Prevalence & incidence

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Chronic Shoulder Pain - In a nutshell - K. Kuppens, F. Struyf, J. Nijs, N. Roussel, M. Meeus, I. Slegers, G.

be) 19 & 20 oktober 20125 Wilrijk (www.scholingrandstadwest.

primary care Approximately 1% of adults consult a general practitioner with new shoulder pain annually.

given period Prospective studies 3 Urwin et al.

total economic cost for shoulder pain Luime et al. 2004, Ryall et al. 2006, Croft et al. 1996, Van der Windt et al. 1996, Kuypers et al.

1 Chronic Shoulder Pain - In a nutshell - K. Kuppens, F. Struyf, J. Nijs, N. Roussel, M. Meeus, I. Slegers, G. Hens Shoulder pain: a challenging phenomenon Mira Meeus - Filip Struyf Kevin Kuppens o.a. 25 & 26 juni 2015 Genk ( 19 & 20 oktober Wilrijk ( 1 Prevalence & incidence Lifetime prevalence up to 66,7% Point prevalence 6,9 to 26% 3rd most common cause of musculoskeletal consultation in primary care Approximately 1% of adults consult a general practitioner with new shoulder pain annually. Prevalence Proportion of patients with shoulder pain Cross sectional studies Incidence New cases of shoulder pain arising in a population over a given period Prospective studies 3 Urwin et al % recovers within first 6 months An additional 10% during the 6 months afterwards 40% still has shoulder complaints after 1 year 80% of the total economic cost for shoulder pain Luime et al. 2004, Ryall et al. 2006, Croft et al. 1996, Van der Windt et al. 1996, Kuypers et al. 2006a,b 4 Chronic Shoulder Pain! How To Explain? Description of patients with painful shoulder syndrome Excl: fractures, surgery, cancer, shoulder-hand syndrome Chronic > Acute (1,6 x)!!! Women!!! Imaging - 66,2 % Tendinosis - 26,9 % Arthropathy - 18,5 % Bursitis - 22,3 % Normal Reference diagnosis - 75,4 % Rotator cuff syndrome - 8,7 % Unspecified Lesion - 6,3 % Frozen Shoulder - 6,3 % Cervicalgia - 2,4 % Instability - 0,8 % Arthrosis Dias et al (2008) 5 6 1

Evaluation of a (shoulder pain) patient World Health Organization - Advices framework for measuring health and disability at individual

Planetary model - Colleagues from Ghent University 7 http://www.who.int/classifications/icf/en/ 8 Dewitte et al 2014 Rotator Cuff?

Large amount of mechanoreceptors in both the superior, middle and inferior glenohumeral ligaments; Free nerve endings in glenohumeral

1997; Maass et al. 2001; Guanche et al. 1999; Hashimoto et al. 1994 Minaki et al.

2 Evaluation of a (shoulder pain) patient World Health Organization - Advices framework for measuring health and disability at individual and population levels - International Classification of Functioning, Disability and Health (ICF) Didactic representation of ICF - Planetary model - Colleagues from Ghent University Dewitte et al 2014 Rotator Cuff? High density of nociceptors around the rotatorcuff insertion (supraspinatus) Glenohumeral joint? Large amount of mechanoreceptors in both the superior, middle and inferior glenohumeral ligaments; Free nerve endings in glenohumeral capsule & labrum (mainly capsulolabral & capsulohumeral) Activation and protection in case of extreme movement. Backenkohler et al. 1997; Maass et al. 2001; Guanche et al. 1999; Hashimoto et al Minaki et al Bursa subacromialis Many subacromial decompression and bursectomy in patients with impingement related symptoms Very richly innervated (in comparison to other structures around the shoulder) Ide et al. 1996; Soifer et al. 1996; Tomita et al

3 Lesniak et al., 2013 AJSM 21 asymptomatic baseball pitchers 2 seasons MRI Baseball pitchers Tissue based pathologypain model?! Lack of association between pathology & pain No corresponding change in observable structural pathology 15 Local Biochemical Basis For Pain Known mediators such as Substance P Potassium Serotonin Bradykinin Histamine Prostaglandins Dewitte et al

Movement dysfunction Articular Myofascial Neurogenic

. Impairment of function Movement dysfunction A. Articular A.

Muscle length B. Muscle strength C. Muscle tonus C.

Nerve glide Upper limb tension test D. Sensorimotor control A.

