Shoulder pain

There are a large variety of shoulder disorders and some classification systems to categorise these into different groups. Most shoulder problems fall into three major categories: soft tissue disorders, articular injury or instability, and arthritis (Dinnes, Loveman, McIntyre, & Waugh, 2003). One of the studies classified these into six diagnostic categories: capsular syndrome (adhesive capsulitis, arthrosis, frozen shoulder, etc.), acute bursitis, acromioclavicular syndrome, subacromial syndrome (chronic bursitis, tendinitis, rotator cuff tears), rest group, and mixed clinical picture (De Winter et al., 1999), whilst another study described three different patterns of shoulder pain. These were Pattern 1: impingement pain, Pattern 2: acromioclavicular joint pain and Pattern 3: shoulder pain (frozen shoulder; glenohumeral osteoarthritis; complete cuff tear; subscapularis tear; painful laxity; post-traumatic instability; and internal derangement) (Carter et al., 2012). They all have some specific features as well as common characteristics. It is not always easy to diagnose these as they may not be an isolated problem but may be a rather a complex and mixed one.

Active MTrPs, which are painful spots that produce familiar shoulder pain during contraction, stretching or compressing, these MTrPs may provide an alternative explanation for shoulder pain, which is independent of the presence of subacromial abnormalities. According to Simons, Travell and Simons [26], MTrPs within the infraspinatus muscle (which were most prevalent) cause pain in the anterior and middle deltoid regions which expands into the frontal upper arm, as well as referred pain and referred sensations felt in the wrist and the hand. In addition, internal rotation and cross-body adduction may be impaired, which is often the case in patients with shoulder pain. Both experimentally induced and spontaneous muscle pain lead to an aber- rant motor activation pattern that is also present in patients with shoulder pain [68,69]. Although latent MTrPs are not usually an immediate source of pain, they can elicit referred pain when mechanically stimu- lated, or during sustained or repeated muscle contrac- tion. In addition, latent MTrPs may disturb normal motor recruitment patterns and movement efficiency.

with some caution. For duration of the complaints, in secondary care the evidence is conflicting but consists of four low and just one high quality study in which dur- ation is not associated with outcome. The latter is easily explained because only patients with chronic shoulder complaints were included so little variation could be ex- pected. Also in primary care quite some people wait long before they seek help for shoulder pain and this distribu- tion is reflected in research. However, included studies do contain patients with acute, sub-acute and chronic complaints and reveal that there is very strong evidence that longer duration is associated with poorer outcome. Many clinicians may endorse this finding from clinical experience. As for psychological factors, in recent years this has been the subject or special interest of many studies. Although it is a broad construct including an array of psychological traits, present summary of the lit- erature suggests that they have no clear association with outcome in either primary or secondary care settings. Table 3 Results of the methodological assessment of prognostic cohort studies on shoulder disorders

Red flags are sign and symptoms alerting the physiother- apist on a possible presence of a non-musculoskeletal, life-threatening pathology, fracture, infection, tumor and inflammatory rheumatic conditions [59]. However, phys- iotherapists must be careful in the evaluation of signs and symptoms of patients [60]. The prevalence and inci- dence of red flags in shoulder disorders are unknown [59, 61], thus limiting the identification of serious non-musculoskeletal pathology at the first consultation [62]. Specific shoulder pain indicates that symptoms could refer to a pathology that has a clear structural, patho-anatomic or pathophysiologic origin (e.g. symptom- atic rotator cuff tears, superior labral tear from anterior to posterior [SLAP] or instability). It requires referral to an orthopaedic specialist to clarify diagnostic aspects or sur- gical needs [63, 64]. Signs and symptoms characteristic of these two categories are listed in Table 2. It is not neces- sary that all symptoms have to be present at the same time to guide physiotherapists during their clinical reasoning process [65–68]. When a conservative approach has been chosen for specific shoulder pain, physiotherapists may refer to specific options for treatment available in litera- ture (e.g. for conservative treatment of patients with massive rotator cuff tears, we could propose stretching, proprioceptive and active exercises towards functional

NSAIDs in maximum dosage on a time contingent base, receive advice regarding activities of daily living, work, hobbies and sports. This advise fits within the first line treatment as recommended in the guideline for SP of the DCGP. Moreover, patients are referred for US of the shoulder to the radiology department of the Maastricht University Medical Centre (MUMC) or Orbis Medical Centre (OMC) in Sittard-Geleen, The Netherlands. Based on the qualification assessment at 2 weeks, patients with insufficient improvement qualify for the RCT. These patients are randomly assigned to the inter- vention or the control group. The therapies used in both groups are the same except that therapies used in the intervention group will be tailored based on the US results. Primary and secondary outcome measures will be assessed at baseline, 13, 26, 39 and 52 weeks after inclusion. Patient recruitment started in November 2010 and patients will be included until October 2012. The Medical Ethics Committee of the Maastricht University Medical Centre has approved this protocol (NTR2403). This trial is officially called the Maastricht Ultrasound Shoulder pain Trial (MUST).

