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1 Guideline Ref No: 0900 Version 4 Title: Document Author: Ratified by: Specialist Orthopaedic Physiotherapist Care and Clinical Policies Group Date: 13 February 2017 Date: 19 April 2017 Review date: 5 May 2020 Links to policies: Evidence-based Clinical Guidelines for the diagnosis, assessment and physiotherapy management of Shoulder Impingement Syndrome issued by the Chartered Society of Physiotherapy Commisioning guide : Sub-acromial pain 2014 NICE accredited 1. Purpose of this document To facilitate best practice in physiotherapists diagnosis, assessment and management of shoulder impingement syndrome, and related professionals awareness of such practice To standardise physiotherapists diagnosis, assessment and management of shoulder impingement syndrome To identify and critically appraise the best available evidence relating to the assessment and diagnosis of shoulder impingement syndrome To make recommendations for the assessment and diagnosis of shoulder impingement syndrome To make recommendations for the physiotherapy management of shoulder impingement syndrome To highlight areas where further research is required 2. Guideline: 2.1 Evidence Base Guidelines are based on the documents - Evidence-based Clinical Guidelines for the diagnosis, assessment and physiotherapy management of Shoulder Impingement Syndrome issued by the Chartered Society of Physiotherapy in Commisioning guide : Sub-acromial pain 2014 issued buy British Elbow and Shoulder Society NICE accredited. 2.2 General Principles. The evidence suggests that Shoulder Impingement Syndrome does respond to appropriate physiotherapy interventions. Version 4 (May 2017) Page 1 of 6

2 2.3 Definition of Shoulder Impingement Syndrome. During elevation of the shoulder, the humeral tuberosities pass close under the coracoacromial arch with little clearance left for the intervening soft tissues. If, for any reason, the available space reduces, these soft tissues are liable to become pinched. This is called shoulder impingement syndrome. Pain comes from the sub-acromial space of the shoulder which contains the rotator cuff tendons and the subacromial bursa and NOT the glenohumeral joint. A number of possible mechanisms underlie SIS. Bony anatomical and pathological factors Shoulder instability Impaired scapulohumeral rhythm and scapular instability Capsular tightness Postural factors Soft tissue changes 2.4 Epidemiology. Shoulder pain accounts for over 2.4% of GP consultations and 30% of these patients are referred for physiotherapy. 2.5 Methods Evidence was derived from high quality research where this was available and consensus opinion where the literature was incomplete or equivocal. The literature search was broad based not just confined to RCTs or cohort studies. Eight relevant systematic reviews were appraised. Inclusion criteria formulated and there was a final update search prior to publication. The guideline development group graded the evidence according to the recommendations in the CSP information paper Guidance for developing Clinical Guidelines. Recommendations were graded according to the level of the evidence. Grade A recommendations included at least one RCT as part of a body of literature of overall good quality and consistency addressing the specific recommendation. Grade B recommendations were well conducted clinical studies but no RCT evidence on the topic of recommendation. Grade C recommendations were based on expert committee reports and/or clinical experience of respected authorities. Grade C recommendations were made when applicable studies of good quality were absent. 2.6 The Recommendations Recommendation Assessment. Available evidence does not support the concept of a relationship between static scapular posture and SIS SIS patients demonstrate reduced scapular rotation in mid range scaption, more so with loading and increased anterior tilt in the last third of range Active and passive ranges should be measured No method of measurement is entirely reliable and valid A negative Hawkins-Kennedy test largely rules impingement out but positive results do not rule it in with any certainty A painful arc probably rules impingement in but the absence of an arc does not rule it out with any certainty Version 4 (May 2017) Page 2 of 6

3 2.6.2 Recommendation Imaging Radiographs enable visualisation of calcific deposits Radiographs are of limited value in stage 1 impingement but may show bony changes in the latter stages Positive identifications of full-thickness tears by ultrasound and MRI are probably reliable Recommendation Aims and objectives of physiotherapy for SIS Aims To minimise pain To optimise function To refer those patients who are unresponsive to physiotherapy to other appropriate services Objectives To reduce subacromial inflammation and manage pain To improve posture To restore range, strength, stability and scapulohumeral rhythm To identify when patients should be referred for an orthopaedic opinion Recommendation Rest Initially, relative rest should be recommended: overhead or other aggravating activities should be avoided in particular Absolute rest should be avoided Recommendation Cold therapy Cold packs may be used to reduce the pain and inflammation of SIS and to settle irritation post-exercise. Cold packs should not be applied prior to exercise Recommendation Steroid Injections Steroid injections benefit SIS in the short term Steroid injection should be only used as needed to facilitate rehabilitation. Unless severe pain is present, a trial of more conservative therapy should precede injection. Resistive exercise should be withheld for 2 weeks following injection. The same subacromial space should not be injected on more than 2 occasions. The second injection is occasionally appropriate after 6 weeks but should only be administered in patients who received good initial benefit from the first injection Recommendation Posture An attempt to correct forward-head posture is appropriate in view of its association with shoulder pain Recommendation Exercise Passive mobilisation of the upper quadrant augments the beneficial effects of exercise and should be used A programme of exercises to restore range, strength, stability and scapulohumeral rhythm benefits SIS. Version 4 (May 2017) Page 3 of 6

