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Pandey V, Aier S, Agarwal S, Sandhu AS, Murali SD. Prevalence of prediabetes in patients with idiopathic frozen shoulder: a prospective study. JSES Int 2024; 8:85-89. [PMID: 38312298 PMCID: PMC10837728 DOI: 10.1016/j.jseint.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background The association between diabetes and frozen shoulder is well established. However, the data regarding prediabetes and primary frozen shoulder (PFS) are still lacking. Methods In a prospective study, 158 patients with PFS were included. The prediabetes status was ascertained by estimating serum hemoglobin A1c (HbA1c) levels in patients with PFS. According to the level of HbA1c, patients were classified into normoglycemic, prediabetic, and diabetic. In addition, random blood sugar (RBS) was also performed. Results Out of 158 participants, 84 (53.2%) were male and 74 (46.8%) were female. Nine patients had bilateral shoulder involvement, and all were diabetics; 47.5% (n = 75) of the patients were in the age group of 51-60 years, 16.5% (n = 26) of the participants were normoglycemic, 37.3% (n = 59) were prediabetics, and 46.2% (n = 73) were diabetics. The difference in mean HbA1c values between the 3 groups was statistically significant (P < .001). However, there was no statistical difference in various age groups (P = .86) or gender (P = .68) between normoglycemics, prediabetics, and diabetics. The difference in mean RBS values between diabetic-nondiabetic and diabetic-prediabetic groups were statistically significant (P < .001), whereas no significant difference was detected between nondiabetic and prediabetic (P = .355). Conclusion The prevalence of prediabetes is 37.5% in patients with PFS. Single-point HbA1c estimation is an acceptable tool to detect prediabetes, whereas RBS estimation should not be used to detect prediabetes.
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Affiliation(s)
- Vivek Pandey
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, India
| | - Sashitejmen Aier
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, India
| | - Saksham Agarwal
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, India
| | - Avneet Singh Sandhu
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, India
| | - Sujayendra D. Murali
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, India
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Zhou K, Xie X, Liu J, Tao J, Liu Q, Zhou N, Zhou W, Tao Y, Chen Y. One-time relieving of frozen shoulder motor dysfunction with pure acupotomy: A case report. Medicine (Baltimore) 2023; 102:e36783. [PMID: 38206707 PMCID: PMC10754542 DOI: 10.1097/md.0000000000036783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/13/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Frozen shoulder (FS) is characterized by shoulder pain and restricted movement of the shoulder joint. While it tends to resolve on its own, it significantly affects an individual quality of daily life. The pure acupotomy technique employs needle-knife manipulation as the sole treatment, without the use of medications, such as steroids or vitamins, and local anesthesia if necessary. It aims to restore soft tissue mechanical balance and circulation through techniques such as cutting and stripping, creating a "gap effect." This technique can rapidly, safely, and effectively relieve functional impairments in patients with FS. This article presents a case study of the successful treatment of FS using a purely needle-knife technique. PATIENT CONCERNS The patient, aged 57 years, presented with chronic pain in the right shoulder, which was particularly aggravated at night, and moderate limitations in joint mobility. DIAGNOSES The patient was diagnosed with periarthritis of the right shoulder (moderate FS, frozen period), type 2 diabetes, and supraspinatus tendinitis of the right shoulder. INTERVENTIONS Conventional treatments, such as topical analgesics and acupuncture, produced insignificant improvements in symptoms. So, the patient chose acupotomy treatment and signed the treatment consent form. OUTCOMES After undergoing one minimally invasive acupotomy treatment, the patient experienced immediate restoration of normal shoulder joint mobility and a significant reduction in pain intensity 3 days post-treatment. LESSONS We believe that utilizing a purely acupotomy treatment for passive functional impairments in FS not only yields good results but also saves patients time and reduces their financial burden. This is worth promoting extensively in clinical practice.
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Affiliation(s)
- Kangyan Zhou
- Chengdu University of Traditional Chinese Medicine, Sichuan, China
| | - Xiaolin Xie
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Jie Liu
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Jing Tao
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Qiong Liu
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Nan Zhou
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Wenchao Zhou
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Yinli Tao
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Yongliang Chen
- Zhongxian Hospital of Traditional Chinese Medicine, Chongqing, China
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Kim JH, Kim BS, Han KD, Kwon HS. The Risk of Shoulder Adhesive Capsulitis in Individuals with Prediabetes and Type 2 Diabetes Mellitus: A Longitudinal Nationwide Population-Based Study. Diabetes Metab J 2023; 47:869-878. [PMID: 37915186 PMCID: PMC10695720 DOI: 10.4093/dmj.2022.0275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 12/11/2022] [Indexed: 11/03/2023] Open
Abstract
BACKGRUOUND This study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and shoulder adhesive capsulitis (AC) using a large-scale, nationwide, population-based cohort in the Republic of Korea. METHODS A total of 3,471,745 subjects aged over 20 years who underwent a National Health Insurance Service medical checkup between 2009 and 2010 were included in this study, and followed from the date of their medical checkup to the end of 2018. Subjects were classified into the following four groups based on the presence of dysglycemia and history of diabetes medication: normal, prediabetes, newly diagnosed T2DM (new-T2DM), and T2DM (claim history for antidiabetic medication). The endpoint was new-onset AC during follow-up. The incidence rates (IRs) in 1,000 person-years and hazard ratios (HRs) of AC for each group were analyzed using Cox proportional hazard regression models. RESULTS The IRs of AC were 9.453 (normal), 11.912 (prediabetes), 14.933 (new-T2DM), and 24.3761 (T2DM). The adjusted HRs of AC in the prediabetes, new-T2DM, and T2DM groups were 1.084 (95% confidence interval [CI], 1.075 to 1.094), 1.312 (95% CI, 1.287 to 1.337), and 1.473 (95% CI, 1.452 to 1.494) compared to the normal group, respectively. This secular trend of the HRs of AC according to T2DM status was statistically significant (P<0.0001). CONCLUSION This large-scale, longitudinal, nationwide, population-based cohort study of 3,471,745 subjects confirmed that the risk of AC increases in prediabetic subjects and is associated with T2DM status.
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Affiliation(s)
- Jong-Ho Kim
- Department of Orthopedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bong-Seoung Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Kyung-do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Hyuk-Sang Kwon
- Department of Endocrinology and Metabolism, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Alghamdi A, Alyami AH, Althaqafi RMM, Alzeyadi A, Alrubaei FS, Alyami AA, Singer MS, Saati AA, Alotaibi WT, Alsharif MO. Cytokines' Role in the Pathogenesis and Their Targeting for the Prevention of Frozen Shoulder: A Narrative Review. Cureus 2023; 15:e36070. [PMID: 37056530 PMCID: PMC10092900 DOI: 10.7759/cureus.36070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/14/2023] Open
Abstract
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.
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Sex Is Associated with the Success or Failure of Manipulation Alone for Joint Stiffness Associated with Rotator Cuff Repair. J Clin Med 2022; 11:jcm11237192. [PMID: 36498766 PMCID: PMC9739455 DOI: 10.3390/jcm11237192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose: One-stage arthroscopic rotator cuff repair with manipulation has been recently performed for rotator cuff tears with shoulder stiffness, whereas some patients require capsular release due to severe stiffness that is difficult to treat with manipulation. The purpose of this study was to analyze patient backgrounds and related factors of success or failure of manipulation alone for the treatment of shoulder stiffness associated with rotator cuff tears. Methods: This study included 64 patients with rotator cuff tears and shoulder stiffness who underwent arthroscopic rotator cuff repair with manipulation alone or with manipulation and capsular release of the glenohumeral joint at our institution between January 2015 and September 2019. The patients were divided into two groups: those whose shoulder stiffness could be improved by manipulation alone (Manipulation group) and those whose stiffness could not be improved by manipulation alone and required capsular release (Capsular release addition group). Analysis was performed between the two groups regarding patient backgrounds and related factors, including rotator cuff tear morphology and range of motions pre- and postoperatively. Results: Exactly 45 patients and 19 patients were included in Manipulation group and Capsular release addition group, respectively. A comparison between the two groups showed that patient age (p = 0.0040), sex (p = 0.0005), and injury due to trauma (p = 0.0018) were significantly related to the success or failure of manipulation alone. Multivariate logistic regression analysis on these three factors showed that sex (odds ratio, 5.5; p = 0.048) was significantly associated with the success or failure of manipulation alone. In both groups, the passive ROM of all patients improved at the last postoperative follow-up compared to their pre-operative values (p < 0.001), except for internal rotation in the Capsular release addition group (p = 0.49). Conclusion: Young male patients who have shoulder stiffness associated with rotator cuff tears should be considered for arthroscopic capsular release rather than manipulation.
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Park HB, Gwark JY, Jung J, Jeong ST. Involvement of inflammatory lipoproteinemia with idiopathic adhesive capsulitis accompanying subclinical hypothyroidism. J Shoulder Elbow Surg 2022; 31:2121-2127. [PMID: 35447316 DOI: 10.1016/j.jse.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Thyroid functional abnormalities are considered risk factors for idiopathic adhesive capsulitis (IAC) though that relationship remains uncertain. Although dyslipidemias are associated with IAC, no readily accessible study has reported associations between dyslipidemias and IAC patients with subclinical hypothyroidism. The purposes of this study were to investigate whether subclinical hypothyroidism is an independently associated factor for IAC and to determine the differences in prevalence of dyslipidemias between two groups of persons with subclinical hypothyroidism: one composed of IAC patients and the other of individuals without IAC. METHODS This case-control study included a case group of 412 IAC patients without intrinsic shoulder lesions, extrinsic causes, or medication for thyroid dysfunction. The control group comprised 1236 age- and sex-matched persons seeking general checkups at the authors' health promotion center during the same period as the case group. Control subjects had normal shoulder function and no previously diagnosed adhesive capsulitis, no medication for thyroid dysfunction, and no history of trauma or of shoulder surgery. The studied variables were age, gender, obesity, diabetes, dyslipidemias, subclinical hypothyroidism, hypothyroidism, and hyperthyroidism. A conditional logistic regression analysis evaluated the matched sets of subjects to determine odds ratios and 95% confidence intervals for the studied variables. The differences in the prevalence of dyslipidemias between IAC patients with subclinical hypothyroidism and individuals with subclinical hypothyroidism but without IAC were determined with generalized estimating equations, using covariates of age, sex, and diabetes. The P values were set at < 0.05. RESULTS Subclinical hypothyroidism (odds ratio, 2.10; 95% confidence interval, 1.36-3.15; P = .001) was significantly associated with IAC. Patients with IAC and subclinical hypothyroidism had a significantly higher prevalence of hyper-low-density lipoproteinemia, an inflammatory lipoproteinemia, than individuals with subclinical hypothyroidism but without IAC (P = .002). CONCLUSIONS Subclinical hypothyroidism is significantly associated with IAC. Hyper-low-density lipoproteinemia, an inflammatory lipoproteinemia, is involved in IAC accompanied by subclinical hypothyroidism.
