No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Using a Hypotheticodeductive Reasoning Approach to Identify Coronary Artery Stenosis and Myocardial Ischemia in a Patient With Upper Arm, Scapular, and Wrist Pain
Abstract
BACKGROUND: A 58-year-old male with left upper extremity pain presented for second opinion via video teleconferencing secondary to his physician’s recommendation for potential rotator cuff surgery.
CASE PRESENTATION: He reported subacute variable left upper extremity pain. He denied questioning targeting the cardiopulmonary symptoms but also denied movement-based aggravating factors of the cervical spine and shoulder.
OUTCOME: A movement-based exam targeting potential cervical and shoulder differential diagnoses failed to elicit symptoms. The physical therapist advocated for referral by the primary care provider to a cardiologist to rule out an underlying cardiac etiology. Per-recommendation stress EKG testing reproduced his symptoms and caused abnormal EKG behavior, leading to angiography and stenting.
FOLLOW-UP: At follow-up forty-eight hours, one week, and four weeks after stent placement, the patient reported complete resolution of symptoms.
DISCUSSION: This case underscores the importance of ruling out competing differential diagnoses, the role the physical therapist can have in entry-point care, and the value that telehealth-based services can have in patient triage.
ResearchGate has not been able to resolve any citations for this publication.
Although current guidelines on the management of stable coronary artery disease acknowledge that multiple mechanisms may precipitate myocardial ischemia, recommended diagnostic, prognostic and therapeutic algorithms are still focused on obstructive epicardial atherosclerotic lesions, and little progress has been made in identifying management strategies for non-atherosclerotic causes of myocardial ischemia. The purpose of this consensus paper is three-fold: 1) to marshal scientific evidence that obstructive atherosclerosis can co-exist with other mechanisms of ischemic heart disease (IHD); 2) to explore how the awareness of multiple precipitating mechanisms could impact on pre-test probability, provocative test results and treatment strategies; and 3) to stimulate a more comprehensive approach to chronic myocardial ischemic syndromes, consistent with the new understanding of this condition.
Background
This study was designed to investigate the prevalence of rotator cuff tears in a population who had never sought for symptoms from their shoulders. The aim was to see whether there is a correlation between dysfunction and the presence of cuff tears seen with ultrasonography or radiology.
Materials and methods
Clinical assessment with constant score, ultrasound and radiographic examination was done on 106 voluntary subjects (212 shoulders). There were 52 men and 54 women with a median age of 66 years. The correlations between complaints, cuff tears, constant score, ultrasound and radiological findings were calculated.
Results
Of 106 subjects, 64 (60%) had shoulder problems. The prevalence of full-thickness cuff tears was 30% (21% of all the 212 shoulders). 61% of the shoulders with full-thickness tears had symptoms compared to 33% of the shoulders without tears. The constant score was lower in shoulders with full-thickness tears. Partial tears or acromioclavicular degeneration had no impact on shoulder complaints or constant score. The subacromial index was lower for shoulders with full-thickness tears. Patients with primary osteoarthritis had a lower acromion index than patients with full-thickness tears.
Conclusion
The prevalence of shoulder complaints and/or cuff tears was high in this population, which had never sought medical care for shoulder problems. Only full-thickness tears had an impact on shoulder function and constant score. Partial-thickness tears and degenerative changes in the acromioclavicular joint may be considered as age-related changes. The subacromial index can be used as a predictor for full-thickness cuff tears.
Level of evidence
Level III, cross-sectional study, prevalence study.
Background
Knee MRI is increasingly used to inform clinical management. Features associated with osteoarthritis are often present in asymptomatic uninjured knees; however, the estimated prevalence varies substantially between studies. We performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees.
Methods
We searched six electronic databases for studies reporting MRI osteoarthritis feature prevalence (ie, cartilage defects, meniscal tears, bone marrow lesions and osteophytes) in asymptomatic uninjured knees. Summary estimates were calculated using random-effects meta-analysis (and stratified by mean age: <40 vs ≥40 years). Meta-regression explored heterogeneity.
Results
We included 63 studies (5397 knees of 4751 adults). The overall pooled prevalence of cartilage defects was 24% (95% CI 15% to 34%) and meniscal tears was 10% (7% to 13%), with significantly higher prevalence with age: cartilage defect <40 years 11% (6%to 17%) and ≥40 years 43% (29% to 57%); meniscal tear <40 years 4% (2% to 7%) and ≥40 years 19% (13% to 26%). The overall pooled estimate of bone marrow lesions and osteophytes was 18% (12% to 24%) and 25% (14% to 38%), respectively, with prevalence of osteophytes (but not bone marrow lesions) increasing with age. Significant associations were found between prevalence estimates and MRI sequences used, physical activity, radiographic osteoarthritis and risk of bias.
Conclusions
Summary estimates of MRI osteoarthritis feature prevalence among asymptomatic uninjured knees were 4%–14% in adults aged <40 years to 19%–43% in adults ≥40 years. These imaging findings should be interpreted in the context of clinical presentations and considered in clinical decision-making.
