Diabetes as a risk factor for the onset of frozen shoulder: a systematic review and meta-analysis

Risk factors and predictive models for frozen shoulder

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

Factors associated with frozen shoulder in adults: a retrospective study

OBJECTIVE

This study aims to explore the risk factors associated with frozen shoulder patients and further analyze the relationship between gender and diabetes with frozen shoulder.

METHOD

We have reviewed the data of 1205 frozen shoulder patients in China's Xinjiang region from 2018 to 2023. The collected information included patients' gender, occupation, place of origin, marital status, age, the season of disease onset, duration of illness, etiology, surgical history, hypertension, diabetes, respiratory diseases, knee joint disease, hyperlipidemia, cardiovascular diseases, cervical spondylosis, lumbar disc herniation, rheumatoid arthritis, hyperuricemia, sleep quality, smoking and alcohol consumption, and constipation. We have used multifactor logistic regression analysis to identify the risk factors for a frozen shoulder.

RESULTS

Single-factor logistic regression analysis showed that the number of females, patients with diabetes, knee joint disease, constipation, and patients with poor sleep quality in the observation group are higher than in the control group (P < 0.05). There were no statistically significant differences between the two groups in terms of occupation, place of origin, marital status, age, season of disease onset, duration of illness, etiology, surgical history, hypertension, respiratory diseases, hyperlipidemia, cardiovascular diseases, cervical spondylosis, lumbar disc herniation, rheumatoid arthritis, hyperuricemia, smoking, and alcohol consumption history (P > 0.05). Multivariate analysis showed that the final model included four variables: gender, diabetes history, sleep, and constipation. Among them, the OR values of gender and diabetes history were more significant than 1, indicating that they were independent risk factors for frozen shoulder, while the OR values of sleep and constipation were less than 1, suggesting that they were negatively associated with the occurrence of frozen shoulder.

CONCLUSION

The results of this study suggest that gender and diabetes are independent risk factors for frozen shoulder. Additionally, poor sleep quality and constipation also can be correlated with the occurrence of a frozen shoulder.

Comparative effectiveness of low-level laser therapy versus muscle energy technique among diabetic patients with frozen shoulder: a study protocol for a parallel group randomised controlled trial

BACKGROUND

Diabetes mellitus is one of the fastest-growing health challenges of the twenty-first century with multifactorial impact including high rates of morbidity and mortality as well as increased healthcare costs. It is associated with musculoskeletal complications, with frozen shoulder being commonly reported. While low-level laser therapy (LLLT) and muscle energy technique (MET) are commonly used to manage  this condition, there remains a lack of agreement on the most effective approach, with limited research available on their comparative efficacy.

OBJECTIVES

To evaluate the comparative effectiveness of LLLT versus MET among diabetic patients with frozen shoulder.

METHODS

This is a single-centre, prospective, single-blind, randomised controlled trial with three parallel groups to be conducted at Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria. Sixty diabetic patients with frozen shoulder will be randomly assigned into LLLT group, MET group, or control group in a 1:1:1 ratio. All the groups will receive treatment three times weekly for 8 weeks. The primary outcome will be shoulder function and the secondary outcomes will include pain intensity, shoulder ROM, interleukin-6 (IL-6), depression, anxiety, and quality of life (QoL). All outcomes will be assessed at baseline, at post 8-week intervention, and at 3 months follow-up.

DISCUSSION

This will be the first randomised controlled trial to evaluate the comparative effectiveness of LLLT versus MET on both clinical and psychological parameters among diabetic patients with frozen shoulder. The findings of the study may provide evidence on the efficacy of these interventions and most likely, the optimal treatment approach for frozen shoulder related to diabetes, which may guide clinical practice.

TRIAL REGISTRATION

Pan African Clinical Trials Registry (PACTR202208562111554). Registered on August 10, 2022.