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Affiliation(s)
- Hyung Bin Park
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea.
| | - Ji-Yong Gwark
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Jaehoon Jung
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Soon-Taek Jeong
- Gyeongsang Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea; Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
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Stinton S, Beckley S, Salamani A, Dietz D, Branch T. Efficacy of high-intensity home mechanical stretch therapy for treatment of shoulder stiffness: a retrospective review. J Orthop Surg Res 2022; 17:434. [PMID: 36175903 PMCID: PMC9524064 DOI: 10.1186/s13018-022-03325-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Shoulder stiffness resulting in motion loss can be caused by numerous conditions, the most common of which is adhesive capsulitis. Surgical intervention is often necessary when conservative methods fail. High-intensity stretch (HIS) treatment may be able to provide increased motion gains while avoiding the cost and complications of surgery. Objectives The purpose of this study was to review data from patients who were prescribed a HIS device to recover their shoulder motion to determine the efficacy of the device. The hypotheses were that patients would achieve significant range of motion (ROM) gains and that ROM would increase to a level at which patients would be able to avoid a motion loss surgery and perform activities of daily living. Methods Clinical notes were reviewed for patients whose progress plateaued after 4 weeks of therapy and were subsequently prescribed the HIS device after failing to meet their treatment goals. ROM data were recorded for external rotation, abduction, forward flexion, and internal rotation. Pre- and post-treatment ROM data were compared using t-tests. Results Significant ROM gains were seen in all planes of motion (p < 0.001). Patients gained an average of 29.9° in external rotation with a last recorded rotation of 59.2°. In abduction, patients gained 40.5° with a last recorded abduction of 123.3°. In forward flexion, patients gained 30.3° with a last recorded flexion of 138.7°. In internal rotation, patients gained 15.2° with a last recorded rotation of 57.6°. These last recorded ranges of motion were sufficient to perform nearly all activities of daily living. Conclusions The HIS device was effective in treating patients with shoulder motion loss as demonstrated by the significant ROM gains in all planes of motion. The ability for a patient to recover lost motion quickly without surgery is of great value to quality of life and in healthcare cost savings. We believe this high-intensity stretch device should be considered for use by patients who are at risk for a motion loss surgery.
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Affiliation(s)
- Shaun Stinton
- ArthroResearch LLC, 441 Armour Place NE, Atlanta, GA, 30324, USA.
| | - Samantha Beckley
- ArthroResearch LLC, 441 Armour Place NE, Atlanta, GA, 30324, USA
| | - Alicia Salamani
- ArthroResearch LLC, 441 Armour Place NE, Atlanta, GA, 30324, USA
| | - Devinne Dietz
- ArthroResearch LLC, 441 Armour Place NE, Atlanta, GA, 30324, USA
| | - Thomas Branch
- Ermi LLC, 2872 Woodcock Blvd. Suite 100, Atlanta, GA, 30341, USA
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Mertens MGCAM, Struyf F, Meert L, Lauwers M, Schwank A, Verborgt O, Meeus M. Factors influencing treatment outcome of physical therapy in frozen shoulder patients: a systematic review. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2022. [DOI: 10.1080/21679169.2020.1827029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Michel G. C. A. M. Mertens
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium
- Pain in Motion International Research Group, Brussels, Belgium
| | - Filip Struyf
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium
| | - Lotte Meert
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium
- Pain in Motion International Research Group, Brussels, Belgium
| | - Magalie Lauwers
- Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium
| | - Ariane Schwank
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium
- Pain in Motion International Research Group, Brussels, Belgium
- Department of Physiotherapy, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Olivier Verborgt
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium
- Department of Orthopedic Surgery and Traumatology, AZ Monica, Antwerp, Belgium
| | - Mira Meeus
- Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), University of Antwerp, Wilrijk, Belgium
- Pain in Motion International Research Group, Brussels, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
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van der Stok J, Fitzsimons M, Queally JM, O'Donnell T. Does capsular distension and a short period of countertraction improve outcome following manipulation under anesthesia for the treatment of primary adhesive capsulitis of the glenohumeral joint? J Shoulder Elbow Surg 2022; 31:772-781. [PMID: 34619350 DOI: 10.1016/j.jse.2021.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/24/2021] [Accepted: 08/29/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite the fact that primary adhesive capsulitis of the glenohumeral joint is often considered a self-limiting condition, not all patients make a full recovery. Manipulation under anesthesia (MUA) is performed to forcibly rupture the contracted capsule in a controlled manner. However, the technique, timing, and use of additional injections are often debated. In this study, we report the outcomes following the addition of capsular distension and countertraction to MUA as a treatment for adhesive capsulitis. METHODS We performed a retrospective case-cohort study comparing 3 groups: Group 1 underwent MUA alone (n = 54); group 2, MUA with capsular distension (n = 114); and group 3, MUA with capsular distension and countertraction (n = 167). The re-MUA rate, Constant-Murley shoulder (CMS) score, and visual analog scale (VAS) score (for pain) were measured after 6 weeks and 6 months. RESULTS The re-MUA rate fell with the addition of both capsular distension and countertraction: 63% in group 1, 39% in group 2, and 18% in group 3. Patients in group 3 recorded the greatest improvement in the CMS score after 6 weeks (+90% vs. +68% in group 2 and +58% in group 1), with all groups showing improvements compared with before treatment. The only independent risk factor identified for re-MUA was smoking. If a second MUA was performed, the CMS (+67%) and VAS (+61%) scores improved, but at 6 months, the CMS score (74.57 ± 7.6 vs. 83.30 ± 5.5) and VAS score (10.57 ± 1.8 vs. 12.96 ± 1.5) remained inferior to those of patients who only needed a single MUA. DISCUSSION AND CONCLUSION MUA combined with capsular distension and countertraction reduces the need for a second MUA and results in a faster improvement in functional outcome (CMS score) and reduction of pain (VAS score) compared with MUA alone or MUA with capsular distension. The results of this case-cohort study are of clinical relevance because they show that the efficacy of an MUA can be improved through relatively simple adaptations of the treatment protocol.
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Affiliation(s)
| | | | - Joseph M Queally
- The Centre for Orthopaedics, Beacon Hospital, Sandyford, Ireland
| | - Turlough O'Donnell
- The Centre for Orthopaedics, Beacon Hospital, Sandyford, Ireland; University College Dublin School of Medicine, Health Sciences Centre, Donnybrook, Ireland
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Aïm F, Chevallier R, Marion B, Klouche S, Bastard C, Bauer T. Psychological risk factors for the occurrence of frozen shoulder after rotator cuff repair. Orthop Traumatol Surg Res 2022; 108:103212. [PMID: 35077897 DOI: 10.1016/j.otsr.2022.103212] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/24/2021] [Accepted: 08/03/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Frozen shoulder is a dreaded complication after rotator cuff repair. HYPOTHESIS There are psychological determinants for this complication. MATERIALS AND METHODS We prospectively included 77 consecutive patients who underwent arthroscopic rotator cuff repair between May 2018 and April 2019. Along with a functional evaluation, we determined the Constant score, anxiety and depression levels based on the HADS, and kinesiophobia based on the Tampa Scale preoperatively and 6months after the surgery. RESULTS At the 6-month follow-up, 8 patients had been diagnosed with frozen shoulder (group A), 65 patients had satisfactory joint range of motion (group B) and 4 were lost to follow-up. In the frozen shoulder group, the preoperative anxiety rate was significantly higher than in group B (50% versus 17%, p=0.04). Furthermore, there were significantly more women (p=0.028) and more patients with an occupational disease in group A (75% versus 18%, p=0.027). At 6months postoperative, the Constant score was 55 in the group with a frozen shoulder versus 72 in group B (p=0.004). Neither depression nor kinesiophobia were risk factors for the development of frozen shoulder after rotator cuff repair. CONCLUSION Preoperative anxiety, the female sex and occupational disease are all risk factors for the occurrence of frozen shoulder after rotator cuff repair. Knowing these predisposing factors will help us better manage at-risk patients. LEVEL OF EVIDENCE III, prospective study.
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Affiliation(s)
- Florence Aïm
- Service de chirurgie orthopédique, centre de référence des infections ostéoarticulaires, groupe hospitalier Diaconnesses Croix Saint-Simon, Paris, France.
| | - Romain Chevallier
- Service de chirurgie orthopédique, hôpital Henri-Mondor, Créteil, France
| | - Blandine Marion
- Service de chirurgie orthopédique, centre de référence des infections ostéoarticulaires, groupe hospitalier Diaconnesses Croix Saint-Simon, Paris, France
| | | | - Claire Bastard
- Service de chirurgie orthopédique, hôpital Henri-Mondor, Créteil, France
| | - Thomas Bauer
- Service de chirurgie orthopédique, AP-HP, hôpital Ambroise-Paré, Boulogne-Billancourt, France
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Cogan CJ, Cevallos N, Freshman RD, Lansdown D, Feeley BT, Zhang AL. Evaluating Utilization Trends in Adhesive Capsulitis of the Shoulder: A Retrospective Cohort Analysis of a Large Database. Orthop J Sports Med 2022; 10:23259671211069577. [PMID: 35097146 PMCID: PMC8793616 DOI: 10.1177/23259671211069577] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 10/07/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Nonoperative and operative treatment modalities have been used for symptom management of adhesive capsulitis, but neither has been shown to significantly alter the long-term natural history. Purpose/Hypothesis: The purpose was to evaluate the current trends in resource and treatment strategy utilization for patients with adhesive capsulitis. It was hypothesized that (1) patients with idiopathic adhesive capsulitis will primarily undergo nonoperative treatment and (2) patients with systemic medical comorbidities will demonstrate relatively higher utilization of nonoperative therapies. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We searched the Mariner/PearlDiver database for Current Procedural Terminology and International Classification of Diseases codes to identify patients with adhesive capsulitis from 2010 to 2020 and to track their usage of diagnostic and therapeutic modalities, including radiography, magnetic resonance imaging (MRI), physical therapy, surgery, opioids, and injection. Patients with active records 1 year before and 2 years after initial diagnosis of adhesive capsulitis were eligible. Excluded were patients with secondary causes of adhesive capsulitis, such as fracture, infection, prior surgery, or other intra-articular pathology. Results: The median age of this 165,937-patient cohort was 58 years, with 67% being women. There was a high prevalence of comorbid diabetes (44.2%), thyroid disorder (29.6%), and Dupuytren contracture (1.3%). Within 2 years of diagnosis of adhesive capsulitis, diagnostic and therapeutic modality utilization included radiography (47.2%), opioids (46.7%), physical therapy (43.1%), injection (39.0%), MRI (15.8%), arthroscopic surgery (2.7%), and manipulation under anesthesia (2.5%). Over 68% of the diagnostic and therapeutic modalities were rendered from 3 months before to 3 months after diagnosis. Patients with diabetes, thyroid disorders, tobacco use, and obesity had greater odds for treatment with physical therapy, opioids, radiography, and injection when compared with patients without these comorbidities (odds ratio [OR] range, 1.05-2.21; P < .0001). Patients with diabetes and thyroid disorders had decreased odds for surgery (OR range, 0.88-0.91; P ≤ .003). Patients with Dupuytren contracture had increased odds for all therapeutic modalities (OR range, 1.20-1.68; P < .0001). Conclusion: Patients with adhesive capsulitis underwent primarily nonoperative treatment, with a high percentage utilizing opioids. The most active periods for treatment were from 3 months before diagnosis to 3 months after, and patients with medical comorbidities were more likely to undergo nonoperative treatment.
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Affiliation(s)
- Charles J. Cogan
- Department of Orthopaedic Surgery, University of California–San Francisco, San Francisco, California, USA
| | - Nicolas Cevallos
- Department of Orthopaedic Surgery, University of California–San Francisco, San Francisco, California, USA
| | - Ryan D. Freshman
- Department of Orthopaedic Surgery, University of California–San Francisco, San Francisco, California, USA
| | - Drew Lansdown
- Department of Orthopaedic Surgery, University of California–San Francisco, San Francisco, California, USA
| | - Brian T. Feeley
- Department of Orthopaedic Surgery, University of California–San Francisco, San Francisco, California, USA
| | - Alan L. Zhang
- Department of Orthopaedic Surgery, University of California–San Francisco, San Francisco, California, USA
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12
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Migliorini F, Maffulli N. Arthroscopic Management of Femoroacetabular Impingement in Adolescents: A Systematic Review. Am J Sports Med 2021; 49:3708-3715. [PMID: 33740385 DOI: 10.1177/0363546521997138] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is highly prevalent in adolescent athletes. There has been an increasing trend for arthroscopic surgery for FAI, and the results of several clinical studies on outcome after arthroscopic surgery for FAI are available. PURPOSE To conduct a systematic review to investigate the role of arthroscopic management for FAI in adolescents. STUDY DESIGN Systematic review. METHODS This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In August 2020, PubMed, Scopus, Google Scholar, and EMBASE were accessed. All clinical trials concerning the arthroscopic treatment for adolescents with FAI were identified. Only studies on patients aged less than 18 years at the time of surgery reporting data over a minimum follow-up of 12 months were considered. RESULTS Data from 406 adolescents (470 procedures; mean age at surgery, 15.9 years; mean follow-up, 30.4 months) with FAI were retrieved. At a mean of 28.0 months of follow-up, 94% of the adolescents had already returned to sport. All the scores of interest were improved at the final follow-up: visual analog scale (P = .01), modified Harris Hip Score (P < .0001), Non-Arthritic Hip Score (P = .03), Hip Outcome Score-Activities of Daily Living (P = .01), Hip Outcome Score-Sport-Specific Subscale (P < .0001), and Tegner score (P < .0001). Complications occurred in 1.1% (5/470) of procedures, and revision arthroscopy was performed in 4.7% (22/470) of procedures. CONCLUSION Arthroscopic surgery in adolescents with FAI achieves excellent outcomes and a high rate of return to sport, with rates of complication and revision surgery of 1% and 5%, respectively.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (SA), Italy.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, UK
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MENGİ A. The Effect of Glenohumeral Joint Injection Prior to Physical Therapy on Treatment Outcomes in Adhesive Capsulitis. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2021. [DOI: 10.17944/mkutfd.918699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Ko YW, Park JH, Youn SM, Rhee YG, Rhee SM. Effects of comorbidities on the outcomes of manipulation under anesthesia for primary stiff shoulder. J Shoulder Elbow Surg 2021; 30:e482-e492. [PMID: 33359399 DOI: 10.1016/j.jse.2020.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/31/2020] [Accepted: 11/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Studies on the effects of manipulation under anesthesia (MUA) for primary stiff shoulder when different comorbidities are present are lacking. Our aim was to assess how comorbidities influence the recovery speed and clinical outcomes after MUA. METHODS Between April 2013 and September 2018, 281 consecutive primary stiff shoulders in the frozen phase treated with MUA were included in this study. We investigated the comorbidities of patients and divided them into the control (n = 203), diabetes mellitus (DM) (n = 32), hyperlipidemia (n = 26), and thyroid disorder (n = 20) groups. The range of motion (ROM) and clinical scores for each group before MUA and 1 week, 6 weeks, and 3 months after MUA were comparatively analyzed. We identified the ROM recovery time after MUA and the responsiveness to MUA. Then, subjects were subdivided into early and late recovery groups based on their recovery time and into successful and nonsuccessful MUA groups based on their responsiveness to MUA. RESULTS Significant improvements in ROM and clinical scores at 3 months after MUA were observed in all groups. Significant differences in ROM among the 4 groups were also observed during follow-up (P < .05). The DM group had significantly lower ROM values, even at 3 months after MUA, compared with the control group. The ROM recovery speed after MUA was slowest in the DM group, followed by the thyroid disorder, hyperlipidemia, and control groups. Most (90.6%) of the DM group experienced late recovery. The proportion of nonsuccessful MUA was higher in the DM and thyroid disorder groups than that in the control and hyperlipidemia groups (P = .004). During follow-up, there were no differences among groups regarding the visual analog scale, University of California at Los Angeles shoulder, and Constant scores. CONCLUSION The ROM recovery speed and responsiveness to MUA for primary stiff shoulder were poorer for the DM and thyroid disorder groups than for the control group. In particular, compared with any other disease, outcomes were poorer when the comorbidity was DM. If patients have comorbidities, then they should be informed before MUA that the comorbidity could affect the outcomes of treatment.
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Affiliation(s)
- Young Wan Ko
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Joon Hong Park
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Seung-Min Youn
- Department of Orthopaedic Surgery, Myongji Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Yong Girl Rhee
- Department of Orthopaedic Surgery, Myongji Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Sung-Min Rhee
- Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea.
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Diabetes: a silent player in musculoskeletal interventional radiology response. Porto Biomed J 2021; 6:e112. [PMID: 33532654 PMCID: PMC7846412 DOI: 10.1097/j.pbj.0000000000000112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 10/14/2020] [Indexed: 11/26/2022] Open
Abstract
Diabetes has an important role in the development of several musculoskeletal disorders, such as adhesive capsulitis of the shoulder (ACs) and stenosing flexor tenosynovitis of the finger (SfTf). The etiopathophysiology of ACs and SfTf in diabetic patients is associated with both chronic hyperglycemia, increased amounts of visceral adiposity and chronic inflammation. Chronic hyperglycemia stimulates the creation of cross-links between collagen molecules, impairing degradation and resulting in the build-up of excessive collagen deposits in the cartilage, ligaments, tendon sheaths and tendons. Increased adipocytes in diabetic patients secrete proteins and cytocines such as TNF-α, IL-6 and IL-13 which result in overproduction of pro-inflammatory factors, destruction of normal tissue architecture and fibrosis. Both hyperglycemia and adipocytes inhibit efferocytosis, limiting natural resolution. Recently, multiple image-guided interventional radiology musculoskeletal treatment options have been developed, such as ultrasound-guided glenohumeral capsule hydrodistension for ACs and ultrasound-guided percutaneous pulley release for trigger finger. Diabetes can negatively influence outcomes in patients with ACs and SfTf and may impact the decision of which specific procedure technique should be employed. Further studies are necessary to define how diabetes influences response to interventional radiology treatments of these disorders, as well as the extent to which control of blood sugar levels can contribute towards the personalization and optimization of patient follow up.
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Park HB, Gwark JY, Kam M, Jung J. Association between fasting glucose levels and adhesive capsulitis in a normoglycemic population: a case-control study. J Shoulder Elbow Surg 2020; 29:2240-2247. [PMID: 32713668 DOI: 10.1016/j.jse.2020.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/14/2020] [Accepted: 03/20/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hyperglycemia is the most commonly cited risk factor for adhesive capsulitis. However, no study has established whether fasting glucose levels within the normoglycemic range are associated with idiopathic adhesive capsulitis (IAC). This study hypothesized that increments of fasting glucose levels within the normoglycemic range would be linked to IAC. This study investigated any association between normoglycemic fasting glucose levels and IAC. METHODS This case-control study comprised a group of 151 patients with IAC without intrinsic shoulder lesions, extrinsic causes, or known metabolic risk factors such as diabetes, dyslipidemia, and thyroid dysfunction. The control group comprised 453 age- and sex-matched persons seeking general check-ups at the authors' health promotion center during the same period as the case group. Control subjects had normal shoulder function, no previous diagnosis of adhesive capsulitis or of metabolic disease, and no history of trauma or of shoulder surgery. The studied variables were body mass index, serum lipid profiles, thyroid hormone levels, fasting glucose levels, glycosylated hemoglobin A1c, and high-sensitivity C-reactive protein. Fasting glucose levels were studied as scale data and categorical data (<85, 85-89, 90-94, and 95-99 mg/dL). Multivariable conditional logistic regression analysis evaluated the matched sets of subjects. Odds ratios and 95% confidence intervals were determined for various potentially associated factors. RESULTS Fasting glucose level, hypercholesterolemia, and high-sensitivity C-reactive protein were significantly associated with IAC (P ≤ .030). Fasting glucose levels in the <85 mg/dL quartile were significantly negatively associated with IAC (P ≤ .001). In contrast, fasting glucose levels in the 90-94 mg/dL quartile or higher were significantly positively associated with IAC (P ≤ .034). CONCLUSION IAC is positively associated with fasting glucose levels of 90-99 mg/dL, which are currently considered normoglycemic.
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Affiliation(s)
- Hyung Bin Park
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea.
| | - Ji-Yong Gwark
- Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Mincheol Kam
- Department of Orthopaedic Surgery, Himchan Hospital, Changwon, Republic of Korea
| | - Jaehoon Jung
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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El Naggar TEDM, Maaty AIE, Mohamed AE. 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. J Shoulder Elbow Surg 2020; 29:1300-1309. [PMID: 32553435 DOI: 10.1016/j.jse.2020.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/18/2020] [Accepted: 03/01/2020] [Indexed: 02/01/2023]
Abstract
UNLABELLED To compare the efficacy of radial extracorporeal shock-wave therapy (rESWT) vs. an ultrasound-guided low-dose intra-articular steroid injection in pain reduction and functional improvement in diabetic patients with shoulder adhesive capsulitis (AC). METHODS This was a 2-parallel-group, active-control, assessor-blinded, randomized trial. We randomized 103 diabetic patients with shoulder AC to receive either 4 sessions of rESWT, 1 week apart (rESWT group, n = 52), or a single ultrasound-guided low-dose intra-articular steroid injection of 20 mg of triamcinolone acetonide (steroid group, n = 51). The primary outcome measure was functional improvement evaluated by the Quick Disabilities of the Arm, Shoulder and Hand (qDASH) score. Secondary outcome measures were pain evaluated by the visual analog scale score and shoulder range of motion (ROM). An assessor who was blinded to treatment assignment assessed both groups at baseline and at 4, 8, and 12 weeks thereafter. RESULTS By 12 weeks, both groups demonstrated a significant reduction in the qDASH score and pain severity, as well as improvement in ROM. However, significantly improved function (qDASH score, 40.4 ± 12.9 vs. 50.5 ± 13.3; P < .001) and shoulder pain reduction (visual analog scale score, 1.6 ± 1.2 vs. 2.8 ± 1.7; P < .001) were found in the rESWT group vs. the steroid group. Similar improvement in shoulder ROM was observed in both groups. CONCLUSION At short-term follow-up, rESWT was superior to a low-dose intra-articular steroid injection in improving function and pain in diabetic patients with shoulder AC. Therefore, rESWT might be considered a safe alternative to steroid injections in diabetic patients with shoulder AC.
