Posts tagged shoulder pain
Energetic, Outgoing Physical Therapists Achieve Better Treatment Results
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An important shift has taken place in medicine away from the old paternalistic model of care toward the development of the therapeutic alliance. Patients are now encouraged to engage and interact with their medical providers in order to find an optimal path forward. The alliance aims to incorporate patient values and expectations, the best available medical evidence, and available resources to augment the treatment effects. Prior research has shown expert Physical Therapists create a collaborative, patient-centered environment focused on problem solving and treatment. Within this alliance a patient’s specific symptoms and goals can be more quickly and effectively addressed. It is no surprise research shows more optimal outcomes among clinicians utilizing this approach vs. the former paternalistic model of care. New research is also highlighting how a Physical Therapist’s personality may enhance outcomes in the clinic.

Kooijman and colleagues reviewed data from 2800 patient seen in Physical Therapy clinics for shoulder pain over a 3 year period (Physiotherapy. 2019). Authors also collected data on the personality traits of the treating Physical Therapist based on the big five inventory assessment. They were interested in finding the effect of personality on outcomes among patients with shoulder pain. Authors found a significant impact of personality on treatment outcomes with extraverted traits responsible for up to 12% of treatment outcomes. In addition, enthusiasm was also found to significant impact outcomes during treatment of these patients. Unfortunately, the patient’s personality traits were not assessed but future studies may indicate an optimal match of personality traits may even further improve treatment outcomes. This study highlights the importance of assessing psychological factors within in the patient and clinician to augment the effects of known, effective treatments.

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Should I Undergo Surgery Or Physical Therapy For My Shoulder Pain?
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Shoulder pain remains one of the top 3 reasons patients seek care from their primary care physician and Physical Therapist. The most common diagnosis causing pain among these patients is subacromial impingement syndrome. Impingement can be found along with rotator cuff tendon pain (tendinopathy) or partial rotator cuff tears on clinical exam and imaging. Impingement is often found in patients with rotator cuff and scapular muscle weakness leading to pain and loss of arm function. Physical Therapy remains the first line of treatment for impingement but surgery has also been utilized to treat this condition. A recent review of the literature compared these two approaches.

Nazari and colleagues compared the available research on the effectiveness of Physical Therapy vs. shoulder surgery for patients with impingement (PLoS One. 2019). Authors included 11 randomized controlled trials including over 900 patients with follow up periods up to 10 years after the interventions were performed. Authors reported no difference in outcomes between Physical Therapy vs. Surgery plus post operative Physical Therapy at short or long term follow up periods. Based on this review of the literature Physical Therapy remains a first line treatment for shoulder pain.

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Physical Therapy Shown To Accelerate Recovery After Rotator Cuff Injury Compared To Wait And See
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Shoulder pain remains the 3rd most common reason, behind the common cold and low back pain, patients seek out the care of their primary care providers. Impingement and rotator cuff tendon pain are the most common diagnoses associated with these symptoms. The vast majority of rotator cuff injuries do not require surgical intervention and patients are faced with conservative treatments including medication, Physical Therapy, and a wait and see approach. Unfortunately the natural history of shoulder pain is recurrent in nature and over 50% of all new shoulder patients experience continued symptoms at 6 months. A recent research article compared the effectiveness of Physical Therapy to a wait and see approach for patients with shoulder pain.

Dickinson and colleagues completed an analysis of healthcare outcomes in a multi centered cohort of patients with rotator cuff tears (J Shoulder Elbow Surg. 2019). Enrolled patients underwent clinical and demographic questionnaires at 3, 6, 12, and 18 months to determine their perceived recovery from either Physical Therapy or a wait and see or control condition. Authors reported patients who received Physical Therapy within the first 3 months demonstrated significantly better improvements in pain and function compared to those not receiving Physical Therapy. Authors reported similar scores between groups at long term follow ups demonstrating Physical Therapy had the greatest impact accelerating a patient’s recovery up to the 3 month time point.

