'Thinking about pain in a different way': Patient perspectives of a neuroscience-informed physiotherapy programme for rotator cuff-related shoulder pain.

BACKGROUND: Rotator cuff-related shoulder pain (RCRSP) is a common musculoskeletal problem. The multi-factorial contributors to persistent pain are often overlooked during treatment. Pain neuroscience education (PNE) contributes to a holistic approach for patients with persistent pain but has not yet been researched for patients with RCRSP. OBJECTIVE: To explore the perspectives and experiences of participants with RCRSP who had completed a programme of PNE-informed pragmatic physiotherapy. DESIGN: A qualitative study using semi-structured interviews. METHODS: We included a sub-group of five males and five females, aged 46-75 years, with persistent RCRSP of at least three months. They had undertaken a three-month pragmatic physiotherapy integrated with PNE. Individual semi-structured interviews were recorded, transcribed verbatim, and analysed using the General Inductive Approach. RESULTS: Four themes emanated from the interviews. The first two themes were named 'Patient Beliefs' and overall 'Rapport and Relationship'. Another theme, 'Perspective and Understanding of the Resources', indicated diverse uptake of the resource information. The participants reported developing self-management skills, active coping strategies and a reduction in fear of pain described by the theme: 'Empowerment: My Shoulder into the Future'. CONCLUSIONS: Participants experienced a change in their beliefs, which were enhanced by an individualised delivery and a strong therapeutic relationship through the course of the physiotherapy care. The participants appeared to value when the physiotherapist listened to and understood their beliefs. This required a shift in the patient-therapist relationship from the physiotherapist being the 'expert' to facilitating the patient's ability to take control of their shoulder health.

Time to expand the circle of care - General practitioners' experiences of managing concussion in the community.

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

Tailored exercise and manual therapy versus standardised exercise for patients with shoulder subacromial pain: a feasibility randomised controlled trial (the Otago MASTER trial).

OBJECTIVES: The aim of this study was to assess whether it was feasible to conduct a full trial comparing a tailored versus a standardised exercise programme for patients with shoulder subacromial pain. DESIGN: Two-arm, patient-blinded and assessor-blinded, randomised controlled feasibility trial. METHODS: Twenty-eight participants with shoulder subacromial pain were randomly allocated into one of two intervention groups-tailored or standardised exercise. Participants in the tailored exercise programme received exercises and manual therapy tailored to their scapular and shoulder movement impairments. Participants in the standardised exercise programme received progressive strengthening exercise. The primary outcome measures were (1) the participant recruitment rate; (2) the proportion of participants enrolled from the total number screened; (3) drop-out rates; and (4) adherence to the rehabilitation programme. Other outcome measures were: (5) pain levels; (6) Patient-Specific Functional Scale; (7) the Shoulder Pain and Disability Index; and (8) pain self-efficacy. We compared changes in pain and disability scores between groups using a repeated mixed-model analysis of variance. Since this is a feasibility study, we did not adjust alpha for multiple comparisons, and considered 75% CI as the probability threshold at 3-month follow-up. Health-related quality of life was assessed using the Short-Form 12 and quality-adjusted life years (QALYs) were estimated. RESULTS: The recruitment rate was 3 participants per month, the proportion of participants enrolled was 23%, the drop-out rate was 14% and the overall adherence to the rehabilitation programme was 85%. No between-group differences were found for most outcome measures. Adverse events (n=2, only in the tailored group) were minor in nature and included skin injury or pain following taping. CONCLUSIONS: Our feasibility trial showed that additional strategies are required for improving recruitment, enrolment and minimising drop-out of participants into the trial and making it feasible to conduct a full trial. TRIAL REGISTRATION NUMBER: ANZCTR: 12617001405303.

Between-Day Reliability of Scapular Locator for Measuring Scapular Position During Arm Elevation in Asymptomatic Participants.

OBJECTIVE: The aim of this study was to assess the between-day reliability of the scapular locator for measuring scapular rotations during arm elevation in patients without shoulder pain/conditions/disorders. METHODS: Twenty-three asymptomatic individuals were measured during 2 sessions separated by 24 hours. One observer measured scapular position with a scapular locator while participants held their arms at 30°, 60°, 90°, and 120° elevation in the scapular plane. Three trials were performed for each arm position. RESULTS: At 30°, between-day intraclass correlation coefficients (ICCs) for all scapular rotations were poor (ICC 0.10-0.40). At higher arm elevations (60°, 90°, and 120°), ICCs ranged from 0.73 to 0.93 for scapular upward rotation, 0.80 to 0.87 for posterior tilt, and 0.37 to 0.62 for scapular internal rotation. For all scapular rotations, the standard error of measurement was less than 6°, and the smallest detectable difference ranged from 11° to 18°. CONCLUSION: The findings indicate good to excellent reliability for measuring scapular upward/downward rotation and anterior/posterior tilt between 60° and 120° of shoulder elevation in the scapular plane. However, low reliability was found for all scapular rotations at 30° elevation, and for scapular internal rotation at higher arm elevation.

Differences between clinician- and self-administered shoulder sustained mobilization on scapular and shoulder muscle activity during shoulder abduction: A repeated-measures study on asymptomatic individuals.