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Affiliation(s)
| | - Ahmed Ibrahim Elsayed Maaty
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Aly Elsayed Mohamed
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
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18
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Chen X, Fan H, Chen J, Fan H, Wu P. Bee venom acupuncture for adhesive capsulitis: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19975. [PMID: 32358370 PMCID: PMC7440301 DOI: 10.1097/md.0000000000019975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 03/09/2020] [Accepted: 03/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Bee venom acupuncture has been used in treating patients with shoulder adhesive capsulitis, yet the effectiveness and safety remains unclear. Therefore, this systematic review will aim to assess the effectiveness and safety of bee venom acupuncture for shoulder adhesive capsulitis. METHODS Electronic databases including EMBASE, PUBMED, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Database, and Chinese Biomedical Literature Database will be searched for relevant randomized controlled trials from their inception to the search data without language and publication status. Randomized controlled trials involving bee venom acupuncture for treating shoulder adhesive capsulitis will be included. The primary outcome will be pain visual analogue scale, and secondary outcomes include active and passive range of motions, shoulder pain and disability index. Meta-analysis will be conducted using Review Manager software (V.5.3). The results will be presented as risk ratio for dichotomous data, and standardized or weighted mean difference for continuous data. RESULTS The results will be disseminated through a peer-reviewed journal publication. CONCLUSION These systematic review findings will provide an evidence of bee venom acupuncture for shoulder adhesive capsulitis, and help to inform clinical practitioners and policy-makers in the decision-making. ETHICS AND DISSEMINATION Ethics approval and patient consent are not required as this study is a systematic review based on published articles.
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Affiliation(s)
- Xiaohua Chen
- Department of Central Transportation Center, West China Hospital, Sichuan University
| | - Huaying Fan
- College of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine
| | - Jiao Chen
- College of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine
| | - Huayu Fan
- Respiratory Failure Center and Lung Transplant Unit, Sicuhan Province Hospital, Chengdu City, Sichuan Province, China
| | - Ping Wu
- College of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine
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Nicholson JA, Slader B, Martindale A, Mckie S, Robinson CM. Distension arthrogram in the treatment of adhesive capsulitis has a low rate of repeat intervention. Bone Joint J 2020; 102-B:606-610. [PMID: 32349602 DOI: 10.1302/0301-620x.102b5.bjj-2020-0082] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AIMS The primary aim of this study was to evaluate the efficacy of distension arthrography in the treatment of adhesive capsulitis of the shoulder. The secondary aim was to assess which patient and procedural factors predicted the recurrence of symptoms after the procedure. METHODS All patients referred to our shoulder clinic over a ten-year period, between 2008 and 2018, with a clinical diagnosis of capsulitis and symptoms persisting for more than six months, were offered treatment with a distension arthrogram. All procedures were performed by one of five musculoskeletal radiologists, with a combination of steroid, local anaesthetic, and a distention volume of 10 ml, 30 ml, or 50 ml. Patient demographics, procedural details, recurrence of symptoms, and the need for further intervention were evaluated. RESULTS A total of 2,432 distension arthrograms were performed during the study period. The mean time between arthrography and analysis was 5.4 years (SD 4.4; 1 to 11). Recurrent symptoms occurred in 184 cases (7.6%), all of whom had a repeat distension arthrogram at a median of nine months (interquartile range (IQR) 6.0 to 15.3). The requirement for further intervention for persistent symptoms following arthrography was significantly associated with diabetes (p < 0.001) and bilateral capsulitis (p < 0.001). The volume of distension, either with air or saline, showed a dose-dependent advantage. Distension of 50 ml versus 30 ml showed a significantly decreased odds ratio for recurrence of 2.2 (95% confidence interval (CI) 1.6 to 3.0; p < 0.001). Capsule rupture (p = 0.615) or steroid dose (p = 0.275) did not significantly affect the rate of recurrence. There were no infections or neurovascular injuries. Following the second distension arthrogram, the symptoms resolved in 137 cases (74.5%) with no further intervention being required. An arthroscopic capsular release was ultimately required in 41 cases, comprising 1.7% of the entire cohort. CONCLUSION We found a low rate of repeat intervention following distension arthrography in patients with adhesive capsulitis of the shoulder, at long term follow-up. Greater volumes of distension are associated with lower rates of recurrence independent of capsule rupture. Cite this article: Bone Joint J 2020;102-B(5):606-610.
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Affiliation(s)
- Jamie A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - Ben Slader
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - Aleksis Martindale
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - Scott Mckie
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - C Mike Robinson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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Cohen C, Tortato S, Silva OBS, Leal MF, Ejnisman B, Faloppa F. Association between Frozen Shoulder and Thyroid Diseases: Strengthening the Evidences. Rev Bras Ortop 2020; 55:483-489. [PMID: 32904783 PMCID: PMC7458737 DOI: 10.1055/s-0039-3402476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/26/2019] [Indexed: 12/03/2022] Open
Abstract
Objective
To clarify the association of thyroid disorders and primary frozen shoulder by comparing this group with controls without shoulder disease and with patients with rotator cuff tears.
Methods
We evaluated 166 patients who presented frozen shoulder with treatment in progress or already treated, which were compared with 129 patients with diagnosis of rotator cuff tears and 251 control subjects. All of the participants answered the questionnaire on the following variables: age, gender, body mass index (BMI), occupation, physical activity, presence of thyroid disorders and other comorbidities, smoking and use of alcohol.
Results
When comparing the frozen shoulder group with the control and rotator cuff groups, there is a specific association between the presence of thyroid disorders and frozen shoulder. By calculating relative risk, it is possible to state that an individual with thyropathy has 2.69 more chance of developing frozen shoulder. Also, there was an association with gender, since women with frozen shoulder exceeded significantly the risk.
Conclusions
Thyroid disorders, especially hypothyroidism and the presence of benign thyroid nodules, are risk factors significantly associated with frozen shoulder, rising the chances to 2.69 times of developing frozen shoulder.
This is the first study that uses, in addition to the control group, a second group with rotator cuff tears, so it was shown that there is a specific association of thyroid disorders and frozen shoulder, but not with shoulder disorders in general.
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Affiliation(s)
- Carina Cohen
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Simone Tortato
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Otavio Bento Souza Silva
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Mariana Ferreira Leal
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Benno Ejnisman
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Flavio Faloppa
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Huang SW, Wang JY, Lin CL, Huang CC, Liou TH, Lin HW. Patients with Axial Spondyloarthritis Are at Risk of Developing Adhesive Capsulitis: Real-World Evidence Database Study in Taiwan. J Clin Med 2020; 9:jcm9030787. [PMID: 32183158 PMCID: PMC7141228 DOI: 10.3390/jcm9030787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 11/16/2022] Open
Abstract
Patients with axial spondyloarthritis (ax-SpA) present with inflammation invading the axial skeleton. Symptoms of ax-SpA interfere with patients' quality of life, and peripheral symptoms are also noted. Human leukocyte antigen B27 was associated with adhesive capsulitis. However, epidemiological studies investigating the associated incidence and risk factors for patients with ax-SpA with adhesive capsulitis are limited. The data of patients with ax-SpA were recorded during the 2004-2008 period and followed to the end of 2010. The control cohort comprised age- and sex-matched non-ax-SpA subjects. A Cox multivariate proportional hazards model was applied to analyze the risk factors for adhesive capsulitis. The hazard ratio (HR) and adjusted hazard ratio (aHR) were estimated between the study and control cohorts after confounders were adjusted for. Effects of sulfasalazine (SSZ), methotrexate (MTX), and hydroxychloroquine (HCQ) use on adhesive capsulitis risk were also analyzed. We enrolled 2859 patients with ax-SpA in the study cohort and 11,436 control subjects. A higher incidence of adhesive capsulitis was revealed in the ax-SpA cohort: The crude HR was 1.63 (95% CI, 1.24-2.13; p < 0.001), and the aHR was 1.54 (95% CI, 1.16-2.05; p = 0.002). For patients with ax-SpA using SSZ or HCQ, no difference in aHR was noted compared with control participants, but patients with ax-SpA treated with MTX had higher HR and aHR than controls. Patients with ax-SpA are at risk for adhesive capsulitis. When these patients receive SSZ or HCQ, the risk of adhesive capsulitis can be lowered compared with that of the control cohort.
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Affiliation(s)
- Shih-Wei Huang
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei 23561, Taiwan (T.-H.L.)
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan 33301, Taiwan;
| | - Jr-Yi Wang
- Department of Orthopedic Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (J.-Y.W.); (C.-L.L.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Che-Li Lin
- Department of Orthopedic Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (J.-Y.W.); (C.-L.L.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chi-Chang Huang
- Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan 33301, Taiwan;
| | - Tsan-Hon Liou
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei 23561, Taiwan (T.-H.L.)
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Hui-Wen Lin
- Department of Mathematics, Soochow University, Taipei 11102, Taiwan
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
- Correspondence: ; Tel.: +886-2-2881-9471 (ext.) 6701; Fax: +886-2-8861-1230
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Stelter J, Malik S, Chiampas G. The Emergent Evaluation and Treatment of Shoulder, Clavicle, and Humerus Injuries. Emerg Med Clin North Am 2020; 38:103-124. [DOI: 10.1016/j.emc.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Abstract
Supplemental Digital Content is available in the text. Objectives: Identify the prevalence of shoulder impairment in ICU survivors within 6 months of discharge from ICU. Evaluate the impact of shoulder impairment on upper limb functional status in patients treated on an ICU. Identify risk factors for the development of shoulder impairment. Design: Prospective cohort study. Setting: A tertiary care medical-surgical-trauma ICU at a U.K. hospital over 18 months, with a further 6-month follow-up after hospital discharge. Subjects: Adult patients with an ICU length of stay of greater than 72 hours with no preexisting or new neurologic or traumatic upper limb injury. Interventions: None. Measurements and Main Results: Patients underwent targeted shoulder assessments (pain, range of movement, Constant-Murley Score, shortened version of the disabilities of the arm, shoulder, and hand [DASH] score [QuickDASH] score) at hospital discharge, 3 and 6 months after hospital discharge. Assessments were undertaken on 96 patients, with 62 patients attending follow-up at 3 months and 61 patients at 6 months. Multivariate regression analysis was used to investigate risk factors for shoulder impairment. ICU-related shoulder impairment was present in 67% of patients at 6 months following discharge from hospital. Upper limb dysfunction occurred in 46%, with 16% having severe dysfunction (equivalent to shoulder dislocation). We were unable to identify specific risk factors for shoulder impairment. Conclusions: Shoulder impairment is a highly prevalent potential source of disability in ICU survivors. This persists at 6 months after discharge with a significant impact on upper limb function. More research is needed into potential mechanisms underlying shoulder impairment and potential targeted interventions to reduce the prevalence.
