Subacromial impingement syndrome: a survey of Italian physiotherapists and orthopaedics on diagnostic strategies and management modalities

Do patients with fibromyalgia syndrome receive updated management strategies? A web-based survey among Italian physiotherapists

INTRODUCTION

Fibromyalgia syndrome (FMS) causes significant pain, disability, and costs among patients. It is paramount that healthcare professionals have an updated knowledge of its characteristics and Clinical Practice Guidelines (CPGs).

OBJECTIVES

To determine the knowledge, adherence to CPGs, and confidence of Italian physiotherapists in managing patients with FMS, explore barriers to the implementation of CPG' recommendations, compare groups' adherence to CPGs, and determine which variables explained most of the participants' knowledge.

METHODS

The survey was administered via social media and newsletter (i.e., Italian Association of Physiotherapists, AIFI) to Italian practicing physiotherapists. The protocol of this work was prospectively registered in the Open Science Framework.

RESULTS

Total replies were 398. Italian physiotherapists showed a good knowledge of FMS and adherence to CPGs. Ninety-one percent reported a medium or lower confidence in managing patients with FMS. Sixty-seven percent judged their knowledge of CPGs as poor or very poor. The remaining 33% mentioned patients' psychosocial aspects, multidisciplinary relationships, and lack of training on communication strategies as the main barriers to the implementation of CPGs. Being an Orthopaedic Manipulative Physical Therapist (OMPT) resulted in a better adherence to CPGs on 11/14 items. Knowledge scores were correlated (r = 0.244) with being an OMPT (Stand β = 0.123) and years of professional activity (Stand β = -0.126).

CONCLUSIONS

Although Italian physiotherapists demonstrated a good knowledge of FMS and reported a good adherence to CPGs' recommendations, they may still experience barriers to the implementation of evidence-based management strategies.

The immune pathology of bursitis in rheumatic inflammatory diseases, degenerative conditions and mechanical stress: A systematic review

OBJECTIVE

To summarize current insights on the immune pathology of bursitis caused by rheumatic inflammatory diseases, degenerative conditions, or mechanical stress and identify knowledge gaps in this field. Data on tenosynovitis pathology was included for comparison.

METHODS

We performed a systematic review encompassing an electronic database search of all published literatures in PubMed/MEDLINE from inception to February 13, 2023, investigating the immunological changes occurring in the bursa of patients with inflammatory rheumatic diseases, degenerative conditions or mechanical stress (e.g., impingement syndrome).

RESULTS

Thirty-two articles provided data on the immune pathology of bursal tissue inflammation were identified. Histological and immunological perturbations included alterations of tissue morphology, infiltration of macrophages and some T cells, and enhanced expression of proinflammatory cytokines, such as interleukin (IL)-6, IL-1β and tumor necrosis factor alpha (TNF-α). These changes were described for all three underlying causes, although studies on bursitis associated with rheumatic inflammatory diseases were rare. Fibrosis was only reported in subacromial bursitis caused by mechanical stress within our included studies.

CONCLUSION

Current insights on bursitis were outdated and studies on bursitis associated with rheumatic inflammatory diseases are particularly lacking. Substantial overlap of enhanced expression of IL-6, IL-1β, TNF-α and infiltrating macrophages were found in bursitis irrespective of the underlying cause. In depth investigation on bursitis such as high throughput multi-omics are urgently needed to guide disease-specific therapeutic management.

Frozen shoulder: subjects' needs and perspectives and clinicians' beliefs and management strategies: do they align? A cross-sectional study

OBJECTIVE

Physiotherapists (PTs) play a crucial role in managing individuals with Frozen Shoulder (FS), frequently being the first healthcare professionals involved in the treatment of this condition.

AIM

This study aimed to compare the beliefs, expectations, and perspectives of individuals with FS with the knowledge, skills, and strategies of PTs, highlighting similarities and differences.

METHOD

This study adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). From May 1st to August 1st, 2023, a two-part survey was conducted involving PTs and individuals diagnosed with FS. The survey focused on comparing key areas such as clinical assessment, patient education, treatment expectations, and the psychological aspects of the patient-clinician relationship.

