Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
thoracic oulet syndrome undiagnosed cause of shoulder pain
- Carlos A Selmonosky (11 November 2005)
-
Only your thumb...........!!! for the shoulder
- harold jitschak bueno de mesquita (11 November 2005)
-
musculo skeletal medicine
- Fenella Lemonsky (13 November 2005)
-
“Shoulder pain”……………”A pain in the neck”!
- Sidha Sambandan (14 November 2005)
-
Shoulder pain and acupuncture/CAM provision in the NHS
- Tanya Trayers (16 November 2005)
-
Re: Shoulder pain and acupuncture/CAM provision in the NHS
- John P Heptonstall (17 November 2005)
-
Back to basics
- Richard Bartley (18 November 2005)
-
Re: Re: Shoulder pain and acupuncture/CAM provision in the NHS
- John P Heptonstall (18 November 2005)
-
What Basics Are We talking About?
- Dr. Herbert H. Nehrlich (19 November 2005)
-
Re: Back to basics
- John P Heptonstall (19 November 2005)
-
Diagnosis first, treatment second; Patterns of pain
- Gavin R Tait (19 November 2005)
-
Re: Diagnosis first, treatment second; Patterns of pain
- Richard Bartley (21 November 2005)
-
corticosteroids are effective for rotator cuff disorders
- Bruce ARROLL (27 November 2005)
-
Is Steroid Injection The Best Option ?
- Dr. Herbert H. Nehrlich (28 November 2005)
-
No treatment without diagnosis
- Gabriel Symonds (21 December 2005)
|
|
|||
|
Carlos A Selmonosky, Physician 22041
Send response to journal:
|
Shoulder pain is a common complain in patiens with Thoracic Outlet Syndrome.There are 19 references in PUB-MED relating shoulder pain to Thoracic outlet Syndrome.The diagnosis is made by the use of a triad of physical findings (www.tos-syndrome.com),associated or not with the White Hand Sign. This triad of signs is not reported to be present or not in articles about shoulder pain,therefore the diagnosis of Thoracic Outlet Syndrome is frequently missed. The triad of signs consist of 1)weakness of abduction and adduction oif the fifth finger,2)paresthesias and/or paleness of the hand on elevation of the upper extremities, 3)tenderness on thumb pressure in the supraclavicular area. Competing interests: None declared |
|||
|
|
|||
|
harold jitschak bueno de mesquita, family-physician Jerusalem 93384
Send response to journal:
|
Was it not for a acupuncture course in Sri-lanka many years ago with the late prof. Anton Jayasuriya , then I would probably still not know what to do with the various shoulder-conditions described extensively in your paper and so common in general practice.
Really one just needs only one's thumb!! Far better still, one single needle. In at least half of the patients with a "shoulder-condition" [with purpose I don't define frozen shoulder, rotator cuff etc], even longstanding cases, one can see a miraculous improvement within a minute or so of pressure [even better by needling] on the acupuncture point: stomach 38. This improvement may be temporary and need to be repeated or just one treatment maybe enough. A family member may be taught to repeat the treatment, if necessary [by pressure or repeating the needle. If the treatment does not work at once, then it is not likely to work in the future. Again within seconds or less then a minute the patient [and the doctor!!] maybe both amazed by the results. If you wish to start today and see with your "own eyes": The point is located halfway between the underside of the patella and the malleolus lateralis, one thumb-breadth lateral from the tibia. Probably best to use the side of the effected shoulder. But the other side may work as well. Try with strong pressure of your thumb or better use an acupuncture needle, if you have one and are a bit familiar with this. I would be happy to receive your feedback. bdmesq@gmail.com Competing interests: None declared |
|||
|
|
|||
|
Fenella Lemonsky, Chronic pain patient and communication skills trainer to NHS staff Barnet
Send response to journal:
|
This study was rather biased. There was no discussion on the value of the role of musculoskeletal medicine. Every year doctors trained in musculoskeletal medicine or medical osteopathy do thousands of successful manipulations to those with chronic shoulder pain and obviate the need for surgery.This is better for the patient , less traumatic and less expensive. Physiotherapy is very limited in prognosis however pain specialist physiotherapists do have a good role to play here as do pain clinics in the management of chronic pain. Surgery should always be the last resport as like with back pain it does not always lead to a significant improvement and in some cases can make symptoms--including movement restriction. Competing interests: None declared |
|||
|
|
|||
|
Sidha Sambandan, GP / GPwSI in Orthopaedics Yare Valley Medical Practice, 202 Thorpe Rd, Norwich NR1 1TJ
Send response to journal:
|
The precise patho-anatomical diagnosis of shoulder pain can be difficult for GPs who do not have experience in the assessment of musculoskeletal problems. A working diagnosis can be made by excluding referred pain, palpating for localised tenderness, and assessing active, passive and active resisted movements of all the muscles involved in shoulder movement. The prevalence of Bicipital tendinopathy in the community is underestimated as there is a tendency to miss the diagnosis by not examining the active resisted movement of the Biceps. It is more common in the 20-40 age group. Accurate diagnosis of the site and nature of the shoulder problems determines the self-help management advice we give to patients in primary care, the instructions on activity modification, physiotherapy and injecting steroids. The outcomes from steroid injections depend not only on the acuteness of onset and underlying inflammatory pathology, but also on the accuracy of the placement. The “evidence based” view that steroids have limited benefit does not match the patient orientated evidence that matters. The latter is far more important in the context of primary care. An elaboration on the use and timing of X Rays, Ultrasound, and MRI by the authors would have been useful, especially in the ethos of Practice Based Commissioning as already open access to these investigations are available in primary care. Two significant contributions to community based “shoulder pain” management are from the Dutch College of GPs guidelines on “Shoulder pain”(1) and the Cambridge study(2) . A further useful prospective cohort study on outcomes was from Primary Care Rheumatology Society.(3) Bibliography: 1)NHG Practice Guidelines “Shoulder Complaints” (May 1999), accessed via Google. nhg.artsennet.nl/upload/104/guidelines2/E08.htm 2)Vecchio P, Kavanagh R, Hazleman BL, King RH. Shoulder pain in a community-based rheumatology clinic. Br J Rheumatol. 1995 May;34(5):440-2. 3)Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care BMJ 1996;313:601-602 Competing interests: None declared |
|||
|
|
|||
|
Tanya Trayers, Research Training Fellow, Academic Unit of Primary Health Care and Physiotherapist University of Bristol BS6 6JL
Send response to journal:
|
As a physiotherapist trained to practise acupuncture I was delighted to read the letter regarding the use of the acupuncture point, ST 38 to treat shoulder pain. This letter highlights two very topical points. Firstly related to the continued debate regarding the cost effectiveness of using acupuncture and CAM (complementary and alternative medicine) in the NHS, which recently was subject of a review (1) and secondly the scope in which current NHS clinicians practise. Thompson and Feder (2) contributed to this, suggesting that complementary and alternative interventions could be provided in a more cost effective manner by being carried out by existing clinicians. Physiotherapists, who received many referrals for musculoskeletal conditions, including shoulder pain, incorporate manual therapy, exercise and electrotherapy into their treatments. For those physiotherapists trained and accredited to practise acupuncture, this offers another treatment modality and a very useful skill for the treatment of pain. Physiotherapists can carry out a variety of acupuncture training courses, such as completing an undergraduate module, a short or long postgraduate course, or a specific Master of Sciences course (MSc). The Acupuncture Association of Chartered Physiotherapists (AACP) monitors the standards of training and practise offered by chartered physiotherapists and has nearly 5,000 members. It seems like a particularly cost effective procedure to have physiotherapists, or other NHS clinicians, including doctors and nurses, trained to provide acupuncture. The cost of training current NHS staff to deliver acupuncture or possibly other CAM modalities, would I expect be much less than employing additional therapists trained exclusively in these modalities to deliver them. In addition, when using the point ST 38, I find it beneficial for the patients to actively rotate the shoulder within the limits of pain while this point is being stimulated. Reference List (1). Canter PH, Coon JT, Ernst E. Cost effectiveness of complementary treatments in the United Kingdom: systematic review. BMJ 2005;331:880-881. (2). Thompson T, Feder G. Complementary therapies and the NHS. BMJ 2005;331:856-857. Competing interests: None declared |
|||
|
|
|||
|
John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG
Send response to journal:
|
Sir/Madam Tanya Trayers enthusiasm for the effectiveness of acupuncture is certainly not misplaced although her apparent suggestion that a cheap equally effective 'acupuncture service' might be gained from additional training in the technique for physios, nurses, doctors and other medical professionals, as compared to employing acupuncture professionals having an extensive background in the doctrine that underpins the safest most effective delivery of acupuncture, is certainly misplaced. I suspect she does not appreciate the value of an extensive training in traditional principles and methodologies that have underpinned the use of acupuncture for generations. I welcome any opportunity to improve her understanding in that regard. The acupoint S38 is generally used to treat acute frozen shoulder at the opposite side; for same side, GB34 is traditionally used for best effect. Neither are as effective when the condition becomes more chronic and other points are better used according to the location, type and chronicity of disorder in each patient; both points must be used with caution because, as their titles imply, S38 also has a powerful effect on stomach function and GB34 on gall bladder function so patients with underlying pathologies affecting those organs a. might find those pathologies are affected positively or adversely depending what kind of stimulation is applied and for how long to those points and b.might find the shoulder problem is a reflection of those pathologies which are actually involved in causation of the frozen shoulder symptoms I find that such considerations are usually ignored, or not understood at all, by practitioners unfamiliar with TCM doctrine and, as such, they are incapable of recognising the full implications of their acupuncture intervention. In addition, anyone familiar with TCM would also be aware that stimulation of any stomach point has a knock on effect to other organ systems depending how stimulation is applied; for example over- tonification or sedation of stomach points can affect heart, kidney, liver and lung functions to different degrees; similarly for GB points, and indeed any point selected. Those potential effects are predictable through TCM considerations so acupoints are selected for simultaneous stimulation according to a patient's individual state of health and constitution to ensure a safe balance when any single point has been identified for stimulation. I hope Tanya is familiar with these essential considerations before, as one of my old Chinese professors used to instill in his students, she decides it RIGHT to insert an acupuncture needle into the right patient at the right time in the right place. Regards John H. Competing interests: Specialist in Traditional Chinese Medicine - acupuncture & moxibustion |
|||
|
|
|||
|
Richard Bartley, Chartered Physiotherapist Colwyn Bay LL29 8ES
Send response to journal:
|
Papers of this type serve the primary care clinician well, as they emphasis safety (recognition of Red Flags), and promote effectiveness (i.e. enabling GPs and physiotherapists to recognise clinical patterns and pursue evidence-based treatments). Acupuncturists who have not been exposed to the type of vigorous conventional medical training undertaken by doctors and allied professionals, are simply not equipped with the appropriate safety baseline for screening, diagnosing and managing musculo-skeletal disorders. However doctors and physiotherapists with training in both allopathic and alternative therapies, meet the necessary safety standards and may find papers of this type a welcome addition to their knowledge base. I do not doubt for one minute that the inappropriate application of TCM could lead to adverse events in the eyes of its followers. However, the substition of a combined allopathic/acucopunture approach by TCM alone may be a step too far. Competing interests: Member of the Acupuncture Association of Chartered Physiotherapists |
|||
|
|
|||
|
John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG
Send response to journal:
|
Sir/Madam In my last response I noticed, after publication unfortunately, I had mistakenly said GB34 is used on the same and S38 opposite sides; this note is to correct that - we use GB34 stimulation during acute frozen shoulder on the opposite side to the affected shoulder and stimulate whilst asking the patient to try gradually losen the shoulder through circular movements; even the most painful 'stuck' (to use a useful expression of one of my old teachers) shoulder can respond to this action at GB34. The trick is to try maintain sufficient stimulation at GB34 (which can be uncomfortable in itself) to induce loosening of the affected shoulder whilst not producing too much stimulatory discomfort that the patient cannot endure the acupuncture. This kind of stimulation is not common generally and acupuncture usually does not involve considerable discomfort, only such procedures. For chronic frozen shoulder GB34 may be part of a prescription that, for myself, often includes electroacupuncture between LI4 and GB21 on the affected side and perhaps the "shoulder 3 point" prescription on the affected side (LI15, Jian front and Jian rear points). Other points may be combined depending on patient and symptoms. S38 can often assist the process, as Tanya says, and is stimulated rather like GB34 but on the affected side. The constitution and unique charteristics of patient and condition will dictate what prescription is used at each treatment. Regards John H. Competing interests: None declared |
|||
|
|
|||
|
