- Email: [email protected]
The relation between pain extent and quality-of-life, psychological factors and neck function in patients with chronic neck pain
Abstracts / Manual Therapy 25 (2016) e57ee169
Book (Waddell et al 2001) and the control group did not. The Self Efficacy Scale (SES) (Bunketorp-Kall 2007)., Numerical Pain Rating Scale (NPRS) and Neck Disability Index (NDI) (Vernon & Mior 1991) were administered at baseline and 1 week after receiving the booklet by a blinded assessor. All participants were referred for physiotherapy, as per usual ED care. Pilot work was undertaken to establish mean SES values to estimate sample size. Postulating a mean difference of 30/200 in SES between groups as a minimum clinically important difference, to achieve a significance level of 0.05, at 80% power, a sample size of n¼24 per group was required. Allowing for a 10% dropout rate, n¼53 subjects was the target sample size for this study. Results: This small trial only recruited n¼18 participants and so was not powered to identify between group differences. However, when combined with pilot study data (n¼13), baseline data on 31 participants can be presented. The mean (SD) age of the 31 participants was 39 years (13.4) and 16 were male. The majority of participants presented with Grade II WAD (n¼17). Only 5 participants were diagnosed with Grade III WAD. Mean NPRS score over 24hrs was 5.9 (+/- 1.8). Mean NDI score was 23 (7.6). Mean SES score was 94 (47.4). The majority of participants (n¼ 28) were taking a range of prescribed medication for their pain, including paracetamol, tylex, tramadol, solpadeine & NSAIDs. Groups were comparable at baseline. Conclusion: Moderate levels of pain and disability were observed at baseline in this study. However, baseline SES scores in Ireland were noticeably low, particularly in comparison to other published data from Scandinavia, suggesting that acute patients have lower self efficacy in an Irish setting. A larger cohort is needed to confirm this finding. Implications: Low self-efficacy should be considered a target of any educational intervention for acute WAD patients, in addition to pain & disability. Funding Acknowledgements: RCSI Summer Student Research Alumni Award. Ethics Approval: Received from Connolly Hospital Research Ethics Committee, Dublin. Disclosure of Interest: None Declared Keywords: Education, Self-efficacy, Whiplash Associated Disorders Advanced assessment/practice and managing complex patients PO2-CS-020 IS THERE AN OPTIMAL MANUAL MUSCLE TEST FOR SUBSCAPULARIS? D. Reed 1, *, M. Halaki 2, C. Jones 1, A. Downes 1, K. Ginn 1. 1 Sydney Medical School, Australia; 2 Faculty of Health Sciences, The University of Sydney, Sydney, Australia * Corresponding author.
Background: Subscapularis is the largest and only anterior muscle of the rotator cuff. It is crucial to normal shoulder function producing internal rotation and dynamic stability at the glenohumeral joint. Manual muscle tests (MMTs) to assess the integrity of subscapularis have traditionally involved its action of internal rotation. An optimal MMT for subscapularis would ideally activate the subscapularis to a high level and significantly higher than the other internal rotators of the shoulder. Alternative exercises that recruit subscapularis in its stabilising role (eg. extension) may also fulfil the criteria for an optimal MMT. However, no study has compared common subscapularis MMTs and included a shoulder extension test. Therefore, it is still unclear if one test more effectively fulfils both criteria for an optimal subscapularis MMT. Purpose: To compare the activation levels of the internal rotators of the shoulder during six MMTs to determine if there is an optimal MMT for subscapularis. Methods: Twenty asymptomatic volunteers performed maximum isometric contractions during the lift off test, belly press, shoulder extension and shoulder internal rotation at 90 and 0 abduction in standing and 90 abduction in supine. A combination of indwelling and surface electrodes recorded activation levels from subscapularis, latissimus dorsi, teres major, pectoralis major and anterior deltoid. Activation levels were normalised to maximum voluntary contractions (MVC) and averaged.