Agomir-122-loaded nanoparticles coated with cell membrane of activated fibroblasts to treat frozen shoulder based on homologous targeting

As a common musculoskeletal disorder, frozen shoulder is characterized by thickened joint capsule and limited range of motion, affecting 2-5% of the general population and more than 20% of patients with diabetes mellitus. Pathologically, joint capsule fibrosis resulting from fibroblast activation is the key event. The activated fibroblasts are proliferative and contractive, producing excessive collagen. Albeit high prevalence, effective anti-fibrosis modalities, especially fibroblast-targeting therapies, are still lacking. In this study, microRNA-122 was first identified from sequencing data as a potential therapeutic agent to antagonize fibroblast activation. Then, Agomir-122, an analog of microRNA-122, was loaded into poly(lactic-co-glycolic acid) (PLGA) nanoparticles (Agomir-122@NP), a carrier with excellent biocompatibility for the agent delivery. Moreover, relying on the homologous targeting effect, we coated Agomir-122@NP with the cell membrane derived from activated fibroblasts (Agomir-122@MNP), with an attempt to inhibit the proliferation, contraction, and collagen production of abnormally activated fibroblasts. After confirming the targeting effect of Agomir-122@MNP on activated fibroblasts in vitro, we proved that Agomir-122@MNP effectively curtailed fibroblasts activation, ameliorated joint capsule fibrosis, and restored range of motion in mouse models both prophylactically and therapeutically. Overall, an effective targeted delivery method was developed with promising translational value against frozen shoulder.

Corticosteroid Injection Methods for Frozen Shoulder: A Network Meta-analysis

OBJECTIVE

To investigate the efficacy of corticosteroid (CS) injection methods for frozen shoulder.

DATA SOURCES

PubMed, Embase, and Cochrane Library were searched up to May 6, 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) that investigated CS injection methods for frozen shoulder were included.

DATA EXTRACTION

Data were extracted independently by 2 authors. Risk of bias was assessed using the RoB 2 tool.

DATA SYNTHESIS

A random-effects network meta-analysis was performed within a frequentist framework. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. A total of 66 RCTs involving 4491 patients were included. For short-term outcomes, 4-site injection (vs placebo [PLA]: standardized mean difference [SMD]=-2.20, 95% confidence interval [CI], -2.81 to -1.59 in pain; SMD=2.02; 95% CI, 1.39-2.65 in global function) was the most effective (low certainty). Rotator interval injection was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.07, 95% CI, -1.51 to -0.64 in pain; SMD=0.94, 95% CI, 0.49-1.40 in global function). For midterm outcomes, 4-site injection was most effective (vs PLA: SMD=-1.71, 95% CI, -2.41 to -1.01 in pain; SMD=2.22, 95% CI, 1.34-3.09 in global function; low certainty). Distension via rotator interval (D-RI) was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.10, 95% CI, -1.69 to -0.51 in pain; SMD=1.46, 95% CI, 0.73-2.20 in global function). Distension and intra-articular injection via anterior or posterior approaches produced effects equivalent to those of rotator interval injection and D-RI.

CONCLUSIONS

Rotator interval injection, distension, and intra-articular injection had equivalent effects on symptom relief. More RCTs are required to validate the superiority of multisite injections.

Type 2 diabetes and fasting glycemic traits are causal factors of frozen shoulder: a 2-sample Mendelian randomization analysis

BACKGROUND

The causal relationship between type 2 diabetes (T2D) and frozen shoulder is unclear. This study aims to explore the genetic causal association between T2D and glycemic traits (fasting glucose [FG], fasting insulin [FI], glycated hemoglobin [HbA1c], and 2-hour postprandial glucose [2hGlu]) on frozen shoulder.

METHODS

Using 2-sample Mendelian randomization (MR), we analyzed nonconfounded estimates of the effects of T2D and glycemic traits on frozen shoulder. Single-nucleotide polymorphisms (SNPs) strongly associated (P < 5 × 10-8) with exposures from genome-wide association studies (GWAS) were identified. We employed fixed effect mode inverse variance weighting (IVW-FE), random effect mode IVW (IVW-MRE), MR-Egger, and weighted median to assess the association of exposures and outcome. Sensitivity analysis was conducted to test for heterogeneity and multidirectionality bias in MR.

RESULTS

We found a significant genetic causal correlation between T2D (IVW-MRE P = .007, odds ratio [OR] 1.093, 95% confidence interval [CI] 1.03-1.16), FG (IVW-FE P < .001, OR 1.455, 95% CI 1.173-1.806), and frozen shoulder, but no evidence for causal correlation between FI, HbA1c, and 2hGlu and frozen shoulder. Although there was certain heterogeneity, sensitivity analysis reveals no deviation from the MR assumptions.

CONCLUSION

This study supports a genetic causal relationship between T2D and FG and frozen shoulder.

Arthroscopic capsular release for frozen shoulder: when etiology matters

PURPOSE

No therapeutic intervention is universally accepted for frozen shoulder, and the most effective management to restore motion and diminish pain has yet to be defined. The aim of this study was to investigate functional and psychological outcomes in patients who underwent arthroscopic capsular release for a frozen shoulder.

METHODS

A retrospective study with prospective data collection was conducted with 78 patients suffering from frozen shoulder resistance to conservative treatment. Considering the etiology, there were 36 (46.2%) idiopathic, 31 (39.7%) postoperative, and 11 (14.1%) posttraumatic cases. Preoperatively, each patient was evaluated with the range of motion (ROM) assessment and the Constant-Murley score (CMS). At follow-up, the 4-point subjective satisfaction scale (SSS), the ROM assessment, the SF-12 questionnaire, the numerical rating scale (NRS) for the subjective assessment of pain, the CMS and the Hospital Anxiety and Depression Scale (HADS) were assessed.

RESULTS

After a mean follow-up of 54.2 ± 22.3 months, ROM and CMS showed a statistically significant improvement between pre- and postoperative values (all p < 0.001). Before surgery, the mean CMS was 36.9% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 99.9% that of sex- and age-matched healthy individuals, and 49 (62.8%) patients showed a CMS equal to or higher than the normative data. The mean increase in the CMS was 56.1 ± 8.3 points. The mean SSS, HADS-A, HADS-D, and NRS were 3.7 ± 0.5, 2.5 ± 1.6, 2.2 ± 1.3, and 2.2 ± 1.0, respectively. All patients returned to their previous level of work and sports activity after 2 and 2.5 months, respectively. The multivariate analysis showed the association between a higher postoperative CMS and the idiopathic etiology of a frozen shoulder (p = 0.004, β = 3.971). No intraoperative complications occurred. Postoperatively, four patients (5.1%) were treated with intra-articular steroid injections to manage residual symptoms. One patient (1.3%) with a postoperative frozen shoulder showed persistent symptoms and underwent a new successful arthroscopic capsular release.

CONCLUSION

High patient satisfaction and statistically significant ROM and CMS recovery can be achieved after arthroscopic capsular release to manage frozen shoulder. Better functional outcomes are expected when the etiology is idiopathic. Results can help surgeons identify the patients who will most benefit from surgery and should be discussed with the patient.

LEVEL OF EVIDENCE

III.

ProBDNF and its receptors in immune-mediated inflammatory diseases: novel insights into the regulation of metabolism and mitochondria

Immune-mediated inflammatory diseases (IMIDs) consist of a common and clinically diverse group of diseases. Despite remarkable progress in the past two decades, no remission is observed in a large number of patients, and no effective treatments have been developed to prevent organ and tissue damage. Brain-derived neurotrophic factor precursor (proBDNF) and receptors, such as p75 neurotrophin receptor (p75^NTR) and sortilin, have been proposed to mediate intracellular metabolism and mitochondrial function to regulate the progression of several IMIDs. Here, the regulatory role of proBDNF and its receptors in seven typical IMIDs, including multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, allergic asthma, type I diabetes, vasculitis, and inflammatory bowel diseases, was investigated.

A Case Series: Effect of Comorbidities on the Outcomes of Prolotherapy Injection for Frozen Shoulder Patients

Frozen shoulder (FS) is a disease caused by an inflammatory condition that causes severe pain and decreased range of motion by loss of glenohumeral mobility. Frozen Shoulder restricts daily life's functional aspect, increasing morbidity. Hypertension and diabetes mellitus are risk factors that make an FS poor prognosis during treatment because of the diabetes glycation process and hypertension-enhanced vascularization. Prolotherapy injects an irritant solution into the tendon, joints, ligaments, and joint spaces to release growth factors and collagen deposition, reducing pain, restoring joint stability, and increasing the quality of life. We report 3 cases of patients with confirmed FS. Patient A with no comorbidity, patient B with diabetes mellitus, and patient C with hypertension, with all patient's chief complaints of shoulder pain and limited ROM, and symptoms affected the general quality of daily life. This patient was provided injection with Prolotherapy treatment combined with physical therapy intervention. Patient A had significantly improved ROM to maximum after 6 weeks with relieved pain and improved shoulder function. Patients B and C showed increased ROM, still tiny, decreased pain, and improved shoulder function. In conclusion, prolotherapy demonstrated a beneficial effect in a patient with FS with comorbidities, although not to the maximum extent in patients without comorbidity.