Effectiveness of neural mobilisation for the treatment of nerve-related cervicobrachial pain: a systematic review with subgroup meta-analysis.

ABSTRACT: Neural mobilisations (NM) have been advocated for the treatment of nerve-related cervicobrachial pain; however, it is unclear what types of patients with nerve-related cervicobrachial pain (if any) may benefit. Medline, Web of Science, Scopus, PeDro, Cinahl, and Cochrane databases were searched from inception until December 2022. Randomised controlled trials were included if they assessed the effectiveness of NM in nerve-related cervicobrachial pain, and outcome measures were pain intensity and/or disability. Studies were classified according to their inclusion/exclusion criteria as radiculopathy , Wainner cluster , Hall , and Elvey cluster or other . Meta-analyses with subgroup analyses were performed. Risk of bias was assessed using Cochrane Rob2 tool. Twenty-seven studies were included. For pain and disability reduction, NM was found to be more effective than no treatment (pooled pain mean difference [MD] = -2.81, 95% confidence interval [CI] = -3.81 to -1.81; pooled disability standardized mean difference = -1.55, 95% CI = -2.72 to -0.37), increased the effectiveness of standard physiotherapy as an adjuvant when compared with standard physiotherapy alone (pooled pain MD = -1.44, 95% CI = -1.98 to -0.89; pooled disability MD = -11.07, 95% CI = -16.38 to -5.75) but was no more effective than cervical traction (pooled pain MD = -0.33, 95% CI = -1.35 to 0.68; pooled disability MD = -10.09, 95% CI = -21.89 to 1.81). For disability reduction, NM was found to be more effective than exercise (pooled MD = -18.27, 95% CI = -20.29 to -17.44). In most comparisons, there were significant differences in the effectiveness of NM between the subgroups. Neural mobilisations was consistently more effective than all alternative interventions (no treatment, traction, exercise, and standard physiotherapy alone) in 13 studies classified as Wainner cluster . PROSPERO registration: CRD42022376087.

Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory study.

OBJECTIVES: To estimate Achilles tendon forces and their relationship with self-reported pain in runners with Achilles tendinopathy (AT) during common rehabilitation exercises. DESIGN: Cross-sectional. SETTING: Laboratory. PARTICIPANTS: 24 recreational male runners (45.92 (8.24) years old; 78.20 (8.01) kg; 177.17 (6.69) cm) with symptomatic AT. MAIN OUTCOME MEASURES: Kinematic and kinetic data were collected to estimate Achilles tendon forces during 12 commonly prescribed exercises. Achilles tendon forces were estimated from biomechanical data and normalised to the participant's bodyweight. The secondary aim was to investigate the relationship between Achilles tendon forces and pain during these exercises. RESULTS: Two exercise clusters were identified based on Achilles tendon forces. Cluster1 included various exercises including double heel raises, single heel raises, and walking (range: 1.10-2.76 BWs). Cluster2 included running, jumping and hopping exercises (range: 5.13-6.35 BWs). Correlation between tendon forces and pain was at best low for each exercise (range: -0.43 - 0.20). Higher force exercises lead to more tendon load for a given amount of pain (R2 = 0.7505; y = 0.2367x + 0.6191). CONCLUSION: This study proposes a hierarchical exercise progression based on Achilles tendon forces to guide treatment of runners with AT. Achilles tendon forces and pain are not correlated in runners with AT.

Recreational runners with Achilles tendinopathy have clinically detectable impairments: A case-control study.

