A critical appraisal of web-based information on shoulder pain comparing biomedical vs. psychosocial information.

BACKGROUND: Websites have become a primary way for patients to access health-related information, which allows patients to not only understand their condition better but also to engage in better decision making with their health care provider. However, this can be a double-edged sword, as information patients access may not be of high quality, easily readable, or could be biased based on website authorship. This study examines the readability and content quality of common websites about shoulder pain, with a specific focus on biomedical vs. psychosocial information. METHODS: The Flesch reading-ease score (FRES) and Flesch-Kincaid grade level (FKGL) instruments were used to assess website readability. Health on the net code of conduct (HONcode) certification and the DISCERN tool were used to evaluate the reliability and quality of information. Lastly, shoulder-specific content quality and focus was gauged using a Shoulder-specific Website Appraisal Tool (SWAT) created for this study. A systematic search protocol was used to identify popular shoulder injury websites. The websites were identified using 5 search terms (shoulder pain, shoulder muscle pain, shoulder impingement, shoulder rotator cuff pain, and shoulder pain diagnosis) across 5 English-speaking regions (United States, Canada, United Kingdom, Australia, and New Zealand) using the Google search engine. The top 10 websites for each term and region combination were included and combined, yielding 41 original websites for appraisal; several (6) websites were omitted as duplicates, behind paywalls, or nontext (video) for a total of 35 websites appraised. RESULTS: On average, the FRES shoulder pain websites readability was 55.37, which is categorized as "fairly difficult" to read, and a seventh- or eighth-grade reading level based on the FKGL. For trustworthiness and bias, 57% (20 of 35) of the websites were HONcode certified. The quality of health care information using the DISCERN score averaged 50.92%. Examining shoulder-specific content quality, the average SWAT score was 10.54 out of 14 possible points, with only 1 website reporting information on psychosocial aspects of shoulder pain. CONCLUSIONS: This study suggests that shoulder pain websites present information that is at too high of a reading level for public consumption, has a strong bias toward biomedical causes of shoulder pain, and would benefit from implementation of website screening tools to improve evidence-based content.

Subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder manual therapy plus exercise intervention in individuals with subacromial impingement syndrome: a prospective, randomized controlled clinical trial pilot study.

OBJECTIVES: To determine the subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder non-thrust plus exercise in patients with subacromial pathology. METHODS: This was a randomized, single blinded controlled trial pilot study. This trial was registered at ClinicalTrials.gov (NCT01753271) and reported according to Consolidated Standards of Reporting Trials requirements. Patients were randomly assigned to either shoulder treatment plus cervicothoracic spinal thrust/non-thrust or shoulder treatment-only group. Primary outcomes were average pain intensity (Numeric Pain Rating Scale) and physical function (Shoulder Pain and Disability Index) at 2 weeks, 4 weeks, and patient discharge. RESULTS: 18 patients, mean age 43.1(15.8) years satisfied the eligibility criteria and were analyzed for follow-up data. Both groups showed statistically significant improvements in both pain and function at 2 weeks, 4 weeks, and discharge. The between-group differences for changes in pain or physical function were not significant at any time point. DISCUSSION: The addition of cervicothoracic spinal thrust/non-thrust to the shoulder treatment-only group did not significantly alter improvement in pain or function in patients with subacromial pathology. Both approaches appeared to provide an equally notable benefit. Both groups improved on all outcomes and met the criteria for clinical relevance for both pain and function. LEVEL OF EVIDENCE: 2b.

A new approach to determining net impulse and identification of its characteristics in countermovement jumping: reliability and validity.

