Relationships Between Capsular Stiffness and Clinical Features in Adhesive Capsulitis of the Shoulder

Comparison of combined suprascapular and axillary nerve pulsed radiofrequency and nerve block for the treatment of primary frozen shoulder: a prospective cohort study

OBJECTIVES

To compare the effects of pulsed radiofrequency (PRF) and block of the suprascapular nerve (SSN) and axillary nerve (AN) in patients with primary frozen shoulder (FS).

METHODS

Patients with primary FS received PRF (Group P) or block (Group B). Shoulder pain during rest, activity and sleep was measured by a numerical rating scale (NRS), the Shoulder Pain and Disability Index (SPADI) was used to assess shoulder function and disability, and the passive range of motion (PROM) of the shoulder joint was measured by a digital inclinometer. Assessments were made at baseline and 2 weeks and 1, 3, and 6 months after the procedure.

RESULTS

Of the 74 patients, 63 were eventually included, and a total of 3 patients were lost to follow-up. Finally, 60 patients (30 in each group) completed the final analysis. There was a significant improvement in all outcome measures from baseline to 6 months after the procedure. Compared with those in group B, the NRS scores during activity and sleep in group P decreased more at 6 months after the procedure (p = 0.005 and 0.028). SPADI total scores were lower at 3 and 6 months after the procedure (p = 0.021 and 0.001). At different time after the procedure, most of the parameters of PROM improved more in group P than those in group B (flexion at 3 and 6 months, p = 0.042 and <0.001; abduction at 3 and 6 monthse, p = 0.001 and 0.001; extension at 3 and 6 months, p = 0.038 and 0.007, internal rotation at 6 months, p = 0.015; external rotation at 1, 3, and 6 months, p = 0.002, 0.002, and 0.001, respectively).

CONCLUSIONS

In patients with primary FS who completed both manipulation under anesthesia and intra-articular injections, PRF with SSN and AN appears to provide better pain relief, better PROM recovery, and more shoulder function improvement than nerve block treatment.

Research trends and emerging treatment in frozen shoulder research: A bibliometric analysis and meta-analysis

Frozen shoulder (FS), characterized by pain and restricted mobility, remains a challenging condition with unclear optimal treatment. This study aims to investigate the development of FS research, identify hotspot treatments, and verify their efficacy. Analyzing 3139 FS-related publications from the Web of Science Core Collection revealed a significant rise in publications (R2 = 0.9478), with the United States as a leader in this research area. Our keyword analysis pinpointed suprascapular nerve block (SSNB) as a notable research focus since 2021. To assess the effectiveness of SSNB, we conducted a meta-analysis of eight randomized controlled trials including 435 patients. The results at the 6-8 weeks follow-up showed SSNB significantly reduced pain and improved active shoulder function compared to intra-articular corticosteroid injections (IACI). Specifically, SSNB led to considerable enhancements in abduction (SMD: 12.88; 95 % CI: 4.13, 21.64; p = 0.004; I2 = 54 %), flexion (SMD: 9.16; 95 % CI: 6.50, 11.82; p < 0.00001; I2 = 0 %), and external rotation (SMD: 18.03; 95 % CI: 6.59, 29.48; p = 0.008; I2 = 59 %). Additionally, there was a significant reduction in Shoulder Pain and Disability Index (SPADI) scores (SMD: 4.46; 95 % CIs: 7.75, -1.17; p = 0.008; I2 = 59 %). Despite these findings, no differences were observed in the improvement of passive activities between the SSNB and IACI groups at any follow-up. This study supports the short-term benefits of SSNB for FS, prompting further investigation into its long-term efficacy and comparison with other treatments.

Comparison of the rounded shoulder, kyphosis postures, and glenohumeral range of motion in patients with primary and secondary frozen shoulder

BACKGROUND

Frozen shoulder syndrome is a common pathological condition of the shoulder characterized by pain, capsular stiffness, and limited movement of the glenohumeral joint. Shoulder joint problems can be related to the posture of the shoulder girdle and position of the scapula. This study aimed to compare the rounded shoulder and kyphotic posture and shoulder range of motion in patients with primary and secondary frozen shoulders.

METHODS

Fifty-five female patients with frozen shoulder, diagnosed by a physician, were divided into primary (n = 25) and secondary (n = 30) groups. Photography and Kinovea software were used to measure the rounded shoulder angle, a flexible ruler for the kyphosis angle, and a universal goniometer for shoulder range of motion. For data analysis, we utilized SPSS software. In order to compare the groups, independent t-test was used at a significance level of 0.05.

RESULTS

The results showed that the rounded shoulder (p = 0.001) and kyphosis (p = 0.002) angles were significantly greater in the primary group compared to the secondary group. There was no significant difference between the two groups for flexion (p = 0.874), abduction (p = 0.786), extension (p = 0.331), and internal rotation (p = 0.128) range of motion. However the external rotation range of motion in the primary group was significantly less (p = 0.028) compared to the secondary group.

CONCLUSIONS

People with primary frozen shoulder are more likely to experience postural problems in the shoulder girdle and have a limited range of motion for external rotation compared to those with secondary frozen shoulder.

