PAUL SCOTT-COLLINS

Question 1

Shared Decision Making (Grenfell et al., 2022)

Answer 1

• Trust, communication, decision ability, decision preferences
• 2 way communication, power control, collaborative relationship, know risks and options

Question 2

Biopsychosocial Model (Cormack et al., 2022)

Answer 2

• BPSM only partially implemented in healthcare
• Humanistic ( Patient centred care) and Causation (multi-factorial contributions to illness) interpretations
• George Engel’s model
• Human experience of illness and disease
• Increase rigour for Pt’s Hx
• Heuristic framework for clinical medicine

Question 3

Value-Based Care (Cook et al., 2021)

Answer 3

• patient-centredness
• guideline-orientated strategies
• measurement of Pt outcomes and experiences
• cost-effectiveness

Question 4

Frozen Shoulder

Answer 4

• Thickening of Synovial Capsule / Adhesions to the biceps tendon / Excessive scar tissue or adhesions across the glenohumeral joint, leading to pain, stiffness and dysfunction. Hypothyseized that adhesions of the GH joint and biceps tendon lead to stiffness
• 6 months to 3.5 years
• idiopathic, can also be traumatic, 40-60, diabetic more common in women
• Rest, steroid injection, education, physiotherapy, manipulation under anaesthesia, arthroscopic capsular release

Question 5

Rotator Cuff Related Pain

Answer 5

• An umbrella term for many different shoulder disorders including tendinopathy, bursitis and impingement
• multifactorial aetiology, hypothesized irritation of the overlying acromion
• months for recovery (age, activity, history)
• Physiotherapy, shockwave (calcific tendinopathy), surgery (full tear)

Question 6

AC joint Related Pain

Answer 6

• trauma causing AC ligament (sup, inf, ant, post) damage, potentially CC and SC ligaments
• trauma (90%) overload (10%)
• 2-52 weeks depending on grade (1-6)
• rest, immobilisation, analgesics, ice, strengthening, surgery (grad 4-6)

Question 7

Horn et al., 2012 (Patient-Specific Functional Scales, SR)

Answer 7

• 0.74 construct validity
• 0.84 test re-test reliability
• facilitates PCC
• identify an activity they are struggling with and rate 0-10

Question 8

Nociceptive Ascending Pathway

Answer 8

• Stimulus
• First-order neuron
• Decussates
• Second-order neuron
• ST tract
• Thalamus
• SSC

Question 9

Descending Inhibition

Answer 9

• Ascending Nociception at SSC
• Triggers Descending Pain modulatory system
• Nociceptive info relayed down SMC tract to Periaqueductal gray in brain
• Noc info processed at PAG relayed to rostral ventral medulla
• neurons in RVM send signal down spinal cord endorphins and enkephalins suppress pain

Question 10

What are the predominant patient-reported dysfunctions for Adhesive Capsulitis?

Answer 10

• Severe pain at night
• Insidious shoulder stiffness

Question 11

What dysfunctions may be found during an objective assessment for Adhesive Capsulitis?

Answer 11

• Global loss of glenohumeral ROM: mainly with passive external rotation and abduction.
• In a true frozen shoulder there is almost complete loss of external rotation

Question 12

What are the predominant patient-reported dysfunctions for RCRPS?

Answer 12

Pain and weakness of the shoulder, inability to lift arm above shoulder level (brushing hair, dressing, reaching), weakness, reduced ROM.

Question 13

What were the key findings of Salamah et al (2020) regarding special tests for the RCPS?

Answer 13

• Shoulder “special tests” cannot identify the structure causing RCRSP symptoms
• A comprehensive clinical interview and physical examination can be used to inform a working hypothesis to implicate RCRSP without the need for special tests

Question 14

What are the key treatments for RCRPS (with references)?

Answer 14

• Education (Dube et al, 2023; Crindland et al, 2021)
• Exercise (Peters et al, 2020; Scott & Khan, 2008)
• Manual Therapy - Supplementary (Peters et al, 2020)

Question 15

What were the key findings of the FROST study (Rangan et al, 2020) regarding the key treatments for frozen shoulder?

