A case of long thoracic nerve palsy

A 31 year old male developed unilateral neck pain associated with increased kyphotic posture 24 hours after having general anaesthesia for ankle surgery. The pain and postural adaptation resolved, but a painless shoulder dysfunction developed. Following assessment a provisional diagnosis of long thoracic nerve palsy was made, and a 'wait and see' approach to management was taken. The dysfunction gradually resolved over a 12 month period without further investigation or intervention. The case study is discussed in light of possible neurophysiological mechanisms involved and of published literature on the management of long thoracic nerve palsy

Reliability of the shoulder symptom modification procedure and association of within-session and between-session changes with functional outcomes

Despite being a common problem, there is considerable diagnostic uncertainty with regard to shoulder pain. This uncertainty relates to the reliability and validity of current examination tests. The Shoulder Symptom Modification Procedure (SSMP) has been proposed as an alternative to existing approaches. To evaluate interclinician reliability of the SSMP and the association of within-session and between-session changes on clinical outcome at 1 week, and at 1 and 3 months. A single-centre reliability study, with prospective follow-up. Twenty-six patients with shoulder pain were recruited. Following an initial SSMP-based examination, a second examination was performed by a second physiotherapist, blinded to the results of the first examination. Clinical outcome data were completed after 1 week, 1 month and 3 months via theNumeric Pain Rating Scale and the Shoulder PainandDisability Index. Reliability was evaluated using kappa and associations were evaluated using Spearman's r. Inter-rater reliability of the SSMP was moderate (κ=0.47). Association of within-session changes ranged from fair to poor in the short term (r=0.24-0.01) to poor in the mid-term (r=-0.03). The association of between-session changes ranged from substantial to moderate in the short term (r=0.74-0.47) but slight in the mid-term (r=0.22). Based on this study, we cannot recommend the SSMP as a reliable tool for physical examination of patients with shoulder pain. The importance of within-session and between-session changes remains uncertain

Quality appraisal as a part of the systematic review: a review of current methods

Systematic reviews frequently underpin national and international practice guidelines. Different approaches to the systematic review process, in particular quality appraisal, have been advocated. This paper discusses these approaches and highlights possible limitations which might impact upon the validity of the conclusions drawn. Practical alternatives are offered upon which systematic reviews may be appraised and conducted

Rotator cuff disorders: An updated survey of current (2023) UK physiotherapy practice

BackgroundClinical guidelines recommend treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorder. Despite this recommendation, research evidence supporting the effectiveness of treatment by a physiotherapist is uncertain. While developing a randomised controlled trial to test the effectiveness of treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorders we first aimed to understand current practice as a basis for defining usual care.MethodsAn online survey was developed based on a clinical vignette used in a previous survey exploring physiotherapy practice for people with shoulder pain due to rotator cuff disorder. UK-based physiotherapists were invited to complete the survey via X and email across professional networks.Results170 complete responses were received. 167 (98%) respondents would offer advice/education to patients with shoulder rotator cuff disorders; 146 (86%) would use isotonic exercise (including concentric/eccentric strengthening); 20 (12%) would offer a corticosteroid injection; 7 (4%) would use joint mobilisation. 168/169 (99%) would offer in-person assessment; 115 (68%) expect to deliver treatment over 3-4 sessions. 50% agreed there is uncertainty about the effectiveness of physiotherapy treatment for patients with shoulder rotator cuff disorders. 76% agreed that patients with this condition can recover without physiotherapy intervention. ConclusionsExercise and advice remain the most common treatments offered by physiotherapists for people with shoulder pain due to rotator cuff disorder. Corticosteroid injections are infrequently considered. Uncertainty about the effectiveness of treatment by a physiotherapist for shoulder pain due to rotator cuff disorder is evident.<br/

The association of working alliance, outcome expectation, adherence and self-efficacy with clinical outcomes for Achilles tendinopathy: A feasibility cohort study (the MAP study)

Introduction: This study evaluated the feasibility of a large longitudinal cohort study utilizing an online platform to investigate the association and predictive relationship of working alliance, outcome expectations, adherence and self-efficacy with outcome in Achilles tendinopathy. The objectives were: (1) to determine the recruitment and retention rate and (2) to carry out preliminary data analysis of the selected variables and clinical outcomes. Methods: A multi-centred, longitudinal feasibility cohort study was used. Eligible participants were directed to a bespoke online platform hosting study information and the outcome measures in the form of an online questionnaire. Responses from the online questionnaire were collected on three occasions: at baseline, at 6 and at 12 weeks following completion of the first questionnaire. Feasibility outcomes (recruitment and retention rates) were described using descriptive statistics. Results: The website recorded a total 55 views. These 55 views resulted in 24 participants consenting to join the study. The questionnaire at baseline was started 63 times and completed on 60 separate occasions resulting in a 95% conversion rate. Retainment for completion of the questionnaire for a second time was 83.3% and for the third time was 66.6%. All questionnaires were completed fully yielding a missing data indicator of 0%. Conclusions: Feasibility studies ask the question ‘can this be done’? Based on the data from recruitment and rates and exploratory correlation analysis a future study can be done; this previously untested online platform appears feasible, but changes could be useful before proceeding to a much larger study