Decreased rotator cuff muscle cross-sectional areas in subjects with adhesive capsulitis: a study comparing male and female subjects

OBJECTIVE

To compare rotator cuff (RC) muscle cross-sectional areas (CSA) in subjects with adhesive capsulitis (AC) to age- and sex-matched controls.

MATERIALS AND METHODS

We retrospectively analyzed 97 shoulder MRIs or MR arthrography studies, of which 42 were clinically diagnosed with AC (27 female, 15 male) and 55 were age- and sex-matched controls (38 female, 17 male). All AC subjects underwent imaging ≥ 6 months after symptom onset. All imaging was examined to exclude RC full-thickness tears and prior surgery. A standardized T1 sagittal MR image was segmented in each subject to obtain the CSA of subscapularis (SSC), supraspinatus (SSP), and infraspinatus (ISP) muscles. Differences in CSAs between AC and control subjects were analyzed by sex (females and males separately) and all subjects combined.

RESULTS

AC females had significantly decreased SSC (P = 0.002) and total (P = 0.006) CSAs compared to controls. Male AC subjects showed decreased SSC (P = 0.044), SSP (P = 0.001), and total (P = 0.005) CSAs. Across all subjects, male and female, the AC cohort had significantly decreased SSC (P = 0.019) and total (P = 0.029) CSAs compared to controls.

CONCLUSION

Decreased RC muscle CSAs were present in AC subjects with ≥ 6 months of symptom duration, with decreased SSC and total CSAs in male and female subjects, and decreased SSP CSA in males.

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.

A prospective, randomized, blinded study on the efficacy of using corticosteroids in hydrodilatation as a treatment for adhesive capsulitis of the shoulder

Background

This study aimed to compare hydrodilatation with or without corticosteroid administration on the outcomes of patients with shoulder adhesive capsulitis.

Methods

This was a prospective, randomized, blinded study of 82 patients with adhesive capsulitis treated with hydrodilatation with corticosteroids (HDC) or without corticosteroids (HDA). Assessments were performed at 48 h and 1, 3, 6, and 12 months.

Results

Pain in HDC patients was significantly lower after 48 h of treatment than that of HDA, and the functional scales were better after the first month. These differences were maintained after 1 year. (visual analog scale: 0.8 vs. 1.6, p = 0.018; shoulder pain and disability index: 4.8 vs. 9.8, p = 0.003; simple shoulder test: 11.4 vs. 8.7, p = 0.008; subjective shoulder value: 96.6 vs. 90.1, p = 0.024).

Conclusion

We found that hydrodilatation with corticosteroids improved pain levels, shoulder function, and subjective perception of shoulder status compared to hydrodilatation without corticosteroids.

Ultrasound-guided hydrodilatation for adhesive capsulitis: capsule-preserving versus capsule-rupturing technique

OBJECTIVE

To compare the clinical efficacy of capsule-rupturing versus capsule-preserving ultrasound-guided hydrodilatation in patients with shoulder adhesive capsulitis (AC). To determine potential factors affecting the outcome over a 6-month follow-up.

MATERIALS AND METHODS

Within a 2-year period, 149 consecutive patients with AC were prospectively enrolled and allocated into (i) group-CR, including 39 patients receiving hydrodilatation of the glenohumeral joint (GHJ) with capsular rupture and (ii) group-CP, including 110 patients treated with GHJ hydrodilatation with capsular preservation. Demographics, affected shoulder, and AC grade were recorded. Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and visual analog scale (VAS) were used for clinical assessment at baseline/1/3/6 months. Comparisons were performed with Mann-Whitney U test and Kolmogorov-Smirnov test. Linear regression was used to identify predictors of outcome. P value < 0.05 defined significance.

RESULTS

DASH and VAS scores in both groups improved significantly compared to baseline (P < 0.001) and were significantly lower in the CP compared to CR group at all time-points following intervention (P < 0.001). Capsule rupture was a significant predictor of DASH score at all time-points (P < 0.001). DASH scores correlated to initial DASH score at all time-points (P < 0.001). DASH/VAS scores at 1 month were correlated to the AC grade (P = 0.025/0.02).

CONCLUSION

GHJ hydrodilatation results in pain elimination and functional improvement till the mid-term in patients with AC, with improved outcome when adopting the capsule-preserving compared to the capsule-rupturing technique. Higher initial DASH score is predictive of impaired functionality in the mid-term.

Exploration of the clinical course of frozen shoulder: A longitudinal multicenter prospective study of functional impairments

BACKGROUND

Contradictory evidence exists regarding the clinical course of frozen shoulder (FS).

OBJECTIVES

To explore the clinical course of FS regarding disabilities, pain, range of motion (ROM), muscle strength, scapular upward rotation, and proprioception and to establish longitudinal correlations between these variables.

METHODS

Patients with FS were prospectively followed for 9 months at 3-month intervals. Assessment included the Disabilities of the Arm, Shoulder and Hand questionnaire; visual analogue scale for pain; an inclinometer for shoulder external rotation (ER), internal rotation (IR), flexion, and abduction ROM, and scapular upward rotation and proprioception, as well as handheld dynamometry for muscle strength in shoulder abduction, ER, and IR.

RESULTS

Initially, 149 patients (98 females; mean (SD) age 53 (9) years) were included, with 88 completing all follow-up assessments. Most variables showed early improvement in the clinical course of FS, particularly ER and IR at 90° abduction, which continued to improve from 6 to 9 months of follow-up. Associations were observed between disabilities and pain (r = 0.61), disabilities/pain and ROM (r=-0.62 to -0.59 and r=-0.47 to -0.39, respectively), disabilities/pain and muscle strength (r=-0.24 to -0.35 and r=-0.36 to -0.17, respectively), and between disabilities/pain and scapular upward rotation below shoulder level (r = 0.23 to 0.38 and r = 0.24 to 0.30, respectively). ROM correlated with muscle strength (r = 0.14 to 0.44), while both ROM and ER muscle strength correlated with scapular upward rotation below shoulder level (r=-0.37 to -0.23 and r=-0.17 to -0.12, respectively). Muscle strength correlated with scapular upward rotation above shoulder level (r = 0.28 to 0.38) and lift-off muscle strength correlated with joint repositioning (r=-0.17 to -0.15).

CONCLUSION

Almost all factors improved in the early phase (3-6 months) after baseline assessment, while ER and IR ROM at shoulder level continued to improve long term.

Shear Wave Elastography of the Coracohumeral Ligament With Frozen Shoulder in Different Stages

OBJECTIVES

To study the shear wave elastography (SWE) of the coracohumeral ligament (CHL) in different stages of frozen shoulder and to analyze its correlation with the visual analogue scale (VAS) score and shoulder range of motion (ROM).

METHODS

Sixty-four patients with frozen shoulder were divided into three stages: stage I (freezing phase), stage II (frozen phase), and stage III (thawing phase). The SWE of the CHL of the affected and healthy sides was measured and compared in the different stages. The VAS score and ROM of the affected side were evaluated, and their correlation with the SWE of the CHL was analyzed in the different stages.

RESULTS

In stage I frozen shoulder, the SWE of the CHL on the affected side was lower than that on the healthy side, while in stages II and III, the SWE on the affected side was higher (P = .001 for all). The SWE of the CHL of the affected side was different across the three stages; the SWE in stages II and III higher than that in stage I (P < .01), while the difference between stages II and III was not significant (P > .05). The SWE of the CHL of the affected side was negatively correlated with the VAS score but not with forward flexion (Ff), external rotation (Er) or internal rotation (Ir) in stage I; in stages II and III, it was positively correlated with the VAS score and negatively correlated with Ff, Er, and Ir.

CONCLUSIONS

The CHL stiffness of the affected side and its correlation with the shoulder VAS score and ROM are different for different stages of frozen shoulder.

Ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of frozen shoulder

BACKGROUND

Frozen shoulder (FS), also known as shoulder adhesive capsulitis, is a musculoskeletal disorder associated with pain and functional disability. There is a lack of evidence on the optimal treatment strategy for FS.

OBJECTIVE

The present study aimed to evaluate the effectiveness and safety of ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of FS.

METHODS

In this prospective randomized, double-blind, controlled study, 63 FS patients were recruited, and equally allocated to treatment group and control group. The treatment group was treated with ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy, while the control group was only treated with ultrasound-guided hydrodilatation of glenohumeral joint. The pain and mobility of shoulder, overall efficacy and adverse reactions were evaluated 3 months after treatment.

RESULTS

At baseline, no significant difference in all characteristic value was found between the treatment group (n= 33) and control group (n= 30). Three months after operation, the joint's Active Range of Motion (AROM) and Constant-Murley Scale (CMS) scores in the experimental group were higher than those in the control group, and the coracohumeral ligament (CHL) thickness and the rate of hypoechoic thickening in rotator cuff space in the experimental group were lower than those in the control group (all P< 0.05). The amount of injection volume at the third hydrodilatation was significantly higher in the experimental group than that in the control group (15.8 ± 4.7 vs 12.2 ± 5.2, P= 0.03). After 2 times of treatment, the volume increment of glenohumeral joint Δ2 in the experimental group was greater than that in the control group (3.5 ± 1.8 vs 1.2 ± 1.6, P< 0.001). There were significant differences in the effective rate between the two groups (93.94% vs. 76.67%, P= 0.04).

CONCLUSION

The ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy may benefit FS patients.

Intra-articular pressure characteristics of the knee joint: An exploratory study

Inflammation-predominant osteoarthritis is an important clinical type of osteoarthritis, with synovitis suggested as its distinct pathophysiology. We investigated whether the synovium's mechanical properties in knees differed by osteoarthritis and other clinical parameters through retrospectively analyzing intra-articular pressure-volume characteristics. We analyzed 60 knees that were administered intra-articular corticosteroids while undergoing pressure monitoring. McMurray's test, pain complaints at end-range knee flexion, Kellgren-Lawrence classification from standing anteroposterior radiographs, and suprapatellar effusion from ultrasound constituted clinical parameters. Pressure-volume profiles-phasic changes in pressure by volume infusion, the volume of Phase 1-the potential volume of the synovial space, the pressure at 45 ml infusion-intra-articular pressure at a standardized volume, and the slope of Phase 2-synovial stiffness were compared with clinical parameters. All graphs were biphasic. Knees with suprapatellar effusion or radiologically definite osteoarthritis (Kellgren-Lawrence grade ≥2), had a lower Phase 1 volume. Knees with definite radiographic osteoarthritis also showed higher pressures at 45 ml and Phase 2 slopes (171.11 ± 94.35 mmHg and 5.08 ± 3.07 mmHg/ml, respectively) than those without (101.88 ± 58.12 mmHg and 2.84 ± 1.27 mmHg/ml, respectively). The Phase 2 slope was higher for knees with positive provocative tests than in those with negative provocative tests, although not statistically significant. The synovium stretched earlier in knees with effusion or radiologically definite osteoarthritis. Intra-articular pressure and synovial stiffness were significantly higher in patients with radiologically definite osteoarthritis. The synovium's mechanical characteristics are altered by osteoarthritis of the knee joint. Intra-articular pressure characteristics could be utilized for synovial evaluation clinically.