Examining a countermovement jump (CMJ) force-time curve related to net impulse might be useful in monitoring athletes' performance. This study aimed to investigate the reliability of alternative net impulse calculation and net impulse characteristics (height, width, rate of force development, shape factor, and proportion) and validate against the traditional calculation in the CMJ. Twelve participants performed the CMJ in two sessions (48 hours apart) for test-retest reliability. Twenty participants were involved for the validity assessment. Results indicated intra-class correlation coefficient (ICC) of ≥ 0.89 and coefficient of variation (CV) of ≤ 5.1% for all of the variables except for rate of force development (ICC = 0.78 and CV = 22.3%). The relationship between the criterion and alternative calculations was r = 1.00. While the difference between them was statistically significant (245.96 ± 63.83 vs. 247.14 ± 64.08 N s, p < 0.0001), the effect size was trivial and deemed practically minimal (d = 0.02). In conclusion, variability of rate of force development will pose a greater challenge in detecting performance changes. Also, the alternative calculation can be used practically in place of the traditional calculation to identify net impulse characteristics and monitor and study athletes' performance in greater depth.

The efficacy of incorporating partial squats in maximal strength training.

The purpose of our study was to examine the effects of 2 different training methods on dynamic and isometric measures of maximal strength. Seventeen recreationally trained men (1 repetition maximum [1RM] squat: 146.9 ± 22.4 kg) were assigned to 2 groups: full range of motion (ROM) squat (F) and full ROM with partial ROM squat (FP) for the 7-week training intervention. Repeated measures analysis of variance revealed that there was a statistically significant group-by-time interaction for impulse scaled at 50, 90, and 250 milliseconds at 90° of knee flexion and rate of force development at 200 milliseconds with 120° of knee flexion (p ≤ 0.05). There was also a statistically significant time effect (p ≤ 0.05) for the 1RM squat, 1RM partial squat, isometric squat peak force allometrically scaled (IPFa) 90°, IPFa 120°, and impulse allometrically scaled at 50, 90, 200, and 250 milliseconds at 90° and 120° of knee flexion. Additionally, the FP group achieved statistically larger relative training intensities (%1RM) during the final 3 weeks of training (p ≤ 0.05). There was a trend for FP to improve over F in 1RM squat (+3.1%, d = 0.53 vs. 0.32), 1RM partial squat (+4.7%, d = 0.95 vs. 0.69), IPFa 120° (+5.7%, d = 0.52 vs. 0.12), and impulse scaled at 50, 90, 200, and 250 milliseconds at 90° (+6.3 to 13.2%, d = 0.50-1.01 vs. 0.30-0.57) and 120° (+3.4 to 16.8%, d = 0.45-1.11 vs. 0.08-0.37). These larger effect sizes in the FP group can likely be explained their ability to train at larger relative training intensities during the final 3 weeks of training resulting in superior training adaptations. Our findings suggest that partial ROM squats in conjunction with full ROM squats may be an effective training method for improving maximal strength and early force-time curve characteristics in men with previous strength training experience. Practically, partial squats may be beneficial for strength and power athletes during a strength-speed mesocycle while peaking for competition.

Diagnostic accuracy of scapular physical examination tests for shoulder disorders: a systematic review.

OBJECTIVE: To systematically review and critique the evidence regarding the diagnostic accuracy of physical examination tests for the scapula in patients with shoulder disorders. METHODS: A systematic, computerised literature search of PubMED, EMBASE, CINAHL and the Cochrane Library databases (from database inception through January 2012) using keywords related to diagnostic accuracy of physical examination tests of the scapula. The Quality Assessment of Diagnostic Accuracy Studies tool was used to critique the quality of each paper. RESULTS: Eight articles met the inclusion criteria; three were considered to be of high quality. Of the three high-quality studies, two were in reference to a 'diagnosis' of shoulder pain. Only one high-quality article referenced specific shoulder pathology of acromioclavicular dislocation with reported sensitivity of 71% and 41% for the scapular dyskinesis and SICK scapula test, respectively. CONCLUSIONS: Overall, no physical examination test of the scapula was found to be useful in differentially diagnosing pathologies of the shoulder.

Agreement and screening accuracy between physical therapists ratings and the Ó¦rebro Musculoskeletal Pain Questionnaire in screening for risk of chronic pain during Musculoskeletal evaluation.

INTRODUCTION: Identifying patients at risk for chronic musculoskeletal pain can inform evaluation and treatment decisions. The ability of physical therapists to assess patients' risk for chronic pain without use of validated tools has been questioned. The Ó¦rebro Musculoskeletal Pain Questionnaire (OMPQ) is used to determine risk for chronic pain. METHODS: The aim of this pragmatic study was to prospectively quantify the agreement between physical therapists' assessment of patients' risk for chronic symptoms compared to the OMPQ. Patients were asked to complete the OMPQ during the initial visit. Physical therapists, blinded to OMPQ risk classification, carried out their usual patient assessment procedures. The physical therapists rated patients as either high or low risk for chronic pain based on their clinical assessment. Agreement between therapist and OMPQ was determined using Cohen's Kappa (κ) and screening accuracy compared clinician risk to the OMPQ risk classification (reference standard) by way of contingency table analysis. RESULTS: Ninety-six (96) patients' risk classifications and 15 corresponding physical therapists' risk estimates were available for analysis. The OMPQ identified a 47% prevalence for high risk of chronic pain. Agreement (κ and 95% confidence interval) between physical therapist rating and OMPQ was slight, κ = 0.272 (0.033-0.421), p = .026. Therapists' sensitivity and specificity (95% CI) for determining risk classifications were 60.0% (44.3-74.3) and 62.8% (48.1-75.6), respectively. The positive and negative likelihood ratios (95% CI) were 1.61 (1.05-2.47) and 0.64 (0.42-0.97). DISCUSSION: The use of validated self-report questionnaires are recommended to supplement clinician prognosis for patients at risk of chronic musculoskeletal pain.

Flipped classroom versus traditional teaching methods within musculoskeletal physical therapy: a case report.

BACKGROUND AND PURPOSE: The flipped classroom method is a popular way to use technology to assist with the delivery of educational experiences. Yet there is insufficient information regarding student opinions or outcomes about the flipped classroom method within physical therapy. The purpose of this case report was to describe student opinions and outcomes of the flipped classroom teaching and traditional lecture/lab methods of teaching within musculoskeletal physical therapy. CASE DESCRIPTION: Thirty-six (36) first-year physical therapy students enrolled at a regional physical therapy program completed an anonymous internet-based survey regarding their impressions of traditional and flipped classroom teaching methods. Flipped classroom and traditional teaching methods were both used within the same musculoskeletal course. The survey was created to aid in planning subsequent courses and asked questions about student's preferred teaching method (flipped, traditional, or both equal) across a variety of categories. Student exams scores, using the same question bank, were compared to the year prior as a quantitative outcome measure. OUTCOMES: Twenty-nine (29) students (81%) completed the survey. Generally, students preferred the flipped classroom. Compared to the previous year, test scores for all content areas were similar (± 4%) except cervical spine which was improved (>10%). When asked outright, 28/29 students preferred the flipped teaching method. DISCUSSION AND CONCLUSION: Student opinions indicate the flipped classroom is preferable to traditional methods yet objective outcomes appear similar. Physical therapy educators seeking ways to improve the student experience using technology in the classroom may consider utilizing the flipped classroom method.

The Role of Patient Recovery Expectations in the Outcomes of Physical Therapist Intervention: A Systematic Review.

OBJECTIVE: The purpose of this study was to determine the association between baseline patient recovery expectations and outcomes following physical therapy care. METHODS: PubMed, CINAHL Complete, PEDro, SPORTDiscus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and PsycINFO were searched from inception to February 2021. Concepts represented in the search included physical therapy, patient expectations, patient outcomes, and their relevant synonyms. Two reviewers independently screened studies of article abstracts and full texts. Eligibility criteria included English language studies that evaluated adults seeking physical therapist intervention for any health condition where both patient outcome (recovery) expectations and functional or other outcome measures were reported. Methodologic standards were assessed using the Critical Appraisal Skills Program criteria. Data were extracted using a custom template for this review with planned descriptive reporting of results. Vote counting was used to measure reported outcomes. RESULTS: Twenty-one studies were included in this review, representing 4879 individuals. Studies were most commonly prospective cohort studies or secondary analyses of controlled trials. Varied expectation, outcome, and statistical measures that generally link patient recovery expectations with self-reported outcomes in musculoskeletal practice were used. CONCLUSION: Patient recovery expectations are commonly associated with patient outcomes in musculoskeletal physical therapy. IMPACT: Evidence supports measuring baseline patient expectations as part of a holistic examination process.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study.

BACKGROUND: There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP). OBJECTIVE: To identify the most relevant clinical descriptors for diagnosing RCRSP. METHODS: A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus. RESULTS: Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus. CONCLUSION: In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Scapulohumeral kinematic assessment of the forward kayak stroke in experienced whitewater kayakers.

By understanding the normal humeral and scapular kinematics during the kayak stroke, inferences about the relationship of kayaking technique and shoulder injury may be established. The purpose of this study was to describe scapular and humeral kinematics and to compare dominant versus nondominant symmetry in healthy whitewater kayakers performing the forward stroke. Twenty-five competent whitewater kayakers (mean age: 34.1 +/- 9.4 years, mean height: 1.768 +/- 0.093m, mean mass: 78.2 +/- 13.0 kg) underwent humeral and scapular kinematic assessment, using an electromagnetic tracking device, while kayaking on a kayak ergometer. Paired t-tests were used to determine symmetry. Scapular and humeral kinematic means and standard deviations at six time points during the kayak stroke were described. Scapular and humeral kinematics were shown to be similar upon bilateral comparison. The greatest potential for injury during the forward stroke may be at thrust paddle shaft vertical when the humerus is maximally elevated in internal rotation and adduction as subacromial structures may be mechanically impinged. The relationship between scapulohumeral kinematics related to injury at other time points are also described.

Pain knowledge, attitudes and beliefs of doctor of physical therapy students: changes across the curriculum and the role of an elective pain science course.

Introduction: Entry-level physical therapist education on pain has been described as lacking. Calls have been made to include pain science courses to address this knowledge gap.Methods: Physical therapist students' pain knowledge and attitudes were measured using the revised Neurophysiology of Pain Questionnaire (rNPQ) and Pain Attitudes and Beliefs Scale for Physical Therapists (PABS-PT), respectively. Univariate ANOVAs, with post hoc pairwise comparison and effect sizes, were used to measure these aspects over time.Results: Pain knowledge and clinician beliefs were significantly different (p < 0.001) at various curricular timepoints. rNPQ scores increased from 1st to 2nd year (effect size: 1.10), remained similar between years 2 and 3, and improved following the pain course (effect size: 1.25). Biomedical beliefs were similar during years 1, 2 and 3, and declined following the pain course (effect size: 1.56). Conversely, psychosocial belief scores increased from 1st to 2nd year (effect size: 0.82), remained similar between years 2 and 3, and increased following the pain course (effect size: 1.08).Discussion/Conclusions: Physical therapist education, without a dedicated pain science course, may be insufficiently preparing students to treat patients in pain. Educators should consider adopting a dedicated pain science course or substantially bolstering embedded curricular pain content to promote best practice in pain treatment.

The impact of experimental pain on shoulder movement during an arm elevated reaching task in a virtual reality environment.