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
Send response to journal:
|
To make a blanket statement about some alleged superior training of either physiotherapists or doctors with training in CAM etc. contributes little to the discussion. In well over thirty years of practice, a good portion of which involved Sport Medicine I was often impressed with the treatment results of Osteopaths/Chiropractors, Acupuncturists and Massage Therapists. Physiotherapy in the USA, Europe and Australia (personal experience on the three continents) has often been a disappointment, notably because of lengthy treatment regimens that seemed to kill time above all. I had always put down these outcomes to the relative lack of comprehensive training and relatively subservient position of physiotherapists but remain open-minded. Competing interests: None declared |
|||
|
|
|||
|
John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG
Send response to journal:
|
Sir/Madam Richard states "However doctors and physiotherapists with training in both allopathic and alternative therapies, meet the necessary safety standards". However, that statement is untrue when viewed from a TCM perspective - remembering that acupuncture is a technique that was developed effectively through, and has evolved safely from, TCM principles, methodology and practices over hundreds of years. Modern Western medical concepts cannot begin to explain the numerous mechanisms and fundamentals of this technqiue, and therefore its safe use can only be expected to be derived from a sound understanding of TCM doctrine, principles and practices through which it evolved. The doctrine has been used to diagnose, and the technique to treat, musculo-skeletal conditions amongst many other conditions for generations successfully and safely without western medical knowledge or intervention and there is no reason to suppose that status quo needs altering for phsyiotherapy or any other medical doctrine which cannot meet the stringent approach TCM demands for safe efficacious use of one of its technqiues. Physiotherapy developed through a western medical doctrine and that is fine for such usage; it cannot presume, nor can any other western medically derived system of intervention, to be capable of using a technqiue - called ACUpuncture for good reason - effectively and safely by virtue of its background in western medicine. Perhaps a useful way to demonstrate this would be for Richard to describe a typical musculoskeletal condition with point prescription typically applied with reasoning and allow me to explein typical TCM considerations that may apply thereto? Many physios are increasing their background knowledge of TCM principles, I have taught a number myself, and that can only be a good thing but in the main, I find that the average physio with "acupuncture training" still appears to have limited understanding and knowledge of the essentials of TCM that I would consider are a basic requirement for the safe efficacious use of acupuncture. Regards John H. Competing interests: Specialist in TCM acupuncture & moxibustion |
|||
|
|
|||
|
Gavin R Tait, Consultant Orthopaedic Surgeon Crosshouse Hospital Kilmarnock KA2 0BE
Send response to journal:
|
Congratulations to Andy Carr et al in highlighting the morbidity associated with shoulder disease. However he misses the opportunity to clarify the main problem in resolving shoulder problems; a correct diagnosis of the source of the patients complaint. Many wasted hours of physiotherapy, acupuncture and other treatments are suffered by patients who are treated without first having a diagnosis. Only 3 paragraphs of a 5 page article and one table are given to diagnosis. All the common shoulder complaints can be correctly identified by clinical history and examination, so why are patients so often mistreated at length for the wrong condition. Too often shoulder pain is treated as just that: shoulder pain. The shoulder is of 5 joints each of which can be the source of pain. Only by identifying the source of the pain precicely can treatment be directed correctly. No mention is made of the basic pattern of pain suffered when one or other of the shoulder joints is diseased. The clinical assessment described (Box 1)continues with the error of discussing shoulder pain as one entity when there are several clear and recognised patterns of pain in the shoulder which will usually accurately localise the presenting disease. The diagnosis of shoulder disease can be made with a clear understanding of the clinical patterns of pain and associated signs. Only then will treatment be properly targeted and effective. Maybe then patients will be spared ineffectual and prolonged "holistic treatment" with no clear scientific and clinical evidence base (See the other rapid responses). Competing interests: None declared |
|||
|
|
|||
|
Richard Bartley, Chartered Physiotherapist Colwyn Bay LL29 8ES
Send response to journal:
|