Causes of Shoulder Dysfunction in Diabetic Patients: A Review of Literature

Objective: Understanding the underlying mechanisms behind shoulder dysfunctions in patients with diabetes mellitus. Study Design: Systematic qualitative literature review. Participants: Patients with shoulder dysfunctions and diagnosed with impaired glucose tolerance or diabetes mellitus. Intervention: Published scientific literature containing evidence about the mechanisms of shoulder dysfunctions in the diabetic population. Articles were selected based on criteria containing diabetic population, shoulder dysfunction, methodological quality ≥ 6/9 and >20 subjects. Main Outcome measures: range of motion; questionnaires (QoL, UCLA-m, SPADI, DASH); blood glucose, blood HbA1C; calculated capsular stiffness (Kcap); calcification shoulder joint; shoulder dysfunction in patients with glucose metabolism disorders and diabetes mellitus. Results: We found 17 published articles with level 2 and 3 evidence. Multiple factors such as age, duration of diabetes mellitus (DM), glycated hemoglobin (HbA1c), advanced glycation end products (AGE), vascular endothelial growth factor (VEGF), interleukin-1ß (IL-1ß) were shown to be associated with tendon changes and increased capsular stiffness (Kcap) conceivably leading to limited range of motion (ROM) or frozen shoulder. Decreased ROM and frozen shoulder have a significantly higher prevalence in DM than in non-DM. Conclusions: Based on the current literature we confirm a high prevalence of shoulder dysfunctions in patients with diabetes mellitus. The cause of the shoulder complications is unknown, and more research is mandatory to shed more light on the complex interplay between the multifactorial causes of shoulder dysfunction in diabetes mellitus.

Is there evidence to recommend transcatheter arterial embolisation in adhesive capsulitis: A review of literature

BACKGROUND

Hypervascularity of the rotator interval with increased expression of the vascular endothelial growth factor may be the causative factor of conventionally managed adhesive capsulitis. Hence, transcatheter arterial embolisation(TAE) has emerged as an alternative treatment option to occlude the target neovessels by infusing an embolic agent. The present study reviews the literature regarding the efficacy of the TAE for adhesive capsulitis.

MATERIAL AND METHODS

The systematic review was performed following PRISMA guidelines. MEDLINE, Google Scholar, Scopus and Cochrane database of systemic reviews (CDSR) were searched for relevant publication (from 1960 to 2021). The search algorithm used was Transcatheter arterial embolisation and resistant adhesive capsulitis or refractory adhesive capsulitis or vascular adhesive capsulitis. The database search produced a total of 12026 publications. After exclusion of the non relevant titles, 113 abstracts were reviewed. From these abstracts, three full-text articles were obtained for final review.

RESULTS

All the studies were analyzed in depth. Patients with no or minimal improvement with conservative treatment for at least 3 months underwent TAE. Pre and post embolisation visual analog score(VAS), shoulder range of motion(ROM) were noted. Any additional therapy was also taken into account. Significant improvement of the VAS score and shoulder ROM was noted immediately after surgery and maintained till final follow up at 24.5 months.

CONCLUSION

Resistant cases of adhesive capsulitis can be managed successfully with TAE. But ample evidence is lacking regarding the appropriate patient selection and efficacy of TAE as a sole management option of resistant AC.

Therapeutic efficacy of low-dose steroid combined with hyaluronidase in ultrasonography-guided intra-articular injections into the shoulder for adhesive capsulitis

PURPOSE

The purpose of this study was to compare the efficacy of low-dose steroid, high-dose steroid, and low-dose steroid combined with hyaluronidase with respect to intra-articular injection therapy for adhesive capsulitis (AC) of the shoulder.

METHODS

Thirty patients with primary AC in the initial stage were randomly assigned into three groups to receive ultrasound-guided intra-articular injections with 20 mg of triamcinolone acetonide (group A, n=10), 40 mg of triamcinolone acetonide (group B, n=10) and 20 mg of triamcinolone acetonide combined with hyaluronidase (group C, n=10). The outcome measures included a visual analogue scale (VAS), the Shoulder Disability Questionnaire (SDQ), abduction and external rotation range of motion, and intra-sheath fluid (ISF) before treatment and at 2, 4, 8, and 16 weeks after treatment.

RESULTS

Among the 30 patients, one participant in group B dropped out; therefore, a total of 29 patients completed this study and were successfully injected. After the injection, the VAS, SDQ, range of flexion and external rotation, and ISF improved in all groups compared with the preinjection status, regardless of treatment or time point. In the comparison between groups, the SDQ and ISF showed significantly greater improvements in groups B and C than in group A.

CONCLUSION

The therapeutic efficacy of combined low-dose corticosteroid and hyaluronidase is superior to that of low-dose corticosteroid and equivalent to that of high-dose corticosteroid in early AC.

Updates on the treatment of adhesive capsulitis with hydraulic distension

Adhesive capsulitis of the shoulder joint is a common disease characterized by pain at the insertional area of the deltoid muscle and decreased range of motion. The pathophysiological process involves fibrous inflammation of the capsule and intraarticular adhesion of synovial folds leading to capsular thickening and contracture. Regarding the multidirectional limitation of motion, a limitation in external rotation is especially prominent, which is related to not only global fibrosis but also to a localized tightness of the anterior capsule. Ultrasound and magnetic resonance imaging studies can be applied to rule out other structural lesions in the diagnosis of adhesive capsulitis. Hydraulic distension of the shoulder joint capsule provides pain relief and an immediate improvement in range of motion by directly expanding the capsule along with the infusion of steroids. However, the optimal technique for hydraulic distension is still a matter of controversy, with regards to the infusion volume and rupture of the capsule. By monitoring the real-time pressure-volume profile during hydraulic distension, the largest possible fluid volume can be infused without rupturing the capsule. The improvement in clinical outcomes is shown to be greater in capsule-preserved hydraulic distension than in capsule-ruptured distension. Moreover, repeated distension is possible, which provides additional clinical improvement. Capsule-preserved hydraulic distension with maximal volume is suggested to be an efficacious treatment option for persistent adhesive capsulitis.

The puzzling pathophysiology of frozen shoulders - a scoping review

PURPOSE

The pathophysiology of frozen shoulders is a complex and multifactorial process. The purpose of this review is to scope the currently available knowledge of the pathophysiology of frozen shoulders.

METHODS

A systematic search was conducted in Medline, Embase and the Cochrane library. Original articles published between 1994 and October 2020 with a substantial focus on the pathophysiology of frozen shoulders were included.

RESULTS

Out of 827 records, 48 original articles were included for the qualitative synthesis of this review. Glenohumeral capsular biopsies were reported in 30 studies. Fifteen studies investigated were classified as association studies. Three studies investigated the pathophysiology in an animal studies. A state of low grade inflammation, as is associated with diabetes, cardiovascular disease and thyroid disorders, predisposes for the development of frozen shoulder. An early immune response with elevated levels of alarmins and binding to the receptor of advance glycation end products is present at the start of the cascade. Inflammatory cytokines, of which transforming growth factor-β1 has a prominent role, together with mechanical stress stimulates Fibroblast proliferation and differentiation into myofibroblasts. This leads to an imbalance of extracellular matrix turnover resulting in a stiff and thickened glenohumeral capsule with abundance of type III collagen.

CONCLUSION

This scoping review outlines the complexity of the pathophysiology of frozen shoulder. A comprehensive overview with background information on pathophysiologic mechanisms is given. Leads are provided to progress with research for clinically important prognostic markers and in search for future interventions.

LEVEL OF EVIDENCE

Level V.

Stuck-moving needle acupuncture myofascial trigger point to treat idiopathic frozen shoulder: study protocol for a randomized controlled trial

BACKGROUND

There are evidence for the efficacy of acupuncture treatment for chronic shoulder pain, however, it remains unclear the best acupuncture modes for effective treatment. We compared the effect of the myofascial trigger point (MTrp) stuck-moving needle acupuncture with that of common acupuncture treatments. Further, we evaluated the efficacy and safety of stuck-moving needle acupuncture for the MTrp in improving pain and range of motions in patients with idiopathic frozen shoulder. The aim of present study is to select an effective therapy for patients with idiopathic frozen shoulder.

METHODS

Randomized controlled trial will be conducted in the three clinical centers of Qingyang Traditional Chinese Medicine Hospital, Qingyang Xifeng district People's Hospital, and Qingyang Second People's Hospital in China from February 2020 to January 2021. One hundred and eight frozen shoulder patients will be recruited and randomized into one of three groups in a 1:1:1 ratio of the stuck-moving needle acupuncture group, common acupuncture control group, and physical exercise control group. This trial will include a 1-week baseline period, a 3-week treatment period, and a 12-week follow-up period. During the 3 weeks of the treatment period, patients will receive nine sessions of acupuncture. The primary outcome will be related to change in the Visual Analogue Scale (VAS) and measurement of range of joint motion (ROM) from the baseline period to the 12-week follow-up period. Secondary outcome measures will include measurement of pressure pain threshold (PPT), pressure pain tolerance (PTT), Oxford Shoulder Score (OSS), 36-item short form survey, and patient satisfaction evaluation. Adverse events also will be recorded for safety assessment.

DISCUSSION

The results of this trial will allow us to compare the difference in efficacy between stuck-moving needle acupuncture MTrP with that of common acupuncture treatments. The findings from this trial will be published in the peer-reviewed journals.

TRIAL REGISTRATION

Acupuncture-Moxibustion Clinical Trial Registry (ChiMCTR1900002862) and Chinese Clinical Trial Registry (ChiCTR1900028452). Registered on 22 December 2019. http://www.chictr.org.cn/showproj.aspx?proj=47354.

Correlations between clinical features and MRI findings in early adhesive capsulitis of the shoulder: a retrospective observational study

Background

This retrospective study investigated the association between clinical features and MRI findings in patients with early adhesive capsulitis of the shoulder.

Methods

The study included 29 patients with early adhesive capsulitis of the shoulder. The clinical diagnostic criteria were significantly restricted passive range of motion (ROM) and a symptom duration of up to 9 months. Various measurements related to adhesive capsulitis, including humeral and glenoid capsular thickness in the axillary recess, maximal axillary capsular thickness, coracohumeral ligament thickness, and anterior capsular thickness were measured on MRI. Abnormal humeral and glenoid capsular hyperintensity in the axillary recess, abnormal hyperintensity in the rotator interval, and obliteration of the subcoracoid fat triangle were also evaluated. Correlations between MRI findings and clinical features, including limited ROM, pain, and symptom duration were sought.

Results

Maximal axillary and humeral capsular thickness measured on MRI were negatively correlated with ROM for internal rotation. Also, hyperintensity in axillary recess and glenoid capule were correlated with ROM for abduction. Humeral capsular hyperintensity was correlated with ROM for forward flexion. There were no MRI findings that showed correlations with ROM for external rotation and severity of pain. The hyperintensity in the humeral capsule among MRI findings was only correlated with duration of symptoms.

Conclusions

MRI can be useful for assessment of several measures of clinical impairment in patients with adhesive capsulitis. Thickening and hyperintensity of the joint capsule in the axillary recess on MRI is associated with limited ROM and duration of symptoms.

Comparing Three Modalities of Treatment for Frozen Shoulder: A Prospective, Double-Blinded, Randomized Control Trial

PURPOSE

To compare the effects of three modalities of pain management i.e. SSNB (suprascapular nerve block) with NIR (non invasive rehabilitation), IAI (intra articular injection) with NIR and, NIR alone in idiopathic frozen shoulder patients.

METHODS

A double blinded randomized clinical trial was conducted. 60 cases of idiopathic frozen shoulder were selected and randomly divided into three treatment groups; group 1: NIR, group 2: NIR + SSNB, group 3: NIR +IAI. Range of motion, pain score and disability (SPADI: shoulder pain and disability index) score were evaluated pre-treatment and at 12 weeks follow up.

RESULTS

All three groups were homogenous and comparable regarding their age, sex ratio, pretreatment pain score, disability score and range of motion. There was significant improvement (p < 0.05) post treatment in all three groups with respect to pain score, disability score and range of motion. SSNB with NIR group patients demonstrated better improvement in all parameters examined, which was statistically significant in pain score, disability score and internal rotation but was statistically equivalent for total range of motion and external rotation as compared to shoulder injection group.

CONCLUSION

SSNB in combination with non invasive rehabilitation is an effective and safe mode of treatment for idiopathic frozen shoulder. Present study also proves that SSNB with NIR is a more effective mode of treatment for idiopathic frozen shoulder as compared to NIR alone or in combination with IAI.Level of evidence: Level 1.

Shoulder adhesive capsulitis: diagnostic value of active and passive range of motion with volume of gleno-humeral capsule as a reference

BACKGROUND

The diagnosis of adhesive capsulitis is currently based on restricted range of motion (ROM) but its diagnostic value has only been rarely investigated.

AIM

The aim of this study is to assess the diagnostic value of active global and passive gleno-humeral ROM to diagnose shoulder adhesive capsulitis.

DESIGN

Cross-sectional descriptive study.

SETTING

One French center for Rehabilitation Medicine.

POPULATION

Patients referred for treatment of shoulder adhesive capsulitis in our center were included. Inclusion criteria were: shoulder pain; limitation of active global ROM (abduction or flexion <180°); limitation of passive gleno-humeral ROM (abduction or flexion <90° or 25% reduction at less of lateral rotation versus the opposite shoulder); no gleno-humeral arthropathy on radiography.

METHODS

The volume of the gleno-humeral capsule was assessed during a procedure of arthro-distension. The reference criterion for adhesive capsulitis was a volume <12 mL. We analyzed the correlation between the parameters of mobility and the volume of the gleno-humeral capsule; and the positive predictive value (PPV) of inclusion criteria, with the reference criterion for the diagnosis of adhesive capsulitis.

RESULTS

We included 38 patients. Passive gleno-humeral ROM in abduction only was correlated with volume of the gleno-humeral capsule: r=0.33, P=0.043. The PPV of inclusion criteria was 82% for the diagnosis of shoulder adhesive capsulitis. Rather than 90°, when we considered 80°, 60° and 40° as the threshold of passive gleno-humeral ROM in abduction, the PPV increased from 83% to 100%.

CONCLUSIONS

Passive gleno-humeral ROM in abduction is correlated with volume of the gleno-humeral capsule. The PPV is high for active global and passive gleno-humeral ROM for diagnosis of shoulder adhesive capsulitis.

CLINICAL REHABILITATION IMPACT

Limitation of active and passive shoulder ROM, especially passive abduction gleno-humeral, is a good criterion to diagnose shoulder adhesive capsulitis, in patients with shoulder pain and no gleno-humeral arthropathy on radiography.