Answer 15

Compared the effectiveness of three care pathways for the treatment of frozen shoulder - all of which resulted in significant improvements with none been clinically clearly superior - according to patient reported questionaires.
1. Early physiotherapy with corticosteroid injection: included information on pain management, mobilisation techniques (increasingly stretching into the stiff part of the range of movement), and a graduated home exercise programme that progressed from gentle pendular exercises to firm stretching exercises according to the stage of frozen shoulder: we’re more likely to require further treatment.
2.** Manipulation under anaesthsia** (supplemented with cortico-steroid injection) with subsequent graded physiotherapy: most cost-efffective. - provided the best value for money when considering the patients improved QoL.
3. **Arthroscopic capsular release **(supplemented with cortico-steroid injection) with subsequent graded physiotherapy: associated with greater costs and risk.

Question 16

Frozen Shoulder Stages

Answer 16

Stages of the pathology
1. Freezing Stage (3-9 months) = acute synovitis of GHJ
1. Frozen Stage (4-12 months) = pain does not necessarily worsen
1. Thawing Stage (12-42 months) = gradual return of shoulder mobility (12)

Question 17

Q
Three conceptual models?

What pathophysiological mechanisms underpin RCRPS and the associated pain response?

Answer 17

RCS includes subacromial impingement syndrome (SIS) and bursitis, RC tendonopathy, partial-versus full-thickness RC tears (PTTs versus FTTs), and, chronically, can influence the development of glenohumeral degenerative disease (DJD) and rotator cuff arthropathy (RCA).
* **Tendinopathy: **pathogenesis not fully understood. Likely to be combination of 3 conceptual models involving tendon cell response, collagen disruption and inflammation.
* Impingement: Internal (Posteiror capsular tightness & internal rotation deficit) & External (encompasses etiologies of external compressive sources (i.e. the acromion) leading to subacromial bursitis and bursal-sided injuries to the RC)
* Bursitis: Inflamation of the surrounding bursal sacs.

Related to Pain
* Pain mechanism includes nociception - usually localised. Modulated by spinal, peripheral & central mechanisms.
* Non-nociceptive pathway has also been hypothesized.
* Can manifest as allodynia.
* Mirroring in opposite limb occurs occasionally
* Can exist without pain

Question 18

What dysfunctions may be found during an objective assessment for RCRPS?

Answer 18

Clicking/catching of the shoulder joint when moved through PROM.
Problems with shoulder elevation and abduction in AROM.
Painful arch of abduction, unable to reach higher than 90 degrees.
Pain provocation on internally rotated abduction which is exacerbated against resistance.

Question 19

What are the key treatments for RCRPS (with references)?

Answer 19

Education (Dube et al, 2023; Crindland et al, 2021)
Exercise (Peters et al, 2020; Scott & Khan, 2008)
Manual Therapy - Supplementary (Peters et al, 2020)

Question 20

What were the key findings of Powell et al (2022) regarding the mechanisms of effect for the use of exercise in treating RCRSP?

Answer 20

Four themes were identified:
1. Neuromuscular: The aim of the training program in the present study was to strengthen the musculature of the rotator cuff, which is likely to have been one of the factors that led to the improvement of pain.
2. Tissue Factors: Possible mechanisms for explaining treatment effects are improved circulation in the affected structures.
3. Neuro-endocrine-immune (DNIC): Possible mechanisms for explaining treatment effects are pain modulation by activating the gate control system in the posterior horn of the spinal cord.
4. Psychological: The mechanisms are probably several, ranging from effects on a cellular level to cognitive functions such as coping and self-efficacy.

Despite the numerous potential mechanisms, many fail to substantially improve with exercise-based treatment.

Question 21

What were the key findings of the FROST study (Rangan et al, 2020) regarding the key treatments for frozen shoulder?

Answer 21

Compared the effectiveness of three care pathways for the treatment of frozen shoulder - all of which resulted in significant improvements with none been clinically clearly superior - according to patient reported questionnaires.

1. Early physiotherapy with corticosteroid injection: included information on pain management, mobilisation techniques (increasingly stretching into the stiff part of the range of movement), and a graduated home exercise programme that progressed from gentle pendular exercises to firm stretching exercises according to the stage of frozen shoulder: we’re more likely to require further treatment.

2.** Manipulation under anaesthsia** (supplemented with cortico-steroid injection) with subsequent graded physiotherapy: most cost-efffective. - provided the best value for money when considering the patients improved QoL.

3. **Arthroscopic capsular release **(supplemented with cortico-steroid injection) with subsequent graded physiotherapy: associated with greater costs and risk.