British Elbow & Shoulder Society (BESS) Clinical Updates – Coventry 2017

It’s been a week since the recent British Elbow & Shoulder Society (BESS) conference held at the Ricoh Arena in Coventry. A predominantly surgical conference but one that is always good fun and packed with learning for the Physiotherapist attendees also. Whist there it was good to catch up with old friends as well as meet new colleagues that share a similar interest.

Our recent qualitative work was presented as part of one of the keynote talks delivered by Dr Chris Littlewood (co-author) as well as in poster format; the messages seem well received and when the full manuscript gets published I will deliver the key messages via this blog. The photo below shows one of Chris’ slides with some of the quotes from the patients in our study:

Slide from Dr Chris Littlewood's talk: Mind your language!

Slide from Dr Chris Littlewood’s talk: Mind your language!

The point of this blog is to provide some of the insight from this years scientific programme. The statements below are all from talks delivered at the conference and are those that I’ve highlighted as most relevant to my practice within Primary Care and as Physiotherapist.

For full references of to whom conducted and presented the work; as well as full abstract please see here:

Basic Science and Miscellaneous

  • There is limited evidence that steroid injections to the ACJ delivered by ultrasound guidance are more effective than landmark guidance in terms of pain reduction or increasing function in both the short term (3 weeks) and medium term (6 months) – there is no evidence for long term outcomes (12 months+). Further research is needed to justify the additional cost and wait times associated with Ultrasound Guided injections in light of similar clinical outcomes.

 

  • A new outcome measure; the ‘Combined Shoulder Assessment’ has been developed which appears to be a more convenient and patient-friendly method to obtain equivalent Oxford, Constant and QuickDASH shoulder outcome scores. This was awarded the prize for best presentation and comes from the Wrightington Upper Limb Team.

Rotator Cuff

  • Physiotherapist-led exercise in patients with ‘Subacromial Impingement Syndrome’ leads to greater improvements in pain and function than providing a standardised advice and exercise leaflet (Phew!). Ultrasound-guided injection confers little additional benefit over landmark guided injection.

 

  • A controversial conclusion next! The Exeter team presented that in patients randomised to arthroscopic capsular release (ACR), a significantly higher improvement on the Oxford Shoulder Score was seen compared to those randomised to hydrodilation (HD). On this basis, they recommend ACR as their first line therapy for Frozen Shoulder.

However, the study demonstrated no difference in External Rotation range or EQ5D and there were a few short comings that may weaken the strength of this conclusion. The difference on Oxford Shoulder Score was 6 points; 5 points is the Minimally Clinically Important Difference (the point at which patients notice a change). The sample was very small; 25 were randomised into each group, 19 were available for follow up in the ACR group and 12 in the HD group. Four of the HD group crossed over to ACR and were excluded from the analysis leaving the final standings as 19 in the ACR group and 8 in the HD group. Further, the procedural time and cost were not considered when drawing the conclusion.

  • An interesting study from Monash University in Australia looking at long-term rotator cuff integrity following repair of a tear. At an average of 16.25 years post-surgery a recurrent tear was noted in 37% of patients with only one of these increasing in size. 85% of patients were satisfied with their surgery and those with a recurrent tear had equivalent outcome scores to those with an intact rotator cuff. What may therefore be the mechanism by which they improve? The group identified no independent risk factors for recurrent tear.

Elbow

  • Four outcome measures satisfied the Evaluating Measures of Patient-Reported Outcomes (EMPRO) criteria for recommendation of use to quantify Health-Related Quality of Life in Lateral Epicondylar Tendinopathy (Tennis Elbow); DASH, QuickDASH, Oxford Elbow, Patient-rated Tennis Elbow Evaluation (PRTEE). The QuickDASH scored the highest and this may lead to a practice change within my ‘Tennis Elbow Clinic’ where I currently use the PRTEE.

 

  • The addition of a ‘Tenease’ device offered no benefit above ‘standard conservative treatment’ in a RCT from the Exeter team; which is pleasing as the scientific plausibility of such a device is poor and would not be something I recommend to patients with this complaint!

 

  • Another study from the Exeter team injected dye (either 1ml or 3ml) into the common extensor origin of 20 cadaveric elbows; in all cadaveric samples, the dye found its way into the joint and following injection, there was a 2.5% increase in tears attributable to the injection. Whilst this research is in vitro, the findings are interesting and may suggest that joint contamination may be inevitable following CEO injection.

 

Physiotherapy 

  • 3% of UK Physiotherapists (8/287 respondents) reported delivering supra-scapular nerve blocks to patients with persistent, complex and multi-component shoulder pain for whom shoulder surgery was either not an option or not preferred; suggesting that use amongst Physiotherapists is uncommon.

 

  • Patients treated by Physiotherapists using landmark-guided supra-scapular nerve blocks achieve clinically important changes in pain and function in both the short term (six weeks) and medium term (six months) that were not significantly different to those provided by an anaesthetist via ultrasound guidance.

 

  • The National Institute of Clinical Excellence (NICE) suggests that not only does treatment need to be clinically effective, but also cost-effective. This is calculated utilising the Incremental Cost-Effectiveness Ratio (ICER) in relation to Quality Adjusted Life Year (QALY) gained. NICE state that an ICER below £20,000 per QALY is indicative of cost effectiveness. This paper from the Nottingham unit shows that Specialist Shoulder Physiotherapy provides excellent value for money at £774 per QALY gain (Phew!). Whilst I don’t want to critique this paper as it fits my bias (!!), further work is needed to see how this compares to ‘Non-Specilalist’ Physiotherapists before we shout too loudly from the roof tops.

 

  • A local study from Doncaster presented an update on current Physiotherapy practice in relation to rotator cuff disorders. There were 191 respondents; the most commonly used intervention was advice/education (91%) and exercise therapy (isotonic 67%; isometric 53%; scapula 50%; general exercise 50%). There is less reliance on both physical tests and further investigations to inform treatment as well as less reliance on passive modalities. We often quote that it takes 17-years for research to get into practice; this study shows a changeover 5-years which is progressive.

There are of course some questions; the majority of the respondents were from twitter which has been suggested as more evidence-based, evidence informed forum – does this study reflect wider practice? 91% of respondents provide advice/education, what does this consist of? And ultimately, has this change in practice resulted in better outcomes…?

  • Due to widespread uncertainty in relation to the reliability and validity of examination procedures around the Shoulder; the Shoulder Symptom Modification Procedure (SSMP) has been suggests as an alternative. This study showed that the inter-rater reliability was moderate (k = 0.47); for a procedure to have clinical utility it is reported that it should reach a level of reliability above k = 0.70. Thus, the authors concluded that they were unable to recommend the SSMP as a reliable physical examination tool. There are some limitations of this study, it was underpowered, the washout period between trials was only 10-minutes and there is some difficulty assessing the reliability of a procedure that aims to change symptoms as one could argue that the patient presentation has not remained stable between trials implicating on the measure of reliability.

 

  • Another paper from the Nottingham group presenting a case series of Physiotherapy rehabilitation of atraumatic shoulder instability (Type II/III axis). They showed a non-significant correlation between posterior instability and better outcome scores; a significant relationship was seen between earlier provision of Physiotherapy and better outcome following diagnosis. Previous surgery significantly increased the risk of re-referral and further operation; patients re-referred after initial discharged were more likely to undergo subsequent surgery if they had anterior or multidirectional instability symptoms, versus those with posterior instability.

 

  • The previously described scapula dyskinesis test by McClure (2009) demonstrated reliability of k= 0.48-0.61 in an athletic population with a BMI < 30. This study from Cardiff looked at replicating the results in an NHS population; they found not only did it lack reliability (k = 0.33) but it appeared to also lack ecological validity as a lot of the patients (42%) were unable to elevate their arm through a full range of motion under load due to pain or weakness.

 

  • An interesting paper from Ireland demonstrated that an Extended Scope Physiotherapist and Orthopaedic Surgeon agreed on initial diagnosis 70% of the time; this increased to 90% when the secondary diagnosis was considered (k = 0.87). They agreed on treatment recommendations 90% of the time and the agreed need for further investigations required was 70%. The findings suggest high diagnostic concordance which is encouraging. However, the limitations of this study were that it only compared one Consultant with one Physiotherapist. Further, the two clinicians had worked together for many years and this study may reflect a merging of clinical reasoning due to familiarity.

 

  • You can’t have a Physiotherapy session at BESS without a paper from the Stanmore group on Instability. They presented a cracking insight into the burden of shoulder instability on both work and health provision. Upon admission at Stanmore, 37% of patients (31% adults, 53% paediatrics) were attending A&E for their dislocations; at 12-month follow up only one paediatric patient had the need to attend A&E. At admission, 30% of adults were in full time work, this increased to 54% at 6-month follow up. They concluded that a focus on self-management strategies and return to function can lead to an improvement in patient outcomes, help facilitate a return to work as well as reducing dependency on emergency services.

 

  • The Stanmore group are like London buses; you wait for one cracking paper and along comes a second in quick succession! They presented an association between developmental milestones and atraumatic shoulder instability; there was a higher prevalence of non-crawlers in the instability group compared to controls. This association did not appear to simply be due to hyperlax joints; supporting the findings of Ghibellini et al. (2015) who demonstrated that the literature collectively suggests that there is a non-causal association between generalised joint hypermobility and impaired motor co-ordination. It would appear therefore that asking about their developmental milestones as part of a full subjective history could assist in the classification of the Type III unstable shoulders.

 

Could crawling be a key gross motor developmental activity which provides some of the foundations for motor pattern? Could crawling promote development of the cuff? Could crawling increase proprioceptive mechanisms?

Or, is an adaptive behaviour? Could the lack of crawling be due to the shoulder already being unstable?

 

  • Significantly reduced pressure-pain thresholds and enhanced temporal summation was observed between symptomatic and asymptomatic sides in young adults with shoulder pain. This difference was maintained between the symptomatic side and the control group at both distal and remote sites.

 

  • Further, there was a significant difference in neural mechanosensitvity, measured through nerve palpation, between the symptomatic and asymptomatic sides in young adults with shoulder pain. This difference was maintained between the symptomatic side and the control group. There was no significant association between hypermobility and any of the measures of neural sensitisation.

This paper therefore suggests that in this sub-group of patients presenting with shoulder pain, we should be aware of, and assess for the presence of both peripheral and central pain mechanisms.

 

For those of you who have read this far, well done! I hope you found it useful and wish you the best applying it to your patients in clinic!

Best,

Andrew

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