Journal of Physiotherapy & Sports Medicine by adnan iftikhar

Vol 1 Issue 1 June 2012

ISSN: 2226-9541

JOPSM Journal of Physiotherapy and Sports Medicine

Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 1, Issue 1, June 2012

Editor-in-Chief

Umer Sheikh, MSc. Advancing Physiotherapy (UK), MSc. APA (Ireland/Belgium), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) - Woking, UK

Editorial Board

Muhammad Atif Chishti, MSc. Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) - Middlesborough, UK Sameer Gohir, MSc Sports Physiotherapy (UK), MSc APA (Ireland/Belgium), MCSP (UK), SRP (UK), MISCP (Ireland), MSHC (KSA) - London, UK Rashid Hafeez M.Phil (Physiotherapy), MSc. APA (Belgium/Ireland), BSPT (PK)

Associate Editor

Adnan Khan, MSc (UK), MCSP (UK), MICSP (Ireland), MAACP (UK), BSPT (PU) Staffordshire, UK

Regional Coordinator

Haseeb Ammad, tDPT (PK), BSPT (PK) â&#x20AC;&#x201C; Lahore, PK

International Advisory Board

Shumaila Umer Sheikh, MSc Paediatric Physiotherapy (UK), MSc APA (Belgium/Ireland), MISCP (Ireland), BSPT (PU) - West Byfleet, UK Muhammad Atif Khan, BSc, MSc, Pgd (Ortho med), ESP, Spinal Practitioner, Berkshire, UK

Dr. Fariha Shah, DPT (USA) - Lahore, PK

Muhammad Asim Ishaque, MSc Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), BSPT (PK) - London, UK

Mohammad Bin Afsar Jan, MSPT (AUS), BSPT (PK) - Peshawar, PK

Usman Ghani MSPT (UK), BSPT (PK)

Syed Hasan Abbas Rizvi, BS (Physiology) B.S.P.T, M.S.P.T, Postgraduate Dip (SLP), C.C.P (Birmingham), C.S.M (Pak)

Dr Junaid Amin DPT (PK), BSPT (PK) - KSA Shahbaz Iqbal MSc Physiotherapy (USA), tDPT (USA), McKenzie Cert.

Managing Editor

Beenish Zaman, tDPT (PK), BSPT (PK) Lahore, PK

This journal subscribes to the principles of the Committee on Publication Ethics http://publicationethics.org/

The Journal of Postgraduate Institute of Physiotherapy Visit the journal website at http://www.pgip.co.uk/jopsm JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk

JOPSM 1 (2012)

Table of Contents

Editorial

3-4

Can aerobic exercises normalize endothelial growth factor (VEGF) in patients of peripheral arterial disease? Muhammad Mustafa Qamar, Anoop Dev.

5-15

Reflections of post graduate physiotherapy students in palliative care: qualitative study. J Sharma. 16-27 Diagnostic Value of subacromial impingement tests in subacromial impingement syndrome stage I. Ramneet kaur. 28-43 The Role of Intra-articular Corticosteroid in the treatment of OA Knee: Case Report. Muhammad Atif Khan. 44-49 Morphological and Architectural variation of supraspinatus tendon. Jonathan Morris Letter to Editor

50-60 61

Guidelines for Authors

JOPSM 1 (2012)

Editorial Clinical Reasoning – Understanding the basics

research literature.

Clinical reasoning plays an important role in clinical practise. It is a key component of evidence base practise, however there is still an ongoing debate on finding the balance between evidence and patient needs.

Researchers still looking for agreement on the mechanism involving the application of literature evidence in a specific context of individual patient condition6. It’s always been considered as a good practise to consider empirical evidence in the first instance. However, this is not always the case in clinical practise.

More and more evidence is coming out of new researches that underpins the way Physiotherapy been practised; however there are some conditions/areas where we need further evidence to formulate our practice1. Clinician has to apply conscious deliberation to undertake effective and best treatment strategy. Such undertakings further testify physiotherapist reasoning skills. There is various clinical reasoning models have been proposed most important one is hypothetico-deductive reasoning. In this model a hypothesis is developed and been tested throughout the assessment and treatment process2.

evidence

from

published

Various models have been proposed to help increase the understanding of clinical reasoning one of which is proposed by Tonelli (2006) in which five factors were proposed. These five factors includes, • Empirical evidence)

evidence

(Research

• Experimental (Experience) •

Pathophysiology

• Patient values (Patient centeredness)

Pattern recognition of similar conditions/patients based on prior clinical experiences also a beneficial tool in decision making process but it do come with cognitive biasness and may lead to false conclusions2.

•

Evidence

and

preferences

Resources (Time/sessions)

This model also provides the linkage between the evidence base practice and patient role in deciding their care (patient centeredness)7,4. Further details about this model can be found elsewhere.

Clinical reasoning involves both deductive and inductive reasoning process3. In deductive reasoning decision been made more on the basis of theoretical knowledge while in inductive reasoning, clinical experience forms the basis of the decision. There is an evidence of agreement amount researchers about reasoning process been largely inductive3. Equally important is the fact that evidence need to be gathered before to decide which reasoning process have priority over r the other type4,5.

Physiotherapy practise in Pakistan is still under the influence of referral system from the Doctor. Understanding clinical reasoning process will help the physiotherapist to decide and treat what is effective and productive rather than relying on the referrals. It’s a long journey to follow but with the effort and dedication one can formulate success closer and quicker.

In addition, clinical reasoning may involve combination of pattern recognition based on clinical experience and searching

Umer Sheikh, Editor-In-Chief, United Kingdom. 3

JOPSM 1 (2012)

References: 1. Schon DA. The Reflective Practitioner: How Professionals thin in Action. London: Temple Smith; 1983. 2. Elstein AS. Thinking about diagnostic thinking: a 30 year perspective. Advances in Health Science Education. 2009; 14: 7-18. 3. Gotzsche 2007 Rational Diagnosis and Treatment: Evidence Based Clinical Decision Making 4th ed. John Wiley and Sons Ltd. 4. Tonelli MR. Integrating evidence into clinical practice: an alternative to evidencebased approaches. J Eval Clin Pract. 2006; 12: 248-256. 5. Fenstein AR. Twentieth century paradigms that threaten both scientific and humane medicine the twenty-first century. J Clin Epidemiol. 1996; 49: 615-617. 6. Grimmer-Somers. Incorporating research evidence into clinical practice decisions. Physiother Res Int. 2007: 12, 55-58. 7. Sacristan JA. Exploratory trials, confirmatory observations: a new reasoning model in the era of patient-centred medicine. BMC Med Res Methodol. 2011; 11:57.

JOPSM 1 (2012) 5-15/ Muhammad Mustafa Qamar, Anoop Dev

Can aerobic exercises normalize endothelial growth factor (VEGF) in patients of peripheral arterial disease? Muhammad Mustafa Qamara, Anoop Narayna Devb a,b Orebro University, Sweden

Abstract: Purpose: The purpose of the current study was to find out the effect of eight weeks of aerobic training on vascular endothelial growth factor (VEGF) protein and capillarization in peripheral arterial disease (PAD) patients. Therefore, we aimed to compare VEGF and capillarization of PAD subjects (n=10), who trained aerobic exercise for eight weeks against that of normal healthy subjects (n=9). Methods: The muscles biopsies were taken from the middle part of vastus lateralis muscle at baseline and post -training. Vascular endothelial growth factor and capillarization was determined, using the immuno- histochemistry and RT-PCR protocol used previously for assessment of skeletal muscles and angiogenesis. Results: The peripheral arterial disease subjects had lower vascular endothelial growth factor (30%) as compared to control group at baseline (P<0.01). Capillary to fiber ratio was almost similar in both groups before the training intervention. However, after eight weeks of aerobic exercises, there was about 65% increment in VEGF (P<0.05), 20% increment in capillary to fiber ratio (P<0.01) and 10% increment in capillary density in peripheral arterial disease group compared with control group. There was also some increment in fiber size too in PAD group but no changes were seen in myofiber distribution. Conclusion: In summary, aerobic training significantly increase the vascular endothelial growth factor (VEGF) level in muscle tissue of peripheral arterial disease group. There was also improvement in capillary to fiber ratio, capillary density and fiber area, which shows that aerobic training, is the effective strategy to combat and prevent peripheral arterial disease.

Key words: Aerobic exercises, VEGF, Capillarization, peripheral arterial disease. insult1. Angiogenesis may be physiological or pathological and normally it is very effective mechanism of regeneration after tissue injury or insult. However sometimes angiogenesis also occurs in pathological conditions like in growth of tumor2. Angiogenesis is controlled by the existence

Introduction: Angiogenesis is the natural process characterized by the formation of new blood vessels. It is the important process which plays key part in restoration of blood flow to the tissues after injury or 5

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of physiological balance between the angiogenetic stimulator and endogenous inhibitors1.There is many pro-angiogenic factors identified but VEGF is recognized as best pro-angiogenic growth factor because it is very specific for vascular endothelium3. Vascular endothelial growth factor (VEGF) is one of the potent glycoprotein which is very specific mitogen for the cells of endothelium. Its size ranges about 34-45 KD4.

musculoskeletal and cardiovascular system. Aerobic exercises induce skeletal muscle angiogenesis which helps in aerobic capacity of skeletal muscle and increase microcirculation9. The aim of this study was to find out the affect of eight weeks of aerobic exercise training on the level of vascular endothelial growth factor (VEGF) and on capillarization in patient suffering from peripheral arterial disease. For this purpose we had taken subjects suffering from peripheral vascular disease and these subjects had taken part in eight weeks for aerobic exercises on treadmill under the supervision of physiotherapist. Muscle biopsies were taken for analysis of VEGF and capillarization at baseline and post training in both groups.

Inactivity or sedentary life style leads to different chronic diseases in the form of obesity and in the form of arterial insufficiency. There are about 5 million people only in USA suffered from obstructive vascular disease i.e. peripheral arterial disease (PAD) and it is one of the main reason of morbidity and impairment5. Exercises are the effective tool which can be helpful for improving good quality of life in such type of diseases by promoting angiogenesis6. In response of aerobic exercises in peripheral arterial disease, there are adaptive changes in skeletal muscles in the form of angiogenesis or arterio-genesis. There is increased capillary density and mitochondrial activity in exercises skeletal muscles7. Exercise training is one of the few physiological processes that activate organized angiogenic response in adults and results in formation of new blood vessels5.

Material and methods: Participants: 10 (6 male and 4 female) individual suffering from mild to moderate peripheral vascular disease diagnosed by their physician, selected randomly by clinical database and 9 (5 male, 4 female) normal healthy individuals as control group was participated in this study. All participants were recruited from Orebro city. They were not taking any medication and had not been engaged with any endurance or strength training programme. They were ranked sedentary according to their level of activity (Ë&#x192;30 minute moderate physical activity 3days/wk).They were participated voluntarily in this study after oral and verbal explanation of the methods and purpose of the study according to the guidelines of the research committee of Orebro University. They had been

Exercises induced hypoxia is potent stimulus for angiogenesis by the up regulation of vascular endothelial growth factor7. Exercises to improve endurance or aerobic exercises may cause the formation of new blood vessels but it does depend on intensity and type of exercise8. In response to endurance exercises, there are number of adaptive changes occurs, mostly in 6

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informed about related risks and benefits of the study and they could withdraw from study at anytime. The research was approved by the research department of the Orebro University. The participants were

instructed to participate regularly in performing aerobic exercises. The physical characteristic of the subjects with peripheral arterial disease is shown in the table below.

Table-1 Physical characteristic of PAD group, data presented as mean and SD. Study design:

training 4 days per week for eight weeks. For sample collection of muscle biopsies, they had come in lab two day before and two day post intervention.

All subjects were participated in eight weeks of aerobic exercise training under the supervision of Physiotherapist. The instructions and guidelines about aerobic exercise training were provided to each individual in written and oral form. The training programme consisted of total 40 minutes workout 4days/ week 10 for eight weeks 16 including aerobic training, warm up and cool down period. Started with 5-7 minutes of warm up exercises which consisted of light physical activities and stretching of large muscles groups of body was performed followed by paddling on cycle ergometer for 30 minutes with 50 rpm and cool down period of 5 minutes 11,17 .

Muscle biopsy: Muscle biopsies were taken in two separate occasions, pre-training and other one on post- training period from the middle part of vastus lateralis. First of all anesthetize the local area of vastus lateralis near to the muscle belly by using local anesthesia in the form of 1% xylocaine, make a cut of 12cm long and 0.3cm in diameter in vastus lateralis and then was taken biopsy with the help of weil-blakesely forceps10. The post training muscle biopsy was taken from same muscle and horizontally about 2cm apart from previous incision. Then muscle tissue was blotted, freeze in liquid nitrogen and store in -70 Celsius. The sample was divided into parts for further analysis. This is valid method and used previously by Charifi et al10.

Visits: Muscles biopsies were taken at pre and post training period. The subjects had visited in gym on regular basis for aerobic 7

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Immuno-histochemistry:

RNA was examined for integrity with the help of Agilent 2100 bioanalyzer and RNA 6000 Nano assay kit (Agilent technology, Santa Clara, CA, USA) and stored at -70 Celsius for analysis. Method validated previously by Ryan et al12.

Frozen biopsies were dissected by using cryostat into 6 µm thick transverse section and then microscopic slides were prepared. Care was taken not to stretch or damage the specimen with no air bubbles. The section was fixed by immersion in acetone about -20 Celsius for 1 min followed by incubation for 2 minute in formaldehyde in room temperature. These sections were washed in 10 mmol/liter PBS containing 1 % of bovine serum albumin and retain for one hour. The identification of capillaries was performed by using monoclonal antibody CD31 as a endothelial cell marker in 1:10 dilution (Daku, Glostrup, Denmark; M0823). Capillaries and muscle fibers type composition were analyzed randomly selected cross-sectional areas and visualized at total magnification of ×400. Mean fiber area was quantified by using computer software TEMA (Version 95, Denmark). For each muscle biopsy, capillary density; capillary to fiber area, fiber cross sectional area was measured by using microscopy and TEMA software. CD31 marker is reliable and was used previously by Hansen et al11.

The mRNA content of VEGF was detected by real time polymerase chain reaction. Total mRNA obtained previously was reverse transcribed to cDNA with the help of SuperScript II first-strand synthesis kit (Invitrogen, Carlsbad, California, USA). The manufacturer instruction was followed. The cDNA was kept at -20ºC. For the gene expression of VEGF, quantitative real time Polymerase Chain Reaction (PCR) was executed on ABI Prism Sequence Detection System 7900HT (PE Applied Biosystems, Foster City, California, USA). VEGF was targeted gene in expression analysis, designed and provided by Applied biosystem (Foster City, California, USA). The probe was labeled by FAM and TAMRA as reporter and quencher dye. PCR cycles was consists of 50º C for 2 min, 95ºC for 10 min, 15 sec at 95ºC and one minute for 60ºC. PCR amplification was correlated against standard curve. Recently, some 11, 15 researcher validated this method .

