CHRONIC SHOULDER PAIN AND REHABILITATION

Author: PT MiguelFelipe Alonso PérezTermas de CuntisLeonardoProyect:ThermalBaths for ActiveAgeingTermas de CuntisMay 4-7, 2012

CHRONIC SHOULDER PAIN

● Shoulder pain has been found to be the third most frequent musculoeskeletal complaint in general practice. Is defined as chronic when it has been present for longer than six mounths

● Neck/shoulder disorders are also a frequent cause of work absetnteeism and claims for sickness benefits. Treatment represents a strain for the health-care resources

● Shoulder pain can be seriosly disabling: severe limitations of the range of motion affect dramatically activities of daily living. In elderly this condition is often worsed by other joint dysfunctions

EPIDEMIOLOGY

● 16 % in general population

● 21 % in elderly

● 10-25 / 1000 new cases per year

● Both male / female equal affected

“The overall number of individuals with rotator cuff dysfunction is expected to grow coincident to an aging population that is increasingly active and less willing to accept functional limitations...”

Arthritis & Rheumatism, December 2004

DIAGNOSTIC CATEGORIES

● Rotator cuff disorders / impingement (> 85 %)

● Adhesive capsulitis

● Glenohumeral osteoarthritis

● Glenohumeral instability

● Acromioclavicular joint pathology

● Others: systemic conditions, referred pain from neck, etc...

As it is the most frequent clinical condition, we have focused our research in rotator cuff disorders.

FREQUENCY OF CLINICAL CATEGORIES

Rotator CuffImpingement

AcromioclavicularAdhesive capsulitis

Referred pain/others

0

10

20

30

40

50

60

70

80

90

Percentage

Note about terminology

In many papers reviewed, the terms “impingement syndrome” and “rotator cuff pathology” were used indistinctly. Although we use them at the same way, technically mean different conditions

● Rotator cuff disease was described by Codmann in 1934 as damage in healthy (traumatic) or aged (degenerated) tendons of supraspinatus, subscapularis, infraspinatus or teres minor

● Charles Neer introduced in 1972 the concept of impingement as a mechanic entrapment of the rotator cuff in the subacromial space, initially reversible, that leads to shoulder pain and tendon tears

PATHOPHYSIOLOGY

● Not fully undestood at cellular and molecular point of view

● Extrinsic theoriy (anatomic variables):

– Acromial morphogenic characteristics

– Os acromiale

– Acromial spurs● Intrinsic theory (tendon or bursa itself)

– Tensile overload

– Primary degeneration (aginig)

– Microvascular supply

PATHOPHYSIOLOGY

It is considered that degenerative changes in tendon tissue are the principal factor of clinical development in rotator cuff disorders

Although the role of inflammation in the rotator cuff remains unclear, cytokines were founded to be associated with pain, size of tendon tears, bursal thickening/fibrosis and synovitis

As mineral waters and mud therapies could modulate the inmunitary response, we believe that this agents may be used to decrease pain and improve functional status

PATHOPHYSIOLOGY

● Interleukin-1β contributes to synovitis and bursitis

● Il-10 and Il-6 are present in subacromial bursa in patients withh rotator cuff tears, and participate in angiogenesis

● TNF-α is increased in bursitis

● MMP-1, MMP-9 and MMP-13 are increased in supraspinatus full-thickness tears

● COX-1 and COX-2 are present in bursa and synovium in patients with rotator cuff tear

SURGICAL V.S. CONSERVATIVE MANAGEMENT

● Recent Cochrane review shows that, if there is no absolute indications or contraindications for surgery, none of the existing management protocols can be chosen rationally (surgery or conservative)

● Most patients with chronic shoulder pain may improve with nonoperative tratment (level B of evidence)

● There is little evidence to support or refute the use of corticosteroid injections (level B)

● Physical therapy can provide improved short term recovery and long-term function for rotator cuff disorders (level B)

SURGICAL V.S. CONSERVATIVE MANAGEMENT

● Even in acute traumatic tears of the rotator cuff in previously healthy shoulders (a classical indication for surgery), operative treatment could be delayed at least 3 mounth with the same results than early surgery

● There is an increasing prevalence of assymptomatic tears with advancing age. A cadaveric study shows 25 % of full-thickness rotator cuff tear prevalence

● There seens to be no clear consensous regarding indications for rotator cuff surgery

● Symptoms duration before surgery have an average of 6-12 mounths (more than 48 papers reviewed)

DISTRIBUTION OF SYMPTOMS DURATION

1-6 6-12 12-18 18-24 24-30 30-36 MOUNTHS0

2

4

6

8

10

12

14

16

18

20

N. of papers

PERCENTAGE OF SUCCESFUL TRATMENTS

50

70

85

Imignement conservativeRotator cuff tears conservativeTotal surgical

SURGICAL V.S. CONSERVATIVE MANAGEMENT

Surgery has the highest rate of succes in rotator cuff disorders management. Despite this, conservative treatment is indicated in most of the patients due to the following:

● 5-6 % of recurrent rupture, that leads to revision repair

● Less ability of tendon healing in elder patients (not fully proved)

● 4 % of postoperative stiffness (defined by < 80 % of ROM compared with contralateral shoulder)

● 1 % surgical wound infections

● 1 % nerve damaged

● 0.5 % deltoid intraoperative avulsion

THE ROLE OF PHYSICAL THERAPY

● In small / medium size rotator cuff tears, physiotherapy is recomended as initial management in most of the guidelines and reviews

● In symptomatic large tears, surgery could be the first initial treatment. Howevwer, according to results, at least 3 mounths of conservative management should be taken into account

● Pain relief and restoration of functions have been observed in 62-74 % of patisnts with symptomatic, radiologically proven rotator cuff tears (treatments also include antiinflamatory medication and/or corticoesteroid injetions)

THE ROLE OF PHYSICAL THERAPY

Physiotherapy is considered useful in the following three different clinical situations:

● After an acute rotator cuff tear

● In chronic shoulder pain

● After surgery

Although surgery is more frequently performed after traumatic rotator cuff tears in young to middle aged patients, there is an increasing number of interventions on elder population

MAIN OBJECTIVES IN PHYSIOTHERAPY

● Relief pain: questionaires show that is the most important factor in patients perception of disease. It has an important role in the next three them

● Recover range of motion (ROM). Tipically, active ROM is affected in rotator cuff disorders, but some patients have concomitant stiffness that decreases passive ROM

● Improve streinght

● Restore function: reduction in function may be substantial, including an inability to dress, atend to personal hygiene and use utensils to eat

MEASURING TREATMENT

According to literature, at least 40 assessment tools are avaliable for shoulder pathologies:

● American Shoulder and Elbow Society (ASES), Disabilities of the Arm, Shoulder and Hand (DASH), Shoulder Pain and Disability Index (SPADI), Constant-Murley Score... are samples of non specific evaluation tools

● Oxford Shoulder Questionaire is specific for surgery

● Western Ontario Osteoarthritis of the Shoulder (WOOS), Shoulder Instability Questionaire(SIQ) are specific for each pathology

PHYSIOTHERAPY MODALITIES

● No standarized protocol exists for rotator cuff tendinopathy. Currently, 3 phases treatment was performed:

– Phase 1: analgesic techniques and activity modification

– Phase 2: gentle ROM exercises to prevent adhesions

– Phase 3: strengthening of rotator cuff and scapular stabilizers

● Physical therapy encompasses a large range of treatments. There are therapeutic modalities designed to aliviate pain direcly (heat, ice, massage, dry needling, ultrasonid, iontophoresis), and stretching and strenghtening exercises to improve to improve shoulder function

PYSIOTHERAPY MODALITIES: exercise

● Recent Cochrane review showed that stretching and strenghtening provide improved short-term recovery and long-term function in patients with rotator cuff disease

● A recent study showed that specific exercise for rotator cuff and scapular stabilizers are better than unspecific in patients with impingement syndrome

● Specific strenghtening program reduces need for surgery in patients with impingement syndrome

● Early active (since 1st. week) mobilisation reduces pain and improves function after arthroscopic rotator cuff repair

● Progressive resistance training improve symptoms in patients with impingement syndrome

SPECIFIC EXERCISE: mean change within groups (baseline to 3 mounths)

CM score DASH score VAS rest VAS activity VAS night

-5

0

5

10

15

20

25

30

35

40

SpecificUnspecific

PHYSIOTHERAPY MODALITIES: hand therapy

● Manual therapies have been found to be effective in addition to exercise programs (improving ASES score). Hand therapies include thrust manipulations, soft tissue mobilisations, massage and neuromuscular techniques

● Myofascial trigger points could play an inportant role in pain and disfunction of the neck and shoulder. An RCT shows that therapies focused on trigger points inactivation improve pain and functional status in patients with chronic shoulder pain

● In our expeience, dry needleing or acupuncture are effective in chronic shoulder pain, probably by gate control mechanism or by desensibilisation of trigger points. An spanish RCT was started in 2009, but results have not been published

PHYSIOTHERAPY MODALITIES: Apparatus

● TENS: improve function and decrease pain (recent trial compared TENS vs. corticosteroid injection: TENS was slightly less effective at short term)

● Ultrasound therapy: no evidence to support or refuse its use

● Extracorporeal shock wave therapy: benefits in pain and function (Constant-Murley score), in chronic calcifying tendonitis. Little evidence in other rotator cuff conditions

● Iontophoresis: no benefits founded

● Low-energy laser: limited evidence support its use in impingement syndrome

AQUATIC EXERCISE

Water rehabilitation has been recomended by specialists since decades for tratment of shoulder disorders and many other joint diseases

Although many handbooks advice to include aquatic exercise in shoulder rehabilitation, and many hospital are fitted with therapeutic pools, a little amount of scientific trials about this treatment modality are avaliable

Our experience supports that aquatic exercise should be considered as an important tool in the management of rotator cuff disorders, specially in patients whith important loss of streinght or even pseudopalsy

AQUATIC EXERCISE

● Bouyancy: helps to early and less pain mobilisation in acute rotator cuff tears, or after surgery

● Dynamic resistance: facilitates slow and controlled resisted movement

● Warmth: may block nociception and enhance blood flow

● Others: propioception, sympathetic nervous system

In addition, most of the land esercises designed for shoulder rehabilitation can be performed in water whith adapting material, so strenghtening aquatic programs may be carry out

SCIENTIFIC EVIDENCE FOR AQUATIC EXERCISE (Shoulder rehabilitation)

● A systematic review of non RCT trials on the curative effects of aquatic exercise was published in 2011 (International Journal of General Medicine)

● Electromyographic activity of rotator cuff muscles were compared during rehabilitation exercises performed in water or in dry land. Activation during 30 and 45 degrees/s was significantly less when performed in water. This decreased muscle activation during aquatic physical therapy allows for earlier active motion (Kelly BT, et al. 2000)

● Combined aquatic and land-based physiotherapy programme following surgical rotator cuff repair improves WORC score and ROM in all subjects. ROM was significantly more increased in aquatic participants

CHRONIC SHOULDER PAIN AND BALNEOTHERAPY

● At our knowledge, an unique trial regard to chronic shuolder pain treatment in spa was performed in 1976, in Polland. Patients were treated whith baths, mud-packs, massage and therapeutic exercise. Results were satisfactory, but there was no control gruop

● Good prognosis for future studies due to:

– Possitive effects of mineral waters and mud in other joint diseases (knee, hip, back pain)

– Evidence of physical therapy efficacy

– Good response to aquatic exercise● We hope that this international project and collaboration leads

to improve scientific evidence about treatment of shoulder chronic pain in spa and balnearium

Acknowledgements:

For your time, attention and gently participation in this multicentre project, whitch we are sure that will contributes to improve the balneotherapy practice and achieve more

scientific evidences in this field