RESULTS

A total of 501 PTs and 110 subjects with FS participated in the survey. Most PTs showed proficiency in FS pathoanatomical conditions and were also attentive to psychological aspects (88.4%), describing the pathology evolution in three or two stages (68.2%). They also highlighted the importance of patient education (89.6%) and recognized the potential benefits of a multiprofessional collaboration in managing FS (82.2%). Reassurance was reported as a priority by 32.3% of PTs. Subjects with FS expressed a preference for PTs who are both expert and empathetic (73.6%). Regarding their understanding of FS, 29.09% of subjects reported receiving a three-phase explanation, while 26.36% felt inadequately informed. Nearly half of the subjects (49.09%) anticipated being managed independently by a PT, with 93.64% prioritizing the improvement of their range of motion.

CONCLUSION

This study revealed a general agreement between subjects with FS and PTs regarding aspects of the therapeutic relationship, patient education, pathology management, compliance and motivation strategies, and pain management preferences. However, significant differences emerged concerning the perception of physiotherapy effectiveness, primary treatment goals, subjects' priorities, and the importance of psychological assessment.

Rehabilitation in subjects with frozen shoulder: a survey of current (2023) clinical practice of Italian physiotherapists

OBJECTIVE

Frozen Shoulder (FS) is a musculoskeletal pathology that leads to disability, functional decline, and a worsening in quality of life. Physiotherapists are the primary professionals involved in the treatment of FS, and it is essential to determine if their practice aligns with evidence-based suggestions.

AIM

The aim is to assess the knowledge, skills, and operational strategies of Italian physiotherapists regarding FS and compare them with the existing literature.

METHODS

A web-based, anonymous, and voluntary cross-sectional survey was developed and administered to Italian physiotherapists to evaluate their clinical practices.

RESULTS

A total of 501 physiotherapists (38.5% female), completed the survey. More than half were under 35 years old (67.8%), declared working in private practice settings or being self-employed (57.1%), and were primarily engaged with musculoskeletal patients (81.8%). For subjects with FS at their first access, 21.4% identified X-rays as the most useful imaging technique to recognize pathologies beyond rehabilitation competence. In terms of general management, the majority reported working with an orthopaedic or physiatrist (47.5%) or in a multidisciplinary team (33.5%). Regarding manual therapy techniques, 63.3% of physiotherapists preferred intense degree mobilization, posterior direction, and moderate pain at the end of the range of motion for low irritable/high stiffness FS; however, there is a lack of consensus for managing very irritable/low stiffness FS. The majority of physiotherapists (57.7%) concurred that stretching improves the balance between metalloproteinase and its inhibitors. Additionally, 48.3% of physiotherapists selected mobile phone videos and messages to improve patients' compliance with exercises at home and for motivational/educational purposes.

DISCUSSION AND CONCLUSION

The clinical practices of Italian physiotherapists in FS subjects sometimes deviate from evidence-based recommendations. While some discrepancies may be attributed to the existing uncertainties in the literature regarding knowledge and management strategies for FS patients, the authors recommend a stronger adherence to evidence-based practice.

Perspectives, perceptions, and expectations of subjects with frozen shoulder: a web-based Italian survey

Introduction

Frozen shoulder (FS) is a musculoskeletal disorder affecting the glenohumeral joint. This condition leads to disability and a worsening in quality of life. Despite its considerable impact on patients and its economic burden, research on the psychological and social implications of FS-as well as patients' perspectives and needs-is limited. This study aims to explore the perspectives, perceptions, and expectations of individuals suffering from FS, providing a comprehensive understanding of their experiences and needs.

Methods

A cross-sectional observational study was conducted following STROBE guidelines. A 59-question survey was administered to Italian individuals diagnosed with FS from April 1 to July 1, 2023.

Results

All 110 participants completed the survey. Most preferred an experienced and empathetic physiotherapist (73.64%) and relied primarily on physiotherapy (49.09%) for FS management. Additionally, 45.45% were open to a multidisciplinary approach. Subjects reported reducing night pain (71.82%) and achieving full range of motion (ROM) recovery (70.91%) as their top priorities. Participants reported a notable shift in their mood from "pre" to "post" FS, with many experiencing fear and catastrophizing thoughts and perceiving a lack of social support. Furthermore, 27.27% were open to cortisone use, while 25.45% considered electrophysical agents beneficial for managing the painful phase of FS.

Conclusion

These results underscore a strong preference for empathetic physiotherapists and the value of a multidisciplinary approach. Addressing night pain and restoring ROM are crucial priorities-emphasizing the need for tailored and shared decision-making. Additionally, these findings highlight the importance of addressing psychological well-being alongside physical symptoms.

Rehabilitation following shoulder arthroplasty: a survey of current clinical practice patterns of Italian physiotherapists

BACKGROUND

The incidence of Total Shoulder Arthroplasty (TSA) and Reverse Total Shoulder Arthroplasty (RTSA) is constantly increasing. As a result, the interest in post-surgical rehabilitation has grown, since it is crucial in order to achieve full recovery and successful outcomes. The first aim of this study is to investigate the Italian physiotherapists (PTs) clinical practice in the management of patients with TSA and RTSA and to compare it with the best evidence available in the literature. The second purpose of this study is to assess any existing difference between the survey answers and the different sample subgroups.

MATERIALS AND METHODS

This cross-sectional observation study was designed following the CHERRIES checklist and the STROBE guidelines. A 4-sections survey with a total of 30 questions was developed for investigating post-surgery rehabilitation management in patient with TSA and RTSA. The survey was sent to Italian PTs from December 2020 until February 2021.

RESULTS

Six-hundred and seven PTs completed the survey regarding both TSA and RTSA; 43.5% of participants (n = 264/607) stated that TSA is more likely to dislocate during abduction and external rotation. Regarding reverse prosthesis, 53.5% (n = 325/607) affirmed RTSA is more likely to dislocate during internal rotation, adduction and extension. In order to recover passive Range of Motion (pROM), 62.1% (n = 377/607) of participants reported that they gain anterior flexion, abduction, internal rotation, external rotation up to 30°, with full pROM in all directions granted at 6-12 weeks. Regarding the active ROM (aROM), 44.2% (n = 268/607) of participants stated that they use active-assisted procedures within a range under 90° of elevation and abduction at 3-4 weeks and higher than 90° at 6-12 weeks, with full recovery at a 3-month mark. Sixty-five point seven percent of the sample (n = 399/607) declared that, during the rehabilitation of patients with TSA, they tend to focus on strengthening the scapular and rotator cuff muscles, deltoid, biceps and triceps. Conversely, 68.0% (n = 413/607) of participants stated that, for the rehabilitation of patients with RTSA, they preferably focus on strengthening the periscapular and deltoid muscles. Finally, 33.1% (n = 201/607) of participants indicated the instability of the glenoid prosthetic component as the most frequent complication in patients with TSA, while 42.5% (n = 258/607) of PTs identified scapular neck erosion as the most frequent post-RTSA surgery complication.

CONCLUSIONS

The clinical practice of Italian PTs effectively reflects the indications of the literature as far as the strengthening of the main muscle groups and the prevention of movements, which may result in a dislocation, are concerned. Some differences emerged in the clinical practice of Italian PTs, regarding the restoration of active and passive movement, the starting and progression of muscle strengthening and the return to sport (RTS). These differences are actually quite representative of the current knowledge in post-surgical rehabilitation for shoulder prosthesis in the rehabilitation field.

LEVEL OF EVIDENCE

V.

Rehabilitation after Hip Fracture Surgery: A Survey on Italian Physiotherapists’ Knowledge and Adherence to Evidence-Based Practice

The average life expectancy of the Italian population has increased over the last decades, with a consequent increase in the demand for healthcare. Rehabilitation after hip fracture surgery is essential for autonomy, recovery, and reintegration into the social context. The aim of this study was to determine the level of knowledge and adherence to the recent treatment recommendations of the Italian physiotherapists. A web-based survey, composed of 21 items, was conducted and the frequencies and percentages of the responses were analyzed to evaluate if there was an integration and adherence to the recommendations of greater than 70%, with respect to the desired response. A total of 392 responses were collected and analyzed. Recommendations regarding the multidisciplinary approach, early mobilization, and progressive muscle strength training, achieved the desired value in the inpatient setting. Intensive rehabilitation and full weight bearing did not reach the threshold values. The results of this survey show a partial integration of the recommendations for rehabilitation after hip fracture surgery by Italian physiotherapists. Adherence seems to be better in the inpatient setting and with physiotherapists with higher levels of education.

Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists

BACKGROUND AND OBJECTIVE

High-velocity low-amplitude thrust spinal manipulation (SM) is a recommended and commonly used manual therapy intervention in physiotherapy. Beliefs surrounding the safety and effectiveness of SM have challenged its use, and even advocated for its abandonment. Our study aimed to investigate the knowledge and beliefs surrounding SM by Italian physiotherapists compared with similar practitioners in other countries.

METHODS

An online survey with 41 questions was adapted from previous surveys and was distributed via a mailing list of the Italian Physiotherapists Association (March 22-26, 2020). The questionnaire was divided into 4 sections to capture information on participant demographics, utilization, potential barriers, and knowledge about SM. Questions were differentiated between spinal regions. Attitudes towards different spinal regions, attributes associated with beliefs, and the influence of previous educational background were each evaluated.