4 Scapulohumeral and scapulothoracic rhythmic stabilisation training may be introduced from an early stage. Strengthening exercises may be introduced in the form of isotonic medial and lateral rotation of the shoulder performed elbow at side. Scapular stability when performing strengthening exercises is paramount. Stretching exercises may also be introduced at an early stage. Treatment should be ongoing for 6 weeks with appropriate goal setting. Any patient not improving after 3 sessions should be discussed with the physiotherapists supervisor or seen along side the shoulder specialist physiotherapist. 3. Training Physiotherapists will have the opportunity to follow a patients journey gaining experience in specialist input and where appropriate surgery. Upper limb Musculo-skeletal (MSK) clinical interest group will include teaching and practical experience in assessment and management of shoulder pain. Physiotherapists have the opportunity to carry out joint appointments with the specialist shoulder physiotherapy team with those paitents who are more complex. 4. References: Clinical Guidelines for the diagnosis, assessment and physiotherapy management of Shoulder Impingement Syndrome issued by the Chartered Society of Physiotherapy in Commisioning guide : Sub-acromial pain 2014 issued buy British Elbow and Shoulder Society NICE accredited. Amendment History Issue Date Status Authorised 1 30 March 2006 New Consultant Physiotherapist 1 31 January 2008 Date change Consultant Physiotherapist 1 4 February 2010 Date change Consultant Physiotherapist 2 3 November 2010 Amended Consultant Physiotherapist Page 2 - Recommendation NSAIDs taken out of guideline 3 17 January 2013 Amended Consultant Physiotherapist 3 7 November 2014 Date change Consultant Physiotherapist Version 4 (May 2017) Page 4 of 6

5 4 5 May 2017 Amended Page 2 added Commisioning guide : Sub-acromial pain 2014 issued buy British Elbow and Shoulder Society NICE accredited. Pain comes from the subacromial space of the shoulder which contains the rotator cuff tendons and the subacromial bursa and NOT the glenohumeral joint. Shoulder pain accounts for over 2.4% of GP consultations Page 4 ammended Original suggested up to 3 injections now The second injection is occasionally appropriate after 6 weeks but should only be administered in patients who received good initial benefit from the first injection Page 4 - Added further recommendations for exercise Treatment should be ongoing for 6 weeks with appropriate goal setting. Any patient not improving after 3 sessions should be discussed with the physiotherapists supervisor or seen along side the shoulder specialist physiotherapist. Page 4 Added training opportunities - Physiotherapists will have the opportunity to follow a Version 4 (May 2017) Page 5 of 6

6 patients journey gaining experience in imaging specialist input and where appropriate surgery. Upper limb MSK clinical interest group will include teaching and practical experience in assessment and management of shoulder pain. Physiotherapists have the opportunity to carry out joint appointments with the specialist shoulder physiotherapy team with those paitents who are more complex. Care and Clinical Policies Group 4 19 February 2018 Review Date Extended - 2 Years to 3 Years Version 4 (May 2017) Page 6 of 6

7 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. The Mental Capacity Act Version 4 (May 2017) Page 1 of 1

8 Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Policy Author Version and Date An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favorably than Yes No the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centred care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing Yes No process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or marisa.cockfield@nhs.net For Torbay and South Devon NHS Trusts, please call or pfd.sdhct@nhs.net This form should be published with the policy and a signed copy sent to your relevant organisation. Rapid (E)quality Impact Assessment Version 4 (May 2017) Page 1 of 1

This guideline was adapted in collaboration with Dr Georgina Walker and the Palliative Care Team at Rowcroft Hospice. With thanks.

This guideline was adapted in collaboration with Dr Georgina Walker and the Palliative Care Team at Rowcroft Hospice. With thanks. Title: Directorate: Responsible for review: Ratified by: DIABETES, MANAGEMENT OF IN PALLIATIVE CARE PATIENTS General Medicine Diabetes Specialist Nurse Service Delivery Unit Clinical Director of Pharmacy