e73
Results: Average muscle activation of subscapularis ranged from 35% MVC during standing internal rotation at 90 abduction to 51% MVC during the lift off test, with no significant difference between all six tests (p¼0.50). The belly press test was the only test in which subscapularis activation levels was significantly higher than all other internal rotators of the shoulder (p<0.01). All other tests had one or more shoulder muscles activated at similar or higher levels than subscapularis. Conclusion: All six tests activated subscapularis to similar moderately high levels and therefore fulfil the first criteria for an optimal subscapularis MMT. However, only the belly press also activated subscapularis significantly higher than all other internal rotators of the shoulder, fulfilling both criteria for an optimal MMT. Implications: The belly press is recommended as an optimal MMT to assess the integrity of subscapularis. Funding Acknowledgements: This work was unfunded. Ethics Approval: Ethics was approved by the Human Research Ethics Committee at the University of Sydney, 2012/538. Disclosure of Interest: None Declared Keywords: Electromyography, Manual muscle test, Subscapularis Advanced assessment/practice and managing complex patients PO2-CS-021 THE RELATION BETWEEN PAIN EXTENT AND QUALITY-OF-LIFE, PSYCHOLOGICAL FACTORS AND NECK FUNCTION IN PATIENTS WITH CHRONIC NECK PAIN I. Ris 1, 2, 3, *, M. Barbero 1, D. Falla 2, M. Holst Larsen 3, M. Nielsen Kraft 3, K. Søgaard 3, B. Juul-Kristensen 3. 1 Department of Sports Science and Clinical Biomechanics, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland; 2 Pain Clinic, Center for Anesthesiology, €ttingen, Emergency and Intensive Care Medicine, University Hospital Go €ttingen, Germany; 3 Department of Sports Science and Clinical Go Biomechanics, University of Southern Denmark, Odense, Denmark * Corresponding author.
Background: Neck pain is a common disease ranking 4th highest as years lived with disability according to Global Burden of Disease 2010. Patients with chronic neck pain often present with a variety of other symptoms. Some of these may depend upon the origin being traumatic or not. Pain drawings are used widely clinically in the initial phase of assessment of neck pain patients. Pain drawing is a method of gathering data, the pain area, regarding patients’ pain extent. The drawing represents the patient’s perception of pain localisation and pain extent. Pain areas may represent psychological factors and/or decreased function of the involved body parts. Purpose: To study the relation between pain extent with 1) quality of life, 2) kinesiophobia, depression, 3) cervical muscle function and mobility and additionally the relation of pain extent with the origin of pain being traumatic or non-traumatic in chronic neck pain patients. Methods: In this correlation-study patients from primary and secondary healthcare locations with chronic neck pain (200) with traumatic or nontraumatic origin participated. Participants completed pain drawings, as well as questionnaires: Short Form 36 (SF36), Tampa Scale of Kinesiophobia (TSK), Beck Depression Inventory-II (BDI-ll), Neck Disability Index (NDI) and clinical tests: Craniocervical Flexion Test (CCFT), Cervical Extension Test (CE), and Cervical Range of Motion (CROM). Results: Significant positive correlations were observed between pain extent and NDI (r ¼ 0.33; p<0.001), TSK (r¼0.21; p¼0.012) and BDI-II (r¼0.29; p<0.001), in addition to significant negative correlations of pain extent to CCFT (r¼-0.24; p¼0.001) and CE (r¼-0.19; p¼0.006). Correlations between pain extent and SF-36 or CROM were non-significant, and there was no difference in pain extent related to the origin being traumatic or non-traumatic. Conclusion: Pain extent extracted from pain drawings are moderately correlated with patient-reported neck function, and weakly correlated with depression, kinesiophobia and cervical clinical tests. In clinical decision-making, pain extent may indicate reduced neck function and be a
e74
Abstracts / Manual Therapy 25 (2016) e57ee169
Disclosure of Interest: None Declared
discrimination improved by 10mm. At the end of 12 weeks following the addition of manual therapy and exercise, her SPADI had decreased to 22%, her NPRS at rest was a 0/10, her FABW was 14 and her FABQPA was 8. Her active flexion, abduction and external rotation had improved to 162, 111 and 65 degrees, respectively. Conclusion: Aggressive physical therapy in the early stages of frozen shoulder can be detrimental. In this case, a top-down approach including NE, LL, TD and GMI training led to clinically meaningful improvements in pain, motion, function, limb laterality and tactile discrimination in the first 6 weeks of treatment. Implications: This case study suggests that clinicians should consider using a top-down approach in patients with painful frozen shoulder. Traditional approaches using aggressive physical therapy in the early stages of this condition may be detrimental to long term outcomes. This approach allows clinicians to educate patients about pain and calm the central nervous system which may lead to a quicker transition from the freezing stage to the thawing phase of frozen shoulder. Funding Acknowledgements: This work was unfunded. Ethics Approval: Ethics approval was not required as this was a case report.
