Using the Research to Improve our Management of Shoulder Pain. Ian Horsley PhD,MMACP, MCSP Technical Lead Physiotherapist (Upper Limb) EIS

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1 Using the Research to Improve our Management of Shoulder Pain Ian Horsley PhD,MMACP, MCSP Technical Lead Physiotherapist (Upper Limb) EIS

2 Outline What do we call it? How can we reliably assess it? What about the scapula? What about the muscle activity? Where does this leave us? Movement variability Causality and dispositionality

3 Background Shoulder complaints 3rd most common MSK disorder seen in UK general practice Affect 1 in 5 adults in the UK = 1.5 million GP visits per annum 40-50% of patients reporting persistent symptoms after 6-12 months despite treatment (Urwin et al., 1998; Winters et al., 1999) The prevalence of SP ranged between 7 and 26% within the general population, increasing with age (Luime et al., 2004) There is considerable uncertainty regarding these diagnostic criteria (Schellingerhout et al., 2008) Clinically, it may not be possible to distinguish between these pathoanatomical diagnostic categories with certainty (Buchbinder et al., 1996)

4 Subacromial pain (SAP) Rotator cuff related pain Movement related shoulder pain without significant stiffness Weak and painful shoulder Something hurts in the shoulder syndrome (SHITS) Shoulder pain Soft-tissue shoulder pain Rotator cuff tendinopathy Terminology

5 Which Tests Are Useful? Prognostic factors associated with the outcome of physiotherapy for shoulder pain are unclear and currently cannot support clinical decision making (Chester et al., 2013)

The clinical performance of single PETS is

guide physiotherapist to make diagnostic

selection of physical tests for shoulder

6 The clinical performance of single PETS is limited Bio-psychosocial vision of health may guide physiotherapist to make diagnostic triage and to choose the right treatment for the individual patient. Insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement,

7 Pain Provocation Tests Pain as a warning rather than tissue injury Peripheral/Central sensitisation

8 EXAMINATION QUESTIONABLE- SO LET S GET IMAGING

9 Correlation of Imaging With Tissue Damage SAIS (55%),Control (52%) (Frost et al., 1999)* Asymptomatic baseball pitchers; 79% D, 86% ND (RCT), 79% D, 79% ND (labral involvement) (Miniaci et al.,2002)* Asymptomatic tennis/pitchers 40% FFT/PTT (Connor et al.,2003)* Tempelhoff et al.,1999; - 13% of people aged 50 to 59 20% of people aged 60 to 69 31% of people aged % of people aged 80 or above * MRI + Ultrasound

10 Where Does That Leave Us? Controversial Interpretation of Diagnostic Imaging Lack of uniformity In Diagnostic Labelling Biederwolf, 2013 Untrustworthiness Of Diagnostic Tests Non Correlation Between Pain And Structural Factors

11 ASSESSMENT OF MOVEMENT

12 Scapulothoracic Muscle Activity With Impingement Higher activity in UT with elevation (Ludewig and Cook, 2000; Lin et al., 2011; Cools et al., 2007) No difference in UT activity with elevation (Bandholm et al., 2006; Roy et al., 2008; Diederichsen et al., 2009) MT less active with elevation (Cools et al., 2007) MT no difference (Roy et al. 2008) LT decreased activity (Cools et al., 2004; Cools et al., 2007; Lin et al., 2011) LT increased activity (Ludewig and Cook,2000) LT no difference (Roy et al.,2008) SA decreased activity (Ludewig and Cook, 2000; Diederichsen et al., 2009; Lin et al., 2011) SA no difference (Roy et al. (2008; Diederichsen et al.2009)

13 ASSESSING THE SCAPULA

14 Scapular control and ROM can be assessed on the field with acceptable reliability Validity of scapular dyskinesis test was demonstrated The exact role of dyskinesis in creating or exacerbating Shoulder dysfunction is not clearly defined

15 Procedure demonstrates a good level of reliability. Not a stand-alone procedure and must be embedded within a complete patient care management programme Insufficient evidence to recommend SSMP as a reliable or validated tool

16 Suggestion The velocities and ROM differ with each swing, but the joint actions appear to be the same. (Bernstein,1923)

17 MANAGEMENT

21 Does Exercise need to Be Specific? Scapular stabilization exercises* Rotator cuff resistance exercises* Range of motion* Stretching exercises* (*Hanratty et al.,2012) Proprioceptive exercises (Beaudreuil et al., 2011)

23 Is This Where We Are Heading?

25 Physiotherapy- EBP The conscientious, explicit and judicious use of the current best evidence in making decisions about the care of an individual patient (Sackett)

26 Evidence-Informed Decision-Making Process Does not solely rely on the evidence There are occasions where the evidence alone is not sufficient to support a clinical decision (Portney,2004)

27 Thoughts Evidence Based Practice care that takes place when the decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information Evidence-Informed Practice Integrates the best available evidence and clinical expertise with the patient s needs and values to ensure delivery of best practice (Hicks,1997) (Canadian Physiotherapy Association,2012)

28 Concept of Causality A cause of a disease is an event, condition, characteristic, or combination of these factors which plays an important role in producing the condition. A cause could be sufficient or necessary

29 Causality SUFFICIENT CAUSE sufficient when it inevitably/certainly produces or initiates condition Usually a single factor, but often comprises several components Not necessary to identify all the components before effective prevention can take place NECESSARY CAUSE if a component cannot develop in its absence

30 CAUSALITY B A A NECESSITY B Longstanding presentation Over 40 Scapular Dyskinesis Causal Mechanism Dysfunction Deconditioned DISPOSITIONALITY Create a state of susceptibility to a causal mechanism

-Ve Association Physically Active DISPOSITIONALITY

31 CAUSALITY B A Recent presentation A NECESSITY B Over 40 Scapular Dyskinesis Causal Mechanism Dysfunction -Ve Association Physically Active DISPOSITIONALITY Create a state of susceptibility to a causal mechanism

32 FHP DR Scapula Muscle Imbalance Abnormal Tissue Length Anterior HH Kinetic Chain Deficits Overhead worker Increased Loading Increased Range Increased Frequency Possibility of being harmed physically or emotionally Predisposition + Exposure Vulnerability Vulnerability + Movement Dysfunction = INJURY

33 Conclusion

34 Factors Positively Influencing Outcome Patients' expectation of complete recovery Lower pain severity at rest Absence of previous major operations * Absence of pain in contralateral upper quadrant Reduction of pain/increase in elevation ROM with scapular facilitation (Chester et al.,2016)

35 The patient in front of you is unique Consider the variables Which can you modify? Assign weight to the variables (vectors) Use evidence-informed practice Remember the biopsych-social model

37 Thank

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of chronic shoulder pain Review with some case questions Bones: