Specific physiotherapy management for subacromial shoulder impingement

Diagnostic labels for shoulder pain are frequently used, yet no standardised diagnostic criteria for any of the labels have been described. One such diagnostic label, subacromial shoulder impingement (SSI), is commonly used as an umbrella term for all subacromial pain with no indication of aetiology or mechanism of pain production. Indeed, the aetiology and specific mechanism of SSI remain robustly debated. Physiotherapy is a common conservative treatment intervention in SSI. Current level II evidence (randomised controlled trials [RCTs]) for the effectiveness of physiotherapy in those with SSI has not provided information about targeted interventions linked to specific biomechanical factors. No clear judgements can be deduced from these RCT's due to limitations of heterogeneity in inclusion criteria, limitations in standardisation of interventions, the lack of matching of upper-limb dominance and not including objective outcomes within methodology. A major focus of physiotherapy is the identification of muscular, neuromuscular and joint impairments, with identified impairments targeted in the treatment programme. While several purported biomechanical factors have been suggested for extrinsic SSI, they have not been clearly described, and this has led to current use of nonspecific treatment interventions to embrace all possible impairments. An initial literature review within this research programme identified four biomechanical factors purported to be associated with extrinsic SSI: posterior shoulder tightness, thoracic postural impairment, scapula impairment and rotator cuff impairment. Reliable and valid objective physiotherapy clinical tests for each of these four biomechanical factors were then identified, using a systematic literature review, prior to conducting a rigorous original casecontrol study to establish which, if any, were different between a group experiencing SSI symptoms and an asymptomatic group, matched for age, gender, limb dominance and physical activity level. Crude analyses revealed that the SSI group had significantly increased resting thoracic flexion and forward head posture, as well as a significant reduction in upper thoracic active motion, posterior shoulder range and passive internal rotation range. It is not known if these identified differences were contributing to or a result of SSI. An RCT was conducted to determine if interventions focused on the upper thoracic spine and posterior shoulder were effective in the management of SSI. This original RCT, which followed the CONSORT statement and was a registered trial with the Australian New Zealand Clinical Trials Registry (12615001303538)1, identified mobilisation of the upper thoracic spine or massage and mobilisation of posterior shoulder structures combined with a targeted single home exercise, in a homogeneous group with SSI, significantly improved function and passive internal rotation range, suggesting that manual therapy that addresses these extrinsic contributing factors decreases the signs and symptoms of SSI. The outcomes of this research provide physiotherapists with a focused assessment and treatment pathway of the thoracic spine and posterior shoulder in those aged 40–60 years presenting with signs and symptoms of extrinsic SSI. This study is the first step in developing a physiotherapy clinical pathway for shoulder pain, which can be presented to health insurers and other health providers. Further rigorous research is required for a complete pathway for other causes of shoulder pain

What are the perspectives of speech pathologists, occupational therapists and physiotherapists on using telehealth videoconferencing for service delivery to children with developmental delays? A systematic review of the literature

Objective: To identify the attitudes and perspectives of speech pathologists, occupational therapists and physiotherapists on using telehealth videoconferencing for service delivery to children with developmental delays. Design: Systematic Literature Review. Method: An electronic search of databases Scopus, CINAHL, MEDLINE, PEDro, Speechbite, OTseeker and ScienceDirect was undertaken in October 2020. Articles were compared with eligibility criteria by 2 authors. All articles were appraised for quality and level of evidence. Findings: Fourteen studies were deemed to be eligible. Results were synthesised using a narrative analysis. The themes identified were technology, self-efficacy, replacement of face-to-face services, time management, relationships, access and family-centred care. Each of these themes was seen as both a potential barrier and a facilitator when trying to provide services via telehealth. Conclusions: The results in this review cannot be generalised due to small sampling size, low response rates, lack of maximum variation sampling and under-representation of occupational therapists and physiotherapists. Study design was either mixed-methods survey or interview or only survey or interview. Risk of bias in studies was high. Further research is required including comparison studies and cost-benefit analysis

Reply to the letter to the editor regarding 'Clinical assessment of subacromial shoulder impingement – which factors differ from the asymptomatic population?'

[Extract] Not surprisingly, impingement is a term which does not reflect the underlying cause of all shoulder pain. Hence there is healthy debateregarding alternate terminology (Braman et al., 2013; J. S. Lewis, 2011 ; McFarland et al., 2013). However, it continues to be a term used throughout the medical literature and in an attempt to embrace this wider audience, until there is agreement about terminology, it was chosen for use in this paper

Isokinetic clinical assessment of rotator cuff strength in subacromial shoulder impingement

Background: Current conservative management of subacromial shoulder impingement (SSI) includes generic strengthening exercises, especially for internal (IR) and external (ER) shoulder rotators. However, there is no evidence that the strength or the ratio of strength between these muscle groups is different between those with SSI (cases) and an asymptomatic population (controls). Objective: To identify if isokinetic rotator cuff strength or the ratio of strength is significantly different between cases and controls. Study Design: Case Control Study. Method: Fifty one cases with SSI and 51 asymptomatic controls matched for age, gender, hand dominance and physical activity level completed isokinetic peak torque glenohumeral IR and ER testing. Within the SSI group, 31 dominant limbs were symptomatic and 20 non-dominant limbs were symptomatic. IR and ER were measured separately using continuous reciprocal concentric (con) and eccentric (ecc) contraction cycles at a speed of 600 degrees per second and again at 1200 degrees per second. Values of peak torque (PT), relative peak torque (RPT) and ratios were compared using independent t-tests between the SSI and asymptomatic groups. Results: Significant strength differences between the two groups were present only when the symptomatic SSI shoulder was the dominant shoulder (con ER PT at 600 /second, ecc ER PT at 1200 /second, ecc ER RPT at 1200 /second and ecc IR PT at 600 /second and 1200 /second). Conclusions: Changes in rotator cuff strength in SSI may be related to limb dominance, which may have implications for strengthening regimes

Clinical assessment of subacromial shoulder impingement – Which factors differ from the asymptomatic population?