RNA Isolation and Real time PCR analysis: Approximately 20 mg of muscle tissues collected previously was frozen in liquid nitrogen and was homogenized in Dounce homogenizer in RIPA. RNA was isolated by using RNEasy fibrous tissue mini kit (Qiagen, Valencia, California, and USA) in accordance with the guidelines provided by the company. Quantification of total protein was done by using bicinchoninic acid (Bio-Rad Laboratories, Hercules, CA). After quantification, the isolated

Statistical analysis: All data was presented as mean and standard deviation. Paired sampled Ttest was used to obtain statistical significance values before and after training. Pearson Correlation coefficient was used to measure the degree of relationship between the variables. P 8

JOPSM 1 (2012) 5-15/ Muhammad Mustafa Qamar, Anoop Dev

After the training period morphology:

value less than 0.05 was considered significant.

The capillary to fiber ratio (C: F) in subjects with peripheral arterial disease was 20% higher (P<0.01) than before training (Fig. 1A). There is about 10% increment in capillary density but insignificant improvement in fiber cross sectional area in peripheral arterial disease group after training (Fig. 1B). There was improvement in fiber size area. The skeletal muscle fiber size after training was 6110 ± 1008 µm2.

Results: Before aerobic training morphology analysis: The participants with peripheral arterial disease had 30% lower capillary density (CD) than control group (P<0.01). Whereas, the fiber cross sectional area (FCSA) was slightly higher in subjects with peripheral arterial disease than control group. There was little difference in capillary to fiber ratio(C: F) between the two groups. The skeletal muscle fiber size before training was 5,251 ± 861 µm2 and fiber type distribution in the peripheral arterial disease patients before training was 54.1% type I and 45.9 % Type II.

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Fig. 1A- capillary to fiber ration in PAD subjects before and after aerobic training

330

capillary denisty

325 320 315 310 305 300 Baseline

Post-training

Fig. 1B- capillary density in PAD subjects before and after aerobic training. VEGF protein level and mRNA in muscle biopsies: Before training:

with control group. While the VEGF protein level was 30% lower in peripheral arterial disease participants than control group.

In peripheral arterial disease patients, there was not marked difference in the level of VEGF mRNA in comparison

JOPSM 1 (2012) 5-15/ Muhammad Mustafa Qamar, Anoop Dev

After training:

increase in VEGF protein level, about 65% (P<0.05) in peripheral arterial disease subjects. After training the VEGF protein level was approximately similar to the control group.

The level of mRNA did not alter significantly after training in subjects with peripheral arterial disease. However there was marked

0.5

VEGF

0.4 0.3 0.2 0.1 0 Control

PAD (Baseline)

PAD (post-training)

Fig. 2- VEGF Level in PAD subjects before and after aerobic training Physical characteristics:

the angiogenic response and capillarization in peripheral arterial disease subjects. This is obvious in our results as there is marked increase in level of VEGF protein and capillarization in term of capillary to fiber ratio and in capillary density. Subjects with peripheral arterial disease had lower VEGF level and capillary density than normal subjects. There was about 65% increase in VEGF protein level, 20 % in capillary to fiber ratio, and 10% in capillary density, after the eight weeks of supervised aerobic training programme in subjects with mild to moderate peripheral arterial disease. The increase in capillary to fiber ratio and capillary density indicates that there was more capillary growth and oxygenation capacity in peripheral arterial disease subjects after aerobic training.

There was no marked difference regarding the sex and age in response to training for capillarization or VEGF protein (P>0.05) in subjects with peripheral arterial disease in comparison with control group. However, subjects with peripheral arterial disease differ in term of body mass index (BMI) and their physical activity level from control group. Subjects with PAD had more BMI (Ë&#x192;32) but less physical activity than normal subjects.

Discussion: Our current study demonstrated that, the aerobic exercise training in subjects suffered from peripheral arterial disease have a very positive effect on the level of VEGF protein level in the muscles. Furthermore, aerobic training augmented

These changes help in more uptake of oxygen and availability of more blood supply to the muscles. There were no significant changes in fiber type 11

JOPSM 1 (2012) 5-15/ Muhammad Mustafa Qamar, Anoop Dev

by Lloyd et al14, demonstrated that increase in VEGF level is directly related with mRNA level in skeletal muscles. In response of increase in mRNA the VEGF level is increases, in a manner that they are directly correlated with each other. This effect may be due to intensity and frequency of the exercise8 or other factors like aging12.

composition but improvement in muscle fiber size. The present finding of enhancement of VEGF level with aerobic training in PAD subjects is not reported before but Hansen et al11 have demonstrated the role of combined exercise training (strength + endurance exercises) in hypertensive patient. They had found significant response of exercise training on hypertensive patient in the form of improvement in the VEGF level and capillarization in term of capillary to fiber ration and increment in capillary density.

These factors suggested that, greater the stimulus in the form of intense exercise, there will more increment in mRNA and in return VEGF level. It might be the mRNA is the controlling machinery for VEGF level which regulates the VEGF level and angiogenesis in response of intensity and frequency of the stimulus. The stimulus for angiogenesis may be in the form of hypoxia or hypoglycemia4.

Gavin et al13 showed the acute systemic exercises have positive effect on pro angiogenic factors but some researchers13, demonstrated that, there is less angiogenic response in human after exercise training with increasing age.

It is worth of noticing in our results that subjects with peripheral arterial disease have more BMI and less physical activity in comparison with normal subjects. So, it seems overweight and sedentary lifestyle may be the causative factors for arterial disorders. There is no significant difference regarding the sex of the participants suffered from peripheral arterial disease.

Jansen et al8, discussed the intense intermittent enduring training can bring changes in VEGF level after 4 week of training. So it seems that exercises are the good intervention for angiogenesis but response depends mainly on the type, duration, frequency and intensity of exercise. More intense and long duration exercises seem to have more positive effects on angiogenesis.

The reduction in BMI after aerobic training has positive effect in relieving the symptom of intermittent claudication. So, aerobic exercises can be used as therapeutic intervention for preventing and managing arterial diseases or other cardiovascular problems.

In the current study, the level of mRNA was almost similar before and after training in subjects with peripheral arterial disease. From these facts, it seems that increase in VEGF protein level in muscles have no direct association with VEGF mRNA level in response of aerobic training programme. The same finding was reported before11; increase in VEGF level is not dependent on VEGF mRNA level in muscles. In contrast to this, some studies

It is obvious from the different studies that aerobic exercises play a vital role to combat different conditions. As, in our studies aerobic training bring positive changes on angiogenesis. Some studies 12

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Acknowledgements:

demonstrated that the angiogenic capacity decrease with age in response of exercises, so aerobic exercises can be used as preventive strategy to combat different conditions including peripheral arterial disease because mostly people suffered in their middle or later part of life.

The author is grateful to Ayesha Basharat (Lecturer, Sargodha Medical College, Pakistan) for her invaluable support and services provided in this study.

In early part of the life, proper aerobic exercises will be more helpful in preventing and managing these types of cardiovascular disorders. In short, current study suggests that aerobic exercise training is very useful for promotion angiogenesis, increase in VEGF level and more capillarization in skeletal muscles. So, aerobic exercise therapy can be used to get benefit in patient with peripheral arterial disease.

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References: 1. William WL, Vincent WL. Angiogenesis in wound healing. Contemp surg. 2003: 519. 2. Risau W. Mechanism of angiogenesis. Nature. 1997; 386:671-674. 3. McMahon G. VEGF receptor signaling in tumor angiogenesis. Oncologist. 2000;5 Suppl 1:3-10. 4. Gustafsson T, Kraus WE. Exercise-induced angiogenesis-related growth and transcription factors in skeletal muscle, and their modification in muscle pathology. Front Biosci. 2001;6:D75-89. 5. Chinsomboon J, Ruas J, Gupta RK, Thom R, Shoag J, Rowe GC. The transcriptional coactivator PGC-1alpha mediates exercise-induced angiogenesis in skeletal muscle. 6. Proc Nat Acad Sci U S A. 2009; 106(50): 21401-21406. 7. Gavin TP, Spector DA, Wagner H, Breen EC, Wagner PD. Nitric oxide synthase inhibition attenuates the skeletal muscle VEGF mRNA response to exercise. J Appl Physiol. 2000;88(4):1192-8. 8. Yang HT, Prior BM, Lloyd PG, Taylor JC, Li Z, Laughlin MH, et al. Training-induced vascular adaptations to ischemic muscle. J Physiol Pharmacol. 2008;59 Suppl 7:57-70. 9. Jensen L, Bangsbo J, Hellsten Y. Effect of high intensity training on capillarization and presence of angiogenic factors in human skeletal muscle. J Physiol. 2004;557(Pt 2):571-82. 10. Amaral SL, Papanek PE, Greene AS. Angiotensin II and VEGF are involved in angiogenesis induced by short-term exercise training. Am J Physiol Heart Circ Physiol. 2001;281(3):H1163-9. 11. Charifi N, Kadi F, FĂŠasson L, Costes F, Geyssant A, Denis C. Enhancement of microvessel tortuosity in the vastus lateralis muscle of old men in response to endurance training. J Physiol. 2004;554(Pt 2):559-69. 12. Hansen AH, Nielsen JJ, Saltin B, Hellsten Y. Exercise training normalizes skeletal muscle vascular endothelial growth factor levels in patients with essential hypertension. J Hypertens. 2010;28(6):1176-85. 13. Ryan NA, Zwetsloot KA, Westerkamp LM, Hickner RC, Pofahl WE, Gavin TP. Lower skeletal muscle capillarization and VEGF expression in aged vs. young men. J Appl Physiol. 2006;100(1):178-85. 14. Gavin TP, Robinson CB, Yeager RC, England JA, Nifong LW, Hickner RC. Angiogenic growth factor response to acute systemic exercise in human skeletal muscle. J Appl Physiol. 2004;96(1):19-24.

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15. Lloyd PG, Prior BM, Yang HT, Terjung RL. Angiogenic growth factor expression in rat skeletal muscle in response to exercise training. Am J Physiol Heart Circ Physiol. 2003;284(5):H1668-78. 16. Bustin SA. Absolute quantification of mRNA using real-time reverse transcription polymerase chain reaction assays. J Mol End. 2000; 25:169â&#x20AC;&#x201C;193. 17. Hickey JP, Donne B, O'Brien D. Effects of an eight week military training program on aerobic indices and psychomotor function. J R Army Med Corps. 2012;158(1):41-61. 18. Higashi Y, Sasaki S, Sasaki N, Nakagawa K, Ueda T, Yoshimizu A, et al. Daily aerobic exercise improves reactive hyperemia in patients with essential hypertension. Hypertension. 1999;33:591-7.

JOSPM 1 (2012) 16-27/ Jivan J Sharma

Reflections of post graduate physiotherapy students in palliative care: qualitative study Jivan J Sharma, MSc, Sheffield Hallam University

Abstract: The purpose of this qualitative study was to explore the perceptions of Indian physiotherapists for palliative care. In this twenty – first century where newer technical expertise and recent advances in treatment are reaching its heights, the concept of palliative care has also undergone a sea change in the past few years. It is to be viewed that in India the curriculum of medicine, nursing and other paramedical services such as physiotherapy, occupational therapy, psychology etc. don’t include palliative care as a specialization in post graduation or as a subject in under graduate studies. In this study, the researcher explored physiotherapists understanding of palliative care via one to one face interviews. Participants displayed a reasonable grasp of the wider concept of palliative care, but the specialists’ role was illdefined and it was clear from the way the participants narrated their experience that they view their role more than just a physiotherapist and also a strong sense of putting appropriate holistic approaches together to improve overall QOL was evident. 3 themes and 5 sub themes emerged from the interviews. Main themes were recognising role, emotional concerns and lack of resources. Taking the perceptions of physiotherapists it will be a research to raise the consciousness of all physiotherapists about their role, responsibilities and skills in this important area of patient care that may act as catalyst for future strategies to be devised.

Key words: physiotherapist; palliative care; post graduate; terminal illness. Introduction

(QOL) of not only patients but as well as their families by a multi disciplinary approach. The widely accepted definition of World Health Organisation (WHO) describes palliative care as ‘‘Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with a life-limiting illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual''.2

The twenty – first century is being proclaimed as the era of medical excellence. Where newer technical expertise and recent advances in treatment is reaching its heights, the concept of palliative care have also undergone a sea change in the past few years.1 Concept of palliation has extend his boundaries from the more traditional cancer therapy to many other contemporary life limiting illnesses such as pulmonary, cardiac, AIDS, neurology and elderly which conforms to the holistic approach of treatment, thereby bringing about an improvement of the overall quality of life 16

JOSPM 1 (2012) 16-27/ Jivan J Sharma

An empirical understanding of the various needs of patient with life limiting illness is essential for effective palliative care so that we (medical, paramedical, social workers) can try to fulfil all these while delivering our services to improve overall QOL.

education that is footing far ahead in terms of physiotherapists and developing countries perspectives. Although a physiotherapy student has no specific training in palliative care, he or she must face the realities.8 Emotional concerns, stress and helplessness have been increasingly recognised by health 10 professionals in the care of dying but how do physiotherapists muddle through this? Taking the perceptions of physiotherapists it will be a research to raise the consciousness of all physiotherapists about their role, responsibilities and skills in this important area of patient care that may act as catalyst for future strategies to be devised.

Other than symptomatic problems which can be effectively alleviated by providing quality care and the concept of dying with dignity3 further includes psychological, spiritual and social aspects of end of life care. To meet these essential needs of patient and care givers, effective interprofessional team work4 and 5 communication skills are necessary. Extensive literature exists elaborating the view points of medical doctors, nurses, patients and even care takers but a little result comes out with physiotherapy or physiotherapist as search terms in palliative care studies. Even though physiotherapist as a part of team have a substantial role in improving the condition of the patients for the remaining span of their mortal lives (through exercises6, symptom controls7, improving daily activities8), this role has gone unrecognised9 and is evident from the fact that insufficient literature exists defining the role and the significance of physiotherapists as palliative care givers. Studies are yet to be conducted to consider their view points.

Study design: The author selected descriptive 11 phenomenological approach to understand the perspectives of Indian physiotherapists as his participants. This approach is found to be useful when scant information exists12 and the result produced is a description of those with exposure to the phenomenon13. Participants: Study commenced after gaining appropriate ethical approval from Sheffield Hallam University (SHU) research ethics board. Initial invitations for the study were provided via electronic mails to all the Indian physiotherapists doing their post graduation in SHU. Potential participants with experiences in palliative care in any set ups were identified. Keeping the confidentiality and participants safety in mind one to one semi structured interviews were conducted to explore their in depth perceptions and experiences. Participants were made fully aware of the nature and

This qualitative paper will take into account the individualistic approach of physiotherapists which may be further helpful for evidence based practice and development of a rational approach to provide optimal patient care. Research conducted in developed countries have suggested provision and opportunities for inclusion of palliative care in undergraduate (UG) curriculum for medical students and nurses coupled with post graduation 17

JOSPM 1 (2012) 16-27/ Jivan J Sharma

purpose of the study through participation information sheet and written consent was obtained. As the study deals with the experiences of treating patients at the end stage of their lives, the author was prepared before hand in case any emotional issues breaks up, and SHU support and counselling address and booklet was kept handy.

information from study participants without imposing preconceived categories or theoretical perspectives14. First each transcribed verbatim was read several times in a go to obtain a sense of whole followed by word to word understanding. Initial codes were derived by highlighting the words that appear to capture key thoughts and potential concepts. Data was organised by topics and themes were coded into categories which were refined and findings were developed.

Procedure and data collection: 10 potential participants were identified and 8 were approached for one to one face interviews. 2 participants could not participate because of their other responsibilities. The interviews were conducted at locations chosen by the participants. Most choose to be interviewed at their homes although 2 choose to be interviewed at the learning centre of SHU. The interviews lasted between 19 to 38 minutes. Initial 2 to 3 questions were asked to set the interview tone and to make the environment calm and relaxing. All broad and open ended questions were designed with an aim of discovery rather than checking (Appendix 4). More information was gathered by using probes and prompts. Based on the ongoing analysis the interview was modified and 2 questions were reframed. Finally at the end of the interview also, an open ended question was asked that if the participants want to add something that they feel the interviewer has left or missed which was important to them.

All transcribed verbatim were forwarded to respective participants for member checking and their feedback enhanced the methodological rigor. Inter researcher triangulation approach was used through an independent researcher who further analysed the data and themes for a check under strict confidentiality. Only the primary researcher knew the identities of the participants and all identities from the data was erased. Peer debriefing further helped the author to maintain objectivity and participants were allowed to assist with an open ended prospect with the notion of data triangulation.

Findings: Participants 8 eligible physiotherapists volunteered to participate in the study with an overall experience from 2 to 5 years. Majority of them have worked in multi speciality hospital set ups while 2 were having an additional home based palliative experience of 6 months to 1 year. One of the participants has worked at community level on an average on 6 hours every week. Half of the participants gained some experience during their compulsory internship

Data analysis: All interviews were digitally recorded and transcribed. Conventional content analysis was used to evaluate the data. This approach is suitable to gain direct 18

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programme during bachelor’s degree where as none of the participants received any specialised formal training in palliative care. However one member attended a 3 days workshop of understanding palliative care though it was for general medical professionals and nurses. It was clear from

the way the participants narrated their experience that they view their role more than just a physiotherapist and also a strong sense of putting appropriate holistic approaches together to improve overall QOL was evident. 3 themes and 5 sub themes emerged from the interviews.

Table I Key themes and sub themes Themes

Sub themes

Recognising role

*Modification as per patient’s needs *With respect to relative query *With respect to patient enquiry



Emotional concerns

*During the sessions

Lack of resources

*Demise of the relationship

Recognising role:

like respiratory management, analgesic modalities, different re-education techniques and relaxation therapy was mentioned and a great emphasis on clinical reasoning was given. Main aim was to concentrate on the QOL not the duration.

Although the participants were trained and worked in different specialties with no specific training in palliative care, they were attentive and recognised patient’s needs at the end of their lives.

Participant 2 -I could realise the pain and suffering in the bio psychosocial context. I had to change my approach from hands on to hands off…making them comfortable through my words.

Modification as per patient’s needs: Approach of providing care was found to be modified in all the participants keeping the physical and emotional conditions of these patients in mind. Physiotherapists do have skills to assists patients in symptoms relief and range of physiotherapy methods

Participant 8 -- It many times depends on the patients also. Some are strong and need less support or actually they are prepared, 19

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but… can’t leave them like that… we should modify ourselves to deliver the best.

Participant 4 -- I never tried to tell them what they are suffering from, but used to explain the pathology part in lay terms. I used to say, I am a physiotherapist and more information you can avail from your consultant.

Response against enquiry from the relative and patient: Anyone can become sad, depressed and anxious when some dear one is near to death. There are always lots of queries from the care givers side and health care team needs to discuss these carefully. Informing the diagnosis was viewed as complex and varied responses were identified. Although consultant plays a major role here but the physiotherapists have to answer to these enquires due to their profound communication with the patients.

Where the patients know: Participant 6 -- It is very difficult to handle this situation and the best you can say is, everyone has to try their best and we also have to…we have to encourage them for maximum participations and efforts. Participant 2 -- It was difficult for me to what to tell and what to hide…the words were never planned, they just comes out according to the situation having more emotional concerns and support.

With respect to relative query: 

Participant 3 -- Sometimes relatives are curious about the rehabilitation part and how we can help the patients, then we must share our short and long term plans.

Emotional concerns:

All participants described their work as stressful, struggling and emotionally challenging during their physiotherapy services and after the demise of the relationship as patient expired. 80% mentioned their feelings as depressed and sad with the news that patient has expired and 20% of the participants said they were prepared, not a sudden shock and better for the patients and carers. During the sessions: because of the nature of the work and the responsibilities, physiotherapists have to cope up with the emotional demands of their work and need to provide the psychological and emotional support to the patients.

Participant 1 -- I used to reassure them, explain them about the current situation and tried to minimise the suffering … after all they are going to lose their near or dear ones [long pause]. I think they also need some type of care and counselling. With respect to patient enquiry: cultural complexities were emphasised by the participants that makes it difficult and different for each individual patient. Many of the relatives do not want to inform their sufferer member. So physiotherapists have to mould as per the team decisions. This ethical issue of informing the patient stills persists and is beyond the scope for this article. Some comments from the participants were as in case where relatives refused to give clear picture,

Participant 8 – I always used to encourage my patients, giving them more support and motivation, but somewhere back of my mind it was always there that the patient is

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not going to survive for long… was very hectic and challenging.

Emphasis on additional training in UG, planning of continuous professional development (CPD’s) through specialist physiotherapists and skills development was outlined.

Participant 2 – I have to challenge myself with a strong heart that even I can't cure them, but I know I can make them feel better and I used to have more of healing words instead of healing touch.

Participant 7 – Lack of opportunities are keeping physiotherapists behind in this area. We do have PG in MSK, Respiratory, Neurology but we don’t have anything in this and I haven’t heard of any short physiotherapy courses also in this…

Demise of the relationship: this moment is always traumatic for everyone but the intensities vary. Because of the profound communication a therapist also guarantees a personal relationship up to the time of death. Emotionally challenge vies were:

Participant 8 – If I would have taught this in the same way I learned anatomy and biomechanics; I would have given a lot to my patients.

Participant 5 – It is always sad and traumatic for me, as I share good therapeutic relations with them, but I had to avoid the emotional component.

Discussion:

Participant 2 – At the start of your professional life, initially when you hear such news, you become sad and disappointed. But it’s a part of life …have to take it.

The findings of this study displayed the perceptions of Indian physiotherapists in this challenging field of care. Although the participants had less experience in specialised palliative care their narratives establish the fact that they are able to identify the various needs of patients with life limiting illness and hence aware of the wider concept of palliative care. Recognising their role with all the holistic approaches of symptom control, emotional and psychological support was evident, but the means by which it can be organised to provide such therapy were limited to changes in the current curriculum in under graduate and post graduate studies.

Some participant’s viewed that illness was a burden for not only patients, but for family also and recognising this is also essential for a practical approach. Participant 6 – Everyone was prepared for it and it did not come as a sudden shock, though it is stressful and shocking, but that unbearable pain is no longer there. 

Lack of resources:

Research has shown that students acquire skills more effectively when taught in experiential format15 and interaction with the patients and relatives can be an effective learning tool16.

Though all the participants showed a great confidence level in providing care to palliative patients with their less specialised experience, all of them expressed the need for lot more support in the form of specialised training and education.

While the participants in the study described their reflective practice as their 21

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learning tool; literature has suggested a need for ongoing learning 17, not only for the professional development but also for the inner qualities and relationships – insight which is not possible only through classroom learning. Thus if more opportunities are available more skills, knowledge, understanding and values can be developed that will not only improve the standard of care but also humanity. Though the participants were attentive and recognised patient’s needs at the end of their lives; eliciting the patients and relative’s perceptions will provide directions for the professional to approach them. Tailoring the information was evident and do vary on individualistic basis. As the patients and the carers have distinct needs and issues, they have to be carefully discussed.

that their role as a physiotherapist is limited and in this family members should be involved. India being home to many cultures consists of a multi faith society. A broad understanding of all the regions will be definitely difficult and adequate time and skills may be required to uncover and address such issues. Overall the participants identified palliative care as one of the core content area for undergraduate education. This requirement is necessary for better care and understanding. They believe that the way they learnt or adapted their approach towards the patients can be further improved by providing a generic evaluated undergraduate curriculum coupled with continuing professional development and post graduate education. The age of the patient was also one of the contributing factors that increase the challenges for physiotherapists. It was found to be difficult for the participants to vary their treatment in terms of psychological needs of these different age groups and the need for more education was expressed with emphasis on more of training associated with their bachelor’s degree and other relevant specialised areas in palliative care like paediatrics, geriatrics, cancer, elderly, etc.

Emotional concerns were surrounded by the participants and they described their work as emotionally challenging and stressful. Motivation, psychological support and encouragement were expressed for a sense of security and hope for the patient and family. Physiotherapists do have to cope up with this emotional demand throughout their work and even after the death of their patients. Literature also suggests that health professionals are increasingly recognising this stress. This is only from the physician 18 and oncologist’s 19 view points and thus more research is also needed from physiotherapist’s sight.

Furthermore participants recognized that local guidelines of the hospital trust and team decisions will also explains their hidden roles and effective communication with not only patients but also between team that will enhance the quality of care. Thus it is suggested that if palliative care is a multidisciplinary speciality then in order to emphasis this approach, teachers should include doctors, paramedical, nurses, social workers, voluntary agencies, chaplaincy and care takers which may help to achieve effective communication skills and team

Participant's thoughts were found to be limited for dealing with the religious and spiritual needs of these patients. All participants accepted that this is one of the important components at the end stages of life to improve overall QOL and identified 22

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work that is essential in any care and organisation.10

but newer approaches are need to be considered to equip them to cater the needs of patients with life limiting illness. Also the other point of relevance pinpointed by this study is to look for avenues such as workshops, curriculum devised for imparting skills to deal with these specialised group of patients and to research the improvement of the overall scenario from a physiotherapist's perspective thereby suggesting a definitive role that needs to be played by them in palliative care in India.

The views generated in this study were of physiotherapists with less specialised palliative care experience, further expert opinions may help to refine or addition of some hidden themes. Researcher's focus was on perceptions of Indian physiotherapists and it is accepted that these perspectives may be different in other cultures and countries. However it is prudent not to generalise, as cultural diversity influence the principles and values, therefore views from ethnically different physiotherapists will provide broader understanding and are recommended for future researches.

Acknowledgements: The author is grateful to his supervisor Dr Hazel Horobin for her invaluable support and would like to acknowledge all the participants, independent researcher and peer for their valuable thoughts and services provided in this study.

Conclusion: This study points out the fact that lack of understanding of palliative care is not the problems faced by Indian physiotherapists

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Appendix 1: Palliative care in India

field of palliative care is a problem with all healthcare professionals and thus hinders an effective team effort to provide care to the patients.

India is a developing country and healthcare issues concerning its more than a billion strong populations are many.1 of these the major health hazards being infectious diseases the lion share of whatever resource available is utilized for detection and its control. Recent trends emerging show that leaving behind infectious diseases cancer and AIDS have taken center stage as the main cause of mortality in India. This trend has caused the healthcare sector to take essential steps towards palliative care which was unknown until the last 15 -20 years. Although recent measures suggest the advent of specialized care centers to provide palliative care but the rate at which the number of patients with life limiting illness are rising, the care center have been unable to provide services to all. Other than the rapid rate of occurrence of these diseases there are other obstacles for development of a palliative care standard equivalent to those in countries like United States of America and United Kingdom.

Another major setback to the provision of palliative care in India is the governing economics linked to it.3 India being such a big population and the number of patients suffering from different life limiting illness doesnâ&#x20AC;&#x2122;t have a social security system unlike USA and UK. The social security system in these countries allows the patient to afford palliative care which is costly. This problem of affordability is further enhanced when the majority of patients belong to a stratum of the society mostly rural and semi-urban which lacks proper nutrition, health care facilities and are mostly daily wage workers and small scale farmers. The lack of infrastructure in these sectors i.e. rural and semi-urban sectors worsens the scenario a bit more. Health awareness is an issue to be regarded in the Indian context as this is not a problem faced by developed countries in palliative care. Majority of life limiting illness is asymptomatic in initial stages. Due to a lack of awareness among the population about these disorder most of them are detected at end stage and during this period and the period leading up to detection and treatment, the patient sustains a lot of trauma and emotional stress. According to World Health Organization guidelines palliative care should strive to control and reduce the suffering of patients.4 Thus due to lack of awareness among patients and family members the care which should have been provided during such traumatic conditions is not available to them. This distress on part of the patient is further increased manifold due to the prevailing stigma

Among the many obstacles faced the lack of training for healthcare professionals to provide palliative care is the chief and primary concern.2 It is to be viewed that the curriculum of medicine, nursing and other paramedical services such as physiotherapy, occupational therapy, psychology etc. donâ&#x20AC;&#x2122;t include palliative care as a specialization in post graduation or as a subject in under graduate studies. Thus when a physiotherapist after completion of training during under graduation suddenly faces the uphill task of providing care to terminally ill patients and many a times is unable to cope with the emotional stress associated with it. This lack of understanding in the specialized 24

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associated with these disorders in the society. In some sections of the society such illness is termed as the curse of previous misdeeds by the individual. This clearly highlights the ignorance rampant among the general public.

doesn’t matter how long, but how you live”. Thus be it whatever country or religion, everyone wants soul should rest in peace.

India being a panorama of different cultures a large number of alternative systems of medicines is available.1 In mostly the rural sectors of the healthcare system where proper medical facilities are lacking patients consult the local vaidyas (doctor of ayurveda) or the hakims( physician in Unani medicine). Mostly the symptoms are treated with much concern rather than the underlying pathology. This though may provide temporary relief to the terminally ill patients but doesn’t fulfil the continuous care necessary for these patients. India being home to many cultures consists of a multi faith society. Many different religions thrive in such optimal conditions. Religions like Hinduism preach the idea of reincarnation, supreme salvation etc. Thus a ditto copy of the prevailing palliative care systems in other countries may not suit the conditions in India. Hence an ethical dilemma persists among the patients as well as the care givers to chart out the actual course of action to be followed. Many of the above described obstacles need to surmounted and by meticulous multi-pronged strategies to simultaneously counter lack of health awareness, lack of infrastructure, ethical acceptance in the society and financial aid to this specialized field of healthcare India can develop an indigenous model for the sake of providing some respite to these patients in their final journey and as Oscar Wilde remarked” It 25

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References: 1. Cannaerts N, Casterle BD, Grypdonck M. Palliative Care, Care for Life: A Study of the Specificity of Residential Pallative Care. Qual Health Res. 2004; 14: 816-835. 2. World Health Organisation. WHO Definition of Palliative Care [online]. Available from:http://www.who.int/cancer/palliative/definition/en/ [ accessed 24th November 2007]. 3. Chochinov HM. Dignity-conserving care - a new model for palliative care: helping the patient feel valued. JAMA 2002; 287: 2253-2260. 4. Wee B, Hillier R, Coles C, Sheldon F, Turner P. Palliative care: a suitable setting for undergraduate interprofessional education. Palliat Med 2001; 15: 487-492. 5. Williams ML, Dogra N. First year medical students’ attitudes towards patients with life-limiting illness: does age make a difference? Pall Med 2004; 18: 137-138. 6. Oldervoll LM, Loge JH, Paltiel H. The effect of a physical exercise program in palliative cares phase II study. J Pain Symptom Manage 2006; 31: 421-430. 7. Laakso EL, McAuliffe AJ, Cantlay A. The impact of physiotherapy intervention on functional independence and quality of life in palliative patients. Cancer Forum 2003; 27: 15–20. 8. Marcant D, Rapin CH. Role of Physiotherapist in Palliative Care. J of Pain and Symptom Management 1993; 8: 68-71. 9. Rashleigh L. Physiotherapy in palliative oncology. Aust J of Physiotherapy 1996; 42: 307-312. 10. Schofield P, Peter MC. Would you like to talk about your future treatment options?’ discussing the transition from curative cancer treatment to palliative care. Pall Med 2000; 20: 397-406. 11. Moustakas C. Phenomenological research methods.Thousand Oaks, CA: Sage 1994. 12. Cohen M Z, Omery A. Schools of phenomenology: Implications for research. In J. M. Morse (Ed.), Critical issues in qualitative research methods.Thousand Oaks, CA: Sage 1994:136-56. 13. Hsieh HF, Shannon SE. Three approaches of qualitative content analysis. Qual Health Res. 2005; 15: 1277-1288. 14. Kondracki NL, Wellman NS. Content analysis: Review of methods and their applications in education. J of Educ and Beh 2002; 34: 224-230. 15. Linder J, Blais J, Enders S, Melberg S, Meyers F. Palliative education: a didactic and experiential approach to teaching end of life care. J Cancer Educ 1999; 14: 154-160. 16. Charlton R, Ford E. Education needs in palliative care. Fam Pract 1995; 12: 70-74.

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17. Williams ML, Carter YH. Can medical education extend palliative care? Palliat Med 2003; 17: 640-642. 18. Meier DE, Back AL, Morrison S. The inner life of physicians and care of the seriously ill. JAMA 2001; 286: 3007-3014. 19. Wang XS, Di LJ, Reyes-Gibby CC, Guo H, Lui SJ, Cleeland CS. End-of-life care in urban areas of China: a survey of 60 medical oncology clinicians. J Pain Symptom Manage 2004; 27:125-132. 20. Sebastin P, Varghese C, Sankaranarayan R et al. Evaluation of symptomatology in planning palliative care. Palliat Med 1993; 7: 27-34. 21. Burn G. Promoting effective palliative care in India. Eur J Pall Care 1996; 3: 113-117. 22. Rajagopal MR. Problems of palliative care delivery in India. Indian J Palliat Care 1996; 2: 31-33. 23. World Health Organisation. WHO Definition of Palliative Care [online].Available from:http://www.who.int/cancer/palliative/definition/en/ [ accessed 29 November 2007].

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Diagnostic

Value

Subacromial

Impingement

Tests

Subacromial Impingement Syndrome Stage I. Ramneet Kaur MSc. Physiotherapy (Sheffield Hallam University) Abstract: Objectives: The aim of this study is to review the various diagnostic tests applied for detection of subacromial impingement syndrome (stage I) according to its diagnostic values. Data sources: CINAHL, MEDLINE (SP), MEDLINE via SCIRUS, AMED, PubMed, The Cochrane Library and various sources including general medical databases were explored. Review methods: Electronic databases search along with the hand searching reference lists of identified studies and journals were carried out. Studies were included that evaluated physical examination tests (The Neer impingement test, Hawkins-Kennedy test, painful arc test , crossbody adduction test, Speed’s tests, drop arm test, empty can test, infraspinatus test, yergason’s test and yocum’s test) in patients suspected of having subacromial impingement syndrome with pathologies at stage I. Outcomes assessed were specificity, sensitivity, predictive values, likelihood ratios and accuracy. Only cohort studies were included. Results: Four studies were critiqued with only half demonstrating acceptable high quality. The sensitivity, specificity, predictive value, accuracy and likelihood ratio of 10 tests varied considerably. Neer test and Hawkins-Kennedy test were the commonly used tests in all the four articles and highest accuracy among the entire tests was of Hawkins-Kennedy with 72.8% followed by Neer test with 72%. The Hawkins-Kennedy test was found to have high sensitivity of 92% followed by Neer test with high sensitivity value of 89%. Conclusion: Author has been unable to draw any conclusion about the diagnostic values of subacromial impingement syndrome for stage I. Only four studies were identified which assessed the diagnostic values of different tests in stage I. Among these studies there was wide variation regarding patient population, variability in symptoms and inconsistency in testing performance. Further research is needed for more validated conclusion about the diagnostic value of subacromial impingement syndrome for stage I which ultimately help us to provide more targeted treatment. Keywords: Subacromial impingement syndrome; diagnostic tests; sensitivity; specificity; predictive values; likelihood ratio.

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Introduction:

impingement are shoulder bursitis, rotator cuff tendinosis and rotator cuff tears. In these pathologies the structures involved get irritated and inflamed that leads to subacromial impingement syndrome. The main features of subacromial impingement syndrome were first described by Neer7 in 1972. He has classified three stages of subacromial impingement syndrome. In stage I: oedema and haemorrhage; stage II: cuff fibrosis, thickening and partial cuff tearing and stage III: full thickness tendon tears, bony changes and tendon rupture.7,8 There has been lack of consensus regarding the understanding of pathology of subacromial impingement syndrome and above classification has been criticised as it does not considers structures and processes involved in pathology.9

Shoulder joint is the most mobile joint in the human body and shoulder dysfunction is one of the most common causes of disability. A survey in UK estimated the prevalence of self reported shoulder pain at 16%1 which rises to 26% in the elderly.2 Study showed that in primary care shoulder pain is the third most common cause of musculoskeletal consultation. In a one year period, prevalence of shoulder pain is as high as 50% and some fraction of those afflicted only consult a physician.3 Also about 50% of all new episodes of shoulder complaints presented in primary care show complete recovery within 6 months4, although after a period of 1 year the proportion of patients having shoulder dysfunction increases to 60%.5 There are many contributing factors that lead to progressive degeneration and weakening of the tissues that vary with the individualistic life styles and age. Shoulder dysfunction is often difficult diagnose properly due to lack understanding of diagnostic values diagnostic tests used and secondly lack understanding of complex pathology shoulder dysfunction. This often results poor prognosis and recurrences.

Due to lack of consensus regarding shoulder disorders classification it becomes difficult to approximate the frequency of the underlying causes of shoulder pain. Research suggests that several diagnostic tests should be carried out when making a diagnosis of subacromial impingement syndrome and efforts should be made to identify the faulty structures.10,11,12. Therefore diagnostic tests play a vital role in diagnosing the subacromial impingement which further helps in its treatment.

to of of of of in

Most of the shoulder problems fall into 3 major categories: articular injury, soft tissue disorders, and arthritis and in that subacromial impingement syndrome is one of the common shoulder problems which cover a range of shoulder pathologies with different clinical symptoms like pain and weakness.6 Subacromial impingement was diagnosed in 29% of shoulder pain cases making it most frequent diagnostic cause of musculoskeletal shoulder pain.6The common pathologies of subacromial

There are many diagnostic tests available to confirm the diagnosis of shoulder problems. Tests like X- rays, MRI (magnetic resonance imaging), anthrogram and injection under anaesthesia can provide added benefit for the identification of the subacromial impingement but a physiotherapist has a substantial role in detailed physical examination with clinical diagnostic tests before putting a treatment programme. Several studies 10,13,14,15,16 have 29

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clinical practice17 and so studies utilising only asymptomatic subjects were excluded from this review.18 Studies conducted on cadavers were also excluded as to investigate biomechanics may under estimate variables which are found in human subjects such as inflammation, swelling or muscle contraction.19

examined the accuracy of individual diagnostic tests. However, till now there is no systematic review which has investigated diagnostic values of these diagnostic tests in subacromial impingement syndrome for the stage I pathologies. According to one of the author14 the specificity and sensitivity have been studied on a limited basis with no documentation reflecting a biased diagnostic accuracy on shoulder impingement syndrome. Thus the reviewer emphasises that there is a necessity of evaluating the evidence for the diagnostic values in terms of sensitivity, specificity, predictive values, likelihood ratios and accuracy of diagnostic tests in subacromial impingement syndrome.

Types of instruments / procedures: Those studies which evaluated the diagnostic values of diagnostic tests in subacromial impingement syndrome for stage I was included. Tests which are commonly used in the clinical practice were included that are Neer test, HawkinsKennedy test, painful arc test, supraspinatus muscle test, Speed test, cross-body adduction test, drop-arm test, infraspinatus muscle test, yocumâ&#x20AC;&#x2122;s test and yergasonâ&#x20AC;&#x2122;s test. Studies that have used any kind of reference tests like arthroscopy, MRI, surgery, arthrography or subacromial injection test for comparison were also included. Plain X-rays and CTA were excluded from the study as these techniques have a limited value in diagnosis of subacromial impingement syndrome. All the studies were having one of the above mentioned impingement tests.

Methods: Criteria for considering studies for the systematic review: Types of Studies: Only English language studies were included to evaluate the diagnostic values of the tests for stage I subacromial impingement syndrome. Types of participants:

Types of outcome measures:

Patients which were diagnosed with soft tissue disorders of shoulder including subacromial impingement syndrome, bursitis and rotator cuff tendinosis and studies which involved human subjects with age (14years<more) were included. Studies that included inflammatory or systematic diseases, acute traumatic conditions and shoulder problem due to neck and elbow disorders were excluded. Attempts to identify abnormality in asymptomatic subjects may not represent

This review includes only studies that considered any of the diagnostic values: sensitivity, specificity, predictive values, and likelihood ratio for any of the impingement tests for stage I pathology. Identification and selection of studies: An electronic search of CINAHL (1984November 2007), AMED (1982-November 2007), OVID Medline (1980-November 2007), Pub med (1985-November 2007) 30

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and the Cochrane Library (1980November 2007) using the displayed search term (appendix 01) was carried out initially; which was further followed by hand searching.

All the 14 steps is scored as “yes”,” no”, or “unclear”. For scoring each of the 14 items individual procedures including questions have been published even though a cumulative methodological score is not advocated.21 Studies used in the past17,23,24 have used score of 7 out of 14 or greater “yeses” to show high quality diagnostic accuracy study whereas if the score is below 7 it indicate low quality study. Experience based on 2 authors in using the QUADAS tool in their text25, we recognised high quality score as 10 of 14 or greater “yeses”, whereas score below 10 is considered with low quality study.

Definition of different shoulder conditions and their synonyms were carefully taken into consideration in search strategy to ensure that studies which are relevant are identified. All searched studies were reviewed against the inclusion criteria for eligibility. Likely eligible studies, whose titles and abstracts provide insufficient information to determine suitability for inclusion, were obtained in full-text by hand search. Hand searching was carried out with the help of reference list of the articles found from the electronic search. Some of the articles were obtained by inter library loan. The full text version of all the included studies were subsequently collected and used to verify the inclusion of these studies prior to proceeding to their evaluation.

Data analysis: Data of studies which were having diagnostic values of the tests were considered for pooling of the results. In those studies statistical analysis was carried out with use of statistical package for the social sciences (version 10.0; SPSS) and the diagnostic values were calculated by using 2x2 methods.10

Quality assessment is as important in systematic reviews of diagnostic test studies as it is in any other review.20The quality grading of the studies was done using QUADAS20,21 tool (table 1). Though QUADAS tool includes items which cover bias, variability and the quality of reporting, this is the tool which is systematically developed through thorough evaluation21 for diagnostic studies and also the most reliable scale for assessing quality of study. The tool used is based on Delphi22 and assess the methodological quality of the trials. By using this tool the reviewer can identify the quality of the included studies. QUADAS assessment tool involves individualized scoring of 14 components. 31

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Table 1: Methodological assessment of studies using QUADAS tool Criteria

Park et al 2005

Calis et al 2000

1 Was the spectrum of patients representative of the patients who will receive the test in practice?

Yes

2 Were selection criteria clearly described?

Yes

3 Is the reference standard likely to correctly classify the target condition?

Yes

4 Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

Yes

Unclear

Yes/No/Unclear

Unclear

MacDona ld et al 2000

Leroux et al 1995

5 Did the whole sample or a random selection of the sample receive verification using a reference standard?

Yes

6 Did patients receive the same reference standard regardless of the index test result?

Yes

7 Was the reference standard independent of the index test (i.e. the index test did not form part of the reference standard)?

Yes

8 Was the execution of the index test described in sufficient detail to permit replication of the test?

Yes

9 Was the execution of the reference standard described in sufficient detail to permit its replication?

Yes

10 Were the index test results interpreted without knowledge of the results of the reference standard?

Yes

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Criteria

11 Were the reference standard results interpreted

Park et al 2005

Calis et al 2000

Yes

MacDonal d et al 2000

Leroux et al 1995

Yes

without knowledge of the results of the index test? 12 Were the same clinical data available when the test results were interpreted as would be available when the test is used in practice?

Yes

13 Were uninterpretable/intermediate test results reported?

14 Were withdrawals from the study explained?

Yes

TOTAL SCORE

Results:

Unclear 8

Yes No 8

Unclear 11

which two studies scored 10 which is believed to be high quality accuracy study.27,28 Out of the 4 studies, 3 used statistical package for the social sciences (SPSS) by using 2x210,14,28 tables for calculation. Whereas in one study no statistical tool was mentioned.27The characteristics of all trials10, 14, 27, 28 are discussed.

Overall 9 studies were identified from electronic databases during initial search. Only 6 studies were found to be potentially relevant for detailed evaluation .Out of 6, 4 studies met the criteria for the systematic review.10,14,27,28 Rest of 2 studies19,26 were relevant but were excluded as one was measuring reliability and validity of the impingement syndrome instead of calculating the sensitivity, specificity, predictive value and likelihood ratio of the impingement tests.9Second study26 was excluded because it was studying the diagnostic accuracy of full can and empty can tests for the torn supraspinatus tendon condition only. All the relevant 4 studies achieved a score of 8 or more out of 14 according to the QUADAS tool .Out of

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Table 2: Total studies =9 Medline =6 CINAHL=1 Sports discuss=2 Cochrane =0

Total studies=9 Total excluded=1 Systematic reviews=2

Articles with Full texts=6

Studies excluded=2

Relevant studies included in review=4

Findings: The diagnostic values of 10 clinical tests used in all the studies for subacromial impingement syndrome are summarised in table 3.

different values of sensitivity and specificity in different papers. Variations in methodology can be attributed to variations in these values.

Neer test and Hawkin-Kennedy test were the commonly used tests in all the four articles and highest accuracy among the entire tests was of Hawkin-Kennedy test with 72.8% followed by Neer test with 72 %.

The Hawkins-Kennedy test10 was found to have high sensitivity of 92% indicating its usefulness in ruling out the subacromial impingement syndrome with its negative results whereas its low specificity of 30.7% decreases its importance. Other studies have also shown the similar pattern of high sensitivity and low specificity for Hawkins-Kennedy test. Neer test was found to have second high sensitivity value of 89 %27 specificity of 49%. Cross-body

Sensitivity and specificity values provide useful information to recognise the probability of that test for positive and negative conditions. Each test produced 34

JOPSM 1(2012) 28-43/ Ramneet Kaur

Adduction Test and painful arc sign were in the middle categories with 80.0% and 72.6% respectively. Tests with lowest sensitivity were supraspinatus/empty can test, infraspinatus test and drop arm test. Drop arm test showed poor sensitivity (6%) but a very high specificity value (97%) explaining its usefulness in positive results. Once the results are known, then likelihood ratio is helpful to quantify the shifts in probability. Large positive likelihood ratio is desirable to favour the shifts in odds for a test to be positive and in our review none of the tests were found to have so. Hawkins-Kennedy test was found to have small negative likelihood ratio of .16 with high sensitivity value of 72.8% which indicates its usefulness for ruling out a condition when itâ&#x20AC;&#x2122;s negative and thus may provide convincing evidence. Drop- arm test with 2.7910as the highest among the entire test that may generate small shifts in probability.

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Table 3. Summary of Articles for Statistical comparison: Impingement Tests Author and Sensitivity/ Positive Accuracy Year Predictive Specificity Value/Negative Predictive Value

Likelihood QUADAS Criterion Standard Ratio Score

Neer Test Park et al 2005

85.7/49.2

20.9/95.7

54.2

1.69

Surgery

88.7/30.5

75.9/52.3

72.0

Subacromial Injection and MRI

75/47.5

36/82.9

Surgery

89/NR

NR/NR

Surgery

Stage I Calis et al 2000 Stage I MacDonald et al 2000 Stage I Leroux et al 1995 Stage I Hawkins-Kennedy Test Park et al 2005

75.7/44.5

17.4/92.2

48.7

1.36

92.1/25.0

75.2/56.2

72.8

Stage I Calis et al 2000

Subacromial Injection and MRI

Stage I MacDonald 91.7/44.3 et al 2000

39.3/93.1

Stage I 36

Surgery

JOPSM 1(2012) 28-43/ Ramneet Kaur

Leroux et al 1995

87/NR

NR/NR

Surgery

Stage I Painful Arc Sign Park et al 2005

70.6/46.9

12.3/93.8

49.2

1.33

Surgery

32.5/80.5

80.5/32.5

46.4

Subacromial Injection and MRI

0.76

Surgery

0.80

Surgery

Stage I Calis et al 2000 Stage I Supraspinatus/Empty Can Test Park et al 2005

25.0/66.9

8.8/87.4

62.1

Stage I Infraspinatus Test Park et al 2005

25.0/68.9

9.4/87.7

63.9

Stage I Speed Test Park et al 2005

33.3/69.8

14.1/87.6

65.1

1.10

Surgery

68.5/55.5

79.2/41.6

64.8

Subacromial Injection and MRI

1.25

Surgery

Stage I Calis et al 2000 Stage I Cross-body Adduction Test Park et al 2005

25.4/79.7

14.9/88.5

73.1

JOPSM 1(2012) 28-43/ Ramneet Kaur

Stage I Calis et al 2000

82.0/27.7

73.7/38.4

66.4

Subacromial Injection and MRI

Surgery

Stage I Drop Arm Test Park et al 2005

13.6/77.3

8.0/86.0

69.2

0.60

7.8/97.2

87.5/29.9

33.6

Subacromial Injection and MRI

Surgery

Stage I Calis et al 2000 Stage I Yergason’s Test Calis et al 2000

37.0/86.1

86.8/35.6

51.2

Stage I Yocum’s Test Leroux et al 1995

78/NR

NR/NR

Stage I

Discussion:

This syndrome which is the common pathway for many of the shoulder pathologies is subdivided into stages (I- IIIII) based on Neer’s original 7,8 classification. Subacromial bursitis or tendonitis comes under stage I. Partial rotator cuff tear as stage II and fullthickness or complete tear of the rotator cuff as stage III. Each successive stage is considered as progressive worsening of the condition.

Subacromial impingement syndrome is a common shoulder problem and many diagnostic tests are available to diagnose this condition therefore it is very important to look into the literature regarding its pathology and diagnostic values of these tests (sensitivity, specificity, predictive values and likelihood ratios) for evidence based therapeutic decisions.

JOPSM 1(2012) 28-43/ Ramneet Kaur

This review mainly focused on stage I which is subacromial bursitis or tendonitis to assess the diagnostic values of the tests performed for this stage as it has been suggested [11] that the use of different tests at different stages in the disease process can prove more useful.

article. For example, Neer test as the commonest test was done with different components involved in it, passive elevation and abduction27, only passive elevation28, elevation to its maximum degree of internal rotation14; this contributes to the lack of clarity of the tests. Furthermore there was no check on the physical tests and their reproducibility was not mentioned making the studies less reliable.

There were very few articles which has mentioned about the diagnostic accuracy of subacromial impingement syndrome for stage I. Till now only four articles have been published with respect to the inclusion criteria. Out of four articles two articles 10,28have looked into the diagnostic value of eight physical tests (Neer test, Hawkins-Kennedy test, painful arc test, supraspinatus muscle test, Speed test, cross-body adduction test, drop-arm test, infraspinatus muscle test) whereas other two articles14,27 have only mentioned about three (Neer test, Hawkins-Kennedy test, yocumâ&#x20AC;&#x2122;s test) or two diagnostic tests (Neer test, Hawkins-Kennedy test).

The proportion of the subjects that shows positive and negative tests results, comes under the category of sensitivity (with the condition present) and specificity (without the condition present) respectively. The Hawkins-Kennedy test10 with high sensitivity (92%) and drop arm test with high (97%) specificity may suggest their usefulness for ruling out (negative condition) or confirming (positive condition) impingement syndrome respectively. Further the small negative likelihood ratio of .16 for HawkinsKennedy test and large positive likelihood ratio of 2.79 for drop arm test also favour the small shift in probability. This large positive likelihood ratio may favours drop arm test and small negative likelihood ratio favours Hawkins-Kennedy test for the impingement with their test results as positive and negative.

Variables like reference standard, diagnostic test details and study population also provides important details of the study design and thus influences the strength of the study. Three of the articles14,27,28 reviewed for this study used surgery as reference standard and one study10 used subacromial injection and MRI investigations for verification of the diagnosis. However these standards were administered independently of the tests and to all the participants, the physicians who performed the test and the criterion standard were not blinded, thus potential review bias can be present.

The reviewer further looked at the predictive values that could have been beneficial for the decision making. It was difficult to comment upon the prevalence of the condition in reviewed studies as three studies10,14,28 calculated the values with great variation and one did not calculated it.27

Although thick description of the manner in which the tests were performed and the criteria to determine positive and negative results were detailed, they varied in each

One of the causes of this variation can be the heterogeneity of the participantâ&#x20AC;&#x2122;s age 39

JOPSM 1(2012) 28-43/ Ramneet Kaur

and sample size, making it difficult to generalise the idea and influencing the probability.

Also it seems not possible to define standardised and validated diagnostic tests until there is an agreement regarding the subacromial impingement pathology. Further research in this regard will be beneficial not only for the diagnosis but it will also help in providing targeted treatment. Whatever the evidence provided by the studies of diagnostic tests to be, these tests should be reproducible and furthermore the results should be applicable to the patients management in order to make the practice more evidencebased.

One of the limitations in the study was that all the articles have considered the patients with different stages of impingement and also there was a great variability in the degree of symptoms which could have influenced the results. None of the reviewed articles investigated the reliability and reproducibility of the diagnostic tests, so it will be difficult for the author to give conclusions on the basis of only four studies. However on analysis of the diagnostic values it showed that Hawkins- Kennedy test, Neer test and painful arc test were more sensitive and drop arm test was more specific for shoulder impingement syndrome but still more research is needed before extrapolating the results of this study. One of the articles28 has done linear regression analysis and found that combinations of clinical tests increased the likelihood ratio and post test probability though it was done for overall impingement syndrome and full thickness rotator cuff tears. This type of combination examinations have also been found to provide greater accuracy in sacroiliac joint.29 If clinically we use cluster of test to identify the subacromial impingement syndrome in stage I it seems more useful then relying on one or two test as studies done on sacroiliac joint show that out of six diagnostic tests, if four reproduces the patient symptoms implicates sacroiliac joint.29 Similar studies in subacromial impingement syndrome can be helpful. So study including combination of impingement tests in stage I may provide additional beneficial results.

Conclusion: Author has been unable to draw any conclusion about the diagnostic values of subacromial impingement syndrome for stage I. Only four studies were identified which assessed the diagnostic values of different tests in stage I. Among these studies there was wide variation regarding patient population, variability in symptoms and inconsistency in testing performance. Further research in this area is needed to address the above mentioned issues. Lack of consensus regarding the subacromial impingement pathological stages will continue to hinder the diagnostic value of diagnostic tests. Future work in this regard will help us to draw more validated conclusion about the diagnostic value of subacromial impingement syndrome for stage I which ultimately help us to provide more targeted treatment.

JOPSM 1(2012) 44-49/ Muhammad Atif Khan

References: 1. Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxy M. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Annals of Rheumatic Diseases 1998;57:649-55. 2. Chard MD, Hazleman R, Hazleman BL, King RH and Reiss BB. Shoulder disorders in the elderly: a community survey. Arthritis and Rheumatism 1991;34:766-9. 3. Bongers PM. The cost of a shoulder pain at work. British Medical Journal 2001;322:64-5. 4. Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. Primary Care Rheumatology Society Shoulder Study Group. British Medical Journal 1996;313:601-2. 5. Van der Windt DA, Koes BW, Boeke AJ, Devliie W, De Jong BA, Boulter LM. Shoulder disorders in general practice: prognostic indicatiors of outcome. British Journal of General practice 1996;46:519-23. 6. Van der Heijden GJ. Shoulder disorders: A state-of-the-art review. Clinical Rheumatology 1999;13:287-309. 7. Neer CS. Anterior acromioplasty for Chronic impingement syndrome of Shoulder. J Bone Joint Surgery 1972;54A:41-50. 8. Neer CS, 2nd. Impingement lesions. Clin Orthop Relat Res 1983(173):70-7. 9. Funk L, Levy O, Even T, Copeland SA. Subacromial plica as a cause of impingement in the shoulder. Journal of Shoulder and Elbow Surgery 2006;20(10):1-4. 10. Calis M, Akgun K, Birtane M, Karancan I, Calis H, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Annals of the Rheumatic Disease 2000;59:44-7. 11. Fritz JM, Wainner RS. Examining Diagnostic Tests: An Evidence-Based Perspective. Physical Therapy 2001; 81(9):1546-63. 12. Ostor AJ, Richards CA, Prevost AT, Hazleman BL, Speed CA. Interrater 13. reproducibility of clinical tests for rotator cuff lesions. Ann Rheum Dis 2004;63(10):1288-92. 14. Litaker D, Pioro M, El Bilbeisi H, Brems J. Retyrning to the bedside: using the history and physical examination to identify rotator cuff tears. J Am Geriatr Soc 2000;48:1633-7. 15. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. Journal of Shoulder and Elbow Surgery 2000;299-301. 41

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16. Wolf EM, Agrawal V. Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears. J Shoulder Elbow Surg 2001;10:470-3. 17. Zaslav KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. JShoulder Elbow Surg 2001;10:23-7. 18. Shah RV, Everett CR, McKenzie-Brown AM, Sehgal N. Discography as a 19. diagnostic test for spinal pain: a systematic and narrative review. Pain Physician 2005;8(2):187-209. 20. Trijffel E, Andereg Q, Bossuyt P, Lucas C. Inter-examiner reliability of passive assessment of inter-vertebral motion in the cervical and lumbar spine: a systematic review. Man Ther 2005;10(4):256-69. 21. Razmjou H, Holtby R, Myhr Terri. Pain Provocative Shoulder Tests: Reliability and Validity of the Impingement Tests. Phssiother Can 2004;56:229-236. 22. Whiting P, Rutjes Anne WS, Reitsma JB, Bossuyt Patrick MM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Medical Research Methodology 2003;3:25. 23. Whiting P, Harbord R, Kleijnen J. No role for quality scores in systematic reviews of diagnostic accuracy studies. BMC Med Res Methodol 2005;5:19. 24. Verhagen AP, De Vet HCW, De Bie RA, Kessels AGH, Boers M, Bouter LM, Knipschild PG. The Delphi List: A Criteria list for quality assessment of randomised clinical trials for conducting systematic reviews developed by Delphi Consensus. Journal of Clinical Epidemiology 1998;51(12):1235-41. 25. de Graaf I, Prak A, Bierma-Zeinstra S, Thomas S, Peul W, Koes B. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine 2006;31(10):1168-76. 26. Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician 2005;8(2):211-24. 27. Cook C, Hegedus E. Orthopedic Physical Examination Tests: An Evidence-Based Approach. Upper Saddle River, NJ: Preentice Hall 2007. 28. Itoi E, Kido T, Sano A, Urayama M, Sato K. Which is More Useful,the “Full Can Test”or the “Empty Can Test”, in Detecting the Torn Supraspinatus Tendon? Am J. Sports Med. 1999;27:65-68. 29. Leroux JL, Thomas E, Bonnal F, Blotman F. Diagnostic Value of Clinical Tests for Shoulder Impingement Syndrome. Expansion Scientifique Francaise 1995;62(6):42328.

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30. Park HB, Yokota A, Gill HS, Rassi GE, McFarland EG. Diagnostic accuracy of clinical tests for the Different Degrees of Subacromial Impingement Syndrome.The Journal of Bone and Joint Surgery 2005;87(7):1446-55. 31. Stuber KJ. Specificity,sensitivity,and predictive values of clinical tests of the sacroiliac joint:a systematic review of the literature. J Can Chiropr Assoc 2007;51(1):30-41.

JOPSM 1(2012) 44-49/ Muhammad Atif Khan

The Role of Intra-articular Corticosteroid in the treatment of OA Knee: Case Report. Muhammad Atif Khan BSc, MSc, PGD (Ortho Med) Extended Scope Spinal Practitioner Berkshire, UK.

Introduction:

Mr X was given a choice of treatment options based on best practice with regards to his personal need and all options were discussed to make a decision about his treatment.39,16 Various treatment options like hydrotherapy, electrotherapy, exercise, acupuncture, IA corticosteroid injection with lidocaine were offered to patient. Mr X was eager for immediate pain relief so opted for a corticosteroid injection followed by physiotherapy management. Corticosteroid injections can provide short term pain relief but are best for patient to get over pain flare ups.28

Mr X, a 58 year old engineer by profession, who presented with a 5 year history of intermittent right knee pain and stiffness. The pain started gradually and got worse over a period of 1 year with poor mobility. Mr X had anti- inflammatory medications from his GP and was referred to a Rheumatology consultant. A corticosteroid injection was administered to his right knee joint 1 year ago, which helped him for 3 months. Mr X not very keen on surgery, and wants conservative management to improve his quality of life.33, 34

Outcome Measures:

A full subjective and objective assessment is completed in accordance with current clinical guidelines.32,37,39 Differential diagnosis was clinically ruled out and the diagnosis of OA knee was based on American College of Rheumatology Classification criteria for OA Knee as shown in Table B in the appendix .Diagnosis was further confirmed by XRay.3,35,36,38

There were various outcome measures used to indicate the progress of Mr. X. He was asked to complete SF 36 to know the quality of life39, which has been found to be valid and reliable for various clinical conditions to produce a reliable data. VAS was assessed during 10 meter walk test, sit to stand in 1 minute, SCT prior to injection and at 8 weeks of post injection.

Management:

Procedure adopted for Intra articular corticosteroid Injection:

There have been various treatment options for pain relief and improve functions in OA Knee. General advice, patientâ&#x20AC;&#x2122;s education, weight reduction, acupuncture10, self-management and emphasis on adherence to exercise programme can improve the ROM and pain relief.

Mr X was informed about the procedure to be carried out verbally and written information provided. All side effects were verbally explained and documented. A dose of (80mg) 2ml Depomedrone (Methyl Prednisolone acetate) and 4ml of 1% 44

JOPSM 1(2012) 44-49/ Muhammad Atif Khan

Lidocaine39 was administered into patients right knee with a medial approach under comfortable, safe and aseptic 26,27,29,30, technique .

injections are useful in short term pain reduction than placebo. This study does not support enough evidence for functional efficacy though supported reduction in pain within 2-3 weeks post injection. Similar results reported by studies done by Gaffney, Ledingham &Perry.24 This study also showed that a joint should also be aspirated before injecting it to have better results.

Mr X was advised absolute rest 24hours and further rest for 1 week. Mr X was given self management home exercise programme with pain management advice post injection

There are different variety of corticosteroids being used in different studies to show the efficacy of one on other for pain management and functions. A Study done by Bellamy et al5 showed that Triamcilone Hexacetonamide is better than Betamethasone in terms of pain reduction for up to 4 weeks post injection. However another double blind RCT study, by Pyne et al32 showed that Methyl prednisolone is more effective than Triamcilone hexactonide in terms of pain reduction at week 8 measured on VAS and slight improvement in functional activities measured by LEQ tests.

Outcome Assessment: Mr X was reviewed at week 1, week 3 and at 8 weeks which showed dramatic improvement in the pain from 7/10 on VAS pre-injection to 0/10 post injection. There was improvement in the Functional activity without pain. ROM increased from 120 degrees to 130 degrees of flexion in the right knee joint with full extension with no pain overpressure.32Adherence to physiotherapy regime and home based exercise programme led to improvement in muscle strength of right quadriceps, hamstrings and right hip extensors and abductors at 8 week review.47 General improvement was indicated by SF 36.

Mr X had progressive improvement over the period of 8 weeks post injection as evidence suggest short term pain relief after corticosteroid injection7,12,20,32 where as long term pain relief can be achieved if higher dose of corticosteroid is used.4

Discussion:

The short term pain relief could act as a window of opportunity to introduce other modalities like exercise38, change in life style, reduction in weight, use of TENS machine for long term management.

It can be seen from the outcome measures after administering IA methyl prednisolone acetate into Mr Xâ&#x20AC;&#x2122;S right knee, there was overall improvement in pain at rest, mobility, muscle strength, functions and general well being assessed by SF36. However there are various discrepancies about the efficacy and safe use of intra articular corticosteroid.17,18,19,20 Bellamy et al7 in their study states that corticosteroid 45

JOPSM 1(2012) 44-49/ Muhammad Atif Khan

Conclusion:

weeks post injection in relation to pain, improved functions, muscle strength, SLR, ROM and patient was discharge with home advice and exercise programme. Emphasis was laid on self management. NICE28 states that IA steroid injections should be used as an adjunct for the treatment of OA knee. The author feels that ability to provide IA injections have shortened the patient journeys and given more confidence to practice evidence based injection therapy.

The evidence in relation to effectively and benefit of IA steroid injections is still meagre and there is a need for further research as some of the studies are poorly designed, have small sample sizes. There has to be standardisations in use of outcome measures. The efficacies of IA steroid injections have been evident through some of researches for short term.24,25 Mr X had progressive improvement during the review after 8

Appendix 1: Using History and Clinical Examination

Using history, physical examination and radiographic findings:

Using history, physical examination and laboratory findings:

Pain in knee and add 3 or more of the following:  More than 5o years of age  Stiffness lasting less than 30 minutes  Crepitus present on active movement  Bony enlargement  Bony tenderness  No temperature change over knee

Pain in the knee joint and add 1 of the following:  More than 50 years of age  Stiffness lasting for less than 30 minutes  Osteophytes  Crepitus

Pain in knee joint and add 5 of the following:  Over 50 years of age  Stiffness lasting less than 30 minutes  Crepitus present on active movement  Bony tenderness  Bony enlargement  No raised temperature of the synovial  ESR <40MM/HOUR  RF <1:40 SF

Shows 95% sensitivity and 69 % specificity

Shows 91% of sensitivity and 86% of specificity

Shows 92 % of sensitivity and 75% of specificity

Table 1: ACR Clinical Classification Criteria for Osteoarthritis of the knee

JOPSM 1(2012) 44-49/ Muhammad Atif Khan

References: 1. Altman,R.D. The classification of osteoarthritis. Journal of Rheumatology. 1995; 22:42-43. 2. Altman,R., Asch,E., Bloch, D., Bole, G., Borenstein, D., Brandt, K.,et al. Development of criteria for the classification and reporting of osteoarthritis: Classification of osteoarthritis of the knee. Arthritis and Rheumatism.2005; 29 :(8) 1039 – 1049. 3. Arroll,B. and Goodyear-Smith,F. Corticiosteroid Injections for Osteoarthritis of the Knee: Meta Analysis. BMJ.2004; 328-869. 4. Belch H.W., Gibson, J.M.C., ElGhobarey, A.F., Bain, L.S., and Lynch, M.P. Repeated Corticosteroid Injections into Knee Joints. Rheumatology. 2008; 16 :( 3) 137-140s. 5. Bellamy, N., Cambell, J., Robinson, V., Gee, T., Bourne, R., Wells, G. Intra-articular Corticosteroid for the Treatment of Osteoarthritis of the Knee. Cochrane Database of Systemic Reviews. 2006; 19 :(2) Art No: CD005328. 6. Brandt,K.D., Lohmander, L.S. and Docherty, M. Pathogenesis of osteoarthritis: the concept of osteoarthritis as failure for the diarthrodial joint’. Osteoarthritis. 1998; 7074. 7. Brian, M., Berman, M.D., Lixing, L., Langenberg, P.,Lee, W.L. and Adele, M.K., et al. Effectiveness of acupuncture as an adjunctive therapy in osteoarthritis of knee. Annals of Internal Medicine. 2004;141:(12):901-910. 8. Cardone, D.A. and Tallia, A.F.Diagnostic and Thetapeutic Injections of Hip and Knee’ –A Peer Review’. Journal Of American Academy of Family Physicians.2003. 9. Coggon, D., Croft, P. and Kellingray, S. Occupational physical activities and osteoarthritis of knee. Arthritis Rheumatology. 2000; 43:1443-1449. 10. Clinical Inquiries (2004) ‘Do Steroid Injections help with Osteoarthritis of the knee?’ The Journal of Family Practice. 2004; 53:(11): 921-922. 11. Chartered Society of Physiotherapy Position Paper on The Mixing of Medicines in Physiotherapy Practice’. CSP. London.2008. 12. Dieppe,P.A., Doherty,M., Macfarlane,D. and Maddison,P. Rheumatological Medicine, Edinburgh, Churchill Livingstone. 1984. 13. Felson, D.T., Zhang, Y. and Hannan, M.T. Risk factors for incident radiographic osteoarthritis in elderly. The Framigham Study’.Arthritis Rheumatology. 1997; 40:728-733. 14. Felson, D.T., Hannan, M.T. and Naimark, A. Occupational physical demands, knee bending and knee osteoarthritis: results from Framigham Study’. Journal of Rheumatology. 1991; 18:1587-1592. 47

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15. Fransen, M. and McConnell, S. Exercise for osteoarthritis of the knee. Cochrane Systematic Review. 2009: Issue 1. 16. Gaffney, K., Ledingham , J. and Perry, J.D.Intra-articular triamcinolone hexacetonide in knee arthritis: factors influencing clinical response. Annal Rheumatic Disease.1995; 54:379-381. 17. Godwin, M., Dawes, M. Intra-articular Steroid Injections for Painful Knees: Systemic Reviews with Meta-analysis. Canadian Family Physician.2004;50:241-248. 18. Harris, E.D., Barnett, G.D., Budd, R.C. Kelley's Textbook of Rheumatology, 7th edition, PA: Saunders Philadelphia.2005. 19. Haq, I., Murphy, E., Journal.2003;79:377-383.

Dacre,

J.Osteoarthritis

Postgraduate

Medical

20. John, A. and Doherty, M. Intra-articular corticosteroid are effective in osteoarthritis but there are no clinical predictors of response. Ann Rheum Dis. 1996; 55:829-832. 21. Kessen, M., Atkins, E. Orthopaedic Medicine; A Practical Approach, 2nd ed, Elsevier, England: Butterworth –Heinemann Ltd. 2005. 22. Kuettner,K., Goldberg,V.M. Osteoarthritis disorders. American Academy of Orthopaedic Surgeons.1995;21-25. 23. Kujola,V.M., Kettunen, J. and Paananen, H. Knee osteoarthritis in farmers, runners, soccer players, weightlifters and shooters. Arthritis Rheumatology.1995;38:539-546. 24. Lachance, L., Sowers, M.F. and Jamadar, D.The experience of pain and emergent osteoarthritis of knee’. Osteoarthritis Cartilage.2001; 9:527-532. 25. Malanga, G.A., Andrus, S., Nadler, S.F., McLean, J. Physical Examination of the knee: A review of the original test description and scientific validity of common orthopaedic tests. Archives of Physical Medicine and Rehabilitation. 2003;84 (4):592602. 26. McCaffrey, M., Noftall, F. and Rhaman, P. Intra articular Corticosteroid For Osteoarthritis Of The Knee: Does The Dose Or Solubility Effect Outcome?. Journal of Bone and Joint Surgery – British. 2005; 90-B(I): 104. 27. McCarthy, C.J., Mills, P.M., Pullen, R., Richardson, G., Hawkins, N., Roberst, et al. Supplementation of home home based execise programme with a class based programme for people with osteoarthritis of the knees: a RCT and health economic analyses. Health Technology Assessment.2004; 8(48). 28. NICE Clinical Guidelines 59 (Osteoarthritis), London: The National Institute for Health and Clinical Excellence. 2008. 29. NIH Osteoarthritis: new insights Part 2: Treatment approaches’. Annual Internal Medicine. 2000; 133:726-737.

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30. O'Reilly,S.C., Muir, K.R. and Doherty, M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Annal Rheumatic Disease.1999;58:15-19. 31. Petty, N.J. and Moore, A.P. Neuromusculoskeletal Examination and Assessment.2nd Ed; London: Churchill Livingstone. 2001. 32. Pyne, D., Loannou, Y., Mootoo, R., Bahanji, A. Intrarticular steroid in knee osteoarthritis: a comparative study of triamcinolone hexactonamide and methyl prednisolone acetate. Clinical Rheumatology . 2004;23(2):116-120. 33. Roddy, E. and Doherty, M. Changing life styles and osteoarthritis: What is the evidence?’. Best Practice Research Clinical Rheumatology.2006; 20(1): 81-97. 34. Saunders, S. and Longworth, S. Injection Techniques inOrthopedic and Sports Medicine:A Practical Manual for Doctors and Physiotherapists.3rd ed. Philedelphia, USA, Elsevier, Churchill Livingstone. 2006. 35. Malaligned and Lax Knees’. Annal of Internal Medicine. 2003; 138(8):613-619. 36. Sharma, L. The Role of proprioceptive defecits, ligamentous laxity and mal alignment in development and progression of knee osteoarthritis. Journal of Rheumatology Supplement. 2004;70:87-92. 37. Silva, L.S., Valim, V., Paula, A., Pessanha, C., Oliveira, L.M., Myamoto, S., Jones, A. and Natour, J. Hydrotherapy versus Conventional Land-Based Exercise for the Management of Patients with Osteoarthritis of the Knee: A Randomized Clinical Trial. Physical Therapy. 2008;88:(1):12-21. 38. Spector, T. D., Harris, P.A. and Hart, D.J. Risk of osteoarthritis associated with long term weight bearing sports’. Arthritis Rheumatology.1996; 39:988-955. 39. Turner, B., Bayliss, M.S., Ware, J.E., Kosinski, M. Usefulness of the SF-8 Health Survey for Comparing the Impact of Migraine and Other Conditions. Quality of Life Research.2002; 12:1003-12.

