specific challenges. Shoulder pain can be persistent and reoccurring: while prevalence reporting is variable, 20-50% of shoulder presentations were found to be still experiencing pain twelve months after the initial complaint.26,30,31 Furthermore, the aetiology of shoulder injuries is complex which can sometimes lead to contradictory clinical opinions. Considering rotator cuff tears, as one of the most common shoulder injuries, it is known that rotator cuff tears may develop without injury and can be asymptomatic.32 Therefore, in a health care system with injury based funding, as in NZ, pre-existing tendon tears complicate the decision-making for funders. Beyond initial diagnosis and categorising, the treatment pathway decision-making process is also complicated by multifactorial clinical criteria, health systems, and funding. The goal of making the best judgment for the patient is not an easy one, and interpreting clinical information can vary among clinicians.33
Accordingly, with the ready availability of imaging as an early decision-making tool, imaging for shoulder conditions is overused.3 Ideally, the role of imaging is in identifying pathology that will change the treatment pathway and detect red flags. Although making a decision is a tangible challenge, gathering more information in the form of imaging does not necessarily contribute towards better management of the typical rehabilitation patient. An identified small soft tissue injury does not always necessitate a change of care pathway nor surgery. It is known that a small tear caused by injury can heal,34 and a small pathological tear with no injury can progress to a full tear that will not heal.35 Furthermore, the shoulder can function well with a full tear10 and shoulder pathology can be present in both symptomatic and asymptomatic shoulders.36
Decision-making for musculoskeletal shoulder injuries/conditions are not based on a single factor, and each factor in the process carries a level of importance; understanding the weighting of each key factor is a step towards a better understanding of the decision-making process. Potentially, shoulder injury decision-making is an area where MCDM analysis could be used to support both the novice and expert practitioner alike.