A comparison of patients with late-stage rheumatoid arthritis and osteoarthritis of the shoulder using self-assessed shoulder function and health status

The effects of rotator cuff tears, including shoulders without pain, on activities of daily living in the general population

BACKGROUND

Few reports have so far evaluated the possible restrictions of activities of daily living (ADL) in patients with asymptomatic rotator cuff tears (RCTs). The purpose of this study was to examine the effects of RCTs, including shoulders without pain, on ADL in the general population.

METHODS

We performed medical checkups on 462 individuals (924 shoulders). All participants completed a questionnaire regarding their background and medical history. We then assessed their shoulder functions with the Simple Shoulder Test (SST) and performed US (US) examinations of both shoulders to diagnose RCTs. We divided participants into tear and nontear groups and performed statistical analysis to compare total SST scores and each SST item between groups. Furthermore, we performed the same examinations for participants identified as having shoulders without pain.

RESULTS

Among participants, those in the tear group showed significantly lower total SST scores than those in the nontear group. After examining each SST item, a significant difference was observed regarding the ability to sleep comfortably and to lift 3.6 kg to shoulder level. In shoulders without pain, the tear group showed significantly lower total SST scores than the nontear group. A significant difference was observed only regarding the ability to lift 3.6 kg to shoulder level.

CONCLUSIONS

In the general population, ADL were restricted in participants with RCTs; they experienced night pain in the shoulder and muscle weakness during shoulder elevation. Furthermore, participants with RCTs, even if the condition itself did not induce any pain, tended to experience muscle weakness during shoulder elevation, thus resulting in restrictions of ADL.

Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral arthritis

The risk of glenoid component failure has led us to explore nonprosthetic glenoid arthroplasty coupled with humeral hemiarthroplasty, the "ream and run" (R&R) procedure, for the management of glenohumeral arthritis in active patients. We hypothesized that patients having a R&R procedure would have outcomes comparable with those of similar patients having a total shoulder arthroplasty (TSA). A case-matched control study compared 35 consecutive patients (32 men, 3 women) with an average age of 56 years, after R&R with matched controls having TSA. The respective Simple Shoulder Test (SST) scores for the R&R and TSA groups were 4.5 and 4.0 before surgery, 7.8 and 9.6 at 12 months, 8.3 and 10.2 at 18 months, 8.9 and 9.4 at 24 months, 9.4 and 9.6 at 30 months, and 9.5 and 10.0 at 36 months. The "ream and run" procedure can offer similar functional recovery to patients with total shoulder arthroplasty, although the time to recovery may be longer.

Recurrent shoulder instability among athletes: changes in quality of life, sports activity, and muscle function following open repair

BACKGROUND

Recurrent anterior shoulder instability is a disabling condition in young athletes with possibly underestimated impact on quality of life and sports activity. Commonly used clinical scoring systems do not reflect the impairment of quality of life and sports activity. It was our aim to assess the return to preinjury levels of quality of life and sports activity as well as the changes in muscle function among competitive and recreational athletes.

HYPOTHESIS

Patients suffering from post-traumatic recurrent shoulder instability have to adopt their participation in sports and therefore discover a reduction in quality of life. Open stabilization procedures are able to improve shoulder function and to reduce recurrence rates. However, return to preinjury shoulder function is not guaranteed.

STUDY DESIGN

Retrospective longitudinal cohort study on 19 consecutive athletes with recurrent, post-traumatic shoulder instability. All patients were treated with an open, capsulo-labral repair. The minimum follow-up was 24 months.

METHODS

Life quality (SF12) and sports activity data (Athletic Shoulder Outcome Scoring System) were retrospectively collected for the time before injury (time 1) and for the time with recurrent instability (time 2). Two years after surgical stabilization (time 3), we followed our patients with different clinical outcome scores, rotator surface EMG measurement, isokinetic muscle strength testing, and a radiological evaluation. This design of a three-step follow-up allowed for calculating the impact on quality of life and sports activity following the injury.

RESULTS

Two years after surgery, the clinical scoring systems revealed good-to-excellent results in all patients. Quality of life physical component summary remained diminished by 9.2% despite the surgical procedure and was therefore significantly lower as compared to preinjury levels (p < 0.05). Sports activity was also significantly lower at the time of follow-up (p < 0.05). In this specific procedure, external rotation was not impaired postoperatively. EMG testing showed an overall reduction of muscle activity, however not significant. Isokinetic muscle strength was significantly diminished for external rotation and shoulder abduction.

CONCLUSIONS

Open reconstruction procedures for recurrent shoulder instability can restore shoulder function and stability to near-normal values. Despite good-to-excellent clinical results, there is a significant impairment of quality of life and sports activity 2 years after surgery. Muscle activity and muscle strength are diminished. Recurrent shoulder instability remains a disabling condition to the young athlete. Future strategies have to emphasize restoration of quality of life, sports activity, and muscle function.

Long term effects of intra-articular botulinum toxin A for refractory joint pain

The purpose of this case series review is to describe our 12 month clinical experience with intra-articular injections of Botulinum toxin Type A (BoNT/A) for refractory joint pain. Eleven patients with chronic arthritis who had failed treatment with oral and/or intra-articular medications and were not surgical candidates were referred to us for management of moderate to severe refractory joint pain in 15 joints. The use of BoNT/A to treat joint pain is a non-FDA approved "off label" treatment with potential side effects. After a detailed explanation of the joint injection procedure, signed informed consent was obtained for the procedure. Fifteen joints were injected with BoNT/A (Allergan, Inc): six lower extremity joints (3 knees, 3 ankles) with 25-50 units and nine shoulders with 50-100 units. Patients were followed for one year or longer. Maximum relief of pain was measured by comparing baseline pain on a numeric rating scale (0-10) to pain at the time of maximum relief (paired t-test). Maximum improvement in function was assessed using paired t-tests for improvement in active flexion and abduction for the shoulder joint, and by the time to perform sit to stand ten times (the timed stands test, TST) for the lower extremity joints.

RESULTS

Two patients were female and nine were male, aged 42-82 years. Five had osteoarthritis (OA), five had rheumatoid arthritis (RA) and one had psoriatic arthritis. All patients were on analgesic and/or anti-inflammatory medications and all joints had previous intra-articular steroid or viscosupplement injections with inadequate or unsatisfactory benefit. A clinically and statistically significant improvement was noted after IA-BoNT/A injections. The mean maximum decrease in lower extremity joint pain was 55% (p =0.02) and the 36% (p =0.044) improvement in the Timed Stands Test was noted at four to ten weeks after injection. There was a 71% mean maximum reduction in shoulder pain severity from 8.2 +/- 1.1 to 2.4 +/- 1.9 (p <0.001). Active range of motion increased 67% in flexion (from 67.8 +/- 27.6 to 113.3 +/- 46.6 degrees, p =0.001) and 42% in abduction (from 50 +/- 18.5 degrees to 71.1 +/- 23.1 degrees p =0.01). No immediate or delayed adverse effects related to BoNT/A were noted after the injection. Duration of pain relief was variable and ranged from 3 to 12 months. Five joints were re-injected with IA-Bont/A and had a similar decrease in joint pain that lasted 3 to 12 months.

CONCLUSIONS

This is the first report of the long term effects of intra-articular BoNT/A injections to treat chronic joint pain and the efficacy of repeated injections. Although this study was small, and uncontrolled the results suggest that IA-BoNT/A injections are an effective and safe treatment for chronic joint pain disorders.

Deficits in shoulder function and general health associated with sixteen common shoulder diagnoses: a study of 2674 patients

The purpose of this study is to define the self-assessed deficits in function and general health perceived by a large cohort of patients with common shoulder diagnoses. For a 10-year period, all new shoulder patients presenting to the senior author were characterized by diagnosis, age, gender, and self-assessed shoulder function and general health status. This report concerns the 2674 patients having 1 of the 16 most prevalent diagnoses. The deficits in shoulder function and health status were correlated with diagnosis, age, and gender, as well as with each other. Patient self-assessment provided a standardized method for collecting data on shoulder function and health status. These assessments revealed substantial deficits; for example, 81% of patients were unable to sleep on the affected side, and 71% were unable to wash the back of the opposite shoulder. The magnitude of these deficits correlated significantly with gender and diagnosis but not with age.

Healing of reamed glenoid bone articulating with a metal humeral hemiarthroplasty: a canine model

This study characterizes the healing response of the glenoid after spherical reaming and prosthetic humeral head replacement in a canine model of glenohumeral hemiarthroplasty. The right glenoid of twelve skeletally mature female dogs was reamed to a uniform radius of curvature, removing all cartilage down to bleeding subchondral bone. The glenoid was not resurfaced. The humeral head was replaced with a stemmed metal prosthesis. Post-surgery, the operated limbs were immobilized for seven days, with motion allowed ad libitum thereafter. Fluorescent bone labels were administered to identify bone formation. These procedures were not complicated by instability, infection or death. Six animals were euthanized at 10 week and six more at 24 week. The intact glenohumeral joints were evaluated by gross examination, assessment of glenoid concavity, and light microscopy of methylmethacrylate sections. At 10 week, vascular fibrous tissue partially covered the glenoid, maintaining a concave surface congruent with the prosthetic humeral head. New bone formed at the margin of the glenoid, and the density of the periarticular trabecular bone increased. At 24 week, the healing was more advanced; thick fibrocartilaginous tissue covered the entire glenoid surface. These results demonstrate that spherical glenoid reaming produced a consistent healing response characterized by remodelling of the reamed bony concavity to a congruent, living, smooth, securely attached interface articulating with the humeral prosthesis.

Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty

BACKGROUND

The relationship between the characteristics of the shoulder that can be determined before humeral hemiarthroplasty and the functional improvement after surgery is not known. The goal of this study was to test the hypothesis that the functional outcome of this procedure correlated significantly with factors that are identifiable preoperatively.

METHODS

The study group included seventy-one shoulders in sixty-eight patients undergoing hemiarthroplasty, performed by the same surgeon, for diagnoses other than acute fracture. The mean age of the patients was sixty-one years (range, thirty to eighty-three years). The results were characterized in terms of the change in self-assessed shoulder function and general health status at an average of forty-nine months (range, twenty-four to 142 months) after surgery.

RESULTS

The preoperative absence of erosion of the glenoid was associated with greater improvement in shoulder function and level of comfort after hemiarthroplasty (p < 0.001). Shoulders that had not had previous surgery had greater functional improvement than did those that had previous surgery (p = 0.012). Shoulders with an intact rotator cuff showed significantly (p < 0.5) greater improvement in the ability to lift weight above shoulder level after hemiarthroplasty (p <0.5). With regard to diagnoses, shoulders with rheumatoid arthritis, capsulorrhaphy arthropathy, and cuff tear arthropathy had the least functional improvement, whereas those with osteonecrosis (p = 0.0004) and with primary (p = 0.02) and secondary degenerative joint disease (p = 0.03) had the greatest improvement. Patient age and gender did not significantly affect the outcome.

CONCLUSIONS

These results suggest that the functional improvement following humeral hemiarthroplasty is related to factors that are identifiable before surgery. These data may be of benefit in preoperative discussions with patients who have a shoulder disorder and are considering treatment with hemiarthroplasty.

The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease

So that patients with degenerative glenohumeral joint disease who wish to consider total shoulder arthroplasty will be better informed, we sought to document the magnitude and durability of the improvement in shoulder function after this procedure. The function of 124 shoulders with primary degenerative joint disease was documented by patient self-assessment with the Simple Shoulder Test before and sequentially after total shoulder arthroplasty performed with a standardized technique. Patients reported that they could perform 3.8 +/- 0.3 (SEM) of the 12 Simple Shoulder Test functions before surgery. The total number of performable functions was consistent at different follow-up intervals: 8.0 +/- 0.4 at 6 months, 9.5 +/- 0.4 at 1 year, 10.0 +/- 0.3 at 2 years, 9.2 +/- 0.4 at 3 years, 9.6 +/- 0.4 at 4 years, and 10.0 +/- 0.4 at 5 years. We conclude that total shoulder arthroplasty can provide substantial and durable improvement in shoulder function.

Improvement in comfort and function after cuff repair without acromioplasty

The repair of full thickness rotator cuff tears traditionally has included acromioplasty and coracoacromial ligament section. Acromioplasty can be complicated by deltoid detachment, compromise of the deltoid lever arm, anterosuperior instability, and adhesions of the rotator cuff tendons under the bleeding cancellous bone of the osteotomized acromion. This report concerns the improvement in shoulder function at a minimum of 2 years after 27 full thickness rotator cuff repairs were done without deltoid detachment, acromioplasty, or section of the coracoacromial ligament. The mean number of Simple Shoulder Test functions that the patients could do increased from six of 12 before surgery to 10 of 12 at an average followup of 4 years after surgery. Eight of 12 individual Simple Shoulder Test functions were significantly improved after the procedure. There also was a significant improvement in the Short Form-36 comfort, physical role function, and mental health scores. When done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion.

Outcome of nonoperative management of full-thickness rotator cuff tears

The study documented the functional outcome in a consecutive series of 46 patients from an individual practice meeting the inclusion criteria of (1) a full-thickness rotator cuff tear seen by ultrasonography, arthrogram, or magnetic resonance imaging, (2) absence of a Workers' Compensation claim or previous surgery, (3) followup of at least 1 year, and (4) election of nonoperative management by the patient. Twenty-six of the tears involved only the supraspinatus, two involved the supraspinatus and infraspinatus, and two involved the supraspinatus, infraspinatus, and subscapularis (16 reports did not specify the size of the tear). Treatment consisted only of patient education and a home program of gentle stretching and strengthening. Patients completed the Simple Shoulder Test at the initial visit and sequentially at 6-month intervals thereafter. At an average followup of 2.5+/-1.6 years, 27 (59%) patients experienced improvement with nonoperative treatment, 14 (30%) patients experienced worsening, and five (11%) patients remained unchanged. The average number of Simple Shoulder Test functions the patients could perform initially was 5.6+/-3.2. At the latest followup, the average number of Simple Shoulder Test functions the patients could perform improved to 7.0 +/-3.8. The ability to sleep on the affected side and the ability to place the hand behind the head were significantly improved.

Do shoulder patients insured by workers' compensation present with worse self-assessed function and health status?

The purpose of this study was to test the hypothesis that patients whose shoulder problems are covered by workers' compensation insurance perceive worse shoulder function and health status than do comparable patients whose problem is not covered by workers' compensation. Each of 1063 consecutive patients presenting with shoulder problems to an individual consultant completed 2 questionnaires: the Simple Shoulder Test inventory of shoulder function and the Short Form 36 general health assessment. The patients were divided into 2 groups on the basis of whether care of the shoulder problem was covered by injured workers' compensation insurance. The results indicate that patients whose shoulder condition is covered by workers' compensation have significantly lower self-assessed shoulder function and health status than do those patients whose shoulder conditions are not related to on-the-job injuries. The differences between the workers' compensation and non-workers' compensation groups could not be attributed to differences in age, sex, or diagnosis.

A prospective, multipractice study of shoulder function and health status in patients with documented rotator cuff tears

A total of 191 patients from 29 orthopedic practices are analyzed in this report. All had full-thickness tears documented by imaging tests and/or surgical observation; 190 had tears of the supraspinatus, 54 had tears of the infraspinatus, and 13 had tears of the subscapularis. The greatest functional deficits were in the ability to place 8 pounds on a shelf at the level of the head (93% unable), the ability to throw overhand (93% unable), and the ability to sleep on the affected side (86% unable). The SF-36 physical role function and comfort scores were 27% and 48%, respectively, of those of age- and sex-matched controls. Of the variables suggested by a review of the literature, only female sex, involvement of the infraspinatus in the cuff tear, and workers' compensation claims were significantly correlated with lower shoulder function in this series of patients.

Challenges in evaluating patients lost to follow-up in clinical studies of rotator cuff tears

BACKGROUND

Long-term follow-up studies are necessary to critically evaluate the outcome of a treatment intervention for a specific disorder. However, patients may cease participating in a long-term study and become lost to follow-up; thus, their current condition is unknown. The underlying characteristics that predispose a patient to become lost to follow-up are difficult to identify and control. Patients who are lost to follow-up may be contacted by telephone; however, the effect of administering a functional assessment questionnaire by telephone compared with that of mailing a questionnaire is unknown. The purpose of this study was to compare patients who continued to respond to requests for follow-up with those who did not. A second purpose was to compare responses obtained by mail with those obtained by telephone interview.

METHODS

Two hundred and twenty-four patients with a rotator cuff tear were enrolled in an ongoing study of shoulder function and general health. Self-assessment questionnaires were mailed to every patient at six-month intervals. Sixty-seven patients (30 percent) regularly responded to mailings (identified as responders in this study), fifty-five patients (25 percent) responded occasionally (these patients were not included in the analysis), and 102 patients (46 percent) ceased to respond and became lost to follow-up (identified as nonresponders in this study). This investigation was performed to determine: (1) the characteristics of nonresponders compared with those of responders, (2) the functional status of nonresponders as assessed with a questionnaire over the telephone, and (3) the effect of administering a self-assessment functional questionnaire by telephone compared with that of sending the same questionnaire by mail.

