Search

STUDY DESIGN: Retrospective cohort OBJECTIVES: To examine general expectations for treatment by physical therapists and specific expectations for common interventions in patients with shoulder pain. A secondary objective was to assess the extent to which patients’ general and specific expectations for treatment affect clinical outcomes. METHODS: We performed a secondary analysis of data from a clinical trial of interventions for shoulder pain. Prior to beginning treatment for shoulder pain, 140 patients were asked their general expectations of benefit and their specific expectations for individual interventions. Next we examined how these expectations related to the patients’ ratings of the success of treatment at one and six months after treatment. RESULTS: Patients had positive general expectations for treatment by a physical therapist. Specific manual therapy interventions of range of motion and strengthening had the highest proportion of patients who expected these interventions to significantly improve shoulder pain. Seventy-two patients (58%) reported themselves to be improved using the global rating of change (GROC) at one month and six months. In the full model predicting one-month GROC, only the expectation of moderate relief (p = 0.012) and body mass index (BMI) (p = 0.013) had significant effects. Overall, the Shoulder Pain and Disability Index (SPADI) significantly decreased over time (p = 0.004); however, a significant interaction did occur between time and BMI (p = 0.021). DISCUSSION: Patients expect common interventions used by physical therapists to be effective to manage shoulder pain. In conclusion, patients with shoulder pain had high general expectations for physical therapy. LEVEL OF EVIDENCE: Prognosis, level 2b

OBJECTIVES: Physical therapists (PTs) may practice in direct access or act as primary care practitioners, which necessitate patients’ screening and management for red, orange and yellow flags. The objective of the project was to assess the American PT’s ability to manage red, orange and yellow flags in patients with low back pain (LBP), and to compare this ability among PTs with different qualifications. METHODS: The project was an electronic cross-sectional survey. The investigators contacted 2,861 PTs. Participants made clinical decisions for three vignettes: LBP with red flag for ectopic pregnancy, with orange flag for depression and with yellow flag for fear avoidance behaviour (FAB). The investigators used logistic regression to compare management of warning flags among PTs with distinct qualifications: orthopaedic clinical specialists (PTOs), fellows of the AAOMPT (PTFs), PTOs and PTFs (PTFOs), and PTs without clinical specialization (PTMSs). RESULTS: A total of 410 PTs completed all sections of the survey (142 PTOs, 110 PTFOs, 74 PTFs and 84 PTMSs). Two hundred and seventeen PTs (53%) managed the patient with LBP and symptoms of ectopic pregnancy correctly, 115 PTs (28.5%) of them managed the patient with LBP and symptoms of depression correctly, and 177 (43.2%) managed the patient with LBP and FAB correctly. DISCUSSION: In general, PTs with specialization performed significantly better than PTMSs in all three clinical vignettes. PTs ability to manage patients with warning flags was relatively low. Based on our results, further education on patients with LBP and warning flags is needed. The survey had the potential for non-response and self-selection bias. LEVEL OF EVIDENCE: 3b.

The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification.International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed.The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

The cervical range of motion device (CROM) has been shown to provide reliable forward head position (FHP) measurement when the upper cervical angle (UCA) is controlled. However, measurement without UCA standardization is reflective of habitual patterns. Criterion validity has not been reported. The purposes of this study were to establish: (1) criterion validity of CROM FHP and UCA compared to Optotrak data, (2) relative reliability and minimal detectable change (MDC95) in patients with and without cervical pain, and (3) to compare UCA and FHP in patients with and without pain in habitual postures.(1) Within-subjects single session concurrent criterion validity design. Simultaneous CROM and OP measurement was conducted in habitual sitting posture in 16 healthy young adults. (2) Reliability and MDC95 of UCA and FHP were calculated from three trials. (3) Values for adults over 35 years with cervical pain and age-matched healthy controls were compared.(1) Forward head position distances were moderately correlated and UCA angles were highly correlated. The mean (standard deviation) differences can be expected to vary between 1·48 cm (1·74) for FHP and -1·7 (2·46)° for UCA. (2) Reliability for CROM FHP measurements were good to excellent (no pain) and moderate (pain). Cervical range of motion FHP MDC95 was moderately low (no pain), and moderate (pain). Reliability for CROM UCA measurements was excellent and MDC95 low for both groups. There was no difference in FHP distances between the pain and no pain groups, UCA was significantly more extended in the pain group (P0·05).Cervical range of motion FHP measurements were only moderately correlated with Optotrak data, and limits of agreement (LOA) and MDC95 were relatively large. There was also no difference in CROM FHP distance between older symptomatic and asymptomatic individuals. Cervical range of motion FHP measurement is therefore not recommended as a clinical outcome measure. Cervical range of motion UCA measurements showed good criterion validity, excellent test-retest reliability, and achievable MDC95 in asymptomatic and symptomatic participants. Differences of more than 6° are required to exceed error. Cervical range of motion UCA shows promise as a useful reliable and valid measurement, particularly as patients with cervical pain exhibited significantly more extended angles.