Treatment Strategy for Frozen Shoulder

Frozen shoulder (FS) is a common shoulder disorder characterized by a gradual increase of pain of spontaneous onset and limitation in range of motion of the glenohumeral joint. The pathophysiology of FS is relatively well understood as a pathological process of synovial inflammation followed by capsular fibrosis, but the cause of FS is still unknown. Treatment modalities for FS include medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic capsular release, and open capsular release. Conservative management leads to improvement in most cases. Failure to obtain symptomatic improvement and continued functional disability after 3 to 6 months of conservative treatment are general indications for surgical management. However, there is no consensus as to the most efficacious treatments for this condition. In this review article, we provide an overview of current treatment methods for FS.

Glenohumeral joint capsular tissue tension loading correlates moderately with shear wave elastography: a cadaveric investigation

Purpose

The purpose of this study was to investigate changes in the mechanical properties of capsular tissue using shear wave elastography (SWE) and a durometer under various tensile loads, and to explore the reliability and correlation of SWE and durometer measurements to evaluate whether SWE technology could be used to assess tissue changes during capsule tensile loading.

Methods

The inferior glenohumeral joint capsule was harvested from 10 fresh human cadaveric specimens. Tensile loading was applied to the capsular tissue using 1-, 3-, 5-, and 8-kg weights. Blinded investigators measured tissue stiffness and hardness during loading using SWE and a durometer, respectively. Intraobserver reliability was established for SWE and durometer measurements using intraclass correlation coefficients (ICCs). The Pearson product-moment correlation was used to assess the associations between SWE and durometer measurements.

Results

The ICC_3,5 for durometer measurements was 0.90 (95% confidence interval [CI], 0.79 to 0.96; P<0.001) and 0.95 (95% CI, 0.88 to 0.98; P<0.001) for SWE measurements. The Pearson correlation coefficient values for 1-, 3-, and 5-kg weights were 0.56 (P=0.095), 0.36 (P=0.313), and -0.56 (P=0.089), respectively. When the 1- and 3-kg weights were combined, the ICC_3,5 was 0.72 (P<0.001), and it was 0.62 (P<0.001) when the 1-, 3-, and 5-kg weights were combined. The 8-kg measurements were severely limited due to SWE measurement saturation of the tissue samples.

Conclusion

This study suggests that SWE is reliable for measuring capsular tissue stiffness changes in vitro at lower loads (1 and 3 kg) and provides a baseline for the non-invasive evaluation of effects of joint loading and mobilization on capsular tissues in vivo.

Treatment of Adhesive Capsulitis of the Shoulder

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

Patient-related Risk Factors for Postoperative Stiffness Requiring Surgical Intervention After Arthroscopic Rotator Cuff Repair

INTRODUCTION

Risk factors for stiffness after arthroscopic rotator cuff repair (RCR) have been limited to studies with small patient numbers. The objective is to determine patient-related risk factors for stiffness after RCR.

METHODS

The PearlDiver database was queried from 2007 to 2015 for patients undergoing isolated arthroscopic RCR. A multivariate binomial logistic regression analysis assessed for risk factors requiring a postoperative manipulation under anesthesia (MUA) or lysis of adhesions (LOA) within 9 months after RCR.

RESULTS

Two hundred thirty-two of 19,229 patients (1.2%) underwent a LOA and/or MUA within 9 months after arthroscopic RCR. Significant risk factors identified were age less than 50 years (odds ratio [OR], 1.9; P < 0.0001), female gender (OR, 2.0; P < 0.0001), diabetes mellitus (DM) type I (OR, 2.7; P < 0.0001), hypothyroidism (OR, 1.3; P = 0.020), and systemic lupus erythematosus (OR, 2.1; P = 0.004). However, tobacco use was associated with a 0.5 risk of developing stiffness (P < 0.0001).

DISCUSSION

Systemic lupus erythematosus, hypothyroidism, and DMI (but not DMII) in addition to young age and female gender were risk factors for LOA/MUA after arthroscopic RCR.

Ultrasound-guided interventions for painful shoulder: from anatomy to evidence

Shoulder pain is a common musculoskeletal disorder of variable etiology, ranging from rotator cuff pathology to peripheral nerve entrapment. Advances in ultrasound (US) technology have allowed static and dynamic evaluation of shoulder problems and most importantly, offer real-time, radiation-free guidance for interventions. The present review aims to describe shoulder anatomy in detail using information from cadaveric models and to illustrate US-guided techniques using clearly labeled figures and videos. The review will also present evidence of specific US-guided therapies for shoulder pain by summarizing landmark studies, systematic reviews, and meta-analyses. The following shoulder structures will be covered: 1) the biceps long head tendon, 2) the acromioclavicular joint, 3) the subacromial-subdeltoid bursa, 4) the glenohumeral joint, 5) the suprascapular nerve, and 6) the axillary nerve.

Validity of an Alternate Hand Behind Back Shoulder Range of Motion Measurement in Patients With Shoulder Pain and Movement Dysfunction

OBJECTIVES

The purpose of this study was to determine the criterion-related validity of a novel method of measuring hand behind back (HBB) shoulder range of motion (ROM) for evaluating pain and disability in people with shoulder pain and movement impairment.

METHODS

This cross-sectional study design evaluated shoulder ROM, pain, fear-avoidance beliefs, and disability in 60 people (aged 35-70 years, 31 male) with chronic unilateral shoulder dysfunction (mean duration 15.73 weeks). Shoulder HBB ROM was measured with a bubble inclinometer in a manner that did not require the patient to disrobe. Correlations were sought between HBB ROM and other shoulder movements, as well as scores recorded on the Shoulder Pain and Disability Index (SPADI), visual analogue scale for pain, Fear Avoidance Beliefs Questionnaire (FABQ), and duration of symptoms.

RESULTS

Restriction of HBB movement was significantly correlated with SPADI total disability score (r = 0.39, P < .01), flexion ROM (r = 0.30, P < .05), abduction ROM (r = 0.39, P < .01), and external rotation ROM (r = 0.60, P < .01). Other variables were not significantly correlated with HBB ROM. Multiple linear regression analysis indicated that the variance in HBB ROM was explained by the SPADI disability subscore (P = .01) but not by visual analogue scale score (P = .05), FABQ score (P = .65), or duration of symptoms (P = .73). The FABQ score was not explained by limitation in HBB ROM and shoulder movements.

CONCLUSION

These findings suggest that this novel method of measuring HBB ROM could be used as a functional outcome measure in the evaluation of patients with shoulder disorders. This method could be considered as an additional or alternative where there are challenges in measuring HBB because of restrictions in undressing a patient, such as for cultural reasons.

Restriction of Passive Glenohumeral Abduction Combined With Normal Passive External Rotation Is a Diagnostic Feature of Calcific Tendinitis

Background:

Passive glenohumeral range of motion may be characteristically limited to specific shoulder pathologies. While pain associated with loss of range of passive external glenohumeral rotation is recognized as a salient feature in adhesive capsulitis, restriction of glenohumeral range of motion in calcific tendinitis of the supraspinatus tendon has never been studied.

Hypothesis:

On the basis of clinical observation, we hypothesized that calcific tendinitis of the supraspinatus tendon is associated with loss of passive glenohumeral abduction without loss of external rotation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Ranges of passive glenohumeral rotation and abduction, which are measured with a standardized protocol in our institution, were retrospectively reviewed and compared for patients diagnosed with either adhesive capsulitis or calcific tendinitis of the supraspinatus tendon. A total of 57 patients met the inclusion criteria for the calcific tendinitis, and 77 met the inclusion criteria for the adhesive capsulitis group.

Results:

When compared with the contralateral, unaffected shoulder, glenohumeral abduction in the calcific tendinitis group was restricted by a median of 10° (interquartile range [IQR], –20° to –5°) as opposed to glenohumeral external rotation, which was not restricted at all (median, 0°; IQR, 0° to 0°). The adhesive capsulitis group showed a median restriction of glenohumeral abduction of 40° (IQR, –50° to –30°) and a median restriction of passive glenohumeral external rotation of 40° (IQR, –60° to –30°).

Conclusion:

Calcific tendinitis of the supraspinatus does not typically cause loss of external rotation but is frequently associated with mild isolated restriction of abduction. This finding can be used to clinically differentiate adhesive capsulitis from calcific tendinitis.

Active exercise on immobilization-induced contractured rat knees develops arthrogenic joint contracture with pathological changes

This study investigated the effects of treadmill walking during remobilization on range of motion (ROM) and histopathology in rat knee joints, which were immobilized for 3 wk in a flexed position. After fixator removal, rats were divided into a no-intervention (RM) group and a group forced to walk on a treadmill daily at 12 m/min for 60 min (WALK group). Passive knee extension ROMs were measured before (m-ROM) and after (a-ROM) knee flexor myotomy on the first and last day of a 7-day remobilization period, with m-ROM mainly reflecting myogenic factors and a-ROM reflecting arthrogenic factors. Knee joints were histologically analyzed and gene expression of inflammatory or fibrosis-related mediators in the posterior joint capsule were examined. m-ROM and a-ROM restrictions were established after immobilization. m-ROM significantly increased following the remobilization period both in RM and WALK groups compared with that of immobilized (IM) group. Conversely, a-ROM decreased following the remobilization period in both RM and WALK groups compared with that of IM group. Importantly, a-ROM was smaller in the WALK group than the RM group. Remobilization without intervention induced inflammatory and fibrotic reactions in the posterior joint capsule after 1 and 7 days. Treadmill walking promoted these reactions and also increased the expression of fibrosis-related TGF-β1 and collagen type I and III genes. While free movement after immobilization improved myogenic contracture, arthrogenic contracture worsened. Treadmill walking further aggravated arthrogenic contracture through amplified inflammatory and fibrotic reactions. Thus active exercise immediately after immobilization may not improve immobilization-induced joint contracture.

NEW & NOTEWORTHY In clinical practice, it is widely accepted that facilitation of joint movements is effective in improving immobilization-induced joint contracture. However, whether active exercises improve arthrogenic contracture is not known. In this study, we revealed that treadmill walking further promoted remobilization-induced progression of arthrogenic contracture. To our knowledge, this is the first study demonstrating no favorable effect of active exercise on immobilization-induced arthrogenic contracture.