OBJECTIVES: To confirm what impairments are present in runners with Achilles tendinopathy (AT) and explore the variance of AT severity in an adequately powered study. DESIGN: Case-control study. SETTING: Two private physiotherapy clinics in Australia and Spain. PARTICIPANTS: Forty-four recreational male runners with AT and 44 healthy controls matched by age, height, and weight. MAIN OUTCOME MEASURES: Demographics, activity (IPAQ-SF), pain and function (VISA-A), pain during hopping (Hop pain VAS), hopping duration, psychological factors (TSK-11, PASS20), and physical tests regarding lower-limb maximal strength and endurance. RESULTS: Body mass index (BMI), activity, VISA-A, pain, and duration of hopping, TSK-11, PASS20, standing heel raise to failure, seated heel raise and leg extension 6RM, hip extension and abduction isometric torque were significantly different between groups (P < 0.05) with varied effect sizes (V = 0.22, d range = 0.05-4.18). 46% of AT severity variance was explained by higher BMI (ß = -0.41; p = 0.001), weaker leg curl 6RM (ß = 0.32; p = 0.009), and higher pain during hopping (ß = -0.43; p = 0.001). CONCLUSION: Runners with AT had lower activity levels, lower soleus strength, and were less tall. BMI, pain during hopping, and leg curl strength explained condition severity. This information, identified with clinically applicable tools, may guide clinical assessment, and inform intervention development.

Effectiveness of Specific Neck Exercise for Nonspecific Neck Pain; Usefulness of Strategies for Patient Selection and Tailored Exercise-A Systematic Review With Meta-Analysis.

OBJECTIVE: Specific neck exercises (SNE) targeting deep cervical flexors and extensors are commonly used for the treatment of nonspecific neck pain (NSNP). However, whether SNE are more effective than alternative exercise interventions (AEI) remains unclear. Furthermore, it has been postulated that SNE may be most effective when they are tailored and targeted to patients with evidence of motor control dysfunction, yet this notion also remains unproven. The objectives of this study were to compare the effectiveness of SNE with that of AEI for reducing pain and disability in people with NSNP and to assess whether the effectiveness of SNE is increased when the exercises are tailored and provided to patients with evidence of motor control dysfunction. METHODS: For this systematic review with meta-analysis, Medline, Web of Science, Scopus, and Physiotherapy Evidence Database were searched. Eligibility criteria included randomized controlled trials evaluating the effectiveness of SNE against that of AEI in people with NSNP. Meta-analysis included subgroup analyses to determine the effect of exercise tailoring and participant selection criteria on the effectiveness of SNE. RESULTS: Twelve studies were included. Meta-analysis revealed greater effectiveness of SNE in the short to medium term for reducing pain (pooled standardized mean difference [SMD] = -0.41; 95% CI = -0.76 to -0.06; P = .02) and disability (pooled SMD = -0.41; 95% CI = -0.78 to -0.04; P = .03) but no differences in the long term for pain (pooled SMD = -1.30; 95% CI = -3.35 to 0.75; P = .21) and disability (pooled SMD = -1.81; 95% CI = -4.29 to 0.67; P = .15), although evidence was limited for the latter. The effectiveness of SNE was not superior in studies that included only participants with motor control dysfunction or when exercises were tailored to each participant. Overall, the studies were of low quality. Grading of Recommendations Assessment, Development and Evaluation revealed low certainty, serious risk of bias, and inconsistency of findings for short- to medium-term effects and very low certainty, serious risk of bias, and very serious inconsistency for long-term effects. CONCLUSION: The preferential use of SNE may be recommended to achieve better short- to medium-term outcomes, although the low quality of evidence affects the certainty of these findings. Currently used strategies for selecting patients and tailoring SNE are not supported by the evidence and therefore cannot be recommended for clinical practice. IMPACT: SNE are more effective than AEI for reducing pain and disability in patients with NSNP in the short to medium term, but overall evidence is of low quality, affecting the certainty of the findings. Tests of muscle dysfunction (mostly the craniocervical flexion test) currently used in studies to select patients and tailor SNE do not result in greater effectiveness of these exercises. LAY SUMMARY: Evidence suggests SNE are more effective than other forms of exercise, although evidence is overall of low quality. Use of the craniocervical flexion test in isolation to select participants and/or tailor SNE cannot be recommended.

Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain.