Keywords: Chronic neck pain, Pain drawing, Quality of life
Disclosure of Interest: None Declared
Advanced assessment/practice and managing complex patients PO2-CS-022 USE OF NEUROSCIENCE EDUCATION, TACTILE DISCRIMINATION, LIMB LATERALITY AND GRADED MOTOR IMAGERY IN A PATIENT WITH FROZEN SHOULDER
Keywords: Adhesive capsulitis, Central sensitization, Chronic pain
sign for possible depression, kinesiophobia and poor cervical muscle function in chronic neck pain patients of both traumatic and non-traumatic origin. Implications: For the clinician, information gained from pain drawings can indicate the need for assessing these factors with a more in-depth examination. Pain drawings may therefore assist in guiding and targeting the clinical assessment. Therefore, use of pain drawings in clinical assessment may be relevant as part of the clinical decision-making process and be used for generating clinical hypotheses as part of the functional assessment, and in conjunction with other relevant outcomes. Funding Acknowledgements: This study received funding from the Research Fund of the Region of Southern Denmark, the Danish Rheumatism Association, the Research Foundation of the Danish Association of Physiotherapy, Fund for Physiotherapy in Private Practice, and the Danish Society of Polio and Accident Victims (PTU). Ethics Approval: The trial was registered in www.ClinicalTrials.gov identifier NCT01431261. The Regional Scientific Ethics Committee of Southern Denmark approved the study (S-20100069).
P. Mintken 1, *, A. McDevitt 1, E. Puentedura 2, A. Louw 3. 1 Physical Therapy, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; 2 Physical Therapy, University of Nevada Las Vegas, Las Vegas, NV, United States; 3 International Spine and Pain Institute, Story City, IA, United States * Corresponding author.
Background: It has been reported that aggressive physical therapy in the freezing/painful stage of frozen shoulder may prolong the course of recovery. Central sensitization may play a role in the early stages of frozen shoulder. Neuroscience education (NE), limb laterality (LL), tactile discrimination (TD) and graded motor imagery (GMI) have been used with success in a number of conditions with known central sensitization. Purpose: The purpose of this case report is to describe the examination and treatment of a patient in the painful stage of frozen shoulder using NE, LL, TD and GMI training. Methods: The patient was a 54 yo female with insidious onset of right shoulder pain at the deltoid insertion 2 months prior. She was diagnosed with a frozen shoulder by an orthopedic surgeon and sent for aggressive daily physical therapy which resulted in a worsening of her pain and disability, She was then referred to the primary author for a second opinion. At the time of the initial appointment, she had 7/10 pain at rest on a Numerical Pain Rating Scale (NPRS) and a Shoulder Pain and Disability (SPADI) score of 62%. She had 61 degrees of active flexion, 32 degrees of active abduction and 3 degrees of active external rotation. Her Fear Avoidance Beliefs Questionnaire (FABQ) scores were 34 and 22 on the Work and Physical Activity subscales, respectively. Two-point discrimination at the right shoulder was 58mm and her hand and shoulder laterality accuracy was 50 and 60% respectively. She also had hypersensitivity to cold, heat and pressure, suggesting central sensitization. Due to her fear of movement and being touched, we instituted a graded, top-down program focusing on central sensitization. Treatment began with pain science education and progressed to laterality training, tactile discrimination, and graded motor imagery including mirror therapy. During the initial 6 weeks, no therapy was delivered to the shoulder. After 6 weeks a regional interdependence approach using manual therapy and exercise was initiated. The patient was seen for 20 visits over 12 weeks. Results: After 6 weeks of a top-down approach, her resting pain decreased to a 2/10, the SPADI decreased to 32%, and her active flexion, abduction and external rotation had improved to 129, 79 and 42 degrees respectively. Her hand and shoulder laterality accuracy was normal at 80% and her 2-point
Advanced assessment/practice and managing complex patients PO2-CS-023 QUANTIFYING SENSORY THRESHOLD USING SEMMES-WEINSTEIN ESTHESIOMETER: AN INTER-EXAMINER RELIABILITY STUDY OF MANUAL THERAPISTS E. Almpanidis*, N. Heneghan. School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom * Corresponding author.
Background: Reported physiotherapy assessment of cutaneous sensory testing uses light touch and results in a binary response of, ‘yes’, or ‘no’. However, that response does not provide adequate clinical information to examine subtle change in sensory acuity over time and may lead to misinterpretation during the formulation of a clinical hypothesis. The Semmes-Weinstein Esthesiometer (SWE) provides a performance based outcome measure (PBOM) that can quantify cutaneous sensory threshold. Using a series of numbered monofilaments of different lengths, the SWE allows the application of a consistent rather than a ‘one off’ stimulus which is susceptible to measurement error through application of different pressure. Purpose: To investigate the inter-examiner reliability of Semmes-Weinstein Esthesiometer (SWE) for quantifying cutaneous sensory threshold in manual therapists. Methods: A prospective, double-blinded, within day, inter-examiner reliability study was designed. From a power calculation, a convenience sample of asymptomatic subjects was recruited along with two examiners (experienced manual therapists). Exclusion criteria: evidence of neurological deficit (sensory loss, motor weakness, abnormal reflexes) or presence of upper limb pain. Cutaneous sensory thresholds were recorded from skin over the thenar eminence. Results: A sample of convenience comprised of 26 subjects (11 males), mean age (SD) 26.5 years (3.5). Descriptive statistics (mean scores), data normality testing, reliability statistics {intraclass correlation coefficient (ICC: 2,1) and Bland-Altman limits of agreement} were undertaken. Probability was set at <0.05. Results showed significant inter-examiner agreement of 0.7 (95% CI: 0.274 e 0.854, p¼0.003). Conclusion: This is the first study to evaluate inter-examiner reliability of manual therapists using the SWE. Preliminary evidence supports the use of SWE to assess cutaneous sensory threshold. Implications: The SWE can provide a clinically useful tool in the use of manual therapists. The findings support the use of SWE in routine manual therapy practice over the common binary measure of light touch and promptly, it can be used in patients with spinal and/or peripheral neuropathic presentations.
Book (Waddell et al 2001) and the control group did not. The Self Efficacy Scale (SES) (Bunketorp-Kall 2007)., Numerical Pain Rating Scale (NPRS) and Neck Disability Index (NDI) (Vernon & Mior 1991) were administered at baseline and 1 week after receiving the booklet by a blinded assessor. All participants were referred for physiotherapy, as per usual ED care. Pilot work was undertaken to establish mean SES values to estimate sample size. Postulating a mean difference of 30/200 in SES between groups as a minimum clinically important difference, to achieve a significance level of 0.05, at 80% power, a sample size of n¼24 per group was required. Allowing for a 10% dropout rate, n¼53 subjects was the target sample size for this study. Results: This small trial only recruited n¼18 participants and so was not powered to identify between group differences. However, when combined with pilot study data (n¼13), baseline data on 31 participants can be presented. The mean (SD) age of the 31 participants was 39 years (13.4) and 16 were male. The majority of participants presented with Grade II WAD (n¼17). Only 5 participants were diagnosed with Grade III WAD. Mean NPRS score over 24hrs was 5.9 (+/- 1.8). Mean NDI score was 23 (7.6). Mean SES score was 94 (47.4). The majority of participants (n¼ 28) were taking a range of prescribed medication for their pain, including paracetamol, tylex, tramadol, solpadeine & NSAIDs. Groups were comparable at baseline. Conclusion: Moderate levels of pain and disability were observed at baseline in this study. However, baseline SES scores in Ireland were noticeably low, particularly in comparison to other published data from Scandinavia, suggesting that acute patients have lower self efficacy in an Irish setting. A larger cohort is needed to confirm this finding. Implications: Low self-efficacy should be considered a target of any educational intervention for acute WAD patients, in addition to pain & disability. Funding Acknowledgements: RCSI Summer Student Research Alumni Award. Ethics Approval: Received from Connolly Hospital Research Ethics Committee, Dublin. Disclosure of Interest: None Declared Keywords: Education, Self-efficacy, Whiplash Associated Disorders Advanced assessment/practice and managing complex patients PO2-CS-020 IS THERE AN OPTIMAL MANUAL MUSCLE TEST FOR SUBSCAPULARIS? D. Reed 1, *, M. Halaki 2, C. Jones 1, A. Downes 1, K. Ginn 1. 1 Sydney Medical School, Australia; 2 Faculty of Health Sciences, The University of Sydney, Sydney, Australia * Corresponding author.
Background: Subscapularis is the largest and only anterior muscle of the rotator cuff. It is crucial to normal shoulder function producing internal rotation and dynamic stability at the glenohumeral joint. Manual muscle tests (MMTs) to assess the integrity of subscapularis have traditionally involved its action of internal rotation. An optimal MMT for subscapularis would ideally activate the subscapularis to a high level and significantly higher than the other internal rotators of the shoulder. Alternative exercises that recruit subscapularis in its stabilising role (eg. extension) may also fulfil the criteria for an optimal MMT. However, no study has compared common subscapularis MMTs and included a shoulder extension test. Therefore, it is still unclear if one test more effectively fulfils both criteria for an optimal subscapularis MMT. Purpose: To compare the activation levels of the internal rotators of the shoulder during six MMTs to determine if there is an optimal MMT for subscapularis. Methods: Twenty asymptomatic volunteers performed maximum isometric contractions during the lift off test, belly press, shoulder extension and shoulder internal rotation at 90 and 0 abduction in standing and 90 abduction in supine. A combination of indwelling and surface electrodes recorded activation levels from subscapularis, latissimus dorsi, teres major, pectoralis major and anterior deltoid. Activation levels were normalised to maximum voluntary contractions (MVC) and averaged.
e73
Results: Average muscle activation of subscapularis ranged from 35% MVC during standing internal rotation at 90 abduction to 51% MVC during the lift off test, with no significant difference between all six tests (p¼0.50). The belly press test was the only test in which subscapularis activation levels was significantly higher than all other internal rotators of the shoulder (p<0.01). All other tests had one or more shoulder muscles activated at similar or higher levels than subscapularis. Conclusion: All six tests activated subscapularis to similar moderately high levels and therefore fulfil the first criteria for an optimal subscapularis MMT. However, only the belly press also activated subscapularis significantly higher than all other internal rotators of the shoulder, fulfilling both criteria for an optimal MMT. Implications: The belly press is recommended as an optimal MMT to assess the integrity of subscapularis. Funding Acknowledgements: This work was unfunded. Ethics Approval: Ethics was approved by the Human Research Ethics Committee at the University of Sydney, 2012/538. Disclosure of Interest: None Declared Keywords: Electromyography, Manual muscle test, Subscapularis Advanced assessment/practice and managing complex patients PO2-CS-021 THE RELATION BETWEEN PAIN EXTENT AND QUALITY-OF-LIFE, PSYCHOLOGICAL FACTORS AND NECK FUNCTION IN PATIENTS WITH CHRONIC NECK PAIN I. Ris 1, 2, 3, *, M. Barbero 1, D. Falla 2, M. Holst Larsen 3, M. Nielsen Kraft 3, K. Søgaard 3, B. Juul-Kristensen 3. 1 Department of Sports Science and Clinical Biomechanics, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland; 2 Pain Clinic, Center for Anesthesiology, €ttingen, Emergency and Intensive Care Medicine, University Hospital Go €ttingen, Germany; 3 Department of Sports Science and Clinical Go Biomechanics, University of Southern Denmark, Odense, Denmark * Corresponding author.
Background: Neck pain is a common disease ranking 4th highest as years lived with disability according to Global Burden of Disease 2010. Patients with chronic neck pain often present with a variety of other symptoms. Some of these may depend upon the origin being traumatic or not. Pain drawings are used widely clinically in the initial phase of assessment of neck pain patients. Pain drawing is a method of gathering data, the pain area, regarding patients’ pain extent. The drawing represents the patient’s perception of pain localisation and pain extent. Pain areas may represent psychological factors and/or decreased function of the involved body parts. Purpose: To study the relation between pain extent with 1) quality of life, 2) kinesiophobia, depression, 3) cervical muscle function and mobility and additionally the relation of pain extent with the origin of pain being traumatic or non-traumatic in chronic neck pain patients. Methods: In this correlation-study patients from primary and secondary healthcare locations with chronic neck pain (200) with traumatic or nontraumatic origin participated. Participants completed pain drawings, as well as questionnaires: Short Form 36 (SF36), Tampa Scale of Kinesiophobia (TSK), Beck Depression Inventory-II (BDI-ll), Neck Disability Index (NDI) and clinical tests: Craniocervical Flexion Test (CCFT), Cervical Extension Test (CE), and Cervical Range of Motion (CROM). Results: Significant positive correlations were observed between pain extent and NDI (r ¼ 0.33; p<0.001), TSK (r¼0.21; p¼0.012) and BDI-II (r¼0.29; p<0.001), in addition to significant negative correlations of pain extent to CCFT (r¼-0.24; p¼0.001) and CE (r¼-0.19; p¼0.006). Correlations between pain extent and SF-36 or CROM were non-significant, and there was no difference in pain extent related to the origin being traumatic or non-traumatic. Conclusion: Pain extent extracted from pain drawings are moderately correlated with patient-reported neck function, and weakly correlated with depression, kinesiophobia and cervical clinical tests. In clinical decision-making, pain extent may indicate reduced neck function and be a
e74
Abstracts / Manual Therapy 25 (2016) e57ee169
Disclosure of Interest: None Declared
discrimination improved by 10mm. At the end of 12 weeks following the addition of manual therapy and exercise, her SPADI had decreased to 22%, her NPRS at rest was a 0/10, her FABW was 14 and her FABQPA was 8. Her active flexion, abduction and external rotation had improved to 162, 111 and 65 degrees, respectively. Conclusion: Aggressive physical therapy in the early stages of frozen shoulder can be detrimental. In this case, a top-down approach including NE, LL, TD and GMI training led to clinically meaningful improvements in pain, motion, function, limb laterality and tactile discrimination in the first 6 weeks of treatment. Implications: This case study suggests that clinicians should consider using a top-down approach in patients with painful frozen shoulder. Traditional approaches using aggressive physical therapy in the early stages of this condition may be detrimental to long term outcomes. This approach allows clinicians to educate patients about pain and calm the central nervous system which may lead to a quicker transition from the freezing stage to the thawing phase of frozen shoulder. Funding Acknowledgements: This work was unfunded. Ethics Approval: Ethics approval was not required as this was a case report.
Keywords: Chronic neck pain, Pain drawing, Quality of life
Disclosure of Interest: None Declared
Advanced assessment/practice and managing complex patients PO2-CS-022 USE OF NEUROSCIENCE EDUCATION, TACTILE DISCRIMINATION, LIMB LATERALITY AND GRADED MOTOR IMAGERY IN A PATIENT WITH FROZEN SHOULDER
Keywords: Adhesive capsulitis, Central sensitization, Chronic pain
sign for possible depression, kinesiophobia and poor cervical muscle function in chronic neck pain patients of both traumatic and non-traumatic origin. Implications: For the clinician, information gained from pain drawings can indicate the need for assessing these factors with a more in-depth examination. Pain drawings may therefore assist in guiding and targeting the clinical assessment. Therefore, use of pain drawings in clinical assessment may be relevant as part of the clinical decision-making process and be used for generating clinical hypotheses as part of the functional assessment, and in conjunction with other relevant outcomes. Funding Acknowledgements: This study received funding from the Research Fund of the Region of Southern Denmark, the Danish Rheumatism Association, the Research Foundation of the Danish Association of Physiotherapy, Fund for Physiotherapy in Private Practice, and the Danish Society of Polio and Accident Victims (PTU). Ethics Approval: The trial was registered in www.ClinicalTrials.gov identifier NCT01431261. The Regional Scientific Ethics Committee of Southern Denmark approved the study (S-20100069).
P. Mintken 1, *, A. McDevitt 1, E. Puentedura 2, A. Louw 3. 1 Physical Therapy, University of Colorado Anschutz Medical Campus, Aurora, CO, United States; 2 Physical Therapy, University of Nevada Las Vegas, Las Vegas, NV, United States; 3 International Spine and Pain Institute, Story City, IA, United States * Corresponding author.
