MSK: shoulder and elbow (FS-02)

Focused symposium
Saturday 11 May 2019, 08:30-10:00
Room B

Lewis J1,2,3Ginn K4Cools A5,6Vicenzino B7Roy J-S8,9 
1University of Hertfordshire, School of Health and Social Work, Hatfield, United Kingdom, 2Central London Community Healthcare NHS Foundation Trust, Physiotherapy, London, United Kingdom, 3University of Limerick, Clinical Therapies, Limerick, Ireland, 4The University of Sydney, Discipline of Anatomy & Histology, Sydney Medical School, Sydney, Australia, 5Ghent University, Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent, Belgium, 6University of Copenhagen, . Department of Occupational and Physical Therapy and Institute of Sports Medicine, Bispebjerg Hospital, Copenhagen, Denmark, 7The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, Australia, 8Laval University, Department of Rehabilitation, Faculty of Medicine, Quebec, Canada, 9Quebec Rehabilitation Institute, Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, Canada

Learning objective 1: To provide a state of the art update, synthesising the best research evidence, on the assessment and management of: 1. Rotator cuff related shoulder pain (subacromial impingement and rotator cuff tendinopathy) and frozen shoulder.
Learning objective 2: 2. Common extensor related elbow pain (tennis elbow), and,
Learning objective 3: 3. The interconnection between local structures and the central nervous system.
Description: Rotator cuff related shoulder pain (RCRSP) is an over-arching term that encompasses a spectrum of shoulder conditions that include; subacromial pain (impingement) syndrome, bursitis, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears.1 Findings from high quality peer-reviewed research investigations suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery for RCRSP, and these findings are important for people experiencing RCRSP, clinicians, and health funding bodies, as considerable healthcare savings could be achieved if surgery was only considered for those not obtaining satisfactory benefit from non-surgical intervention.2 It is also possible that benefit from surgery may be due to a placebo effect and possibly the enforced relative rest and graduated rehabilitation imposed by the surgical intervention. In addition there appears to be a stronger relationship between psychosocial factors and outcome than many physical factors for both surgical and non-surgical interventions.3
Frozen shoulder (FS) is a common cause of severe disability characterised by the spontaneous onset of pain and progressive movement restriction4. It has a protracted time course with symptoms lasting on average 30 months although functional recovery is common without treatment. Although the pathoaetiology of FS is not fully understood, chronic inflammation and glenohumeral joint capsule-ligamentous contracture are considered to be responsible for the pain and movement restriction5. Consequently, treatment is commonly aimed at releasing/stretching glenohumeral joint structures to restore movement while managing pain. Recent evidence, however, indicates that active muscle guarding (perhaps in response to pain), and not capsular contracture, is the major contributing factor to painful movement restriction in some patients who exhibit the classical, clinical features of FS6. This could explain why treatment aimed at lengthening passive tissue has not proven more successful and why spontaneous recovery as pain decreases is a common feature of FS.
Tendinopathy at the lateral epicondyle (tennis elbow) presents as pain over the lateral elbow with gripping related activities that are commonly required in day to day activities of life. The condition can be severely disabling in a proportion of patients, notoriously persistent and recalcitrant to interventions. Clinical outcomes with these individuals can be difficult to predict. Recent evidence suggests that outcomes can be improved through recognition of prognostic factors, which define sub-groups and assist in targeting interventions7. An assessment, diagnosis and management pathway has been proposed7,8. It is based on both clinical and laboratory based studies of the condition. The presentation will outline the proposed pathway, the underpinning research evidence and its clinical implications. Clinical trial evidence that challenges commonly applied treatment will also be outlined.
When evaluating individuals with chronic shoulder and elbow disorders, clinicians have to be aware that the central nervous system may have undergone plastic reorganizations, and that these reorganizations may be maladaptive9. These maladaptive changes can be clinically observed by: 1) excessive pain level that can be explained by central sensitization, an amplification of neural signalling within the central nervous system eliciting pain hypersensitivity; 2) modifications in the motor strategies used to control the joint that can be explained by alterations in motor cortical representations (M1). As these maladaptive changes can be reversed, CNS reorganization should be a target during rehabilitation of chronic shoulder and elbow disorders. This presentation will focus on emerging rehabilitation protocols (education on pain neuroscience, sensorimotor training, graded exercises, self-efficacy) and new therapies (non-invasive brain and peripheral neuromuscular stimulations) that are based on central adaptive plasticity and are showing promising results10.
Implications / Conclusions: This symposium will bring together physiotherapists with research and clinical expertise who will synthesis and share the latest information to support the assessment and management of the main musculoskeletal conditions involving the shoulder and elbow. Unique local structural issues will be presented as well as over-arching similarities, including body kinetics and pain science. Areas of uncertainty and suggestions for future research will also be included. As such this symposium will be relevant to clinicians and researchers. 
Key-words: 1. Shoulder 2. Elbow 3. Pain and Disability
Funding acknowledgements: Nil
Relevance to physical therapy globally: Musculoskeletal disorders comprise the second largest group of health conditions associated with the greatest number of years lived with disability (only mental health conditions are associated with more years). Shoulder and elbow problems contribute substantially to this disability, and globally, physiotherapists, working in a range of specialisms will encounter such conditions. This symposium will share the latest research knowledge supporting the diagnosis, assessment, management and associated challenges of the major musculoskeletal conditions of these regions.
Target audience: All health professionals, health commissioners, ministers of health, insurance company executives, and others who are interested in the management of shoulder and elbow conditions.