Does the addition of motor control or strengthening exercises to education result in better outcomes for rotator cuff-related shoulder pain? A multiarm randomised controlled trial.

OBJECTIVE: To compare the short-term, mid-term and long-term effects between three interventions (education only, education and strengthening exercises, education and motor control exercises) for rotator cuff-related shoulder pain (RCRSP) on symptoms and function. METHODS: 123 adults presenting with RCRSP took part in a 12-week intervention. They were randomly assigned to 1 of 3 intervention groups. Symptoms and function were evaluated at baseline and at 3 weeks, 6 weeks, 12 weeks and 24 weeks using the Disability of Arm, Shoulder and Hand Questionnaire (QuickDASH) (primary outcome) and Western Ontario Rotator Cuff Index (WORC). Linear mixed modelling was used to compare the effects of the three programmes on the outcomes. RESULTS: After 24 weeks, between-group differences were -2.1 (-7.7 to 3.5) (motor control vs education), 1.2 (-4.9 to 7.4) (strengthening vs education) and -3.3 (-9.5 to 2.8) (motor control vs strengthening) for the QuickDASH and 9.3 (1.5 to 17.1) (motor control vs education), 1.3 (-7.6 to 10.2) (strengthening vs education) and 8.0 (-0.5 to 16.5) (motor control vs strengthening) for the WORC. There was a significant group-by-time interaction (p=0.04) with QuickDASH, but follow-up analyses did not reveal any clinically meaningful between-group differences. There was no significant group-by-time interaction (p=0.39) for the WORC. Between-group differences never exceeded the minimal clinically important difference of QuickDASH or WORC. CONCLUSION: In people with RCRSP, the addition of motor control or strengthening exercises to education did not lead to larger improvements in symptoms and function compared with education alone. Further research should investigate the value of providing stepped care by identifying individuals who may only need education and those who would benefit from the addition of motor control or strengthening exercises. TRIAL REGISTRATION NUMBER: NCT03892603.

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T).

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

ICON 2019-International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients.

BACKGROUND: The absence of any agreed-upon tendon health-related domains hampers advances in clinical tendinopathy research. This void means that researchers report a very wide range of outcome measures inconsistently. As a result, substantial synthesis/meta-analysis of tendon research findings is almost futile despite researchers publishing busily. We aimed to determine options for, and then define, core health-related domains for tendinopathy. METHODS: We conducted a Delphi study of healthcare professionals (HCP) and patients in a three-stage process. In stage 1, we extracted candidate domains from clinical trial reports and developed an online survey. Survey items took the form: 'The 'candidate domain' is important enough to be included as a core health-related domain of tendinopathy'; response options were: agree, disagree, or unsure. In stage 2, we administered the online survey and reported the findings. Stage 3 consisted of discussions of the findings of the survey at the ICON (International Scientific Tendinopathy Symposium Consensus) meeting. We set 70% participant agreement as the level required for a domain to be considered 'core'; similarly, 70% agreement was required for a domain to be relegated to 'not core' (see Results next). RESULTS: Twenty-eight HCP (92% of whom had >10 years of tendinopathy experience, 71% consulted >10 cases per month) and 32 patients completed the online survey. Fifteen HCP and two patients attended the consensus meeting. Of an original set of 24 candidate domains, the ICON group deemed nine domains to be core. These were: (1) patient rating of condition, (2) participation in life activities (day to day, work, sport), (3) pain on activity/loading, (4) function, (5) psychological factors, (6) physical function capacity, (7) disability, (8) quality of life and (9) pain over a specified time. Two of these (2, 6) were an amalgamation of five candidate domains. We agreed that seven other candidate domains were not core domains: range of motion, pain on clinician applied test, clinical examination, palpation, drop out, sensory modality pain and pain without other specification. We were undecided on the other five candidate domains of physical activity, structure, medication use, adverse effects and economic impact. CONCLUSION: Nine core domains for tendon research should guide reporting of outcomes in clinical trials. Further research should determine the best outcome measures for each specific tendinopathy (ie, core outcome sets).

Self-efficacy and risk of persistent shoulder pain: results of a Classification and Regression Tree (CART) analysis.