Background: It has been reported that aggressive physical therapy in the freezing/painful stage of frozen shoulder may prolong the course of recovery. Central sensitization may play a role in the early stages of frozen shoulder. Neuroscience education (NE), limb laterality (LL), tactile discrimination (TD) and graded motor imagery (GMI) have been used with success in a number of conditions with known central sensitization. Purpose: The purpose of this case report is to describe the examination and treatment of a patient in the painful stage of frozen shoulder using NE, LL, TD and GMI training. Methods: The patient was a 54 yo female with insidious onset of right shoulder pain at the deltoid insertion 2 months prior. She was diagnosed with a frozen shoulder by an orthopedic surgeon and sent for aggressive daily physical therapy which resulted in a worsening of her pain and disability, She was then referred to the primary author for a second opinion. At the time of the initial appointment, she had 7/10 pain at rest on a Numerical Pain Rating Scale (NPRS) and a Shoulder Pain and Disability (SPADI) score of 62%. She had 61 degrees of active flexion, 32 degrees of active abduction and 3 degrees of active external rotation. Her Fear Avoidance Beliefs Questionnaire (FABQ) scores were 34 and 22 on the Work and Physical Activity subscales, respectively. Two-point discrimination at the right shoulder was 58mm and her hand and shoulder laterality accuracy was 50 and 60% respectively. She also had hypersensitivity to cold, heat and pressure, suggesting central sensitization. Due to her fear of movement and being touched, we instituted a graded, top-down program focusing on central sensitization. Treatment began with pain science education and progressed to laterality training, tactile discrimination, and graded motor imagery including mirror therapy. During the initial 6 weeks, no therapy was delivered to the shoulder. After 6 weeks a regional interdependence approach using manual therapy and exercise was initiated. The patient was seen for 20 visits over 12 weeks. Results: After 6 weeks of a top-down approach, her resting pain decreased to a 2/10, the SPADI decreased to 32%, and her active flexion, abduction and external rotation had improved to 129, 79 and 42 degrees respectively. Her hand and shoulder laterality accuracy was normal at 80% and her 2-point
Advanced assessment/practice and managing complex patients PO2-CS-023 QUANTIFYING SENSORY THRESHOLD USING SEMMES-WEINSTEIN ESTHESIOMETER: AN INTER-EXAMINER RELIABILITY STUDY OF MANUAL THERAPISTS E. Almpanidis*, N. Heneghan. School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom * Corresponding author.
Background: Reported physiotherapy assessment of cutaneous sensory testing uses light touch and results in a binary response of, ‘yes’, or ‘no’. However, that response does not provide adequate clinical information to examine subtle change in sensory acuity over time and may lead to misinterpretation during the formulation of a clinical hypothesis. The Semmes-Weinstein Esthesiometer (SWE) provides a performance based outcome measure (PBOM) that can quantify cutaneous sensory threshold. Using a series of numbered monofilaments of different lengths, the SWE allows the application of a consistent rather than a ‘one off’ stimulus which is susceptible to measurement error through application of different pressure. Purpose: To investigate the inter-examiner reliability of Semmes-Weinstein Esthesiometer (SWE) for quantifying cutaneous sensory threshold in manual therapists. Methods: A prospective, double-blinded, within day, inter-examiner reliability study was designed. From a power calculation, a convenience sample of asymptomatic subjects was recruited along with two examiners (experienced manual therapists). Exclusion criteria: evidence of neurological deficit (sensory loss, motor weakness, abnormal reflexes) or presence of upper limb pain. Cutaneous sensory thresholds were recorded from skin over the thenar eminence. Results: A sample of convenience comprised of 26 subjects (11 males), mean age (SD) 26.5 years (3.5). Descriptive statistics (mean scores), data normality testing, reliability statistics {intraclass correlation coefficient (ICC: 2,1) and Bland-Altman limits of agreement} were undertaken. Probability was set at <0.05. Results showed significant inter-examiner agreement of 0.7 (95% CI: 0.274 e 0.854, p¼0.003). Conclusion: This is the first study to evaluate inter-examiner reliability of manual therapists using the SWE. Preliminary evidence supports the use of SWE to assess cutaneous sensory threshold. Implications: The SWE can provide a clinically useful tool in the use of manual therapists. The findings support the use of SWE in routine manual therapy practice over the common binary measure of light touch and promptly, it can be used in patients with spinal and/or peripheral neuropathic presentations.