Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice.

BACKGROUND: Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny. AIMS: The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment. RESULTS AND DISCUSSION: Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often-valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision-making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals. CONCLUSION: We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.

Can resistance training improve throwing performance in handball players? A Systematic review and meta-analysis.

BACKGROUND: Throwing is one of the most important movement in handball. Throwing performance is crucial for success in handball. OBJECTIVE: Τo investigate the level of evidence for the effect of resistance training (RT) on throwing performance in handball players. METHODS: Systematic searches of Pubmed, Medline complete, Cinahl, Sport Discus and Scopus were undertaken for peer reviewed articles published between 18 March 1995 to 18 March 2023. Randomized, controlled, clinical studies, written in English, aiming to investigate the effect at least one modality of RT on throwing performance (velocity or/and accuracy) in handball players were considered for inclusion in the study. The eligible studies were assessed for methodological quality using the Physical Therapy Evidence Database (PEDRO) scale. The Best Evidence Synthesis (BES) approach was used for synthesizing and reporting the results. Furthermore, the random-effects model was used for the meta-analysis and the Q-statistic was used to test the null hypothesis that all studies in the analysis share a common effect size. RESULTS: One hundred ninety-eight studies were identified, of which 30 were included. A total of 727 handball players (males = 388, females = 292) were included. 28 of the 30 studies were rated as high methodological quality studies (PEDRO score > 70%) while the rest of the studies were rated as moderate methodological quality studies (PEDRO score ≤ 60%). The mean effect size for the effectiveness of resistance training (RT) in improving jumping throw, running throw, and standing throw velocity were 1.128 (95% CI 0.457 - 1.798), 1.756 (95% CI 1.111 - 2.400), and 1.098 (95% CI 0.689 - 1.507) correspondingly. Traditional weight training using barbells in mostly compound lifts yielded the most significant and robust results. Other RT modalities such as elastic bands, medicine balls, core training and ballistic training showed no significant results or positive effects due to the limited number of the studies. CONCLUSION: Strong evidence exists only for the effectiveness of RT using barbells in increasing throwing velocity. In contrast, the remaining RT modalities, while yielding positive results, have limited support due to limited number of studies and the high heterogeneity between studies. Furthermore, there is insufficient evidence to support various forms of RT in increasing throw distance. Finally, medicine ball training and elastic band training demonstrated no benefits in improving throwing accuracy. TRIAL REGISTRATION: PROSPERO ID: CRD42023393574.

Human red blood cell acetylcholinesterase activity: a revisit after fifteen years.

Human red blood cell acetylcholinesterase (RBC-AChE) activity is valuable for detecting potential exposure to cholinesterase inhibiting substances (CIS). A reliable population-based RBC-AChE activity reference range is critical for early and massive clinical and occupational toxicology screening. Previous published studies were often limited to small numbers of subjects, various testing methods, and crude statistical data analyses. We tested 4818 adult subjects with a well-established 17-minute modified Michel method over a 2-year period. We conducted a retrospective data analysis and systematically investigated on the influences to testing values from gender, age, age group, and their combinations and interactions. No significant difference was observed in the testing values between males (mean, medium, interquartile range = 0.76, 0.76, 0.71-0.80 ΔpH/h, respectively) and females (mean, medium, interquartile range = 0.76, 0.76, 0.71-0.81 ΔpH/hour, respectively), when gender was the only factor considered (p = 0.7238). However, with age progression, male testing values exhibited a consistent upward trend, while females did not show any clear patterns. Linear regression analysis of the data revealed that gender, age, and age group more or less affected testing values either as independent variables or with their combinations and interactions. However, more potential factors need to be included to achieve better testing value predictions. We recommend the toxicological testing community to adopt a new set of age group specific RBC-AChE activity reference ranges for males (0.68-0.80, 0.69-0.81, 0.70-0.83, 0.71-0.84, and 0.73-0.87 ΔpH/h for 18-29, 30-39, 40-49, 50-59, and ≥60 years old, respectively) while keeping the current reference range (0.63-0.89 ΔpH/hour) for females.

Experiences of physiotherapists considering virtual reality for shoulder rehabilitation: A focus group study.

Introduction: Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR. Methods: A qualitative interpretive design was used to explore physiotherapists' experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis. Results: Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention. Conclusion: Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners.

OBJECTIVE: To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care. DESIGN: A qualitative descriptive study using reflexive thematic analysis. SETTING: In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams. PARTICIPANTS: Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11). RESULTS: Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty. CONCLUSIONS: The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Effectiveness of non-surgical management in rotator cuff calcific tendinopathy (the effect trial): protocol for a randomised clinical trial.

INTRODUCTION: Rotator cuff calcific tendinopathy (RCCT) involves calcific deposits in the rotator cuff. Non-surgical interventions such as extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) are recommended for its early management. Exercise therapy (ET) has shown to be an effective intervention for people with rotator cuff tendinopathy, but it has not been formally tested in RCCT. The main objective of this study is to compare the effectiveness of an ET programme with ESWT and US-PICT in people with RCCT. As a secondary aim, this study aims to describe the natural history of RCCT. METHODS AND ANALYSIS: A randomised, single-blinded four-group clinical trial will be conducted. Adults from 30 to 75 years diagnosed with RCCT who accomplish eligibility criteria will be recruited. Participants (n=116) will be randomised into four groups: ET group will receive a 12-week rehabilitation programme; ESWT group will receive four sessions with 1 week rest between sessions during 1 month; US-PICT group will receive two sessions with 3 months of rest between sessions; and (actual) wait-and-see group will not receive any intervention during the 12-month follow-up. The primary outcome will be shoulder pain assessed with the Shoulder Pain and Disability Index at baseline, 2 weeks, 4 months, 6 months and 12 months from baseline. The primary analysis will be performed at 12 months from baseline. Secondary outcomes will include pain, range of motion, patient satisfaction and imaging-related variables. Moreover, the following psychosocial questionnaires with their corresponding outcome measure will be assessed: Central Sensitization Inventory (symptoms related to central sensitization); Pain Catastrophizing Scale (pain catastrophizing); Tampa Scale for Kinesiophobia 11 items (fear of movement); Fear Avoidance Belief Questionnaire (fear avoidance behaviour); Hospital Anxiety and Depression Scale (anxiety and depression); Pittsburgh Sleep Quality Index (sleep quality); and the EuroQol-5D (quality of life). An intention-to-treat analysis will be performed to reduce the risk of bias using a worst-case and best-case scenario analysis. ETHICS AND DISSEMINATION: Ethics committee approval for this study has been obtained (reference number: 1718862). The results of the main trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05478902.

Developing an international competency and capability framework for advanced practice physiotherapy: a scoping review with narrative synthesis.

INTRODUCTION: The need to address increasing numbers of people seeking care, insufficient numbers of physicians, and providing high-value and sustainable care has contributed to changing physiotherapy practice across the world, often referred to as advanced practice physiotherapy. Currently, there is no internationally standardized competency and capability framework to support advanced practice physiotherapy. OBJECTIVES: This scoping review has two aims; 1) To identify and map out the competencies of advanced practice physiotherapy available in the literature. 2) To develop a competency and capability framework by mapping the competencies identified from the review. DESIGN: The Arksey and O'Malley framework and the PRISMA Scoping review methodology were used. Databases searched included CINAHL Plus, MEDLINE Ovid, PubMed, and Scopus. The competency and capability framework was developed through a narrative synthesis approach. RESULTS: Nineteen documents were included in the final review, with 13 grey literature (government reports, policy documents, thesis) and six research papers. Included publications came from the United Kingdom, Ireland, Australia, New Zealand, and Canada. The included documents covered predominantly musculoskeletal practice (n = 17). The others focused on cardiorespiratory care, incontinence and pelvic health. Through narrative synthesis, 27 competencies and capabilities were identified and grouped under seven domains. CONCLUSION: The synthesis of this scoping review provides the first competency and capability framework for advanced practice physiotherapy that integrates competencies and capabilities from five different countries. With the expansion of advanced practice physiotherapy, the framework developed from this review is the first step towards international recognition, standardization and consistency of education and training of practitioners. CONTRIBUTION OF THE PAPER.

"Restoring That Faith in My Shoulder": A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff-Related Shoulder Pain.

OBJECTIVE: Rotator cuff-related shoulder pain (RCRSP) is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for RCRSP. However, the causal mechanisms underpinning the benefits of exercise for RCRSP are not well understood. Moreover, how individuals with lived experience of RCRSP believe exercise helped or did not help them is unknown. This study aimed to gain insights into how individuals with RCRSP believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs. METHODS: This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semi-structured interview. The data were coded by 2 members of the research team (J.K.P. and N.C.) and verified by a third (B.S.). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations. RESULTS: Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psychoemotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress. CONCLUSION: Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with RCRSP was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself. IMPACT: Exercise is a recommended first-line intervention to manage RCRSP. The results of this study suggest that a positive experience and outcome with exercise for RCRSP is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context that an exercise program is prescribed and delivered within should be considered by clinicians.

Virtual reality in the management of stress and anxiety disorders: A retrospective analysis of 61 people treated in the metaverse.

Mental health is the second largest group of health disorders associated with prolonged disability. Treating conditions such as stress and anxiety are a global health challenge due to inadequate funding and resources. Therefore, providing virtual treatment in the metaverse may provide a novel method of treatment for these conditions. We conducted a retrospective analysis of health records of people experiencing stress and anxiety who were treated principally in the metaverse using virtual reality. The main objective was to determine if virtual mental health treatment was achievable and safe, with measurable outcomes repeated at multiple time points. Here, 61 participants health records were evaluated (50% were female, 19% male, 31% identified as other). The cohort was 45.7 ± 15.7 years of age and reported no adverse effects with outcomes measured. Specifically, anxiety (via Generalized Anxiety Disorder Scale) decreased by 34% (p = 0.002) and stress (via Perceived Stress Scale) decreased by 32% (p < 0.001) after virtual intervention. The data suggests that this method of treatment was feasible, safe, and outcomes were obtainable over a range of time points. This early data suggest that management in the metaverse for these conditions may be beneficial, however, further prospective studies are necessary to better understand these clinical findings.

The concurrent validity and reliability of virtual reality to measure shoulder flexion and scaption range of motion.

BACKGROUND: Shoulder pain commonly has a detrimental impact on patient's work and social activities. Although pain is the most common reason for seeking care, a reduction in shoulder range of motion (ROM) is another common impairment. ROM assessment is used as an evaluation tool and multiple methods are available to measure shoulder ROM. Virtual reality (VR) has been introduced into shoulder rehabilitation, mostly when exercise and ROM measurement is indicated. This study evaluated the concurrent validity and system reliability of active ROM measurements of VR for people with and without shoulder pain. METHODS: Forty volunteers participated in this study. Virtual goniometry was used to assess active shoulder ROM. Participants performed flexion and scaption to six predetermined angles. Measurements from the VR goniometer and smartphone inclinometers were recorded simultaneously. To assess reliability, two identical test sequences were performed. RESULTS: The concurrent validity ICCs were 0.93 for shoulder flexion and 0.94 for shoulder scaption. The VR goniometer application on average systematically overestimated the ROM compared to the smartphone inclinometer. The mean difference between goniometer values was -11.3 degrees for flexion and -10.9 for scaption. The system reliability was excellent with an overall ICC of 0.99 for the flexion movements and 0.99 for the scaption movements. CONCLUSION: Although the VR system demonstrated excellent reliability, and high ICC's for concurrent validity, the large range between the lower and upper 95% CI limits suggests it lacks measurement precision. This suggests VR, as used in this study, should not be used interchangeably with other measurement tools. CONTRIBUTION OF THE PAPER.

Are clinical outcomes associated with baseline sensory profiles in people with musculoskeletal shoulder pain? Protocol for a prospective longitudinal observational study.

BACKGROUND: Musculoskeletal shoulder pain is a common problem and its symptoms often become persistent. The experience of pain is multidimensional, and therefore, a range of patient characteristics may influence treatment response. An altered sensory processing has been associated with persistent musculoskeletal pain states and may contribute to outcomes in patients with musculoskeletal shoulder pain. The presence and potential impact of altered sensory processing in this patient cohort is not currently known. The aim of this prospective longitudinal cohort study is to investigate if baseline sensory characteristics are associated with clinical outcomes in patients presenting to a tertiary hospital with persistent musculoskeletal shoulder pain. If found, a relationship between sensory characteristics and outcome may lead to the creation of more effective treatment strategies and improvements in risk adjustment and prognosis. METHODS: This is a single-centre prospective cohort study with 6-, 12- and 24-month follow-up. A total of 120 participants aged ≥18 years with persistent musculoskeletal shoulder pain (≥3 months) will be recruited from an Australian public tertiary hospital orthopaedic department. Baseline assessments, including quantitative sensory tests and a standardised physical examination, will be performed. In addition, information will be obtained from patient interviews, self-report questionnaires and medical records. Follow-up outcome measures will comprise information from the Shoulder Pain and Disability Index and a six-point Global Rating of Change scale. ANALYSIS: Descriptive statistics will be used to report baseline characteristics and outcome measures over time. Change in outcome measures at the primary endpoint of six months from baseline will be calculated using paired t-tests. Associations between baseline characteristics and outcomes at a 6-month follow-up will be reported using multivariable linear and logistic regression models. DISCUSSION: Understanding the relationship between sensory profile and the variable response to treatment in people with persistent musculoskeletal shoulder pain may enhance our understanding of the mechanisms contributing to the presentation. In addition, through better understanding of the contributing factors, the results of this study may contribute to the development of an individualised, patient-centred approach to treatment for people with this highly prevalent and debilitating condition.

Living with frozen shoulder. 'Here are the risks. I want the injection'. An interpretative phenomenological analysis.

BACKGROUND: Frozen shoulder is a disabling condition characterised by severe pain and loss of shoulder movement and may affect up to 5% of the population. Qualitative research documents debilitating pain and how treatment to reduce pain is a priority for people diagnosed with frozen shoulder. Corticosteroid injections are a principal treatment to reduce the pain of frozen shoulder, however little is known about the patient experience. OBJECTIVES: This study aims to address this gap in the knowledge by exploring the lived experience of people with frozen shoulder who have undergone an injection and to highlight other novel findings. DESIGN: This is a qualitative study using interpretative phenomenological analysis. One-to-one, semi-structured interviews were conducted with seven people diagnosed with frozen shoulder who had received a corticosteroid injection as part of their management. METHODOLOGY: A purposive sample of participants were interviewed via MSTeams™ due to Covid-19 restrictions. Data was collected through semi-structured interviews and analysed in accordance with interpretive phenomenological analysis methods. RESULTS: Three group experiential themes were identified: the dilemma surrounding injections; the challenges of understanding the causes of frozen shoulder; the impact on self and others. CONCLUSION: Participants conveyed a strong desire in seeking a corticosteroid injection whilst seemingly dismissing the risks. A novel concept was illuminated as frozen shoulder seemed inextricably linked with the ageing process, which negatively impacted body-image. The impact on others is driven by a sense of the unfamiliar nature of illness and it is incumbent on healthcare professionals to seek opportunities to explore the individual's beliefs.

Virtual reality in the management of patients with low back and neck pain: a retrospective analysis of 82 people treated solely in the metaverse.

BACKGROUND: Clinically, neck pain disorders (NPD) and non-specific low back pain (NS-LBP) are respectively the fourth and first most common conditions associated with the greatest number of years lived with disability. Remote delivery of care may benefit healthcare sustainability, reduce environmental pollution, and free up space for those requiring care non-virtual care. METHODS: A retrospective analysis was performed on 82 participants with NS-LBP and/or NPD who received exercise therapy delivered solely in the metaverse using virtually reality. The study was to determine if this was achievable, safe, had appropriate outcome measures that could be collected, and if there was any early evidence of beneficial effects. RESULTS: The study demonstrated that virtual reality treatment delivered via the metaverse appears to be safe (no adverse events or side effects). Data for more than 40 outcome measures were collected. Disability from NS-LBP was significantly reduced (Modified Oswestry Low Back Pain Disability Index) by 17.8% (p < 0.001) and from NPD (Neck Disability Index) by 23.2% (p = 0.02). CONCLUSIONS: The data suggest that this method of providing exercise therapy was feasible, and safe (no adverse events reported), that complete reports were obtained from a large selection of patients, and that software acquired outcomes were obtainable over a range of time points. Further prospective research is necessary to better understand our clinical findings.

Physiotherapist beliefs and perspectives on virtual reality supported rehabilitation for the management of musculoskeletal shoulder pain: A focus group study.

BACKGROUND: Virtual Reality (VR) is an immersive computer-generated environment that provides a multi-sensory experience for the user. Modern technology allows the user to explore and interact with the virtual environment, offering opportunities for rehabilitation. The use of immersive VR in the management of musculoskeletal shoulder pain is relatively new and research is required to demonstrate its feasibility and effectiveness in this field. AIM: The aims of this study were, firstly, to explore physiotherapists' beliefs and perspectives of immersive VR as a platform for rehabilitation in patients with musculoskeletal shoulder pain, secondly, to identify potential barriers and facilitators to using VR in a musculoskeletal setting and thirdly, to gain insight from clinicians that would inform the development of a VR intervention for the rehabilitation of musculoskeletal shoulder pain. METHODS: This study used qualitative descriptive design methodology. A series of three focus group interviews were carried out, via Microsoft Teams. Physiotherapists received an Oculus Quest™ headset to use at home prior to the focus group interviews. A six-phase process of reflexive thematic analysis was carried out to identify themes within the data. Atlas Ti Qualitative Data Analysis software was used to facilitate thematic analysis. RESULTS: Five themes were identified within the data. They reflected physiotherapists beliefs that VR provides novel opportunities for shoulder rehabilitation and may offer new avenues for managing movement-related fear and improving concordance with rehabilitation. However, barriers related to safety and practical considerations associated with using VR were also identified in the final themes. CONCLUSION: These findings provide valuable insight into clinician acceptability of immersive VR as a platform for rehabilitation and the need for further research to answer the questions posed by physiotherapists in the current study. This research will contribute to human-centered design of VR-supported interventions for managing musculoskeletal shoulder pain.

Complementary and alternative medicine for children with sickle cell disease: A systematic review.

BACKGROUND: Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population. METHODS: The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science. RESULTS: Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores. CONCLUSIONS: CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

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

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

Developing a core competency and capability framework for advanced practice physiotherapy: A qualitative study.

INTRODUCTION: There is an urgent need to develop an international competency and capability framework to support standardization of education and roles in advanced practice physiotherapy (APP). This need arose due to the rapid growth of the APP model of care, implemented out of necessity in the absence of agreement as to the competencies and capabilities or formal education required for the roles. This study explores the views and perceptions of practitioners and key stakeholders on a draft competency and capability framework for advanced practice physiotherapists. OBJECTIVES: The purpose of this study was to: 1) gather feedback from key stakeholders (advanced practice physiotherapists, researchers, and leaders) on a draft competency and capability framework and 2) use that feedback to revise and improve the draft framework. DESIGN: Qualitative study using a series of four multi-national online focus groups. Thematic analysis was conducted according to Braun and Clarke. RESULTS: Sixteen participants from the United Kingdom, Ireland, Canada, Australia, and New Zealand participated in the study. Five themes were generated after data analysis: clinical expert, experienced communicator, strong leader, collaborator, and knowledge creator). A modified competency and capability framework was developed based on feedback from the focus groups and input from subject matter experts (SMEs). CONCLUSION: This study provides a modified core competency and capability framework comprising 24 competencies grouped under six domains. This study is a step toward international standardization of advanced practice physiotherapy based on a commonly agreed framework for the education and training of advanced practice physiotherapists.

Physiotherapists nearly always prescribe exercise for rotator cuff-related shoulder pain; but why? A cross-sectional international survey of physiotherapists.

BACKGROUND AND AIMS: This cross-sectional international survey explored the beliefs of physiotherapists regarding the possible mechanisms of benefit of exercise for rotator cuff-related shoulder pain (RCRSP). Clinical practice guidelines recommend physiotherapists use exercise as a primary treatment to help people with RCRSP, but the explanations provided to patients by physiotherapists regarding its mechanism of effect is unknown. MATERIALS AND METHODS: Registered physiotherapists were surveyed about 'how and why' they believe exercise provides a clinical benefit for people with RCRSP. Information was also gathered about commonly used exercise types and preferred diagnostic labels. The survey was designed and reported in concordance with Consensus-Based Checklist for Reporting of Survey Studies guidelines. RESULTS: Four hundred and eighty physiotherapists from forty-nine countries completed the survey. Psychosocial and biomedical mechanisms of exercise were evenly selected by participants. Improving muscle strength, muscle endurance, pain self-efficacy and reducing kinesiophobia, and fear avoidance beliefs were the most common individual mechanisms thought to underpin exercise therapy for RCRSP. Rotator cuff-related shoulder pain was the most commonly used diagnostic label. DISCUSSION AND CONCLUSION: Physiotherapists hold beliefs regarding exercise mechanisms that is largely concordant with the current evidence base, which is commendable. Future research should consider the patients perspective and consider testing commonly selected mechanisms of exercise, such as shoulder muscle strength, pain self-efficacy and kinesiophobia as possible mediators of recovery.

A Systematic Review of COVID-19 and Pericarditis.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China in December 2019. Since then, the disease has spread globally, leading to the ongoing pandemic. It can cause severe respiratory illness; however, many cases of pericarditis have also been reported. This systematic review aims to recognize the clinical features of pericarditis and myopericarditis in COVID-19 patients. Google Scholar, Medline/PubMed, CINAHL, Cochrane Central, and Web of Science databases were searched for studies reporting "Coronavirus" or "COVID" and "Peri-myocarditis," "heart," or "retrospective." Case reports and retrospective studies published from May 2020 to February 2021 were reviewed. In total, 33 studies on pericarditis, myopericarditis, and pericardial infusion were included in this review. COVID-19 pericarditis affected adult patients at any age. The incidence is more common in males, with a male-to-female ratio of 2:1. Chest pain (60%), fever (51%), and shortness of breath (51%) were the most reported symptoms, followed by cough (39%), fatigue (15%), myalgia (12%), and diarrhea (12%). Laboratory tests revealed leukocytosis with neutrophil predominance, elevated D-dimer, erythrocyte rate, and C-reactive protein. Cardiac markers including troponin-1, troponin-T, and brain natriuretic peptide were elevated in most cases. Radiographic imaging of the chest were mostly normal, and only 31% of chest X-rays showed cardiomegaly and or bilateral infiltration. Electrocardiography (ECG) demonstrated normal sinus rhythm with around 59% ST elevation and rarely PR depression or T wave inversion, while the predominant echocardiographic feature was pericardial effusion. Management with colchicine was favored in most cases, followed by non-steroidal anti-inflammatory drugs (NSAIDs), and interventional therapy was only needed when patient developed cardiac tamponade. The majority of the reviewed studies reported either recovery or no continued clinical deterioration. The prevalence of COVID-19-related cardiac diseases is high, and pericarditis is a known extrapulmonary manifestation. However, pericardial effusion and cardiac tamponade are less prevalent and may require urgent intervention to prevent mortality. Pericarditis should be considered in patients with chest pain, ST elevation on ECG, a normal coronary angiogram, and COVID-19. We emphasize the importance of clinical examination, ECG, and echocardiogram for decision-making, and NSAIDs, colchicine, and corticosteroids are considered to be safe in the treatment of pericarditis/myopericarditis associated with COVID-19.