Very High Prevalence of Frozen Shoulder in Patients With Type 1 Diabetes of ≥45 Years' Duration: The Dialong Shoulder Study

Releasing Forces in Adhesive Capsulitis Are Imporant Indicators of Shoulder Stiffness and Postoperative Function

BACKGROUND

Manipulation under anesthesia is a widely used treatment for frozen shoulder, but the factors that influence patient outcomes after manipulation remain unclear. The degree of shoulder stiffness, a critical feature of frozen shoulder, likely reflects the severity of the condition but currently lacks standardized, objective assessment methods.

QUESTIONS/PURPOSES

(1) What are the releasing forces in patients with frozen shoulder, and do the forces vary across different stages of frozen shoulder? (2) Are there differences in postoperative outcomes of manipulation under anesthesia among patients with frozen shoulder at different stages of the condition? (3) Is a higher releasing force associated with poorer outcomes of manipulation, and what threshold of releasing force is optimal for better outcomes? (4) What clinical factors influence the magnitude of releasing forces?

METHODS

This prospective cohort study included patients with primary unilateral frozen shoulder who underwent manipulation under anesthesia after at least 3 months of unsuccessful nonsurgical treatment, which was defined as progressive worsening ROM, failure to make progress, or residual functional impairment after 3 months of treatment. Between December 1, 2022, and December 31, 2023, we treated 280 patients with unilateral frozen shoulder, all of whom were considered potentially eligible for this study. The inclusion criteria were: a reduction of passive external rotation in the affected shoulder to less than 50% compared with the contralateral side, at least 3 months of unsuccessful nonsurgical treatment, absence of shoulder trauma, radiographs and MRI showing no other pathologic lesions in the shoulder, and no prior medical history in the contralateral shoulder. The exclusion criteria were patients who had previously undergone shoulder surgery, those who had bilateral frozen shoulder, patients with anesthesia intolerance, and those with incomplete preoperative assessments. One hundred fifty-six patients were enrolled in follow-up assessments at 1, 3, and 6 months after manipulation. The mean ± SD age for enrolled patients was 54 ± 8 years, 35% (55 of 156) of all participants were male, and the mean BMI was 23 ± 3 kg/m2. Two percent (3 of 156) withdrew consent, and 4% (7 of 156) were lost to follow-up, leaving 94% (146 of 156) for analysis. The contralateral unaffected shoulder was used as a self-control. During the manipulation process, the force-time curves for the affected and unaffected shoulders were sequentially recorded using a handheld dynamometer, following the order of forward flexion, external rotation, and internal rotation. Two key force values, an initial tear value and a peak value, were extracted from the curve for the affected shoulder, while only the peak value was recorded for the unaffected shoulder. Passive ROM, the Oxford shoulder score (OSS), and the VAS were evaluated at the baseline and at 1, 3, and 6 months postoperatively. Patients were categorized into four stages according to the patient-reported duration of pain: Stage 1 (0 to 3 months), Stage 2 (3 to 9 months), Stage 3 (9 to 15 months), and Stage 4 (> 15 months). To address our first and second questions, we used ANOVA for multistage comparisons of continuous variables, followed by a post hoc Tukey test for pairwise comparisons. For the third question, we performed univariate regression to analyze the correlation between factors like age, sex, symptom duration, frozen shoulder stage, preoperative ROM, upper arm circumference, fat-free mass, diabetes, thyroid disease, hyperlipidemia, tear value, peak value, and 6-month postoperative ROM, VAS, and the OSS. Factors with p < 0.05 were included in a multivariate regression. A tear value threshold of poor ROM outcomes was evaluated with a receiver operating characteristic (ROC) curve and the Youden index. For the fourth question, we used similar regression models to examine potential factors associated with the releasing force, focusing on both tear and peak values. Pairwise comparisons in this subgroup analysis were performed using the Student t-test. All p values less than 0.05 were considered significant.

RESULTS

Tear values of each stage were as follows: 25 ± 13 N in Stage 2, 28 ± 15 N in Stage 3, and 38 ± 18 N in Stage 4. The tear value for patients in Stage 4 was higher compared with both Stage 2 and Stage 3 (Stage 4 versus Stage 2, mean difference 13 [95% CI 6 to 20]; p < 0.001; Stage 4 versus Stage 3, mean difference 10 [95% CI 2 to 19]; p = 0.01). Patients in Stage 4 exhibited an increased peak value relative to the other two stages (Stage 4 versus Stage 2, mean difference 11 [95% CI 2 to 20]; p = 0.02; Stage 4 versus Stage 3, mean difference 8 [95% CI 0 to 16]; p = 0.04). The peak value in the affected shoulder was higher than that in the unaffected (mean difference 40 [95% CI 36 to 44] in forward flexion; p < 0.001). At the 6-month endpoint after manipulation, patients in Stage 2 and 3 showed greater ROM in forward flexion than those in Stage 4 (Stage 2 versus Stage 4, mean difference 12 [95% CI 9 to 14]; p < 0.001; Stage 3 versus Stage 4, mean difference 14 [95% CI 11 to 17]; p < 0.001) and a lower OSS than those in Stage 4 (Stage 2 versus Stage 4, mean difference -8 [95% CI -9 to -7]; p < 0.001; Stage 3 versus Stage 4, mean difference -7 [95% CI -8 to -6]; p < 0.001). Two factors were associated with the OSS at the 6-month endpoint: increased tear value (β = 0.47; p = 0.004) and diabetes (β = 0.28; p = 0.02). The optimal thresholds for predicting a forward flexion at least 164° at 6 months was a tear value of 53 N (area under curve [AUC] 0.79 [95% CI 0.68 to 0.91]). Patients with a tear value of below 53 N demonstrated better postoperative ROM (mean difference 10 [95% CI 3 to 16]; p = 0.004) and OSS (mean difference -4 [95% CI -8 to 0]; p = 0.04). The tear value was associated with male sex (β = 0.36; p = 0.03) and ROM in flexion (β = 0.20; p = 0.049), whereas peak value was associated with male sex (β = 0.45; p = 0.001) and diabetes (β = 0.16; p = 0.048).

CONCLUSION

These findings suggest that performing manipulation before reaching Stage 4 may result in more favorable outcomes for patients, and evaluating shoulder stiffness by measuring releasing force proved to be feasible.

LEVEL OF EVIDENCE

Level II, prognostic study.

Targeting the Sweet Spot: A Systematic Review With Meta-Analysis of Anterior Versus Posterior Glenohumeral Joint Injections for Adhesive Capsulitis

OBJECTIVE

To compare clinical outcomes following steroid injections using the anterior and posterior approaches.

DESIGN

Systematic review with meta-analysis.

SETTING

Embase, Web of Science, and Cochrane Center Register of Controlled Trials were searched for randomized control trials (RCTs) and prospective comparative studies.

