Factors Influencing Final Outcomes in Patients with Shoulder Pain: A Retrospective Review

Study Design Retrospective cohort. Introduction Rehabilitation interventions are commonly prescribed for patients with shoulder pain, but it is unclear what factors may help clinicians\u27 prognosis for final outcomes. Purpose of the Study The purpose of this study is to determine what factors are the best predictors of improved patient-reported outcomes at discharge in patients with shoulder pain. Methods Retrospective chart review of 128 patients presenting with shoulder pain to an outpatient physical therapy clinic. Chart review captured data regarding patient demographics, treatment interventions, patient history, and patient-reported outcome scores. The primary dependent variable was the overall change score of the QuickDASH (initial to discharge). Thirty-eight predictor variables were entered into a forward stepwise multivariate linear regression model to determine which variables and to what degree contributed to the dependent variable. Results The linear regression model identified 5 predictor variables that yielded an R = 0.74 and adjusted R2 = 0.538 (P \u3c .001). The 5 predictor variables identified in order of explained variance are QuickDASH change at the fifth visit, a total number of visits, initial QuickDASH score, scapular retraction exercise, and age. Discussion Early change scores, equal to minimal detectable change scores on patient-reported outcomes appear to be strong indicators that patients with shoulder pain are on a positive trajectory to benefit from rehabilitation. Conclusion Using patient-reported outcomes throughout care, not just at the start and end of care, will provide therapist feedback regarding patient\u27s progress and indicate treatment effectiveness. Levels of Evidence 4

Triceps Activation Amplitudes during Functional Activities

Objective: To investigate the muscular activation amplitudes of three regions of triceps musculature during functional activities. We hypothesized that the medial and lateral triceps would be greatest in the terminal 30° arc of extension activities. Design: Cross sectional. Setting: Musculoskeletal Clinical Laboratory. Participants: 20 healthy subjects recruited from a sample of convenience. Intervention: Fine wire electromyograhical (EMG) electrodes were placed into the medial, central, and lateral triceps to measure muscular activation amplitude and two dimensional electrogoniometric kinematic activity was recorded during functional activities associated with activities of daily living. Main Outcome Measure(s): Root mean squared amplitudes of triceps muscles normalized to maximal voluntary isometric contractions that are sub-divided into 30° arcs of motion. Results: The medial triceps generated significantly more EMG activity during the terminal 30° arc of supine extension (54±11%MVIC, p\u3c.05) and during the pushing activity (29±7% MVIC, p\u3c.01). The lateral triceps remained relatively constant throughout all arcs, while the central triceps consistently generated the lowest EMG activation level across all functional tasks. Conclusion: The hypothesis is partially supported as the medial triceps generated more activity in two of the three tasks during the terminal 30° of extension. The lateral portion is activated consistently throughout the extension motion and acts as a dynamic stabilizer during extension activities. These results indicate that the constant activity of the lateral insertion of the triceps, in conjunction with the terminal extension activity of the medial insertion, play a primary role in terminal elbow extension, especially in anti-gravity and load bearing activities. This new data has implications for surgical approaches to the elbow, management of elbow injuries, and rehabilitation of this joint

Reproducibility and Discriminant Validity of the Posterior Shoulder Endurance Test in Healthy and Painful Populations

OBJECTIVE: This investigation measured the reproducibility and discriminant validity of the Posterior Shoulder Endurance Test (PSET) on painful and non-painful populations. DESIGN: Reliability and validity study. SETTING: Laboratory setting. PARTICIPANTS: Thirty subjects (male = 11; female = 19). MAIN OUTCOME MEASURES: Time to failure (TTF) was the primary outcome measure to determine reliability of the PSET. Discriminant validity identified with receiver operator characteristic (ROC) curves utilized TTF separately in men and women since they used different loads. RESULTS: There were 25/30 subjects (painful = 12; non-painful = 13) tested a second time. ICC, SEM, and MDC90 ranged respectively from 0.77, 13.1 s, 30.6 s in the painful group to 0.85, 7.3 s, 17 s in the non-painful group. The male ROC curve AUC was 0.833 with 47 s resulting in the best combination of sensitivity = 0.833, and specificity = 0.80. The female ROC curve AUC was 0.633 with 46 s resulting in the best combination of sensitivity = 0.600 and specificity = 0.889 at 46 s. CONCLUSION: The PSET is a reliable way to measure shoulder girdle muscular endurance. These data suggest that the PSET discriminates painful and non-painful individuals better in men compared to women

Muscle Activity during Maximal Isometric Forearm Rotation Using a Power Grip

This study aimed to provide quantitative activation data for muscles of the forearm during pronation and supination while using a power grip. Electromyographic data was collected from 15 forearm muscles in 11 subjects while they performed maximal isometric pronating and supinating efforts in nine positions of forearm rotation. Biceps brachii was the only muscle with substantial activation in only one effort direction. It was significantly more active when supinating (µ = 52.1%, SD = 17.5%) than pronating (µ = 5.1%, SD = 4.8%, p \u3c .001). All other muscles showed considerable muscle activity during both pronation and supination. Brachioradialis, flexor carpi radialis, palmaris longus, pronator quadratus and pronator teres were significantly more active when pronating the forearm. Abductor pollicis longus and biceps brachii were significantly more active when supinating. This data highlights the importance of including muscles additional to the primary forearm rotators in a biomechanical analysis of forearm rotation. Doing so will further our understanding of forearm function and lead to the improved treatment of forearm fractures, trauma-induced muscle dysfunction and joint replacements

Ambulatory Electromyogram Activity in the Upper Trapezius Region: Patients With Muscle Pain vs. Pain-free Control Subjects

Study Design: This study compared the ambulatory electromyogram activity of persons reporting pain in the shoulder and cervical regions with an equal group of persons not reporting such pain. Ambulatory electromyogram data were obtained over 3-day periods. In addition, all participants completed several standard psychological questionnaires. Objectives: The results were analyzed with inferential statistics to determine whether subjects reporting significant pain in the shoulder and cervical regions had greater ambulatory electromyogram activity than an equal number of subjects not reporting pain. Summary of Background Data: Considerable controversy exists regarding the role of muscle activity in the etiology and maintenance of muscle pain disorders. Given the availability of ambulatory recording devices that can provide a detailed record of muscle activity over an extended period of time, the present research was conducted to determine whether persons reporting shoulder and cervical pain could be differentiated from a group of normal subjects. Methods: All subjects (N = 20) completed a battery of tests with standardized psychometric instruments and then were fitted with ambulatory electromyogram monitors to record electromyographic activity of the upper trapezius region of the dominant side; the time, duration, and amplitude of electromyogram activity greater than 2 μV was recorded. The monitors were worn during normal working hours (mean, 6.2 hours per day) over 3 consecutive days. In addition to wearing the monitors, all subjects completed hourly self-ratings of perceived muscle tension during the recording periods. Results: As expected, subjects with muscle pain reported significantly more pain (mean, 4.9) than did the normal control subjects (mean, 0.9), t(15) = 3.29, P \u3c 0.01. However, patients with muscle pain did not have greater average electromyogram activity (mean, 6.4 μV) over the 3-day period as compared to the normal controls (mean, 7.1 μV), t(18) = -0.25, P \u3c 0.80. Self-monitoring of perceived muscle tension also did not reveal differences between pain subjects and the normal control subjects (P \u3c 0.75). Conclusions: Ambulatory measurements of electromyogram activity did not differentiate persons reporting upper trapezius or cervical pain from those that did not report such pain. Persons reporting pain are also not distinguishable from normal control subjects on a variety of self-report measures. These results raise questions regarding the role of ambulatory electromyogram recordings in the evaluation and treatment of muscle pain disorders

The Effect of Muscle Energy Techniques on Disability and Pain Scores in Individuals with Low Back Pain

Low back pain is the most common type of pain reported by adults in the United States. A variety of manual therapy techniques are used in the management of low back pain to reduce pain, improve function, and reduce disability. In recent years, muscle energy techniques have been increasingly used in clinics to treat low back pain. By definition, a muscle energy technique involves the patient performing a voluntary muscle contraction in a precisely controlled direction, against a distinctly executed counter force applied by the operator. Muscle energy techniques provide a conservative alternative for clinicians treating patients with precautions or contraindications to joint manipulation

Negative side effects of Self-Regulation Training: Relaxation and the Role of the Professional in Service Delivery

Procedures used for relaxation training can resolve or precipitate dysfunction in patients undergoing self-regulation treatments. The present article discusses the role of the clinician in administering relaxation training via thermal biofeedback and coping with unforeseen negative effects of treatment. A case illustration involving the biobehavioral treatment of chest pain is presented and discussed to remind the reader of the significance of the therapist\u27s role in helping tailor treatment programs to unique responses of the individual patient. The case highlights the value of thorough case management and clinical formulation in the successful resolution of relaxation-induced leg pain

The Efficacy of Cervical/Thoracic Active Range of Motion for Detecting Changes Associated with Individuals Receiving Muscle Energy Techniques

Background: Muscle energy techniques (METs) have been used to treat cervical and thoracic range of motion (ROM) restrictions for over 40 years. Of the trials published on METs, most have examined the effectiveness of METs on ROM in the cervical and thoracic spine. Objectives: The aim of this systematic review was to investigate the sensitivity of cervical and thoracic rotation active range of motion, as an objective measure of function, for detecting changes associated with individuals receiving METs compared to (1) individuals receiving no treatment and (2) individuals receiving manipulation. Methods: Relevant databases were searched from January 1970 up to March 2010. Methodological quality of each included study was assessed using the PEDro scale. Effect sizes (Hedges\u27 g) and their 95% confidence intervals were calculated for active rotation ROM scores between and within the MET and comparison groups. Results: Five randomized controlled trials were included in this review. Four studies addressed the first clinical question and one study answered the second. The average PEDro score was 5.8. In general, between and within group effect sizes were moderate to strong in favor of METs. Conclusion: There is fair evidence that cervical and thoracic active range of motion is sensitive to changes associated with individuals who receive an MET. The change in ROM was associated with asymptomatic individuals having restricted rotation. Further studies with higher methodological quality are needed to make a stronger clinical conclusion about the effectiveness of METs