4 Movement dysfunction Articular Myofascial Neurogenic Sensorimotor control Posture Pain.. Impairment of function Movement dysfunction A. Articular A. Hypomobility B. Hypermobility B. Myofascial A. Muscle length B. Muscle strength C. Muscle tonus C. Neurogenic A. Sensory function B. Nerve glide Upper limb tension test D. Sensorimotor control A. Proprioception B. Muscle setting C. Coordination E. (Posture) F. (Pain) KINETIC CHAIN MIND THE CENTRAL NERVOUS SYSTEM C. Littlewood et al., Manual Therapy 2013: pain associated with rotator cuff tendinopathy, that persists beyond expected recovery times, should be evaluated within a framework that recognises the potential for altered processing and modulated output of the CNS

recognises the potential for altered processing and modulated output of the CNS 25 26 Dewitte et al 2014 PAIN = Widespread Hyperalgesia Allodynia Referred pain

5 C. Littlewood et al., Manual Therapy 2013: pain associated with rotator cuff tendinopathy, that persists beyond expected recovery times, should be evaluated within a framework that recognises the potential for altered processing and modulated output of the CNS Dewitte et al 2014 PAIN = Widespread Hyperalgesia Allodynia Referred pain Product (output) of the CNS processsing - Spinal cord (dorsal horns) - Brain Modulated by thougths, feelings, reflects state of peripheral tissues! Central sensitization = Hyperexcitability CNS = Hypersensitivity for all mechanic stimuli Allodynia Generalized hyperalgesia Referred pain Chronic pain

) - higher n of MTrP - lower PPT s (also distant) Hyperalgesia in unilateral shoulder pain 31 Nijs,

syndrome Chronic whiplash associated disorders Irritable bowel syndrome Chronic low back pain

Tennis elbow Chronic shoulder pain / impingement Algoritme recognition CS International consensus

2007, Langemark et al. 1993, Pielsticker et al. 2005, Burnstein et al. 2000, Weissman-Fogel et al.

Severity of pain and related disability disproportionate to the nature and extent of injury or

6 Chronic SIS (Gwilym et al.) - Referred pain - Hyperalgesia to punctuate stimuli SIS (Hidalgo-Lozano et al.) - higher n of MTrP - lower PPT s (also distant) Hyperalgesia in unilateral shoulder pain 31 Nijs, Medical diagnoses associated with central sensitization Fibromyalgia Chronic fatigue syndrome Chronic whiplash associated disorders Irritable bowel syndrome Chronic low back pain Temporomandibular dysfunction Myofascial pain sydromes Osteoarthritis Rheumatoid arthritis Headache Tennis elbow Chronic shoulder pain / impingement Algoritme recognition CS International consensus document Meeus et al. 2008, Curatolo 2001, Wand and O Connell 2008, Yunus et al. 2007, Langemark et al. 1993, Pielsticker et al. 2005, Burnstein et al. 2000, Weissman-Fogel et al Criterion1: Disproportionate pain? Severity of pain and related disability disproportionate to the nature and extent of injury or pathology Origin Result Criterion 2: Diffuse pain distribution? One of the following options: Large pain area with a non-segmental distribution Pain varying in (anatomical) location Widespread pain Bilateral pain / mirror pain (i.e. symmetrical pain pattern) Hemilateral pain

- Smell - Light - Sound - Touch - Drugs - Cold / heat

Central Sensitization Inventory Measuring hypersensitivity

me feel dizzy and sick - When I want to go to bed at night,

physical symptoms - I am sensitive to bright light

pdf part A only Cutoff = 40 Mayer et al.

Journal of Pain 2013 37 37 38 38 Additional signs and

timeline Sleeping difficulties Memory- and concentration

Impaired tactile localization Dyskinaesthesia 39 39 40

7 - Smell - Light - Sound - Touch - Drugs - Cold / heat Criterion 3: Hypersensitivity of nonmusculoskeletal senses? Central Sensitization Inventory Measuring hypersensitivity to various stimuli: - Certain smells, such as parfums, make me feel dizzy and sick - When I want to go to bed at night, my legs feel uncomfortable and restless - Stress enhances my physical symptoms - I am sensitive to bright light part A only Cutoff = 40 Mayer et al. Pain Practice 2012; Neblett et al. Journal of Pain Additional signs and symptoms Abnormal therapeutic response Abnormal pain timeline Sleeping difficulties Memory- and concentration difficulties Fatigue Muscle weakness Phantom swelling Impaired tactile localization Dyskinaesthesia Dewitte et al 2014 Psychosocial context of the rotator cuff - Perception of pain varies across gender, age, race, - Health care professional Manteo Mitchell

! Dancing is not that bad for a shoulder!

8 I ve inherited weak shoulders so I m limited in what I can do - Wrong beliefs & attitudes The last time I cleaned the windows it resulted in a painful shoulder - Wrong beliefs ~ pain memory Pt: Same problem other side? Ph: Both sides grey Take Home Messages Evaluate within a bio-psycho-social context Mind the central nervous system Careful in therapeutic communication Jump on the bandwagon?! Dancing is not that bad for a shoulder! kevin.kuppens@uantwerpen.be kevin@kinecoach.be

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: