Research Review - Tendinopathy

Physiology/Pathophysiology:

· The clinical presentation of tendinopathy includes localized tendon pain with loading, tenderness to palpation and impaired function

· Microscopic examination of tissue biopsies from painful tendon reveals variable features of tendon pathology, including collagen disorientation, disorganization and fiber separation, increased proteoglycans (PG) and water, increased prominence of cells, and areas with or without neovascularization, which collectively are termed tendinosis

· Tendon pain has a transient on/off nature closely linked to loading, and excessive energy storage and release in the tendon most commonly precedes symptoms. Pain is rarely experienced at rest or during low-load tendon activities. A further characteristic pain pattern is that the tendon ‘warms up’, becoming less painful over the course of an activity, only to become very painful at variable times after exercise.

· Innervation studies in human tendon show scant innervation in the tendon proper; however, tendon connective tissue and blood vessels are well innervated with three neuronal signaling pathways: autonomic, sensory and glutamatergic

· As classical (i.e. cell-mediated/prostaglandin-driven) inflammation has not been associated with tendinopathy and as the innervation pattern does not differ greatly for normal and pathological tendon, potential sources of nociception in tendon include changes in the matrix, vascular supply, cell function, bioactive substance production, ion channel expression, cytokine and neurotransmitter expression, metabolism and mechanotransduction, or a combination of these

The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain

JOSEPH B. STRUNCE PT, DSc, OCS, FAAOMPT1; MICHAEL J. WALKER PT, DSc, OCS, FAAOMPT2; ROBERT E. BOYLES PT, DSc, OCS, FAAOMPT3; BRIAN A. YOUNG PT, DSc, OCS, FAAOMPT4

· statistically and clinically significant changes in shoulder pain and ROM may occur immediately following thoracic or rib manipulative therapy

· mechanism for increased shoulder motion is the restoration of neurophysiologic motor control for the scapular and shoulder musculature as a result of de- creased muscle inhibition

· thoracic and rib segmental mobility following manipulation may provide biomechanical contributions towards improved shoulder range of motion, particularly for overhead movements.

· increase in lower trapezius muscle strength immediately following thoracic manipulation. Suter et al have also demonstrated decreased biceps muscle inhibition following cervical manipulation

Eslamian F, Shakouri S, Ghojazadeh M, Nobari O, Eftekharsadat B. Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis. Lasers In Medical Science [serial on the Internet]. (2012, Sep), [cited February 3, 2016]; 27(5): 951-958. Available from: MEDLINE with Full Text.

· LLLT was performed by gallium-aluminum-arsenide (Ga-Al-As) infrared diode laser 476, wavelength 830 nm, average power output of 100 mW, and energy density or intensity of 4 J/cm2. Laser irradiation was delivered in continuous-wave mode on 1-cm2 surface area with 20-s irradiation for each point and total treatment duration of 5 min over the painful regions of shoulder up to ten painful points

· VAS average in the experimental which after treatment changed to showed a statistically significant difference by performing routine physiotherapy plus laser therapy (p <0.001).

· ROM was not increased by LASER over physio alone

· Data analysis for the mean difference of shoulder functional problems after physiotherapy combined with laser therapy as well as after physiotherapy alone were both statistically significant (p < 0.001)

Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol. John E. Kuhn, MD, Nashville, TN

· The data from this systematic review strongly suggest that exercise improves symptoms in patients with impingement syndrome

· Strength was not shown to improve significantly for exercise alone but did improve when exercise was combined with manual therapy in 1 study

· Function improved with exercise in most studies

· The effect of manual therapy (joint and soft tissue mobilization) was evaluated in 3 studies. In each study, pain relief was statistically better when patients received manual therapy.

· The general findings from this study are:

1. exercise is effective as a treatment for the reduction of pain

2. home exercise programs may be as effective as supervised exercise, yet

3. the effect of exercise may be augmented with manual therapy

· we suggest that patients have supervised therapy 2 to 3 times each week, with the addition of manual therapy

· ROM work: postural (shrugs) + scap retraction to start

· GH movement: Pendulum --> active assisted motion

· Flexibility exercises generally were performed for anterior and posterior shoulder tightness (sleeper, cross body)

o holding each stretch for 15 or 30 seconds and repeating 3 to 5 times, with a 10-second rest between each stretch

· Strength: shoulder flexion, extension, scaption, rows, internal rotation of the adducted arm, and external rotation of the adducted arm.

o Most authors used elastic bands. Most allowed joint movement for isotonic exercise, others relied on static resistance with isometric muscle contraction

o 3 sets of 10 reps with a 60-second rest between each, 2 or 3 sets of 10 the first week, followed by 3 sets of 15 the second week, 3 sets of 20 the third week

· Scapular stabilizing: seated press up and elbow push-up plus

o performed on a chair or stable bench. Each was per- formed as 1 set of 25 repetitions

Hand grip increases shoulder muscle activity: An EMG analysis with static handcontractions in 9 subjects. Hakan Sporrong, Gunnar Palmerud & Peter Herberts

· Supraspinatus: EMG activity increased in humeral flexion from and above 60" and in 120" abduction (so had increased muscle activity in both levels or hand grip AND in all positions)

o This added activity is of clinical interest, since shoulder peritendinitis or impingement to a large extent are connected with an over-load of this muscle and we know that there is a heavy static loading in this muscle in overhead work

· Infraspinatus: the changes were less; a significant increase, however, was noticed in flexion.

· Deltoid: tendency towards increased activity in positions lower than 90°, in the higher arm positions, the activity decreased.

· Our findings imply that high static hand grip force, particularly in elevated arm positions, increases the load on some shoulder muscles. The stabilizing muscles (the rotator cuff) were more influenced than the motor muscles by hand activity.

· Handgrip activity is important to evaluate while assessing shoulder load in manual work and in clinical evaluations of patients with shoulder pain.

Effects of shoulder girdle dynamic stabilization exercise on hand muscle strength

Alena Kobesovaa, Jan Dzvonika, Pavel Kolara, Angie Sardinab and Ross Andelb,

· Many studies have emphasized the critical influence of elbow or shoulder position on hand muscle strength. For example, Alexander et al. demonstrated that coordinated control of the shoulder girdle muscles is necessary to properly position the hand for delicate manipulation

· Shoulder girdle exercises based on DNS may generate clinically significant gains in hand muscle strength.

· The treatment approach emphasizes training of natural postural-locomotion patterns as defined by developmental kinesiology. The brain must be properly stimulated and trained to automatically activate optimal movement patterns that are necessary for co-activation of the stabilizers.

· Each training session consisted of six exercises performed in the following order: 1) prone static; 2) quadruped static; 3) quadruped dynamic rock forward; 4) bear position; 5) side-sitting with dominant arm support; and 6) side-sitting with non-dominant arm support.

o Exercise - participant was asked to hold the proper position isometric as long as possible. Once a fatigue occurred and decentration of hand, shoulder or scapula emerged the exercise in the position was terminated.

o exercise session took up to 25–30 minutes, 1-2 minutes of rest between each position

Treatment

2014 systematic review – 45% of people may not respond to eccentrics

Phase 1 – Isometric 45s hold / 5 sets, 3/10 VAS or 80% MVC, mid-range hold

Phase 2 – HSR – 3s eccentric and concentric, 3-4 sets at 15 RM, work down to 6 RM

Phase 3 – Energy Storage / Ballistic

Phase 4 – Return to Play

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Dr. Mike Hadbavny

Chiropractor, Sports Sciences Resident RCCSS(C)

If you are interested in learning more about how chiropractic care can be effective for your particular condition or health goals, contact Dr. Mike Hadbavny at 250-881-7881 today to make an appointment and discover the many benefits of chiropractic care in Victoria, BC. Contact us today.