OBJECTIVES: To (i) identify predictors of outcome for the physiotherapy management of shoulder pain and (ii) enable clinicians to subgroup people into risk groups for persistent shoulder pain and disability. METHODS: 1030 people aged ≥18 years, referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited. 810 provided data at 6 months for 4 outcomes: Shoulder Pain and Disability Index (SPADI) (total score, pain subscale, disability subscale) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH). 34 potential prognostic factors were used in this analysis. RESULTS: Four classification trees (prognostic pathways or decision trees) were created, one for each outcome. The most important predictor was baseline pain and/or disability: higher or lower baseline levels were associated with higher or lower levels at follow-up for all outcomes. One additional baseline factor split participants into four subgroups. For the SPADI trees, high pain self-efficacy reduced the likelihood of continued pain and disability. Notably, participants with low baseline pain but concomitant low pain self-efficacy had similar outcomes to patients with high baseline pain and high pain self-efficacy. Cut-off points for defining high and low pain self-efficacy differed according to baseline pain and disability. In the QuickDASH tree, the association between moderate baseline pain and disability with outcome was influenced by patient expectation: participants who expected to recover because of physiotherapy did better than those who expected no benefit. CONCLUSIONS: Patient expectation and pain self-efficacy are associated with clinical outcome. These clinical elements should be included at the first assessment and a low pain self-efficacy response considered as a target for treatment intervention.

Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review.

OBJECTIVE: To compare the effectiveness of corticosteroid injections to local anaesthetic injections in the management of rotator cuff-related shoulder pain (RCRSP). DESIGN: Systematic review with best evidence synthesis. DATA SOURCES: The Cochrane, PubMed, CINAHL Plus, PEDro and EMBASE electronic databases were searched (inception until 8 June 2017). Reference lists of included articles were also hand searched. ELIGIBILITY CRITERIA: Two reviewers independently evaluated eligibility. Randomised controlled trials (RCTs) were included if they compared subacromial injections of corticosteroid with anaesthetic injections. Two reviewers independently extracted data regarding short-term, midterm and long-term outcomes for pain, self-reported function, range of motion and patient-perceived improvement. RESULTS: Thirteen RCTs (n=1013) were included. Four trials (n=475) were judged as being at low risk of bias. Three studies of low risk of bias favoured the use of corticosteroid over anaesthetic-only injections in the short term (up to 8 weeks). There was strong evidence of no significant difference between injection types in midterm outcomes (12-26 weeks). There was limited evidence of no significant difference between injection types in long-term outcomes. CONCLUSION: Corticosteroid injections may have a short-term benefit (up to 8 weeks) over local anaesthetic injections alone in the management of RCRSP. Beyond 8 weeks, there was no evidence to suggest a benefit of corticosteroid over local anaesthetic injections. TRIAL REGISTRATION NUMBER: PROSPERO CRD42016033161.

Exploring experiences, barriers, and enablers to home- and class-based exercise in rotator cuff tendinopathy: A qualitative study.

STUDY DESIGN: Qualitative study. INTRODUCTION: Adherence is paramount to the successful outcome of exercise-based treatment. PURPOSE OF STUDY: The barriers and enablers to adherence to a home- and class-based exercise program were explored in this qualitative study. METHODS: Semi-structured interviews were carried out to establish common themes relating to the participants' experiences during a year-long randomized controlled trial. RESULTS/DISCUSSION: Twelve participants were interviewed. The main enablers to exercise were highlighted as equipment, perceived benefit from the exercises, and longer and more intensive monitoring. Barriers included the lack of motivation, lack of equipment, and pain. CONCLUSIONS: Implications for practice are incorporating enablers and addressing barriers including self-discharge from classes; the importance of longer term follow-up and the benefits of adopting exercise into a well-established routine may provide potential benefits. LEVEL OF EVIDENCE: N/A.

The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review.

BACKGROUND: Frozen shoulder is a common yet poorly understood musculoskeletal condition, which for many, is associated with substantial and protracted morbidity. Understanding the pathology associated with this condition may help to improve management. To date this has not been presented in a systematic fashion. As such, the aim of this review was to summarise the pathological changes associated with this primary frozen shoulder. DATABASES: Medline, Embase, CINAHL, AMED, BNI and the Cochrane Library, were searched from inception to 2nd May, 2014. To be included participants must not have undergone any prior intervention. Two reviewers independently conducted the; searches, screening, data extraction and assessment of Risk of Bias using the Cochrane Risk of Bias Assessment Tool for non-Randomised Studies of Interventions (ACROBAT-NRSI). Only English language publications reporting findings in humans were included. The findings were summarised in narrative format. RESULTS: Thirteen observational studies (involving 417 shoulders) were included in the review. Eight studies reported magnetic resonance imaging or arthrography findings and 5 recorded histological findings. When reported mean ages of the participants ranged from 40.0 to 59.8 years. Duration of symptoms ranged from 0 to 30 months. The majority of studies (n = 7) were assessed to be of moderate risk of bias, two studies at high risk and the remaining four were rated as low risk of bias. Study characteristics were poorly reported and there was widespread variety observed between studies in respect of data collection methods and inclusion criteria employed. Pathological changes in the anterior shoulder joint capsule and related structures were commonly reported. Imaging identified pathological changes occurring in the coracohumeral ligament, axillary fold and rotator interval. Obliteration of the subcoracoid fat triangle also appeared to be pathognomonic. Histological studies were inconclusive but suggested that immune, inflammatory and fibrotic changes where associated with primary frozen shoulder. CONCLUSIONS: This systematic review presents a summary of what is currently known about the tissue pathophysiology of primary frozen shoulder. Further studies that use standardised inclusion and exclusion criteria and investigate changes in naïve tissue at different stages of the condition are required.