RESULTS

Of the 7398 registered physiotherapists, 575 (7.8%) completed the survey and were included for analysis. The majority of respondents perceived SM as safe and effective when applied to the thoracic (74.1%) and lumbar (72.2%) spines; whereas, a smaller proportion viewed SM to the upper cervical spine (56.8%) as safe and effective. Respondents reported they were less likely to provide and feel comfortable with upper cervical SM (respectively, 27.5% and 48.5%) compared to the thoracic (respectively, 52.2% and 74.8%) and lumbar spines (respectively, 46.3% and 74.3%). Most physiotherapists (70.4%) agreed they would perform additional screening prior to upper cervical SM compared to other spinal regions. Respondents who were aware of clinical prediction rules were more likely to report being comfortable with SM (OR 2.38-3.69) and to perceive it as safe (OR 1.75-3.12). Finally, physiotherapists without musculoskeletal specialization, especially those with a traditional manual therapy background, were more likely to perform additional screening prior to SM, use SM less frequently, report being less comfortable performing SM, and report upper cervical SM as less safe (p < 0.001).

DISCUSSION

The beliefs and attitudes of physiotherapists surrounding the use of SM are significantly different when comparing the upper cervical spine to other spinal regions. An educational background in traditional manual therapy significantly influences beliefs and attitudes. We propose an updated framework on evidence-based SM.

Assessing cardiovascular parameters and risk factors in physical therapy practice: findings from a cross-sectional national survey and implication for clinical practice

BACKGROUND

Cardiovascular diseases are the leading cause of death and comorbidity worldwide. High blood pressure and resting heart rate are risk factors (or vital signs) critical to cardiovascular health, patient safety, and medical management. Physiotherapists play a fundamental role in risk factor identification, early diagnosis, and subsequent management of cardiovascular disease. To date there is limited research in Europe investigating the level of knowledge and skills possessed by physiotherapists regarding cardiovascular disease screening. Three studies previously observed inadequate vital signs screening behaviors of physiotherapists practicing in the United States and Saudi Arabia. The primary aim of this study was to investigate cardiovascular knowledge and screening practices among Italian physiotherapists, according to the current practice recommendations.

METHODS

A Cross-Sectional Survey was developed adapting two previous surveys. The survey was administered to members of the Italian Physiotherapy Association. Chi squared test, Mann-Whitney test or Kruskal-Wallis test were used to study differences among subgroups and question responses.

RESULTS

The required sample size was met with total of 387 Italian physiotherapists completing the survey. 80% consider relevant cardiovascular assessment. However, 72.2% were not familiar to guidelines recommendations and only 50% screen vital signs routinely. Their knowledge of normative blood pressure (high-normal, 16%; hypertension, 12%) and heart rate values (bradycardia, 24%; tachycardia, 26%) were low. Although participants reported being skilled for blood pressure measurement (quite sure, 52%; sure, 27%), their adherence to guidelines is low (baseline measurement on both arm, 25%; 3 repeated measures, 46%). Only 27.8% reported to measure exercise related BP and 21.3% of them understood the concept of exaggerated BP. No significant differences between subgroups were found.

CONCLUSIONS

Our study revealed that a concerning proportion of Italian physiotherapists are not versed in fundamentals of properly performing cardiovascular screenings. This lack of knowledge is present across the profession and may impact on appropriate triage and management. The poorly executed screening has the potential to negatively impact the patient and the practitioner. Given the absence of Italian guidelines, we produced and implemented three infographics for public use, which have the dual objective of raising awareness about this subject and providing practical resources for everyday practice.

Assessing Cranial Nerves in Physical Therapy Practice: Findings from a Cross-Sectional Survey and Implication for Clinical Practice

BACKGROUND AND OBJECTIVE

Serious pathologies of the neck can potentially result in cranial nerve palsy. Knowledge about cranial nerve examination (CNE) seems sparse, and its use is still unknown. We aim to investigate the knowledge, skills, and utilization of CNE of Italian physiotherapists.

MATERIALS AND METHODS

An online cross-sectional survey.