BACKGROUND: Sustained glenohumeral postero-lateral glide administered by a clinician is commonly used in the management of patients with shoulder pain. This technique reduced shoulder muscle activity in asymptomatic individuals, but it is unknown whether a self-administered version of the mobilization leads to similar neuromuscular response. This study compared the effect of sustained shoulder mobilizations (performed by a physiotherapist) with self-administered mobilization (with a belt) on activity levels of scapular and glenohumeral shoulder muscles. METHODS: Twenty-two individuals participated in this study, which had a cross-over, repeated measures design. Seven shoulder muscles (upper and lower trapezius, supraspinatus, infraspinatus, posterior deltoid, middle deltoid, and serratus anterior) were monitored using surface electromyography (SEMG) during shoulder abduction performed with a clinician-administered sustained mobilization, and with self-administered sustained mobilization. Muscle activity levels were measured prior, during and after the sustained glide was applied to the shoulder. Mixed-effect models for repeated measures were used for within- and between-condition comparisons. RESULTS: There was no carry-over effect. Within-condition comparisons suggest that both interventions lead to changes in scapular and shoulder muscle activity levels. No differences between clinician-administered and self-administered mobilizations at intervention and follow-up were found for the monitored muscles, with the exception of upper trapezius. CONCLUSIONS: In young, asymptomatic individuals, self- or clinician-administered sustained mobilizations reduced activity levels of most scapular and shoulder muscles during shoulder abduction. This effect was observed only while the sustained glides were applied to the shoulder. At the immediate follow-up, muscle activity levels were similar to baseline measurements.

Evaluation of changes in pelvic belt tension during 2 weight-bearing functional tasks.

OBJECTIVE: The purposes of this study were to evaluate changes in pelvic belt tension during 2 weight-bearing functional tasks (transition from bipedal to unipedal stance [BUS] and walking) and to evaluate the reliability and the percentage variation for belt tension scores from trial to trial. METHODS: A cross-sectional repeated-measures study was conducted with 10 healthy male participants (mean age, 28.3 ± 8.8years). Participants performed 10 trials of BUS and walking while wearing a nonelastic pelvic compression belt (PCB) applied distal to the anterior superior iliac spines, with a load cell positioned in the center of the belt. The load cell was calibrated using known weights (1-10kg) to define the relationship between the applied tension and voltage change (R(2) = 0.99). Load cell tension values were recorded in voltage signals and then converted to newtons of force using appropriate conversion values (0.012V = 10N). Mean and standard deviation values, intraclass correlation coefficients (ICC 3,1), and percentage standard error of measurements (% SEM) were analyzed for PCB tension recorded during the BUS and walking trials. RESULTS: The mean tension achieved with a PCB was found to be 41.02 (±4.23) N during BUS and 44.07 (±5.80) N during walking. The trial-to-trial reliability (ICC 3,1) was high (ICC ≥0.9), and the variation in PCB tension across 10 trials (% SEM) was 4% or less. CONCLUSION: The mean tension achieved during the tasks was 44 N or less. The reliability is high, and the variation is low across the trials, which implies that a PCB could be used to produce consistent effects during repetition of the tasks (BUS and walking).

Effects of external pelvic compression on form closure, force closure, and neuromotor control of the lumbopelvic spine--a systematic review.

Optimal lumbopelvic stability is a function of form closure (joint anatomy), force closure (additional compressive forces acting across the joints) and neuromotor control. Impairment of any of these mechanisms can result in pain, instability, altered lumbopelvic kinematics, and changes in muscle strength and motor control. External pelvic compression (EPC) has been hypothesised to have an effect on force closure and neuromotor control. However, the specific application parameters (type, location and force) and hypothesized effects of EPC are unclear. Thus, a systematic review was conducted to summarize the in vivo and in vitro effects of EPC. Eighteen articles met the eligibility criteria, with quality ranging from 33% to 72% based on a modified Downs and Black index. A modified van Tulder's rating system was used to ascertain the level of evidence synthesised from this review. There is moderate evidence to support the role of EPC in decreasing laxity of the sacroiliac joint, changing lumbopelvic kinematics, altering selective recruitment of stabilizing musculature, and reducing pain. There is limited evidence for effects of EPC on decreasing sacral mobility, and affecting strength of muscles surrounding the SIJ, factors which require further investigation.

A rationale for the provision of extrinsic feedback towards management of low back pain.

Low back pain (LBP) is associated with dysfunction of global and local muscle systems, feedback and feedforward postural control mechanisms. Physiotherapists include the use of feedback as part of treatment protocols. Such feedback can focus on a variety of neuromuscular impairments, although the literature related to feedback on the management of LBP has focused mainly on local muscle system impairments. Furthermore, there are various characteristics of feedback that can lead to motor control enhancement or deterioration. The aim of this manuscript is to present a rationale for feedback provision as a rehabilitation tool on the management of LBP. Feedback provision should focus on the main neuromuscular impairment presented by the patient. The suggested rationale describes decision-making stages for the use and progress of feedback interventions. Local muscle system impairment might benefit more from parameter feedback provision, while global muscle system and feedback mechanism impairments may benefit better from program feedback. The described rationale has the potential to help clinicians select the appropriate feedback for the treatment of their patients. Additionally, the presented rationale could be used by researchers to assess how different forms of feedback provision impact on clinical outcomes.

The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: a systematic review.

A systematic review of randomised controlled trials (RCTs) was conducted to determine the effectiveness of manual therapy (MT) techniques for the management of musculoskeletal disorders of the shoulder. Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and relevant MT journals were screened. Fourteen RCTs met the inclusion criteria and their methodological qualities were assessed using the PEDro scale. Results were analyzed within diagnostic subgroups (adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunction) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. For SIS, there was no clear evidence to suggest additional benefits of MT to other interventions. MT was not shown to be more effective than other conservative interventions for AC, however, massage and Mobilizations-with-Movement may be useful in comparison to no treatment for short-term outcomes for shoulder dysfunction.