The OSS was conceptualized as a composite measure of Pain and Function, where, in developmental interviews, both aspects were frequently experienced as overlapping or inex- tricably linked. Different factor extraction methods indicated that the OSS can be understood as consisting of either one or two common factors. In a two-factor solution, however, the distinction between self-reported pain and function was somewhat indistinct (ie, the second factor was “weak” and some items cross-loaded), suggesting that shoulder pain and function are constructs that might indeed have some overlap, particularly in the way the patients perceive them, with pain influencing functional ability. While a Pain subscale consist- ing of either 3 or 4 items could nonetheless be supported, for researchers wishing to investigate pain separately, we would recommend including 4 items (items 1, 8, 11, and 12 = Pain, all 8 remaining items = Function) as each asks about pain, and this model was associated with good internal inconsistency. We further recommend scoring each of the two-component subscales on a scale of 0 (worst) to 100 (best):

No significant difference in pain intensity measured on VAS “today” was found between the intervention group and the control group or within the groups. If everything above 0 on the VAS was accounted as pain, there was a tendency toward a decrease in players reporting pain throughout the season. The intervention group went from 21 players (40.4%) that reported pain at baseline down to eight players (17.4%) at posttest. In the control group, 13 players (24.5%) reported pain at baseline, while 11 players (26.8%) reported pain at posttest. These tendencies are opposite to previous assump- tions that shoulder pain will be higher during the season compared to the start of the season, since the load and the stress of the shoulder are thought to increase throughout the season. 29 Andersson, 18 who also found a seasonal variance in

100 petrol pump workers with a mean age of 30±5.47 years were included in this study. Petrol Pump Workers having experience more than 5 years of working were maximum i.e. 62%, 3 years – 5 years were 20%, 1 year to 3 years were 15%, 6 Months – 1 year were 3%. In this study, it shown that among all, 88% of the petrol pump workers spend 8-10 hours daily in their working. In this study only 49% Petrol Pump Workers people had shoulder pain whereas 51% did not had shoulder pain. Out of total shoulder pain Petrol Pump Workers population, 31% from age group of 31 – 40 years and 18% from age group 20 - 30 years and 77% of population working for more than 5yrs, 14% working for 3-5 yrs and only 4% working 1-3 yrs. Among the shoulder pain Petrol Pump Workers population,18% of the Petrol Pump Workers had vague pain and only 14% have radiation to arm, 68% population doesn’t have any pain radiation.

To be included in this study, participants had to be over 18 years of age, be able to speak fluent Nepali, and have current shoulder pain. Shoulder pain was defined as; pain over the antero-lateral, proximal aspect of the shoulder and/ or upper arm, which was aggravated by shoulder movements. Participants were also required to test posi- tive to one of the following; Hawkins-Kennedy test, Neer’s impingement test or maximally resisted isometric manual muscle tests (abduction, external/internal rotation). Par- ticipants were excluded if they presented with; cervical spine symptoms (pain on neck movements, pain in a der- matomal pattern and/or upper limb paraesthesia), pain of systemic or bioplastic origin. Participants were recruited from the physiotherapy outpatient department of three hospitals in Nepal; a not-for-profit rural, community-based hospital, a general urban hospital and a large orthopedic referral centre. These centers were chosen to provide a representative sample of both rural and urban participants. All volunteers were given verbal information about the study and provided with a partici- pant information statement in Nepali to read if they were able or, if they were illiterate, to have it read to them. Lit- erate participants provided a written consent and illiterate participants ’ consent was obtained verbally and signed by a witness. A target of 150 participants was chosen to meet the requirements considered adequate to test the meas- urement properties of a PROM [10].

