Is there an association between metabolic syndrome and rotator cuff-related shoulder pain? A systematic review

Metabolic syndrome is prevalent and undiagnosed in clients attending private practice physiotherapy: a cross-sectional study

OBJECTIVES

To determine the prevalence of metabolic syndrome in clients presenting for primary care physiotherapy within private practice settings, and the factors that may be associated with metabolic syndrome. The secondary aim was to determine client's attitudes towards lifestyle change.

DESIGN

A cross-sectional study in which self-report and biometric data were collected. The study was conducted in physiotherapy private practices across metropolitan and regional areas, Australia.

PARTICIPANTS

230 clients (mean age 54 (SD18) years, 64% women) presenting for physiotherapy participated.

MAIN OUTCOME MEASURES

Participant socio-demographic and lifestyle characteristics were collected. Metabolic syndrome presence was determined by the existence of three or more risk factors on physical examination and capillary blood sample: abdominal obesity, hypertension, elevated random blood glucose, elevated triglycerides and/or reduced HDL cholesterol.

RESULTS

Thirty-seven percent of participants had metabolic syndrome, but none knew they had it. Metabolic syndrome was associated with older age and poorer socio-economic status and may have been associated with lower levels of physical activity but not diet. Of those identified as having hypertension and elevated triglycerides, many were undiagnosed (56% and 29% respectively).

CONCLUSION

Metabolic syndrome is prevalent and undiagnosed in clients attending private practice physiotherapy. Clients felt lifestyle change was important and they were willing to make changes. This study highlights the need for greater screening of metabolic risk factors in primary care and presents an opportunity for physiotherapists in private practice to identify risk and intervene to improve the overall health of their clients and contribute to chronic disease prevention. CONTRIBUTION OF THE PAPER.

Occupational Stress as a Possible Risk Factor for Rotator Cuff Damage - Systematic Review and Meta-analysis

PURPOSE

In September 2021, the Federal Ministry of Labour and Social Affairs in Germany (BMAS) recommended recognising rotator cuff lesions caused by occupational long-term overhead work, repetitive movements, hand-arm-vibration and carrying and lifting heavy loads as an occupational disease. To gain a more detailed understanding of the correlation between occupational risk factors and lesions of the rotator cuff, a systematic literature review was carried out to determine their influence on the development of rotator cuff disease.

MATERIAL AND METHOD

A systematic literature review was used to search in the databases PubMed, Cochrane and Web-of-Science for papers dealing with occupational shoulder load and associated shoulder disorders. The influence of overhead work, repetitive movements, hand-arm-vibrations and carrying and lifting heavy loads were examined.

RESULTS

58 studies were read in full text, of which 13 papers were included in the meta-analysis. In all risk factors, a significant association can be found with the strongest dose-response relationship in "overhead work" and "repetitive movements": overhead work: 2.23 (95% CI 1.98-2.52), repetitive movements: 2.17 (95% CI 1.92-2.46), hand-arm-vibration: 1.59 (95% CI 1.13-2.23), carrying and lifting heavy loads: 1.57 (95% CI 1.15-2.15).

CONCLUSION

Although a significant effect could be shown in our study for all the four risk factors examined, due to the low number of studies with high-quality study design and insufficient pathophysiological explanation for the development of a rotator cuff disease in these mechanical activities, no reliable correlation can currently be established.

Increased Risk of Coronary Artery Disease in People with Diagnosis of Neuromuscular Disorders: A Nationwide Retrospective Population-Based Case-Control Study

The existing literature has explored carpal tunnel syndrome (CTS) and determined that it could be a risk for coronary artery disease (CAD), but there has been little research comparing the relevance of CAD with other neuromuscular disorders (NMDs) to CTS. This case-control study explored the association between CTS, stenosing tenosynovitis (ST), and ulnar side NMDs and CAD. The study utilized data from Taiwan's National Health Insurance Research Database, focusing on health insurance claims. Between January 2000 and December 2011, we employed the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes to identify 64,025 CAD patients as the case group. The control group consisted of an equal number of individuals without CAD, matched for age, sex, and index year of CAD. Logistic regression analysis was employed to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for each variable. Multivariate analysis, after adjusting for sociodemographic factors and comorbidities, revealed a significantly higher likelihood of a previous diagnosis of CTS in the CAD group compared to the comparison control group. However, neither ST nor the ulnar side NMDs had any statistical significance. These results indicated that median nerve injury, rather than other NMDs, may uniquely serve as a predisposing factor of CAD.

Effectiveness of non-surgical management in rotator cuff calcific tendinopathy (the effect trial): protocol for a randomised clinical trial

INTRODUCTION

Rotator cuff calcific tendinopathy (RCCT) involves calcific deposits in the rotator cuff. Non-surgical interventions such as extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) are recommended for its early management. Exercise therapy (ET) has shown to be an effective intervention for people with rotator cuff tendinopathy, but it has not been formally tested in RCCT. The main objective of this study is to compare the effectiveness of an ET programme with ESWT and US-PICT in people with RCCT. As a secondary aim, this study aims to describe the natural history of RCCT.

METHODS AND ANALYSIS

A randomised, single-blinded four-group clinical trial will be conducted. Adults from 30 to 75 years diagnosed with RCCT who accomplish eligibility criteria will be recruited. Participants (n=116) will be randomised into four groups: ET group will receive a 12-week rehabilitation programme; ESWT group will receive four sessions with 1 week rest between sessions during 1 month; US-PICT group will receive two sessions with 3 months of rest between sessions; and (actual) wait-and-see group will not receive any intervention during the 12-month follow-up. The primary outcome will be shoulder pain assessed with the Shoulder Pain and Disability Index at baseline, 2 weeks, 4 months, 6 months and 12 months from baseline. The primary analysis will be performed at 12 months from baseline. Secondary outcomes will include pain, range of motion, patient satisfaction and imaging-related variables. Moreover, the following psychosocial questionnaires with their corresponding outcome measure will be assessed: Central Sensitization Inventory (symptoms related to central sensitization); Pain Catastrophizing Scale (pain catastrophizing); Tampa Scale for Kinesiophobia 11 items (fear of movement); Fear Avoidance Belief Questionnaire (fear avoidance behaviour); Hospital Anxiety and Depression Scale (anxiety and depression); Pittsburgh Sleep Quality Index (sleep quality); and the EuroQol-5D (quality of life). An intention-to-treat analysis will be performed to reduce the risk of bias using a worst-case and best-case scenario analysis.

ETHICS AND DISSEMINATION

Ethics committee approval for this study has been obtained (reference number: 1718862). The results of the main trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05478902.

Patellofemoral Pain Syndrome Is Associated With Chronic Disease and Allergies in 60 997 Distance Runner Race Entrants: SAFER XXX Study

OBJECTIVE

Patellofemoral pain syndrome (PFPS) is a common running-related injury. Independent risk factors associated with PFPS have not been described in a large cohort of distance runners.

DESIGN

Descriptive, cross-sectional study.

SETTING

21.1 and 56 km Two Oceans Marathon races (2012-2015).

PARTICIPANTS

60 997 race entrants.

ASSESSMENT OF RISK FACTORS

Participants completed a compulsory prerace medical screening questionnaire (history of PFPS in the past 12 months, n = 362; no injury history, n = 60 635). Selected risk factors associated with a history of PFPS were explored using univariate & multivariate analyses: demographics, training/running variables, history of chronic diseases (composite chronic disease score), and any allergy.

MAIN OUTCOME MEASURES

Prevalence ratios (PRs, 95% confidence intervals).

RESULTS

Risk factors associated with PFPS (univariate analysis) were increased years of recreational running (PR = 1.09; P = 0.0107), older age (>50 years), and chronic diseases (PR > 2): gastrointestinal disease (PR = 5.06; P < 0.0001), cardiovascular disease (CVD) (PR = 3.28; P < 0.0001), nervous system/psychiatric disease (PR = 3.04; P < 0.0001), cancer (PR = 2.83; P = 0.0005), risk factors for CVD (PR = 2.42; P < 0.0001), symptoms of CVD (PR = 2.38; P = 0.0397), and respiratory disease (PR = 2.00; P < 0.0001). Independent risk factors (multivariate analysis) associated with PFPS (adjusted for age, sex, and race distance) were a higher chronic disease composite score (PR = 2.68 increased risk for every 2 additional chronic diseases; P < 0.0001) and a history of allergies (PR = 2.33; P < 0.0001).

CONCLUSIONS

Novel independent risk factors associated with PFPS in distance runners are a history of multiple chronic diseases and a history of allergies. Identification of chronic diseases and allergies should be considered as part of the clinical assessment of a runner presenting with a history of PFPS.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Efficacy of combined strategies of physical activity, diet and sleep disorders as treatment in patients with chronic shoulder pain. A systematic review

Introduction: The objective of this systematic review was to analyze the existing scientific evidence on the influence of dietary strategies, exercise, and sleep disorders on the symptomatology of patients with chronic shoulder pain, as well as to assess the methodological quality of the literature collected. Methods: The selection criteria were as follows: we included randomized controlled clinical trials written in English that investigated the effects of such interventions in patients with chronic shoulder pain and excluded studies where pre-operative rehabilitation or rehabilitation combined with corticosteroid injections was performed. We searched six databases Pubmed, Cochrane Library, Web of Science, CINAHL, Sportdiscus and Scopus, using the keywords "shoulder pain," "fasting," "physical therapy modalities," "rehabilitation," "exercise," "circadian clocks," and "chronic pain" to select randomized controlled clinical trials conducted in humans and written in English. The last search was conducted on 24/01/2023. (PROSPERO:CRD42023379925). Results: We used the tool proposed by the Cochrane Handbook to assess the risk of bias in the included studies of the 17 studies included, nine had a high risk of bias, two studies had an unclear risk of bias, and the remaining six studies had a low risk of bias. A total of 17 articles were selected, including 10 studies that showed a positive influences of exercise on chronic shoulder pain and five studies that showed a negative influence of sleep disorders on this patient profile. The remaining two articles analyzed the influence of nutritional strategies and metabolic problems in patients with chronic shoulder pain. The total sample size of the 17 included articles amounted to 9,991 individuals. Discussion: Studies confirm that exercise generates a hypoalgesic effect that improves chronic shoulder pain, functionality, and quality of life. Although dietary strategies and sleep disorders are known to influence chronic shoulder pain, there is a lack of studies that conduct interventions on these problems to assess how chronic shoulder pain varies.

Metabolic Syndrome: Is Arthroscopic Rotator Cuff Repair Safe in This Patient Population?

Purpose Metabolic syndrome is associated with postoperative morbidity and mortality in surgical patients. With the increased use of arthroscopic techniques for rotator cuff repair (RCR), it is important to identify the impact this disorder has on surgical patients. The purpose of this study is to evaluate the clinical impact of metabolic syndrome on outcomes following arthroscopic RCR. Methods The 2006-2019 National Surgical Quality Improvement Program database was queried for adult patients who underwent arthroscopic RCR. Two patient groups were categorized: patients with metabolic syndrome and patients without metabolic syndrome. Demographics, comorbidities, and 30-day postoperative outcomes were compared using bivariate and multivariate analyses. Results Of 40,156 patients undergoing arthroscopic RCR, 36,391 did not have metabolic syndrome and 3,765 had metabolic syndrome. After adjusting for differences in baseline characteristics between the two groups, those with metabolic syndrome had an increased risk of developing renal complications and cardiac complications, as well as requiring hospital admission postoperatively and hospital readmission. Conclusion Metabolic syndrome is an independent risk factor for developing renal and cardiac complications, as well as requiring overnight hospital admission and hospital readmission. Providers should understand the need for preoperative evaluation and surveillance of these patients following their surgery to minimize the risk of poor outcomes.

Biopsychosocial Approach in Identifying Risk Factors of Kinesiophobia in Persons with Subacromial Pain Syndrome and Developing a Clinical Prediction Tool

Introduction

Although the negative effects of kinesiophobia on functional status in subacromial pain syndrome (SAPS) patients are clearly demonstrated, no study examines the risk factors of kinesiophobia in individuals with SAPS from a biopsychosocial perspective. The present study aims to determine the risk factors of kinesiophobia in individuals with SAPS using a biopsychosocial approach. This study also aims to explore the compounding effects of multiple associative risk factors by developing a clinical prediction tool to identify SAPS patients at higher risk for kinesiophobia.