Background/purpose: Plantar foot pain of neural origin is a challenging diagnosis to identify and treat. The purpose of this paper is to illustrate the novel way in which cupping was utilized in conjunction with neural glides to better diagnose and manage a patient who presented with symptoms of peripheral neuropathic plantar foot pain. Case description: A 65-year-old male presented to physical therapy with the diagnosis of plantar fasciitis by an orthopedic surgeon. The presentation included a diffuse area of pain toward the medial border of the foot with a peripheral neuropathic pain description. Cupping was used to identify pain in the saphenous nerve distribution and aided in resolving symptoms with the concomitant use of lower quarter neural glides. Outcome: At discharge and 1-year follow-up, the patient had a full resolution of symptoms and a return to prior level of function. Self-report outcomes included the numeric pain rating scale and the lower extremity functional scale. Discussion: This case is the first to describe the use of cupping combined with neural glides in the diagnosis and management of peripheral neuropathic pain from the saphenous nerve that was previously diagnosed as plantar fasciitis. The proposed mechanisms behind this treatment are also reviewed. Conclusion: In patients that present with symptoms of plantar fasciitis, testing neural glides combined with cupping may be warranted to confirm or refute the presence of a peripheral neuropathic pain source. Further studies are necessary to determine the mechanisms and further utility of the combined interventions in well controlled trials. Level of Evidence: Level IV.

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.

A relationship between muscle and joint impairments has been proposed in the literature; however, the prevalence and the extent of a possible correlation between these disorders in a patient population with mechanical neck pain have been documented in only a few papers. Our aims for this cross-sectional study were to assess the prevalence of myofascial trigger points (TrPs) in the upper trapezius, sternocleidomastoid, and levators capulae muscles; the prevalence of posterior-anterior (PA) joint hypomobility in the mid-cervical spine (C3-C6); and the correlation of these impairments in patients presenting with mechanical neck pain. Thirty patients with neck pain were examined for the presence of TrPs, according to the diagnostic criteria described by Simons et al and Gerwin et al, and for the presence of mid-cervical spine join thypomobility as described by Maitland. One clinician first examined for TrPs. A second clinician blinded to the TrP results then examined the patients for PA joint hypomobi...

Subacromial Impingement Syndrome is a common disorder affecting the shoulder. This paper discusses the pertinent clinical anatomy and biomechanics relative to impingement. Neer's three stages of impingement and Jobe's classification of shoulder injuries are provided. Clinical findings common in patients with impingement are presented as well as a recommended composite examination of the shoulder. A list of disorders about the shoulder that may mimic impingement are included to assist in differential diagnosis. The author describes several ideas for treatment that may be effective in resolving subjective complaints and functional limitations.

Patients with dynamic lumbar instability often present with a variety of clinical signs and symptoms. A possible assessment finding is the presence of abnormal movement patterns during osteokinematic movement of the extremities. This paper discusses possible mechanisms involved in establishing normal and abnormal movement patterns. A unique approach to rehabilitating movement patterns in patients presenting with dynamic lumbar instability is discussed. The concepts of open and closed kinetic chain exercises for the treatment of dynamic lumbar instability are introduced.