Chris Littlewood

Subacromial impingement syndrome – What does this mean to and for the patient? A qualitative study

BACKGROUND Structured exercise has been reported as the current treatment of choice for patients diagnosed with subacromial impingement syndrome (SIS). However, it has been suggested that this diagnostic term and the language used to explain this condition might negatively influence patient expectations and serve as a barrier to engagement with exercise, hence compromising clinical outcomes. AIM To explore how patients rationalise their shoulder pain following a diagnosis of SIS and how this understanding might impact on their perception of physiotherapy and engagement with exercise. DESIGN A qualitative study using semi-structured interviews and analysed using the Framework method. SETTING One NHS Physiotherapy department in South Yorkshire, England. PARTICIPANTS Nine patients diagnosed with SIS were purposively sampled from those referred to the outpatient physiotherapy department by the orthopaedic team (consultant surgeons and registrars). RESULTS Three main themes were generated: (1) The diagnostic experience, (2) Understanding of the problem, (3) Expectation of the treatment required; with one subtheme: (3b) Barriers to engagement with physiotherapy. CONCLUSION The findings from this study suggest that diagnosis of shoulder pain remains grounded in a biomedical model. Understanding and explaining pain using the subacromial impingement model seems acceptable to patients but might have significant implications for engagement with and success of physiotherapy. It is suggested that clinicians should be mindful of the terminology they use and consider its impact on the patients treatment pathway with the aim of doing no harm with the language used.

A Systematic Review of Electromyography Studies in Normal Shoulders to Inform Postoperative Rehabilitation Following Rotator Cuff Repair

STUDY DESIGN: Systematic review. BACKGROUND: Electromyography (EMG) has previously been used to guide postoperative rehabilitation progression following rotator cuff repair to prevent deleterious loading of early surgical repair. OBJECTIVE: To review the current literature investigating EMG during rehabilitation exercises in normal shoulders, and to identify exercises that meet a cut point of 15% maximal voluntary isometric contraction (MVIC) or less and are unlikely to result in excessive loading in the early postoperative stages. METHODS: An electronic search of MEDLINE via Ovid, Embase, CINAHL, SPORTDiscus, PubMed, and the Cochrane Library for all years up to June 2016 was performed. Studies were selected in relation to predefined selection criteria. Pooled mean MVICs were reported and classified as low (0%‐15% MVIC), low to moderate (16%‐20% MVIC), moderate (21%‐40% MVIC), high (41%‐60% MVIC), and very high (greater than 60% MVIC). RESULTS: A search identified 2159 studies. After applying the selection criteria, 20 studies were included for quality assessment, data extraction, and data synthesis. In total, 43 exercises spanning passive range of motion, active‐assisted range of motion, and strengthening exercises were evaluated. Out of 13 active‐assisted exercises, 9 were identified as suitable (15% MVIC or less) to load the supraspinatus and 10 as suitable to load the infraspinatus early after surgery. All exercises were placed in a theoretical‐continuum model, by which general recommendations could be made for prescription in patients post rotator cuff repair. CONCLUSION: This review identified passive and active‐assisted exercises that may be appropriate in the early stages after rotator cuff repair.

Identification of Walking Strategies of People With Osteoarthritis of the Knee Using Insole Pressure Sensors

Insole pressure sensors capture the different forces exercised over the different parts of the sole when performing tasks standing up. Using data analysis and machine learning techniques, common patterns and strategies from different users to execute different tasks can be extracted. In this paper, we present the evaluation results of the impact that clinically diagnosed osteoarthritis of the knee at early stages has on insole pressure sensors while walking at normal speeds focusing on the effects caused at points, where knee forces tend to peak for normal users. From the different parts of the foot affected at high knee force moments, the forefoot pressure distribution and the heel to forefoot weight reallocation strategies have shown to provide better correlations with the user’s perceived pain in the knee for OA users with mild knee pain. This paper shows how the time differences and variabilities from two sensors located in the metatarsal zone while walking provide a simple mechanism to detect different strategies used by users suffering OA of the knee from control users with no knee pain. The weight dynamic reallocation at the midfoot, when moving forward from heel to forefoot, has also shown to positively correlate with the perceived knee pain. The major asymmetries between pressure patterns in both feet while walking at normal speeds are also captured. Based on the described features, automatic evaluation self-management rehabilitation tools could be implemented to continuously monitor and provide personalized feedback for OA patients with mild knee pain to facilitate user adherence to individualized OA rehabilitation.