OBJECTIVE: Distal fibular mobilization with movement (MWM), with and without a posterior gliding fibular tape, and anteroposterior mobilization of the talus (MOB) are widely used to treat acute lateral ankle sprains. The purpose of this study was to investigate the short-term and long-term relative effectiveness of these techniques. METHODS: In this double-blind randomized controlled trial, 45 amateur soccer players with acute (<72 hours) lateral ankle sprain were randomly allocated to 6 sessions (3/wk within the first 2 weeks) of either MWM, MWM with tape (MWMtape), or MOB. All participants also received general advice, transcutaneous electrical nerve stimulation, edema draining massage, and a program of proprioception exercises. Participant ratings of function on the Foot and Ankle Ability Measure and Patient Global Impression of Improvement Scale were the primary outcomes measured over 52 weeks. Secondary outcomes were ankle pain, pressure pain threshold, range of motion, volume, and strength. RESULTS: MWM and MWMtape were equally effective and participants demonstrated greater function on the Foot and Ankle Ability Measure at 12 and 52 weeks when compared with those receiving MOB; however, the latter demonstrated superior function at 2 weeks. No differences between groups were observed for Patient Global Impression of Improvement Scale or any of the secondary outcomes. CONCLUSION: There are limited differences in the short term among techniques, with the exception of better sport function with MOB. Over the longer term, the distal fibular MWM is most effective to achieve activities of daily living and sport function when added to usual physical therapy care. The addition of a posterior gliding fibular tape provides no additional benefit. IMPACT: Distal fibular mobilization with movement may be the most appropriate choice of treatment for acute lateral ankle sprain to achieve long-term activities of daily living and sport function. In the short term, anteroposterior mobilization of the talus offers greater improvement in sport function. The use of fibular tape provides no added benefit as an adjunct to a treatment that includes distal fibular mobilization with movement.

Immediate effects of cervical mobilisations on neck muscle activity during active neck movements in patients with non-specific neck pain. A double blind placebo controlled trial.

BACKGROUND: Cervical mobilisations are used to treat people with neck pain but their mechanisms of action are unclear. One theorised reason for induced analgesia is effect on neck muscle activity. OBJECTIVES: To assess the effects of cervical mobilisations on muscle activity during active neck movements and whether changes in muscle activity are associated with changes in symptoms. DESIGN: Double-blind randomised placebo controlled trial. SETTING: Primary care. PARTICIPANTS: 40 patients (aged 19 to 80 years, 24 female) with non-specific neck pain. INTERVENTIONS: One session of cervical mobilisations or motionless manual contact (placebo). MAIN OUTCOME MEASURES: sternocleidomastoid (SCM), scalene (SCA), upper trapezius (UT) and erector spinae (ES) surface electromyography (SEMG) during active neck flexion, extension, side flexion and rotation was measured immediately before and after the intervention. Patients were classified as responders according to change in symptoms assessed using the Global Rating of Change Scale (GROC). RESULTS: Compared with placebo, patients receiving mobilisation showed an increase in contralateral UT and ES SEMG during rotation and contralateral and ipsilateral SCM, SCA and UT during side flexion (P<0.05), however changes were mostly associated with an increase in range and speed of movement. The only association with GROC was increased (5%) SEMG in the contralateral SCM during side flexion in the mobilisation group (P=0.013). CONCLUSION: Cervical mobilisations caused increased neck SEMG, mostly due to increased movement range and speed. Change in muscle activity is unlikely to be a major mechanism of action of cervical mobilisations in symptomatic improvement with physiological neck movements. (ClinicalTrials.gov record number: 2016/066). CLINICAL TRIALS REGISTRY: ClinicalTrials.gov record number: 2016/066.

Enhanced Pronociceptive and Disrupted Antinociceptive Mechanisms in Nonspecific Chronic Neck Pain.

OBJECTIVE: Evidence suggests altered pronociceptive and antinociceptive mechanisms in many chronic pain conditions. Knowledge about these mechanisms in nonspecific chronic neck pain (NSNP) would improve understanding of the causes and the design of more effective treatments. Pressure pain threshold (PPT) is often used to assess presence of altered nociceptive processing in NSNP; however, its usefulness to detect this is yet to be established. The purpose of this study was to determine the functional status of temporal summation of second pain (TSSP) and conditioned pain modulation (CPM) in NSNP and to characterize the association of both measures with PPT and clinical features of NSNP. METHODS: Thirty-two participants with NSNP (mean [SD] age = 44 [11] years; 27 female) and 32 age- and sex-matched healthy controls were recruited. TSSP was assessed using an electrical stimulus at the dorsum of the hand, and CPM was evaluated with the Cold Pressor Test. PPT was assessed bilaterally at the neck and tibialis anterior muscles. RESULTS: Participants with NSNP showed greater TSPP (mean difference = 0.23; 95% CI = 0.46-0.01; Cohen d = 0.51) and lower CPM (mean difference = 19.44; 95% CI = 10.42-28.46; Cohen d = 1.09). Pooled data from all participants showed lower PPTs at the neck than the tibialis anterior. However, PPT measures did not differ between groups at either location. PPT measures were not correlated with CPM and TSP. CONCLUSION: NSNP is associated with enhanced pronociceptive and impaired antinociceptive mechanisms, which may explain long-lasting pain and failure of some treatments to resolve symptoms. However, due to the observational nature of this study, a clear cause-effect relationship cannot be established. Normal PPT values in the clinic should not be interpreted as absence of altered nociceptive processing. IMPACT: This study fills in some gaps in knowledge. Changes in central nociceptive processing may explain persistent and recurrent symptoms in NSNP and failure of treatments to obtain long-lasting relief. Further research is required to ascertain if TSSP and CPM assessment in the clinic may help predict physical therapy treatment outcome. Whether symptomatic relief with physical therapy is mediated by an improvement in TSSP and CPM should also be explored. PPTs were unaltered in participants with NSNP despite evidence of impairment in the central pain modulatory systems. Normal PPTs should not be interpreted as evidence of unaltered central pain-related processing.

Association between sympathoexcitatory changes and symptomatic improvement following cervical mobilisations in participants with neck pain. A double blind placebo controlled trial.

BACKGROUND: sympathoexcitation observed with passive cervical mobilisations may imply activation of an endogenous pain inhibition system resulting in hypoalgesia. However, research is mostly in asymptomatic participants and there is very limited evidence of a relationship between sympathoexcitation and symptomatic improvement in people with clinical pain. OBJECTIVE: to investigate the effects of cervical mobilisations on the sympathetic nervous system in participants with neck pain, and to explore the relationship between symptomatic improvement and sympathoexcitation. DESIGN: double-blind randomised controlled trial. METHOD: 40 participants with neck pain (aged 20-69 years, 25 female) were randomly allocated to either cervical mobilisations or motionless placebo. Skin conductance was measured before, during, and after intervention. After interventions were completed, their credibility was assessed. Participants were classified as responders or non-responders according to global symptom change. RESULTS: participants receiving mobilisations were more likely to be classified as responders (odds ratio: 4.33, p = 0.03) and demonstrated greater change in most outcome measures of sympathoexcitation from baseline to during the intervention but not from during to after the intervention. There was no association between sympathoexcitation and symptomatic improvement. Mobilisations and placebo were equally credible. CONCLUSIONS: These findings suggest sympathoexcitatory changes may be caused by an orienting response unrelated to the activation of an endogenous pain inhibition system Alternatively, the observed lack of an association may be explained by the existence of various mechanisms for pain relief. This study used single outcome measures of sympathoexcitation and symptomatic improvement and other measures may reveal different things. CLINICALTRIALS. GOV NUMBER: M10/2016/095.

Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial.