RESULTS

396 completed the survey, reaching the required sample size. Although Italian physiotherapists consider CNE relevant (mean ± SD = 7.6/10 ± 2.0), over half of all responders (n = 229 (57.8%)) were not trained in the fundamentals and around a third did not use it in their daily practice (n = 138 (34.8%)). Additionally, participants were unconfident and insecure in conducting (n = 152 (38.4%) and n = 147 (37.1%)), interpreting (n = 140 (35.4%) and n = 164 (41.4%)), and managing the CNE (n = 141 (35.6%) and n = 154 (38.9%)). Possessing a musculoskeletal specialization was associated with an increased value attributed to clinical practice guidelines and reduced the lack of confidence in conducting, interpreting, and managing the CNE (respectively, n = 35 (25.5%), p = 0.0001; n = 32 (23.4%) p = 0.0002; n = 32 (23.4%) p = 0.0002). Working in a direct access setting significantly increased the considered relevance of guidelines and the concerns about arterial (p = 0.004) and other serious pathologies (p = 0.021). Pain and visual disturbances were considered the main indicators to CNE, demonstrating limited knowledge of signs and symptoms' indicating CNE. Participants considered specific training in CNE as relevant (mean ± SD = 7.6/10 = 2.1).

CONCLUSIONS

a substantial proportion of Italian physiotherapists are not schooled in the fundamentals of cranial nerve examination. Given the number of physiotherapists who work in first contact roles, this is a professional concern.

Spinal Orthoses Prescription for Vertebral Fragility Fractures by Italian Physical and Rehabilitation Medicine Physicians: The SPIN-VER Survey

Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fractures, related to pain and disability. In this scenario, physical and rehabilitative medicine (PRM) physicians prescribe a patient-tailored rehabilitation plan, including spinal orthoses. However, there is a high heterogeneity in the clinical indications of spinal orthoses. Thus, the aim of this survey was to investigate common clinical practice in terms of the prescription of spinal orthoses. This nationwide cross-sectional survey recruited Italian PRM physicians commonly involved in the management of patients with VFFs. One hundred twenty-six PRM physicians completed the survey. The results showed that most PRM physicians prescribe spinal orthoses in outpatients suffering from VFFs (n = 106; 83.9%). The most prescribed spinal orthosis for acute VFF patients was the three-point rigid orthosis (n = 64; 50.8%), followed by the semirigid thoraco-lumbar orthosis (n: 20; 15.9%). However, most PRM physicians prescribed dynamic orthoses in outpatients with chronic VFFs (n = 66; 52.4%). Albeit that a correct management of VFFs is mandatory to improve pain and reduce disability, our findings highlighted uncertainty in the type of spinal orthosis prescription in both the acute and chronic VFF phase. Therefore, high-quality research trials are warranted to provide clear recommendations for the correct clinical management of VFF.

Post-surgery rehabilitation following rotator cuff repair. A survey of current (2020) Italian clinical practice

AIMS

To analyse the clinical practice of Italian physiotherapists within the framework of postoperative rehabilitation of rotator cuff (RC) surgery patients, and to compare it with similar studies carried out in other countries.

METHODS

A web-based, voluntary, cross-sectional survey with 27 closed multiple-choice questions was developed and submitted to Italian-based physiotherapists in order to assess their clinical practice.

RESULTS

Data from 1160 questionnaires were then analysed. Thirty-five percent of respondents (n = 413/1160) reported that they commence passive range of motion from the first postoperative week, while 49.2% (n = 571/1160) start during the second or third week. The majority of respondents (n = 603/1160, 52.0%) introduce active mobilisation between the fourth and the sixth week after surgery and 41.1% (n = 477/1160) introduce overhead movements between the fourth and the sixth week after surgery.

DISCUSSION AND CONCLUSIONS

When managing the postoperative rehabilitation of RC surgery patients, Italian physiotherapists' practice is congruent with the guidelines published by American Society of Shoulder and Elbow Therapists (ASSET) and also with other UK surveys. However, while Italian physiotherapists manage immobilisation periods, active and passive mobilisation and the return to sport activities, according to evidence-based best practice guidelines, there is less consistency with respect to physical exercise, patient follow-up and referral.IMPLICATIONS FOR REHABILITATIONItalian physiotherapists' practice with patients following rotator cuff (RC) repair complies with evidence-based practice guidelines regarding immobilisation periods, passive and active mobilisation, and return to sport activities.There is less consistency between reported/declared practice and available evidence concerning physical exercise, patient follow-up, and referral.Physiotherapist with Orthopaedic Manipulative Physical Therapy (OMPT) training is more aligned with the current literature compared to physiotherapists without specific training, in terms of managing rehabilitation programmes, period of immobilisation and therapeutic exercise.More careful adherence to the international guidelines is recommended, in order to manage patients following RC repair in accordance with the evidence and to achieve the best possible outcomes.