Meaningful coproduction with clinicians: establishing a practice-based research network with physiotherapists in regional Australia.

BACKGROUND: The disconnect between research and clinical practice leads to research evidence that is often not useful for clinical practice. Practice-based research networks are collaborations between researchers and clinicians aimed at coproducing more useful research. Such networks are rare in the physiotherapy field. We aimed to describe (i) clinicians' motivations behind, and enablers to, participating in a network, (ii) the process of network establishment and (iii) research priorities for a practice-based network of physiotherapists in the Hunter Region of New South Wales (NSW), Australia that supports research coproduction. METHODS: We describe the methods and outcomes of the three steps we used to establish the network. Step 1 involved consultation with local opinion leaders and a formative evaluation to understand clinicians' motivations behind, and enablers to, participating in a network. Step 2 involved establishment activities to generate a founding membership group and codesign a governance model. Step 3 involved mapping clinical problems through a workshop guided by systems thinking theory with local stakeholders and prioritizing research areas. RESULTS: Through formative evaluation focus groups, we generated five key motivating themes and three key enablers for physiotherapists' involvement in the network. Establishment activities led to a founding membership group (n = 29, 67% from private practice clinics), a network vision and mission statement, and a joint governance group (9/13 [70%] are private practice clinicians). Our problem-mapping and prioritization process led to three clinically relevant priority research areas with the potential for significant change in practice and patient outcomes. CONCLUSIONS: Clinicians are motivated to break down traditional siloed research generation and collaborate with researchers to solve a wide array of issues with the delivery of care. Practice-based research networks have promise for both researchers and clinicians in the common goal of improving patient outcomes.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia.

OBJECTIVES: To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions. DESIGN: We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting. SETTING: Australian primary care. PARTICIPANTS: Registered physiotherapists who are members of a practice-based research network (n=31). RESULTS: The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application. CONCLUSION: High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

Analysis of phase detects altered timing of muscle activation in subjects with chronic shoulder pain.

Optimal exercise therapy for shoulder pain is unknown due to limited information regarding specific changes in muscle function associated with pain. Timing of muscle activity with respect to movement (phase) can provide information about muscle activation patterns without requiring electromyography data normalization which is problematic in the presence of pain. The aim of this study was to determine if a phase measure is able to detect differences in the timing of shoulder muscle activation in subjects with chronic shoulder pain. Fourteen subjects with pain and 14 without pain were recruited. Electromyography from eight shoulder muscles was recorded. Approximately 20 cycles of small amplitude (∼30°) rapid shoulder flexion/extension was performed. A cross-correlation and spectrographic analysis provided a measure of phase. Welch's t-tests were used to compare mean phase angles between groups. Subjects with chronic shoulder pain had greater variability in the relative timing of muscle activation with significant differences found in the phase angles for pectoralis major, infraspinatus, supraspinatus, upper and lower trapezius and serratus anterior. This preliminary study indicates that the examination of the timing of muscle activation using a phase measure can identify significant differences in muscle function between normal subjects and those with chronic shoulder pain.

Subscapularis tendinopathy is highly prevalent in elite swimmer's shoulders: an MRI study.

OBJECTIVES: The aim of this study is to determine the prevalence of abnormal anatomical change present on MRI in elite swimmers' shoulders compared to age-matched controls. DESIGN: Descriptive epidemiological study. METHODS: Sixty (aged 16-36 years) elite Australian swimmers and 22 healthy active, age and gender matched controls (aged 16-34 years). All participants completed a demographic, and training load and shoulder pain questionnaire and underwent shoulder MRI. Tests for differences in the population proportion was used for comparison between swimmers dominant and non-dominant shoulders and those of the controls. RESULTS: Subscapularis and supraspinatus tendinopathy was the most common tendon abnormality identified in swimming participants, being reported in at least one shoulder in 48/60 (73 %) and 46/60 (70 %) swimmers, respectively. There was no significant difference between dominant and non-dominant shoulders for either tendinopathy, however, grade 3 tendinopathy was significantly more prevalent in subscapularis than in supraspinatus (P < 0.01). Compared with controls, significantly more abnormalities were reported in swimmers' shoulders in both subscapularis and supraspinatus tendons along with the labrum and acromioclavicular joint. Pathology was not a predictor of current pain. CONCLUSIONS: This data confirms that tendon abnormality is the most common finding in elite swimmers' shoulders. Furthermore, that subscapularis tendinopathy is not only as common as supraspinatus but has a greater prevalence of grade 3 tendinopathy. With significant varied abnormalities including tendinopathy being so common in both symptomatic and asymptomatic shoulders of swimming athletes', clinicians should consider imaging findings alongside patient history, symptom presentation and clinical examination in determining their relevance in the presenting condition.

A comprehensive analysis of muscle recruitment patterns during shoulder flexion: an electromyographic study.