BACKGROUND: People with chronic shoulder pain have been shown to present with motor adaptations during arm movements. These adaptations may create abnormal physical stress on shoulder tendons and muscles. However, how and why these adaptations develop from the acute stage of pain is still not well-understood. OBJECTIVE: To investigate motor adaptations following acute experimental shoulder pain during upper limb reaching. METHODS: Forty participants were assigned to the Control or Pain group. They completed a task consisting of reaching targets in a virtual reality environment at three time points: (1) baseline (both groups pain-free), (2) experimental phase (Pain group experiencing acute shoulder pain induced by injecting hypertonic saline into subacromial space), and (3) Post experimental phase (both groups pain-free). Electromyographic (EMG) activity, kinematics, and performance data were collected. RESULTS: The Pain group showed altered movement planning and execution as shown by a significant increased delay to reach muscles EMG peak and a loss of accuracy, compared to controls that have decreased their mean delay to reach muscles peak and improved their movement speed through the phases. The Pain group also showed protective kinematic adaptations using less shoulder elevation and elbow flexion, which persisted when they no longer felt the experimental pain. CONCLUSION: Acute experimental pain altered movement planning and execution, which affected task performance. Kinematic data also suggest that such adaptations may persist over time, which could explain those observed in chronic pain populations.

Three-dimensional scapular and clavicular kinematics and scapular muscle activity during retraction exercises.

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To describe and compare scapular and clavicular kinematics and muscle activity during 6 retraction exercises in young healthy adults (mean +/- SD age, 23.2 +/- 2.4 years). BACKGROUND: Based on the association between shoulder injuries and scapular/clavicular movement, muscle activity during various exercises that target muscles surrounding the scapula have been investigated. However, the scapular and clavicular movements occurring during these exercises remain uninvestigated. Evaluation of the scapular and clavicular kinematics in addition to muscle activity provides additional information that allow clinicians to select exercises that best meet the patient's needs. METHODS: Three-dimensional scapular and clavicular kinematics and scapular muscle activity data were collected while the participants performed 6 scapular retraction exercises. One-way repeated-measures ANOVA and post hoc analyses were used to determine differences in scapular/clavicular kinematics and activation levels of the upper, middle, and lower trapezius and serratus anterior muscles occurring during the exercises. RESULTS: The general pattern of the kinematics observed during all retraction exercises was scapular external rotation, scapular upward rotation, scapular posterior tilting, clavicular retraction, and clavicular depression. However, the exercises resulted in varying amounts of scapular movement and muscle activity. CONCLUSION: Clinicians can select appropriate exercises for their patients based on their need to strengthen specific retractor muscles and to improve specific scapular and clavicular movement patterns, pre-existing conditions, and available range of motion.

LOWER EXTREMITY AEROBIC EXERCISE AS A TREATMENT FOR SHOULDER PAIN.

BACKGROUND: Shoulder girdle pain is a common disabling complaint with a high lifetime prevalence. Interventions aimed at decreasing shoulder pain without stressing shoulder girdle structures have the potential to improve participation in multimodal shoulder rehabilitation programs. HYPOTHESIS/PURPOSE: The aim of this study was to determine the acute effects of moderate intensity lower extremity exercise on mechanically induced shoulder pain in individuals without shoulder injury. It was hypothesized that participants would exhibit less shoulder pain, as indicated by increased pain thresholds, following lower extremity exercise. STUDY DESIGN: Repeated measures study. METHODS: Thirty (30) healthy participants were recruited to participate in this study. Pain pressure algometry was used to mechanically induce shoulder pain over the infraspinatus muscle belly. This was performed on the dominant shoulder before and immediately after performing 10 minutes of moderate intensity lower extremity exercise using a recumbent exercise machine. Heart rate and rate of perceived exertion were measured following exercise. Repeated measures ANOVA was used to compare pain pressure threshold scores between the baseline and post-exercise time points. Significance was set at p ≤ 0.05 a priori. Effect size (ES) was calculated using Glass's Δ. RESULTS: Moderate intensity lower extremity aerobic exercise led to significantly (F = 8.471, p = 0.003) decreased evoked shoulder pain in healthy adults with moderate effect sizes (0.30-0.43). CONCLUSIONS: Lower extremity aerobic exercise significantly decreased pain of the infraspinatus in this sample of young healthy participants. Utilization of lower extremity exercise may be of benefit for younger patients to decreased acute shoulder pain. LEVEL OF EVIDENCE: 2b: individual cohort study.

