Jeremy Lewis

Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review

Purpose: To review the evidence for the effectiveness of therapeutic exercise for the treatment of full thickness (including massive and inoperable) tears of the rotator cuff. Relevance: There is little consensus as to the most effective treatment of full thickness and massive tears of the rotator cuff. There is consensus that the outcome of rotator cuff tendon surgery in the elderly is generally very poor. As such, exercise therapy is usually recommended for this patient group. Although commonly prescribed, the evidence to support this approach is equivocal. The aim of this study was to conduct a systematic review of the literature to determine the efficacy of exercise therapy for the management of full thickness rotator cuff tears. Methods: A systematic review was conducted to synthesise the available research literature on the effectiveness of exercise therapy for full thickness tears of the rotator cuff. Data source: Reports up to and including September 2006 were located from MEDLINE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), AMED, EMBASE, the Cochrane Database of Systematic Reviews and the Physiotherapy Evidence Database (PEDro) using the terms “rotator cuff” and “tear/s” and “exercise” or “physiotherapy” or “physical therapy” or “rehabilitation”. Study selection: Studies were included if they related to full thickness rotator cuff tears and exercise. Data extraction: Two independent reviewers assessed the methodological quality of the studies. Differences were resolved by consensus. Analysis/Data synthesis: Ten studies met the inclusion criteria: eight were observational case series and two were single case studies. There were no randomised clinical trials. Results: Four studies were specific to massive rotator cuff tears. One study had a sub-group with massive cuff tears and five studies were not specific as to the size of the full thickness tear. Due to the heterogeneity of outcome measures used, it was not possible to combine results. In all studies an improvement in outcome scores was reported. Exercise programmes were well documented in five studies. Conclusions: No randomised controlled trials met the inclusion criteria and the evaluation has been based on observational studies of lower scientific merit. The findings suggest that some evidence exists to support the use of exercise in the management of full thickness rotator cuff tears. There is a definite need for well-planned randomised controlled trials investigating the efficacy of exercise in the management of full thickness and massive rotator cuff tears.

Rotator cuff tendinopathy

Purpose: A review was conducted to synthesise the available research literature on the pathogenesis of rotator cuff tendinopathy. Relevance: Musculoskeletal disorders of the shoulder are extremely common, with reports of prevalence ranging from one in three people experiencing shoulder pain at some stage of their lives to approximately half the population experiencing at least one episode of shoulder pain annually. Pathology of the soft tissues of the shoulder, including the musculotendinous rotator cuff and subacromial bursa, is a principal cause of pain and suffering. Conclusions: The pathoaetiology of rotator cuff failure is multifactorial and results from a combination of intrinsic, extrinsic and environmental factors. The specialised morphology of the rotator cuff, together with the effects of stress shielding, may contribute to the development of rotator cuff tendinopathy. Profound changes within the subacromial bursa are strongly related to the pathology and resulting symptoms. A considerable body of research is necessary to more fully understand the aetiology and pathohistology of rotator cuff tendinopathy and its relationship with bursal pathology. Once this knowledge exists more effective management will become available.

The effect of kinesiotape on function, pain, and motoneuronal excitability in healthy people and people with Achilles tendinopathy.

Objective:To investigate the effect of kinesiotape on hop distance, pain, and motoneuronal excitability in healthy people and people with Achilles tendinopathy (AT). Design:Within-subject design. Setting:An academic health science center, which is an acute London National Health Service trust. Participants:With ethical approval and informed consent, a convenience sample of 26 healthy people and 29 people with AT were recruited. Seven participants were lost after functional testing, leaving 24 participants in each group. Interventions:Kinesiotape applied over the Achilles tendon. Main Outcome Measures:The single-leg hop test and visual analog scale were measured with and without the tape. Using the Hoffman (H) reflex, change in motoneuronal excitability of calf muscles was measured before tape application, with the tape on and after its removal. Results:There were no changes to hop distance when tape was applied (P = 0.55). Additionally, there were no changes to pain (P = 0.74). The H reflex amplitude of soleus and gastrocnemius increased in the healthy group after its removal (P = 0.01 and P = 0.03, respectively), whereas the H reflex remained unchanged in people with AT (P = 0.43 and 0.16, respectively). Conclusions:Calf muscles were facilitated by kinesiotape in healthy participants. Despite this, there was no change to hop distance. Kinesiotape had no effect on hop distance, pain, or motoneuronal excitability in people with AT. These results do not support the use of kinesiotape applied in this way for this condition.

Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review

Background Alterations in scapular orientation and dynamic control, specifically involving increased anterior tilt and downward rotation, are considered to play a substantial role in contributing to a subacromial impingement syndrome (SIS). Non-surgical intervention aims at restoring normal scapular posture. The research evidence supporting this practice is equivocal. Objective The aim of this study was to systematically review the relevant literature to examine whether a difference exists in scapular orientation between people without shoulder symptoms and those with SIS. Data sources MEDLINE, AMED, EMBASE, CINAHL, PEDro and SPORTDiscus databases were searched using relevant search terms up to August 2013. Additional studies were identified by hand-searching the reference lists of pertinent articles. Review methods Of the 7445 abstracts identified, 18 were selected for further analysis. Two reviewers independently assessed the studies for inclusion, data extraction and quality, using a modified Downs and Black quality assessment tool. Results 10 trials were included in the review. Scapular position was determined through two-dimensional radiological measurements, 360° inclinometers and three-dimensional motion and tracking devices. The findings were inconsistent. Some studies reported patterns of reduced upward rotation, increased anterior tilting and medial rotation of the scapula. In contrast, others reported the opposite, and some identified no difference in motion when compared to asymptomatic controls. Conclusions The underlying aetiology of SIS is still debated. The results of this review demonstrated a lack of consistency of study methodologies and results. Currently, there is insufficient evidence to support a clinical belief that the scapula adopts a common and consistent posture in SIS. This may reflect the complex, multifactorial nature of the syndrome. Additionally, it may be due to the methodological variations and shortfalls in the available research. It also raises the possibility that deviation from a ‘normal’ scapular position may not be contributory to SIS but part of normal variations. Further research is required to establish whether a common pattern exists in scapular kinematics in SIS patients or whether subgroups of patients with common patterns can be identified to guide management options. Non-surgical treatment involving rehabilitation of the scapula to an idealised normal posture is currently not supported by the available literature.

The aetiology of subacromial impingement syndrome

Summary Subacromial impingement syndrome has been described as the most common form of shoulder pathology ( Jobe and Jobe, 1983 ; Kessel and Watson, 1977 ). Neer, et al., 1972 , Neer, et al., 1983 argued that 100% of impingement lesions and 95% of rotator cuff pathology are caused by friction between the acromion and surrounding tissues within the subacromial space. This concept has been challenged and the literature suggests that the aetiology of subacromial impingement is multifactorial. These causes include anatomical and mechanical factors, rotator cuff pathology, glenohumeral instability, restrictive processes of the glenohumeral joint, imbalance of the muscles controlling the scapula, and postural considerations. The purpose of this paper is to explore the potential factors contributing to pathology.

A Study to Examine Patient Adherence to Wearing 24-Hour Forearm Thermoplastic Splints after Tendon Repairs

Adherence is believed to be essential in ensuring a successful clinical outcome. There is a paucity of research available investigating adherence and the effect of nonadherence in hand therapy. This study was conducted to investigate adherence relating to acute hand flexor and extensor tendon injuries. This exploratory descriptive study used a self-report questionnaire. Eighty subjects were recruited four weeks after flexor or extensor tendon repair to complete the anonymous questionnaire. Descriptive statistics were used to analyze the patient group profile. Chi-square test was used to determine any associations between patient profile and adherence. Seventy-six questionnaires were completed and this constitutes a return rate of 95%. Sixty-seven percent of patients reportedly removed their splints, commonly to wash and dress. No significant correlation (p < or = 0.0001) was found between patient profile and nonadherence. Two thirds (67%) of patients report to being nonadherent to their splinting regime, removing their splint after flexor and extensor tendon repairs.

Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion?

Abstract Background: Subacromial impingement syndrome is considered by many to be the most common of the musculoskeletal conditions affecting the shoulder. It is based on a hypothesis that acromial irritation leads to external abrasion of the bursa and rotator cuff. Objectives: The aim of this paper is to review the evidence for the acromial irritation theory and in doing so challenge the rationale for subacromial decompression. Major findings: There is a body of evidence that suggests there is a lack of concordance regarding (i) the area of tendon pathology and acromial irritation, (ii) the shape of the acromion and symptoms, (iii) the proposal that irritation leads to the development of tendinitis and bursitis, and (iv) imaging changes and symptoms and the development of the condition. In addition, there is no certainty that the benefit derived from the surgery is due to the removal of the acromion as research suggests that a bursectomy in isolation may confer equivalent benefit. It is also possible that the benefit of surgery is due to placebo or simply enforces a sustained period of relative rest which may allow the involved tissues to achieve relative homeostasis. It is possible that pathology originates in the tendon and as such surgery does not address the primary pathoaetiology. This view is strengthened by the findings of studies that have demonstrated no increased clinical benefit from surgery when compared with exercise. Additionally, exercise therapy is associated with a substantially reduced economic burden and less sick leave. Conclusion: As there is little evidence for an acromial impingement model, a more appropriate name may be ‘subacromial pain syndrome’. Moreover, surgery should only be considered after an appropriate period of appropriately structured rehabilitation.

Changes in Mechanical Tension in the Median Nerve: Possible implications for the upper limb tension test

Summary Movements which increase neural tension have been considered useful in determining whether pathology of neural tissue is associated with clinical symptoms. In order to investigate changes in neural tension a buckle force transducer was attached to the median nerve at a site approximately 2 cm distal to the axilla in five unembalmed cadavers. A series of ipsilateral and contralateral upper and lower limb manoeuvres was performed and changes in tension were recorded. The results showed a significant increase in the tension in the median nerve when the ipsilateral movements of elbow extension and wrist extension were applied. The movements of contralateral cervical side flexion and ipsilateral straight leg raise were also found to increase tension significantly. No significant change in tension was recorded during ipsilateral shoulder depression, glenohumeral abduction and glenohumeral external rotation. Further, there was no significant change in tension when the contralateral arm movement or the contralateral straight leg raise was applied. These findings indicate that certain manoeuvres increase tension in the median nerve. Further research is required to determine the relevance of neural tension tests in the assessment and treatment of patients suffering from neuromusculoskeletal pathology.