Ultrasound measures of supraspinatus tendon thickness and acromiohumeral distance in rotator cuff tendinopathy are reliable.

PURPOSE: Rotator cuff (RC) tendinopathy has been widely ascribed to impingement of the supraspinatus tendon (SsT) in the subacromial space, measured as the acromiohumeral distance (AHD). Ultrasound (US) is suitable for measuring AHD and SsT thickness, but few reliability studies have been carried out in symptomatic populations, and interrater reliability is unconfirmed. This study aimed to examine the intrarater and interrater reliability of US measurements of AHD and SsT thickness in asymptomatic control subjects and patients with RC tendinopathy. METHODS: Seventy participants were recruited and grouped as healthy controls (n = 25) and RC tendinopathy (n = 45). Repeated US measurements of AHD and SsT thickness were obtained by one rater in both groups and by two raters in the RC tendinopathy group. RESULTS: Intrarater and interrater reliability coefficients were excellent for both measurements (intraclass correlation > 0.92), but the intrarater reliability was superior. The minimal detectable change values in the symptomatic group were 0.7 mm for AHD and 0.6 mm for SsT thickness for a single experienced examiner; the values rose to 1.2 mm and 1.3 mm, respectively, for the pair of examiners. CONCLUSIONS: The results support the reliability of US for the measurement of AHD and SsT thickness in patients with symptomatic RC tendinopathy and provide minimal detectable change values for use in future research studies.

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

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.

The Elbow-EpiTrainer: a method of delivering graded resistance to the extensor carpi radialis brevis. Effectiveness of a prototype device in a healthy population.

BACKGROUND: Tennis elbow or lateral epicondylopathy (LE) is experienced as the lateral elbow has a reported prevalence of 1.3%, with symptoms lasting up to 18 months. LE is most commonly attributed to tendinopathy involving the extensor carpi radialis brevis (ECRB) tendon. The aim of tendinopathy management is to alleviate symptoms and restore function that initially involves relative rest followed by progressive therapeutic exercise. OBJECTIVE: To assess the effectiveness of two prototype exercises using commonly available clinical equipment to progressively increase resistance and activity of the ECRB. METHOD: Eighteen healthy participants undertook two exercise progressions. Surface electromyography was used to record ECRB activity during the two progressions, involving eccentric exercises of the wrist extensors and elbow pronation exercises using a prototype device. The two progressions were assessed for their linearity of progression using repeated ANOVA and linear regression analysis. Five participants repeated the study to assess reliability. RESULTS: The exercise progressions led to an increase in ECRB electromyographic (EMG) activity (p<0.001). A select progression of exercises combining the two protocols increased EMG activity in a linear fashion (p<0.001). The ICC values indicated good reliability (ICC>0.7) between the first and second tests for five participants. CONCLUSIONS: Manipulation of resistance and leverage with the prototype exercises was effective in creating significant increases of ECRB normalised EMG activity in a linear manner that may, with future research, become useful to clinicians treating LE. In addition, between trial reliability for the device to generate a consistent load was acceptable.

Predicting response to physiotherapy treatment for musculoskeletal shoulder pain: protocol for a longitudinal cohort study.

BACKGROUND: Shoulder pain affects all ages, with a lifetime prevalence of one in three. The most effective treatment is not known. Physiotherapy is often recommended as the first choice of treatment. At present, it is not possible to identify, from the initial physiotherapy assessment, which factors predict the outcome of physiotherapy for patients with shoulder pain. The primary objective of this study is to identify which patient characteristics and baseline measures, typically assessed at the first physiotherapy appointment, are related to the functional outcome of shoulder pain 6 weeks and 6 months after starting physiotherapy treatment. METHODS/DESIGN: Participants with musculoskeletal shoulder pain of any duration will be recruited from participating physiotherapy departments. For this longitudinal cohort study, the participants care pathway, including physiotherapy treatment will be therapist determined. DISCUSSION: This study may offer service users and providers with guidance to help identify whether or not physiotherapy is likely to be of benefit. Clinicians may have some direction as to what key factors indicate a patient's likely response to physiotherapy.