I agree with Gavin Tait. Without proper diagnosis, treatment regimes are more likely to be ineffective, i.e. we end up with Voltaire's principle of simply entertaining the patient whilst nature takes its course (for better or for worse). Diagnostic triage for shoulder pain depends on the ability of the clinician to accurately identify diagnostic sub-groups. The authors suggest that this should be straight forward. However, the diagnostic triage system for low back pain advocated some years ago by CSAG and the RCGP does not appear to have improved back pain management in this country. This may be due to a failure of clinicians to adopt the principles of diagnostic triage and acquire the skills to carry it out effectively. It may also reflect that determination of many health care practitioners to pursue evidence-weak treatments at all cost, simply to justify their involvement in the care of the patient. Acupuncture may have a role in the management of shoulder pain, but the evidence for its use is weak. This does preclude its use, but it does require the clinician to justify any treatment protocol on the basis of accurate diagnosis and sound clinical reasoning. Competing interests: Member of Acupuncture Association of Chartered Physiotherapists |
|||
|
|
|||
|
Bruce ARROLL, Professor of General Practice and Primary Health Care University of Auckland
Send response to journal:
|
The authors report that the evidence for corticosteroids in shoulder disorders is weak. This is perhaps because they only examined the Cochrane reviews which did not report numbers needed to treat. I was part of a review "Arroll B, Goodyear-smith F. Corticosteroid injections for painful shoulder a meta-analysis. Br J Gen Pract 2005;55:224-8." where the the relative risk (RR) for improvement for subacromial corticosteroid injection for rotator cuff tendonitis was 3.1 (95%CI 1.9-4.9). This translated to a numbers needed to treat of 3.3 to get an improvement which is better than almost any thing we do in clinical medicine. The experience of myself and some of my colleagues that this NNT translates in to everyday clinical practice. There is an absence of data on harm but plenty on effectiveness. Thus if we are cautious we can improve the situation for our patients. Competing interests: None declared |
|||
|
|
|||
|
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
Send response to journal:
|
Pofessor Arroll is undoubtedly correct in his assessment of the efficacy of corticosteroid injections for rotator cuff syndrome. This efficay however, reflects symptomatic relief, as I am reminded that cortisone acts by altering the tissue response and does nothing to treat the cause. Yes, Cyriax was a proponent of steroid injections as well, it seems like such a cop-out though. Manual manipulation as applied by osteopaths or chiropractors often obtains objective improvement in a reasonable time span, thus I would always consider this the treatment of choice. Also, we ought not forget that many people who present with symptoms that point toward RCS are in reality suffering from a problem in the cervical spine and are misdiagnosed and given the easy treatment of steroid injection. When results fail to materialize it adds to the perception that the evidence for this kind of management is weak. Competing interests: None declared |
|||
|
|
|||
|
Gabriel Symonds, General Practitioner Tokyo
Send response to journal:
|
It is unhelpful that the treatments recommended for the commonest stated types of shoulder pain – rotator cuff disorders and gleno-humeral and acromio-clavicular joint problems – are analgesics (obvious), ‘relative rest’ (whatever that means), encouragement of activity (difficult when your shoulder hurts) and provision of a leaflet. The impression is given that steroid injections for rotator cuff disorders should be done reluctantly, and illogically into the subacromial bursa. Practitioners are discouraged from injecting the shoulder joint since apparently this needs to be guided by fluoroscopy. If patients are still suffering after six months, referral for consideration for surgery is suggested. It may be that ‘the evidence for common primary care interventions, including steroid injections, is relatively weak’, but this merely reflects the fact that trials of specific treatments in accurately diagnosed patients have not been done. There are at least two current textbooks (1,2) setting out in detail how to carry out a systematic clinical examination in patients with shoulder pain, and how to treat them effectively with simple techniques such as local steroid injections. It will be found that accurate diagnoses can regularly be made, treatment can given to the part at fault, and the great majority of such patients will thus be rapidly relieved of their symptoms. 1. Ombregt L, Bisschop P, ter Veer H J. A System of Orthopaedic Medicine, Churchill Livingstone, 2003. 2. Cyriax J. Textbook of Orthopaedic Medicine, Bailliere Tindall, 1982 Competing interests: None declared |
|||