The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have generated several pathoaetiological models in the literature. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. While the continuum has been cited extensively in the literature, its clinical utility has yet to be fully elucidated. The continuum model proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy. Here we revisit and assess the merit of the continuum model in the context of new evidence. We (1) summarise new evidence in tendinopathy research in the context of the continuum, (2) discuss tendon pain and the relevance of a model based on structure and (3) describe relevant clinical elements (pain, function and structure) to begin to build a better understanding of the condition. Our goal is that the continuum model may help guide targeted treatments and improved patient outcomes.
Degenerative changes are commonly found in spine imaging but often occur in pain-free individuals as well as those with back pain. We sought to estimate the prevalence, by age, of common degenerative spine conditions by performing a systematic review studying the prevalence of spine degeneration on imaging in asymptomatic individuals.
We performed a systematic review of articles reporting the prevalence of imaging findings (CT or MR imaging) in asymptomatic individuals from published English literature through April 2014. Two reviewers evaluated each manuscript. We selected age groupings by decade (20, 30, 40, 50, 60, 70, 80 years), determining age-specific prevalence estimates. For each imaging finding, we fit a generalized linear mixed-effects model for the age-specific prevalence estimate clustering in the study, adjusting for the midpoint of the reported age interval.
Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.
Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient's clinical condition.
© 2015 American Society of Neuroradiology.
Context Patients with unstable angina/non–ST-segment elevation myocardial
infarction (MI) (UA/NSTEMI) present with a wide spectrum of risk for death
and cardiac ischemic events.Objective To develop a simple risk score that has broad applicability, is easily
calculated at patient presentation, does not require a computer, and identifies
patients with different responses to treatments for UA/NSTEMI.Design, Setting, and Patients Two phase 3, international, randomized, double-blind trials (the Thrombolysis
in Myocardial Infarction [TIMI] 11B trial [August 1996–March 1998] and
the Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and
Non-Q-Wave MI trial [ESSENCE; October 1994–May 1996]). A total of 1957
patients with UA/NSTEMI were assigned to receive unfractionated heparin (test
cohort) and 1953 to receive enoxaparin in TIMI 11B; 1564 and 1607 were assigned
respectively in ESSENCE. The 3 validation cohorts were the unfractionated
heparin group from ESSENCE and both enoxaparin groups.Main Outcome Measures The TIMI risk score was derived in the test cohort by selection of independent
prognostic variables using multivariate logistic regression, assignment of
value of 1 when a factor was present and 0 when it was absent, and summing
the number of factors present to categorize patients into risk strata. Relative
differences in response to therapeutic interventions were determined by comparing
the slopes of the rates of events with increasing score in treatment groups
and by testing for an interaction between risk score and treatment. Outcomes
were TIMI risk score for developing at least 1 component of the primary end
point (all-cause mortality, new or recurrent MI, or severe recurrent ischemia
requiring urgent revascularization) through 14 days after randomization.Results The 7 TIMI risk score predictor variables were age 65 years or older,
at least 3 risk factors for coronary artery disease, prior coronary stenosis
of 50% or more, ST-segment deviation on electrocardiogram at presentation,
at least 2 anginal events in prior 24 hours, use of aspirin in prior 7 days,
and elevated serum cardiac markers. Event rates increased significantly as
the TIMI risk score increased in the test cohort in TIMI 11B: 4.7% for a score
of 0/1; 8.3% for 2; 13.2% for 3; 19.9% for 4; 26.2% for 5; and 40.9% for 6/7
(P<.001 by χ2 for trend). The pattern
of increasing event rates with increasing TIMI risk score was confirmed in
all 3 validation groups (P<.001). The slope of
the increase in event rates with increasing numbers of risk factors was significantly
lower in the enoxaparin groups in both TIMI 11B (P
= .01) and ESSENCE (P = .03) and there was a significant
interaction between TIMI risk score and treatment (P
= .02).Conclusions In patients with UA/NSTEMI, the TIMI risk score is a simple prognostication
scheme that categorizes a patient's risk of death and ischemic events and
provides a basis for therapeutic decision making.
Numerous studies have shown that diagnostic failure depends upon a variety of factors. Psychological factors are fundamental in influencing the cognitive performance of the decision maker. In this first of two papers, we discuss the basics of reasoning and the Dual Process Theory (DPT) of decision making. The general properties of the DPT model, as it applies to diagnostic reasoning, are reviewed. A variety of cognitive and affective biases are known to compromise the decision-making process. They mostly appear to originate in the fast intuitive processes of Type 1 that dominate (or drive) decision making. Type 1 processes work well most of the time but they may open the door for biases. Removing or at least mitigating these biases would appear to be an important goal. We will also review the origins of biases. The consensus is that there are two major sources: innate, hard-wired biases that developed in our evolutionary past, and acquired biases established in the course of development and within our working environments. Both are associated with abbreviated decision making in the form of heuristics. Other work suggests that ambient and contextual factors may create high risk situations that dispose decision makers to particular biases. Fatigue, sleep deprivation and cognitive overload appear to be important determinants. The theoretical basis of several approaches towards debiasing is then discussed. All share a common feature that involves a deliberate decoupling from Type 1 intuitive processing and moving to Type 2 analytical processing so that eventually unexamined intuitive judgments can be submitted to verification. This decoupling step appears to be the critical feature of cognitive and affective debiasing.
We conducted a study to ascertain specific patterns of pain in patients with common shoulder disorders and to describe a comprehensive shoulder pain map. We prospectively studied 94 cases involving an upper limb pain map and correlated the maps with the final diagnoses made by 2 clinicians who were blinded to the pain map findings. Pattern, severity, and type of pain were specific to each common shoulder disorder. In subacromial impingement, pain was predominantly sharp, occurred around the anterior aspect of the shoulder, radiated down the arm, and was associated with dull, aching pain radiating to the hand. A similar pain pattern was found in rotator cuff tears. In acromioclavicular joint pathology, pain was sharp, stabbing, and well localized to the anterosuperior shoulder area. Glenohumeral joint arthritis was marked by the most severe pain, which occurred in a mixed pattern and affected the entire arm. Whereas the pain of instability was a mixture of sharp and dull pain, the pain of calcific tendonitis was severe and sharp. Both pains were limited to the upper arm and shoulder. Pain mapping revealed definitive patterns for shoulder pathologies. We advocate using pain maps as useful diagnostic guides and research tools.
The morning peak in myocardial ischemia has been related to diurnal variations in physical and mental activities and to postural changes upon awakening. This study assesses (1) the effects of exogenous activity triggers at different times of the day and (2) the contribution of an endogenous (ie, activity- and posture-independent) circadian vulnerability for ambulatory ischemia. METHODS and
Sixty-three stable coronary artery disease patients underwent ambulatory ECG monitoring and completed a structured diary assessing physical and mental activities. During 2519 hours of observation, a morning increase in ischemia coincided with increases in physical and mental activities, and an evening decrease in ischemia coincided with a decline in activities. During the morning, ischemic versus ischemia-free periods were more likely to occur with high levels of physical activity (P < .001). High physical activity triggered ischemia to a lesser but still significant extent (P < .05) in the afternoon but not in the evening (P = NS). High levels of mental activity triggered ischemia significantly during the morning (P < .04) and evening (P < .04) but not in the afternoon. When a residualized score procedure was used to correct ischemic time for each patient's simultaneously measured activities, for hourly heart rates, or for activity-related heart rate fluctuations, the circadian variation in ischemia was still observed (P < .001), with a peak at 6 AM. A significant increase in ischemia occurred immediately after awakening (P < .05), but activity-adjusted increases in morning ischemia persisted (P < .05) for 2 hours after awakening.
Exogenous factors (physical and mental activities) are most potent as triggers of ischemia during the morning hours, and the postural change after awakening contributes to the morning increase in ischemia. There is also evidence for an endogenous, activity-independent circadian influence on ischemic susceptibility that is independent of exogenous factors and that sustains the increase in ischemia upon awakening.
Compromised shoulder movement due to pain, stiffness, or weakness can cause substantial disability and affect a person's ability to carry out daily activities (eating, dressing, personal hygiene) and work.w1 Self reported prevalence of shoulder pain is estimated to be between 16% and 26%; it is the third most common cause of musculoskeletal consultation in primary care, and approximately 1% of adults consult a general practitioner with new shoulder pain annually.1 Occupations as diverse as construction work and hairdressing are associated with a higher risk of shoulder disorders. Physical factors such as lifting heavy loads, repetitive movements in awkward positions, and vibrations influence the level of symptoms and disability, and psychosocial factors are also important.w1 Recent studies suggest that chronicity and recurrence are common.2 3
Common shoulder disorders exhibit similar clinical features, and the lack of consensus on diagnostic criteria and concordance in clinical assessment complicates treatment choices.3 w2-w5 This review proposes an evidence based approach using a simplified classification of shoulder problems, incorporating diagnostic techniques applicable to a primary care consultation and a “red flag” system to identify potentially serious disease.
We incorporated the latest consensus from systematic reviews and publications identified by a literature search through Medline, CINAHL, AMED, the Cochrane Library (Central, CDSR, HTA, DARE), Clinical Evidence, Best Evidence, Embase, British Nursing Index, PEDro,w6 Web of Science (social science and science citation indexes), and bmj.com. The search strategy included the terms “shoulder pain”, “rotator cuff disorder”, “rotator cuff tear”, “frozen shoulder”, and “primary care”.