Validity identifies the extent to which an instrument mea- sures what it is designed for. This was assessed through content, face and convergent construct validity. Although content validity was ensured by the development of the original scale, the Expert Committee’s composed of a methodologist, 3 health professionals (1 physical therapist, 1 physician, 1 gynaecologist), 1 language professional and 2 translators (forward and backward translators); face val- idity was ensured by the pilot study subjects’ opinion. Content and face validity were taken into account to valid- ate the ability of items to collect the health status of re- spondents. Convergent construct validity was measured with a multiple comparison with questionnaires that are mainly used for shoulder pain and dysfunction assessment, assuming that correlations and mean comparisons be- tween groups of participants with versions of validated questionnaires would run, in all cases, in the right direc- tion. Therefore, the correlation between the SPADI and OSS Spanish versions was calculated with FACT-B, NSDQ and SF-36 adapted and validated for the Spanish popula- tion. Convergent construct validity was evaluated using Spearman’s correlation (r), high validity being considered when the range was between 0.30 and 0.40.

acromioclavicular joints and supporting soft tissue structures, and inflammatory diseases such as rheumatoid arthritis (RA), seronegative spondyloarthropathies, and crystal arthropathies, vascular diseases and may also be referred from the hand, neck, or viscera. 9 In one survey of patients with RA, shoulder pain affected 40% of patients early in the disease and the majority eventually had shoulder pain. 10 The resultant pain and loss of function is also a major cause of disability in people with these conditions, particularly in the elderly. 11 Evidence for the efficacy of various treatments of shoulder pain is limited. 12,13,14 Most studies of interventions are of questionable quality and frequently lack outcome data relating to disability. There is little evidence to support or refute the efficacy of common interventions for shoulder pain. From a clinician’s perspective, therapeutic options for the management of this problem are limited. Simple analgesia, non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular steroid injection, and surgery all have their limitations, particularly in older populations with comorbidities. Although there are still many treatment modalities aiming at increasing the range of motion (ROM), relieving pain and as a result improving disability, the results reported about their effectiveness are inconsistent. 15

The current study discovered 15 common shoulder pain qual- ity descriptors and identified different patterns or profiles of shoulder pain quality between male and female participants. The findings contribute to the growing research on various experiences of pain quality from a patient’s perspective. Because sex-related differences were observed in pain quality but not in pain intensity, our findings suggest that the scores based on global pain intensity may fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms in men and women.

Database searches for articles and reviews were conducted in the following databases: PubMed, Scopus, Web of Sci- ence, MEDLINE, and CINAHL for articles published from January 1990 up to July 2016 using the following search terms: (“breast cancer” OR “breast carcinoma” OR “breast neoplasm*” OR “breast tumor”) AND (“treatment” OR “ther- apy”) AND (“shoulder pain” OR “shoulder dysfunction” OR “lymphoedema” OR “lymphedema” OR “range of motion”) AND (“angiogenesis” OR “inflammat*”). A search was also conducted using the same terms excluding (“breast cancer” OR “breast carcinoma” OR “breast neoplasm*” OR “breast tumor”) and (“treatment” OR “therapy”) to capture articles implicating angiogenesis in general shoulder conditions independent of breast cancer treatment. The articles were

Some previous studies have shown that women have a higher risk of upper extremity disorders, compared to men (age and occupation adjusted) [25,35,36]. A system- atic review of several databases found that women more often than men had neck-shoulder complaints with job tasks involving the same arm postures as men, while for job performances with hand-arm vibration men domi- nated [26]. Some studies indicate that gender differences in response to physical work exposure may reflect gen- der segregation in work and differences in pinch and lift- ing capacity [37,38]. Our study did not show any substantial differences between new onset consultation rate of shoulder pain diagnoses among women and men at large, which is in accordance with the result from Linsell et al [15]. Other studies did find a higher incidence among women [14,17,18]. Our results showed, however, that women reached their peak of annual consultation preva- lence as well as new onset consultation rate earlier in their lifespan than did men. Notably, within the group of shoul- der pain diagnoses, men consulted more frequently due to impingement syndrome compared to women, while adhe- sive capsulitis, which is not typically associated with occu- pational conditions [39], was more often diagnosed among women. Possibly the patients sex could influence the choice of diagnosis, so that it is more likely that the doctor will give a diagnosis of frozen shoulder to a woman than a man, since it is known that this condition is more com- mon among women [40].

As part of the CATI assessment, participants were asked if they had ever had pain or aching in their shoulder at rest or when moving, on most days for at least a month and if they had ever had stiffness in their shoulder when getting out of bed in the morning on most days for at least a month. Participants who answered positively to either of these questions were also asked the Shoulder Pain and Disability Index (SPADI) [1,4]. As outlined above, the SPADI consists of 13 questions grouped into two subscales of pain and function, asking about pain and function over the past week. Scores range from 0-100 with higher scores indicating greater impairment. It has been shown to have acceptable test-retest reliabil- ity [1]. For this study, the numerically scaled SPADI was used. Although initially used as a self administered clini- cal index utilizing the visual analogue scale (VAS), a numerically scaled SPADI has been found to be highly correlated to the VAS version and suitable for telephone administration [4]. Participants were also asked to com- plete the Short Form-36 (SF-36) [16], and a range of demographic information was also collected.

