Purpose: To explore perceptions and initial outcomes of patients with rotator cuff-related pain to a pain education session. Materials and Methods: Ten individuals with persistent rotator cuff-related pain (≥3 months duration) attended an individual pain education session. They completed patient-reported outcomes measures on a weekly basis, three weeks prior and three weeks following the session. Individual semi-structured interviews were conducted three weeks following the pain education. Interviews were recorded, transcribed verbatim, and analyzed using the General Inductive Approach. Results: There were two over-arching key themes: firstly, ‘Participants’ Perspectives’ of the session generated four themes: Improved understanding of ‘the whole’; Mindful self-awareness; Taking charge; “The pain is still there”. Their understanding of pain was reconceptualised, evident by their ability to describe the role of neurophysiological mechanisms, stress and general well-being towards their pain. The second over-arching key theme, ‘Participants’ Recommendations’, had two themes: Integrating neuroscience with pathoanatomical knowledge and Educating other health professionals. Pain levels decreased post-pain education compared to pre-pain education. Conclusions: Following the pain education session, participants had greater understanding of factors influencing their shoulder pain. Pain education, in addition to pathoanatomical information may be useful as part of treatment for persistent rotator cuff-related pain.

Rotator cuff disease is multi-factored and has been attributed to both intrinsic and extrinsic factors. Extrinsic factors contribute to compression of the rotator cuff tendons. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. Subacromial impingement is related to factors that encroach upon the subacromial space, while internal impingement affects the articular side of the tendons adjacent to glenoid. While the mechanisms of impingement are varied, further research is necessary to improve treatment and patient outcomes. Chapter 2 is a thorough review of literature on the mechanisms of rotator cuff disease. Alterations in scapular kinematics may influence subacromial space and either contribute to the etiology of subacromial impingement with rotator cuff tendon compression or serve as a compensation to alleviate compression. Furthermore alterations in scapular position may directly influence rotator cuff muscle strength. Chapter 3 compares the influence of the scapular assistance test on scapular upward rotation, posterior tilt, subacromial space, and shoulder strength between healthy individuals and subjects with subacromial impingement syndrome. Scapular upward rotation and posterior tilt induced with scapular assistance test appears to influence subacromial space, but not shoulder muscle strength; however, the influence of these scapular rotations do not differ between asymptomatic individuals and those with subacromial impingement. Furthermore scapular posterior tilt appears to have a greater influence on increasing subacromial space and should be emphasized in the treatment of individuals with subacromial impingement. In chapter 4, we examine the influence that obvious scapular dyskinesis and passive scapular correction with the scapular assistance test have on 3D scapular kinematics and subacromial space. Scapular dyskinesis did not alter scapular kinematics or acromiohumeral distance during active elevation in static positions, in the scapular plane, and without a load when compared to those without scapular dyskinesis. This suggests other contributing factors, such as pain, increased load, or fatigue is requisite to alterations in scapular kinematics or AHD. Passive correction with the scapular assistance test increased scapular upward rotation, posterior tilt, and subacromial space in individuals with and without dyskinesis. In patients with obvious dyskinesis, there was a greater increase in scapular upward rotation with passive scapular assistance. This increased scapular upward rotation had a negative relationship with change in the acromiohumeral distance. The scapular dyskinesis test increased acromiohumeral distance and therefore may be helpful identifying individuals where subacromial compression is producing symptoms, regardless of dyskinesis. The results of this research suggest scapular kinematics and subacromial space are altered with the passive maneuver of the scapular assistance test in all individuals, regardless of subacromial impingement syndrome or scapular dyskinesis. Scapular dyskinesis alone may not be detrimental to scapular position and subacromial space when evaluated in static positions of active arm elevation. Other potential factors may be required to alter scapular kinematics to reduce subacromial space including pain, dynamic movement, load or fatigue. Further study is necessary to determine the influence of the combination of these factors in individuals with scapular dyskinesis.

EFFECTS OF THORACIC SPINAL MANIPULATIVE THERAPY ON THORACIC SPINE AND SHOULDER KINEMATICS, THORACIC SPINE FLEXION/EXTENSION EXCURSION, AND PRESSURE PAIN SENSITIVITY IN PATIENTS WITH SUBACROMIAL PAIN SYNDROME By Joseph R. Kardouni, Ph.D., PT A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, at Virginia Commonwealth University. Virginia Commonwealth University, 2013. Major Director: Lori A. Michener, PhD, PT, ATC, Professor, Department of Physical Therapy In patients with shoulder pain, the use of manual therapy directed at the spine and shoulder have been reported to provide superior outcomes to exercise based interventions or usual care without the use of manual therapy. Clinical trials have also reported improved pain and disability after thoracic spinal manipulative therapy (SMT) as a stand-alone treatment for shoulder pain. Although clinical efficacy is reported for the use of thoracic SMT for the treatment of shoulder pain, the mechanisms underlying the clinical benefits are not well understood. This limits the directed use of SMT. The benefits could be due to changes in spine or shoulder motion or neurophysiologic mechanisms of pain modulation. Elucidating the mechanism of manual therapy will aid the directed use of thoracic SMT for treating patients with shoulder pain. The research described in chapters 3 and 4 was performed to assess the effects of thoracic SMT in patients with subacromial pain syndrome with regard to biomechanical changes at the thoracic spine and shoulder and effects on central and peripheral pain sensitivity. Subjects with shoulder impingement pain symptoms were randomly assigned to receive 1 visit of thoracic SMT or sham SMT, applied to the lower, middle, and upper (cervicothoracic junction) thoracic spine. A 3-dimensional electromagnetic tracking system was used to measure thoracic and scapular kinematics during active arm elevation, and thoracic excursion at end-range of flexion and extension pre- post-treatment. Pressure pain threshold (PPT) was measured at the painful shoulder (deltoid) and unaffected regions (contralateral deltoid and bilateral lower trapezius areas) immediately pre- and post-treatment. PPT measures at the painful shoulder were used to assess peripheral and/or central pain sensitivity, and PPT at unaffected regions measured central pain sensitivity. Patient-rated outcomes measures of pain (Numeric Pain Rating Scale-NPRS), function (Pennsylvania Shoulder Score-Penn), and global rating of change (GROC) were used to assess changes in clinical symptoms following treatment. No significant differences were found between treatment groups for the thoracic kinematics or excursion, shoulder kinematics, PPT measures, or patient-rated outcomes. No differences were noted pre- to post-treatment in either group for thoracic kinematics or excursion or PPT measures. In both groups, there was a decrease in mean scapular external rotation over time during ascending arm elevation, but the change was less than measurement error. Outcome measures of NPRS, Penn and GROC indicated clinical improvements in both groups following treatment, but there were no differences between the thoracic SMT or sham SMT groups. There were no meaningful correlations between thoracic and scapular kinematics or thoracic excursion with the outcome measures of NPRS, Penn, or GROC. There was a significant positive correlation (r=0.52 , p=0.009) between change in PPT at the lower trapezius on the unaffected side and baseline Penn scores. Biomechanically, thoracic spine extension and excursion did not change following thoracic SMT, and the SMT group had no greater changes in shoulder kinematics or patient-rated pain and function than the sham SMT group. Additionally, thoracic SMT did not improve peripheral or central pain sensitivity as measured by PPT. Furthermore, improvements in patient-rated outcomes were not found to be related to changes in thoracic spine mobility, or shoulder kinematics with SMT. The single correlation between change in PPT and baseline Penn may indicate a neurophyciologic effect of SMT in patients with higher baseline function scores, but the since no other significant relationships between PPT and outcome were seen, the implications of this finding are limited. Overall, alterations in thoracic spine mobility and pressure pain sensitivity do not appear to be responsible for improved outcomes in patients with subacromial pain syndrome. Future studies should explore the effects of SMT using other measures of thoracic spine motion and experimental pain modalities, as well as greater dosing of SMT over a longer follow-up.

Title: The effect of shoulder girdle stabilization exercises on muscle activity during direct impact in rugby players with sub-acromial impingement syndrome Objectives: Comparison of muscle activity during direct impact while performing the rugby tackle to tackle bag and to player using amplitude analysis of electromyographic signal (EMG) before and after intervention programme for players with subacromial impingement syndrome (SIS). Application of intervention programme consisting stabilization excercises for shoulder complex and activation of deep stabilization muscles of the spine. Methods: Theoretical part contains topics about shoulder girdle, rugby and rugby injuries, mainly subacromial impingement syndrome and electromyography. Mentioned issues are included into the thesis due to the research of current literature from international sources and studies. Practical part regards the aplication of three- months long intervention programme for eight rugby players at junior national level with diagnosis of SIS, when pre-testing a post-testing is realized by clinical tests and EMG measurement. Results: Intervention programme was sufficient for changes of EMG amplitude values expressed as percentage of maximal voluntary isometric contraction (MVIC) in some of rugby players with SIS only for some...

Made available in DSpace on 2016-06-02T20:19:06Z (GMT). No. of bitstreams: 1 DissPRC.pdf: 1620178 bytes, checksum: 0a7281e175babc5ee5b1017fd36a1d02 (MD5) Previous issue date: 2007-02-28 / Financiadora de Estudos e Projetos / This study evaluated the effectiveness of a standardized supervised therapeutic program performed during working hours on physical function and pain in workers with shoulder impingement stages I and II. Methods: Fourteen assembly line male workers (31.93 ± 5.86 years) with unilateral shoulder impingement stages I and II. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire evaluated function of the upper limbs. The McGill Pain Questionnaire quantified the pain by the number of words chosen and the pain rating index (PRI). Physical performance was evaluated by torque, total work and acceleration time that were measured bilaterally during isokinetic concentric abduction and lateral and medial rotations in the scapular plane, at 60°/s and 180°/s. Subjects completed an eight-week intervention program, consisting of cryotherapy, strengthening and stretching exercises, performed twice a week during working hours, and they were evaluated pre- and post-intervention. Results: DASH scores improved (P < 0.05) and the number of words chosen and PRI decreased (P < 0.05) at post-intervention. Torque improved (P < 0.05) in the abduction at 60°/s and in the medial rotation for both speeds after the therapeutic intervention. Total work increased (P < 0.05) at post-intervention for abduction and medial rotation at 60°/s and 180°/s. Acceleration time decreased (P < 0.05) in the abduction at 180°/s compared to the pre-intervention period. No changes were observed (P > 0.05) in any variable during lateral rotation. Conclusion: A rehabilitation program performed during working hours seems to improve symptom and physical performance in workers with shoulder impingement stages I and II. / Este estudo avaliou a efetividade um programa terapêutico, supervisionado e padronizado e realizado durante a jornada de trabalho, na função física e na dor de trabalhadores portadores da síndrome do impacto graus I e II. Métodos: Foram avaliados quatorze trabalhadores (idade média de 31,93 ± 5,86 anos), do sexo masculino, de uma linha de produção de uma indústria de material escolar portadores da síndrome do impacto unilateral, graus I e II de Neer.O questionário Disabilities of the Arm, Shoulder and Hand (DASH) avaliou a função do membro superior. Por meio do questionário McGill de dor, a dor foi quantificada pelo número de palavras escolhidas e pelo índice de avaliação da dor (IAD). O desempenho físico foi avaliado por meio do torque, trabalho total e tempo de aceleração que foram medidos bilateralmente durante movimentos isocinéticos concêntricos de abdução e rotação lateral e medial, no plano da escápula, a 60°/s e 180°/s. Os sujeitos realizaram, durante a jornada de trabalho, um programa de intervenção que consistiu de crioterapia, fortalecimento com bandas elásticas e alongamento. A intervenção foi realizada duas vezes por semana, por oito semanas. A avaliação foi realizada pré e pósintervenção. Resultados: No período pós-intervenção, as pontuações do DASH melhoraram (P < 0,05) e o número de palavras escolhidas e o IAD diminuíram (P < 0,05). O torque melhorou (P < 0,05) na abdução a 60°/s e na rotação medial em ambas as velocidades após o período de intervenção terapêutica. O trabalho total aumentou (P < 0,05), após a intervenção, na abdução e na rotação medial a 60°/s e 180°/s. O tempo de aceleração diminuiu (P < 0,05) na abdução a 180°/s quando comparado ao período préintervenção. Não houve alterações (P > 0,05) em nenhuma variável durante a rotação lateral. Conclusão: Um programa de reabilitação realizado durante a jornada de trabalho parece melhorar os sintomas e a função dos trabalhadores portadores da síndrome do impacto graus I e II de Neer.

Title: The effect of shoulder girdle stabilization exercises on muscle activity during direct impact in rugby players with sub-acromial impingement syndrome Objectives: Comparison of muscle activity during direct impact while performing the rugby tackle to tackle bag and to player using electromyographic amplitude analysis before and after intervention programme for players with subacromial impingement syndrome (SIS). Application of intervention programme consisting stabilization excercises for shoulder complex and activation of deep stabilization muscles of the spine. Methods: Theoretical part contains topics about shoulder girdle, rugby and rugby injuries, mainly subacromial impingement syndrome. Mentioned issues are included into the thesis due to the research of current literature from international sources and studies. Practical part regards the aplication of three-months long intervention programme for eight players at junior national level with diagnosis of SIS, when pre-testing a post-testing is realized by clinical tests and EMG measurement. Assessment of enter and control examination is realized with analysis of variance ANOVA. Results: Intervention programme was sufficient for changes in EMG amplitude for two muscle groups in rugby players with SIS. Hypothesis comparing the EMG measure...

This diploma thesis is focused on the observation of influence of Vojta's reflex locomotion on the activity of shoulder girdle's muscles at patients with the subacromial impingement syndrome. We examined ten patients with the subacromial impingement syndrome as well as twenty asymptomatic individuals. We evaluated the impact of just one Vojta's reflex locomotion therapy on the activity of muscles using the Method of the Surface Electromyography. At the same time we evaluated if the reaction on the therapy had some impact on measured values. The therapy always took at least time necessary to obtain any reaction of each of the individuals, although the maximum limit of the therapy was 32 minutes. The impact of Vojta's reflex locomotion therapy had not statistical importance with regard on changes of muscle activity after and before the therapy, with regard on the symmetry of muscle activity, as well as the difference of beginning of activation of every muscle before and after the therapy. The statistical importance was influenced just by the corporeal disposition of every measured individual, which was observed on the timing. The influence of the corporeal disposition on the average measured values with regard of the left - right side symmetry has no statistical importance. The statistical...

Les troubles musculo-squelettiques de l’épaule constituent un problème majeur de santé au travail. Le principal mécanisme à l’origine de ces pathologies est le conflit sous-acromial, dont le développement est intimement lié à la qualité du contrôle neuromusculaire de l’épaule. Nos données montrent que les tâches expérimentales classiquement utilisées pour l’exploration des facteurs de développement du conflit sous-acromial sont insuffisantes pour rendre compte de la complexité du contrôle neuromusculaire mis en jeu lors des tâches industrielles. Il semble primordial que les actions de lutte contre les TMS considèrent la réalité de l’organisation motrice à l’origine de leur développement. L’application dans ce travail de la technique d’enregistrement électromyographique au secteur industriel met en évidence la pertinence de cet outil afin d’orienter et d’évaluer les actions ergonomiques qui visent à réduire la charge musculo-squelettique. Un moyen complémentaire de lutte contre les TMS a été proposé afin de pallier aux limites propres à la démarche ergonomique. Il s’agit d’un exercice de recentrage dynamique de la tête humérale exécuté en chaîne cinétique fermée, déployé lors d’un programme d’intervention destiné aux opérateurs ayant des symptômes de conflit sous-acromial. Nos données mettent en évidence une diminution de la douleur et une amélioration de la fonction de l’épaule suite à cette intervention. Les bénéfices associés à cette démarche répondent au double enjeu de santé et de performance, essentiel pour les individus comme pour l’entreprise. Finalement, l’ensemble des contributions expérimentales et des applications industrielles présentées dans ce travail de thèse souligne le rôle central que peuvent jouer les spécialistes de la motricité humaine dans la démarche de lutte contre les TMS. Leur intégration dans les équipes pluridisciplinaires de prévention constitue un réel enjeu pour la réduction de ce risque professionnel majeur / Shoulder disorders represent a major health problem at the workplace. The most common shoulder disorder is the subacromial impingement syndrome. Shoulder neuromuscular control has a critical role in the development of shoulder disorders. Our data show that the experimental tasks generally use to investigate subacromial impingement causative factors are insufficient to represent the complexity of shoulder neuromuscular control involved during industrial tasks. It is essential that workplace interventions take into consideration the actual motor control associated with the development of work-related musculoskeletal disorders. The use of the electromyography in the industrial context, during this thesis work, highlights the interest of this tool in order to conduct and evaluate ergonomic interventions that aimed to reduce exposure to physical risk factors. Another work-related musculoskeletal disorder management way was proposed as a supplement to ergonomic interventions. It is about a dynamic closed chain humeral head centering exercise performed by assembly line workers with clinical signs of subacromial impingement syndrome. Our data demonstrated that the intervention program was effective in decreasing shoulder pain as well as improving shoulder function. This study underlined the relevance of therapeutic exercises for shoulder disorders management at the workplace. Finally, the whole of this thesis work highlights the decisive role of specialists in human motor analysis for work-related musculoskeletal disorders management