Rotator Cuff-Related Shoulder Pain: Is It Time to Reframe the Advice, "You Need to Strengthen Your Shoulder"?

SYNOPSIS: Progressive resistance exercise, in isolation or in combination with other noninvasive therapies such as therapeutic touch, is the first-line approach to managing nontraumatic rotator cuff-related shoulder pain (RCRSP). Resistance exercise may be effective for people with RCRSP secondary to improving mechanical features of the shoulder, including strength, kinematics, and muscle timing and activation. However, strength gains are often small and clinically unimportant when measured during clinical trials. In this Viewpoint, we argue that clinicians should (1) continue to prescribe resistance exercise when managing RCRSP, and (2) embrace the broad biological mechanisms underpinning the efficacy of resistance exercise. Any benefit is governed by more than simple mechanical changes. The clinical message must go beyond the idea that the patient's weak, deconditioned, or frail shoulder is the basis of his or her pain, and all the patient needs to do is to get strong. J Orthop Sports Phys Ther 2021;51(4):156-158. doi:10.2519/jospt.2021.10199.

Reframing how we care for people with persistent non-traumatic musculoskeletal pain. Suggestions for the rehabilitation community.

There have been repeated calls to re-evaluate how clinicians provide care for people presenting with persistent non-traumatic musculoskeletal conditions. One suggestion is to move away from the 'we can fix and cure you' model to adopting an approach that is more consistent with approaches used when managing other persistent non-communicable diseases; education, advice, a major focus on self-management including lifestyle behavioural change, physical activity and medications as required. Currently the global delivery of musculoskeletal care has many of the elements of a 'super wicked problem', namely conflict of interest from stake-holders due to the consequences of change, prevailing expectation of a structural diagnosis and concomitant fix for musculoskeletal pain, persistent funding of high risk, more expensive care when low risk more economic viable options that don't impact on the quality of outcome exist, and an unquestionable need to find a solution now with the failure resulting in a growing social and economic burden for future generations. To address these issues, 100 participants included clinicians, educators and researchers from low-, middle- and high-income countries, eight presenters representing the physiotherapy, sport medicine and the orthopaedic professions and the insurance industry, together with three people who shared their lived experiences of persistent musculoskeletal pain, discussed the benefits and barriers of implementing change to address this problem. This paper presents the results from the stakeholders' contextual analysis and forms the basis for the proposed next steps from an action and advocacy perspective.

Outcome measures in chronic low back pain.

The purpose of this prospective, single site cohort quasi-experimental study was to determine the responsiveness of the numerical rating scale (NRS), Roland-Morris disability questionnaire (RMDQ), Oswestry disability index (ODI), pain self-efficacy questionnaire (PSEQ) and the patient-specific functional scale (PSFS) in order to determine which would best measure clinically meaningful change in a chronic low back pain (LBP) population. Several patient-based outcome instruments are currently used to measure treatment effect in the chronic LBP population. However, there is a lack of consensus on what constitutes a "successful" outcome, how an important improvement/deterioration has been defined and which outcome measure(s) best captures the effectiveness of therapeutic interventions for the chronic LBP population. Sixty-three consecutive patients with chronic LBP referred to a back exercise and education class participated in this study; 48 of the 63 patients had complete data. Five questionnaires were administered initially and after the 5-week back class intervention. Also at 5 weeks, patients completed a global impression of change as a reflection of meaningful change in patient status. Score changes in the five different questionnaires were subjected to both distribution- and anchor-based methods: standard error of measurement (SEM) and receiver operating characteristic (ROC) curves to define clinical improvement. From these methods, the minimal clinically important difference (MCID) defined as the smallest difference that patients and clinicians perceive to be worthwhile is presented for each instrument. Based on the SEM, a point score change of 2.4 in the NRS, 5 in the RMDQ, 17 in the ODI, 11 on the PSEQ, and 1.4 on the PSFS corresponded to the MCID. Based on ROC curve analysis, a point score change of 4 points for both the NRS and RMDQ, 8 points for the ODI, 9 points for the PSEQ and 2 points for the PSFS corresponded to the MCID. The ROC analysis demonstrated that both the PSEQ and PSFS are responsive to clinically important change over time. The NRS was found to be least responsive. The exact value of the MCID is not a fixed value and is dependent on the assessment method used to calculate the score change. Based on ROC curve analysis the PSFS and PSEQ were more responsive than the other scales in measuring change in patients with chronic LBP following participation in a back class programme. However, due to the small sample size, the lack of observed worsening of symptoms over time, the single centre and intervention studied these results which need to be interpreted with caution.

Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain.

BACKGROUND: Clinical sagittal plane assessment of the thoracic kyphosis angle is considered an essential component of the postural examination of patients presenting with upper body pain syndromes. Cervical headaches and conditions involving the shoulder, such as subacromial pain syndrome, have all been associated with an increase in the thoracic kyphosis. Concomitantly a decrease in the thoracic kyphosis as a result of a stretching and strengthening rehabilitation programme is believed to be associated with a reduction in symptoms and pain and improvement in function. Clinicians generally measure the sagittal plane kyphosis angle visually. There is no certainty that this method is reliable or is capable of measuring angular changes over time or in response to intervention. As such a simple and reliable clinical method of measuring the thoracic kyphosis would enable clinicians to record this information. The aim of this investigation was to determine the intra-tester reliability of measuring the thoracic kyphosis angle using a clinical method METHODS: Measurements were made in 45 subjects with and 45 subjects without upper body symptoms. Measurements were made with the subjects in relaxed standing. Two gravity dependent inclinometers were used to measure the kyphosis. The first was placed over the region of the 1st and 2nd thoracic spinous processes. The other, over the region of the 12th thoracic and 1st lumbar spinous processes. The angle produced by each inclinometer was measured 3 times in succession. Each set of 3 measurements was made on two occasions (separated by a minimum of 30 minutes and additional data collection involving 46 further measurements of posture and movement on the same and an additional subject before the thoracic kyphosis measurements were re-measured) by one rater. The reliability of the measurements was analyzed using 2-way ANOVA intraclass correlation coefficients (ICC), 95% confidence intervals (CI) and standard error of measurement (SEM) for precision, for a single measurement [ICC(single)] and the average of 3 measures [ICC(average)]. The assessor remained 'blinded' to data input and the measurements were staggered to reduce examiner bias. RESULTS: The measurement of the thoracic kyphosis as used in this investigation was found to have excellent intra-rater reliability for both subjects with and without symptoms. The ICC(single) results for the subjects without symptoms were, .95; (95% CI .91-.97). The corresponding ICC(average) results were; .97; (95% CI .95-.99). The results for the subjects with symptoms were; 93; (95% CI .88-.96), for ICC(single) and for ICC(average); .97; (95% CI .94-.98). The SEM results for subjects without and with symptoms were 1.0 degrees and 1.7 degrees , respectively. CONCLUSIONS: The findings of this immediate test-retest reliability study suggest that the clinical measurement of the thoracic kyphosis using gravity dependent inclinometers demonstrates excellent intra-rater reliability. Additional research is required to determine the inter-rater reliability of this method. TRIAL REGISTRATION: National Research Register: N0060148286.

Rotator cuff tendinopathy: a model for the continuum of pathology and related management.

BACKGROUND: Pathology of the soft tissues of the shoulder including the musculotendinous rotator cuff and subacromial bursa are extremely common and are a principal cause of pain and suffering. Competing theories have been proposed to explain the pathoaetiology of rotator cuff pathology at specific stages and presentations of the condition. This review proposes a model to describe the continuum of the rotator cuff pathology from asymptomatic tendon through full thickness rotator cuff tears. CONCLUSIONS: The pathoaetiology of rotator cuff failure is multifactorial and results from a combination of intrinsic, extrinsic and environmental factors. Recently a new and generic model detailing the continuum of tendon pathology has been proposed. This model is relevant for the rotator cuff and provides a framework to stage the continuity of rotator cuff pathology. Furthermore, it provides a structure to identify the substantial deficiencies in our knowledge base and areas where research would improve our understanding of the pathological and repair process, together with assessment and management. The strength of this model adapted for the rotator cuff tendons and subacromial bursa will be tested in its ability to incorporate and adapt to emerging research.

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.

The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice.

While advances in assessment and management of musculoskeletal conditions have improved care for many people, there have been other, less beneficial developments in the provision of care for people with musculoskeletal pain conditions, one of which is the worrying tendency to provide too much medicine. Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive. Another concern in musculoskeletal health care is medicalizing normality-when a normal human function or condition is labeled as abnormal. In this Viewpoint, the authors argue that medicalizing normality creates health concerns where none exist, while too much medicine involves provision of care where benefits do not outweigh harms, and wastes precious health care resources. The authors (1) list 2 common examples of too much medicine, and 2 examples of medicalizing normality, relevant to physical therapy practice; (2) outline the drivers of too much medicine and medicalizing normality; and (3) make suggestions for change. J Orthop Sports Phys Ther 2020;50(1):1-4. doi:10.2519/jospt.2020.0601.