1 1 Chronic Shoulder Pain - In a nutshell - K. Kuppens, F. Struyf, J. Nijs, N. Roussel, M. Meeus, I. Slegers, G. Hens Mira Meeus - Filip Struyf – Kevin Kuppens o.a. 25 & 26 juni 2015 – Genk (www.smarteducation.be ) 19 & 20 oktober 20125 – Wilrijk (www.scholingrandstadwest.nl) Shoulder pain: a challenging phenomenon 3 Prevalence & incidence • Lifetime prevalence up to 66,7% • Point prevalence 6,9 to 26% • 3rd most common cause of musculoskeletal consultation in primary care • Approximately 1% of adults consult a general practitioner with new shoulder pain annually. Urwin et al. 1998 Incidence New cases of shoulder pain arising in a population over a given period Prospective studies Prevalence Proportion of patients with shoulder pain Cross sectional studies 4 • 50% recovers within first 6 months • An additional 10% during the 6 months afterwards • 40% still has shoulder complaints after 1 year 80% of the total economic cost for shoulder pain Luime et al. 2004, Ryall et al. 2006, Croft et al. 1996, Van der Windt et al. 1996, Kuypers et al. 2006a,b 5 Chronic Shoulder Pain ! How To Explain ? Description of patients with painful shoulder syndrome Excl: fractures, surgery, cancer, shoulder-hand syndrome Chronic > Acute (1,6 x) !!! Women !!! Imaging - 66,2 % Tendinosis - 26,9 % Arthropathy - 18,5 % Bursitis - 22,3 % Normal Reference diagnosis - 75,4 % Rotator cuff syndrome - 8,7 % Unspecified Lesion - 6,3 % Frozen Shoulder - 6,3 % Cervicalgia - 2,4 % Instability - 0,8 % Arthrosis Dias et al (2008) 6
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Chronic Shoulder Pain
- In a nutshell -K. Kuppens, F. Struyf, J. Nijs, N. Roussel, M. Meeus, I. Slegers, G. Hens
Mira Meeus - Filip Struyf – Kevin Kuppens
o.a. 25 & 26 juni 2015 – Genk (www.smarteducation.be)
19 & 20 oktober 20125 – Wilrijk (www.scholingrandstadwest.nl)
Shoulder pain: a challenging phenomenon
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Prevalence & incidence• Lifetime prevalence up to 66,7%
• Point prevalence 6,9 to 26%
• 3rd most common cause of musculoskeletal consultation in primary care
• Approximately 1% of adults consult a general practitioner with new shoulder pain annually.
Urwin et al. 1998
Incidence
New cases of shoulder pain arising in
a population over a given period
Prospective studies
Prevalence
Proportion of patients with
shoulder pain
Cross sectional studies
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• 50% recovers within first 6 months• An additional 10% during the 6 months
afterwards• 40% still has shoulder complaints after 1
year
80% of the total economic cost for shoulder pain
Luime et al. 2004, Ryall et al. 2006, Croft et al. 1996, Van der Windt et al. 1996, Kuypers et al. 2006a,b
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Chronic Shoulder Pain !How To Explain ?
Description of patients with painful shoulder syndrome
Activation and protection in case of extreme movement.
Backenkohler et al. 1997; Maass et al. 2001; Guanche et al. 1999; Hashimoto et al. 1994
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Bursa subacromialis
• Many subacromial decompression and bursectomyin patients with impingement related symptoms
• Very richly innervated (in comparison to other structures around the shoulder)
Ide et al. 1996; Soifer et al. 1996; Tomita et al. 1997
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Baseball pitchers
Lesniak et al., 2013 AJSM
21 asymptomatic baseball pitchers
2 seasons
MRI
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Tissue based pathology-pain model ?!
Lack of association between pathology & pain
No corresponding change in observable structural pathology
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Local Biochemical Basis For Pain
Known mediators such as
• Substance P
• Potassium
• Serotonin
• Bradykinin
• Histamine
• Prostaglandins
18Dewitte et al 2014
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Impairment of function
• Articular
• Myofascial
• Neurogenic
• Sensorimotor control
• Posture
• Pain
• …..
Movement
dysfunction
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Movement dysfunctionA. Articular
A. Hypomobility
B. Hypermobility
B. Myofascial
A. Muscle length
B. Muscle strength
C. Muscle tonus
C. Neurogenic
A. Sensory function
B. Nerve glide Upper limb tension test
D. Sensorimotor control
A. Proprioception
B. Muscle setting
C. Coordination
E. (Posture)
F. (Pain)
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KINETIC CHAIN
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MIND THE
CENTRAL
NERVOUS
SYSTEM
C. Littlewood et al., Manual Therapy 2013:
“pain associated with rotator cuff tendinopathy, that persists beyond expected
recovery times, should be evaluated within a framework that recognises the
potential for altered processing and modulated output of the CNS”
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C. Littlewood et al., Manual Therapy 2013:
“pain associated with rotator cuff tendinopathy, that persists beyond expected
recovery times, should be evaluated within a framework that recognises the
potential for altered processing and modulated output of the CNS”
26Dewitte et al 2014
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PAIN =
• Product (output) of the CNS processsing
- Spinal cord (dorsal horns)
- Brain
• Modulated by thougths, feelings, …
≠ reflects state of peripheral tissues !
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Widespread Hyperalgesia
Allodynia
Referred pain
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Central sensitization
= Hyperexcitability CNS
= Hypersensitivity for all mechanic stimuli
AllodyniaGeneralized hyperalgesia
Referred painChronic pain
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• Chronic SIS (Gwilym et al.)
- Referred pain
- Hyperalgesia to punctuate stimuli
• SIS (Hidalgo-Lozano et al.)
- higher n of MTrP
- lower PPT’s (also distant)
• Hyperalgesia in unilateral shoulder pain
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Nijs, 2010
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Meeus et al. 2008, Curatolo 2001, Wand and O’Connell 2008, Yunus et al. 2007, Langemark et al. 1993, Pielsticker et al. 2005, Burnstein et al. 2000, Weissman-Fogel et al. 2003
Medical diagnoses associated with central sensitization
• Fibromyalgia
• Chronic fatigue syndrome
• Chronic whiplash associated disorders
• Irritable bowel syndrome
• Chronic low back pain
• Temporomandibular dysfunction
• Myofascial pain sydromes
• Osteoarthritis
• Rheumatoid arthritis
• Headache
• Tennis elbow
• Chronic shoulder pain / impingement
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Algoritme recognition CS
• International consensus document
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Criterion1: Disproportionate pain?
• Severity of pain and related disability disproportionate to the nature and extent of injury or pathology
Origin Result
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One of the following options:
• Large pain area with a non-segmental distribution
