Synopsis of Update 2010
The committee of the ISOM has prepared a synopsis of the presentations made at the Annual Update in October 2010 at the Post-Graduate Centre, St. Vincent's Hospital, Dublin 4.
Mr. John Lunn gave a presentation on the shoulder, Dr. Pierce Molony presented musculo-skeletal ultrasound in general practice, Liam Heavin presented a physiotherapy approach to spinal stabilisation, Mr. Michael Kelleher outlined new approaches to neuro-surgical spinal intervention, Dr. Paul Murphy gave a presentation on pain management in spinal pathology, and Mr. Cees Verlooij outlined the capabilities of dynamic CT scanning.
The committee was pleased with the day, much new information was made available and it was a real opportunity for attendees to gain access to such information.
ISOM plan to hold UPDATE 2011 on 15th October 2011.
Dr. Pierce Molony
“Dynamic CT in musculo-skeletal imaging”
Mr. Cees Verlooij, Toshiba Holland
Advances in this area include dose reduction, wider area detection and specific acquisition modes and he proceeded to give clinical examples to demonstrate these.
His first clinical slide was of his own hand, static as can be produced by any CT scanner. However, as he spoke the fingers extended and flexed and for the first time for most of us in the audience, we witnessed dynamic scanning and immediately it became apparent that there was new potential here for musculo-skeletal scanning, introducing physiology into what was previously a static anatomical and pathology arena opening up a complete new field of applications.
The concept of wide area detection refers to the ability of the scanner to cover 16cm in one rotation compared to previous machines which needed eight rotations to cover such an area, hence the concept of dose reduction. Previously, with narrower area detection, the table carrying the patient had to move, to ensure full coverage of the part to be examined but with wide area detection the table (and patient) remain static with no resultant artifact. He showed a single rotation image of a stabilised spine following multiple fractures following a six meter fall when exposure time was one second while an older scanner would have taken 8-9 seconds.
Single and intermittent acquisitions on the same anatomical region. Multiple rotations allow you to follow something in time. This allows one to do such things as perfusion studies and functional CT angiography. He showed an image of a vascular tumour in the neck filling and emptying using simple intra-venous injection as compared with the more invasive alternative of angiography.
He went on to discuss imaging with the patient moving. He demonstrated a moving wrist – the point being that a painful movement can be followed by the scanner so you can get a direct image of the movement causing the pain and although the part is moving in two planes, the image scanned is a 3600 rotation around the two- dimensional movement creating a three-dimensional kinetic image.
There followed a series of slide demonstrations.
Snapping shoulder which demonstrated the supero-medial part of the scapula riding over and catching the 4th rib creating a clicking sensation and sound.
13 year old girl who following a judo accident had abnormal scapular appearance and dynamic CT demonstrated abnormal scapular movement with full explanation of cosmetic appearance.
Scapho-lunate instability with scaphoid avulsion of the radio-scaphoid capitiae ligament and excellent imaging of excess movement between scaphoid and lunate when imaging occurred while fist was being clenched and unclenched.
Imaging of snapping hip where defect in IT band.
Painful elbow with reduced pronation/supination, imaging demonstrated an exostosis of bone blocking the elbow joint movements.
Patellar tracking. Very poor engagement of patella in trochlea.
Poor clinical outcome of shoulder prosthesis with normal x-ray, CT showed the prosthesis was actually dislocated.
Knee instability doing drawer test visualising the actual drawer motion on dynamic CT.
“Scandinavian Shoulder Rehabilitation Model”
Liam Heavin MISCP, DBC Ashleaf, Walkinstown, Dublin 12
Liam runs a DBC (Documentation Based Care) physiotherapy clinic in Dublin, part of the global DBC network which consists of 140 centres in 24 countries worldwide. The clinics were established on scientific research carried out in two leading Finnish Universities in the early nineties.
The majority of the initial research done in the nineties was in chronic lower back pain and chronic neck pain. The clinical application of this research is what became DBC through a series of private clinics, first in Finland, before spreading internationally.
The DBC Network is in existence in 24 countries, using a standardised I.T. package which allows them to collate data from all their patients. DBC use this information to develop better treatment techniques and protocols. Treatments are constantly evolving and developing, trying to set the gold standard rather than follow it.
Liam explained the DBC approach. The main fundamental was to develop an evidence based platform which was based on the best available scientific evidence; to put together ongoing research and a mass database and to put together tools to help with objective measures including the bio-psychosocial.
The research and development is managed on three specific focus areas; first the scientific research, second the clinical development based on scientific research and third the technical development, which is clinically led.
The first application of the shoulder in its conceptual phase started in 2000; DBC put together protocols for six diagnostic subgroups in 2003, software-based quality assurance in 2003 and added CBA approach model and made it systematic in 2005. Specialised equipment was developed to match the clinical needs of rehabilitating the shoulder.
For the subjective patient assessment, DBC document age, profession, mechanism of injury along with questionnaires including a Modified ASES (impairment scale), RBDS (depression scale), LOC (Locus of Control) and FAB (Fear Avoidance Behaviour). This is all classified and forms part and parcel of the treatment planning.
The clinical exam includes inspection, palpation, mobility, strength, special diagnostic tests as well as added range of motion and strength testing using the GHR rotation device as developed by DBC.
Treatment is planned based on a selection of exercises with a recommended progression. Detailed programmes are developed for conservative care and post- operative care. Patients are treated in groups after the initial assessment and one individual treatment session. DBC feel that two patients can be seen at the same time by any one physiotherapist, which creates a positive influence through group behaviour. For example, chronic pain patients are mixed with sports patients.
Liam shared with us the results of a two-year pilot study conducted in Finland in 2000-2002, which looked at 75 subjects with chronic shoulder pain. Initial VAS scores for pain were high at 59mm; scores for impairment were 68mm. The average patient attended 19 sessions. VAS improved from 59mm to 37mm, impairment from 68mm to 40mm. It has been shown that patients who have pain exceeding 30mm on VAS have a significant impact on their quality of life. Long term follow-up showed a VAS pain and impairment of 20mm.
Following this, a multicentre study was carried out in clinics in Finland, Ireland, Luxemburg and South Africa. Data was collected from questionnaires and patient’s information was recorded from their baseline assessment and outcome results.
Results were analysed in Finland. The vast majority of patients were classified as impingement followed by instability. Total patient numbers were 1104. Baseline and outcome VAS scores improved from just over 50mm down to over 20mm; surprisingly quite a linear response rate was recorded amongst the different classifications of shoulder pain.
DBC has put together a systematic and evidence based objective assessment, which helps them structure a rehabilitation programme. Liam spoke about one of the biggest components of the results being the bio-psychosocial element and the cognitive behavioural approach, which he felt needed to be taken into account when dealing with this subgroup of chronic pain patients.
“Non-operative interventions for Rotator Cuff Lesions, some new approaches to chronic shoulder pain”
Mr. John Lunn, Consultant Orthopaedic Surgeon, Hermitage Clinic, Dublin 20
The patient usually presents with pain and without an accurate knowledge of the source of that pain there will be poor outcomes with surgery and/or physiotherapy. Identifying the pain generator is critical when diagnosing. MRI will confer but a detailed history during examination of the activity that precipitated the onset of pain and which position the shoulder was in during this activity. An example, a man with anterior shoulder pain who was thrown out of a nightclub with his hand forced behind his back, who is now tender over the biceps, has torn the long head out of the bicipital groove.
Neck and shoulder pain can present together and it may not be a direct shoulder problem, it could be sourced in the neck. With neck pain the patient is usually holding onto their upper trap region, with pain usually radiating from facet joints in the neck. This is often seen after a RTA, primarily rear-end collision and usually apparent from the history where extension of the cervical spine increases the pain due to pinching of the facet joints as opposed to shoulder, where the patient will report increased pain with working overhead type activities. Facet joints don’t show up that well on x-ray/MRI – pain is primarily with extension of the cervical spine which is RTA force and they do reasonably well if you send them onto a pain specialist and get injection into facet joints. It will take the pain away and also confirms the diagnosis, which is very reassuring for the patient.
Be aware of other conditions such as cardiac, pancoast tumor, diaphragmatic pain, gallbladder/liver or peritoneal irritation.
EXAMINATION OF THE ROTATOR CUFF
Inspection: Palpate for muscular atrophy – more significant problem and may have neural association, such as brachial plexus. Start palpation at front, with the biceps tendon often being the source of pain and compare to other side. A lot of RC problems are non-specific. Pain is diffuse in the shoulder with a lot of lateral arm pain, which is classic shoulder pain. Palpate over the acriomioclavicular (AC) joint, then lateral and posterior regions.
Range of Motion (ROM): ROM is lost extremely quickly into Internal Rotation – goes almost immediately, and again compare to other side for symmetry. Stiffness in the shoulder is a big problem and often have to treat the stiffness first excluding everything else. More appropriate to test ROM in supine to get true measurement. Typically find 1500 to 1600 of flexion. If stiffness is present, be aware, and you must address stiffness first and then come back and treat what caused it. Stiffness is a shoulder’s way of asking the person to stop moving it as its too sore before it eventually freezes.