This study was approved by the Ethics Committee of Costa del Sol, March 2014, Spain. All participants in the study gave a written informed consent. Participants were recruited from six primary health care centres in the province of Malaga, Spain. Participants met the follow- ing inclusion criteria: i) shoulder pain, defined as “pain in the shoulder region brought on or exacerbated by movement at that shoulder”. ii) aged between 18 and 80 years, iii) first language was Spanish (Spain), iv) able to read written Spanish. Participants were excluded from the study if they did not have the capacity to compre- hend the questionnaire due to cognitive or emotional impairment. Prior to conducting study, the authors ob- tained permission for the original author (Dr KE Roach), who was also involved in the study.

We report the case of a female Field Guide based at the British Antarctic Survey’s Rothera Science Research Station on Adelaide Island, Antarctica who independently contacted a physiotherapist specialising in climbing related injuries (GJ) located in the UK. for a second opinion. The Field Guide was experiencing significant work difficulties due to shoulder pain and subsequent loss of function particularly in overhead activities. The case raises important issues about the medical management of Field Guides operating in extreme environments and remote locations.

Medical treatment and rehabilitation following spinal cord injury typically requires a lengthy period of hospitalization and rehabilitation. Literature confirms that, SCI survivors who use manual wheelchair has a high prevalence of shoulder pain and it effect on daily activities, work, and participation in recreational activities. In our study the shoulder pain prevalence is 98.11% which show that the wheelchair users have high prevalence as the previous literature supports. In my study, all the participants were using the wheelchair that also shows the more rate of shoulder pain.

position used to measured CHD (cross arm position) in both studies was different in comparison to the present study. The excellent values achieved for CHD measure- ments are similar to those obtained in similar studies reporting AHD also measured by US, in patients with shoulder pain [24, 25]. These promising findings are supported by different factors that were considered in the present study in order to improve the quality of the results: (1) the ultrasound examiner was blind to the af- fected shoulder before measurements were taken; (2) a wash out period of one minute between measurements, allowing patients to move freely between these measure- ments; (3) no landmarks were used on the skin in an at- tempt to make every measurement independent with respect to the others; 4) the ultrasound examiner was fully qualified. With respect to the normative values for CHD in people with shoulder pain, our results showed values of 1.03 (0.21) cms at 0 degrees of shoulder eleva- tion, and 0.95 (0.25) cms at 60 degrees. Only one study [14] has reported CHD using US, obtaining values of 0.70 (1.4) cms, although CHD was taken in adduction and internal shoulder rotation. This position reduces CHD and so, makes the comparison between findings difficult. MRI has also been used in the assessment of CHD. Specifically, one study has reported values of 0.72 cms [5] in maximal shoulder internal rotation, while with shoulder neutral rotation, values of 1.12 (0.33) cms have been found [10], which are in consonance with the results from this paper. Our values were similar in CHD at 0 degrees of shoulder evaluation (1.03 ± 0.21 cms) to those obtained by Oh et al. [13] (1.01 ± 0.21 cms), but in different patient samples (anterior shoulder pain versus full rotator cuff tear).

source of shoulder pain; one study [21] excluded patients with nerve root signs and another excluded patients with cervical spondylosis [24], three studies [19,22,23] stated that the cervical spine was excluded as a source of refer- ral, but only one study [22] stated the mechanism by which this decision was made. One study purposely did not exclude participants with cervical spine pathology [25]. Five studies only included participants with adhe- sive capsulitis [18,19,24-26], four studies only included participants with subacromial impingement syndrome [20,22,23,27], one study only included participants with posterior inferior instability of the shoulder [17] and one study only included participants with a positive posterior impingement sign and the presence of a posterosuperior glenoid labral lesion on MRI [28]. One study [29] used the International Classification of Diseases (ICD-9) codes [30] to divide “musculoskeletal shoulder pain” into 8 disease categories. The authors themselves report ICD-9 codes as lacking specificity and reliability, yet rather than report comprehensive results for their full cohort, only report re- sults for these disease specific categories. Within each sub- group of shoulder classification, no two studies used the same eligibility criteria. Five studies, [16,21,29,31,32] did not sub-categorize shoulder pain using a clinical diagnosis; all providing minimal details of eligibility criteria. However these results are transferable to the wider range of patients.