Although flexion is a common component of the routine clinical assessment of the shoulder the muscle recruitment patterns during this movement are not clearly understood making valid interpretation of potential muscle dysfunction problematic. The purpose of this study was to comprehensively examine shoulder muscle activity during flexion in order to compare the activity levels and recruitment patterns of shoulder flexor, scapular lateral rotator and rotator cuff muscles. Electromyographic (EMG) data were recorded from 12 shoulder muscles sites in 15 volunteers. Flexion was performed in standing in the sagittal plane at no load, 20%, and 60% of each subject's maximum load. EMG data were normalized to maximum values obtained during maximum voluntary contractions. Results indicated that anterior deltoid, pectoralis major, supraspinatus, infraspinatus, serratus anterior, upper, and lower trapezius were activated at similar moderate levels. However, subscapularis was activated at low levels and significantly lower than supraspinatus and infraspinatus. Similar activity patterns across time were demonstrated in the muscles that produce flexion torque, laterally rotate the scapula, as well as supraspinatus and infraspinatus, and did not change as flexion load increased. The onset of activity in supraspinatus and anterior deltoid occurred at the same time and prior to movement of the limb at all loads with infraspinatus activity also occurring prior to movement onset at the medium and high load conditions only. Posterior rotator cuff muscles appear to be counterbalancing anterior translational forces produced during flexion and it would appear that supraspinatus is one of the muscles that consistently "initiates" flexion.

Is the Normal Shoulder Rotation Strength Ratio Altered in Elite Swimmers?

INTRODUCTION: It is commonly believed that the shoulder external rotation (ER) to internal rotation (IR) strength ratio is decreased in swimmers due to predominant IR loading during the pull-through (propulsive) phase which predisposes to shoulder pain. However, the evidence supporting this hypothesis is inconclusive. Therefore, the aim of this study was to examine shoulder rotation strength parameters in elite swimmers and investigate potential associations with shoulder pain. METHODS: Sixty-eight (40 men; age, 19.9 ± 3.2 yr) elite swimmers provided demographic and shoulder pain history data before measurement of shoulder rotation strength. Mixed model analyses were used to examine differences in shoulder IR and ER strength normalized to body weight (BW) and the shoulder rotation strength ratio. A multinomial logistic regression model was utilized to examine associations between shoulder rotation strength parameters and shoulder pain. RESULTS: Mean shoulder IR strength (BW) was approximately 0.29 for male swimmers and 0.26 for female swimmers. Mean shoulder ER strength (BW) was approximately 0.19 for male swimmers and 0.18 for female swimmer. The shoulder ER/IR strength ratio was approximately 0.70 bilaterally for all swimmers. There were no significant differences between dominant and nondominant shoulders in IR or ER strength normalized to BW (P ≥ 0.547). There were no associations between any shoulder strength parameters and shoulder pain (r = 0.032, P = 0.107). CONCLUSIONS: Despite the high IR loading, optimal swimming technique does not alter the normal ER/IR strength ratio at the shoulder. Elite swimmers who report current or a history of shoulder pain demonstrate normal shoulder rotation strength ratios. The finding of symmetrical shoulder rotation strength points to side-to-side strength comparisons as a valuable clinical tool in managing swimmers with unilateral shoulder pain.

Humeral torsion and shoulder rotation range of motion parameters in elite swimmers.

OBJECTIVES: Optimal shoulder rotation range of motion (ROM) for swimming is unknown. The primary aim of this study was to examine shoulder rotation ROM in elite swimmers, including the influence of humeral torsion on rotation ROM, in order to establish optimal shoulder rotation parameters for swimming. In addition, we examined the relationship between rotation ROM and shoulder pain. DESIGN: Descriptive cohort study. METHODS: Seventy elite Australian swimmers provided shoulder pain history data prior to measurement of humeral torsion and passive and active shoulder rotation ROM. Repeated measure analyses of variance were used to investigate within and between participant differences for all variables. Associations between humeral torsion and rotation ROM were investigated using Pearson's correlation coefficient. Multiple regression analysis was utilised to examine the associations between rotation ROM and shoulder pain. RESULTS: Average humeral torsion angles of 27±10° (dominant side) and 31±10° (non-dominant side) were demonstrated in this elite swimming cohort. In general, increased humeral torsion was positively associated with increased internal rotation (IR) and decreased external rotation (ER) ROM. There were significant differences in both IR and ER ROM measured passively and actively (F2,136≥93.1, p<0.001) with passive ROM greater than active ROM (p<0.001) and active IR ROM measured in supine greater than measured in prone (p<0.001). There were no associations between any rotation ROM variables and current or history of shoulder pain (r2=0.058; p=0.46). CONCLUSIONS: Humeral torsion angle and passive shoulder IR ROM were similar while passive ER ROM was greater in elite swimmers compared to reported normal population values.

The role of shoulder muscles is task specific.

