Clinical Monthly

196th Edition

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The Clinical Monthly Team

Joe Russell News of the Month

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: Persistent pain and tendons

Josh Featherstone Fracture of the Month

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: I love rehab

Abi Peck Editor

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: Hands and spinal pathology, netball rehab

Scott Rowbotham Podcast of the Month

Qualified: BSc (Hons) Physiotherapy

Clinical Interests: climbing and improving physical activity for children and adults with long term disabilities

Lee Platt Journal of the Month

Qualified: MSc (Hons) Physiotherapy

Clinical Interests: all areas in MSK

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News of the Month

New guidance on atraumatic shoulder instability

This is an essential piece of reading for anyone working with MSK patients. The au-thors list reads as a who’s who of shoulder specialists and they combine their exper-tise with best care evidence around atraumatic shoulder instability. They make some in-teresting points around primary care management of at-raumatic shoulder in-stability that are di-rectly relevant to physiotherapists in the outpatient clinics. They state imaging and injection thera-pies should be re-served for secondary care and rehabilitation should focus on pro-prioception, strength and education. Does this reflect in your practice? See the attached flowchart for more in-formation:

#NewsOfTheMonth by Joe Russell

https://journals.sagepub.com/doi/pdf/10.1177/1758573218815002

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News of the Month

SPeEDY Trial

It seems you need to have some catchy acronym if you wish to publish something now, that aside it is really interesting to understand the design and rationale of how clinical studies are done. Lots of trials have their protocols published before the study commences so the design is peer reviewed before spending years collecting and analysing data. Use this link to watch an excellent video on the design of a shoulder study that could improve our understanding of managing rotator cuff tears comparing surgical and conservative approaches. Chris Littlewood also does a great job of summarising the existing evidence base around this. This is a go to source for the most up-to-date information on rotator cuff tear management.

https://www.youtube.com/watch?time_continue=1&v=eDn4OxMkcDs

#NewsOfTheMonth by Joe Russell

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Differentials of the Month

Shoulder Differentials by Josh Featherstone

Last months case study

Clinical case

Subjective: 30 year old man with neck and shoulder pain following an RTA.

Objective: He has reduced shoulder elevation and strength in multiple planes of movement. When elevating his arms there is winging of the scapular on the symp-tomatic side .

The working diagnosis of last issues ‘differential diagnosis’ case study is long thoracic nerve palsy. Patho-aetiology. The long thoracic nerve starts from the anterior branch of C5 – C7 nerve root and descends in front of the posterior scalene and over the chest wall laterally to the serratus anterior muscle (Safran 2004). The serratus anterior muscle originates from the 1st-9th rib and inserts onto the costal surface of the medial border of the scapular (ibid). The mus-cle is large and flat and covers the side of the chest wall (Palastanga 2006). Its functional role is protraction of the pec-toral girdle as well as stability of the scapular when elevating and abducting the arms (Palastanga 2006, Safran 2004). Injury to the long thoracic nerve will therefore reduce/paralyse activity of the serratus anterior and increase ‘winging’ of the scapular away from the chest wall. It also incapacitates its role to laterally rotate the scapular during overhead movements thus losing overhead stability of the shoulder. When considering our case studies objective markers; overhead weakness and visible winging of the scapular took precedence and therefore it is probable that he has indeed developed an acute onset of a long thoracic nerve palsy. Long thoracic nerve palsy can occur from traumatic or non-traumatic events (Patten 1982). Non-traumatic events such as neuralgic amyotrophy (inflammation of the brachial plexus) can affect the nerves around the shoulder as well as compressive components of the surrounding muscular system (Patten 1982, Safran 2004). An example of compression might be backpackers carrying heavy back packs for many hours throughout the day. Traumatic events consist of repetitive microtrauma causing traction of the nerve which is largely seen amongst over-head athletes as well as significant traction with the shoulder girdle depressed (Safran 2004). This can be encountered in tackling sports or in the case of our case study, depression from the seat belt and forced flexion of the neck from rear impact sustained in the car accident.

Management and treatment options. Tests to confirm diagnosis and to follow recovery are neurodiagnostic tests such as nerve conduction studies and plain radiographs such as xray’s to rule out an MSK cause for the palsy (Safran 2004). Assuming that there has not been any trauma/damage sustained to the nerve; significant recovery at 1 year post onset is expected (ibid). Conservative management options consist of: rest and reducing risk of further nerve irritation maintaining shoulder and neck ROM strengthening shoulder muscles associated with overhead activity to help compensate for reduced activity of

serratus anterior muscle education and re-assurance to manage the patients expectations NSAIDS or anti-neuropathic pain relief for symptomatic cases (Safran 2004).

References Patten (1982) Neurological differential diagnosis. London: Harold starke Ltd Palastanga N, Field D, Soames R (2006) Anatomy and Human movement: structure and function. 5th edition. London: Elsevier Safran M.R (2004) ‘Nerve injury about the shoulder in athletes, part 2: Long thoracic nerve, spinal accessory nerve, burners and stingers, thoracic outlet syndrome’ The American journal of sports medicine 32 (4): 1063-1076

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Differentials of the Month

Shoulder Differentials by Josh Featherstone

Clinical case

Subjective A 55 year old female presented to clinic with a PMH of breast cancer and has recently un-dergone surgery for secondary metastasis found in her neck. She reports over the few past few months of recovery; shoulder weakness is apparent. Objective She has difficulty with overhead activities such as shoulder elevation, abduction and when shrugging her shoulders actively. There is an apparent reduction in trapezius muscle bulk around the left shoulder. There are substantial strength deficits of her left shoulder into elevation more than abduc-tion. Aside from shoulder movement she also re-ports a sense of weakness with rotating her neck to the right when leaving the clinic room.

Differential diagnosis

1) Mechanical neck pain

2) Supraspinatus nerve palsy

3) Accessory nerve palsy

Last months differential diagnosis has been revealed as long thoracic nerve palsy. This months differential diagnosis is detailed below, lets see how well you

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Podcast of the Month

Physiopedia podcast -

BJSM – Lifestyle management of type 2 diabetes #351

1) What key dietary advice can we give people with type 2 diabetes?

Avoid processed foods. These have added sugar, salt and bad lipids. People who are genetically pre-disposed to diabetes should avoid these foods.

“Ultra-processed foods” – contain more than 5 ingredients, is packaged and normal-ly heavily marketed are the main food to avoid.

True Mediterranean diet/ Pioppi diet

This can be advised by following these rules

Low starch carbohydrate (including wholegrains) intake is effective.

Plant-based diet

1-2 portions of meat a week

1-2 portions of fish a week

Daily intake of nuts and olive oil

No more than 2 portions of fruit a day

Fibre

Any breads are from freshly made sources rather than shop bought also

# Podcasts by Scott

Last months podcast revealed

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Podcast of the Month

2) What other lifestyle measures should we consider?

Stress – We should be discussing mindfulness courses, use of apps and self-meditation to help regulate metabolic control

Sleep – less than 7-8 hours uninterrupted sleep affects our blood-glucose me-tabolism. Improving sleep quality will help improve diabetic control

Physical activity – initially through guidance of increasing physical activity; such as parking further away from shops, walking to certain places etc. then find a sustainable and enjoyable exercise that they can participate in.

These measures included with dietary and nutritional improvements can regulate type 2 diabetes as effectively if not more so than medication. Due to the side-effects of glucose controlling medication including raised insulation, blood pressure and effect on micro-vascular structures such as the kidneys it is very important that people understand it is not simply a medical management strategy.

3) Can Physiotherapists have a role in Type 2 diabetes?

Definitely. Physiotherapists should be advising patients on management of diabe-tes through management strategies to improve stress, sleep, physical activity and nutrition.

# Podcasts by Scott

Next months podcast:

Physio Edge 073 Neck pain rehabilitation and strengthening with Kay Robin-son

Questions

1) What patients will benefit from strength train-ing?

2) When should you include strength training in your rehabilitation?

3) How can you incorporate strengthening into your treatment?

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Journal of the Month

#Journal club by Lee Platt

Treatment after traumatic shoulder dislocation: A systematic review with a network meta-analysis.

Kavaja L et al (2018)

Section A: Are the results of the review valid? 1) Did the review address a clearly focused question? Yes – 1) what are the best

treatments to reduce the incidence of chronic shoulder instability after a first time traumatic shoulder dislocation? How can the clinician best treat a patient with chronic post-traumatic shoulder instability?

2) Did the authors look for the right type of papers? Yes 3) Do you think all the important, relevant studies were included? Yes, this included

studies with a 2 year outcome and with the desired number to treat and number to harm calculations completed, as well as including studies with statistically sig-nificant outcomes. This resulted in 22 RCTs being included.

4) Did the review’s authors do enough to assess quality of the included studies? Yes – the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence. All evidence was considered to be of low to moderate quality.

5) If the results of the review have been combined, was it reasonable to do so? Yes; combined into ‘first time traumatic shoulder dislocation’ and ‘chronic post-traumatic shoulder instability’

Section B: What are the results? 1) What are the overall results of the review? Early surgery led to fewer shoulder re-dislocations, however approximately half of the patients treated non-surgically did not experience a shoulder redislocation or develop shoulder insta-bility within two years of the primary injury. 2) How precise are the results? Confi-dence intervals and standard deviations varied between studies.

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Journal of the Month

#Journal club by Lee Platt

Questions: Section A: Are the results of the review valid? 1. Did the review address a clearly focused question? 2. Did the authors look for the right type of papers? 3. Do you think all the important, relevant studies were included? 4. Did the review’s authors do enough to assess quality of the included studies? 5. If the results of the review have been combined, was it reasonable to do so? Section B: What are the results? 1. What are the overall results of the review? 2. How precise are the results? Section C: Will the results help locally? 1. Can the results be applied to the local population? 2. Were all important outcomes considered? 3. Are the benefits worth the harms and costs?

Section C: Will the results help locally? 1) Can the results be applied to the local population? The RCTs included consist-

ed of mostly young men and the majority of dislocations were sports related therefore the results can be applied to one of the main groups who may expe-rience traumatic shoulder dislocation, however the results cannot be general-ised to women, non-athletes and older patients.

2) Were all important outcomes considered? There were no RCTs exploring the effectiveness of surgery versus non-surgical treatment in the chronic post-traumatic instability group. Also the effect of shoulder redislocation on pa-tient quality of life was not addressed.

3) Are the benefits worth the harms and costs? Yes – some patients experienced pain during the trials however the results may help a number of patients to avoid unnecessary surgery following first time traumatic dislocation.

Next article: Hip and Knee Strengthening Is More Effective Than Knee Strengthening Alone for Reducing Pain and Improving Activity in Individuals With Patellofemoral Pain: A Sys-tematic Review With Meta-analysis (2018) Nascimento, L., Teixeira-Salmela, L., Souza, B. and Resende, R. (Journal of Orthopaedic & Sports Physical Therapy)

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#Journal club by Lee Platt