PATIENTS

Patients with adhesive capsulitis.

INTERVENTIONS

Glenohumeral steroid injections using either anterior or posterior approach.

MAIN OUTCOME MEASURES

Pain visual analog scale (VAS) and shoulder range of motion (ROM) at 12 weeks, accuracy, and adverse events. Standardized mean difference (SMD) for VAS and weighted mean difference (WMD) for ROMs.

RESULTS

We identified 6 RCTs and one prospective comparative study with a total of 468 patients. While there was no difference in pain VAS at 12 weeks between the 2 approaches (SMD, -0.86; 95% CI, -1.76 to 0.04), the anterior approach resulted in greater improvements in external rotation (WMD, 8.08; 95% CI, 0.79-15.38) and abduction (WMD, 6.76; 95% CI, 3.05-10.48) compared with the posterior approach. Subgroup analysis with RCTs that utilized steroid injection with hydrodilatation for both approaches demonstrated greater reduction in pain VAS at 12 weeks with the anterior approach (SMD, -0.52; 95% CI, -0.98 to -0.07). Overall, procedures were well tolerated without major complications.

CONCLUSIONS

While pain reduction is similar, the anterior approach may be more beneficial in restoring shoulder external rotation and abduction compared with the posterior approach at 12 weeks. Steroid injection combined with hydrodilatation may further improve pain control when performed with the anterior approach at 12 weeks.

Rat models of frozen shoulder: Classification and evaluation

Frozen shoulder (FS), also known as adhesive capsulitis, is a condition that causes contraction and stiffness of the shoulder joint capsule. The main symptoms are persistent shoulder pain and a limited range of motion in all directions. These symptoms and poor prognosis affect people's physical health and quality of life. Currently, the specific mechanisms of FS remain unclear, and there is variability in treatment methods and their efficacy. Additionally, the early symptoms of FS are difficult to distinguish from those of other shoulder diseases, complicating early diagnosis and treatment. Therefore, it is necessary to develop and utilize animal models to understand the pathogenesis of FS and to explore treatment strategies, providing insights into the prevention and treatment of human FS. This paper reviews the rat models available for FS research, including external immobilization models, surgical internal immobilization models, injection modeling models, and endocrine modeling models. It introduces the basic procedures for these models and compares and analyzes the advantages, disadvantages, and applicability of each modeling method. Finally, our paper summarizes the common methods for evaluating FS rat models.

Does the intervention for adhesive capsulitis in patients with diabetes differ from that for patients without diabetes?: A systematic review

BACKGROUND

Adhesive capsulitis (AC) is often accompanied by pain and restriction in range of movement, which long lasting symptoms often have negative impact on patients' work and lives. Since diabetes mellitus (DM) is an independent risk factor for developing AC, and AC with DM have more limitations of joint motion than general people.

AIMS

The aim of the present study is to evaluate the difference of clinical efficacy between diabetes and non-diabetes, and to explore whether AC with diabetes need special intervention compared to non-diabetes.

METHODS

Pubmed NCBI and Embase were searched for studies published in the last 30 years. We conducted a literature search for terms regarding AC and DM on Pubmed NCBI and Embase.

RESULTS

A total of 9 studies eligible for inclusion. The affected shoulders in these studies ranged from 26 to 135, 460 shoulders (551 participants) in total, including 166 shoulders in diabetic group and 394 shoulders in non-diabetic/idiopathic group. Interventions included shock wave therapy, hydrodilatation, arthroscopic capsular release, manipulation under cervical nerve root block. Evaluation indicators included pain, certain shoulder questionnaires, range of motion. Positive clinical efficacy were emerged after interventions between the 2 groups. The studies that better improvement of pain in non-diabetic/idiopathic group were 2 of 6, that of certain shoulder questionnaires were 4 of 8, that of range of motion were 3 of 6.

CONCLUSIONS

Whether AC combined with DM or not, the current treatment could achieve positive clinical effectiveness and there is some statistical evidence show that the curative effect of AC combined with DM is worse than non-diabetic. In other words, the available evidence suggests that patients with DM might require additional rehabilitation measures with routine glycemic control.

A Narrative Review of Adhesive Capsulitis with Diabetes

Background/Objectives: To update the perspectives of the association between diabetes (DM) and adhesive capsulitis (AC). Methods: Our findings were summarized in a narrative review. We searched PubMed, Embase, and Consensus databases, using keywords such as "diabetes", "adhesive capsulitis", and "frozen shoulder", for articles published from January 2015 to June 2024, covering both type 1 and type 2 DM. Results: After compiling relevant articles on DM-related AC published since 2015, we found that most studies show an increased prevalence of AC in DM patients, ranging from 3 to 10 times. A longer duration of DM is a risk factor for AC. Whether T1DM or prolonged insulin use will increase the risk of AC is still controversial. Poor blood sugar control seems to increase the risk of AC. Recent studies also show a correlation between blood sugar levels and the prevalence of AC. Cytokines, such as IL-6, IL-8, TNF-α, VEGF, and AGEs, related to inflammation and fibrosis may contribute to the pathophysiological processes of AC. Conclusions: Recent research findings have revealed new perspectives divergent from past notions, while also presenting some topics worthy of exploration. Due the close relationship between DM and AC, clinicians need to be alert to the presence of AC, especially early stage, in DM cases, and control the blood glucose level to reduce the risk of AC. Further research is still needed to provide better prevention and management for DM patients with AC.

Causal associations of hypothyroidism with frozen shoulder: a two-sample bidirectional Mendelian randomization study

BACKGROUND

Many studies have investigated the association between hypothyroidism and frozen shoulder, but their findings have been inconsistent. Furthermore, earlier research has been primarily observational, which may introduce bias and does not establish a cause-and-effect relationship. To ascertain the causal association, we performed a two-sample bidirectional Mendelian randomization (MR) analysis.

METHODS

We obtained data on "Hypothyroidism" and "Frozen Shoulder" from Summary-level Genome-Wide Association Studies (GWAS) datasets that have been published. The information came from European population samples. The primary analysis utilized the inverse-variance weighted (IVW) method. Additionally, a sensitivity analysis was conducted to assess the robustness of the results.

RESULTS

We ultimately chose 39 SNPs as IVs for the final analysis. The results of the two MR methods we utilized in the investigation indicated that a possible causal relationship between hypothyroidism and frozen shoulder. The most significant analytical outcome demonstrated an odds ratio (OR) of 1.0577 (95% Confidence Interval (CI):1.0057-1.1123), P = 0.029, using the IVW approach. Furthermore, using the MR Egger method as a supplementary analytical outcome showed an OR of 1.1608 (95% CI:1.0318-1.3060), P = 0.017. Furthermore, the results of our sensitivity analysis indicate that there is no heterogeneity or pleiotropy in our MR analysis. In the reverse Mendelian analysis, no causal relationship was found between frozen shoulders and hypothyroidism.

CONCLUSION

Our MR analysis suggests that there may be a causal relationship between hypothyroidism and frozen shoulder.

Differences in biomechanical and metabolic factors between patients with frozen shoulder and asymptomatic individuals. A cross-sectional study

BACKGROUND

the pathogenesis of frozen shoulder (FS) is thought to be one of inflammation and fibrosis possibly influenced by hyperglycemia. Biomechanical changes of the shoulder joint in terms of muscle strength, scapular kinematics and proprioception might occur in FS.

OBJECTIVES

to compare muscle strength, scapular kinematics, proprioception, and blood glucose levels within patients with FS and to asymptomatic individuals.

DESIGN

cross-sectional study.

METHOD

Thirty-five patients with FS and 35 asymptomatic age and gender-matched individuals underwent physical assessment to determine muscle strength (abduction, external and internal rotation), scapular kinematics (both visually and with a plurimeter), proprioception (joint position sense), and blood glucose level.

RESULTS

Patients with FS showed a decrease in muscle strength in their affected shoulder compared to both the unaffected shoulder and asymptomatic individuals. Significant differences were found between the affected and unaffected shoulder in the FS group and between groups (FS versus controls) in scapular upward rotation (plurimeter) at 30° and 60° abduction. No difference in scapular kinematics (visual observation), proprioception, and blood glucose levels was found neither between shoulders in the FS group nor between groups.

CONCLUSION

A clinically relevant difference in muscle strength and increase in scapular upward rotation were found in the affected shoulder of patients with FS compared to their unaffected side and controls. However, no evidence of different levels of scapular kinematics (visual observation), proprioception, and blood glucose levels in the affected shoulder compared to the unaffected shoulder or controls is lacking.

Risk factors and predictive models for frozen shoulder

This study aims to explore the risk factors associated with frozen shoulder (FS) and develop a predictive model for diagnosing FS, in order to facilitate early detection of the condition. A total of 103 patients diagnosed with FS and admitted to the Department of Joint Surgery at Suining Central Hospital between October 2021 and October 2023 were consecutively included in the study. Additionally, 309 individuals without shoulder joint diseases, matched for age and gender, who visited the department during the same time, were included as the control group.The complete recording of clinical data for all patients was followed by the utilization of statistical tests such as the Mann-Whitney U test, sample t test, and chi-square test to compare different groups. Additionally, multivariate binary logistic regression analysis was employed to identify risk factors associated with the occurrence of FS in patients, leading to the establishment of a prediction model and derivation of a simplified equation. The diagnostic effectiveness of individual indicators and prediction models was assessed through the use of receiver operating characteristic (ROC) curve analysis. In the sample of 103 individuals, 35 were identified as male and 68 as female, with an average age range of 40-70 years (mean age: 54.20 ± 6.82 years). The analysis conducted between different groups revealed that individuals with a low body mass index (BMI), in conjunction with other factors such as diabetes, cervical spondylosis, atherosclerosis, and hyperlipidemia, were more susceptible to developing FS. Logistic regression analysis further indicated that low BMI, diabetes, cervical spondylosis, and hyperlipidemia were significant risk factors for the occurrence of FS. These variables were subsequently incorporated into a predictive model, resulting in the creation of a simplified equation.The ROC curve demonstrated that the combined indicators in the predictive model exhibited superior diagnostic efficacy compared to single indicators, as evidenced by an area under the curve of 0.787, sensitivity of 62.1%, and specificity of 82.2%. Low BMI, diabetes, cervical spondylosis, and hyperlipidemia are significant risk factors associated with the occurrence of FS. Moreover, the utilization of a prediction model has demonstrated superior capability in forecasting the likelihood of FS compared to relying solely on individual indicators. This finding holds potential in offering valuable insights for the early diagnosis of FS.

Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis

OBJECTIVE

Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS.

METHODS

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, -0.44; 95% CI, -0.71 to -0.18; I2 = 6%; p = 0.001) at over 12-month follow-up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow-up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention.

CONCLUSIONS

In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short-term follow-up periods. Notably, ACR exhibited statistically superior improvement in the long-term pain relief compared to the MUA group, although it did not reach the MCID.

Patient experiences of hydrodistension as a treatment for frozen shoulder: A longitudinal qualitative study

BACKGROUND

Frozen shoulder is a condition associated with severe shoulder pain and loss of function impacting on a persons' physical and mental health. Hydrodistension treatment that has been widely adopted within the UK National Health Service for the condition. However, evidence of clinical effectiveness and understanding of the patient experiences of this treatment are lacking. This study explored the experiences of people with a frozen shoulder who received hydrodistension treatment.

METHODS

A qualitative design with repeat semi-structured interviews was used to explore participants' experiences of hydrodistension treatment. Participants were interviewed 2-4 weeks and again at 8-10 weeks after treatment. Interviews were audio-recorded and transcribed verbatim. Findings were analysed using an inductive thematic analysis framework. The study is reported in accordance with the consolidated criteria for reporting qualitative (COREQ) research.

RESULTS

15 participants were interviewed online or over the phone. Three themes were identified: 'Preparing for and having a hydrodistension', 'Physiotherapy after hydrodistension', and 'Outcome of hydrodistension '. Participants believed hydrodistension would benefit them, was well tolerated by many, and the effects were apparent to most within the first week. Physiotherapy still seemed to be valued to support recovery beyond this timepoint, despite these early effects. Some participant's experienced harms including severe procedural pain and blood sugar dysregulation.

CONCLUSION

This is the first study to investigate the experiences of people who undergo hydrodistension for frozen shoulder. Hydrodistension appears an acceptable treatment to participants with a frozen shoulder, acceptability is enhanced through adequate shared decision making. Further high-quality research is required to understand the comparative effectiveness of hydrodistension as a treatment for frozen shoulder, including adverse events, and the benefit of treatment by a physiotherapist after hydrodistension.

Gene association analysis to determine the causal relationship between immune-mediated inflammatory diseases and frozen shoulder

Multiple studies have indicated a potential correlation between immune-mediated inflammatory diseases (IMIDs) and Frozen shoulder (FS). To explore the genetic causal relationship between IMIDs and FS using 2-sample Mendelian randomization (MR) analysis. Genome-wide association study (GWAS) summary data for FS were obtained from Green's study, while data for 10 IMIDs were sourced from the FinnGen Consortium. The MR analysis was performed using inverse variance weighting, MR Egger, and weighted median methods. IVW, as the primary MR analysis technique, was complemented with other sensitivity analyses to validate the robustness of the results. Additionally, reverse MR analysis was further conducted to investigate the presence of reverse causal relationships. In the forward MR analysis, genetically determined 4 IMIDs are causally associated with FS: rheumatoid arthritis (odds ratio [OR] (95% confidence interval [95% CI]) = 1.05 [1.02-1.09], P < .01); type 1 diabetes (OR [95% CI] = 1.06 [1.03-1.09], P < .01); hypothyroidism (OR [95% CI] = 1.07 [1.01-1.14], P = .02); and Celiac disease (OR [95% CI] = 1.02 [1.01-1.04], P = .01). However, no causal relationship was found between 6 IMIDs (autoimmune hyperthyroidism, Crohn disease, ulcerative colitis, psoriasis, sicca syndrome and systemic lupus erythematosus) and FS. Sensitivity analyses did not detect any heterogeneity or horizontal pleiotropy. In the reverse MR analysis, no causal relationship was observed between FS and IMIDs. In conclusion, this MR study suggests a potential causal relationship between rheumatoid arthritis, type 1 diabetes, hypothyroidism, and Celiac disease in the onset and development of FS. Nevertheless, more basic and clinical research will be needed in the future to support our findings.

Cytokines' Role in the Pathogenesis and Their Targeting for the Prevention of Frozen Shoulder: A Narrative Review

Frozen shoulder (FS) is a common name for shoulder movement limitation with different degrees of shoulder rigidity and pain. It is characterized by varying developmental courses, different levels of shoulder movement limitation, and background ambiguity due to the multiplicity of its causative factors. Systemic inflammatory cytokines monitoring and restraining is easy to apply, fast to conduct, and needs lower costs compared to invasive methods for frozen shoulder stage evaluation and early controlling of its progress to the stage that necessitates surgical intervention. The aim of this review was to assess the recent findings concerning the role of cytokines in FS pathogenesis and the possibility of preventing or controlling their progress through targeting these cytokines by the new drugs candidates, such as hyaluronan (HA), botulinum toxin type A (BoNT A), Tetrandrine, tumor necrosis factor-stimulated gene-6 (TSG-6), and cannabidiol. Searching the PubMed site, we encountered out of 1608 records, from which 16 original studies were included for the quantitative construction of this systematic review screening of the recent studies to investigate the different FS pathogenic pathways. Most of the scenarios are centered around the inflammatory and fibrotic process triggered by synovial and capsular fibroblast stimulation. This mechanism depends mainly on alarmins cytokines, including thymic stromal lymphopoietin (TSLP), interleukin-33 (IL-33), and interleukin-25 (IL-25), with the stimulation of interleukin-1 α (IL-1α), interleukin-1 β (IL-1β), tumor necrosis alpha (TNF-α), cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) in a joint capsule. Different pathways of transforming growth factor- β (TGF-β) stimulation, resulting in overexpression of the fibrotic factors as tenascin C (TNC), fibronectin 1, collagen I (COL 1) and collagen III (COL III), and matrix metalloproteinases (MMPs) in the capsular or synovial/capsular fibroblasts. The overall investigation of these studies led us to conclude that the new drug candidates proved their efficiency in controlling the common pathogenesis of the inflammatory and fibrotic pathways of frozen shoulder and therefore represent a prospect for easy and early controlling and efficiently treating this serious disease.

Metabolic predictors of pain, fatigue, depression and quality of life in people with long-term type 1 diabetes-the Dialong study

AIM

To examine associations of metabolic parameters (mean 30 years' time-weighted HbA_1c and low-density lipoprotein-cholesterol [LDL-c], current methionine sulfoxide [MetSO], advanced glycation end products [AGEs], inflammatory markers and hypoglycaemia) with pain, fatigue, depression and quality of life (QoL) in people with long-term type 1 diabetes.

METHODS

A total of 104 persons with type 1 diabetes ≥45 years duration were included. Participants completed questionnaires measuring bodily pain (RAND-36 bodily pain domain with lower scores indicate higher levels of bodily pain), fatigue (Fatigue Questionnaire), depression (Patient Health Questionnaire), overall QoL (World Health Organization Quality of Life-BREF) and diabetes-related QoL (Audit of Diabetes-Dependent Quality of Life). In this observational study, mean time-weighted HbA_1c and LDL-c were calculated based on longitudinal measures obtained from medical records of up to 34 years, while current HbA_1c , LDL-c and inflammatory markers were analysed in blood samples and collagen MetSO and AGEs in skin biopsies. History of hypoglycaemia was self reported. Associations between metabolic parameters and questionnaire scores were analysed using linear regression analyses and are reported as standardized regression coefficients (beta).

RESULTS

Of the metabolic variables, higher mean time-weighted HbA_1c was associated with higher levels of bodily pain and total fatigue (beta [p-value]) -0.3 (<0.001) and 0.2 (0.001).

CONCLUSIONS

Long-term chronic hyperglycaemia may have a negative influence on pain and fatigue in people with type 1 diabetes. These results may assist health care workers in emphasizing the importance of strict glycaemic control in people with diabetes and identifying and treating type 1 diabetes-related pain and fatigue.

Understanding the clinical profile of patients with frozen shoulder: a longitudinal multicentre observational study

INTRODUCTION

There is a large diversity in the clinical presentation of frozen shoulder (FS) and the clinical outcome is not always satisfactory. The aim of the current study was to examine to what extent range of motion (ROM) limitation, metabolic factors (diabetes mellitus and thyroid disorders), autonomic symptoms and pain sensitivity may contribute to the prognosis in terms of shoulder pain and disability and quality of life in patients with FS.

METHODS

Patients with stage 1 or 2 FS were longitudinally followed-up during 9 months after baseline assessment. They completed six questionnaires and underwent quantitative sensory testing (pressure pain thresholds, temporal summation and conditioned pain modulation) and ROM assessment.

RESULTS

One hundred and forty-nine patients with FS were initially recruited and 121 completed at least one follow-up measurement. Shoulder pain and disability improved over time and diabetes mellitus was found to be a prognostic factor for final outcome. Several domains of quality of life also improved over time and external rotation ROM, diabetes mellitus, thyroid disorder and autonomic symptoms were found to be prognostic factors for final outcome. These prognostic factors explained 2.5%-6.3% of the final outcome of shoulder pain and disability and quality of life.

DISCUSSION AND CONCLUSION

In patients with FS, prognostic variables were able to predict different outcomes, indicating that outcomes in this population can be variable-dependent. Other variables not explored in this study might contribute to the prognosis of patients with FS, which should be investigated in future research. In clinical practice, baseline assessment of prognostic factors and focusing on a more holistic approach might be useful to inform healthcare practitioners about progression of patients with FS during a 9-month period.

Frozen shoulder

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

Acupuncture management for the acute frozen shoulder: A case report

After an acupuncture treatment 24 times, the symptoms are recovered right shoulder both active and passive full range of movement in all directions, and pain-free. Furthermore, no adverse effects were observed.

Idiopathic Frozen Shoulder in Individuals with Diabetes: Association with Metabolic Control, Obesity, Antidiabetic Treatment and Demographic Characteristics in Adults with Type 1 or 2 Diabetes from the DPV Registry

AIMS

To examine the association of frozen shoulder (FS) with demographic and diabetes-related outcomes in individuals with type 1 (T1D) or type 2 (T2D) diabetes aged ≥30 years.

MATERIALS AND METHODS

Multivariable logistic regression models, adjusted for demographics were used to calculate the proportion of FS in association with age, gender, diabetes duration, body mass index (BMI), haemoglobin A1C (HbA1c) and diabetes treatment.

RESULTS

The unadjusted percentage of FS was higher in T1D compared to T2D (0.22% vs. 0.06%). In T1D, adjusted regression models revealed higher prevalence of FS in women than men (0.26 [0.20-0.34] % vs. 0.15 [0.11-0.21] %, p=0.010). No significant relationship of age and BMI with FS was found in both diabetes types. Longer diabetes duration was associated with a higher proportion of FS in T1D (p<0.001) and T2D (p=0.004). In T1D, HbA1c >7% was related to a higher proportion of FS compared to HbA1c ≤7% (0.25 [0.19-0.32] vs. 0.12 [0.08-0.20] %, p=0.007), while an inverse relationship was found in T2D (HbA1c ≤7%: 0.08 [0.07-0.10] vs. HbA1c >7%: 0.05 [0.04-0.06] %, p=0.001).

CONCLUSIONS

Different associations of FS with gender and HbA1c were observed for T1D and T2D; however, longer diabetes duration increases the risk for FS independent of diabetes type. Musculoskeletal diseases are still underreported in individuals with diabetes and awareness should be raised for FS as a specific diabetes complication.

Discoveries from the study of longstanding type 1 diabetes

Award programmes that acknowledge the remarkable accomplishments of long-term survivors with type 1 diabetes have naturally evolved into research programmes to determine the factors associated with survivorship and resistance to chronic complications. In this review, we present an overview of the methodological sources of selection bias inherent in survivorship research (selection of those with early-onset diabetes, incidence-prevalence bias and bias from losses to follow-up in cohort studies) and the breadth and depth of literature focusing on this special study population. We focus on the learnings from the study of longstanding type 1 diabetes on discoveries about the natural history of insulin production loss and microvascular complications, and mechanisms associated with them that may in future offer therapeutic targets. We detail descriptive findings about the prevalence of preserved insulin production and resistance to complications, and the putative mechanisms associated with such resistance. To date, findings imply that the following mechanisms exist: strategies to maintain or recover beta cells and their function; activation of specific glycolytic enzymes such as pyruvate kinase M2; modification of AGE production and processing; novel mechanisms for modification of renin-angiotensin-aldosterone system activation, in particular those that may normalise afferent rather than efferent renal arteriolar resistance; and activation and modification of processes such as retinol binding and DNA damage checkpoint proteins. Among the many clinical and public health insights, research into this special study population has identified putative mechanisms that may in future serve as therapeutic targets, knowledge that likely could not have been gained without studying long-term survivors.

A Comprehensive View of Frozen Shoulder: A Mystery Syndrome

Frozen shoulder is a common epidemiological affliction. Data acquired from people who suffer from this type of damage in other joints such as the hip, wrist and ankle also exist; although these syndromes are less common. Treatment for frozen shoulder is primarily physical (physiotherapy, manual therapy), secondary medical (corticosteroid injections) and finally surgical but with limited success. The difficulty in treating this type of condition successfully lies in the lack of knowledge about the risk factors involved and the pathophysiology underlying this mysterious syndrome. This review gives an overview of the current scientific position of frozen shoulder in terms of evolutionary factors, etiology, the different mechanisms of action involved, current treatment options and other possible interventions based on recent discoveries of pathophysiological mechanisms. The overall objective is to clarify several unknown aspects of a syndrome that affects up to 5% of the world's population.

Shoulder pain and functional disability in type 1 diabetic patients: A cross-sectional survey

Objective

To assess the prevalence of shoulder pain and functional disability (SPFD) in Type-1 diabetic patients, and to explore its association with duration of the disease, age and gender.

Methods

A cross-sectional survey was carried out on previously diagnosed patients with Type-1 diabetes mellitus between April 2019 and March 2020. Data was collected from six hospitals including three tertiary care hospitals of Islamabad and Rawalpindi. Three hundred and twenty-eight patients were recruited through convenience sampling. Shoulder Pain and Disability Index was used to determine SPFD among participants. Point-biserial and Pearson correlation coefficients were calculated to find out the correlation between the variables. Independent t-test was used to determine the difference in the mean scores between the variables.

Results

The prevalence of SPFD was found 85.7%. A significant correlation was found of the SPFD with age (r = 0.332, p < 0.001), duration of the diabetes mellitus (r = 0.154, p = 0.005) and gender (r_pb = 0.171, p = 0.002). A significant difference was found in SPFD mean scores between female and male patients (female patients = 43.42±22.80, male patients = 35.31±22.91, p = 0.002).

Conclusion

SPFD seems prevalent among Type-1 diabetic patients. Increasing age, long history of diabetes mellitus and female gender appear the associated risk factors for the shoulder pain and disability.

Efficacy and safety of warm needle treatment for scapulohumeral periarthritis: A protocol for systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of warm needle acupuncture (WNA) treatment for Scapulohumeral periarthritis.

METHODS

Relevant randomized controlled trials will be searched from the databases of Pubmed, the Cochrane Library, Embase, CNKI, Wanfang Database, CBM and VIP Database from their inception to September 2021. The primary outcomes are effective rate, visual analog scale score. The secondary outcomes are Constant-Murley score, Japanese Orthopaedic Association scores, adverse events. Two reviewers will independently select studies, collect data, and assess the methodology quality by the Cochrane risk of bias tool. The Stata 14.0 will be used for meta-analysis.

RESULTS

This study is ongoing and will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will provide an assessment of the current state of WNA for the scapulohumeral periarthritis, aiming to show the efficacy and safety of WNA treatment.

ETHICS AND DISSEMINATION

There is no requirement of ethical approval and informed consent, and it will be in print or published by electronic copies.

REGISTRATION

INPLASY2020100049.

Effectiveness of surgical and non-surgical interventions for managing diabetic shoulder pain: a systematic review

PURPOSE

This systematic review evaluated and compared the effectiveness of non-surgical and surgical interventions for managing shoulder pain in patients with diabetes.

METHODS

PubMed, Scopus, CINAHL, EMBASE, Sport Discus, and Cochrane library were searched for studies published in the last 20 years. Randomized clinical trials (RCTs) and cohort studies that assessed shoulder pain in patients with diabetes and implemented one or a combination of non-surgical and surgical interventions were eligible for inclusion. The quality of the included studies was assessed using the Structured Effectiveness Quality Evaluation Scale (SEQES) tool. Data extracted from the eligible studies included study design, patient characteristics, duration of symptoms, type of interventions, outcome measures used to assess pain, follow-up intervals, and research findings.

RESULTS

A narrative synthesis with effect sizes (ES) or between-group differences was conducted. A total of 25 (14 non-surgical and 11 surgical) studies met the inclusion criteria. Six studies addressed physiotherapeutic interventions (three RCTs and three cohorts - ES = 0.07-1.3), three studies assessed the effect of steroid injections (two RCTs and one cohort - ES = 0.2-0.4), two cohorts addressed arthrographic capsular distension (between-group difference of 1.1 on Visual Analogue Scale), two cohorts addressed MUA, and one RCT addressed suprascapular nerve block (ES = 1-6). For the surgical studies, six cohorts addressed arthroscopic capsular release (ES = 0.2), three cohorts addressed arthroscopic rotator cuff repair (ES = 0.05-0.5), and one cohort addressed arthroplasty (ES = 0.3).

CONCLUSION

Moderate- to very-low-quality evidence suggests large effects of physiotherapy modalities plus exercise and suprascapular nerve block, and trivial to small effects for surgical interventions for improving shoulder pain in patients with diabetes. Future well-designed studies are needed to provide accurate estimates of the true effects of these interventions on improving shoulder pain in patients with diabetes.Implications For RehabilitationShoulder pain may lead to disability in patients with diabetes.We recommend the use of physiotherapy interventions to reduce shoulder pain.Corticosteroid injections are recommended for short-term shoulder pain relief.

Higher levels of bodily pain in people with long-term type 1 diabetes: associations with quality of life, depressive symptoms, fatigue and glycaemic control - the Dialong study

AIMS

To compare reported level of bodily pain, overall and health-related quality of life (QoL), depression and fatigue in people with long-term type 1 diabetes vs. a comparison group without diabetes. Further, to examine the associations of total bodily pain with QoL, depression, fatigue and glycaemic control in the diabetes group.

METHODS

Cross-sectional study of 104 (76% of eligible) people with type 1 diabetes of ≥ 45 years' duration attending the Norwegian Diabetes Centre and 75 persons without diabetes who completed questionnaires measuring bodily pain (RAND-36 bodily pain domain), shoulder pain (Shoulder Pain and Disability Index), hand pain (Australian/Canadian Osteoarthritis Hand Index), overall QoL (World Health Organization Quality of Life - BREF), health-related QoL (RAND-36), diabetes-specific QoL (Audit of Diabetes-Dependent Quality of Life; only diabetes group), depression (Patient Health Questionnaire) and fatigue (Fatigue questionnaire). For people with type 1 diabetes, possible associations between the bodily pain domain (lower scores indicate higher levels of bodily pain) and other questionnaire scores, were measured with regression coefficients (B) per 10-unit increase in bodily pain score from linear regression.

RESULTS

The diabetes group reported higher levels of bodily (P = 0.003), shoulder and hand pain (P < 0.001) than the comparison group. In the diabetes group, bodily pain was associated with lower overall and diabetes-specific QoL [B (95% confidence intervals)]: 0.2 (0.1, 0.2) and 0.2 (0.1, 0.3); higher levels of depression -1.0 (-1.3, -0.7) and total fatigue -1.5 (-1.9, -1.2); and worse glycaemic control HbA_1c (mmol/mol; %) -0.8 (-1.5, -0.1); -0.1 (-0.1, -0.01).

CONCLUSIONS

People with long-term type 1 diabetes experience a high level of bodily pain compared with a comparison group. Total bodily pain was associated with worse QoL and glycaemic control.

Influence of type 1 diabetes on the postural control of women in the third gestational trimester

BACKGROUND

Diabetes can cause biomechanical alterations that may be responsible for additional changes to those existing in a regular gestational period. The way a maternal body responds when affected by diabetes has not been clearly understood. This study aimed to describe the influence of type 1 diabetes on pregnant women's postural control.

METHODS

Forty pregnant women in their third gestational trimester were allocated in two equal groups - the control group and the type 1 diabetic group. The variables related to postural control and balance were assessed using photogrammetry (head protrusion; cervical lordosis; thoracic kyphosis; lumbar lordosis; pelvic anteversion, knee flexion, tibiotarsal and foot inclination angles were measured), and baropodometry (anteroposterior and mediolateral distance trajectory of the center of pressure, amplitude and average speed of displacement of the center of pressure).

FINDINGS

The results of the type 1 diabetic group showed, in the postural analysis, lower head protrusion and pelvic anteversion angles, while there was higher cervical lordosis, thoracic kyphosis, and lumbar lordosis angles. In the baropodometry, the anteroposterior distance and the amplitude of the center of pressure displacement with eyes open and closed were higher.

INTERPRETATION

The findings suggest that type 1 diabetes mellitus in the third trimester of pregnancy is associated with postural changes, a decrease in the active ankle range of motion and increase in the anteroposterior oscillation of the center of pressure, with negative repercussions for postural control.

Clinical Examination and Self-Reported Upper Extremity Impairments in Patients with Long-Standing Type 1 Diabetes Mellitus

AIM

The aims of the current study were (1) to determine the prevalence of upper extremity impairments (UEIs) in patients with type 1 diabetes by clinical investigation; (2) to investigate if self-reported impairments were concordant with clinical findings and if key questions could be identified; and (3) to investigate if answers to our self-reported questionnaire regarding UEIs are reliable.

METHODS

Patients with type 1 diabetes were invited to participate in a cross-sectional study of clinical and self-reported (12 items) UEIs in adjunction to ordinary scheduled clinical visit. Before the visit, a questionnaire on UEIs was filled in twice (test-retest) followed by clinical testing at the planned visit.

RESULTS

In total, 69 patients aged 45 ± 14 years and with diabetes duration 26 ± 15 were included in the study. In the clinical examination, two-thirds (65%) of the patients showed one or more UEI, with failure to perform hand against back as the most common clinical finding (40%) followed by positive Phalen's test (27%), Tinel's test (26%), and Prayer's sign (24%). UEIs observed by clinical examination were often bilateral, and multiple impairments often coexisted. Self-reported shoulder stiffness was associated with impaired shoulder mobility and with Prayer's sign. Self-reported reduced hand strength was associated to lower grip force, Prayer's sign, trigger finger, fibrosis string structures, and reduced thenar strength as well as reduced shoulder mobility. In addition, self-reporting previous surgery of carpal tunnel and trigger finger was associated with several clinical UEIs including shoulder, hand, and finger. The test-retest of the questionnaire showed a high agreement of 80-98% for reported shoulder, hand, and finger impairments.

