Effectiveness of radial extracorporeal shock-wave therapy versus ultrasound-guided low-dose intra-articular steroid injection in improving shoulder pain, function, and range of motion in diabetic patients with shoulder adhesive capsulitis

Association of Range of Motion Deficit and Recurrence of Pain After Treatment of Adhesive Capsulitis

INTRODUCTION

We evaluated the factors influencing the duration of significant pain reduction after conservative management for adhesive capsulitis (AC).

METHODS

Follow-up for 6-8 months was performed with 141 patients with AC who experienced significant pain reduction after treatment. Clinical and demographic factors, numeric rating scale (NRS) scores, and shoulder range of motion (ROM) were collected and assessed pretreatment (T0), at 5 weeks post-treatment (T1), and at 6-8 months post-treatment (T2). Patients were divided into successful (n = 96) and unsuccessful (n = 45) NRS groups according to the degree of pain reduction at T2. We assessed post-treatment NRS and ROM improvement scores within each group and compared these parameters between the two groups.

RESULTS

Significant NRS and ROM improvements were achieved in all patients who participated in our study. The unsuccessful NRS group demonstrated a lack of significant improvement in abduction at T1 and T2. All T1 and shoulder ROM measurements among the unsuccessful NRS group were significantly smaller than those among the successful NRS group.

CONCLUSIONS

Failure to achieve a significant improvement in abduction angle after conservative management of AC was significantly associated with pain recurrence.

Preliminary investigation on the effect of extracorporeal shock wave combined with traction on joint contracture based on PTEN-PI3K/AKT pathway

To investigate the intervention effect of extracorporeal shock wave combined with manual traction on fixation-induced knee contracture and its influence on PTEN-PI3K/AKT signaling pathway. Thirty-six SD male rats were randomly divided into six groups. The left knee joints were not fixed in the control group (C group). Rats in other groups underwent brace fixation in the extended position of the left knee. After 4 weeks of bracing, it is randomly divided into five groups: Model group (M group), natural recovery group (NR group), extracorporeal shock wave treatment group (ET group), manual traction group (MT group), and extracorporeal shock wave combined with manual traction group (CT group). Joint range of motion (ROM) of left knee was carried out to assess joint function. Hematoxylin and eosin (HE) staining and Masson staining were respectively used to assess the cell number and collagen deposition expression. Immunohistochemical staining and Western blot were used to assess protein levels of phosphatase and tensin homolog (PTEN), phosphatidylinositol 3-kinase (PI3K), and protein kinase B (AKT). The combined therapy was more effective than extracorporeal shock wave therapy or manual traction alone against the joint ROM, cell number and the collagen deposition, low-expression of PTEN, and overexpression of PI3K/AKT in the anterior joint capsule of rats with knee extension contracture. Extracorporeal shock wave combined with manual traction can promote the histopathological changes of anterior joint capsule fibrosis, upregulate the protein expression of PTEN and downregulate the protein expression of PI3K/AKT in the fibrotic joint capsule in a rat joint contracture model.

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus

PURPOSE

Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS.

METHODS

The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience.

RESULTS

Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS.

CONCLUSIONS

A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale.

LEVEL OF EVIDENCE

Level I.

Effectiveness of electrophysical agents in subjects with frozen shoulder: a systematic review and meta-analysis

PURPOSE

This systematic review with meta-analysis aimed to assess the effectiveness of electrophysical agents in improving pain, function, disability, range of motion, quality of life, perceived stiffness, and time to recovery in subjects with frozen shoulder (FS).

METHODS

A thorough search of MEDLINE, Cochrane Library, PEDro, and EMBASE yielded 1143 articles, of which 23 randomized controlled trials were included. Risk of bias (RoB) was assessed through Cochrane Risk of Bias 2 tool. The certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

The analysis included a total of 1073 subjects. None of the studies were judged as low RoB. Potentially clinically significant differences were observed in pain at 6 weeks and 5 months after extracorporeal shockwave therapy (ESWT), and in disability up to 3 months with laser therapy, albeit with uncertain results due to the high RoB and to the study heterogeneity. Ultrasound (US) therapy did not yield significant differences in any outcomes. The certainty of evidence was very low.

CONCLUSIONS

Based on the high heterogeneity and low quality and certainty of evidence, ESWT, laser, and US cannot be recommended for FS treatment. Caution should be exercised in interpreting the findings.

Extracorporeal Shock Wave Therapy Improves Nontraumatic Knee Contracture in a Rat Model

BACKGROUND

Joint contractures occur frequently after trauma or immobilization, but few reliable treatments are available. Extracorporeal shock wave therapy (ESWT) is often used for various musculoskeletal conditions, but whether it is effective for treating joint contractures and the mechanisms through which it might work for that condition remain unclear.

QUESTIONS/PURPOSES

Using a rat model, we asked, does ESWT (1) inhibit the progression of knee contracture, (2) ameliorate histopathologic joint changes, and (3) improve serum and myofascial fibrosis-related factors? We also asked, (4) what is the possible mechanism by which ESWT inhibits knee contracture?

METHODS

Thirty-two male Sprague-Dawley rats (12 weeks old and weighing 300 to 400 g) were randomly separated into two groups: control group (eight rats) and noncontrol group (24) in the first week. Rats in the control group were kept free in cages for 4 weeks, and the right lower limbs of the rats in the noncontrol group were immobilized in plaster for 4 weeks. ROM was then measured for each rat with or without 4 weeks of immobilization. After ROM measurement, rats in the noncontrol group were randomly separated into three groups: immobilization group (eight rats), remobilization group (eight rats), and remobilization with ESWT group (eight rats) at Week 4. Knee contracture was induced in rats by fixing the right knee with a plaster cast as in a previous study. The plaster cast was removed after 4 weeks; knee contracture was established when passive ROM was decreased and dysfunction such as abnormal gait occurred. Subsequently, rats with a remobilized joint contracture were treated with or without ESWT for 15 days (on Days 5, 10, and 15). The therapeutic effect was examined using ROM, joint diameter (as an indication of swelling), histopathologic changes, and the levels of fibrosis-related extracellular matrix component factors (hyaluronic acid, serum procollagen peptide, and laminin). The effect of ESWT on fibrosis protein was also evaluated using immunohistochemistry, quantitative polymerase chain reaction (qPCR), and Western blot. The expressions of factors in the TGF-β/SMADs pathway were also determined using Western blot and qPCR.

RESULTS

ESWT mitigated immobilization-induced knee contracture in rats by improving ROM (immobilization versus remobilization with ESWT: 53° ± 8° versus 32° ± 8° [95% confidence interval 13° to 30°]; p < 0.001) and joint swelling (immobilization versus remobilization with ESWT: 8 ± 0.8 cm versus 6 ± 0.3 cm [95% CI 0.4 to 2.2 cm]; p = 0.01). Histopathologic features of remission were alleviated after ESWT (immobilization versus remobilization with ESWT: thickness of the knee space: 0.2 ± 0.03 mm versus 0.6 ± 0.01 mm [95% CI -0.49 to -0.33 mm]; p < 0.001. On Masson staining, the positive expression area, which indicates collagen fiber deposition, was 24% ± 5% versus 9% ± 2% ([95% CI 10% to 21%]; p < 0.001). ESWT improved the serum fibrosis factors of hyaluronic acid, procollagen peptide, and laminin (immobilization versus remobilization with ESWT: hyaluronic acid: 412 ± 32 versus 326 ±15 ng/mL [95% CI 29 to 144 ng/mL]; p = 0.003; serum procollagen peptide: 19 ± 1 versus 12 ±1 ng/mL [95% CI 3 to 11 ng/mL]; p < 0.001; laminin: 624 ± 78 versus 468 ±9 ng/mL [95% CI 81 to 231 ng/mL]; p = 0.006) and myofascial factors of α-SMA and Type I collagen associated with immobilization-induced contractures.

CONCLUSION

The findings suggest that ESWT improved joint contracture by inhibiting the TGF-β1/SMADs signaling pathway in rats.

CLINICAL RELEVANCE

This work suggests ESWT may be worth exploring in preliminary research in humans to determine whether it may be a treatment option for patients with nontraumatic knee contractures. If the mechanism of ESWT can be confirmed in humans, ESWT might be a therapy for diseases involved in the TGF-β1/SMADs signaling pathway, such as hypertroic scarring and scleroderma.

Ultrasound-Guided Injections and Proprioceptive Neuromuscular Facilitation as Shoulder Rehabilitation for Multiple Sclerosis and Neuropathic Pain

Multiple sclerosis (MS) represents a major cause of chronic neurological disability in young adults and can result in upper limb sensorimotor impairment with a huge impact on manual dexterity and activities of daily living. Moreover, pain is common in MS and a large proportion of patients suffer from central neuropathic pain. To date, no rehabilitative treatment has been described as useful for these patients. A 46-year-old woman, affected by relapsing-remittent MS, described a one-year history of right shoulder pain (Visual Analogue Scale = 8) that started gradually and without trauma. The patient also presented balance and gait impairments, upper limb strength deficit, and fatigue (Expanded Disability Status Scale = 5.5). A multidisciplinary treatment was proposed, including three intra-articular corticosteroid injections and one month of manual therapy, three sessions/week, based on proprioceptive neuromuscular facilitation for the upper limb. At the end of the rehabilitative treatment, pain relief and an improvement in the range of motion of the affected shoulder, upper limb muscle strength, and hand dexterity were observed. The present paradigmatic case report with literature review demonstrated that a multidisciplinary approach seems to be effective in pain relief in a patient with central neuropathic shoulder pain and relapsing-remitting MS.

Radial shock-wave therapy for frozen shoulder patients with type 2 diabetes mellitus: a pilot trial comparing two different energy levels

BACKGROUND

Extracorporeal shock-wave therapy (ESWT) is highly recommended for the management of orthopedic shoulder pathologies. Yet, the clinical relevance of the dose difference effect of radial ESWT approaches in the management of frozen shoulder patients with type 2 diabetes mellitus remains uncertain.

AIM

The aim was to examine the short-term effects of medium-and high-energy levels of radial ESWT (rESWT) in the treatment of frozen shoulder patients with type 2 diabetes mellitus.

DESIGN

Prospective clinical pilot study.

SETTING

This study was conducted in an outpatient clinic.

POPULATION

Thirty-nine patients who had frozen shoulder untreated for at least 3 months, diagnosed with type 2 diabetes mellitus for ≥3 years were included.

METHODS

The patients were randomly allocated to receive either high-energy rESWT (hrESWT), or medium-energy rESWT (mrESWT) or placebo at 8 Hz twice a week for six weeks. The primary outcome measure was pain, evaluated by the Visual Analog Scale (VAS) Score. Secondary outcome measures were function evaluated by the Shoulder Pain and Disability Index (SPADI) Score, and shoulder active range of motion (AROM). The mechanical properties of the deltoid and trapezius muscles were assessed using the MyotonPRO (Myoton AS, Tallinn, Estonia).

RESULTS

The mrESWT resulted in statistically significant reductions in night pain at 6 weeks (η<inf>p</inf>²=0.27, P=0.003). Significantly improved function (SPADI scores: -35.42±21.29 vs.-29.59±22.60; η<inf>p</inf>²=0.39, P˂0.001) was found in both hrESWT and mrESWT group by 6 weeks. Significantly higher mean shoulder AROM values were recorded for external rotation (η<inf>p</inf>²=0.53, P<0.001), and internal rotation (η<inf>p</inf>²=0.21, P=0.020), in the hrESWT group at the 6^th week. A significantly improved resting tone (η<inf>p</inf>²=0.58) and stiffness of deltoid muscle (η<inf>p</inf>²=0.62) were found in the mrESWT group (P<0.001). The trapezius muscle resting tone reduced with hrESWT (η<inf>p</inf>²=0.17, P=0.033).

CONCLUSIONS

Regardless of the energy levels, rESWT appears to be an effective therapeutic intervention for frozen shoulder patients with type 2 diabetes mellitus in the short-term results.

CLINICAL REHABILITATION IMPACT

Our results suggest that this rESWT can be a useful strategy for the rehabilitation of frozen shoulder patients with type 2 diabetes mellitus. This is the first study on dose difference effectiveness in terms of the clinical significance of rESWT which is key to transfer research evidence into practice.

Effects of Extracorporeal Shock Wave Combined with Vivaphototherapy on Blood Perfusion, Inflammatory Response, and Prognosis in Burn Patients

Objective

To investigate the effect of extracorporeal shock wave treatment (ESWT) combined with water-filtered infrared-A (wIRA) therapy on pain, blood perfusion, and inflammatory response in burn patients.

Methods

A total of 120 burn patients treated in our hospital from May 2019 to June 2021 were selected and randomly divided into observation group (n = 60) and control group (n = 60). The control group was treated with wIRA, and the observation group was treated with ESWT combined with wIRA. The hospitalization conditions of the two groups were observed; the visual analogue scale (VAS) was used to evaluate the pain on the 1st, 7th, and 14th days of treatment in the two groups; the blood perfusion was compared between the two groups; the levels of cerebral neuropeptide (NPY), 5-serotonin (5-HT), prostaglandin E2 (PGE2), C-reactive protein (CRP), interleukin-10 (IL-10), tumor necrosis factor-α (TNF-α), serum intercellular adhesion molecule-1 (sICAM-1), soluble-triggering receptor expressed myeloidcells-1 (sTREM-1), and soluble hemoglobin scavenger receptor (sCD163) were measured. Modified Vancouver Scar Scale (mVSS) was used to evaluate the wound scar at 3 and 6 months after the end of treatment.

Results

The wound healing rate in the observation group was significantly higher than that in the control group, and the wound healing time and hospitalization time were significantly shorter than that in the control group (P < 0.05). On the 7th and 14th days of treatment, the VAS scores of the observation group were significantly lower than those of the control group (P < 0.05). On 1st, 7th, and 14th days of treatment, the blood perfusion volume in the observation group was significantly higher than that in the control group (P < 0.05). The scar scores in the observation group at 3 months and 6 months after treatment were significantly lower than those in the control group (P < 0.05). After treatment, the levels of NPY, 5-HT, PGE2, CRP, IL-10, TNF-α, sICAM-1, sTREM-1, and sCD163 in the observation group were improved more than those in the control group, and the differences were statistically significant (P < 0.05).

Conclusion

ESWT combined with wIRA therapy can effectively improve the hospitalization situation of burn patients, relieve pain, improve blood perfusion, reduce scar hyperplasia, reduce inflammation, and have a good therapeutic effect.