BACKGROUND: Neck pain is prevalent, costly and disabling. Cervical mobilisations are frequently used to treat it but their effectiveness has been questioned by several systematic reviews. Evidence suggests that better outcomes are achieved with mobilisations when they are applied to specific patient subgroups. A criteria for patients suitable for neck mobilisations has been proposed, but the effectiveness on this patient subgroup has not been tested. OBJECTIVE: To assess the effectiveness of cervical mobilisations applied to a subgroup of patients with neck pain who fulfil specific criteria. DESIGN: Randomised controlled trial. METHOD: 40 patients with neck pain attending a Physiotherapy clinic were recruited and randomised to a single session of either cervical mobilisations or motionless manual contact placebo. The immediate effects on global perceived effect, range of movement (ROM), movement velocity and movement associated pain were assessed. RESULTS: mobilisation participants reported significantly better global perceived effect (p˂0.001) and improvements in movement associated pain (p = 0.041). Mobilisations produced a significant increase in ROM in side flexion (p = 0.006) and rotation (p = 0.044) when compared with placebo, but only in patients with pre-intervention ROM restriction. 29-47% of all movement associated pains were resolved following mobilisations and 11-27% following placebo. Patients in both groups showed a significant (p < 0.05) increase in movement velocity, but only in those who had a velocity restriction pre-intervention. CONCLUSIONS: Cervical mobilisations are effective in improving movement-associated pain, increasing ROM and velocity, and patient perceived improvement when applied to patients with neck pain that fulfil a criteria. Their use should be advocated.

Reliability of a Method to Measure Neck Surface Electromyography, Kinematics, and Pain Occurrence in Participants With Neck Pain.

OBJECTIVE: To investigate the reliability of a novel method to measure neck surface electromyography (SEMG), kinematics, and pain during active movements in participants with neck pain. METHODS: This test-retest study evaluated 23 participants with chronic neck pain. Each was measured twice within a single session. Three-dimensional kinematics and SEMG were recorded in 10° increments during forward and side flexion, extension, and rotation of the neck. Neck position during pain occurrence was also measured. RESULTS: Intraclass correlation coefficients were >0.80 for 96% and 100% of SEMG and kinematic data, respectively. The percentage of standard error of the measurement (SEM) values were <25% for 91% of all SEMG measures; most were <15%, and some were <10%. For ranges of motion in the primary plane, percentage of SEM values were all <6% (SEM 1°-3°). Intraclass correlation coefficients for neck position during pain occurrence were all >0.60, except for right rotation (0.48) (SEM values 2°-8°). Pain occurred approximately 59% to 75% into the total range of motion and persisted to its end. CONCLUSIONS: This methodology showed good reliability. It may be suitable for neck pain subclassification to evaluate the effects of treatment on pain, kinematics, and muscle activity during functional neck movements. The point of pain occurrence suggests increasing mechanical load on tissues may be one of the causative factors for movement-associated neck pain.

Differences in neck surface electromyography, kinematics and pain occurrence during physiological neck movements between neck pain and asymptomatic participants. A cross-sectional study.

BACKGROUND: Neck pain has been associated with altered muscle activity and impaired kinematics. Patients frequently report pain during physiological neck movements. Previously, the average muscle activity during these movements has been measured. However, muscle activity is modulated by the position in the range of movement, hence the study of neck muscle activity in discrete sections of the range of movement is warranted. Evidence is conflicting regarding range of movement restriction in neck pain. No study has assessed the point in the range of movement at which pain occurs. This study aimed to investigate neck kinematics, muscle activity and pain during physiological neck movements in participants with and without neck pain. METHODS: Neck kinematics and surface electromyography were recorded continuously and analysed in 10° increments during forward and side flexion, extension and rotation of the neck in 20 neck pain and 20 asymptomatic participants. Point of pain occurrence in the range of movement was recorded. FINDINGS: Neck pain participants demonstrated significantly lower activity of scalene during flexion and extension, and a non-significant higher activity in sternocleidomastoids during rotation. No differences in neck kinematics were observed. 65% of neck pain participants reported pain during at least one neck movement. Pain was reported in the last ≈20-40% of the range of movement. INTERPRETATION: Exercises used in current practice to minimise scalene activity may not be appropriate for all neck pain patients. Restricted range of movement is not a consistent feature of neck pain. Movement associated neck pain is present at the end of range of movement, which has implications for the study of neck pain and rehabilitation.

