Current Concepts in the Management of Patients with Shoulder Pain

Current Concepts in the Management of Patients with Shoulder Pain

CAD Meeting Education Topics Low Back Pain Alternative Medicine Legal Issues NDT Shoulder Pain Aquatics Wound Care Marketing Your Practice Ergonomics Acute Care Neuro Rehab

Shoulder Pain Has physical therapy management of patients with shoulder pain changed in the last 5 years? Maybe Maybe not Has information on best management of patients with shoulder pain changed in the last 5 years? Definitely Do our patients know that? Do our referral sources know that?

Evidence Based Practice (EBP) WHAT IS EBP? The Science of the Art of Medicine The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients. Sackett DL, Spine, 1998

EBP Triad: EBP = Integration Sackett DL, Spine, 1998 Individual clinical expertise Best external clinical evidence Individual patient values

EBP Triad = Integration

EBP Problem: Shoulder Pain Intervention: Evidence: High level studies Referral: PIER

P is for Problem Shoulder pain is third most common problem seen by primary care physicians. (Wang & Trudelle-Jackson, 2006) Primary care physicians will refer at least 50% of patients with shoulder complaints to physical therapists. (Wang & Trudelle-Jackson, 2006) What is the problem here?

I is for Intervention

E is for Evidence Is there evidence for more than therapeutic exercise to help patients with shoulder pain?

Design: RCT Population: N=52, impingement syndrome Intervention: Exercise vs Manual Therapy* + Exercise * Manual therapy (shoulder, shoulder girdle, C-spine, upper T-spine, muscle stretch) Outcomes: Baseline, 1 & 2 mo Measured pre- and post-treatment strength, pain Measured pre- and 30 days post-treatment Functional Assessment Questionnaire (FAQ) RCT

Results (Bang & Deyle, JOSPT, 2000) Pain & Function Both groups significant improvement MT+Ex with significantly more improvement Strength Only MT+Ex group with significant improvement

Impact of treating distant segments? Regional Interdependence Dysfunction and impairments in distant regions, both extremity and spine, may affect or contribute to a patient s primary complaint Impairments are often seemingly unrelated

Design: Multi-site RCT Population: N=150, painful shoulder girdle Outcomes: Baseline, during & end of treatment (6 &12 wks), follow-up (26 & 52 wks) Primary - patient perceived recovery Secondary - severity of main complaint, shoulder disability, additional care received RCT

Usual Medical Care (UMC) Advice/information, therapy NSAIDS/analgesics & *CSIs Interventions Manipulative Therapy (MT) + UMC MT to c-spine, t-spine & ribs < 6 sessions (in 12 wks) (Bergman, Ann Int Med, 2004) *CSI= Corticosteroid injections

Results (Bergman, Ann Int Med, 2004) F/U at 12, 26, 52 Wks: Full Recovery : MT+UMC > UMC Severity of main complaint & disability:mt+umc > UMC

Needs a little help

To learn where to live

Self Manage

Shoulder Complex Glenohumeral jt Scapulothoracic jt Sternoclavicular jt Shoulder Complex - Joints Acromioclavicular jt

Tight Levator scapulae Upper trapezius Scalenes Pectoralis minor Weak Mid/lower trapezius Serratus Anterior DNF Altered Muscle Function & Shoulder Pain Haahr et al, 2005 Ludwig & Borstad, 2003 Hay et al, 2003 Goldberg et al, 2001 Conroy & Hayes, 1998 Van der Windt et al, 1998 Ginn et al, 1997 Brox et al, 1993

Shoulder Complex - Muscles Glenohumeral Motion Flexion (Also See Scapular Upward Rotation) Primary Muscles Anterior Deltoid Supraspinatus Coracobrachialis Extension External Rotation Internal Rotation Abduction (Also See Scapular Upward Rotation) Latissimus Dorsi Teres Major Posterior Deltoid Infraspinatus Teres Minor Subscapularis Supraspinatus Middle Deltoid www.netterimages.com

Shoulder Complex - Muscles Scapulothoracic Motion Scapular Protraction (Abduction) Scapular Retraction (Adduction) Scapular Elevation Scapular Depression Scapular Upward Rotation Scapular Downward Rotation Primary Muscles Serratus Anterior Middle Trapezius Lower Trapezius Rhomboids Upper Trapezius Levator Scapula Lower Trapezius Serratus Anterior Rhomboids

Shoulder Complex - Stretch Scapulothoracic Motion Scapular Protraction (Abduction) Scapular Retraction (Adduction) Scapular Elevation Scapular Depression Scapular Upward Rotation Scapular Downward Rotation Primary Muscles Serratus Anterior Middle Trapezius Lower Trapezius Rhomboids Upper Trapezius Levator Scapula Lower Trapezius Serratus Anterior Rhomboids

And Move

Shoulder Pain Has information on best management of patients with shoulder pain changed in the last 5 years? Definitely

Design: RCT, multi-site primary care N=207; new-episode, unilateral shoulder pain Outcomes (baseline, 6 wks, 6 mo) Primary shoulder disability Secondary - global assessment of change, pain, function, main complaint, shoulder ROM, co-interventions

First 6 wks: CSI - up to 2 injections, 4 wks Community PT - 8 x 20 minute appointments, 6 wks Best current evidence and current practice for pain relief and mobilisation for shoulder problems to include manual therapy Minimum advice/instruction, active shoulder exercises, HEP After 6 wks: any treatments indicated

Similar improvements at 6 wks & 6 months for disability, global assessment of change, report of recovery, pain Fewer healthcare resources used by the community PT group (re-consultation, co-interventions)

What about surgery?

Purpose: compare the effect of graded physiotherapeutic training of the rotator cuff muscles vs. arthroscopic decompression in patients with impingement syndrome Methods: 84 patients PT Group (N=43) HP, CP or STM before exercise Active muscle training (rhomboids, serratus, trapezius, levator scapulae, pect minor) Strengthening rotator cuff mm Arthroscopic Decompression Group (N=41) Bursectomy Partial resection of antero-inferior acromion Resection of coraco-acromial ligament

Conclusions: Surgical treatment of rotator cuff syndrome with subacromial impingement was not superior to physiotherapy with training.

So What s the Bottom Line? Manual physical therapy and exercise is effective for the treatment of shoulder pain, above and beyond what is experienced with usual medical care alone. Manual physical therapy and exercise is as effective as corticosteroid injections, but patients appear to consume fewer health care resources at 6 months. Surgical treatment of rotator cuff syndrome with subacromial impingement is not superior to physiotherapy.

Shoulder Pain Has physical therapy management of patients with shoulder pain changed in the last 5 years? Do our referral sources know what we can do?

R is for Referral Number Needed to Treat (NNT) NNT with manual physical therapy and stretching to achieve one additional successful outcome (classified as improved) (Bang, 2000) 5 It s a powerful message!

Thank You!