RC Tests: A small tear in one muscle can cause inhibition and then the whole RC shuts down.
1. Belly Press Test (Subscapularis): Have the patient keep elbow forward and push onto the belly. Examiner gives resistance and pain usually reported in front of the shoulder. If not in the front, more likely a different problem. Also test with hand behind the back although this is not as reliable particularly in stiff or older patients.
2. Bear Hug Test (Subscapularis): This tests the anterior 1/3 of the subscapularis with presentation of anterior shoulder pain.
3. Empty Can Test (Supraspinatus): This is an non-specific test. There are many individuals with tears in the supraspinatus tendon/tendonitis, sometimes the deltoid compresses so try it in different positions, such as 300 scapular plane and across body, hand up anterior cuff, hand down posterior cuff.
4. Hawkins Impingement Test (Supraspinatus): This test forces the tendon up against the acromion and pain usually in the scapular plane, IR can cause discomfort.
5. Infraspinatus Test: Elbow by the side and rotate outward, apply resistance, if torn infraspinatus won’t be able to hold against resistance.
6. Horn Brothers Test: Ask the patient to bring their hand to their mouth, if unable to do as a lot of ER required, indicates a massive RC tear. If Teres Minor is affected, usually shoulder gone too far.
Weakness: Stiffness and weakness co-exist and difficult to assess because of the stiffness. If MRI shows superior migration of the humeral head due to RC tear, this is inoperable. Pseudo paralysis – associated with large RC tears. They usually present with near full ROM in supine and can feel and hear a lot of grinding/crepitus. Need to do all the tests and stand back and think about what’s going on and what’s causing the pain, history, examination and tie it altogether.
WHO NOT TO REPAIR?
1. RC tears in older individuals as usually less successful outcomes;
2. Smokers;
3. Massive tear, small supraspinatus tears (40/50%) left untreated will over time (5 years) develop into large tears by which time it’s too late;
4. Muscle wasting, usually infraspinatus fossa, infiltration of fat into the muscle which is irreversible. Fix the tear but the muscle will never regenerate, still have weakness and high risk of surgery failure (50%); and
5. Rheumatoid Arthritis and Inflammatory Atrophy – poor outcomes as dealing with degenerative tendon. Typically get a total shoulder replacement as long as they have an intact RC.
SURGICAL PROCEDURES:
Reverse Prosthesis (RP): RP works because it changes the lever arm of the deltoid. It simply doubles the deltoid lever arm. Twice the lever arm means twice the power for the same amount of effort. The round segment goes onto the glenoid side and the socket segment goes onto the humeral head side. This allows the patient to lift their arm up into the air, however, they will not get back to heavy manual labour. It works well for pain relief but does not restore ER unless do additional tendon transfer at same time.
Who does RP work for?: Patients with massive cuff tears, severe pain and not amenable to physiotherapy or injection therapy.
Arthroscopy: Works for those in a lot of pain with poor function, only thing they have left is their deltoid muscle.
MRI Reports:
AC joint arthritis with impingement on supraspinatus tendon – NORMAL. Over 40/45% are not symptomatic.
Supraspinatus Tendonitis – unless it fits with findings don’t include.
Glenoid humeral arthritis is unusual with successful surgical outcomes – replace the joint and the pain goes away similar to THR.
SLAP Lesions: tear of long head of biceps where it attaches onto glenoid labrum. Usually football related injury where throwers wind up tendon and put it under high stress and then tears right off glenoid. It’s very seldom seen in Irish population, may see it with dislocation of shoulder.
AC Arthritis: if it fits with the findings where the patient is tender and they report it as being their pain at AC joint. Classic test is horizontal adduction.
Rehabilitation: Supine exercises especially in very sore patient, then progress to sitting. Prescription is 5 x day, 5 repetitions for 5 second hold on each. Flexion and ER only, and take into consideration the patient’s functional requirements. Not very keen on strengthening exercises. Educate patient to give up overhead work such as cutting hedges especially in springtime.
Small tears do increase over time and do not heal spontaneously, especially if retracted. Bilateral tears are common. Big tears are more likely to be symptomatic because small asymptomatic tears will become symptomatic tears over time.
Incidence rates of RTC tears:
Under 60 years – less 5%
Over 70 years – 15-20% up to 50%
80 and older with RTC tear – cuff probably not source of their pain.
Treatment is usually rest and avoidance of activities that increase their pain, which is usually overhead work. Also avoid shoulder abduction.