Acromiohumeral distance measurement in rotator cuff tendinopathy: is there a reliable, clinically applicable method? A systematic review

Abstract Background Narrowing of the subacromial space has been noted as a common feature of rotator cuff (RC) tendinopathy. It has been implicated in the development of symptoms and forms the basis for some surgical and rehabilitation approaches. Various radiological methods have been used to measure the subacromial space, which is represented by a two-dimensional measurement of acromiohumeral distance (AHD). A reliable method of measurement could be used to assess the impact of rehabilitation or surgical interventions for RC tendinopathy; however, there are no published reviews assessing the reliability of AHD measurement. Objectives The aim of this review was to systematically assess the evidence for the intrarater and inter-rater reliability of radiological methods of measuring AHD, in order to identify the most reliable method for use in RC tendinopathy. Study appraisal and synthesis An electronic literature search was carried out and studies describing the reliability of any radiological method of measuring AHD in either healthy or RC tendinopathy groups were included. Eighteen studies met the inclusion criteria and were appraised by two reviewers using the Quality Appraisal for reliability Studies checklist. Results Eight studies were deemed to be of high methodological quality. Study weaknesses included lack of tester blinding, inadequate description of tester experience, lack of inclusion of symptomatic populations, poor reporting of statistical methods and unclear diagnosis. There was strong evidence for the reliability of ultrasound for measuring AHD, with moderate evidence for MRI and CT measures and conflicting evidence for radiographic methods. Overall, there was lack of research in RC tendinopathy populations, with only six studies including participants with shoulder pain. Conclusions The results support the reliability of ultrasound and CT or MRI for the measurement of AHD; however, more studies in symptomatic populations are required. The reliability of AHD measurement using radiographs has not been supported by the studies reviewed.BACKGROUND Narrowing of the subacromial space has been noted as a common feature of rotator cuff (RC) tendinopathy. It has been implicated in the development of symptoms and forms the basis for some surgical and rehabilitation approaches. Various radiological methods have been used to measure the subacromial space, which is represented by a two-dimensional measurement of acromiohumeral distance (AHD). A reliable method of measurement could be used to assess the impact of rehabilitation or surgical interventions for RC tendinopathy; however, there are no published reviews assessing the reliability of AHD measurement. OBJECTIVES The aim of this review was to systematically assess the evidence for the intrarater and inter-rater reliability of radiological methods of measuring AHD, in order to identify the most reliable method for use in RC tendinopathy. STUDY APPRAISAL AND SYNTHESIS An electronic literature search was carried out and studies describing the reliability of any radiological method of measuring AHD in either healthy or RC tendinopathy groups were included. Eighteen studies met the inclusion criteria and were appraised by two reviewers using the Quality Appraisal for reliability Studies checklist. RESULTS Eight studies were deemed to be of high methodological quality. Study weaknesses included lack of tester blinding, inadequate description of tester experience, lack of inclusion of symptomatic populations, poor reporting of statistical methods and unclear diagnosis. There was strong evidence for the reliability of ultrasound for measuring AHD, with moderate evidence for MRI and CT measures and conflicting evidence for radiographic methods. Overall, there was lack of research in RC tendinopathy populations, with only six studies including participants with shoulder pain. CONCLUSIONS The results support the reliability of ultrasound and CT or MRI for the measurement of AHD; however, more studies in symptomatic populations are required. The reliability of AHD measurement using radiographs has not been supported by the studies reviewed.

Rotator cuff related shoulder pain: Assessment, management and uncertainties

INTRODUCTION Rotator cuff related shoulder pain (RCRSP) is an over-arching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears. For those diagnosed with RCRSP one aim of treatment is to achieve symptom free shoulder movement and function. Findings from published high quality research investigations suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery for; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, partial thickness rotator cuff (RC) tears and atraumatic full thickness rotator cuff tears. However considerable deficits in our understanding of RCRSP persist. These include; (i) cause and source of symptoms, (ii) establishing a definitive diagnosis, (iii) establishing the epidemiology of symptomatic RCRSP, (iv) knowing which tissues or systems to target intervention, and (v) which interventions are most effective. PURPOSE The aim of this masterclass is to address a number of these areas of uncertainty and it will focus on; (i) RC function, (ii) symptoms, (iii) aetiology, (iv) assessment and management, (v) imaging, and (vi) uncertainties associated with surgery. IMPLICATIONS Although people experiencing RCRSP should derive considerable confidence that exercise therapy is associated with successful outcomes that are comparable to surgery, outcomes may be incomplete and associated with persisting and recurring symptoms. This underpins the need for ongoing research to; better understand the aetiology, improve methods of assessment and management, and eventually prevent these conditions.