Learning about your shoulder pain: a case series for patients with shoulder-related pain

The intervention consists of a pain education session with the main researcher (physiotherapist), based on a neuroscience approach to management of pain. Individual interviews will be held at the start and the end of the study, with baseline and follow-up measures at weekly intervals, using a “pre-, post-intervention” design. Treatment of rotator cuff-related pain most commonly involves graduated exercises and manual therapy, with surgery considered when the conservative treatment is unsuccessful. These treatments currently focus on the local tissue pathology-pain model, thus on peripheral mechanisms of symptoms. However, there is not always a direct relationship between “pathology” and pain. It is, thus, unlikely that the peripheral-driven nociceptive mechanisms are solely responsible for the pain experience. Furthermore, patients’ beliefs and understanding of the causes of their (musculoskeletal) pain seem to be associated with better clinical outcomes. Besides the peripheral-driven mechanisms and potential local pathology, recent hypotheses indicate that central sensitization is also likely to contribute towards symptoms of patients with shoulder pain. Central sensitization relates to altered processing by increasingly sensitized dorsal horn cells in the spinal cord. A neuroscience approach for management of central pain mechanisms includes pain education, cognition-targeted exercises and graded exposure to physical activity with the overall aim of decreasing the sensitivity of the central nervous system. Cognition-targeted exercises entail progressive exercises to improve muscle function and strength by including motor imagery (patients imagining that they are performing the exercise prior to physically performing them) and considering their beliefs and perception of the outcomes of the exercise, thereby decreasing fear of (re-)injury and avoidance of movement. Graded exposure to physical activity follows the same principles and are based on the patient's individual interests and capabilities: eg starting a walking programme with 10 minutes per day, and carefully grading increases in duration. It currently is unclear how patients with rotator cuff-related pain understand their pain experience. It is also unclear whether the addition of pain education to usual physiotherapy will be of benefit these patients with rotator cuff-related pain, and whether this approach would be acceptable to the patients. This study will be a case series whereby participants attend 6 physiotherapy sessions over 5 weeks at the School of Physiotherapy, University of Otago, Dunedin in a clinical research laboratory. The first, third and final sessions will last 1 and a half hrs, and the others will be a half to 1 hour. Two qualitative studies will be nested in the study to explore (1) patients’ beliefs and experiences about their pain, and (2) their perception of the usefulness of the educational tool. The first interview will be undertaken during session 1 and the second interview at Session 6. The first interview will be conducted by the primary researcher, while the second interview will be conducted by a research assistant (also a physiotherapist). The second interview will explore the participants' acceptability and perceptions of the usefulness of the pain education as part of the management of their shoulder pain. Results of that interview will be used to modify the educational tools, if necessary, in preparation for potential future studies. The educational tools (Powerpoint presentation, content of the one-hour face-to-face session, and hand-out) will be designed by the researchers based on current research evidence, prior to Session 3. Information gained from the first interview on the participants’ beliefs, will also be used for the final drafting of the educational tools to ensure that the content is specific for patients with shoulder pain. Pain education will be provided by the main investigator (physiotherapist) by individual instruction during Session 3, supported by a Powerpoint presentation, and will last 1 hour. A paper hand-out will also be used, allowing participants to reflect on the information that is provided and how it may relate to their pain, to add notes and questions, and bring it to the follow-up sessions. During the three follow-up sessions (Session 4 to 6), they will have the opportunity to ask the physiotherapist for further clarification allowing individualised information to be provided. All six sessions will be held on an individual basis.