Copyright © 2016. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/ This author manuscript is made available following 12 month embargo from date of publication (19 Dec 2016) in accordance with publisher’s copyright policyBackground To date, the significance of factors purported to be associated with subacromial shoulder impingement (SSI) and what differences, if any, are present in those with SSI compared to a matched asymptomatic population has not been identified. Gaining information about differences between people with SSI and asymptomatic people may direct clinicians towards treatments that impact upon these differences. Objective Compare the assessment findings of factors suggested to be associated with SSI; passive posterior shoulder range, passive internal rotation range, resting cervical and thoracic postures, active thoracic range in standing and scapula positioning between cases experiencing SSI and a matched asymptomatic group (controls). Method Fifty one SSI cases and 51 asymptomatic controls were matched for age, gender, hand dominance and physical activity level. The suggested associated factors were measured bilaterally. Independent t-tests were used to compare each of these measurements between the groups. Any variables for which a significant difference was identified, were then included in a conditional logistic regression analysis to identify independent predictors of SSI. Results The SSI group had significantly increased resting thoracic flexion and forward head posture, as well as significantly reduced upper thoracic active motion, passive internal rotation range and posterior shoulder range than the matched asymptomatic group. No independent predictors of SSI were identified in conditional logistic regression analysis. Conclusion Thoracic posture, passive internal rotation range and posterior shoulder range were significantly different between cases experiencing SSI and a matched asymptomatic group

Physiotherapists’ Perspectives on the use of Telehealth for Service Delivery to Children with Developmental Delays: A Qualitative Focus Group Study

Purpose: The purposes of the study are to (1) determine what barriers and facilitators physiotherapists perceive to using telehealth, (2) to determine willingness to use and (3) to determine perspectives on training in the use of telehealth. Method: This is a qualitative semi structured interview and focus group design. Participants were recruited from the first stage of the larger research process using purposive sampling. A semi structured guide was used to facilitate discussion of shared experiences and to allow themes to emerge from the discussion. Results: Thematic analysis was used to synthesise frequent and important themes. Ten participants took part in either a focus group (n=7) or interview (n=3). Nine main themes identified were split into barriers and facilitators. Facilitators were the right family, right child, adequate technology and space, and collaboration. Barriers were technology, time management, lack of physical touch, lack of organisational support, and work environment. Conclusion: Results suggest that physiotherapists working with children with developmental delay consider telehealth to be unsuitable to replace face-to-face therapy entirely but are willing to use it to provide follow up services to the right family and the right child. Physiotherapists in the study were positive about telehealth’s potential to improve services to children in rural areas. Physiotherapists said that specific physiotherapy training in telehealth was currently lacking

Gross motor assessment tools for children 0-12 years of age using telehealth: a scoping review

Objective: The objective of this review was to understand the scope of evidence relating to the use of telehealth for gross motor assessment tools in children 0-12 years of age. Background: Telehealth has been widely used by physiotherapists since the start of the Covid-19 pandemic, however, little is known about the validity and reliability of using gross motor assessment tools via telehealth. Gross motor assessment tools are used by physiotherapists to understand motor function, support diagnoses of motor disorders, and plan and evaluate interventions. Qualitative research identifies a lack of confidence by physiotherapists in undertaking physical assessment via telehealth. Method: A comprehensive search was undertaken of MEDLINE, Scopus, CINAHL, Physiotherapy Evidence Database (PEDro) and OTseeker in August 2022. Grey searching was also implemented. Two independent reviewers identified articles for inclusion and critically appraised the articles. Data was analysed using a narrative review. Results: 34 studies met the inclusion criteria

The association of knowledge, attitudes and behaviours related to salt with 24-hour urinary sodium excretion

Salt reduction efforts usually have a strong focus on consumer education. Understanding the association between salt consumption levels and knowledge, attitudes and behaviours towards salt should provide insight into the likely effectiveness of education-based programs

The reliability of evidence review methodology in environmental science and conservation

Given the proliferation of primary research articles, the importance of reliable environmental evidence reviews for informing policy and management decisions is increasing. Although conducting reviews is an efficient method of synthesising the fragmented primary evidence base, reviews that are of poor methodological reliability have the potential to misinform by not accurately reflecting the available evidence base. To assess the current value of evidence reviews for decision-making we appraised a systematic sample of articles published in early 2015 (N = 92) using the Collaboration for Environmental Evidence Synthesis Assessment Tool (CEESAT). CEESAT assesses the methodology of policy-relevant evidence reviews according to elements important for objectivity, transparency and comprehensiveness. Overall, reviews performed poorly with a median score of 2.5/39 and a modal score of zero (range 0–30, mean 5.8), and low scores were ubiquitous across subject areas. In general, reviews that applied meta-analytical techniques achieved higher scores than narrative syntheses (median 18.3 and 2.0 respectively), as a result of the latter consistently failing to adequately report methodology or how conclusions were drawn. However, some narrative syntheses achieved high scores, illustrating that the reliability of reviews should be assessed on a case-by-case basis. Given the potential importance of reviews for informing management and policy, as well as research, it is vital that overall methodological reliability is improved. Although the increasing number of systematic reviews and meta-analyses highlight that some progress is being made, our findings suggest little or no improvement in the last decade. To motivate progress, we recommend that an annual assessment of the methodological reliability of evidence reviews be conducted. To better serve the environmental policy and management communities we identify a requirement for independent critical appraisal of review methodology thus enabling decision-makers to select reviews that are most likely to accurately reflect the evidence base