Materials and methods

This cross-sectional study included 549 patients who were diagnosed with SAPS. The Tampa-Scale of Kinesiophobia (TSK) was used to assess kinesiophobia. Visual analog scale (VAS), The Shoulder Pain and Disability Index (SPADI), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the presence of metabolic syndrome, using any non-steroidal anti-inflammatory drugs, Pain Catastrophizing Scale (PCS), Illness Perception Questionnaire-revised (IPQ-R), Hospital Anxiety and Depression Scale (HADS), behavioral pattern of the patient, sociodemographic characteristics, and treatment expectancy were outcome measures.

Results

Thirteen significant risk factors of having kinesiophobia were: VASat rest (≥ 5.2), VASduring activity (≥ 7.1), DASH (≥ 72.1), presence of metabolic syndrome, PCShelplessness (≥ 16.1), IPQ-Rpersonal control (≤ 17.1), IPQ-Rtreatment control (≤ 16.3), HADSdepression (≥ 7.9), avoidance behavior type, being female, educational level (≤ high school), average hours of sleep (≤ 6.8), and treatment expectancy (≤ 6.6). The presence of seven or more risk factors increased the probability of having high level of kinesiophobia from 34.3 to 51%.

Conclusions

It seems necessary to address these factors, increase awareness of health practitioners and individuals.

Level of evidence

Level IV.

Factors associated with patellofemoral pain in recreational road cyclists: A cross-sectional study in 59953 cyclists - SAFER XXXIII

OBJECTIVE

Patellofemoral pain (PFP) is a common cycling-related injury, and independent factors need to be identified to enable effective injury prevention strategies. We aim to determine factors associated with PFP in cyclists entering mass community-based events.

DESIGN

Cross-sectional study.

SETTING

2016-2020 Cape Town Cycle Tour.

PARTICIPANTS

Consenting race entrants.

MAIN OUTCOME MEASURES

62758 consenting race entrants completed a pre-race medical questionnaire, and 323 reported PFP. Selected factors associated with PFP (demographics, cycling experience and training, chronic disease history) were explored using multivariate analyses.

RESULTS

Prevalence ratio (PR) of PFP was similar for sex and age groups. Independent factors associated with PFP (adjusted for sex and age) were history of chronic disease [Composite Chronic Disease Score (0-10)(PR = 2.0, p < 0.0001) and any allergies (PR = 2.0, p < 0.0001)].

CONCLUSION

A history of chronic diseases and allergies is associated with PFP in cyclists. Practical clinical recommendations are: 1) that prevention programs for PFP be considered when cycling is prescribed as a physical activity intervention for patients with chronic disease, and 2) that older cyclists presenting with PFP be assessed for the presence of risk factors or existing chronic disease.

"You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise." A scoping review of the possible mechanisms underpinning exercise therapy

BACKGROUND

Exercise is considered to be both essential and at the forefront of the management of rotator cuff-related shoulder pain (RCRSP). Despite this, many fail to substantially improve with exercise-based treatment. Hence, expanding the current knowledge about the possible mechanisms of exercise for RCRSP is critical.

OBJECTIVE

To synthesise the range of mechanisms proposed for exercise in people with RCRSP.

DESIGN

Scoping review METHODS: A systematic search of the Physiotherapy Evidence Database (PEDro) was conducted from inception to July 3, 2022. Two reviewers conducted the search and screening process and one reviewer extracted the data from each study. Randomised clinical trials using exercise for the management of RCRSP of any duration were included. The PEDro search terms used were "fitness training", "strength training", "stretching, mobilisation, manipulation, massage", "upper arm, shoulder, or shoulder girdle", "pain", and "musculoskeletal". Data were analysed using quantitative and qualitative approaches.

RESULTS

626 studies were identified and 110 were included in the review. Thirty-two unique mechanisms of exercise were suggested by clinical trialists, from which 4 themes emerged: 1) neuromuscular 2) tissue factors 3) neuro-endocrine-immune 4) psychological. Neuromuscular mechanisms were proposed most often (n = 156, 77%). Overall, biomedical mechanisms of exercise were proposed in 95% of cases.

CONCLUSIONS

The causal explanation for the beneficial effect of exercise for RCRSP in clinical research is dominated by biomedical mechanisms, despite a lack of supporting evidence. Future research should consider testing the mechanisms identified in this review using mediation analysis to progress knowledge on how exercise might work for RCRSP.

Prediction of Bilaterality in Patients With 1 Posterosuperior Rotator Cuff Tear

BACKGROUND

In patients with a known unilateral posterosuperior rotator cuff tear (PSRCT), the ability to predict a contralateral PSRCT may assist in earlier diagnosis and improved patient outcomes.

PURPOSE

To determine factors associated with bilateral PSRCT and their most predictive combinations using a nonhospitalized general population.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This study involved 736 individuals (n = 1472 shoulders) drawn from a rural cohort. PSRCT was diagnosed using magnetic resonance imaging. Symptoms of the contralateral shoulder were not considered. The demographic, physical, social, metabolic, and imaging factors, as well as comorbidities, were evaluated using logistic regression analysis. Cutoff values for the significantly associated variables obtained from multivariable logistic regression analysis were calculated using the receiver operating characteristic (ROC) curve. The areas under the ROC curve (AUCs) of the combinations of significantly associated variables were compared using the DeLong method to determine the combination most predictive of bilateral PSRCT. The likelihood ratio and the posttest probability for each of the combinations were assessed.

RESULTS

Age ≥61 years, manual labor, critical shoulder angle (CSA) ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome were significantly associated with bilateral PSRCT in multivariable analysis (P < .001). The 1-by-1 combination of any 4 of the 6 associated factors significantly increased the AUC of any smaller combinations of those 6 factors (P < .001). The AUCs of the 4-somes were all similar (P ≥ .383) and were not significantly increased by further addition of identified associated factors (P ≥ .422). Any combination of 4 of the 6 associated factors was highly predictive of bilateral PSRCT, each having a minimum AUC of 0.70, a likelihood ratio of >10, and a minimum posttest probability of 80%.

CONCLUSION

Unilateral PSRCT, accompanied by any 4 of the variables of age ≥61 years, manual labor, CSA ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome, is highly predictive of PSRCT in the other shoulder.

Understanding the hidden epidemic of metabolic syndrome in people accessing community rehabilitation: a cross-sectional study of physical activity, dietary intake, and health literacy

PURPOSE

To determine the prevalence of metabolic syndrome in patients attending outpatient community rehabilitation in Melbourne, Australia and to compare health literacy, physical activity, and dietary intake of people with and without metabolic syndrome.

MATERIALS AND METHODS

A cross-sectional, multi-centre, observational study of adults (n = 193) presenting to rehabilitation with various health complaints. Metabolic syndrome was determined according to the International Diabetes Federation joint consensus worldwide definition. Health literacy was assessed using the Rapid Estimate of Adult literacy in Medicine (REALM) and the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Physical activity was assessed using accelerometers and dietary intake was assessed using a food frequency questionnaire.

RESULTS

One hundred and twenty three participants (64%) had metabolic syndrome. Of these, only three (2%) knew they had it. People with metabolic syndrome scored lower on health literacy (S-TOFHLA MD -2.10, 95% confidence interval (CI) -3.98 to -0.22) and took 1311 (95%CI 375 to 2246) fewer daily steps than those without metabolic syndrome. There were no differences in dietary intake.

CONCLUSIONS

Metabolic syndrome is a prevalent and under-recognised condition in community rehabilitation. Community healthcare professionals and health services may need to consider a broader approach to management including lifestyle assessment and intervention of patients with various conditions. Implications for rehabilitationAlmost two-thirds of adults in community rehabilitation had underlying, undetected metabolic syndrome.Adults with metabolic syndrome completed less objectively measured physical activity and had lower health literacy levels than those without metabolic syndrome.A broader approach to management may need to be considered in community rehabilitation where patients presenting for rehabilitation of various conditions would likely benefit from lifestyle assessment and intervention.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study

BACKGROUND

There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To identify the most relevant clinical descriptors for diagnosing RCRSP.

METHODS

A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.