Current and future advances in practice: tendinopathies of the shoulder

Tendinopathies of the shoulder are a burdensome problem. Current treatments include exercise, physical therapies, corticosteroid injections, and surgery. However, the clinical outcomes from randomised controlled trials evaluating the effectiveness of these interventions are largely unremarkable. Given the apparent lack of progress in improving clinical outcomes for patients, it is appropriate to consider other avenues. Research has identified a link between lifestyle-related modifiable risk factors including smoking, overweight, physical inactivity, and the onset and persistence of tendinopathies of the shoulder. Further research is required to understand whether addressing these factors results in better clinical outcomes for patients. Teachable moments and shared decision-making are concepts that could enable clinicians to integrate the assessment and management of these lifestyle factors. Given these lifestyle factors also increase the risk of developing other common morbidities, including cardiovascular disease, an evolution of routine clinical care in this way could represent an important step forward

Exploring the experiences and perceptions of patients awaiting rotator cuff repair surgery: an integrated qualitative study within the POWER pilot and feasibility trial

Background: As waiting times for orthopaedic surgery increase, there have been calls to move from ‘waiting lists’ to ‘preparation lists’, to better prepare patients for surgery. In this context, a pilot randomised controlled trial (POWER) was conducted, comparing physiotherapist-led exercise to waiting-list control (usual care), for patients awaiting rotator cuff repair surgery. This qualitative study was integrated within the pilot trial.Objectives: ●Explore experiences of adults awaiting rotator cuff repair surgery in the NHS●Explore the acceptability of the physiotherapist-led exercise intervention●Explore barriers and enablers to recruitment, retention, and adherence Design: Integrated qualitative study with semi-structured telephone interviewsMethods: Adults awaiting rotator cuff repair, consenting to participate in the trial were eligible. Sampling was purposive regarding age, gender, randomised allocation, and hospital site. Interviews were audio-recorded and transcribed. Data were analysed using Reflexive Thematic Analysis.Results: 20 participants were recruited (age range 49 to 81 years; 12 male, 10 randomised to physiotherapist-led exercise). Many participants were unable to recall their experiences of trial processes; nonetheless, three themes were identified from the data: experience of shoulder pain and pathway to treatment; communication and decision-making in the context of rotator cuff repair surgery; and experiences of the POWER physiotherapist-led exercise intervention and processes. Conclusions: Patients experience significant burden due to shoulder pain. Their journey to surgery can be long, confusing, and associated with perceived abandonment. In a future trial, the intervention should offer opportunity for shared decision-making, optional exit from the surgical pathway, and an individualised exercise programme

Development of an optimised physiotherapist-led treatment protocol for lateral elbow tendinopathy:a consensus study using an online nominal group technique

OBJECTIVES: There are a wide range of physiotherapy treatment options for people with lateral elbow tendinopathy (LET); however, previous studies have reported inconsistent approaches to treatment and a lack of evidence demonstrating clinical effectiveness. This study aimed to combine the best available research evidence with stakeholder perspectives to develop key components of an optimised physiotherapist-led treatment protocol for testing in a future randomised controlled trial (RCT). DESIGN: Online consensus groups using nominal group technique (NGT), a systematic approach to building consensus using structured multistage meetings. SETTING: UK National Health Service (NHS). PARTICIPANTS: 10 physiotherapists with special interest in LET, 2 physiotherapy service managers and 3 patients who had experienced LET. INTERVENTIONS: Two consensus groups were conducted; the first meeting focused on agreeing the types of interventions to be included in the optimised treatment protocol; the second meeting focused on specific details of intervention delivery. Participants were sent an evidence summary of available treatments for LET prior to the first meeting. All treatment options were discussed before anonymous voting and ranking of priority. Consensus for inclusion of each treatment option was set at ≥70% based on OMERACT guidelines. Options with 30%-69% agreement were discussed again, and a second vote was held, allowing for a change of opinion. RESULTS: The optimised physiotherapist-led treatment package included: advice and education, exercise therapy and orthotics. Specific components for each of these interventions were also agreed such as: condition-specific advice, health-promotion advice, exercise types, exercise into 'acceptable' levels of pain, exercise dosage and type of orthoses. Other treatment options including electrotherapy, acupuncture and manual therapy were excluded. CONCLUSION: An optimised physiotherapist-led treatment protocol for people with LET was successfully developed using an online NGT consensus approach. This intervention is now ready for testing in a future pilot/feasibility RCT to contribute much needed evidence about the treatment of LET. TRIAL REGISTRATION NUMBER: This is the pre-cursor to the OPTimisE Pilot and Feasibility Randomised Controlled Trial. Registration: https://www.isrctn.com/ISRCTN64444585