RESULTS

Nonresponders tended to have lower initial scores for the mental health summary (p = 0.03) and for social function (p = 0.01), were less likely to have had surgery (p = 0.009), and were less likely to consume alcohol (p = 0.03). At the last known time when they completed the mailed questionnaire, nonresponders reported significantly worse shoulder function than responders (p = 0.0001). However, on telephone questioning the mean number of shoulder functions that the nonresponders indicated that they could perform was greater than the mean number documented on their last mailed questionnaire (p < 0.0001). In a random subgroup of responders, the mean number of functions that the patients indicated that they could perform when interviewed by telephone was significantly greater than the number indicated on their most recent mailed questionnaire (p < 0.01). The results obtained by telephone from this random subgroup of responders were similar to those obtained by telephone from the nonresponders.

CONCLUSIONS

There are differences between patients who continue to participate in a study and those who become lost to follow-up. Functional assessment questionnaires administered by telephone yield different results than the same questionnaires sent by mail. These considerations are relevant to the design, implementation, and interpretation of clinical studies in which functional questionnaires are used.

Randomized controlled trial of nettle sting for treatment of base-of-thumb pain

There are numerous published references to use of nettle sting for arthritis pain but no randomized controlled trials have been reported. We conducted a randomized controlled double-blind crossover study in 27 patients with osteoarthritic pain at the base of the thumb or index finger. Patients applied stinging nettle leaf (Urtica dioica) daily for one week to the painful area. The effect of this treatment was compared with that of placebo, white deadnettle leaf (Lamium album), for one week after a five-week washout period. Observations of pain and disability were recorded for the twelve weeks of the study. After one week's treatment with nettle sting, score reductions on both visual analogue scale (pain) and health assessment questionnaire (disability) were significantly greater than with placebo (P = 0.026 and P = 0.0027).

Self-assessment questionnaires document substantial variability in the clinical expression of rotator cuff tears

The goal of this investigation was to document the variability in the clinical expression of full-thickness rotator cuff tears with practical and standardized patient self-assessment tools. One-hundred twenty-three consecutive patients with full-thickness cuff tears diagnosed by standard cuff-imaging methods (sonography, arthrography, or magnetic resonance imagery) assessed their own shoulder function and health status with the Simple Shoulder Test and the Short Form 36, respectively. As a group, these patients were substantially compromised in their ability to perform the functions of the Simple Shoulder Test and in the Short Form 36 scales of physical role, physical function, and comfort. As individuals, however, their self-assessments varied widely. The standard deviations were often greater than 50% of the mean and the range of responses often covered the entire scale from the minimum possible score to the maximum possible score. These results show the importance of documenting the clinical expression of cuff tears in patients at initial evaluation and when treatment is being considered. The results also show the practicality of standardized self-assessment questionnaires in such documentation.

The correlation of comorbidity with function of the shoulder and health status of patients who have glenohumeral degenerative joint disease

We studied the effect of comorbidities on function of the shoulder and health status in a group of eighty-five consecutive patients who had glenohumeral degenerative joint disease of sufficient severity to meet one surgeon's criteria for the performance of shoulder arthroplasty. A questionnaire was used to identify the comorbidities, such as other diseases, social factors, or a work-related injury, for each patient. The number of functions on the Simple Shoulder Test that the patient could perform had a significant negative correlation with the number of comorbidities (r = -0.32, intercept = 4.6 per cent, slope = -0.6, and p = 0.0031). Each parameter on the Short Form-36 (except for physical role function) had a significant negative correlation with the number of comorbidities (p < 0.05). This negative relationship was strongest for general health perception (r = -0.42) and vitality (r = -0.35). We concluded that the number of comorbidities has a quantitative effect on function of the shoulder. In the evaluation of the functional status of patients and the effectiveness of treatment, the effects of comorbidity must be controlled. The results of the present study demonstrate that the scores on the Short Form-36 are quantitatively related to the number of comorbidities. The six parameters that are unrelated to function of the shoulder (physical function, social function, emotional role function, mental health, vitality, and general health perception) may provide a practical way to integrate the effects of all potential comorbidities on individual patients. Future clinical research will be strengthened by efforts to measure the impact of comorbidities and by strategies to control for their effects.