Perspectives of participants with rotator cuff-related pain to a neuroscience-informed pain education session: an exploratory mixed method study.

Purpose: To explore perceptions and initial outcomes of patients with rotator cuff-related pain to a pain education session.Materials and Methods: Ten individuals with persistent rotator cuff-related pain (≥3 months duration) attended an individual pain education session. They completed patient-reported outcomes measures on a weekly basis, three weeks prior and three weeks following the session. Individual semi-structured interviews were conducted three weeks following the pain education. Interviews were recorded, transcribed verbatim, and analyzed using the General Inductive Approach.Results: There were two over-arching key themes: firstly, 'Participants' Perspectives' of the session generated four themes: Improved understanding of 'the whole'; Mindful self-awareness; Taking charge; "The pain is still there". Their understanding of pain was reconceptualised, evident by their ability to describe the role of neurophysiological mechanisms, stress and general well-being towards their pain. The second over-arching key theme, 'Participants' Recommendations', had two themes: Integrating neuroscience with pathoanatomical knowledge and Educating other health professionals. Pain levels decreased post-pain education compared to pre-pain education.Conclusions: Following the pain education session, participants had greater understanding of factors influencing their shoulder pain. Pain education, in addition to pathoanatomical information may be useful as part of treatment for persistent rotator cuff-related pain.

The experiences and beliefs of patients with complex regional pain syndrome: An exploratory survey study.

Objectives To determine the beliefs and describe the health care experiences of patients with complex regional pain syndrome. Methods A survey tool for patients with complex regional pain syndrome was designed for this study. The survey tool collected self-reported measures associated with pain, disability, health care experiences, education, beliefs, and treatments. Results Thirty-one patients attending physical therapy for complex regional pain syndrome (mean age 40.48; female n = 20) completed the survey. Patients with presented with high levels of pain and disability and reported various changes associated with altered neuroplasticity such as confused body part recognition, left/right discrimination, neglect, and spreading pain. The patients' experiences with diagnostic testing and interventions are not in line with the current pain science research and/or evidence-based practice. Overall, patients are ill-informed, confused, and receive conflicting information. Discussion The suffering associated with complex regional pain syndrome is real, as told by patients. This suffering coincides with a lack of consensus by health care providers and conflicting information on complex regional pain syndrome. Overall, patient experiences show health care providers are not up to date with the current best-evidence regarding complex regional pain syndrome.

The reliability of card-based and tablet-based left/right judgment measurements.

BACKGROUND: Left/right judgment (LRJ) measurement is a potential way to identify dysfunction in cortical body maps, and to measure improvement related to corresponding treatments. Few studies have explored the reliability of various methods for LRJ measurement. OBJECTIVES: To determine measurement reliability of LRJ utilizing two methods: card-based (CB) and tablet-based (TB). Establish minimal detectable difference (MDD) for accuracy and reaction time for both assessments. METHODS: Testing was done over two different days. Session 1 consisted of testing LRJ utilizing CB assessment with photos of left and right hands over two trial periods. The TB format was also tested over two trial periods. Session 2 tested with the CB assessment for two trial periods. 40 images were used in the basic upright position for both CB and TB formats. RESULTS: Fifty participants (N = 50; female = 35) with an average age of 24.3 (range 19-35) were studied. ICC (2,k) for reaction time for both methods were >0.84. The MDD for reaction time was between 0.19 and 0.49 s for various test points for both methods. Combined left and right accuracy ICC (2,k) for both methods were >0.51, with MDD between 5 and 14%. CONCLUSIONS: This study examined the reliability and MDD for the LRJ measurement for card and tablet-based assessments. Generally, LRJ reaction time had good reliability, while accuracy had moderate reliability and varied between testing methods.

Rotator cuff-related pain: Patients' understanding and experiences.