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Rai SK, Kashid M, Chakrabarty B, Upreti V, Shaki O. Is it necessary to screen patient with adhesive capsulitis of shoulder for diabetes mellitus? J Family Med Prim Care 2019; 8:2927-2932. [PMID: 31681669 PMCID: PMC6820405 DOI: 10.4103/jfmpc.jfmpc_244_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 03/25/2019] [Accepted: 04/06/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Idiopathic adhesive capsulitis of shoulder is common cause of pain and restriction of shoulder motion between the ages of 30 and 65. The prevalence of adhesive capsulitis is as high as 10% to 22% in diabetes mellitus as compared normal population which is 02% and 04%. Therefore, the doubt arises whether patients developed adhesive capsulitis are at greater risk to develop diabetes mellitus and should be screen for diabetes so that it can be detected early. PURPOSE To compare the prevalence of prediabeties and diabetes mellitus among patients with features of idiopathic adhesive capsulitis of shoulder who are otherwise healthy. METHODS Patients between 30-65 years of age who attended Orthopaedics OPD with features of idiopathic adhesive capsulitis of shoulder were included. Participated underwent a 2 hour long oral glucose tolerance test and based on fasting and 2-hour plasma glucose levels, patients were diagnosed as normal glucose tolerance, prediabetic, or diabetic and the results were matched with previous published data. RESULTS 135 patients as participated and completed the test. 21 (15.5%) patients with idiopathic adhesive capsulitis of shoulder were found to be prediabetic, and 37 (27.4%) patients were found to be diabetic. However, 31 patients had family history of diabetes. CONCLUSION Based on our study, we can recommend that patients with features of idiopathic adhesive capsulitis of shoulder should be screened at least for fasting and post prandial blood sugar so that diabetes can be detected early.
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Affiliation(s)
- S. K. Rai
- Department of Orthopaedics, 151 Base Hospital, Guwahati, Assam, India
| | - Manoj Kashid
- Department of Orthopaedics, SMBT Medical Colleges, Igatpuri, Nasik, Maharashtra, India
| | | | - Vimal Upreti
- Department of Medicine, 151 Base Hospital, Guwahati, Assam, India
| | - Omna Shaki
- Department of Trauma & Emergency, 151 Base Hospital, Guwahati, Assam, India
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Pogorzelski J, Imhoff AB, Degenhardt H, Siebenlist S. [Primary (idiopathic) shoulder stiffness : Definition, disease progression, epidemiology and etiology]. Unfallchirurg 2019; 122:917-924. [PMID: 31396647 DOI: 10.1007/s00113-019-0703-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Shoulder stiffness is characterized by restriction of the active and passive movement of the glenohumeral joint. The stiffness is ultimately caused by fibrosis and the resulting contracture of the glenohumeral joint capsule and its ligaments; however, the term stiff shoulder is only a descriptive umbrella term that must be further defined as the course of the disease and the recommended treatment are decisively influenced by the cause of the shoulder stiffness. Primary shoulder stiffness, also known as idiopathic shoulder stiffness or "frozen shoulder", must be distinguished from various forms of secondary shoulder stiffness and often occurs in three stages, which can all last for several months to years: the initial "freezing phase", followed by a "frozen phase" and finally a "thawing phase". Although primary shoulder stiffness is a frequent pathological alteration with an prevalence of 2-5% in the general population, the exact etiology remains largely unknown; however, there is consensus throughout the literature that certain systemic pathologies, such as diabetes mellitus are associated with a higher incidence of primary shoulder stiffness.
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Affiliation(s)
- Jonas Pogorzelski
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Andreas B Imhoff
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Hannes Degenhardt
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Sebastian Siebenlist
- Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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Yanlei GL, Keong MW, Tijauw Tjoen DL. Do diabetic patients have different outcomes after arthroscopic capsular release for frozen shoulder? J Orthop 2019; 16:211-215. [PMID: 30906125 PMCID: PMC6411596 DOI: 10.1016/j.jor.2019.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/01/2018] [Accepted: 02/17/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION While the exact mechanism of primary adhesive capsulitis is unknown, we know that it has strong associations with diabetes mellitus (DM). Although self-limiting, a significant percentage of patients still have persistent pain and stiffness beyond 3 years. Arthroscopic capsular release (ACR) has been described as a successful intervention for recalcitrant adhesive capsulitis that provides early and long-term recovery. The aim of this study is to investigate the relationship between DM and ACR. METHODS We reviewed prospectively collected data of 56 consecutive patients with idiopathic frozen shoulder who underwent ACR (360° arthroscopic capsulotomy) under a single surgeon. Range of motion, pain score and shoulder function (Constant Shoulder Score, Oxford Shoulder Score, University of California Los Angeles Shoulder Score) were documented preoperatively and one year postoperatively. Patients were dichotomized into diabetic (n = 32) and non-diabetic patients (n = 24) and compared using a mixed ANOVA design to investigate for differences in outcomes. RESULTS Both group of patients had significant improvement in range of motion, reduced pain scores and improved shoulder scores one year postoperatively (p = 0.000). Diabetic patients had poorer internal rotation (p = 0.000), forward flexion (p = 0.035) and poorer postoperative Constant Shoulder score (p < 0.05). Otherwise both groups improved equally in all other aspects. CONCLUSION ACR offered good outcomes in both diabetic and non-diabetic patients in terms of range of motion, pain relief and shoulder function. However diabetic patients had poorer improvement in internal rotation and forward flexion postoperatively. Preoperative counselling and postoperative rehabilitation can be better tailored to treat diabetic patients with idiopathic adhesive capsulitis.
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Affiliation(s)
- Geraldine Lei Yanlei
- Singapore General Hospital, 20 College Road, 20 College Road Academia Level 4, 1698655, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mak Wai Keong
- Singapore General Hospital, 20 College Road, 20 College Road Academia Level 4, 1698655, Singapore
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Denny Lie Tijauw Tjoen
- Singapore General Hospital, 20 College Road, 20 College Road Academia Level 4, 1698655, Singapore
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Kayar Y, Çetin H, Ağın M. Tip 2 diyabetes mellitus hastalarında sigara içiciliği ve miktarı ile diyabetik komplikasyonlar arasındaki ilişkisi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.412649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Ko JH, Kang YM, Yang JH, Kim JS, Lee WJ, Kim SH, Yang IH, Moon SH. Regulation of MMP and TIMP expression in synovial fibroblasts from knee osteoarthritis with flexion contracture using adenovirus-mediated relaxin gene therapy. Knee 2019; 26:317-329. [PMID: 30770167 DOI: 10.1016/j.knee.2019.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 12/07/2018] [Accepted: 01/17/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to investigate the effects of relaxin (RLN) expression on fibrosis inhibition in synovial fibroblasts. MATERIALS AND METHODS Tissue cells from patients with knee osteoarthritis and >30° flexion contractures were utilised. Synovial fibroblasts were activated by TGF-β1 (two nanograms per millilitre) and then exposed to Ad-RLN as a therapeutic gene, adenovirus-lacZ construct as a marker gene, and SB505124 as an inhibitor for TGF-β1 signal for 48 h. The mRNA expression levels of collagens and MMPs were analysed by reverse transcription-polymerase chain reaction. Also, fibronectin, phosphorylation of Smad2 and ERK1/2, alpha smooth muscle actin, TIMP-1, TIMP-2, MMP-1 and MMP-13 levels were estimated using western blotting, and the total collagen synthesis was assayed. RESULTS Ad-RLN-transduced synovial fibroblasts demonstrated 17%, 13%, and 48% reduction in collagen I, III and IV mRNA expression levels, respectively, and a 40% decrease in MMP-3, MMP-8, 20% decrease in MMP-9, MMP-13 mRNA expression, compared to non-Ad-RLN-transduced cells. In protein expression, Ad-RLN-transduced synovial fibroblasts demonstrated 46% increase in MMP-1, 5% decrease in MMP-2, 51% increase in MMP-9, and 22% increase in MMP-13, compared to non-Ad-RLN-transduced cells. Ad-RLN-transduced synovial fibroblasts showed a 25% decrease in TIMP-1 and 65% decrease in TIMP-2 protein expression at 48h, compared to non-Ad-RLN-transduced cells. Ad-RLN-transduced synovial fibroblasts demonstrated a 45% inhibition of fibronectin in protein expression level and 38% decrease in total collagen synthesis at 48h, compared to non-Ad-RLN-transduced cells. CONCLUSION Relaxin expression exerted anti-fibrogenic effects on synovial fibroblasts from patients with knee osteoarthritis and flexion contractures. Therefore, relaxin could be an alternative therapeutic agent during the initial stage of osteoarthritis with flexion contracture by exerting its anti-fibrogenic effects.
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Affiliation(s)
- Jae Han Ko
- Department of Orthopaedic Surgery, Yonsei Barun Orthopaedic Surgery Clinic, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Young Mi Kang
- Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Jae Ho Yang
- Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Ji Sup Kim
- Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea; Department of Orthopaedic Surgery, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Won Jai Lee
- Department of Plastic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Sang Ho Kim
- Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Ick Hwan Yang
- Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea
| | - Seong Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Republic of Korea.
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Gundtoft PH, Kristensen AK, Attrup M, Vobbe JW, Luxhøi T, Rix FG, Hölmich P, Sørensen L. Prevalence and Impact of Diabetes Mellitus on the Frozen Shoulder. South Med J 2018; 111:654-659. [PMID: 30391999 DOI: 10.14423/smj.0000000000000886] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The objective of this study was to estimate the prevalence of undiagnosed diabetes mellitus in patients with newly diagnosed frozen shoulder (FS) and study whether diabetes mellitus increases the severity of FS disease. METHODS Patients with newly diagnosed FS were consecutively included in this case-control study. Patients who were not already diagnosed as having diabetes mellitus were invited to be tested with the hemoglobin A1c blood sample test. The study population was compared with a control group, consisting of five individuals from the general population matched on age and sex. The passive range of motion, Oxford Shoulder Score, and visual analog scale (VAS) for average and maximum daily pain was recorded for all of the patients in the study group. RESULTS A total of 235 patients were included, 34 (14%) of whom were diagnosed as having diabetes mellitus before the examination. Of the remaining 201 patients, 122 (61%) agreed to be tested for diabetes mellitus. None of the tested patients had undiagnosed diabetes mellitus. This was not significantly different from the prevalence in the matched control population (P = 0.09). There was no difference between patients with and without diabetes mellitus in average daily VAS (P = 0.46) nor maximum daily VAS (P = 0.44). The Oxford Shoulder Score was similar in the two groups (P = 0.23) as was the range of motion. CONCLUSIONS The prevalence of undiagnosed diabetes mellitus is low in patients with FS and does not differ from the general population. Diabetes mellitus does not seem to affect patients' perceived severity of an FS.
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Affiliation(s)
- Per H Gundtoft
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
| | - Anne K Kristensen
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
| | - Mikkel Attrup
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
| | - Jette W Vobbe
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
| | - Torben Luxhøi
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
| | - Flemming G Rix
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
| | - Per Hölmich
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
| | - Lilli Sørensen
- From the Orthopedic Department, Kolding Hospital, Kolding, the Orthopedic Department, Vejle Hospital, Vejle, the Sports Orthopaedic Research Centre-Copenhagen, Copenhagen, and the Department of Orthopedic Surgery, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark
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Longo UG, Ciuffreda M, Locher J, Buchmann S, Maffulli N, Denaro V. The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature. Br Med Bull 2018; 127:111-143. [PMID: 30137234 DOI: 10.1093/bmb/ldy025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/15/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness. SOURCE OF DATA A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed. AREAS OF AGREEMENT Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release. AREAS OF CONTROVERSY No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined. GROWING POINTS The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group. AREAS TIMELY FOR DEVELOPING RESEARCH There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, Trigoria, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, Trigoria, Rome, Italy
| | - Joel Locher
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, Trigoria, Rome, Italy
| | - Stefan Buchmann
- Department of Orthopaedic Sports Medicine, Klinikumrechts der Isar, Technical University of Munich, Ismaningerstr. 22, Munich, Germany
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, Trigoria, Rome, Italy
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A randomized controlled trial of arthroscopic capsular release versus hydrodilatation in the treatment of primary frozen shoulder. J Shoulder Elbow Surg 2018; 27:1401-1406. [PMID: 29798823 DOI: 10.1016/j.jse.2018.04.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthroscopic capsular release (ACR) and hydrodilatation (HD) have been developed for the management of frozen shoulder refractory to conservative treatment. To date no randomized trial has directly compared the efficacy of both interventions. The aim of this trial was to determine whether the Oxford Shoulder Score (OSS) differs between patients with frozen shoulder randomized to treatment with ACR or HD. METHODS Patients presenting with severe idiopathic frozen shoulder deemed suitable for surgical intervention by a consultant shoulder surgeon were randomized to ACR or HD. The primary outcome measure was OSS at 6 months, with secondary outcomes measures of the EuroQol-5D visual analog scale, external rotation, complications, and crossover rate also recorded. RESULTS Between June 2013 and December 2016, 50 patients were randomized to HD or ACR. The average age of the HD and ACR cohorts was 55.2 and 52.6 years, respectively (P = .36). At 6 months after the intervention, 20 patients were available for follow-up in the HD cohort and 19 in the ACR cohort. Both groups demonstrated significant improvements in OSS from baseline, but the OSS was significantly higher in the ACR cohort than the HD cohort (43.8 vs. 38.5, P = .023). The OSS was noted to improve rapidly after the intervention, with 75% of improvement in OSS noted at 6 weeks after surgery in both groups. CONCLUSIONS Patients randomized to ACR reported a significantly higher OSS at 6 months than those randomized to HD. Both groups, however, showed a significant improvement.
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Shoulder adhesive capsulitis: epidemiology and predictors of surgery. J Shoulder Elbow Surg 2018; 27:1437-1443. [PMID: 29807717 DOI: 10.1016/j.jse.2018.04.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 03/27/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Adhesive capsulitis is characterized by a gradual, painful loss of shoulder motion. This study evaluated patient variables significantly associated with developing adhesive capsulitis compared with a sex-matched control group without adhesive capsulitis. We also sought to determine those factors associated with adhesive capsulitis patients requiring surgical intervention. METHODS All patients presenting to our hospital with adhesive capsulitis between 2004 and 2014 were identified. Demographic characteristics were collected, and a sex-matched control group was randomly generated from the electronic medical record and used for comparison. Patients who underwent surgical intervention for adhesive capsulitis were also identified, and factors associated with surgical intervention were identified with logistic regression analysis. RESULTS Included were 2190 adhesive capsulitis patients with a normal age distribution of 56.4 ± 13.1 years. Most were classified as overweight (30.7%) or obese (27.0%). Compared with controls, adhesive capsulitis patients were more likely to be younger (<50 vs. ≥50 years; odds ratio [OR], 0.69; P < .001), obese (OR, 1.26; P < .001), black/African American (OR, 1.71; P < .001), Hispanic/Latino (OR, 4.85; P < .001), or diabetic (OR, 1.12; P < .001) and less likely to have hypertension (OR, 0.93; P = .006). Overall, 361 subsequently underwent surgical intervention. Older patients, racial minorities, and government-sponsored/uninsured patients were significantly less likely to have surgery for adhesive capsulitis (P < .01), whereas workers' compensation patients were 8 times more likely to receive surgery compared with privately insured patients (P < .001). CONCLUSIONS Obesity and diabetes were significantly associated with adhesive capsulitis and should be considered modifiable patient factors. Additionally, younger patients and racial minorities were also significantly more likely to be diagnosed with adhesive capsulitis. Younger, white, and workers' compensation patients were more likely to receive surgery, whereas patients with government-sponsored or no insurance status were more likely to receive nonoperative treatment.
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Comparison Between Image-Guided and Landmark-Based Glenohumeral Joint Injections for the Treatment of Adhesive Capsulitis: A Cost-Effectiveness Study. AJR Am J Roentgenol 2018; 210:1279-1287. [DOI: 10.2214/ajr.17.19011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Acupuncture at Tiaokou (ST38) for Shoulder Adhesive Capsulitis: What Strengths Does It Have? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:4197659. [PMID: 29849707 PMCID: PMC5937513 DOI: 10.1155/2018/4197659] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/09/2018] [Accepted: 01/28/2018] [Indexed: 11/17/2022]
Abstract
Objective Tiaokou (ST38) is used as a crucial distal acupoint for treating shoulder adhesive capsulitis (SAC) in traditional Chinese medicine. The objective of this study was to assess the effectiveness and safety of acupuncture at Tiaokou for treating SAC. Methods We searched eight electronic databases without language restrictions. All the literature was processed to identify RCTs comparing acupuncture at Tiaokou with other therapies (e.g., acupuncture at local shoulder acupoints and nonsteroidal anti-inflammatory drugs). Two reviewers extracted trials and collected outcome data independently. A meta-analysis was performed following a strict methodology. Results 19 RCTs involving 1944 participants met our inclusion criteria. The majority of the trials were determined to be of low quality. Positive results were found for acupuncture treatment at Tiaokou (as sole treatment or in combination with shoulder acupoints), which resulted in an improved percentage of clinical effectiveness and Constant-Murley Score values, as well as a reduction in Visual Analogue Scale values of SAC patients. Conclusion Our review found encouraging evidence for the effectiveness of acupuncture at Tiaokou for SAC. Nonetheless, despite stringent methodological analyses, these results need to be strengthened by additional RCTs of higher quality.
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Hando BR, Rhon DI, Boyles RE, Whitman JM, English JL. Translational manipulation under anesthesia for patients with frozen shoulder: a case series study with five-year health care utilization and post-manipulative arthroscopic findings. J Man Manip Ther 2018; 25:270-278. [PMID: 29449769 DOI: 10.1080/10669817.2017.1292615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Study Design Case series study. Objectives Although there have been no reported complications from translational manipulation under anesthesia (tMUA) for individuals with adhesive capsulitis (AC) there are no cases reporting surgical findings post tMUA. Also, there are no studies evaluating health care utilization following tMUA. The purpose of this study was to: (1) report clinical outcomes following tMUA, (2) describe relevant health care costs and utilization following tMUA, and (3) summarize findings from two cases receiving joint arthroscopy following tMUA. Methods Fourteen Individuals with AC underwent tMUA. Range of motion (ROM) and Shoulder Pain and Disability Index (SPADI) values were collected at baseline and six weeks follow-up. Shoulder-related health care cost and utilization were analyzed for a five-year period following tMUA. Two additional patients with AC underwent tMUA followed by arthroscopic assessment for evidence of iatrogenic injury. Results Thirteen patients completed the six-week follow-up. Mean change scores for ROM and SPADI values were flexion; +38.5°, abduction; +71.1°, external rotation (shoulder abducted); +49.8°, internal rotation (shoulder abducted); +26.6°, SPADI scores; +44.4. 13 patient records were analyzed for health care utilization. Ten of the 13 patients utilized no additional shoulder-related health care. Surgical evaluation revealed no evidence of iatrogenic injury. Discussion Clinical outcomes were similar to previous studies. Utilization data indicated that for the majority of patients, little shoulder-related health care was utilized. Surgical evaluation provided further evidence that tMUA performed by a physical therapist is safe. Future research will be required to establish a causal relationship between tMUA and the results observed in this study. Level of Evidence Therapy, Level 4.
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Affiliation(s)
- Ben R Hando
- Department of Orthopedics and Rehabilitation, Wilford Hall Ambulatory Surgical Center, United States Air Force, San Antonio, TX, USA
| | - Daniel I Rhon
- Center for the Intrepid, United States Army, San Antonio, TX, USA
| | - Robert E Boyles
- School of Physical Therapy, University of Puget Sound, Takoma, WA, USA
| | | | - Jenny L English
- Budget Integration Office, U.S. Army Medical Command, San Antonio, TX, USA
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Kermani ZH, Bazzaz SMM, Farahmand SK, Raoof AA. The comparison of frequency of the upper limb musculoskeletal disorders among patients with diabetes type II with normal cases. Electron Physician 2018; 9:5848-5853. [PMID: 29403629 PMCID: PMC5783138 DOI: 10.19082/5848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/14/2017] [Indexed: 12/25/2022] Open
Abstract
Background and aim Musculoskeletal disease, that is recognized in diabetes and diabetes mellitus (DM) has shown a higher prevalence of chronic musculoskeletal complications. This study aimed at assessing the frequency of upper limb musculoskeletal disorders among patients with diabetes type II with normal cases in Mashhad, Iran. Methods A cross-section of 100 patients with upper limb musculoskeletal disorders were enrolled in this study. The patients were examined by a unique physician considering carpal tunnel syndrome disorder, trigger finger, adhesive capsulitis, and Dupuytren's contracture at Ghaem hospital, Mashhad, Iran in 2015. All collected data were recorded by using SPSS version 21 and were analyzed through independent-samples t-test for comparing changes, and Chi-square. Results In this study, the mean age was 51.7±8.7 years old. Gender frequency was 114 (57%) male, and 86 (43%) female. There was no significant difference between groups in cases of gender frequency and mean of age (p>0.05). In evaluation of association between the two groups, there was significant difference for adhesive capsulitis, (p=0.04). Chi-square test showed significant association for age and adhesive capsulitis between the two groups, (p=0.040); but no other diabetes-related disorders, (p<0.05). Conclusion The results of this study showed that in patients with diabetes mellitus and musculoskeletal complications such as upper limb musculoskeletal abnormalities, it will lead to an increase in skeletal muscle effects in DM patients. It is recommended that musculoskeletal examination is done periodically in DM patients for identification of these disorders and necessary actions are carried out for prevention of the disorders as soon as possible.
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Affiliation(s)
- Zahra Haeri Kermani
- MD, MPH, General Practitioner, Mashhad University of Medical Sciences, Health Centre 3, 24th Akhud Khorasani Street, Mashhad, Iran
| | - Seyed Mojtaba Mousavi Bazzaz
- Associate Professor of Community Medicine and Public Health, Department of Community Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Kazem Farahmand
- MD, PhD, Assistant Professor of Chinese Medicine, School of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Akbar Raoof
- General Practitioner, Director of Parsian Diabetes Centre, Chamran Street, Mashhad, Iran
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Kyhlbäck M, Söderlund A, Thierfelder T, Elmgren Frykberg G. Physiotherapy treatment of the diabetic shoulder: health-related quality of life and measures of shoulder function regarding patients with type 1 diabetes. Disabil Rehabil 2018; 41:1435-1442. [PMID: 29363341 DOI: 10.1080/09638288.2018.1430177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this study was to investigate how health-related quality of life (HRQoL) and functional shoulder range of motion are affected among patients with diabetes with shoulder problems, treated with a specific physiotherapy programme. A further aim was to investigate how health-related quality of life, functional shoulder range of motion, pain intensity, and shoulder function correlate within the group of patients after the treatment period. METHOD A pre-post treatment design was applied for a study group of ten patients with type 1 diabetes and shoulder problems. The physiotherapy treatment consisted of exercises promoting enhanced micro-circulation in the shoulder tissues, optimal shoulder co-ordination, and muscle relaxation. The Short Form-36 (SF-36), shoulder range of motion measures, the Shoulder Rating Scale - Swedish version, and pain intensity measures were used. The results regarding SF-36 were compared with the results of a control group of patients having either type 1 or type 2 diabetes and shoulder problems that did not receive any specific physiotherapy treatment. RESULTS As a potential result of physiotherapy training, a significant change towards higher scores was observed in the physical component summary (PCS) measure of SF-36. There was a significant improvement regarding PCS in the study group as compared with the control group. There were negative correlations between the four aspects of pain intensity and PCS and Shoulder Rating Scale - Swedish version, respectively, but a positive correlation between PCS and Shoulder Rating Scale - Swedish version. "Hand-raising" and "hand-behind-back" were significantly improved, and proved to be positively correlated with Shoulder Rating Scale - Swedish version. CONCLUSIONS The results of this study indicate that patients with type 1 diabetes and shoulder problems, treated with a specific physiotherapy programme, may improve with respect to physical aspects of health-related quality of life, and partially regain their range of motion in the shoulder joint. Based on these results, the associated treatment protocol may be recommended for physiotherapy treatment in such patients. Implications for Rehabilitation Diabetes is a significant risk factor in the development of shoulder pain and disability. Health-related quality of life (HRQoL) is affected in patients with diabetes and shoulder problems. A specific physiotherapy programme may improve physical aspects of HRQoL in patients with diabetes and shoulder problems. Specific physiotherapy intervention may also improve range of motion in the shoulder joint in patients with diabetes and shoulder problems.
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Affiliation(s)
- Maria Kyhlbäck
- a Department of Neuroscience/Rehabilitation Medicine , Uppsala University , Uppsala , Sweden
| | - Anne Söderlund
- b School of Health, Care and Social Welfare , Mälardalen University , Västerås , Sweden
| | - Tomas Thierfelder
- c Department of Energy and Technology , Swedish University of Agricultural Sciences SLU , Uppsala , Sweden
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Prodromidis AD, Charalambous CP. Is There a Genetic Predisposition to Frozen Shoulder?: A Systematic Review and Meta-Analysis. JBJS Rev 2018; 4:01874474-201602000-00004. [PMID: 27490134 DOI: 10.2106/jbjs.rvw.o.00007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Frozen shoulder is a common disorder that leads to substantial functional loss for patients by impairing activities of daily living. It also adversely affects patients and society by impairing the ability to work. Its pathogenesis is not fully understood. The aim of the present study was to perform a systematic review and meta-analysis to assess the evidence suggesting a genetic link to frozen shoulder. METHODS A literature search of MEDLINE, EMBASE, and CINAHL databases using relevant keywords revealed 5506 studies. After appropriate screening of titles, abstracts, and full studies, seven studies were analyzed. RESULTS Three studies investigated rates of frozen shoulder among relatives. One study (n = 1828 twin pairs) showed an 11.6% prevalence in twin pairs and demonstrated a heritability of 42% for frozen shoulder after adjusting for age. A second study (n = 273) showed that 20% of patients with frozen shoulder had a positive family history involving a first-degree relative. The relative risk of frozen shoulder was 4:1 when all patients with frozen shoulder were compared with a control population. A third study (n = 87) showed that 29% of patients with frozen shoulder had a first-degree relative with frozen shoulder. Two studies evaluated racial predilection for frozen shoulder. One study (n = 50) reported a substantially higher number of white patients (76%) with frozen shoulder than black patients (24%). A second study (n = 87) showed that being born or having parents or grandparents born in the British Isles were risk factors for frozen shoulder. Four immunological studies investigated human leukocyte antigen (HLA)-B27 as a risk factor for frozen shoulder. Meta-analysis of two of these studies with clearly defined controls showed significantly higher rates of HLA-B27 positivity in patients with frozen shoulder as compared with controls (p < 0.001). CONCLUSION The limited evidence points toward a genetic link to frozen shoulder. We used family history and racial predilection as markers for genetic association, both of which indicated the presence of a genetic predisposition to frozen shoulder. However, as there is a lack of unbiased genetic approaches, there is an opportunity for genome-wide association studies to address definitively the molecular genetics of frozen shoulder. Such studies may eventually lead to a better understanding of the pathogenesis of frozen shoulder and the development of novel therapeutic interventions. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Apostolos D Prodromidis
- Orthopaedic Department, Blackpool Victoria Hospital, Blackpool, UK.,School of Medicine and Dentistry, University of Central Lancashire, Preston, UK
| | - Charalambos P Charalambous
- Orthopaedic Department, Blackpool Victoria Hospital, Blackpool, UK.,School of Medicine and Dentistry, University of Central Lancashire, Preston, UK.,Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
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Mortada MA, Ezzeldin N, Abbas SF, Ammar HA, Salama NA. Multiple versus single ultrasound guided suprascapular nerve block in treatment of frozen shoulder in diabetic patients. J Back Musculoskelet Rehabil 2018; 30:537-542. [PMID: 27858673 DOI: 10.3233/bmr-150322] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Suprascapular nerve block (SSNB) is used in the management of frozen shoulder. There are no evidences from the literature that can determine how many blocks and the interval between them. OBJECTIVE To compare between single and multiple (nine) SSNB in the treatment of diabetic frozen shoulder. METHODS Ninety six patients with Type 2 diabetic and a frozen shoulder divided into 2 equal groups. Patients in group1 were subjected to single SSNB. Patients in group 2 were subjected to multiple (nine) SSNB. Participants were assessed clinically and by ultrasound at baseline and after 3 weeks and 4 months. RESULTS After 3 weeks, there was a significant improvement of all clinical & ultrasound parameters in both groups. But the improvement in group 2 was significantly better than the improvement in group 1. Also after 4 months, all parameters in both groups showed a further improvement in comparison with the base line parameters but still there was a highly significant improvement in group 2 versus group1. CONCLUSION A course of multiple (nine) injections for suprascapular nerve block gave a better outcome than a single injection for suprascapular nerve block.
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Affiliation(s)
- Mohamed A Mortada
- Rheumatology & Rehabilitation Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Nillie Ezzeldin
- Rheumatology & Rehabilitation Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Samah F Abbas
- Rheumatology & Rehabilitation Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hanan A Ammar
- Rheumatology & Rehabilitation Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Nahla A Salama
- Internal Medicine Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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CELIK HALUK, SECKIN MUSTAFAFAIK, AKCAL MEHMETAKIF, KARA ADNAN, KILINC BEKIRERAY, AKMAN SENOL. MID-LONG TERM RESULTS OF MANIPULATION AND ARTHROSCOPIC RELEASE IN FROZEN SHOULDER. ACTA ORTOPEDICA BRASILEIRA 2017; 25:270-274. [PMID: 29375258 PMCID: PMC5782862 DOI: 10.1590/1413-785220172506174033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Surgical treatment options should be discussed in cases of frozen shoulder, which is usually treated in a conservative manner. In this study, we evaluated the efficacy of manipulation and arthroscopic release in cases of frozen shoulder which resisted conservative treatment. METHODS A total of 32 patients who underwent manipulation and arthroscopic capsular release in 34 shoulders were included in the study. The average follow-up period was 49.5 months (range: 24-90 months). No reason for onset could be found in 8 (25%) patients, who were classified as primary frozen shoulder; twenty-four (75%) patients were classified as secondary frozen shoulder due to underlying pathologies. The average pre-operative complaint period was 11 months (range: 3-24 months). After arthroscopic examination, manipulation was performed first, followed by arthroscopic capsular release. The range of motion in both shoulders was compared before the procedure and in the last follow-up visit. Constant and Oxford classifications were used to assess functional results, and the results were assessed statistically. RESULTS Patient values for passive elevation, abduction, adduction-external rotation, abduction-external rotation, and abduction-internal rotation increased in a statistically significant manner between the preoperative assessment and follow-up evaluation (p<0.01). The average change of 47.97±21.03 units observed in the patients' values obtained in the control measurements against the pre-op Constant scores was determined to be statistically significant (p<0.01). According to the Oxford classification, 29 shoulders were sufficient. CONCLUSION Successful results can be obtained with arthroscopic release performed after manipulation in patients with frozen shoulder resistant to conservative treatment. Level of Evidence IV, Case Series.
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Lamplot JD, Lillegraven O, Brophy RH. Shoulder activity level in patients with idiopathic adhesive capsulitis. J Shoulder Elbow Surg 2017; 26:1514-1519. [PMID: 28372965 DOI: 10.1016/j.jse.2017.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Idiopathic adhesive capsulitis is a common condition resulting in painful multidirectional restriction of motion. Adhesive capsulitis may inhibit shoulder activity level, but this relationship has not been previously studied. This study tested the hypothesis that patients with idiopathic adhesive capsulitis have lower shoulder activity than sex- and age-matched controls. METHODS Seventy-two eligible patients (37 men and 35 women) with idiopathic adhesive capsulitis completed a validated shoulder activity scale that was compared with sex- and age-matched norms from a healthy population with no history of shoulder disorders. The association of shoulder activity level with patient age, sex, and American Shoulder and Elbow Surgeons and Simple Shoulder Test (SST) scores was evaluated. RESULTS Overall, 58% of patients actually had higher shoulder activity scores than sex- and age-matched controls. Among patients aged 51 to 70 years, 68% of patients (73% of men and 63% of women) demonstrated higher Shoulder Activity Scale scores compared with controls. The activity level was higher among all patients aged 51 to 70 years compared with controls (10.3 ± 1.48 vs. 8 ± 0.52, P = .0067). The difference was significant for men in this age group (12.2 ± 1.7 vs. 9 ± 0.75, P = .0042). There was a statistically significant positive correlation of the Shoulder Activity Scale score with the SST score (r = 0.31, P = .009). CONCLUSION Patients with idiopathic adhesive capsulitis do not have a lower shoulder activity level than sex- and age-matched controls, and older men may actually have a higher level of shoulder activity than controls. Shoulder activity level is correlated with the SST score in patients with idiopathic adhesive capsulitis.
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Affiliation(s)
- Joseph D Lamplot
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Olivia Lillegraven
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA.
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Doria C, Mosele GR, Badessi F, Puddu L, Caggiari G. Shoulder Adhesive Capsulitis in Type 1 Diabetes Mellitus: A Cross-Sectional Study on 943 Cases in Sardinian People. JOINTS 2017; 5:143-146. [PMID: 29270543 PMCID: PMC5738482 DOI: 10.1055/s-0037-1605555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Purpose
To evaluate the prevalence of adhesive capsulitis (AC) of the shoulder in patients with type 1 diabetes mellitus (T1DM) in Sardinia.
Methods
In this cross-sectional study, we evaluated 943 patients with T1DM attending the division of Endocrinology and Metabolism at the University Hospital in Sassari, Italy. The criteria for diagnosing AC were: pain for at least 1 month, inability to lie on the affected shoulder, and restricted active and passive shoulder joint movements in at least three planes. Age, gender, duration of DM, blood pressure, and presence of neuropathy and retinopathy were noted. Metabolic control of DM was evaluated with glycosylated hemoglobin A1c (GHbA1c) blood concentrations.
Results
AC was diagnosed in 331 patients (prevalence: 35.1%). Age, duration of DM, high blood pressure levels, and the presence of neuropathy and retinopathy were significantly associated with AC. No significant association was observed between gender and AC. There was no significant difference in mean levels of GHbA1c in T1DM patients with or without AC.