RESULTS

Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus.

CONCLUSION

In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Effectiveness of supervised physiotherapy versus home exercise in subjects with rotator cuff disorders treated surgically: A systematic review and meta-analysis

OBJECTIVE

The aim is to determine the effectiveness of supervised Physiotherapy (PT) versus a home exercise program for functional outcomes in patients with rotator cuff (RC) disorders treated surgically. TYPE: Systematic review and meta-analysis of randomized clinical trials.

METHODOLOGY

An electronic search was performed in the MEDLINE, CENTRAL, EMBASE, PEDro, LILACS, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared supervised PT versus home exercises in functional outcomes, such as shoulder or upper limb function, pain intensity, and range of motion, in subjects older than 18 years with RC disorders treated surgically.

SYNTHESIS

Six trials met the eligibility criteria, and for the quantitative synthesis, five studies were included. At 3 months, the mean difference (MD) for the Constant-Murley questionnaire (0-100 points) was -0.76 points (95% confidence interval (CI) = -15.64 to 14.12, p = 0.92), while the MD for the visual analog scale (0-10 cm) was -0.87 cm (95% CI = -2.8 to 1.06, p = 0.38). These differences were neither clinically nor statistically significant.

CONCLUSION

There was very low quality of evidence towards no better benefits in shoulder pain and function of supervised PT over home exercises programs in patients older than 18 years with RC disorders treated surgically.

PROSPERO REGISTRATION

CRD42020185805.

The Usefulness of Serological Inflammatory Markers in Patients with Rotator Cuff Disease—A Systematic Review

Background and Objectives: Rotator cuff disease (RCD) is a prominent musculoskeletal pain condition that spans a variety of pathologies. The etiology and precise diagnostic criteria of this condition remain unclear. The current practice of investigating the biochemical status of RCD is by conducting biopsy studies but their invasiveness is a major limitation. Recent biochemical studies on RCD demonstrate the potential application of serological tests for evaluating the disease which may benefit future clinical applications and research. This systematic review is to summarize the results of available studies on serological biochemical investigations in patients with RCD. Methods: An electronic search on databases PubMed and Virtual Health Library was conducted from inception to 1 September 2021. The inclusion criteria were case-control, cross-sectional, and cohort studies with serological biochemical investigations on humans with RCD. Methodological quality was assessed using the Study Quality Assessment Tool for Observational Cohort and Cross-sectional studies from the National Heart, Lung, and Blood Institute. Results: A total of 6008 records were found in the databases; of these, 163 full-text studies were checked for inclusion and exclusion criteria. Nine eligible studies involving 984 subjects with RCD emerged from this systematic review. The quality of the studies found ranged from poor to moderate. In summarizing all the studies, several fatty acids, nonprotein nitrogen, interleukin-1 β, interleukin-8, and vascular endothelial growth factor were found to be significantly higher in blood samples of patients with RCD than with control group patients, while Omega-3 Intex, vitamin B12, vitamin D, phosphorus, interleukin-10, and angiogenin were observed to be significantly lower. Conclusions: This is the first systematic review to summarize current serological studies in patients with RCD. Results of the studies reflect several systemic physiological changes in patients with RCD, which may prove helpful to better understand the complex pathology of RCD. In addition, the results also indicate the possibility of using serological tests in order to evaluate RCD; however, further longitudinal studies are required.

Lesão do manguito rotador e obesidade: Uma avaliação demográfica e metabólica

Objective  To analyze the relationship between the presence and severity of rotator cuff (RC) injury with obesity and the time of exposure to obesity. Secondarily, to evaluate the relationship and prevalence of demographic and metabolic factors in obese individuals with RC injury.

Methods  This is a cross-sectional study with 235 obese patients (body mass index [BMI] ≥ 30 kg/m ² ). Demographic data (age and gender), metabolic data (hypertension, diabetes mellitus, lipid profile, and time of exposure to obesity), physical examination (weight, height, waist circumference, and clinical tests), and musculoskeletal ultrasound examination were used to analyze the results.