We found six published systematic reviews of interventions for shoulder disorders and one health technology assessment systematic review of diagnostic tests for the assessment of shoulder pain.4–10 A topic search within Clinical Evidence identified the section “Shoulder pain.”11 We identified and critically appraised other …
Noninvasive cardiac imaging is now central to the diagnosis and management of patients with known or suspected chronic coronary artery disease (CAD). Although rest echocardiography has become the most common of the techniques, nuclear cardiology and more recently cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) play important roles in this regard. This review examines the current applications and interactions of noninvasive cardiac imaging approaches for the assessment of patients with suspected CAD. In addition to considering the strengths and weaknesses of each technique, this review attempts to provide a guide to the selection of a test (or tests) that is based on the question being asked and the ability of each test to answer this question. In patients with suspected CAD, the pretest likelihood of disease, a clinical assessment, becomes the most important determinant of the initial test. If the likelihood is very low, no testing is needed. However, if the likelihood is low, recent data suggest that assessment of early atherosclerosis is likely to be the most useful and cost-effective test. In patients who have an intermediate likelihood of CAD, nuclear cardiology with myocardial perfusion SPECT (MPS) becomes highly valuable; however, coronary CT angiography (CTA), with fast 16-slice or greater scanners, may emerge as the initial test of choice. MPS would then be used if the CTA is inconclusive or if there is a need to assess the functional significance of a stenosis defined by CTA. Coronary CTA, however, is not yet widely available and is limited in patients with dense coronary calcification. In older patients with a high likelihood of CAD, MPS may be the initial test of choice, since a high proportion of these patients have too much coronary calcium to allow accurate assessment of the presence of coronary stenoses. PET/CT or SPECT/CT could emerge as important modalities combining the advantages of each modality. While CMR has great promise as a radiation-free and contrast-free "one-stop" shop, it currently lags behind CTA for noninvasive coronary angiography. Nonetheless, CMR clearly has the potential for this application and has already emerged as a highly effective method for assessing ventricular function, myocardial mass, and myocardial viability, and there is increasing use of this approach for clinical rest and stress perfusion measurements. CMR is particularly valuable in distinguishing ischemic from nonischemic cardiomyopathy. While CT and CMR are likely to grow considerably in diagnostic evaluation over the next several years, MPS and PET will continue to be very valuable techniques for this purpose.
Importance:
Time is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care.
Objective:
To investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians.
Design, setting, and participants:
This cross-sectional study used data from electronic health record systems in primary care offices across the US to analyze adult primary care visits occurring in calendar year 2017. Analysis was conducted from March 2022 through January 2023.
Main outcomes and measures:
Regression analyses quantified the association between patient visit characteristics and visit length (measured using time stamp data) and the association between visit length and potentially inappropriate prescribing decisions, including inappropriate antibiotic prescriptions for upper respiratory tract infections, coprescribing of opioids and benzodiazepines for painful conditions, and prescriptions that were potentially inappropriate for older adults (based on the Beers criteria). All rates were estimated using physician fixed effects and were adjusted for patient and visit characteristics.
Results:
This study included 8 119 161 primary care visits by 4 360 445 patients (56.6% women) with 8091 primary care physicians; 7.7% of patients were Hispanic, 10.4% were non-Hispanic Black, 68.2% were non-Hispanic White, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity. Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and non-Hispanic Black patients had shorter visits. For each additional minute of visit length, the likelihood that a visit resulted in an inappropriate antibiotic prescription changed by -0.11 percentage points (95% CI, -0.14 to -0.09 percentage points) and the likelihood of opioid and benzodiazepine coprescribing changed by -0.01 percentage points (95% CI, -0.01 to -0.009 percentage points). Visit length had a positive association with potentially inappropriate prescribing among older adults (0.004 percentage points; 95% CI, 0.003-0.006 percentage points).
Conclusions and relevance:
In this cross-sectional study, shorter visit length was associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and coprescribing of opioids and benzodiazepines for patients with painful conditions. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care.
Introduction:
The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization.
Objective:
The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students' adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach.
Methods:
A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management.
Results:
The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management.
Conclusion:
DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.
Objectives: To explore if physical therapists are practicing skills necessary to refer patients for musculoskeletal imaging.
Methods: An expert panel established a list of nine requisite skills to refer for musculoskeletal imaging. A blinded expert panel validated the list using a 5-point Likert scale. The skills list was examined via an electronic survey distributed to United States physical therapists.
Results: 4,796 respondents were included. Each of the nine skills were routinely performed by a majority of the respondents (range: 54.52-94.72%). Respondents routinely performed 6.95 (± 0.06) skills, with 67.41% routinely performing seven or more skills. Doctors of physical therapy routinely performed more imaging skills (7.15 ± 0.06) compared to their masters- (6.44 ± 0.19) and bachelors-trained (5.95 ± 0.21) counterparts (p < 0.001). Residency/fellowship-trained physical therapists were more likely to routinely perform more imaging skills (7.60 ± 0.11 vs. 6.79 ± 0.07, p < 0.001). Imaging skill performance was greater among board-certified physical therapists (7.39 ± 0.09 vs. 6.71 ± 0.08, p < 0.001) and APTA members (7.06 ± 0.07 vs. 6.65 ± 0.12, p < 0.001).
Conclusion: Physical therapists are routinely practicing the requisite imaging skills to directly refer to a radiologist for musculoskeletal imaging.
Keywords: Medical imaging; certification; educational status; nonmedical residency; patient education; referral and consultation; triage.
Background:
Physicians' time with patients is a critical input to care, but is typically measured retrospectively through survey instruments. Data collected through the use of electronic health records (EHRs) offer an alternative way to measure visit length.
Objective:
To measure how much time primary care physicians spend with their patients, during each visit.
Research design:
We used a national source of EHR data for primary care practices, from a large health information technology company. We calculated exam length and schedule deviations based on timestamps recorded by the EHR, after implementing sequential data refinements to account for non-real-time EHR use and clinical multitasking. Observational analyses calculated and plotted the mean, median, and interquartile range of exam length and exam length relative to scheduled visit length.
Subjects:
A total of 21,010,780 primary care visits in 2017.
Measures:
We identified primary care visits based on physician specialty. For these visits, we extracted timestamps for EHR activity during the exam. We also extracted scheduled visit length from the EHR's practice management functionality.
Results:
After data refinements, the average primary care exam was 18.0 minutes long (SD=13.5 min). On average, exams ran later than their scheduled duration by 1.2 minutes (SD=13.5 min). Visits scheduled for 10 or 15 minutes were more likely to exceed their allotted time than visits scheduled for 20 or 30 minutes.
Conclusions:
Time-stamped EHR data offer researchers and health systems an opportunity to measure exam length and other objects of interest related to time.
Radiographs of the shoulders of 84 asymptomatic individuals aged between 40 and 83 years were evaluated to determine changes in 23 specific areas. Two fellowship-trained orthopaedic radiologists graded each area on a scale of 0 to II (normal 0, mild changes I, advanced changes II). Logistic regression analysis indicated age to be a significant predictor of change (p < 0.05) for sclerosis of the medial acromion and lateral clavicle, the presence of subchondral cysts in the acromion, formation of osteophytes at the inferior acromion and clavicle, and narrowing and degeneration of the acromioclavicular joint. Gender was not a significant predictor (p > 0.05) for radiological changes. Student’s t-test determined significance (p < 0.05) between age and the presence of medial acromial and lateral clavicular sclerosis, subchondral acromial cysts, inferior acromial and clavicular osteophytes, and degeneration of the acromioclavicular joint.
Radiological analysis in conditions such as subacromial impingement, pathology of the rotator cuff, and acromioclavicular degeneration should be interpreted in the context of the symptoms and normal age-related changes.
Nationally recognized authorities describe how to capture and interpret all normal and abnormal electrocardiography findings in adults and children. They provide you with expert assistance in mastering the many subtle but critical nuances of this complex diagnostic modality.
Pain diagrams are a useful tool to help physicians understand the varying presentation patterns of specific pain generators. This study is the first to describe the potential pain patterns of the glenohumeral joint (GHJ) based on responses to diagnostic image-guided GHJ injections.
To determine potential GHJ pain referral patterns.
162 consecutive patients undergoing 168 GHJ injections recorded their preprocedure pain scores and drew accurate pain diagrams prior to undergoing fluoroscopically guided GHJ injections with local anesthetic. Postprocedure pain scores were recorded and those with complete relief were considered responders. Pain diagrams were overlaid via computer software to facilitate analysis and a composite pain map. A responder composite was also compared with a nonresponder composite.
The GHJ was shown to cause pain in traditionally localized areas of the anterior and/or posterior shoulder and upper arm regions in 100% of patients who experienced complete pain relief after injection. Among 100% responders, 18% had neck pain and 6% had scapular pain. Pain was shown to radiate distally, with anterior forearm pain in 9%, posterior forearm pain in 8%, and hand pain in 9%. No patients with pain both in the medial neck and below the elbow were found to be 100% responders. Similarly, no patients were 100% responders if they had pain in the medial scapula and below the elbow, or medial scapula and medial neck.
Anterior or posterior shoulder and upper arm pain, or a combination of the two, is the most common pain referral area from a symptomatic shoulder joint. Referral to the lateral neck, in combination with shoulder pain, was occasionally seen. Pain referral to the forearm and hand was less common. Rarely did a symptomatic shoulder joint refer pain to the scapula or to the medial neck.
Wiley Periodicals, Inc.
AimThe aim of this study was to determine the prevalence of structural shoulder pathology using magnetic resonance imaging (MRI) in three groups of older people: those with current shoulder pain, those with a previous history of shoulder pain and those with no history of shoulder pain, within a community-based sample.Methods
Thirty subjects (10 within each of the three groups) participated in the study. Subjects were recruited by telephone and underwent a clinical examination of shoulder and neck range of movement (to ensure pain was not referred from the neck). Subjects completed the Shoulder Pain and Disability Index (SPADI) and underwent MRI and X-ray of the relevant shoulder. The X-rays and MRI were read independently by two experienced musculoskeletal radiologists blinded to each participant's symptoms. The MRIs were read using a structured reporting system.ResultsThe mean range of shoulder movement on both the right and left sides was lower for the current pain group compared to both the no and previous pain groups. On X-ray, there was no significant difference between groups in terms of glenohumeral and/or acromioclavicular degenerative changes. Tendinosis and tears of the rotator cuff were present in the majority of participants in each group. Labral abnormalities were rare among all groups.Conclusion
Shoulder pathology is apparent in both symptomatic and asymptomatic shoulders and clinical symptoms may not match radiological findings. The cost burden of ordering MRI scans is significant and the relevance of the findings are questionable when investigating shoulder pain.
The mechanisms underlying symptom development in rotator cuff tears are still unknown. The purpose of this study was to identify the characteristics associated with symptoms of rotator cuff tears.
We performed a medical checkup on residents of a mountain village. The subjects of this study included 211 individuals with 283 shoulders in which a full-thickness rotator cuff tear was observed through ultrasonography. We recorded the subjects' background and medical history and then performed physical examinations. The subjects were divided into 2 groups according to whether they had any pain or disabilities that they felt subjectively while performing their usual daily activities. We determined the prevalence of an asymptomatic rotator cuff tear and conducted a statistical analysis to compare any differences between the 2 groups.
Of the 283 subjects, 65.4% with rotator cuff tears had no symptoms involving the shoulder. Asymptomatic rotator cuff tears were associated with a tear in the nondominant arm, a negative impingement sign, higher active forward elevation, and intact muscle strength in abduction and external rotation. A logistic regression analysis showed that a positive impingement sign, weakness in external rotation, and presence of a tear in the dominant arm were significantly associated with the presence of symptoms of rotator cuff tears.
In the general population, in approximately two-thirds of all rotator cuff tears, there are no symptoms, and the factors involved in the presence of symptoms associated with rotator cuff tears were identified to be a positive impingement sign, weakness in external rotation, and presence of a tear in the dominant arm.
To investigate the reliability and diagnostic accuracy of individual tests and combination of tests for subacromial impingement syndrome (SAIS).
A prospective, blinded study design.
Orthopedic surgeon shoulder clinic.
Patients with shoulder pain (n=55, mean age=40.6y).
Patients were evaluated with 5 physical examination tests for SAIS: Neer, Hawkins-Kennedy, painful arc, empty can (Jobe), and external rotation resistance tests. Surgical diagnosis was the reference standard.
Diagnostic accuracy calculated with a receiver operating characteristic (ROC) curve and sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). A forward stepwise binary logistic regression analysis was used to determine the best test combination for SAIS. An ROC curve analysis was also used to determine the cut point of the number of tests discriminating between the presence and absence of SAIS. Kappa coefficients and percent agreement assessed interrater reliability.
The ROC analyses revealed a significant area under the curve (AUC) (AUC=.67-.72, P<.05) for all tests, except for the Hawkins-Kennedy. The tests with a +LR greater than or equal to 2.0 were the painful arc (+LR=2.25; 95% CI, 1.33-3.81), empty can (+LR=3.90; 95% CI, 1.5-10.12), and the external rotation resistance tests (+LR=4.39; 95% CI, 1.74-11.07). Tests with -LR less than or equal to 0.50 were the painful arc (-LR=.38; 95% CI, .16-.90), external rotation resistance (-LR=.50; 95% CI, .28-.89), and Neer tests (-LR=.35; 95% CI, .12-.97). The regression analysis had no specific test combinations for confirming or ruling out SAIS. The ROC analysis was significant (AUC=.79, P=.001), with a cut point of 3 positive tests out of 5 tests. Reliability was moderate to substantial agreement (kappa=.45-.67) for the painful arc, empty can, and external rotation resistance tests and fair strength of agreement (kappa=.39-.40) for the Neer and Hawkins-Kennedy tests.
The single tests of painful arc, external rotation resistance, and Neer are useful screening tests to rule out SAIS. The single tests of painful arc, external rotation resistance, and empty can are helpful to confirm SAIS. The reliability of all tests was acceptable for clinical use. Based on reliability and diagnostic accuracy, the single tests of the painful arc, external rotation resistance, and empty can have the best overall clinical utility. The cut point of 3 or more positive of 5 tests can confirm the diagnosis of SAIS, while less than 3 positive of 5 rules out SAIS.
To evaluate the variability in the reported diagnostic accuracy of the exercise electrocardiogram, we applied meta-analysis to 147 consecutively published reports comparing exercise-induced ST depression with coronary angiography. These reports involved 24,074 patients who underwent both tests. Population characteristics and technical and methodologic factors, including publication year, number of electrocardiographic leads, exercise protocol, use of hyperventilation, definition of an abnormal ST response, exclusion of certain subgroups, and blinding of test interpretation were analyzed. Wide variability in sensitivity and specificity was found (mean sensitivity, 68%; range, 23-100%; SD, 16%; and mean specificity, 77%; range, 17-100%; SD, 17%). The four study characteristics found to be significantly and independently related to sensitivity were the treatment of equivocal test results, comparison with a "better" test such as thallium scintigraphy, exclusion of patients on digitalis, and publication year. The four variables found to be significantly and independently related to specificity were the treatment of upsloping ST depressions, the exclusion of subjects with prior infarction or left bundle branch block, and the use of preexercise hyperventilation. Stepwise linear regression explained less than 35% of the variance in sensitivities and specificities reported in the 147 publications. There is wide variability in the reported accuracy of the exercise electrocardiogram. This variability is not explained by information reported in the medical literature.
Angina pectoris is cardiac pain that typically is manifested as referred pain to the chest and upper left arm. Atypical pain to describe localization of the perception, generally experienced more by women, is referred to the back, neck, and/or jaw. This article summarizes the neurophysiological and pharmacological mechanisms for referred cardiac pain. Spinal cardiac afferent fibers mediate typical anginal pain via pathways from the spinal cord to the thalamus and ultimately cerebral cortex. Spinal neurotransmission involves substance P, glutamate, and transient receptor potential vanilloid-1 (TRPV1) receptors; release of neurokinins such as nuclear factor kappa b (NF-kb) in the spinal cord can modulate neurotransmission. Vagal cardiac afferent fibers likely mediate atypical anginal pain and contribute to cardiac ischemia without accompanying pain via relays through the nucleus of the solitary tract and the C1-C2 spinal segments. The psychological state of an individual can modulate cardiac nociception via pathways involving the amygdala. Descending pathways originating from nucleus raphe magnus and the pons also can modulate cardiac nociception. Sensory input from other visceral organs can mimic cardiac pain due to convergence of this input with cardiac input onto spinothalamic tract neurons. Reduction of converging nociceptive input from the gallbladder and gastrointestinal tract can diminish cardiac pain. Much work remains to be performed to discern the interactions among complex neural pathways that ultimately produce or do not produce the sensations associated with cardiac pain. © 2015 American Physiological Society. Compr Physiol 5: 929-960, 2015.
We sought to evaluate whether different circadian blood pressure (BP) changes could influence the occurrence of ischemic episodes in untreated and treated hypertensive patients with stable coronary artery disease (CAD).
In hypertensive patients with CAD the occurrence of myocardial ischemia could be influenced by either high or low BP values. Ambulatory monitoring has shown that circadian BP profile is not uniform in hypertensive patients.
Twenty-one patients with a nighttime BP fall < 10% ("nondippers"), 35 with a nighttime BP fall between > 10% and < 20% ("dippers") and 14 with a nighttime BP fall > 20% ("overdippers") with CAD underwent simultaneous ambulatory BP and electrocardiographic monitoring before and during drug therapy with nitrates and atenolol or verapamil in a prospective, randomized, open, blinded end point design.
Daytime BP was not significantly different among the groups both before and during therapy. Nighttime BP was different by definition. Treatment significantly reduced BP values in each group (p < 0.05). Daytime ischemic episodes did not differ among the groups either before or during therapy. Drug therapy significantly reduced daytime ischemia (p < 0.05). In untreated patients, nighttime ischemia was more frequent in nondippers than in dippers and overdippers (p < 0.05). Drug therapy significantly reduced nocturnal ischemia in nondippers (p < 0.05), had no significant effect in dippers and significantly increased nighttime ischemia in overdippers (p < 0.05). During treatment, nighttime ischemia was more frequent in overdippers than in dippers and nondippers (p < 0.05). The same results were achieved when ischemic episodes were defined with more restrictive criteria (ST segment depression > or = 2 mm).
Circadian BP changes can influence the occurrence of myocardial ischemia in untreated and treated hypertensive patients with CAD. Nocturnal ischemia was found to be more frequent in nondippers among untreated patients and in overdippers among treated patients, potentially suggesting different therapeutic approaches based on circadian BP profile.
This study explores gender differences in symptom presentation associated with coronary heart disease (CHD). In this prospective study, nurse data collectors directly observed 550 patients as they presented to the Emergency Department (ED) of Yale-New Haven Hospital. The final sample included 217 patients (41% women) diagnosed with CHD (acute coronary ischemia or myocardial infarction). Chest pain was the most frequently reported symptom in women (70%) and men (71%). Unadjusted analyses revealed that women were more likely than men to present with midback pain (odds ratio [OR] 9.61, 95% confidence interval [CI] 2.10 to 44.11, p = 0.001), nausea and/or vomiting (OR 2.29, 95% CI 1.19 to 4.42, p = 0.012), dyspnea (OR 1.82, 95% CI 1.05 to 3.16, p = 0.032), palpitations (OR 3.42, 95% CI 1.02 to 11.47, p = 0.036), and indigestion (OR 2.13, 95% CI 1.03 to 4.44, p = 0.040). After adjustment for age and diabetes, women were more likely to present with nausea and/or vomiting (OR 2.43, 95% CI 1.23 to 4.79, p = 0.011) and indigestion (OR 2.13, 95% CI 1.10 to 4.53, p = 0.048). Women (30%) and men (29%) were equally likely to present without chest pain, and dyspnea was the most common non-chest pain symptom. In the subgroup of patients without chest pain, unadjusted analyses revealed that women were more likely to report nausea and/or vomiting compared with men (OR 4.40, 95% CI 1.30 to 14.84, p = 0.013). Although we found some significant gender differences in non-chest pain symptoms, we conclude that there were more similarities than differences in symptoms in women and men presenting to the ED with symptoms suggestive of CHD who were later diagnosed with CHD.