CONCLUSION

UEIs are common in type 1 diabetes. Self-reported shoulder stiffness and reduced hand strength might be used to capture patients with UEIs in need of clinical investigation and enhanced preventive and therapeutic strategies, as well as rehabilitative interventions.

A pilot study of ultrasound-guided acupotomy for the treatment of frozen shoulder

This study retrospectively analyzed the feasible effectiveness of ultrasound-guided acupotomy (USGAP) for the treatment of frozen shoulder (FS). A total of 36 patients with FS were analyzed in this retrospective study. All 36 patients received extracorporeal shock-wave therapy (ESWT). In addition, 18 of them also underwent USGAP intervention and were assigned to a treatment group, while the other 18 patients did not receive such intervention and were assigned to a control group. The primary efficacy endpoint was pain intensity, as measured by the Numeric Rating Scale (NRS). The secondary efficacy endpoint was assessed by the score of shoulder pain and disability index (SPADI). Furthermore, the adverse events were also documented during the treatment period. All efficacy endpoints were measured after the treatment. After treatment, patients who received USGAP exerted better efficacy endpoints in pain relief, as measured by NRS scale (P < .01), and shoulder disorders, as evaluated by SPADI (P < .01), than subjects who did not receive USGAP. Additionally, no adverse events occurred in either group. The results of this study indicated that USGAP may be used for the treatment of FS effectively. More studies are still needed to warrant the present results.

Quality of Life is Markedly Impaired by Rheumatological and Skin Manifestations in Patients with Type 1 Diabetes: A Questionnaire Survey

INTRODUCTION

To estimate lifetime prevalence of diabetes-related upper limb and non-acquired skin manifestations in a representative type 1 diabetes (T1D) population and to identify associations between these conditions and quality of life.

METHODS

A questionnaire on these complications and measures of quality of life (World Health Organization-Five Well-Being Index [WHO-5]), depression, and diabetes-specific burden (Problem Areas in Diabetes [PAID] scale) was sent to all T1D patients in a Danish clinic (N = 583).

RESULTS

The response rate was 68.6%. Lifetime prevalence of any upper limb soft tissue lesion was 72%; prevalence of any skin lesion was 10.5%. Frozen shoulder and vitiligo were most common upper limb and skin manifestation, at a prevalence of 53 and 9.1%, respectively. Compared to patients with no skin lesion, those with at least one skin lesion had more depression (19 vs. 33%; P < 0.01) and lower WHO-5 scores. Frozen shoulder was associated with lower WHO-5 scores (P < 0.001), more depression (29 vs. 14%; P < 0.001), and a higher PAID score (P < 0.01). A diagnosis of carpal tunnel syndrome was associated with lower WHO-5 scores (P < 0.001), a higher risk of depression (29 vs. 16%; P < 0.01), and a higher PAID score (P < 0.001).

CONCLUSION

Upper limb soft tissue lesions and diabetes-specific non-acquired skin lesions are very common in patients with T1D and strongly associated with impaired life quality and increased risk of depression.

Effectiveness of Nonsurgical Interventions for Managing Adhesive Capsulitis in Patients With Diabetes: A Systematic Review

OBJECTIVE

This systematic review evaluated the effectiveness of nonsurgical interventions for managing adhesive capsulitis (AC) in patients with diabetes on pain, function, and range of motion.

DATA SOURCES

MEDLINE and other databases were searched for studies published in the last 20 years.

STUDY SELECTION

Randomized controlled trials (RCTs) that assessed AC in people with diabetes and implemented 1 or a combination of physiotherapeutic interventions, corticosteroids, and manipulation under anesthesia (MUA) were eligible for inclusion.

DATA EXTRACTION

The Cochrane Risk of Bias was used by 2 independent raters who met to achieve consensus. The quality of trials was assessed using Grading of Recommendations, Assessment, Development and Evaluations. Data extracted from the eligible studies included study design, participant characteristics and duration of symptoms, type of intervention, outcome measures, follow-up intervals, and research findings.

DATA SYNTHESIS

Because of the lack of similar interventions, a narrative synthesis was conducted, and meta-analyses were not performed. The effect sizes or between-group differences of the interventions were reported. A total of 8 RCTs met the inclusion criteria: 4 addressed physiotherapeutic interventions, 3 corticosteroid injections, and 1 MUA. The effect sizes for physiotherapeutic interventions were 0.8-2.0, 0.9-2.0, and 1.0 for ROM, function, and pain, respectively, with the largest effect size (2.0) being reported for joint mobilization plus exercises. The effect sizes for corticosteroids were 0.2-0.5 and 0.1 for ROM and pain. The between-group improvement for MUA was 5.6 points on Constant Shoulder Score.

CONCLUSION

Low-quality evidence suggests large effects of joint mobilization plus exercises on AC in people with diabetes, although confidence in this conclusion is limited due to the high risk of bias. Even weaker support was available for corticosteroid and MUA. Future high-quality RCTs are needed to determine the best intervention for managing AC in patients with diabetes.

Radiological glenohumeral osteoarthritis in long-term type 1 diabetes. Prevalence and reliability of three classification systems. The Dialong shoulder study

OBJECTIVE

In the present study, we evaluate the intra- and interrater agreement of radiological glenohumeral OA using three different classification systems and estimate the prevalence of radiological and clinical glenohumeral OA in patients with type 1 diabetes mellitus (DM1), for over 45 years and controls (The Dialong study).

MATERIALS AND METHODS

We included 102 patients with DM1 (49% women, mean age, 61.9 years) and 73 controls (57% women, mean age, 62.6 years). Anterior-posterior shoulder radiographs were interpreted by two observers applying the Kellgren-Lawrence (K-L), Samilson-Prieto (S-P) and Samilson-Prieto Allain (S-PA) classifications.

RESULTS

The interrater agreement was moderate (weighted kappa, 0.46 to 0.48) for all classifications and the intrarater agreement mainly substantial (0.48-0.86) for both observers. The agreed prevalence of radiological OA was 26 and 18% (OR 1.6 (0.8 to 3.3), p = 0.22, 44 and 26% (OR 2.2 (1.2 to 4.2), p = 0.02) and 30 and 17% (OR 2.1 (1.0 to 4.5), p = 0.05) for the K-L, S-P and S-PA classifications respectively in the diabetes and control groups. The prevalence of moderate or severe radiological OA was 1 to 6% and clinical OA 1 to 2% with no difference between the groups.