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Abstract Aim: The aim of this study was to investigate if treatment with “dry needling” in myofascial triggerpoints (MTrPs) in the rotatorcuff muscles may affect impingement symptoms such as pain during provocative tests, shoulder mobility, and function. The research questions were: Does the value of pain change on the Visual Analog Pain Scale (VAS) between before and after treatment? Do the positive provocative tests for impingement change between before and after treatment? Does the active shoulder mobility change between before and after treatment? Does the self-rated function change between before and after treatment? Method: The study was a prospective randomized intervention study and 19 persons with impingement symptoms (mean ± standard deviation; 58 ± 18 years, and shoulder pain duration 3.9 ± 1.6 months) were randomized into two groups. The groups were tested before, directly after and 3 weeks after treatment. The intervention group was treated twice, with a week in between, with “dry needling” in MTrPs. The control group was also treated on two occasions but was instead given a superficial needle in the infraspinatus muscle. All subjects were treated by the same physiotherapist. Pain was evaluated on the VAS when subjects performed active shoulder flexion before and after treatment. Provocative tests for shoulder impingement (Neer sign, Hawkins-Kennedy test and Jobe test) as well as range of motion tests were performed before, after and three weeks after treatment. The frequencies of positive/negative provocative tests were presented. Shoulder function was evaluated with the QuickDASH questionnaire. Significance level p≤0.05 was used in the study and a tendency was identified between 0.05 ≤ p &lt; 0.1. Results: There was a tendency (p=0.086) with decreased pain (VAS) in the intervention group after the treatment. Among the impingement tests only significant improved results was observed for Neer sign test three weeks after the treatment (p=0.025) No significant difference could be seen on the active shoulder mobility between before and after the treatment. The perceived function in the intervention group, measured with the Quick DASH questionnaire, showed a tendency (p=0.086) towards a better function. Conclusions: The study showed a tendency towards that”dry needling”  in MTrPs may affect impingement symptoms such as pain and function. The provocative tests for shoulder impingement, Neer sign, showed a significant decrease in pain after treatment. More studies with larger population is needed to make a statement about the effect of “dry needling” in MTrPs as a treatment for shoulder impingement symptoms. / Sammanfattning Syfte och frågeställningar: Syftet med studien var att undersöka om behandling med ”dry needling” (intramuskulär nålstimulering) i myofasciella triggerpunkter (MTrPs) i rotatorcuffmuskulaturen kan påverka impingementsymptom såsom smärta vid provokationstester, axelledsrörlighet och funktion. Frågeställningarna var: Förändras smärtskattning på visuell analog skala(VAS) vid aktiv axelflexion efter jämfört med före behandling? Förändras de positiva provokationstesterna för impingement efter jämfört med före behandling? Förändras den aktiva axelledsrörligheten efter jämfört med före behandling? Förändras den självskattade funktionen efter jämfört med före behandling? Metod: Studien var en prospektiv randomiserad interventionsstudie, 19 forskningspersoner (fp) med impingementsymptom, (medelålder 58 ± 18 år, besvärsdurationens medeltid 3.9 ± 1.6 mån), randomiserades till två grupper. Grupperna undersöktes före, direkt efter och tre veckor efter avslutad behandling. Interventionsgruppen behandlades vid två tillfällen, med en veckas mellanrum, med ”dry needling” i MTrPs medan kontrollgruppen vid två tillfällen istället fick en ytlig akupunkturnål i m infraspinatus. Behandlingen av alla fp utfördes av en och samma fysioterapeut. Smärta utvärderades med (VAS) vid aktiv axelflexion direkt före och efter behandling. Provokationstester (Neer sign, Hawkins-Kennedy test och Jobe test) samt rörlighetsmätning utfördes före, efter och tre veckor efter avslutad behandling. Frekvensen positiva/negativa provokationstesttest summerades. Funktionen utvärderades med frågeformuläret QuickDASH. Signifikansnivå p&lt; 0.05 används i studien och en tendens identifierades mellan 0.05 ≤ p &lt; 0.1. Resultat: Det fanns en tendens (p=0.086) till minskad smärta (VAS) i interventionsgruppen efter jämfört med före behandling. Bland impingementtesterna sågs enbart ett signifikant förbättrat resultat för Neers sign tre veckor efter avslutad behandling jämfört med före behandling (p=0.025). Ingen signifikant skillnad kunde ses gällande rörligheten före och efter behandling. Den upplevda funktionsförmågan mätt med frågeformuläret QuickDASH visade en tendens (p=0.086) mot bättre funktion i interventionsgruppen. Slutsats: Studien har visat tendenser på att ”dry needling” i MTrPs kan påverka impingementsymptom såsom minskad smärta och bättre självskattad funktion efter behandling jämfört med före. Impingementtestet Neer sign visade en signifikant minskad smärta efter behandling. Fler studier med större grupper, större ålderspann och längre behandlingstid behövs för att kunna uttala sig om effekten av ”dry needling” i MTrPs som behandlingsmetod vid impingementsymptom i axeln. / <p>Fristående kurs i Idrottsvetenskap inriktning idrottsmedicin 2013-2015</p>