Screening of the cervical spine in subacromial shoulder pain: A systematic review

Background Subacromial shoulder pain is a common clinical presentation with much diagnostic uncertainty. Some of this uncertainty relates to the involvement of the cervical spine as a source or contribution to subacromial shoulder pain. Currently, there is no accepted method of screening of the cervical spine in the presence of subacromial shoulder pain, which risks patients receiving misguided and/or ineffective interventions. Objective To evaluate approaches used to screen the cervical spine in patients with subacromial shoulder pain. Design Systematic review of randomized controlled trials. Methods Electronic searches of PEDro and MEDLINE to December 2016 were conducted. Randomized controlled trials evaluating the effectiveness of interventions within the current scope of physiotherapy comprising of adult patients complaining of subacromial shoulder pain were included. Data relating to the method of cervical spine screening were extracted and synthesized categorically. Results One hundred and two studies were included. Twenty-six (25.5%) were categorized as “No method of screening undertaken or reported,” 49 (48.0%) were categorized as “Localized cervical spine symptoms and/or radiculopathy/radicular pain,” nine (8.8%) were categorized as “Cervical examination,” two (2.0%) were categorized as “Manual testing,” two (2.0%) were categorized as “History of cervical surgery,” and 14 (13.7%) were categorized as using “Combined approaches.” Conclusion Examination of the cervical spine in patients with subacromial shoulder pain is variable in randomized controlled trials. In many instances, no or minimal attempts to screen were undertaken or reported. This has potential research and management implications and further research is indicated to facilitate development of this aspect of examination.

Psychosocial variables and presence, severity and prognosis of plantar heel pain: A systematic review of cross-sectional and prognostic associations

OBJECTIVE Plantar heel pain (PHP) is often disabling, and persistent symptoms are common. Psychosocial variables are known to affect pain and disability but the association of these factors with PHP has yet to be established. The purpose of the present systematic review was to determine if psychosocial variables are associated with the presence, severity and prognosis of PHP. METHODS A systematic review of the literature and qualitative synthesis was carried out. Electronic searches of MEDLINE, CINAHL, SPORTDiscus, PsycINFO and EMBASE were undertaken from the inception of the respective databases up to November 2017. Any study design incorporating measurements of psychosocial variables with participants with plantar heel pain were included. The quality of included articles was appraised using the Newcastle Ottawa Scale. RESULTS Five articles from four studies were included in the review, with a total of 422 participants. Moderate-level evidence suggested a clinically unimportant association with the incidence of PHP and depression, anxiety and stress, and limited evidence suggested a clinically unimportant association with job dissatisfaction. Moderate-level evidence suggested that there may also be an association between depression, anxiety, stress and catastrophization and PHP pain, and between depression, anxiety, stress, catastrophization and kinesiophobia and PHP function. We also found moderate-level evidence that a psychological disorder may be associated with a poorer outcome to shockwave therapy. CONCLUSION In light of this review, the association of psychosocial variables and plantar heel pain cannot be ruled out. Given recommendations to adopt an individualized and stratified approach to other musculoskeletal conditions, clinicians should remain vigilant to their presence.

Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis

Objective To evaluate the comparative effectiveness of current treatment options for plantar heel pain (PHP). Design Systematic review and network meta-analysis (NMA). Data sources Medline, EMBASE, CINAHL, AMED, PEDro, Cochrane Database, Web of Science and WHO Clinical Trials Platform were searched from their inception until January 2018. Study selection Randomised controlled trials (RCTs) of adults with PHP investigating common treatments (ie, corticosteroid injection, non-steroidal anti-inflammatory drugs, therapeutic exercise, orthoses and/or extracorporeal shockwave therapy (ESWT)) compared with each other or a no treatment, placebo/sham control. Data extraction and analysis Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random effects NMA in the short term, medium term and long term. Relative ranking of treatments was assessed by surface under the cumulative ranking probabilities (0–100 scale). Results Thirty-one RCTs (total n=2450 patients) were included. There was no evidence of inconsistency detected between direct and indirect treatment comparisons in the networks, but sparse data led to frequently wide CIs. Available evidence does not suggest that any of the commonly used treatments for the management of PHP are better than any other, although corticosteroid injections, alone or in combination with exercise, and ESWT were ranked most likely to be effective for the management of short-term, medium-term and long-term pain or function; placebo/sham/control appeared least likely to be effective; and exercise appeared to only be beneficial for long-term pain or function. Conclusions Current evidence is equivocal regarding which treatment is the most effective for the management of PHP. Given limited understanding of long-term effects, there is need for large, methodologically robust multicentre RCTs investigating and directly comparing commonly used treatments for the management of PHP. PROSPERO registration number CRD42016046963.