CONCLUSION

The prevalence of radiological glenohumeral OA was higher in the diabetes group with the Samilson-Prieto classification systems, but not associated with clinical OA. The interrater agreement was moderate. We recommend the Samilson-Prieto Allain classification for glenohumeral OA to avoid interpretation of osteophytes < 1 mm as OA in patient groups with a low pre-test likelihood of glenohumeral OA.

The prevalence of radiological glenohumeral osteoarthritis in long-term type 1 diabetes: the Dialong shoulder study

OBJECTIVES

This study compares the prevalence of radiological osteoarthritis (OA) in patients with type 1 diabetes mellitus (DM1) for > 45 years and controls, and explores the association with shoulder pain and glycaemic burden in patients with DM1.

METHOD

The Dialong study is a cross-sectional, observational study with 30 years of historical data on long-term glycaemic control. We included 102 patients with DM1 and 73 diabetes-free controls. Demographic data, worst shoulder pain last week [numeric rating scale (NRS) 0-10], pain on abduction at examination (NRS 0-10), and current and historical glycosylated haemoglobin (HbA_1c) levels were collected. Standardized shoulder X-rays were taken and interpreted for OA applying the Kellgren-Lawrence classification.

RESULTS

In the diabetes group (49% women), the mean ± sd duration of DM1 was 50.6 ± 4.8 years, mean 30 year HbA_1c 7.4%, and age 61.9 ± 7.1 years. The mean age of controls (57% women) was 62.6 ± 7.0 years. Radiological glenohumeral OA was found in 36 diabetes patients (35%) and 10 controls (14%) [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.6 to 7.5; p = 0.002]. Few persons had moderate and severe OA [6.9% vs 1.3%, OR 5.3 (95% Cl 0.6 to 44.1); p = 0.1]. Fifteen diabetes patients had painful OA versus two controls (adjusted OR 5.4, 95% CI 0.6 to 47.9; p = 0.13). There was no association between OA and long-term glycaemic burden (mean 30 year HbA_1c) in the diabetes group (p > 0.2).

CONCLUSIONS

Radiological glenohumeral OA was more common in patients with DM1 than in controls for mild, but not moderate and severe OA. The radiological findings were not associated with shoulder pain or long-term glycaemic burden.

Risk Factors for Shoulder Stiffness: Current Concepts

Shoulder stiffness is a condition of painful restriction of the glenohumeral range of motion. Numerous risk factors for primary and postoperative shoulder stiffness have been described. This article summarizes the known aspects of the pathophysiology of shoulder stiffness, with special attention to elements of molecular biology and genetics, which could influence the risk of developing shoulder stiffness. Furthermore, the role of hormonal and metabolic factors, medical disorders, drugs, and of other published risk factors for primary and postoperative shoulder stiffness is reviewed and discussed. Finally, aspects related to shoulder surgery and postoperative rehabilitation protocols, which could influence the development of postoperative stiffness are presented.

Hand, shoulder and back stiffness in long-term type 1 diabetes; cross-sectional association with skin collagen advanced glycation end-products. The Dialong study

AIMS

We aimed to: (i) estimate the prevalence of Dupuytren's disease, trigger finger, carpal tunnel syndrome and frozen shoulder; (ii) assess stiffness of the hand, shoulder and back; and (iii) explore the association of joint stiffness with both long-term HbA_1c and collagen advanced glycation end-products (AGEs) in long-term type 1 diabetes mellitus (T1DM).

METHODS

Patients with T1DM from 1970 or earlier attending a specialized diabetes center were included in this cross-sectional controlled study. We collected HbA₁/HbA_1c measurements from 1980 to 2015 and data on hand and shoulder diagnoses and joint stiffness through interviews, charts, and standardized examination. Skin biopsies were analyzed for collagen AGEs by liquid chromatography-mass spectrometry.

RESULTS

Lifetime prevalence of hand and shoulder diagnoses in the diabetes group (n=102) ranged from 37%-76% (frozen shoulder) versus 11%-15% in controls (n=73) (p<0.001). There was an association between joint stiffness and long-term HbA_1c (odds ratio 2.01 [95% CI 1.10-3.7]) and the AGEs methyl-glyoxal-lysine-dimer (odds ratio 1.68 [95% CI 1.03-2.73]) and pentosidine (odds ratio 1.81 [95% CI 1.04-3.16]).

CONCLUSIONS

Patients with T1DM >45years had a very high prevalence of hand and shoulder diagnoses versus controls. Joint stiffness was associated with collagen AGEs. However, joint biopsies and prospective studies must explore this association further.

Mobile Phone-Supported Physiotherapy for Frozen Shoulder: Feasibility Assessment Based on a Usability Study

BACKGROUND

Patients with frozen shoulder show limited shoulder mobility often accompanied by pain. Common treatment methods include physiotherapy, pain medication, administration of corticosteroids, and surgical capsulotomy. Frozen shoulder often lasts from months to years and mostly affects persons in the age group of 40 to 70 years. It severely reduces the quality of life and the ability to work.

OBJECTIVE

The objective of this study was to evaluate the feasibility of a mobile health (mHealth) intervention that supports patients affected by "stage two" frozen shoulder. Patients were supported with app-based exercise instructions and tools to monitor their training compliance and progress. These training compliance and progress data supplement the patients' oral reports to the physiotherapists and physicians and can assist them in therapy adjustment.

METHODS

In order to assess the feasibility of the mHealth intervention, a pilot study of a newly developed app for frozen shoulder patients was conducted with 5 patients for 3 weeks. The main function of the app was the instruction for exercising at home. Standardized questionnaires on usability such as System Usability Scale (SUS) and USE (Usefulness, Satisfaction, and Ease of use), and Technology Acceptance Model-2 (TAM-2) were completed by the study participants at the end of the study. Additionally, a nonstandardized questionnaire was completed by all patients. The correctness of the exercises as conducted by the patients was assessed by a physiotherapist at the end of the study. The mobility of the shoulder and pain in shoulder movement was assessed by a physiotherapist at the start and the end of the study.

RESULTS

The pilot study was successfully conducted, and the app was evaluated by the patients after 3 weeks. The results of the standardized questionnaires showed high acceptance (TAM-2) and high usability (SUS) of the developed app. The overall usability of the system as assessed by the SUS questionnaire was very good (an average score of 88 out of 100). The average score of the TAM-2 questionnaire on the intention to further use the app was 4.2 out of 5, which indicated that most patients would use the app if further available. The results of the USE questionnaires highlighted that the patients learned how to use the app easily (an average score of 4.2 out of 5) and were satisfied with the app (an average score of 4.7 out of 5). The frequency of app usage and training was very high based on patient reports and verified by analysis of the usage data. The patients conducted the exercises almost flawlessly.

CONCLUSIONS

Our results indicate the feasibility of the mHealth intervention, as the app was easy to use and frequently used by the patients. The app supported the patients' physiotherapy by providing clear exercising instructions.