BACKGROUND: Persistent musculoskeletal pain is a multi-factorial entity, influenced by biological, genetic and psychosocial factors. Psychosocial factors, such as individuals' beliefs and experiences, need to be considered in the management of such pain. While extensive research has explored beliefs of individuals with spinal pain, less is known about individuals' beliefs regarding shoulder pain. OBJECTIVES: To explore beliefs about the cause of pain in individuals with persistent rotator cuff-related pain, as well as the experiences of the effect of pain on their daily lives. DESIGN: A mixed methods design, using semi-structured interviews and validated outcome questionnaires. METHOD: Five men and five women, aged 47-68 years, with shoulder pain for at least three months were recruited. Individual semi-structured interviews were audio-recorded, transcribed verbatim and analysed using the general inductive approach. RESULTS/FINDINGS: Four key themes emerged. The cause of pain, 'Understanding the pain', was described in terms of anatomical factors within the context of the participants' lives. The pain impacted all areas of life, creating another theme, 'It affects everything'. Participants responded to their pain by adopting certain, 'Pain-associated behaviours' and sought information for diagnosis, general management and exercise prescription, 'Emotional responses and the future'. CONCLUSIONS: The participants with rotator cuff-related pain believed the cause of their pain to be local to the shoulder region. However, they also described various stressors in their work-, sports- and family-related lives. Rehabilitation may need to include educating the individual, expanding their understanding regarding pain mechanisms and appropriate interventions, based on individual goal-setting.

Sensorimotor contribution to shoulder stability: effect of injury and rehabilitation.

Shoulder joint stability is the humeral head remaining or promptly returning to proper alignment within the glenoid fossa. This is mediated by both mechanical and dynamic restraint mechanisms. Coordination of these restraint systems is required for shoulder joint stability. The sensorimotor system is defined as all of the sensory, motor, and central integration and processing components involved in maintaining joint stability. The sensorimotor system is comprised of several components including proprioception, joint position sense, kinesthesia, sensation of force, and neuromuscular control. With joint injury, not only are the mechanical restraints disrupted (joint capsule, glenoid labrum, etc.) but also, the sensorimotor system is affected. Restoration of the sensorimotor system has been shown to occur through both surgical and conservative intervention and rehabilitation. Surgery has been shown to restore both mechanical restraints and the sensorimotor system. Specific rehabilitation techniques have also been effective at improving the sensorimotor system in healthy and pathological patients.

Cervical & thoracic manipulations: Acute effects upon pain pressure threshold and self-reported pain in experimentally induced shoulder pain.

BACKGROUND: Emerging evidence suggests that cervical and thoracic joint manipulations may be advocated in treating patients with shoulder pain. OBJECTIVES: To determine the acute effects of cervical, cervicothoracic, and thoracic joint manipulations on outcomes of self-reported pain and pain pressure threshold in experimentally induced shoulder pain. DESIGN: Repeated measures. METHODS: Twenty (20) healthy volunteers were tested on two sessions. Session 1 consisted on baseline assessment of pain pressure threshold testing over the infraspinatus bilaterally and self-reported shoulder pain using the shoulder pain and disability index (SPADI) pain scale. An isokinetic exercise protocol was used to induce delayed onset muscle soreness. In session 2 (24-48 h later), all variables were reassessed before and immediately after a combination of cervical, cervicothoracic and thoracic manipulations. RESULTS: SPADI pain scale scores were significantly different between time points (p < 0.001): the exercise protocol significantly increased reported pain [mean increase 14.1, p < 0.001] while the manipulation significantly decreased reported pain (mean decrease 5.60, p < 0.001)) although pain remained higher than baseline levels. Pain pressure threshold differences were also found between time points (p = 0.001): manipulation significantly increased pain threshold bilaterally (p < 0.001) similar to baseline levels. CONCLUSIONS: Cervical, cervicothoracic, and thoracic joint manipulations acutely increased pain pressure threshold and decreased self-reported shoulder pain in participants with experimentally induced shoulder pain. Physiotherapists may consider the combination of such techniques to achieve short-term hypoalgesic effects and facilitate the application of more active interventions.