JOPSM 1 (2012) 50-60/ Jonathan Morris

Morphological and Architectural variation of supraspinatus tendon Jonathan Morris BSc, MSc STD (Keele University, Staffordshire). Abstract: The aims of the article are to specifically look at the anatomical variations of one aspect of the supraspinatus muscle: the morphology and architecture of the insertion of the tendon around the greater tubercle. The article has explored four important techniques like embryological, cadaveric, ultrasound and MRI that can have been used for the detailed analysis of the supraspinatus tendon. The article has also critically evaluated the different studies, discussing whether certain techniques are superior for understanding the structure and function better than others. In anatomical research, all these methods are essential to help develop understanding of the differences in anatomical variation, with each method displaying strengths which contribute to anatomical knowledge of many structures, including the supraspinatus tendon.

Introduction:

supraspinatus, which makes up the rotator cuff of the shoulder. According to which textbooks are read, various interpretations are reached as to the anatomical structures of the supraspinatus tendon. An example of this is the innervation of the muscle. According to Standring et al16 the supraspinatus muscle is innervated by the suprascapular nerve, via nerve root C5 and 6. However, according to Lindsay9 the suprascapular nerve only originates from the C5 nerve root, and, according to Agur and Dalley2 the suprascapular nerve originates from the C4, 5 and 6 nerve roots. This example alone shows the potential variation in human anatomy understanding, and it is clearly important to understand these variances, and why and where they occur.

Since the start of civilisation, anatomical knowledge has always been sought using a range of different methods. A good early example is the ancient Egyptian practice of mummification, whereby at least an understanding of the location of various organs was essential to perform the task. In the ensuing ancient Greek and Roman times, physicians such as Hippocrates and Galen were pioneers in performing dissections on animals as well as live criminals in order to gain anatomical knowledge3. Following the fall of these empires, it was not until the Renaissance Period where the â&#x20AC;&#x153;rebirthâ&#x20AC;? of seeking anatomical knowledge began to arise. Today, there is considerable research that has either been, or is currently being, carried out on a wide range of anatomical structures and their functions. One such area of research relates to the

The aims of the article are, therefore, to specifically look at the anatomical variations of one aspect of the supraspinatus muscle: the morphology and 50

JOPSM 1 (2012) 50-60/ Jonathan Morris architecture of the insertion of the tendon around the greater tubercle. The article will explore four important techniques that can and have been used for the detailed analysis of the supraspinatus tendon. The article will also critically evaluate the different studies, discussing whether certain techniques are superior for understanding the structure and function better than others. It will be concluded, however, that a range of different research methods are essential to allow us to understand the anatomical structures of the tendon to the fullest extent.

interval. The research question formed by the study was clear, but generalised in terms of looking at the “rotator interval” as opposed to a specific structure. However, they used the same orientation with each histological sample that they obtained. The paper was not specific in its description of using “frontal or horizontal” planes of samples, thus making it harder to maintain the validity of the research. Furthermore, Abe et al 1 used hematoxylin and eosin for their staining solution, but did not state why. Despite the weaknesses, Abe et al found some interesting evidence. The study stated that, initially at 9 weeks, the supraspinatus tendon, along with the infraspinatus and subscapularis, were seemingly altogether, being separated away from the joint cavity by the glenohumeral ligament. However, at 12 weeks the tendons have all managed to connect to the humeral head, following development of the shoulder complex. Abe et al1 also suggest, by 12 weeks, that superficially and superiorly the supraspinatus tendon has formed closely with the infraspinatus tendon. The infraspinatus tendon, along with the coracohumeral ligament, seem to squeeze the insertion of the supraspinatus, but again the paper lacks detail as to where they found this specific insertion to be. The paper seems to demonstrate that the infraspinatus and supraspinatus tendons are as one, and form very closely. The research, therefore, may show that these tendons are not separate entities but are anatomically the same tendon.

Embryology: The predominant use for embryonic development is for improving clinical knowledge and the prevention of congenital diseases15. Embryonic studies show that muscles generally derive from the mesoderm, one of the three germ layers10. It is generally accepted that somites have various layers, including the ventral and dorsal aspect. The ventrolateral part near the mesodermal part of the budding forms the muscle which becomes the musculature within the limbs10. No research specifically on the supraspinatus tendon has been conducted by embryologists, however, simply because the muscle has yet to be developed. Nevertheless, this research method has provided some valuable information. One paper by Abe et al1 looks at the rotator cuff interval, which includes the anterior supraspinatus. The research used 20 fetus’ shoulders from the average fetus age of 7-8 weeks (range of 7-15 weeks). Abe et al1 used histological studies in order to research the anatomy of the rotator cuff

Another paper, by Fealy et al4 has a similar approach to Abe et al1 except the study focused more on the joint capsule and 51

JOPSM 1 (2012) 50-60/ Jonathan Morris labrum rather than the rotator cuff muscles. This paper discusses the minimal ossification of the scapula, which in turn impacts on the origin of the supraspinatus, and therefore the tensions on the supraspinatus tendon. This could therefore mean that if not formed correctly, the supraspinatus may not have the appropriate torsion onto the humerus, which could affect shoulder stability, all from a very early age. Fealy et al4 make a significant point of stating that they were not aware of how the fetus subjects perished, and so are inferring that the shoulder joints they were experimenting on were healthy, without pathology. However, Fealy et al4 paper has similar weaknesses to those present in Abe et al1 findings, which suggests reasons as to why further research are needed to develop our understanding of the fetal shoulder joint.

give general overviews of the anatomy, but there is a high risk of generalising conclusions to the human population. From analysing the evidence available, it was difficult to find information from studies in the literature regarding the anatomy of the supraspinatus tendon via cadaveric methods. A lot of studies seemed to focus on pathology or how the pathology came about. Other studies have examined supraspinatus, but either of only the muscle belly, or both the muscle and tendonous unit. One paper, for example, by Roh et al14 examines the muscle belly and tendon, so have taken the evidence only for the tendon aspect. In addition, once more appropriate studies were identified; a common problem was the age of the specimens. For example, one study undertaken by Roh et al14 had the mean age from 25 embalmed cadavers of 82 years. Another study by Halder et al5 had a mean age of 77 years from 13 cadavers. This alone could create problems in the validity of the results obtained. However, as donations of cadaver specimens are not easily obtained, it is difficult to discard results of these studies based on this factor alone. In fact, there is value in these papers that can show very interesting findings which can help with anatomical knowledge.

Cadaver studies: Upon reviewing the literature, there is a high proportion of research that shows cadaveric studies as the anatomist’s choice for analysing the anatomy of the supraspinatus tendon. While using cadavers means that anatomists can look directly into the supraspinatus tendon, there are weaknesses to this method, including the state of the specimens used, as tissue starts to deteriorate quickly once obtained. There is also the question of the age of the specimens, which could show signs of pathology, and may not be representative of the adult population. Cadaveric studies tended to use histological studies, of a similar sort used in embryonic research. Further, there is also cadaveric research used to analyse animal supraspinatus tendons. This may

The study by Roh et al14 tried to examine the gross morphological aspect of the supraspinatus muscle and tendon. From their findings, the study found that, in comparison to the anterior and posterior supraspinatus tendon, although their average mean cross sectional area was proportionally 0.9:1 (anterior = 26.4 ±11.3 mm² and posterior = 31 .1 ± 10.1 mm²), the anterior tendon had to manage tensile strength of up to 288% more than the 52

JOPSM 1 (2012) 50-60/ Jonathan Morris posterior tendon. The assumption is that “Tensile strength is proportional to the physiologic cross sectional area (PCSA)” of the muscle14. The paper overall was difficult to understand initially, but the results obtained can be of value. The results mean that if a patient tears only part or even fully the posterior aspect of the supraspinatus tendon, the patient may still functionally be able to use the shoulder, as a lot more stress is applied to the anterior portion of the tendon.

research into this specific anatomical variation would be needed to substantiate Kolts’ results.

Ultrasound (US): Using US as a method for gaining anatomical knowledge has strengths and weaknesses. A positive aspect is that using US means that pictures can be taken to aid research and thus help with reproducibility. US can also be used on in-vivo subjects, so that the normal average age of subjects could be more reflective of the population. Further, US can help analyse dynamic movement of the supraspinatus tendon, amongst other soft tissue structures, so that function can be researched, in a way unavailable with cadaveric specimens, thus being more accurate, valid and reliable. US can also be used to look at vascularity, measuring blood vessels and blood flow. In anatomical research, analysing blood flow is important because we know that if an anatomical structure is well vascularised, then there is more chance of healing the soft tissue following any lesion. However, there are disadvantages in that sometimes US cannot measure everything. One example involving the supraspinatus tendon is under the acromion on the scapula, which causes “shadowing”. The US will unfortunately be unable to pick up underneath the acromion as it relies on echoes in which bone reflects back strongly and, therefore, the equipment is unable to “see”. Using US is highly `specialised, which means a qualified professional must use the equipment.

Another study undertaken by Kolts8 showed some interesting results. The paper describes a similar pattern to using 37 cadaveric shoulders to examine the gross anatomy of the supraspinatus. Although the paper describes the age range of patients (49-82 years), there is no mention of the mean, which can affect the reliability of the results. The paper does not mention the ratio of male to female cadavers used. However despite these provisos, in 10 of the specimens used, the supraspinatus was seen to be inserting onto the lesser tubercle of the humerus, and even in some instances merging with the subscapularis tendon. The value of the information could be significant, as the results could further indicate variation of anatomy for the tendon for surgical techniques, as well as how the tendon may function differently. Using surgical techniques to operate on the supraspinatus may, therefore, need to consider the position and function of other rotator cuff tendons. The paper raises further questions as to whether the differentiation of tendons in the rotator cuff occur fully, or could potentially all work as one tendon.

Upon searching for papers on the specific technique of using US to analyse the supraspinatus tendon with no pathological

According to Kolts8 a significant amount of the population could demonstrate this variation. It is clear, however, that more 53

JOPSM 1 (2012) 50-60/ Jonathan Morris changes, there seemed to be surprisingly few papers available.

Despite the weaknesses seen within the Turrin & Cappello’s paper17, there are some positive aspects in terms of reliability.

However, one paper that uses US as a means of analysing the supraspinatus tendon is by Turrin & Cappello17. The research project used US to study the right shoulder only of 12 healthy subjects. There are some weaknesses to the research that initially decrease the value of the paper. One such weakness is the fact of having an ambiguous research question, which states the researchers “undertook the following study to look for more detailed anatomic features at sonography and to address features that could cause a misdiagnosis”17.

The research was methodological in its approach to always using the same shoulder for examination, and the position used was clear, with a diagram to illustrate this. The paper also describes the use of anatomical landmarks to show where they would study and take pictures, which, although specific to the individual measured, maintains reproducibility. The study used 12 subjects, and had a mean age of 35 years (range 18-47) which shows a good range of subjects used diminishing the danger of degenerative changes occurring at the supraspinatus tendon. In addition, the research data was analysed by two experienced sonographers, although these were the researchers themselves which could raise the potential for bias in their results.

Although the title of the study suggests that the supraspinatus tendon is predominantly what the researchers wanted to look at, the research question is not clear about this. In addition, the paper makes some assumptions which are not clear. One is the position of the subjects while the US was performed. The paper describes the subjects’ position as supine, with the arm under scrutiny being let to drop towards the floor, the forearm in pronation and elbow in extension. This position is denoted as the best to get a clear view of the supraspinatus tendon; however, this is not shown to be proven by preliminary studies, nor referenced by previous research. A 10 year old subject was used to analyse the supraspinatus, but there is no clear reason why. The paper states that the young subject was used as there is “less acromial shadowing” which could affect the view via the US, but again no reference or preliminary work was done to validate this. The paper also uses only the right shoulder, which could show discrepancies between dominant and non-dominant arms.

Overall, the valuable information shown from the paper seem to demonstrate that there are actually two parts of the tendon, which show two completely different sections, the anterior and posterior supraspinatus tendon. Turrin & Cappello17 describe the anterior part of the tendon as cylindrical, whereas the posterior tendon is described as flat. As seen in the Roh et al14 study, the anterior tendon was far stronger than the posterior tendon, which would suggest the cylindrical shape is used for stronger function, which could be applied to other tendons in the body. The US lateral view of the supraspinatus tendon, seen in Figure 1, shows the anterior tendon (white arrow) and the posterior tendon (black arrow).

JOPSM 1 (2012) 50-60/ Jonathan Morris Figure 1a to 1b illustrates the view going outwards on a lateral plane with the anterior tendon staying uniform, whereas the posterior tendon thickens. The uniform pattern of the anterior tendon, therefore, may show the reason why Roh et al14 found this tendon to be significantly stronger than the variable thickness of the posterior tendon. These results are useful

and therefore the paper has value for the research findings. However, due to the weaknesses of the paper, more research would be needed in order to help corroborate its conclusions.

Figure 1a

Figure 1b Turrin & Cappello

Another paper by Kim et al7 tries to investigate the whole supraspinatus muscle. This includes the superficial, middle and inferior part of the anterior and posterior portions of the supraspinatus muscle belly. The paper had a more specific and focused research question than Turrin and Cappello17, and Kim et al7 interestingly use the Roh et al14 cadaveric study discussed earlier as part of their introduction to the research question. Kim et alâ&#x20AC;&#x2122;s 7 research studies used a much more specific protocol relating to the position of the subject, along with more in-depth inclusion and exclusion criteria. The protocol used, however, was developed from a previous study, conducted by the same researchers, which could introduce bias and thus affect results.

The study was also more specific in wanting to analyse the fibre bundle length, pennation angle of the muscle to the tendon, and muscle thickness, as well as measuring these in different arm positions. However, reading the resultant paper gives the impression that too many aspects were being measured, meaning the study itself is at times difficult follow. Kim et al7 may have benefited from only looking at one specific aspect of the supraspinatus. Furthermore, although Kim et al7 also describe the positions of the patients, more information would be helpful in order to improve the repeatability of their methodology, and thus improve the reliability of the results. By using the cadaveric method of gaining anatomical 55

JOPSM 1 (2012) 50-60/ Jonathan Morris knowledge, the researchers were able to use the results to develop their US study.

many strengths. The fact of being able to see the soft tissue in such detail allows for better quantitative measurement of musculotendinous morphology18.