Conclusion
This study shows that AC of the shoulder is a common disorder in patients with T1DM in Sardinia. It is significantly associated with age, duration of DM, and related complications.
Level of Evidence
Level IV, observational cross-sectional study.
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Affiliation(s)
- Carlo Doria
- Department of Orthopaedic, Medical School of Sassari, Sassari, Italy
| | - Giulia R Mosele
- Department of Orthopaedic, Medical School of Sassari, Sassari, Italy
| | - Francesca Badessi
- Division of Endocrinology and Metabolism, Medical School of Sassari, Sassari, Italy
| | - Leonardo Puddu
- Department of Orthopaedic, Medical School of Sassari, Sassari, Italy
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Safran O, El-Haj M, Leibowitz G, Beyth S, Furman Z, Milgrom C, Kandel L. Should Patients With Frozen Shoulder Be Screened for Diabetes Mellitus? Orthop J Sports Med 2017; 5:2325967117716450. [PMID: 28812038 PMCID: PMC5528946 DOI: 10.1177/2325967117716450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Idiopathic frozen shoulder (nontraumatic) is commonly encountered in patients between the ages of 35 and 60 years in general orthopaedic practice. While the prevalence of frozen shoulder among the general population is estimated to be between 2% and 4%, a significantly higher prevalence of 10% to 22% has been reported in patients with diabetes mellitus. Since diabetic patients are more prone to develop frozen shoulder than nondiabetics, the question arises as to whether patients diagnosed as having idiopathic frozen shoulder are at greater risk to develop diabetes mellitus and should be routinely screened for this condition. Purpose: To compare the prevalence of diabetes mellitus and prediabetes among patients diagnosed with idiopathic frozen shoulder who are not known to have either diabetes mellitus or prediabetic conditions with that of an age-matched group from the general population. Study Design: Case series; Level of evidence, 4. Methods: Patients at a shoulder clinic with a diagnosis of idiopathic frozen shoulder were asked to participate in the study if they were aged between 35 to 60 years and had no known previous diagnosis of diabetes mellitus or prediabetic conditions. These patients underwent a 2-hour oral glucose tolerance test. According to their fasting and 2-hour plasma glucose levels, patients were diagnosed as normal glucose tolerance, prediabetic, or diabetic. Findings were matched with the prevalence in an age-matched general population. Results: Fifty patients completed the test. Four patients with idiopathic frozen shoulder (8%) were found to be prediabetic. No patient was found to be diabetic. All 4 patients reported a history of diabetes in their parents or siblings. Conclusion: Patients diagnosed with idiopathic frozen shoulder who are 60 years or younger and are not known diabetics have a similar probability of having diabetes or prediabetes to an age-matched population. No routine diabetic workup is warranted specifically for these patients.
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Affiliation(s)
- Ori Safran
- Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Madi El-Haj
- Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Gil Leibowitz
- Department of Endocrinology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shaul Beyth
- Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Zohar Furman
- Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Charles Milgrom
- Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Leonid Kandel
- Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Inayat F, Ali NS, Shahid H, Younus F. Prevalence and Determinants of Frozen Shoulder in Patients with Diabetes: A Single Center Experience from Pakistan. Cureus 2017; 9:e1544. [PMID: 29018641 PMCID: PMC5630460 DOI: 10.7759/cureus.1544] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction Frozen shoulder (FS) or adhesive capsulitis is a constellation of symptoms like pain, stiffness, and/or functional deficit at the glenohumeral joint. It is one of the musculoskeletal complications in patients with diabetes that can be particularly debilitating. The aim of this study is to estimate the prevalence of FS and to compare the determinants of this disease in a population with diabetes from Lahore, Pakistan. Materials and Methods We carried out this cross-sectional study on a systematically randomized sample of 80 patients with diabetes. It included 38 males and 42 females from 2,964 patients registered at the Diabetes Management Center, Services Hospital Lahore, Pakistan. The study was conducted in the months of April, May, and June 2017. A structured questionnaire was designed and the responses of patients were recorded at the clinic after informed verbal and written consent. The questionnaire outlined the key factors that can lead to a higher frequency of FS in patients with diabetes. Results Thirty-three of the total 80 respondents included in the study were diagnosed with FS. The estimated prevalence of FS in diabetics from this data was 41.3% in Lahore, which is an urban area of Pakistan with a population of more than seven million. Female sex, insulin dependence, uncontrolled blood glucose levels, and a positive family history were associated with a significantly higher prevalence of FS. In our study, most patients with FS were in Stage 1 of the disease and had unilateral involvement. Conclusion The present study shows that the prevalence of FS is higher in patients with diabetes residing in Lahore than in comparable foreign populations with diabetes. It can be attributed to socioeconomic status, lack of awareness, a higher threshold for diagnosis, and/or poor glycemic control. Mass awareness campaigns, especially for female patients with diabetes, are required to be initiated to create awareness about the disease and to facilitate early diagnosis and appropriate management. In-depth and multicenter studies are needed to further explore the association between FS and diabetes.
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Affiliation(s)
- Faisal Inayat
- Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical College, New York City, NY, USA
| | - Nouman Safdar Ali
- Department of Medicine, Jinnah Hospital, Allama Iqbal Medical College, Lahore, Pakistan
| | - Haroon Shahid
- Department of Radiology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan
| | - Fariha Younus
- Department of Medicine Unit 4, Services Hospital, Services Institute of Medical Sciences, Lahore, Pakistan
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Vaishya R, Agarwal AK, Vijay V. Adhesive capsulitis: Current practice guidelines. APOLLO MEDICINE 2016. [DOI: 10.1016/j.apme.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rouhani A, Mardani-Kivi M, Bazavar M, Barzgar M, Tabrizi A, Hashemi-Motlagh K, Saheb-Ekhtiari K. Calcitonin effects on shoulder adhesive capsulitis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:575-80. [DOI: 10.1007/s00590-016-1816-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/27/2016] [Indexed: 11/30/2022]
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Itoi E, Arce G, Bain GI, Diercks RL, Guttmann D, Imhoff AB, Mazzocca AD, Sugaya H, Yoo YS. Shoulder Stiffness: Current Concepts and Concerns. Arthroscopy 2016; 32:1402-14. [PMID: 27180923 DOI: 10.1016/j.arthro.2016.03.024] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/04/2016] [Accepted: 03/10/2016] [Indexed: 02/02/2023]
Abstract
UNLABELLED Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term "frozen shoulder" as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome. LEVEL OF EVIDENCE Level V, evidence-based review.
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Affiliation(s)
- Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan.
| | - Guillermo Arce
- Department of Orthopaedic Surgery, Instituto Argentino de Diagnóstico y Tratamiento, Buenos Aires, Argentina
| | - Gregory I Bain
- Department of Orthopedic Surgery, Flinders University, Adelaide, South Australia, Australia
| | - Ronald L Diercks
- Sports Medicine Center, Department of Orthopaedic Surgery, University of Groningen, Groningen, the Netherlands
| | - Dan Guttmann
- Taos Orthopaedic Institute, Shoulder and Elbow Service, Taos, New Mexico, U.S.A
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, University of Munich (TUM), Hospital Rechts der Isar, Munich, Germany
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, Farmington, Connecticut, U.S.A
| | - Hiroyuki Sugaya
- Shoulder & Elbow Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Yon-Sik Yoo
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Gyeonggi-Do, Republic of Korea
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Pons-Villanueva J, Escalada San Martín J. The stiff shoulder in diabetic patients. Int J Rheum Dis 2016; 19:1226-1236. [DOI: 10.1111/1756-185x.12890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Juan Pons-Villanueva
- Department of Orthopedic Surgery and Traumatology; Clínica Universidad de Navarra; Pamplona Spain
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Sun Y, Lu S, Zhang P, Wang Z, Chen J. Steroid Injection Versus Physiotherapy for Patients With Adhesive Capsulitis of the Shoulder: A PRIMSA Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicine (Baltimore) 2016; 95:e3469. [PMID: 27196452 PMCID: PMC4902394 DOI: 10.1097/md.0000000000003469] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To compare the effect of steroid injection and physiotherapy for patients with adhesive capsulitis of the shoulder (ACS).An electronic search was performed on Pubmed, Embase, and Cochrane library, and reference lists were also reviewed for randomized controlled trials (RCTs) comparing steroid injection and physiotherapy for patients with ACS. The quality of included studies were assessed using PEDro scale. Standardized mean differences (SMDs) and 95% confidence interval (CI) were used for comparisons. The primary outcome was functional improvement.Nine RCTs including 453 patients were identified. From 6-7 weeks to 24-26 weeks postintervention, no superiority was noted in favor of either steroid injection or physiotherapy for functional improvement (SMD 0.28; 95% CI -0.01-0.58; P = 0.06) or pain relief (SMD -0.10; 95% CI -0.70-0.50; P = 0.75). Steroid injection provided more improvement in passive external rotation at 24 to 26 weeks (3 studies, SMD 0.42; 95% CI 0.11-0.72; P = 0.007) but not at 6 to 7 weeks (4 studies, SMD 0.63; 95% CI 0.36-0.89; P = 0.32) or 12 to 16 weeks (3 studies, SMD -0.07; 95% CI -0.79-0.65; P = 0.85). Steroid injection was as safe as physiotherapy for patients with ACS (risk ratio 0.94; 95% CI 0.67-1.31).Both steroid injection and physiotherapy are equally effective for patients with ACS. One steroid injection might be the 1st choice for ACS. Results should be interpreted with caution due to the heterogeneity among the studies.
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Affiliation(s)
- Yaying Sun
- From the Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai (YS, PZ, JC); and Department of Cardiology, Union Hospital, Huazhong University of Science and Technology, Wuhan, People's Republic of China (SL, ZW)
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Kwaees TA, Charalambous CP. Rates of surgery for frozen shoulder: an experience in England. Muscles Ligaments Tendons J 2016; 5:276-9. [PMID: 26958535 DOI: 10.11138/mltj/2015.5.4.276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
AIM the aim of this study was to identify the incidence of surgical treatment for frozen shoulder in a western population. METHODS patients included in this study all resided within a well-defined area in the North West of England, all had surgery for frozen shoulder over a 3-year period and were identified from theatre logbooks of two local hospitals. Cases having surgery for shoulder stiffness other than frozen shoulder were excluded. Local and national population size estimates were based on data obtained from the UK Office for National Statistics. RESULTS 117 patients underwent surgery for frozen shoulder during the period examined; of these 101 had arthroscopic arthrolysis and 16 had manipulation under anaesthesia. The overall incidence of frozen shoulder surgery was calculated at 2.67 procedures per 10,000 general population per year, and at 7.55 for those aged 40-60. CONCLUSION surgical intervention for frozen shoulder is common, estimated at over 14,180 cases per year in England. Given the variation in costs associated with arthroscopic arthrolysis and manipulation under anaesthesia, comparative studies of the cost effectiveness of the two procedures would be of great value. LEVEL OF EVIDENCE 2C (outcome research).
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Affiliation(s)
- Tariq A Kwaees
- Department of Trauma & Orthopedics, Blackpool Victoria Hospital, UK
| | - Charalambos P Charalambous
- Department of Orthopaedics, Blackpool Victoria Hospital; School of Medicine and Dentistry, University of Central Lancashire; Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, University of Manchester, UK
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