Physio findings - musculoskeletal

Is common shoulder problem a clinical illusion?

Subacromial impingement syndrome is one of the commonest shoulder problems physiotherapists treat.

But does it actually exist?

Physiotherapist Jeremy S. Lewis investigates it in a paper titled ‘Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion?’ that reviews the evidence and goes on to challenge the rationale for surgery.

Patients with the condition certainly experience shoulder pain when lifting their arm.

It’s believed to be caused by the acromion (the bone extending from the shoulder-blade to form the point of the shoulder) pinching or irritating the rotator-cuff tendons below, often because a spur of bone has grown under the acromion.

But, asks Dr Lewis, of Chelsea and Westminster Hospital NHS Foundation Trust, is this what actually happens?

An operation called subacromial decompression aims to shave away the bit of bone that’s causing the irritation.

But does the operation itself help, or does any improvement stem from other causes?  

Experts disagree on many aspects of subacromial impingement, Dr Lewis notes, from the way it develops to the best means of treating it.

There is some evidence that the problem may start in the tendon, he finds, so there’s no need to operate on the bone.

‘This view is strengthened by the findings of studies that have demonstrated no increased clinical benefit from surgery when compared with exercise,’ he says.

Also, exercise therapy is very much more cost-effective and involves less time off work.

‘As there is little evidence for an acromial impingement model, a more appropriate name may be “subacromial pain syndrome”,’ Dr Lewis concludes.

Although an operation sometimes helps, he says, ‘it is also possible that the benefit of surgery is due to placebo or simply enforces a sustained period of relative rest’.

Surgery should only be considered after the patient has continued rehabilitation for the necessary time, he says.

Lewis JS. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews 2011: 16; 388-398.

Stroke

Electric stimulation helps stroke rehab

Tiny electric currents passed across the brain may be able to help in stroke rehabilitation, Oxford University researchers have found. They discovered that transcranial direct current stimulation improved patients’ hand movements.

‘The brain stimulation technique is relatively cheap, easy to use and it’s portable,’ said lead researcher Dr Charlotte Stagg of the Oxford Centre for Functional Magnetic Resonance Imaging of the Brain.

‘You could imagine physiotherapists using it in their practice in the future.’

The study, of 13 patients receiving a single treatment applied across particular regions of the brain, showed a significant 5–10 per cent improvement in patients’ response times.

There was no effect from dummy treatments without a current, nor when the current was passed in the wrong direction.

The effects only lasted for about an hour. But neuroscience studies in other areas suggest that daily application could have effects lasting for months.

‘We are very hopeful that daily brain stimulation would lead to longer-lasting improvements,’ said Dr Stagg.

Stagg CJ et al. Cortical activation changes underlying stimulation-induced behavioural gains in chronic stroke. Brain 2011: doi:10.1093/brain/awr313.

Back pain

Shock results

Available evidence does not support the use of ultrasound or shock wave therapies for treating lower back pain, say researchers.

The team, from the Department of Nursing and Physical Therapy at the University of León in Ponferrada, Spain, did a systematic review of this widespread practice, also known as ‘vibrotherapy’.

Their database search turned up only four appropriate randomised controlled trials (RCTs), covering 252 patients. No adverse effects were reported, say the authors, but none of the unflawed studies found these therapies effective.

‘High-quality RCTs are needed to assess their efficacy versus appropriate sham procedures, and their effectiveness and cost-effectiveness versus other procedures shown to be effective for lower back pain,’ say the authors.

‘In the absence of such evidence, the clinical use of these forms of treatment is not justified and should be discouraged.’

Seco J et al. The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review. Spine Journal 2011: 11; 966-977.

Arthritis

Mind over muscle pain

A traditional meditation technique can reduce the stress and fatigue caused by arthritis, according to a Norwegian study.

Despite advances in treatment, many people with inflammatory rheumatic joint diseases have to cope with pain and disability.

The researchers taught one group ‘mindfulness’ exercises, which focus on experiencing the present moment, no matter how difficult.

Heidi Zangi, of Oslo’s National Resource Centre for Rehabilitation in Rheumatology, and colleagues studied 73 patients aged 20 to 70. All had had painful symptoms of rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis for at least a year.

They were randomly divided into two groups. One followed the Vitality Training Programme (VTP): 10 group sessions of mindfulness exercises led by trained healthcare professionals over 15 weeks, with a booster session six months later.

A control group received standard treatment, plus a CD of the exercises to use if and when they liked.

The VTP, developed for people with chronic musculoskeletal pain, aims at strengthening personal resources. Patients worked on recognising individual limitations, and experiencing strong emotions.

Although their pain had not been reduced, they reported significantly less stress and fatigue, when questioned after the programme and again a year later.

The control group had no relief from fatigue, and a much smaller reduction in stress.  

‘The VTP … significantly improved psychological distress, self-efficacy, processing of emotions and fatigue,’ the authors concluded, suggesting it complement existing treatments in subjects with inflammatory arthritis.’

Annals of the Rheumatic Diseases 2011, doi:10.1136/annrheumdis-2011-200351.

Work in progress

Seeing the patient’s viewpoint

Margaret Hewett, principal physiotherapist for neurological and neurovascular services at Conquest Hospital in St Leonards-on-Sea, East Sussex, investigated transient ischaemic attack (TIA) for her doctorate last year.

Dr Hewett looked into the patient’s experience of TIAs – also known as ‘mini-strokes’. Her aims were to contribute to evidence-based practice by focusing upon narrative reasoning and to explore factors affecting lifestyle change.

‘The expanding field of stroke medicine lacks foundation if it fails to embrace the infrastructure of experiential evidence,’ says Dr Hewett.

She gave a poster presentation of her findings at World Physical Therapy 2011 in Amsterdam and is now preparing her work for publication.

She’s happy to discuss her work with other interested physios: Margaret.hewett@esht.nhs.uk

Physio findings...email  wrightj@csp.org.uk