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Schwank A1,2, Struyf F2, Gisi D1, Pisan M3, Meeus M2
1Kantonsspital Winterthur, Institut für Physiotherapie, Winterthur, Switzerland, 2University of Antwerp, Department of Rehabilitation Sciences and Physiotherapy, Antwerp, Belgium, 3Kantonsspital Winterthur, Klinik für Orthopädie und Traumatologie, Winterthur, Switzerland
Background: Shoulder pain is the third most common musculoskeletal complaint, of which about 50% of patients do not recover within 12months. With 70%, rotator cuff (RC) disorders are identified as the most prevalent problem, which is increasingly approached by rotator cuff repair (RCR).
Little is known about other than biomedical factors (e.g. fatty infiltration in the RC muscle) for recovery failure after RCR. In the literature, only high patients' expectations for surgery was identified as predictor for satisfactory outcome after RCR (Raman et al., 2017), whereas factors like central sensitisation (CS) as pain driving mechanism or psychological factors like high perceived stress as potential pain maintainers, are not sufficiently understood with respect to outcome after RCR. However, there is a growing body of evidence that psychological factors and CS influence shoulder pain (Sanchis et al., 2015).
Still, in clinical practice with shoulder patients undergoing RCR at the hospital Kantonsspital Winterthur (KSW), the focus seemed to be predominantly on biomedical factors (e.g. shoulder function) and a lack of standardized assessments for the influence of central pain processing (CPP) and psychosocial factors was present.
Purpose: The purpose of this clinical project was to develop and implement a standardized, comprehensive assessment, which incorporates CPP and biopsychosocial factors, to get holistic insight into the patients undergoing RCR, to tailor the course of care towards a beneficial outcome.
Methods: Firstly, a literature search was conducted by the physiotherapist to identify the psychophysical measures that detect hypo-, normo- or hyperexcitability of the central nervous system with respect to CPP, which are meanwhile feasible for standardized administration in a 30min physiotherapy session. Secondly, the comprehensive assessment battery was developed in concordance with advisory pain scientists and shoulder surgeons. Thirdly, the assessment was implemented in the perioperative management of patients undergoing RCR, in the KSW, Switzerland. Measurements take place at 3 weeks prior to RCR, and 3 months and 12 months post RCR.
Results: Mechanical temporal summation (TS), cold sensitivity testing, pressure pain threshold (PPT) and CS Inventory (CSI) were identified measures for CPP recognition. TS testing, is a dynamic method to detect central integration for bottom-up excitability. Cold sensitivity is a measure for thermal input and neural excitability. PPT is a static method to measure the point of pressure evolving into pain and is highly reliable.
Secondly, modifiable psychological and lifestyle factors were integrated. The Pain Catastrophizing scale (PCS), the Illness Perception Questionnaire (IPQ-R), the Perceived Stress Scale (PSS), patients' expectations, sleep and quality of life (EQ-5D-5L).
Lastly, the disease-specific Western Ontario Rotator Cuff Index (WORC) and Constant - Score were conventionally used and report on shoulder function and disability.
Conclusion(s): The novel shoulder assessment integrates biopsychosocial aspects of shoulder pain with a focus on CPP. The identified factors are modifiable and entail the potential to be changed in practice for better outcome after RCR. Yet, the assessment may not address all possible influencing aspects and continuous future adaptation is appropriate.
Implications: In practice this novel and holistic shoulder assessment fosters clinical reasoning processes of physiotherapists for pain processing in patients undergoing RCR.
Keywords: Quantitative sensory testingquantitative sensory, rotator cuff tears, outcome prediction
Funding acknowledgements: The hospital Kantonsspital Winterthur in Switzerland is the purchaser of this project.
Little is known about other than biomedical factors (e.g. fatty infiltration in the RC muscle) for recovery failure after RCR. In the literature, only high patients' expectations for surgery was identified as predictor for satisfactory outcome after RCR (Raman et al., 2017), whereas factors like central sensitisation (CS) as pain driving mechanism or psychological factors like high perceived stress as potential pain maintainers, are not sufficiently understood with respect to outcome after RCR. However, there is a growing body of evidence that psychological factors and CS influence shoulder pain (Sanchis et al., 2015).
Still, in clinical practice with shoulder patients undergoing RCR at the hospital Kantonsspital Winterthur (KSW), the focus seemed to be predominantly on biomedical factors (e.g. shoulder function) and a lack of standardized assessments for the influence of central pain processing (CPP) and psychosocial factors was present.
Purpose: The purpose of this clinical project was to develop and implement a standardized, comprehensive assessment, which incorporates CPP and biopsychosocial factors, to get holistic insight into the patients undergoing RCR, to tailor the course of care towards a beneficial outcome.
Methods: Firstly, a literature search was conducted by the physiotherapist to identify the psychophysical measures that detect hypo-, normo- or hyperexcitability of the central nervous system with respect to CPP, which are meanwhile feasible for standardized administration in a 30min physiotherapy session. Secondly, the comprehensive assessment battery was developed in concordance with advisory pain scientists and shoulder surgeons. Thirdly, the assessment was implemented in the perioperative management of patients undergoing RCR, in the KSW, Switzerland. Measurements take place at 3 weeks prior to RCR, and 3 months and 12 months post RCR.
Results: Mechanical temporal summation (TS), cold sensitivity testing, pressure pain threshold (PPT) and CS Inventory (CSI) were identified measures for CPP recognition. TS testing, is a dynamic method to detect central integration for bottom-up excitability. Cold sensitivity is a measure for thermal input and neural excitability. PPT is a static method to measure the point of pressure evolving into pain and is highly reliable.
Secondly, modifiable psychological and lifestyle factors were integrated. The Pain Catastrophizing scale (PCS), the Illness Perception Questionnaire (IPQ-R), the Perceived Stress Scale (PSS), patients' expectations, sleep and quality of life (EQ-5D-5L).
Lastly, the disease-specific Western Ontario Rotator Cuff Index (WORC) and Constant - Score were conventionally used and report on shoulder function and disability.
Conclusion(s): The novel shoulder assessment integrates biopsychosocial aspects of shoulder pain with a focus on CPP. The identified factors are modifiable and entail the potential to be changed in practice for better outcome after RCR. Yet, the assessment may not address all possible influencing aspects and continuous future adaptation is appropriate.
Implications: In practice this novel and holistic shoulder assessment fosters clinical reasoning processes of physiotherapists for pain processing in patients undergoing RCR.
Keywords: Quantitative sensory testingquantitative sensory, rotator cuff tears, outcome prediction
Funding acknowledgements: The hospital Kantonsspital Winterthur in Switzerland is the purchaser of this project.
Topic: Musculoskeletal: upper limb; Pain & pain management; Orthopaedics
Ethics approval required: No
Institution: Kantonsspital Winterthur (KSW)
Ethics committee: Internal ethics committee of KSW
Reason not required: Because the project was developed for and implemented in standard care and no personal data of patients was integrated, no external ethics approval was required
All authors, affiliations and abstracts have been published as submitted.