Results  There was no evidence of an association between RC injury and BMI ( p  = 0.82), time of exposure to obesity ( p  = 0.29), or abdominal circumference ( p  = 0.52). In the subgroup with injury, age ( p  < 0.001), presence of diabetes mellitus ( p  = 0.013), hypertension ( p  < 0.001), level of high-density lipoprotein (HDL) ( p  = 0.026), and time of exposure to obesity ( p  < 0.001) were significantly greater compared to the subgroup without injury. In the search for other parameters independently associated with RC injury, associations were observed with age ( p  = 0.0003) and hypertension ( p  = 0.004).

Conclusion  We did not evidence an association between obesity and the time of exposure to it with the occurrence and severity of RC injury. However, individuals with injury had a longer time of exposure to obesity and prevalence of metabolic disorders than individuals without RC injury. In addition, our findings suggest an association between systemic arterial hypertension (SAH) and advanced age with RC injury.

Primary reverse shoulder arthroplasty in patients with metabolic syndrome is associated with increased rates of deep infection

BACKGROUND

Metabolic syndrome (MetS) is an abnormal physiological condition that has been increasingly identified as a risk factor for complications after orthopedic surgery. Given the lack of information on the effect of MetS in shoulder arthroplasty (SA), this investigation analyzed the rates of postoperative complications and implant survivorship free from reoperation and revision in patients with and without MetS.

METHODS

Between 2007 and 2017, data from 4635 adults who underwent a primary SA were collected and classified based on the presence or absence of MetS. MetS was defined as the existence of type 2 diabetes mellitus and a minimum of 2 of the following diagnoses: hyperlipidemia, hypertension, and body mass index ≥ 30 kg/m² within 1 year of surgery. Of the 4635 arthroplasties, 714 were performed in patients with MetS (anatomic total shoulder arthroplasty [aTSA] in 289 and reverse shoulder arthroplasty [RSA] in 425) and 3921 were performed in patients without MetS (aTSA in 1736 and RSA in 2185). Demographic characteristics, complications, reoperations, and revision surgery were compared.

RESULTS

At a mean of follow-up of 4.5 ± 2.3 years, 67 MetS patients (9.4%) and 343 non-MetS patients (8.7%) had sustained at least 1 postoperative complication (P = .851). Rotator cuff failure was the most common complication overall, with 84 cases (1.8%) (15 MetS cases [2.1%] and 69 non-MetS cases [1.8%], P = .851), and in both MetS and non-MetS patients, followed by infection, with 68 cases (1.2%) (10 MetS cases [1.4%] and 58 non-MetS cases [1.2%], P = .913). For aTSAs, the most common complication was rotator cuff failure (84 shoulders, 1.8%); for RSAs, the most common complication was periprosthetic fracture (52 shoulders, 1.1%). In RSAs, the rates of deep infection (1.9% vs. 0.7%, P = .04), instability (3.1% vs. 1.5%, P = .04), and deep venous thrombosis or pulmonary embolism (0.5% vs. 0.3%, P = .03) were found to be significantly higher in patients with MetS than in those without MetS. Reoperations were observed in 36 MetS patients (5%) and 170 non-MetS patients (4.3%) (P = .4). Revisions were performed in 30 MetS patients (4.2%) and 127 non-MetS patients (3.2%) (P = .19). The Kaplan-Meier 5-year rate of survivorship free from reoperation, revision, and prosthetic joint infection was equal between groups.

CONCLUSIONS

A preoperative diagnosis of MetS in patients undergoing primary SA did not significantly increase the risk of postoperative complications, infection, reoperation, or revision following primary SA. However, in the RSA subgroup, complications were significantly more common in patients with MetS. Individual risk factors may be more appropriate than the umbrella diagnosis of MetS prior to aTSA.