The enigma of rotator cuff tears and the case for uncertainty

It is suggested that tears of the rotator cuff (RC) are a significant cause of shoulder pain. Given that the rates of surgical repair have risen approximately 200% across Europe and the USA over recent years,1 it seems that many clinicians and patients accept this suggestion, yet there is a strong case to question it. The prevalence of RC tears increases with age and asymptomatic RC tears are common in those >50 years in the general population, with twice as many people showing evidence of RC tear without shoulder pain compared with those who show evidence of an RC tear with shoulder pain.2 It therefore seems timely to recognise the enigma of the RC tear and make the case for uncertainty with regard to clinical decision-making. The legitimacy of this proposal becomes more apparent when it is recognised that approximately 40% of RC’s retear or fail to heal following surgery but these patients report similar levels of pain and function as those patients whose RC is judged to be healed.3 Considering that surgical intervention is largely …

Musculoskeletal pain and exercise-challenging existing paradigms and introducing new.

Chronic musculoskeletal pain remains a huge challenge for clinicians and researchers. Exercise interventions are the cornerstone of management for musculoskeletal pain conditions,1 with the benefits being well-established.1 2 Exact mechanisms underpinning this effect on musculoskeletal pain are currently unclear.3 Little is known on the optimal dose and type of exercise, with therapists’ and patients’ behaviour and beliefs around pain during exercise often overlooked in exercise prescription. Exercise-based treatments may be promising, but effect sizes remain small to modest with large variability in exercise prescriptions. The need for pain to be avoided or alleviated as much as possible has been challenged, with a paradigm shift from traditional biomedical models of pain towards a biopsychosocial model of pain, which is particularly relevant in the context of performing therapeutic exercise.4 Indeed, a recent systematic review and meta-analysis of painful exercises versus pain free exercises for chronic musculoskeletal pain that included seven randomised controlled trials found that protocols allowing painful exercises offered a small, but statistically significant, benefit over pain-free exercises in the short-term.4 The improvements in patient-reported pain were achieved with a range of contextual factors, such as varying degrees of pain experienced (ranging from pain being allowed to advised, with/without recommended pain scale) and recovery time (ranging from pain subsiding immediately to within 24 hours). Specifically, we define painful exercises when: exercises are prescribed with instructions for patients to experience pain or where patients are told that it is acceptable and safe to experience pain. Understanding the potential mechanisms behind the effects of therapeutic exercise, in the context of factors associated with chronic musculoskeletal pain, is key to optimising current exercise prescriptions for managing musculoskeletal pain. The aim of the review is to provide an understanding on the potential mechanisms behind exercise and to build on this into …

Reliability of the shoulder symptom modification procedure and association of within-session and between-session changes with functional outcomes

Background Despite being a common problem, there is considerable diagnostic uncertainty with regard to shoulder pain. This uncertainty relates to the reliability and validity of current examination tests. The Shoulder Symptom Modification Procedure (SSMP) has been proposed as an alternative to existing approaches. Objective To evaluate interclinician reliability of the SSMP and the association of within-session and between-session changes on clinical outcome at 1 week, and at 1 and 3 months. Design A single-centre reliability study, with prospective follow-up. Methods Twenty-six patients with shoulder pain were recruited. Following an initial SSMP-based examination, a second examination was performed by a second physiotherapist, blinded to the results of the first examination. Clinical outcome data were completed after 1 week, 1 month and 3 months via theNumeric Pain Rating Scale and the Shoulder PainandDisability Index. Reliability was evaluated using kappa and associations were evaluated using Spearman’s r. Results Inter-rater reliability of the SSMP was moderate (κ=0.47). Association of within-session changes ranged from fair to poor in the short term (r=0.24–0.01) to poor in the mid-term (r=−0.03). The association of between-session changes ranged from substantial to moderate in the short term (r=0.74–0.47) but slight in the mid-term (r=0.22). Conclusions Based on this study, we cannot recommend the SSMP as a reliable tool for physical examination of patients with shoulder pain. The importance of within-session and between-session changes remains uncertain.

Surgery for tennis elbow: a systematic review:

Background There is no consensus on the most suitable treatment for tennis elbow but, in the USA, surgical intervention is increasing despite a lack of supportive research evidence. The aim of this systematic review was to provide a balanced update based on all relevant published randomized controlled trials conducted to date. Methods An electronic search of MEDLINE, EMBASE, CINAHL, BNI, AMED, PsycINFO, HBE, HMIC, PubMed, TRIP, Dynamed Plus and The Cochrane Library was complemented by hand searching. Risk of bias was assessed using the Cochrane Risk of Bias Tool and data were synthesized narratively, based on levels of evidence, as a result of heterogeneity. Results Twelve studies of poor methodological quality were included. The available data suggest that surgical interventions for tennis elbow are no more effective than nonsurgical and sham interventions. Surgical technique modifications may enhance effectiveness compared to traditional methods but have not been tested against a placebo. Conclusions Current research evidence suggests that surgery for tennis elbow is no more effective than nonsurgical treatment based on evidence with significant methodological limitations. Given the recalcitrant nature of tennis elbow for some patients, further research in the form of a high-quality placebo-controlled surgical trial with an additional conservative arm is required to usefully inform clinical practice.