Fibromyalgia (FM) is a chronic condition which causes pain throughout the body. Other symptoms include fatigue, poor sleep quality, anxiety and depression (Antunes and Marques, 2022). The cause of chronic pain in patients with FM is associated with the hypersensitivity of the central nervous system resulting in hyperalgesia and potentially allodynia. The symptoms of fatigue and exhaustion can be explained by the hyporesponsiveness of the hypothalamus-pituitary- adrenal mechanisms in patients with FM (Mengshoel, 2013). Recently, more research is being conducted into the role of physiotherapy in FM and has shown to reduce pain, improve quality of life and function.

Exercise has been shown to improve psychological well-being and a reduction in pain, fatigue and other comorbidities (which is common in patients with FM). The combination of exercise and pain education have been proven to be the most effective intervention for FM (Mengshoel,2013) and also reduce medication consumption. Interestingly, addressing central sensitization and the neuroscience of pain in-person with patients has been shown to be the most successful form of pain education when improving compliance with exercise. However, there is insufficient data on what type of exercises is the most effective (Antunes and Marques, 2022).

Hydrotherapy and land exercise has been shown to be equally effective, although being immersed in water can have an analgesia effect. The heat and the increase of buoyancy causes the release of endorphins, increased capillarization and oxygen consumption. Moderate to high intensity resistance training has shown to reduce fear avoidance and improve neuromuscular ability which is especially important for menopausal and postmenopausal women. However, research demonstrates aerobic exercise to be more tolerated by patients (Antunes and Marques, 2022).

Physiotherapists regularly use massage and manual therapy for pain relief in patients with FM. Unfortunately, there are only a few studies addressing the effects of massage in FM (Antunes and Marques, 2022). Other modalities, such as TENS, have been proven to be effective in modifying pain and in turn an increased activity levels for patients with FM (Mengshoel, 2009).

There is conflicting evidence on the optimum treatment for patients with FM, however it is important to incorporate a multi-faceted approach that addresses the patients’ needs and goals.

Antunes, Mateus Dias, and Amélia Pasqual Marques. “The Role of Physiotherapy in Fibromyalgia: Current and Future Perspectives.” Frontiers in Physiology, vol. 13, no. 13, 16 Aug. 2022, p. 968292, www.ncbi.nlm.nih.gov/pmc/articles/PMC9424756/, https://doi.org/10.3389/fphys.2022.968292.

Mengshoel, Anne Marit. “Physiotherapy and Fibromyalgia: A Literature Review.” Advances in Physiotherapy, vol. 1, no. 2, Jan. 1999, pp. 73–82, https://doi.org/10.1080/140381999443456. Accessed 10 Dec. 2020.

—. “Physiotherapy Management of Fibromyalgia: What Do We Know and How May This Affect Clinical Practice?” Physical Therapy Reviews, vol. 5, no. 2, June 2000, pp. 85–91, https://doi.org/10.1179/ptr.2000.5.2.85. Accessed 17 Nov. 2020.

Calcific Tendinits of the rotator cuff (CTRC) is the accumulation of calcium phosphate within a tendon and is often chronic and recurrent. Majority of CTRC are located within 1-2cm from the insertion of the supraspinatus causing limited range of motion in the shoulder and can cause severe pain (Maja et. al, 2023). Interestingly, CTRC commonly occurs during the age of 30-50 years and twice as likely to occur in women (Kim et. al, 2020).

There are two proposed theories on the formation of CTRC: degenerative and reactive. Degenerative theory suggests changes in the tendon accumulate with age which causes a decrease in distribution of blood vessels. This leads to a hypoxic environment causing necrosis and/or tearing in the tendon which then can develop into calcification (Kim et. al, 2020). The reactive theory suggests that there are 3 phases of calcification: precalcifying phase, calcifying phase and post calcifying phase. Precalcifying phase is the ‘transformation of the tendon into fibrocartilaginous tissue’ (Maja et. al, 2023) which allows the calcium to be deposited more easily. The calcifying phase is the actual deposition of calcium, and the post calcifying is the remodeling of the tendon around the calcium deposit. However, no theory has been proven (Maja et. al, 2023). Secondary complications such as bursitis and synovitis are common with CTRC due to the chemical irritation caused by calcium deposits.

Treatment for CTRC can either be conservative management or surgical. There is a 30-80% success rate of conservative management. NSAIDs are effective for pain relief as well as a steroid injection during the resorptive phase. Barbotage has been shown to provide pain relief in 70% of patients due to its decompression effects. Ultrasound therapy has also been shown to improve quality of life and pain relief, however, requires regular attendance over a 6 week period. ESWT (extracorporeal shockwave therapy) has the highest success rate for chronic calcific tendinitis and has a similar success rate to surgery (Kim et. al, 2020). ESWT is effective in improving function and reducing pain and is more effective when combined with physiotherapy (Maja et. al, 2023). Therefore, conservative treatment should be prioritized and conducted for a minimum of 6 months before considering surgical treatment (Maja et. al, 2023).

Reference List

Kim, M.-S., Kim, I.-W., Lee, S. and Shin, S.-J. (2020). Diagnosis and treatment of calcific tendinitis of the shoulder. Clinics in Shoulder and Elbow, [online] 23(4), pp.203–209. doi:https://doi.org/10.5397/cise.2020.00318.

Маја Manoleva, Erieta Nikolic Dimitrova, Koevska, V., Biljana Mitrevska, Marija Gocevska Gjerakaroska, Cvetanka Savevska, Biljana Kalchovska Ivanovska, Lidija Stojanoska Matjanoska, Gecevska, D., Jugova, T. and Liljana Malinovska Nikolovska (2023). COMPARISON OF IMMEDIATE EFFECTS OF EXTRACORPOREAL SHOCKWAVE THERAPY AND CONVENTIONAL PHYSICAL THERAPY IN PATIENTS WITH CALCIFIC TENDINITIS OF THE SHOULDER ROTATOR CUFF. Academic Medical Journal, 3(1), pp.99–109. doi:https://doi.org/10.53582/amj2331099m.

Subacromial impingement syndrome (SAIS) is an umbrella term for a variety of inflammatory pathologies within the subacromial space. These include rotator cuff syndrome, bursitis, tendinopathy and calcific tendinitis. Conservative treatment is used to decrease inflammation, restore range of motion in the shoulder and strengthen the rotator cuff (Gebremariam et. al, 2013). Physiotherapy has shown to be an effective method for treating SAIS and should be considered as the first line of care (Dicken et. al, 2005). However, it is important to understand which therapeutic modalities should be prioritised and considered when treating SAIS.

There is a wealth of research suggesting to focus on scapular stabilization and rotator cuff strengthening when rehabilitating patients with SAIS. For example, Baskurt et. all investigated the effectiveness of scapular stabilization on pain, shoulder range of motion, joint position sense (JPS), scapular dyskinesis and quality of life in patients with SAIS. They discovered the combination of scapular stabilization, shoulder strengthening and stretching is the most effective method in improving JPS and decreasing scapular dyskinesis (Baskurt et. al, 2011).  Michener et. al compared various treatments for SAIS (exercise, joint mobilisations, laser, ultrasound and acupuncture) in a systematic review. The evidence suggested laser therapy is only beneficial when used in isolation and there is no benefit in using ultrasound or acupuncture. However, the most effective treatment for SAIS is the combination of rotator cuff strengthening and scapular stabilisation alongside joint mobilisations (Michener et. al, 2004). Additionally, Celik concluded that patients with SAIS exhibited a lower visual analog scale score when exercises were performed within pain free range of motion (90 degrees and below). Overall research illustrates rotator cuff strengthening, scapular stabilization and joint mobilization are essential when treating SAIS. Furthermore, during the early stages of rehabilitation, prescribing exercises below 90-degree shoulder flexion can aid in pain management (Celik, 2009).

When creating a rehabilitation programme, practitioners should consider a patient-centered approach. It is important to recognize patients’ pain tolerance and threshold when prescribing exercises for SAIS. Vallés- Carrascosa et. al compared painful eccentric exercises (PEE) to pain free eccentric exercises when treating SAIS. Remarkably, PPE was found to provide no additional benefits. Therefore, practitioners should consider prescribing pain free exercises to promote compliance with rehabilitation programmes, especially for patients with a lower pain tolerance (Vallés- Carrascosa et. al,2018).

Reference List

• Başkurt, Z., Başkurt, F., Gelecek, N. and Özkan, M.H. (2011). The effectiveness of scapular stabilization exercise in the patients with subacromial impingement syndrome. Journal of Back and Musculoskeletal Rehabilitation, 24(3), pp.173–179. doi:https://doi.org/10.3233/bmr-2011-0291.
• Celik, D. (2009). Comparison of the effects of two different exercise programs on pain in subacromial impingement syndrome. Acta Orthopaedica et Traumatologica Turcica, 43(6), pp.504–509. doi:https://doi.org/10.3944/aott.2009.504.
• Dickens, V.A., Williams, J.L. and Bhamra, M.S. (2005). Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study. Physiotherapy, 91(3), pp.159–164. doi:https://doi.org/10.1016/j.physio.2004.10.008.
• Gebremariam, L., Hay, E.M., van der Sande, R., Rinkel, W.D., Koes, B.W. and Huisstede, B.M.A. (2013). Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. British Journal of Sports Medicine, 48(16), pp.1202–1208. doi:https://doi.org/10.1136/bjsports-2012-091802.
• Michener, L.A., Walsworth, M.K. and Burnet, E.N. (2004). Effectiveness of rehabilitation for patients with Subacromial impingement syndrome: a systematic review. Journal of Hand Therapy, 17(2), pp.152–164. doi:https://doi.org/10.1197/j.jht.2004.02.004.
• Vallés-Carrascosa, E., Gallego-Izquierdo, T., Jiménez-Rejano, J.J., Plaza-Manzano, G., Pecos-Martín, D., Hita-Contreras, F. and Achalandabaso Ochoa, A. (2018). Pain, motion and function comparison of two exercise protocols for the rotator cuff and scapular stabilizers in patients with subacromial syndrome. Journal of Hand Therapy, 31(2), pp.227–237. doi:https://doi.org/10.1016/j.jht.2017.11.041.

Delayed onset muscle soreness (DOMS) is defined as ‘ultrastructural damage of muscle cells due to unfamiliar sporting activities or eccentric exercise, which leads to further protein degradation, apoptosis and local inflammatory response’ (Hotfiel et. al 2018) The micro tears caused by eccentric movements can impact performance by reducing joint range of motion and alter muscle recruitment patterns. This can increase risk of a soft tissue injury but treatment strategies for DOMS remain uncertain. Common treatment strategies include anti-inflammatories, massage and cryotherapy. Seidel et. al investigated the optimum treatment for DOMS and found non-steroidal anti-inflammatory drugs did reduce the pain but delayed the recovery.  Other interventions were examined (nutritional and physical) and found that there was a reduction in inflammation but no treatment aided muscle regeneration. (Seidel et. al, 2012)

Massage can be an effective tool to aid recovery from DOMS, however most research states the type and timing of the massage is important.  Hilbert et. al found that there was a reduction in muscle soreness 48 hours post exercise when massage is administered 2 hours after exercise, (Hilbert et. al, 2003). However, Visconti et. al found massage to be an effective tool to reduce DOMS during the onset of symptoms (Visconti et. al, 2015).

Cryotherapy has conflicting research on the effectiveness to alleviate DOMS. For example, Eston and Peters studied the use of cold-water immersion for recovery. They found 2-3 days post exercise, participants who used cold water immersion had increased joint range and reduced creatine kinase activity compared to the control group. However, both groups presented with muscle tenderness, swelling and reduced isometric strength 3 days following exercise. Howaston and Van Someren investigated the impact of ice massage therapy on DOMs, however discovered it is not an effective treatment due to only noticing creatine kinase reduction at 72 hours (Bishop et. al, 2008).

Evidence suggests adapting your exercise programme is the most efficient method to alleviate DOMS however the analgesic effect has been shown to be temporary (Zainuddin et. al, 2011). Cheung et. al suggests when exercising on a daily basis, one should reduce intensity and duration of exercise 1-2 days following DOMS. Training body parts that are less affected by DOMS and progressively overloading eccentric exercises over a 1 to 2 week period are efficient methods to manage DOMS (Cheung et. al 2003).

Reference List

Bishop, P.A., Jones, E. and Woods, A.K. (2008). Recovery From Training: A Brief Review. Journal of Strength and Conditioning Research, [online] 22(3), pp.1015–1024. doi:https://doi.org/10.1519/jsc.0b013e31816eb518.

Cheung, K., Hume, P.A. and Maxwell, L. (2012). Delayed Onset Muscle Soreness. Sports Medicine, [online] 33(2), pp.145–164. doi:https://doi.org/10.2165/00007256-200333020-00005.

Hilbert, J.E., Sforzo, G.A. and Swensen, T. (2003). The effects of massage on delayed onset muscle soreness. British Journal of Sports Medicine, [online] 37(1), pp.72–75. doi:https://doi.org/10.1136/bjsm.37.1.72.

Hotfiel, T., Freiwald, J., Hoppe, M., Lutter, C., Forst, R., Grim, C., Bloch, W., Hüttel, M. and Heiss, R. (2018). Advances in Delayed-Onset Muscle Soreness (DOMS): Part I: Pathogenesis and Diagnostics. Sportverletzung · Sportschaden, 32(04), pp.243–250. doi:https://doi.org/10.1055/a-0753-1884.

Seidel, E., Rother, M., Hartmann, J., Rother, I., Schaaf, T., Winzer, M., Fischer, A. and Regenspurger, K. (2012). Eccentric Exercise and Delayed Onset of Muscle Soreness (DOMS) – an Overview. Physikalische Medizin, Rehabilitation Medizin, Kurortmedizin, 22(02), pp.57–63. doi:https://doi.org/10.1055/s-0032-1304576.

Visconti, L., Capra, G., Carta, G., Forni, C. and Janin, D. (2015). Effect of massage on DOMS in ultramarathon runners: A pilot study. Journal of Bodywork and Movement Therapies, [online] 19(3), pp.458–463. doi:https://doi.org/10.1016/j.jbmt.2014.11.008.

Zainuddin, Z., Sacco, P., Newton, M. and Nosaka, K. (2006). Light concentric exercise has a temporarily analgesic effect on delayed-onset muscle soreness, but no effect on recovery from eccentric exercise. Applied Physiology, Nutrition, and Metabolism, 31(2), pp.126–134. doi:https://doi.org/10.1139/h05-010.

The posterior oblique sling (POS) comprises the latissimus dorsi and contralateral gluteus maximus which is connected through thoracolumbar fascia, erector spinae, multifidus and bicep femoris. This activation pattern provides stability of the lumbopelvic region by transferring force through the trunk. For insistence, erectus spinae generates force whereas the multifidus creates stability. The posterior oblique sling is thought aid recovery from lower back pain (LBP) and is often a fundamental part of rehabilitation despite minimal research on the topic (Kang and Hwang, 2019). However, most recent research suggests patients with LBP have abnormal motor recruitment in the lumbopelvic region (Kim et. al, 2014); therefore, activating the POS may offer spinal mobility, stability and prevent LBP (Kang and Hwang, 2019).

Prone hip extension (PHE) is a useful measure to assess and activate the POS. In healthy individuals, one should be able to maintain neutral lumbar and pelvic position during PHE, however patients with LBP have been found to have altered lumbar and pelvic movement. This in turn can cause lumbopelvic dysfunction, spinal instability and postural disturbance (Kim et. al, 2014). For example, Kang and Hwang found patients with LBP often have delayed onset of gluteus maximus and earlier onset of bicep femoris (Kang and Hwang, 2019).  When the gluteus maximus does not activate, there is a loss of pelvis control which can cause the contralateral latissimus dorsi to become dominant. Therefore, to aid lumbopelvic control, practitioners can manipulate the PHE to focus on the less dominant muscle (Kim et. al, 2014).

Lee et. al altered the PHE technique to assess the impact this has on POS. The PHE was compared to abdominal drawing in maneuverer prone hip extension (ADIM PHE). The ADIM PHE had increased contralateral latissimus dorsi and ipsilateral gluteus maximus compared to hip extension, whereas PHE had increased ipsilateral erector spinae and ipsilateral bicep femoris ((Lee et. al, 2020). Lee et. al also compared PHE to PHE with hip abduction and knee flexion. They discovered the contralateral latissimus dorsi, ipsilateral erector spinae and gluteus maximus electromyography was higher with phone hip extension with hip abduction and knee flexion than PHE (Lee et. al, 2019). Therefore, depending on the clinical presentation of the patient, practitioners can isolate specific muscle groups within the POS. PHE with hip internal rotation and shoulder internal rotation and shoulder extension with 1lb dumbbell was found to be the optimal PHE variation for POS activation to aid recovery with LBP (Kang and Hwang, 2019).

This research highlights the importance of using PHE as an assessment and treatment tool to identify weakness within the POS and then adapting the PHE to support recovery from LBP.

Reference List

Kang, D. and Hwang, Y.-I. (2019). Comparison of Muscle Activities of the Posterior Oblique Sling Muscles among Three Prone Hip Extension Exercises with and without Contraction of the Latissimus dorsi. Journal of The Korean Society of Physical Medicine, 14(3), pp.39–45. doi:https://doi.org/10.13066/kspm.2019.14.3.39.

Kim, J.-W., Kang, M.-H. and Oh, J.-S. (2013). Patients With Low Back Pain Demonstrate Increased Activity of the Posterior Oblique Sling Muscle During Prone Hip Extension. PM&R, 6(5), pp.400–405. doi:https://doi.org/10.1016/j.pmrj.2013.12.006.

Lee, J.-K., Hwang, J.-H., Kim, C.-M., Lee, J.K. and Park, J.-W. (2019). Influence of muscle activation of posterior oblique sling from changes in activation of gluteus maximus from exercise of prone hip extension of normal adult male and female. Journal of Physical Therapy Science, 31(2), pp.166–169. doi:https://doi.org/10.1589/jpts.31.166.

Lee, J.-K., Lee, J.-H., Kim, K.-S. and Lee, J.-H. (2020). Effect of abdominal drawing-in maneuver with prone hip extension on muscle activation of posterior oblique sling in normal adults. Journal of Physical Therapy Science, 32(6), pp.401–404. doi:https://doi.org/10.1589/jpts.32.401.

Menopause causes a deficiency in oestrogen which can result in an increased risk of cardiovascular disease, cancer, cognitive decline, chronic obstructive pulmonary disease, diabetes, metabolic syndrome, depression, sleep disturbances, vasomotor symptoms, migraines and musculoskeletal disorders. The most common musculoskeletal disorders in menopausal women are osteoporosis, sarcopenia and osteoarthritis (Dijk et.al, 2015).

During the menopausal transition, there is an increase of muscle degeneration which can progress to sarcopenia. The decrease in oestrogen and testosterone leads to ‘neuromuscular junction insufficiency, myofiber loss, mitochondrial dysfunction’ (Buckinx and Aubertin-Leheudre, 2022) and reduced muscle regeneration.  These physiological changes increase fat deposits in muscle and increase the difficulty in achieving hypertrophy and maintaining muscle mass (Buckinx and Aubertin-Leheudre, 2022). The prevalence of osteoporosis in menopausal women is extremely high, as more than two million women have osteoporosis in England and Wales. After the menopause, prevalence rises with age from approximately 2% at 50 years to more than 25% at 80 years’ (Peto and Allaby, 2013) This is likely due to the osteoclastic resorption activity increases and the osteoblastic activity decreases, resulting in more bone being absorbed than being formed (Ji and Yu, 2015).

There is an abundance of research illustrating the impact menopause has on osteoporosis and sarcopenia, however there is limited evidence on the impact of osteoarthritis on musculoskeletal disorders (Watt, 2018). However, Richmond et. al found oestrogen receptors in articular cartilage which potentially demonstrates a relationship between oestrogen and articular cartilage health. Zhang et al. discovered that oestrogen has a positive impact on cartilage. These studies illustrate there is relationship between oestrogen and cartilage however unable to identify an explanation for the clinical significance (Hame and Alexander, 2013). Lower back pain (LBP) is also more common in postmenopausal women than men who are within the same age group. This is most likely due to oestrogen deficiency causing postmenopausal women to have increased prevalence of disc degeneration; therefore, resulting in increased risk of spondylolisthesis and facet joint osteoarthritis. Also due to higher rates of osteoporosis in postmenopausal women, osteoporosis related spine fracture, especially at thoracolumbar junction, can cause LBP (Wang, 2017).

There is a wealth of research showing the importance of menopausal women participating in exercise to reduce the risk of musculoskeletal disorders and prevent the worsening of symptoms (Grindler et. al 2015). For example, Mendoza et. al found that exercise reduces osteoarticular pain in postmenopausal women with fibromyalgia or breast cancer (Mendoza et. al, 2016). Research suggests a combination of high impact exercises and weight training is optimal to increase muscle mass and bone density, alongside medical intervention such as hormone replacement therapy and supplementation. Metcalfe et .al found the combination of adding calcium, hormone replacement therapy and weight bearing movement increases bone mass density and muscle strength for post- menopausal women. The weight bearing movements included stair climber or stepping alongside resistance training and balance exercises to reduce the risk of osteoporosis, sarcopenia and fractures (Metcalfe et. al, 2001). Hettchen et. al 2021 also demonstrated the positive impact exercise has on early postmenopausal women with osteopenia or osteoporosis and disorders related to menopausal transition. The exercise regime included a combination of high intensity training, jumping sequences and velocity resistance training (Hettchen et. al 2021).  The evidence illustrates the importance of physical activity for menopausal women, however more research is required to see the impact menopause has on other musculoskeletal disorders.

Reference List

• Buckinx, Fanny, and Mylène Aubertin-Leheudre. “Sarcopenia in Menopausal Women: Current Perspectives.” International Journal of Women’s Health, vol. Volume 14, June 2022, pp. 805–819, https://doi.org/10.2147/ijwh.s340537.

• Grindler, Natalia M., and Nanette F. Santoro. “Menopause and Exercise.” Menopause, vol. 22, no. 12, Dec. 2015, pp. 1351–1358, https://doi.org/10.1097/gme.0000000000000536. Accessed 9 Aug. 2020.

• Hame, Sharon L., and Reginald A. Alexander. “Knee Osteoarthritis in Women.” Current Reviews in Musculoskeletal Medicine, vol. 6, no. 2, 8 Mar. 2013, pp. 182–187, www.ncbi.nlm.nih.gov/pmc/articles/PMC3702776/, https://doi.org/10.1007/s12178-013-9164-0.

• Hettchen, Michael, et al. “Changes in Menopausal Risk Factors in Early Postmenopausal Osteopenic Women after 13 Months of High-Intensity Exercise: The Randomized Controlled ACTLIFE-RCT.” Clinical Interventions in Aging, vol. Volume 16, Jan. 2021, pp. 83–96, https://doi.org/10.2147/cia.s283177.

• Ji, Meng-Xia, and Qi Yu. “Primary Osteoporosis in Postmenopausal Women.” Chronic Diseases and Translational Medicine, vol. 1, no. 1, 21 Mar. 2015, pp. 9–13, www.ncbi.nlm.nih.gov/pmc/articles/PMC5643776/, https://doi.org/10.1016/j.cdtm.2015.02.006.

• Mendoza, Nicolás, et al. “Benefits of Physical Exercise in Postmenopausal Women.” Maturitas, vol. 93, Nov. 2016, pp. 83–88, https://doi.org/10.1016/j.maturitas.2016.04.017. Accessed 28 May 2020.

• Metcalfe, Lauve, et al. Post-Menopausal Women and Exercise for Prevention of Osteoporosis. 2001.

• Peto, Lisa, and Martin Allaby. Screening for Osteoporosis in Postmenopausal Women. Solutions for Public Health, Jan. 2013.

• van Dijk, Gabriella M., et al. “Health Issues for Menopausal Women: The Top 11 Conditions Have Common Solutions.” Maturitas, vol. 80, no. 1, Jan. 2015, pp. 24–30, https://doi.org/10.1016/j.maturitas.2014.09.013.

• Wang, Yi Xiang J. “Menopause as a Potential Cause for Higher Prevalence of Low Back Pain in Women than in Age-Matched Men.” Journal of Orthopaedic Translation, vol. 8, Jan. 2017, pp. 1–4, https://doi.org/10.1016/j.jot.2016.05.012.

• Watt, Fiona E. “Musculoskeletal Pain and Menopause.” Post Reproductive Health, vol. 24, no. 1, 7 Feb. 2018, pp. 34–43, https://doi.org/10.1177/2053369118757537.