Current concepts in the rehabilitation of rotator cuff related disorders

Rotator cuff related disorders (RCRD) are common. Exercise-based rehabilitation can improve outcomes, yet uncertainty exists regarding the characteristics of these exercises. This scoping review paper summarises the key characteristics of the exercise-based rehabilitation of rotator cuff related disorders (RCRD). An iterative search process was used to capture the breadth of current evidence and a narrative summary of the data was produced. 57 papers were included. Disagreement around terminology, diagnostic standards, and outcome measures limits the comparison of the data. Rehabilitation should utilise a biopsychosocial approach, be person-centred and foster self-efficacy. Biomedically framed beliefs can create barriers to rehabilitation. Pain drivers in RCRSD are unclear, as is the influence of pain during exercise on outcomes. Expectations and preferences around pain levels should be discussed to allow the co-creation of a programme that is tolerated and therefore engaged with. The optimal parameters of exercise-based rehabilitation remain unclear; however, programmes should be individualised and progressive, with a minimum duration of 12 weeks. Supervised or home-based exercises are equally effective. Following rotator cuff repair, rehabilitation should be milestone-driven and individualised; communication across the MDT is essential. For individuals with massive rotator cuff tears, the anterior deltoid programme is a useful starting point and should be supplemented by functional rehabilitation, exercises to optimise any remaining cuff and the rest of the kinetic chain. In conclusion, exercise-based rehabilitation improves outcomes for individuals with a range of RCRD. The optimal parameters of these exercises remain unclear. Variation exists across current physiotherapy practice and post-operative rehabilitation protocols, reflecting the wide-ranging spectrum of individuals presenting with RCRD. Clinicians should use their communication and rehabilitation expertise to plan an exercise-based program in conjunction with the individual with RCRSD, which is regularly reviewed and adjusted.

Chronic hyperglycemia, hypercholesterolemia, and metabolic syndrome are associated with risk of tendon injury

Tendon injury is a considerable problem affecting both physically active and sedentary people. The aim of this study was to examine the relationship between markers for metabolic disorders (hyperglycemia, hypercholesterolemia, and metabolic syndrome) and the risk of developing tendon injuries requiring referral to a hospital. The Copenhagen City Heart Study is a prospective study of diabetic and non-diabetic individuals from the Danish general population with different physical activity levels. The cohort was followed for 3 years via national registers with respect to tendon injuries. Data from 5856 individuals (median age 62 years) were included. The overall incidence of tendon injury in both upper and lower extremities that required an out-patient or in-house visit to a hospital was ~5.7/1000 person years. Individuals with elevated HbA1c (glycated hemoglobin) even in the prediabetic range (HbA1c>5.7%) had a ~3 times higher risk of tendon injury in the lower extremities only, as compared to individuals with normal HbA1C levels. Hypercholesterolemia (total cholesterol>5 mmol/L) increased risk of tendon injury in the upper extremities by ~1.5 times, and individuals with metabolic syndrome had ~2.5 times higher risk of tendon injury in both upper and lower extremities. In conclusion, these data demonstrate for the first time in a large cohort with different physical activity levels that the indicators for metabolic syndrome are a powerful systemic determinant of tendon injury, and two of its components, hyperglycemia and hypercholesterolemia, each independently make tendons susceptible for damage and injury.

Management of recent onset tendon-related pain in a primary contact setting: A survey of practice

BACKGROUND

Tendon-related pain is a common and debilitating condition that affects a wide range of people. To inform future research, it is important to understand healthcare professional's current practice.

OBJECTIVES

To describe the practice of First Contact Practitioners (FCPs) and Other Clinicians (OCs) for recent onset tendon pain in a primary contact setting. The secondary aim was to understand if practice differed between the locations of pain.

DESIGN

Cross-sectional online survey METHOD: The online survey asked for responses relating to one scenario of shoulder pain and one of Achilles pain. Except location of pain, the scenarios were identical. Responses were collected over a four-week period to December 2020. The Chi-Square test was used to analyse the difference in proportion of responses between FCPs and OCs, and between locations of pain.

RESULTS

118 responses were received. Rotator Cuff Related Shoulder Pain (RCRSP) was preferred by 64/118 (54.2%) for the shoulder scenario. Achilles tendinopathy was the preferred term by 86/103 (83.5%) for the Achilles. FCPs were more likely to advise NSAIDs for both shoulder (p = 0.006) and Achilles (p = 0.046) scenarios than OCs. Amended duties were more likely to be advised for manual workers for the shoulder scenario compared to Achilles (p = <0.0001).

CONCLUSION

There were similarities in the management of recent onset tendon-related pain; the majority of respondents recommended against further investigations, steroid injections, and recommended exercise. Understanding whether these approaches are clinically effective requires further investigation.