These developments therefore allow us to understand the anatomy of the supraspinatus tendon. An example of this is shown in the study by Kim et al7, where they used a cadaveric study to analyse the supraspinatus musculotendinous unit. The researchers found that, as well as an anterior and posterior supraspinatus tendon, there were two more separate sections, the extra- and intra-muscular portion. Furthermore, Kim et al7 found that in 16 of the 17 subjects, one anterior intramuscular tendon was seen. However in one subject, two intra-muscular tendons were seen. These findings could have happened congenitally, following the formation of the muscles from the embryo formation.

As with US, MRI can be used to take still pictures so that a “slice by slice” account of the anatomy can be analysed, in various 3-dimensional planes. MRI can be even more specific than ultrasound in analysing anatomy and vasculature, but is more difficult to use for functional movement. Usually the subject has to be motionless; otherwise the radiological picture obtained will be inaccurate. The cost of using MRI for research may also be a limiting factor, especially in relation to more cost-effective US research methods. Despite its obvious potential benefits, the literature reveals few MRI studies that actually measure the morphology of the supraspinatus tendon. One paper by 12 Nakajima et al looks into the anatomy of the supraspinatus tendon on cadavers, and forms part of the research question, however the results and discussion focus on what type of MRI technique is best to gain more accurate data for measuring morphology, so therefore the techniques used help to gain anatomical knowledge. Another study by Jones6 focuses on the “critical zone” of the supraspinatus tendon, which is located approximately one centimetre away from the humeral head attachment. Jones6 only reference to the morphology of the supraspinatus tendon is that the musculotendinous junction appears at the highest point of the humeral head in all the healthy volunteers analysed.

Further, the anterior deep and middle layers of the supraspinatus connect to the intra-muscular tendon, and therefore it may be deduced from these results that the superficial layer connects to the extramuscular layer. These results show the further complexities that help explain the reason why the supraspinatus tendon can potentially be prone to injury. Therefore, when the rotator cuff is surgically repaired, the supraspinatus tendon may need more indepth surgery to connect the specific attachments for normal anatomy and thus better recovery.

Magnetic (MRI):

Resonance

Imaging

These findings are very difficult to interpret as no other specifics are described, such as how far in the sagital plane the tendon lies, or even in the frontal

Using MRI as a means of analysing supraspinatus tendon morphology has 56

JOPSM 1 (2012) 50-60/ Jonathan Morris plane, despite having MRI as a 3dimensional tool. This, therefore, shows that both the Nakajima et al12 and Jones6 studies are of limited value to gaining anatomical knowledge as to the tendon morphology of supraspinatus.

not specifically allow for knowing the 3dimensional co-ordinates that MRI can allow, thus decreasing value. Nevertheless, the value of recognising these anatomical variations is significant in relation to whether this can link in functionally with the strength of the muscle. One such instance is that the tendon could be weaker if the tendon forms more laterally, which future MRI studies could investigate. In summary, these studies show that although MRI can allow for better anatomical knowledge of the supraspinatus tendon, all the available literature seems to focus on the method of MRI itself, or with pathology as opposed to anatomical variations, architecture and morphology. However, it is clear that MRI research may significantly help anatomists to increase their understanding of the supraspinatus tendon, by seeing the different variations and therefore the functions of the tendon.

A study by Neumann et al13 also wanted to look at variations of different MRI signal intensities, finding which signal was best for imaging the supraspinatus tendon. The study was explicit in describing the method, including the MRI scanner and planes of view used, the number of subjects (32: 23 men and 9 women), which shoulders were used (55 shoulders used: 31 right and 24 left), and age range (mean 26 years old, range 22-45 years). However, the major weakness of the study came from the results, which focused on shoulders that were asymptomatic, but showed signs of degeneration. The researchers clearly wanted to look at normal anatomy, but the study started to review abnormal shoulder structures.

Conclusion:

Furthermore, the resultant paper then discusses the various MRI signal intensities, and barely covers the architecture or morphology of the supraspinatus tendon. The one aspect of architecture the study describes, briefly, is where the musculotendinous junction starts. Neumann et al13 describe the musculotendinous junction in relation to the “humeral head”, in which 30 shoulders of subjects started at “12 o’clock over the humeral head”.

Overall, there are at least four significant research methods that can be used to look at the architecture and morphology of the supraspinatus tendon. Embryological research has enabled anatomists to propose that the supraspinatus and infraspinatus tendon may actually be the same tendon, rather than two separate entities. Cadaveric studies have helped to show that, although there is an anterior and posterior supraspinatus tendon that roughly has the same cross-sectional area, the anterior portion deals with 288% more torsion than the posterior portion. Kolts6 even found the variation of the subscapularis tendon attaching with the supraspinatus tendon on the lesser tubercle of the humerus, showing

The study found 18 of subjects’ shoulders were 15 degrees lateral to the humeral head, 4 shoulders were 30 degrees lateral, and 3 shoulders were 15 degrees medial to the humeral head. As with the Jones6 study, these descriptions are vague, and do 57

JOPSM 1 (2012) 50-60/ Jonathan Morris further anatomical variations. US studies have allowed further analysis of the tendon, showing not only that there is an anterior and posterior, but also an extramuscular and intra-muscular part to the supraspinatus tendon. Further, the anterior is shown as a cylindrical structure whereas the posterior aspect is the more flat-shaped tendon, which could account for the different functions the tendons have to carry out for the strength and stability of the glenohumeral joint. Finally, there are MRI studies that show variations of normal anatomical features, and, although limited, these studies are of significant potential value in finding more 3-dimensional information about the supraspinatus tendon. In anatomical research, all these methods are essential to help develop understanding of the differences in anatomical variation, with each method displaying strengths which contribute to anatomical knowledge of many structures, including the supraspinatus tendon.

JOPSM 1 (2012) 50-60/ Jonathan Morris

References: 1. Abe, S., Nakamura, T., Rodriguez-Vazquez, J.F., Murakami, G. & Ide, Y. Early fetal development of the rotator interval region of the shoulder with special reference to topographical relationships among related tendons and ligaments. Surgical and Radiologic Anatomy. 2011; 33(7): 609-15. 2. Agur, A. & Dalley A. Grant’s Atlas of Anatomy. 12th Edn. London: Lippincott Williams and Wilkins;2009. 3. Cunningham, A. The Anatomist Anatomis’d. Farnham: Ashgate Publishing;2010. 4. Fealy, S., Rodeo, S.A., Dicarlo, E.F. & O’Brien S.J. The developmental anatomy of the neonatal glenohumeral joint. Journal of Shoulder and Elbow Surgery.2000; 9 (3): 217-22. 5. Hadler, A., Zobitz, M., Schultz, F. & An, K.N. Structural properties of the supraspinatus tendon in two joint positions. Journal of Musculoskeletal Research.2001; 5 (2): 105-112. 6. Jones, A. Magnetic resonance imaging of the supraspinatus tendon: the significance of signal intensity alterations at the 'critical zone'. Australasian Radiology.1998; 42: 106-113. 7. Kim, S., Bleakney, R., Boynton, E., Ravichandiran, K., Rindlisbacher, T., McKee, N et al. Investigation of the static and dynamic musculotendinous architecture of supraspinatus. Clinical Anatomy.2010; 23: 48-55. 8. Kolts, I. A note on the anatomy of the supraspinatus muscle. Archives of Orthopaedic and Trauma Surgery.1991; 111: 247-249. 9. Lindsay, D. Functional Human Anatomy. London: Moseby;1996. 10. Mitchell, B. & Sharma, R. Embryology: An Illustrated Colour Text. 2nd Edn. London: Elsevier; 2009. 11. Mochizuki, T., Sugaya, H., Uomizu, M., Maeda, K., Matsuki, K., Sekiya, I. et al. Humeral Insertion of the Supraspinatus and Infraspinatus. New Anatomical Findings Regarding the Footprint of the Rotator Cuff: Surgical Technique. The Journal of Bone and Joint Surgery.2009; 91: 1-7. 12. Nakajima, T., Hughes, R. & An, K. Validation of MRI-based measurements of supraspinatus morphology. Journal of Musculoskeletal Research.2003; 7 (1): 15-23. 13. Neumann, C., Holt, G., Steinbach, L., Jahnke, A. & Peterson, S. MR imaging of the shoulder: appearance of the supraspinatus tendon in asymptomatic volunteers. The American Journal of Sports Medicine.1992; 158: 1281-1287. 14. Roh, M., Wang, V., April, E., Pollock, R., Bigliani, L & Flatow, E. Anterior and posterior musculotendinous anatomy of the supraspinatus. The Journal of Shoulder and Elbow Surgery.2000; 9: 436-440. 59

JOPSM 1 (2012) 50-60/ Jonathan Morris 15. Sadler, T.W. Langmanâ&#x20AC;&#x2122;s Medical Embryology. 11th Edn. London: Lippincott Williams & Wilkins; 2010. 16. Standring, S., Borley, N., Collins, P., Crossman, A., Gatzoulis, M., Healy, J. et al. Grayâ&#x20AC;&#x2122;s Anatomy: The Anatomical Basis of Clinical Practice. 40th Edn. Oxford:Elsevier;2008. 17. Turrin, A. & Cappello, A. Sonographic anatomy of the supraspinatus tendon and adjacent structures. Skeletal Radiology.1997; 26: 89-93. 18. Warner, J., Higgins, L., Parsons, I. & Dowdy, P. Diagnosis and treatment of anterosuperior rotator cuff tears. The Journal of Shoulder and Elbow Surgery. 2001;10: 3746.

JOPSM 1(2012) 61

Letter to the Editor __________________________________________________________________________________________________________________________________________________________________________________

Dear Editor,

I am also hopeful that we will get many articles which will help us to practice effectively in our field.

I would like to write my concerns to you and would appreciate if you can publish them in your journal. I truly believe that they will create some awareness between our physiotherapists in Pakistan. Can somebody tell me, how many libraries do we have in Pakistan which keeps physiotherapy journals? How many physiotherapy students / physiotherapists do have access to them? Possibly 5% of whole Pakistani physiotherapists or even less than that has access to latest evidence in field of physiotherapy or full access to renowned journals in the world. Therefore, I appreciate your team to create online resource where physiotherapist/students can request articles of interest.

Ali Furqan

At present, we do not have any journal of physiotherapy in Pakistan, which can come up with innovative, constructive and quality studies. I must admit that it is good to see that some physiotherapist who graduated from our countryâ&#x20AC;&#x2122;s institutes and sat on the same benches where we do, are coming up with journal of international standards. I am not sure what would be the contents of that journal, but I am sure that it would be a quality work. I truly think that this journal will set a milestone towards progression of physiotherapy society and practicing physiotherapists in Pakistan and will encourage students and graduates to participate actively in research activities.

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Research

reports,

systematic

that paid for this assistance.

literature reviews, and technical notes require the body of the

References: 75 or fewer. References

JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk

JOPSM 1(2012) 62-66 should be listed in the order of

Journals

appearance

Titles of journals should be abbreviated

numerical

the

manuscript,

superscripts

that

appear

as they appear in the MEDLINE

consecutively in the text. All references

Journals Database.

in the references section must be cited in

Petty NJ, Bach TM, Cheek L. Accuracy

the text. References must be cited in the

of feedback during training of passive

text by using the reference number in

accessory intervertebral movements. J

superscript at the end of the sentence or

Manual Manipulative Ther 2001;9:99-

the referenced portion of the sentence.

108.

The reference goes after the author’s

Book

name when the author’s name is listed

Boscheinen-Morrin J, Conolly WB. The

(e.g., Davies1). If there are only 2

Hand: Fundamentals of Therapy. 3rd ed.

authors in the reference, then the text

Boston: Butterworth Heinemann; 2001.

should include both authors (e.g., Davies

P.26.

and Ellenbecker1). If the reference has

Internet

more than 2 authors, the text should

Australian Institute of Health and

include ‘’et al’’ after the first author’s

Welfare. Chronic diseases and associated

name (e.g., Davies et al1). In the

risk factors [document on the Internet].

reference section, when a reference has 6

Canberra: The Institute; 2004 [updated

or more authors, list the first 3 authors,

2005 June 23; cited 2005 Jun 30].

followed by ‘’et al’’. Abbreviations for

Available from:

the journals in references must conform

http://www.aihw.gov.au/cdarf/index.cfm

to those of the National Library of

E-Journal

Medicine

Evans C, Dunstan H R, Rothkirch T,

Index

Medicus

(http://www.ncbi.nlm.nih.gov/ journals).

Roberts T K, Reichelt K L, Cosford R, et

References that have CrossRef Digital

al. Altered amino acid excretion in

Object Identifiers (doi) should include

children with autism. Nutr. Neurosci

them at the end of the citation.

[Internet]. 2008 [cited 2009 Aug 12];

References must be verified by the

11(3): 259-64. Available from

author(s) against the original documents.

http://www.ingentaconnect.com/content/

Reference style and punctuation should

maney/nns.

conform to the examples that follow: JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk

JOPSM 1(2012) 62-66 Book Chapter Jones MA, Rivett DA. Introduction to clinical reasoning. In: Jones MA, Rivett DA, eds. Clinical Reasoning for Manual Therapists. Edinburgh, UK: Butterworth Heinemann; 2004:3-24. Tables: Tables should be formatted in Word, numbered consecutively, and placed together. There should be no more than 6 tables and figures (total). Additional tables and figures can be posted online only. Appendixes: Appendixes should be numbered consecutively and placed at the very end of the manuscript. Use appendixes to provide essential material not suitable for figures, tables, or text.

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JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk

Welcome to the Postgraduate Institute of Physiotherapy, we are the team of professional physiotherapists working in United Kingdom promoting and uplifting the physiotherapy profession in developing countries particularly in South Asia. Our well trained and qualified physiotherapists conduct postgraduate courses in various countries. The courses ranged from Musculoskeletal Manual Therapy to Sports Physiotherapy. The basic aim is to provide evidenced based way of practice and education to physiotherapy societies of developing nation so that they can uplift the profession and become the contributors to the profession. Date: 00/00/00

Time: 00:00

www.pgip.co.uk

Encouraging Better Education Ob jectives Cou rses:

Provision of education and training in  physiotherapy to the public at large 



Enabling patients to relieve or assist in relieving their own suffering/conditions  

To persons (professionally qualified or not)  providing paid or voluntary care to any person   in need of physiotherapy 



Promotion of research and the dissemination to the public at large of the results of research in the field of physiotherapy     

Spinal Examination and Diagnostic Assessment Management of Neck Disorders Neurodynamics and Neuromatrix Lumbar Spine Cervical Spine Treating Cervicogenic Headaches Low back pain and evidence base approach Spinal Manipulation Evidence Based Practice Clinical Reasoning Professionalism, Empowerment and Autonomy Sports Rehabilitation and injury Prevention