Acute low cervical nerve root conditions may be easily misdiagnosed. The perspective presented is that their symptom presentation is not as straightforward as the classic descriptions of brachialgia would have us believe. This clinical commentary presents a series of observations and reasoning models that are relevant to patient symptom presentations believed to be of cervical nerve root origin. Clinicians are urged to consider low cervical nerve root assessment in the light of our current understanding of neural sensitivity, pain science, nerve root biomechanics and the presence and effect of degenerative changes. This particularly relates to thoughts about cervical movements and postures being able to bring forces to bear on nerve roots via compressive as well as elongation forces.
The TIMI risk score for unstable angina and non-ST elevation myocardial infarction is an effective tool for predicting the risk of death and ischemic events among patients with non-ST elevation acute coronary syndromes, as well as for identifying those who are likely to benefit most from low-molecular-weight heparin and glycoprotein IIb/IIIa inhibition.
To explore the pathobiologic basis for this interaction, we evaluated the relationship between the risk score, assessed at presentation, and angiographic findings among patients with non-ST elevation acute coronary syndromes. Angiographic data regarding thrombus, epicardial flow, and lesion severity were available for 1491 patients from the angiographic substudy of PRISM-PLUS.
Patients with risk scores of 5 to 7 (N = 435) were more likely to have a severe culprit stenosis (81% vs 58%, P < .001) and multivessel disease (80% vs 43%, P < .001) compared to those with scores of 0 to 2 (N = 220). The probability of left main disease (P = .01), visible thrombus, and impaired flow in the culprit lesion also increased progressively with rising risk scores (P < .001). Of the risk indicators that comprise the score, history of coronary disease, advanced age, and ST changes showed the strongest association with severe epicardial disease. Positive biomarkers of necrosis, ST changes, and prior aspirin use emerged as stronger correlates of visible thrombus and/or impaired culprit artery flow.
The TIMI risk score identifies patients who are more likely to have intracoronary thrombus, impaired flow, and increased burden of coronary atherosclerosis. These findings likely explain in part the particular benefit of potent antithrombin and antiplatelet agents among patients with higher risk scores.
High prevalence of rotator cuff tears in a population who never sought for shoulder problems: a clinical, ultrasonographic and radiographic screening study
- S Khoschnau
- J Milsoavjevic
- B Sahlstedt
- R Rylance
- H Rahme
- B Kadum
Khoschnau S, Milsoavjevic J, Sahlstedt B, Rylance R,
Rahme H, Kadum B. High prevalence of rotator cuff
tears in a population who never sought for shoulder
problems: a clinical, ultrasonographic and radiographic screening study. Eur J Orthop Surg Traumatol. 2019;30:457-463. https://doi.org/10.1007/
s00590-019-02593-2
Mechanisms of cardiac pain
- R D Foreman
- K M Garrett
- R W Blair
Foreman RD, Garrett KM, Blair RW. Mechanisms
of cardiac pain. Compr Physiol. 2015;5:929-960.
https://doi.org/10.1002/cphy.c140032
Hickam's dictum: an analysis of multiple diagnoses
- S K Aberegg
- B R Poole
- B W Locke
Aberegg SK, Poole BR, Locke BW. Hickam's
dictum: an analysis of multiple diagnoses. J Gen
Intern Med. 2024;1-8. https://doi.org/10.1007/
s11606-024-09120-y
tears in the general population. J Shoulder Elbow
Surg. 2011;20:1133-1137. https://doi.org/10.1016/j.
jse.2011.01.011
Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy
- R S Wainner
- J M Fritz
- J J Irrgang
Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability
and diagnostic accuracy of the clinical examination and patient self-report measures for cervical
radiculopathy. Spine. 2003;28:52-62. https://doi.
org/10.1097/00007632-200301010-00014
Factors involved in the presence of symptoms associated with rotator cuff tears: a comparison of asymptomatic and symptomatic rotator cuff myocardial ischemia in hypertensive patients with coronary artery disease
- A Yamamoto
- K Takagishi
- T Kobayashi
- H Shitara
- T Osawa
Yamamoto A, Takagishi K, Kobayashi T, Shitara H,
Osawa T. Factors involved in the presence of symptoms associated with rotator cuff tears: a comparison of asymptomatic and symptomatic rotator cuff
myocardial ischemia in hypertensive patients
with coronary artery disease. J Am Col Cardiol.
1998;31:1627-1634. https://doi.org/10.1016/
S0735-1097(98)00163-6
Referred cardiac pain
- F G Thomson
Thomson FG. Referred cardiac pain. Bristol Med
Chir J. 1909;27:193-202.