Mechanism of Action of Spinal Mobilizations: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To review the evidence regarding the mechanism of action of mobilizations. SUMMARY OF BACKGROUND DATA: Spinal mobilizations-low velocity passive oscillatory movements-reduce spinal pain in some patient subgroups. Identifying patients likely to respond remains a challenge since mobilizations' mechanism(s) of action are unclear. METHODS: Medline, Web of Science, Cinahl, Embase, and Scopus databases were searched for relevant studies. Reference lists of included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic, and outcomes evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool. RESULTS: Twenty-four studies were included in the review. Four were classified high risk, 14 moderate risk, and four low risk of bias. Commonest methodological limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. Mobilizations have no effect on temperature pain threshold. Three of four studies reported reduction in spinal stiffness, heterogeneous in location and timing. There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased concentration of substance P in saliva, and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other found no correlation with change in stiffness. CONCLUSION: These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be investigated directly. There is limited evidence regarding other possible mechanisms. LEVEL OF EVIDENCE: 3.

Perioperative physiotherapy in patients undergoing lung cancer resection.

Physiotherapy is considered an important component of the perioperative period of lung resection surgery. A systematic review was conducted to assess evidence for the effectiveness of different physiotherapy interventions in patients undergoing lung cancer resection surgery. Online literature databases [Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, SCOPUS, PEDro and CINAHL] were searched up until June 2013. Studies were included if they were randomized controlled trials, compared 2 or more perioperative physiotherapy interventions or compared one intervention with no intervention, included only patients undergoing pulmonary resection for lung cancer and assessed at least 2 or more of the following variables: functional capacity parameters, postoperative pulmonary complications or length of hospital stay. Reviews and meta-analyses were excluded. Eight studies were selected for inclusion in this review. They included a total of 599 patients. Seven of the studies were identified as having a low risk of bias. Two studies assessed preoperative interventions, 4 postoperative interventions and the remaining 2 investigated the efficacy of interventions that were started preoperatively and then continued after surgery. The substantial heterogeneity in the interventions across the studies meant that it was not possible to conduct a meta-analysis. The most important finding of this systematic review is that presurgical interventions based on moderate-intense aerobic exercise in patients undergoing lung resection for lung cancer improve functional capacity and reduce postoperative morbidity, whereas interventions performed only during the postoperative period do not seem to reduce postoperative pulmonary complications or length of hospital stay. Nevertheless, no firm conclusions can be drawn because of the heterogeneity of the studies included. Further research into the efficacy and effectiveness of perioperative respiratory physiotherapy in this patient population is needed.

Clinical anatomy of the shoulder after treatment for breast cancer.

Normal painfree movement of the upper limb requires movement at the glenohumeral joint and movement of the scapula on the thorax. Co-ordinated movement of these joints is known as the scapulohumeral rhythm and is required during elevation of the arm. Coordinated movement is further achieved by timing of the many muscles acting across the joints. A pilot study from our laboratory has shown significant alterations to this scapulohumeral rhythm and its muscle control following treatment for breast cancer. The aims of this study were to: (1) correlate altered muscle activity from a larger sample with observed movement deviations; (2) compare movement and muscle deviations in survivors with a healthy population and (3) explore the impact of a mastectomy versus a wide local excision (WLE) on the observed deviations. Cross-sectional study. 155 women treated for unilateral carcinoma of the breast and 21 age-matched healthy women were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). Three-dimensional kinematic data and EMG muscle activity were recorded during scaption on the affected and unaffected side. Patients demonstrated a different movement dysfunction depending on whether the left or the right shoulder was affected. Left affected shoulders demonstrated the greatest degree of internal rotation of all shoulders studied. Compared to healthy shoulders patients following a mastectomy demonstrated increased activity in both the left and right affected shoulders in all the measured muscles. In patients having a WLE, such increases were not observed in serratus anterior and pectoralis major activity on the right affected shoulder, where a decrease was noted. Muscle dysfunction was also observed in the unaffected side of patients. Having received chemotherapy contributed significantly to the difference seen between the affected and unaffected shoulders in patients. Differences in scapular tilt between affected and unaffected shoulders in patients were significantly associated with pain and disability, and changes in serratus anterior activity. Patterns of movement deviation resemble those seen in known shoulder conditions. Anatomical and biomechanical evidence supports the need for integrated rehabilitation and surveillance systems for the shoulder in oncology units.