The aim of this study was to compare activity in shoulder muscles during unsupported internal and external rotation to examine their functional roles, and determine whether they retain their 'stabiliser' or 'mover' role regardless of the shoulder task. Electromyographic recordings in the dominant shoulder of 15 normal subjects were taken from 13 shoulder muscle sites using a combination of surface and intramuscular electrodes during isometric shoulder internal and external rotation in an unsupported abducted position under conditions of increasing load. During internal rotation significantly higher activity levels were found in subscapularis (p<0.001). During external rotation significantly higher activity levels were demonstrated in supraspinatus, infraspinatus, trapezius and serratus anterior (p<0.05). There were no significant differences in activity levels in deltoid, pectoralis major and latissimus dorsi during internal and external rotation. As rotational forces increased there was a significant increase in activity in all muscle sites activated above low levels (r(2)=0.93±0.07; mean±s.d.). This study has shown that shoulder muscle function is task specific and that shoulder muscle motor strategy for a particular task does not change with increasing torque. As the only shoulder rotators that demonstrated direction specificity the rotator cuff muscles are likely to be functioning to provide rotation torque while the deltoid is likely to be providing dynamic shoulder stability during the task examined. Higher scapulothoracic muscle activity during external rotation indicated the need for greater dynamic scapular stability as a result of higher rotator cuff activity during external than internal rotation.

The 'empty can' and 'full can' tests do not selectively activate supraspinatus.

Based on previous electromyographic studies the 'empty can' (EC) and 'full can' (FC) tests have been promoted as being able to isolate activity to supraspinatus and are therefore diagnostic of supraspinatus dysfunction. However, there is evidence to suggest that these positions do not selectively activate supraspinatus, and that they may have poor diagnostic accuracy, bringing into question the validity of these tests. Due to limitations in the original EMG papers describing the EC and FC tests the current study aimed to further examine shoulder muscle activity during these tests to determine their ability to selectively activate supraspinatus. EMG activity was recorded from 13 muscles in 15 normal subjects while performing these two tests. Results showed that during the EC and FC muscle tests nine and eight other shoulder muscles, respectively, were equally highly activated as supraspinatus. It was concluded from these results that the EC and FC tests do not primarily activate supraspinatus with minimal activation from other shoulder muscles and therefore, do not satisfy basic criteria to be valid diagnostic tools for supraspinatus pathology. Therefore, these tests should not be interpreted as definitive tests for the clinical diagnosis of supraspinatus pathology. They may, however, be beneficial during shoulder muscle strengthening programs.

Which is the optimal exercise to strengthen supraspinatus?

PURPOSE: Supraspinatus strengthening is an important part of shoulder rehabilitation programs. Because of the force-couple relationship between supraspinatus and deltoid during shoulder abduction, it has been proposed that the optimal exercise to strengthen supraspinatus is one that would maximize supraspinatus activity while minimizing surrounding muscle activity, particularly deltoid. The aim of this study was to simultaneously examine all exercises known to recruit supraspinatus at high levels and to compare the level of recruitment in supraspinatus, deltoid, and infraspinatus. METHODS: Using a combination of surface and intramuscular electrodes, EMG recordings were taken from supraspinatus, infraspinatus, and the three parts of deltoid of 15 subjects with normal dominant shoulder function during maximal isometric contractions in "empty can," "full can," prone elevation, pendant external rotation, and prone external rotation exercise positions. RESULTS: There was no significant difference in the level of supraspinatus activation for all exercise positions examined. No significant difference was found in activation levels across all muscles during the "can" exercise positions. The exercise positions using external rotation were found to activate parts of deltoid significantly less than the "can" and prone elevation positions. Infraspinatus was activated at greater levels than supraspinatus during the external rotation exercises. CONCLUSIONS: Using the criteria that the optimal exercise to strengthen supraspinatus should maximize supraspinatus activity while particularly minimizing deltoid activity, this study has shown that the pendant external rotation and prone external rotation exercises are more valid than the "can" and prone elevation exercises for supraspinatus strengthening in subjects with normal dominant shoulder function.

Standard maximum isometric voluntary contraction tests for normalizing shoulder muscle EMG.

A comparison of electromyographic (EMG) activity of muscles between and within subjects, and during separate occasions of testing, requires normalization. The most common way for generating the reference level used for normalizing shoulder EMG data is with a maximum isometric voluntary contraction (MVIC). The purpose of this study was to develop a parsimonious set of standardized tests that generate an MVIC in all the major muscle groups of the shoulder. Twelve muscles of the dominant shoulder of 15 subjects were examined using a combination of surface and intramuscular electrodes during 15 tests. The results indicated that many tests maximally activated more than one muscle simultaneously. Four tests were identified as being sufficient for generating an MVIC in the 12 muscles examined and are recommended as the standard set for normalizing shoulder muscle EMG: abduction 90 degrees with internal rotation ("empty can"), internal rotation in 90 degrees abduction ("internal rotation 90 degrees"), flexion at 125 degrees with scapula resistance ("flexion 125 degrees"), and horizontal adduction at 90 degrees flexion ("palm press"). The use of these shoulder normalization tests will make comparisons between shoulder EMG studies more reliable.