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Does Treatment Of Trigger Points Improve Outcomes For Patients With Rotator Cuff Injury?
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Rotator cuff injuries span the spectrum from acute strains to chronic tendon pain (tendinopathy) and rotator cuff tears. Physical Therapy remains the gold standard, first line treatment for all rotator cuff injuries due to its’ cost and clinical effectiveness treating these disorders. A Physical Therapy first strategy has been reinforced by recent research demonstrating equivalent outcomes between surgery and Physical Therapy for patients with rotator cuff tears. Strength training exercises remain the most important intervention for patients due to their ability to reduce pain, heal injured tissues, and restore lost function. A recent study examined the effectiveness of adding trigger point treatments to an established Physical Therapy exercise program.

Akbaba and colleagues randomized patients with rotator cuff tears to one of two groups (J Back Musculoskelet Rehabil. 2019). Both groups received the same Physical Therapy strengthening program completed twice a week for 6 weeks, but one group also received manual soft tissue treatment of their shoulder’s trigger points. Authors assessed each patient’s pain, range of motion, function, and mental health outcomes initially and upon completion of the 6 weeks. Both groups improved pain, range of motion, function, and mental health but the addition of trigger point treatments did not improve clinical outcomes in patients with rotator cuff tears. This study highlights exercise remains the most important treatment in patients with rotator cuff injury and soft tissue interventions add little to the overall recovery of patients.

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Physical Therapy Accelerates Recovery From Rotator Cuff Tears
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Rotator cuff tears are a common finding among middle aged adults with shoulder pain, but are also found among their peers without shoulder pain. Many of us will develop these tears as we age and as we have discussed in previous blog posts there is no difference in outcomes at 1 or 2 years if a patient elects for surgery or Physical Therapy for treatment of their symptoms. Our interventions in Physical Therapy are designed at optimizing shoulder function through manual therapy and strength training exercises allowing patients to return to their prior levels of activity without symptoms. Thankfully many rotator cuff tears improve over time due to the natural history of this injury, but a research study suggests Physical Therapy may accelerate this recovery if utilized early in a patient’s recovery.

Dickinson and colleagues studied 55 patients with rotator cuff tears for up to one and half years after the onset of their symptoms (J Shoulder Elbow Surg. 2019). Patients were broken into two different groups based on their utilization of Physical Therapy interventions. Authors reported patients who received Physical Therapy in the first three months after the onset of their symptoms reported greater improvements in pain and function compared to patients utilizing other interventions such as medication or a wait and see approach. Importantly, Physical Therapy was found most effective in the first 8 week of treatment with limited benefits after this 8 week time frame. Patients are encouraged to utilize Physical Therapy early in their recovery process to accelerate their recovery.

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Will The Bone Spur In My Shoulder Cause A Future Rotator Cuff Tear?
Photo Credit: radiopaedia.org

Photo Credit: radiopaedia.org

One commonly sighted reason to perform surgery is to prevent a worsening of an existing pathology. In the shoulder, clinicians aim to preserve important structures such as the rotator cuff with early vs. late surgical interventions despite prior research showing little to no change in progression of tears of rotator cuff tears in patients with a high grade tear. Choosing to delay surgery, without risk of rotator cuff progression, allows a patient to benefit from Physical Therapy. Evidence shows equivocal outcomes between Physical Therapy and surgery for patients with rotator cuff tears. Another structure of concern on a shoulder x ray is a acromion bone spur. In theory, bone spurs on this structure could reduce space between the ball of the shoulder joint and the overlying end of the shoulder blade. New research demonstrates these bone spurs are not as problematic as first theorized.

It has been suggested that a bone spur can lead to shoulder impingement and eventual tearing of the rotator cuff. A recent retrospective study challenged this theory. Yoon et al. examined 119 patients with an intact rotator cuff, diagnosis of impingement, and a 3mm sub-acromial bone spur (Arch Ortho Trauma Surg. 2018). The patients received conservative care including Physical Therapy and received a follow up image to check the cuff integrity as early as 2 years, but as late as 5 years after their initial x ray. The authors found no progression of rotator cuff tears in the 2-5 years after the initial evaluation suggesting the lack of importance the spur relating to tears in the cuff.

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