Shoulder morbidity after treatment for breast cancer is bilateral and greater after mastectomy.

BACKGROUND: A recent study in our laboratory found significant differences in scapular kinematics between the affected and unaffected sides of women reporting shoulder pain following treatment for breast cancer. An earlier smaller study from our laboratory found reduced muscle activity from four key muscles and an association with greater shoulder pain and disability. The aims of this study were to: correlate altered muscle activity from a larger sample with observed movement deviations; compare within subject movement and muscle deviations in survivors with healthy variation; explore the impact of a mastectomy vs. a wide local excision (WLE) on the observed deviations. METHOD: Cross-sectional study. One hundred and fifty-five women treated for unilateral carcinoma of the breast and 21 age-matched healthy women were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). Three-dimensional (3D)-kinematic data and EMG muscle activity were recorded during scaption on the affected and unaffected side. The association between kinematic data, EMG data, SPADI and covariates was determined using a two stage, random effects mixed multiple regression technique. RESULTS: All scapula kinematic and muscle EMG parameters in both arms were altered in breast cancer survivors when compared to healthy participants. Altered movement patterns were different for left vs. right side affected. Mastectomy patients demonstrated greater movement deviations and reported significantly higher levels of pain than WLE patients. CONCLUSION: Shoulder morbidity is bilateral, greater in patients having a mastectomy and is present for up to six years post-surgery. This study and others now provide ample evidence to support prospective surveillance programmes that can be integrated into Survivorship Programmes.

Three-dimensional scapulothoracic motion following treatment for breast cancer.

Varying levels of shoulder morbidity following treatment for breast cancer have been reported. Patients report pain, weakness, tightness and reduced functional capacity. Normal painfree motion of the arm and shoulder requires mobility in the scapulothoracic, glenohumeral, acromioclavicular and sternoclavicular joints. Under healthy conditions elevation of the arm is accompanied by scapula retraction, lateral rotation and posterior tilt. However, when scapulothoracic motion is disproportionate to glenohumeral motion, the potential exists for microtrauma and long term pain. A number of studies on women treated for breast cancer have shown limitations in glenohumeral range of movement and a recent report from our laboratory has shown decreased muscle activity in four key muscles acting on the scapula. However, no study has measured the effect of treatment on three-dimensional (3-D) scapulothoracic motion in relation to glenohumeral motion. 152 women treated for unilateral carcinoma of the breast were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). 3-D-kinematic data for the humerus and scapula was recorded during scaption on the affected and unaffected side. The association between kinematic data, SPADI and covariates was determined using random effects multiple regression techniques. All scapula kinematic parameters were significantly altered on the side of the carcinoma in breast cancer survivors. Both reported levels of pain and dysfunction were associated with altered kinematics. High levels of pain and disability were reported for up to 6 years post surgery. Patients with the left side affected reported higher levels of pain and demonstrated more significant scapulathoracic dysfunction independent of dominance. Altered movement patterns were different for left versus right side affected. Left side affected patients need to be considered as a group of patients at risk of experiencing higher levels of pain and showing greater shoulder dysfunction. Whether cause or effect, pain reports are accompanied by 3-dimensional scapula dysfunction which mimics that of many other shoulder conditions.