Range of motion of diabetic frozen shoulder recovers to the contralateral level

Shoulder-specific rehabilitation combined with aerobic exercises versus solely shoulder-specific rehabilitation in patients with type 2 diabetes mellitus: study protocol for a randomized controlled superiority trial

Background

Musculoskeletal disorders are very common in patients with diabetes mellitus (DM). The upper limb is one of the regions that is most frequently affected generally presenting limited joint mobility, pain, and a decreased muscle strength. Most clinical trials with a focus on shoulder musculoskeletal rehabilitation are carried out in patients who do not present DM. Thus, the purpose of the present study is to compare the effects of two distinct treatment protocols (conventional shoulder musculoskeletal rehabilitation combined with aerobic exercises versus solely conventional shoulder musculoskeletal rehabilitation) on shoulder pain, function, strength, kinematics, and supraspinatus tendon thickness in patients with type 2 DM after 12 weeks of intervention and a subsequent follow-up at week 20.

Methods

A randomized controlled superiority trial will be conducted. Participants with a clinical diagnosis of type 2 DM of both sexes, age between 40 and 70 years, presenting shoulder pain will be randomly assigned to one of the following groups: (1) conventional shoulder musculoskeletal rehabilitation combined with aerobic exercises; (2) solely conventional shoulder musculoskeletal rehabilitation. All individuals will be evaluated before starting the treatment protocol (baseline) and at the end of treatment (post 12 weeks) and as a follow-up at 20 weeks. The shoulder function assessed by the SPADI (Shoulder Pain and Disability Index) questionnaire will be considered as primary outcome; the secondary outcome will be shoulder pain, measured with NPRS scales. Other outcomes will include range of motion, measured using a digital inclinometer; isometric shoulder muscle strength, measured using a manual muscle dynamometer; shoulder kinematics, measured using three-dimensional inertial units measurement; supraspinatus tendon thickness, measured using an ultrasound; AGE accumulation, using a skin autofluorescence measurement; and HbA1c (hemoglobin a1c), fasting glucose and lipid profile measured by a simple blood test.

Discussion

DM is a highly prevalent disease and a public health problem worldwide, and the upper extremity musculoskeletal disorders in DM are barely recognized and largely underestimated. In this way, it would be interesting to analyze if the combination of aerobic exercises with conventional musculoskeletal rehabilitation protocols could generate better results in the functionality, pain, mobility and an improvement in the biochemical aspects related to the hyperglycemia of these patients compared to solely the conventional musculoskeletal rehabilitation.

Trial registration

ClinicalTrials.gov NCT04817514. Registered on March 26, 2021.

Effect of diabetes and corticosteroid injection on glenohumeral joint capsule in a rat stiffness model

PURPOSE

To evaluate the effects of diabetes and corticosteroid injected in the joints on the shoulder motion, gait, and joint capsular properties in a rat stiffness model.

METHODS

A total of 27 rats were randomly distributed into 3 groups-nondiabetes group (group A), diabetes group (group B), and diabetes plus steroid injection group (group C). The diabetes model was developed by inducing hyperglycemia with a submaximal dose of streptozotocin and the stiffness model by completely immobilizing the right shoulder of each animal in all groups with sutures passed between the scapula and humeral shaft. The left shoulder was used as an untreated control in all groups. Three weeks after immobilization, the sutures were removed in all groups, and a single dose of triamcinolone acetonide (0.5 mg/kg) was injected into the glenohumeral joint in group C. After 3 weeks of free activity, range of motion (ROM) evaluation, gait analysis by stride length, and capsular area measurement were performed in all rats.

RESULTS

Hyperglycemia was successfully induced with a mean blood glucose level of 448.9±55.9 mg/dL in group B and 431.6±17.8 mg/dL in group C, which were significantly higher than 136.5±13.4 mg/dL in group A (P < .001). A significantly smaller ROM and stride length were found in the right (stiffness-induced) shoulder than that in the left (control) shoulder only in group B, and significantly larger capsular area in the right shoulder than that in the left shoulder in groups A and B (all P < .05). However, in group C, there were no differences between the right and left shoulders in all measurements (all P > .05). In case of the right shoulders in each group, group C showed significantly larger ROM (68° ± 11° vs. 42° ± 7°) and smaller capsular area (3934.4 ± 537.1 pixels vs. 7402.3 ± 1840.3 pixels) than group B (all P < .0167).

CONCLUSIONS

The diabetic model had a detrimental effect on the development of stiffness by thickening the joint capsule, and an intra-articular steroid injection resolved the thickened joint capsule and restored shoulder motion.

Diabetes as a Prognostic Factor in Frozen Shoulder: A Systematic Review

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People with diabetes may experience worse outcomes from frozen shoulder than those without diabetes; however, the certainty in evidence was moderate to low.

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If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term.

Objective

To summarize evidence from longitudinal observational studies to determine whether diabetes (types 1 and 2) is associated with the course of symptoms in people with frozen shoulder.

Data Sources

A systematic literature search of 11 bibliographic databases (published through June 2021), reference screening, and emailing professional contacts.

Study Selection

Studies were selected if they had a longitudinal observational design that included people diagnosed with frozen shoulder at baseline and compared outcomes at follow-up (>2wk) among those with and without diabetes at baseline.

Data Extraction

Data extraction was completed by 1 reviewer using a predefined extraction sheet and was checked by another reviewer. Two reviewers independently judged risk of bias using the Quality in Prognostic Factor Studies tool.

Data Synthesis

A narrative synthesis, including inspection of forest plots and use of the prognostic factor Grading of Recommendations, Assessment, Development and Evaluations framework. Twenty-eight studies satisfied the inclusion criteria. Seven studies were judged to be at a moderate risk of bias and 21 at a high risk of bias. Diabetes was associated with worse multidimensional clinical scores (moderate certainty in evidence), worse pain (low certainty in evidence), and worse range of motion (very low certainty in evidence).

Conclusions

This review provides preliminary evidence to suggest that people with diabetes may experience worse outcomes from frozen shoulder than those without diabetes. If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term.

Idiopathic Frozen Shoulder in Individuals with Diabetes: Association with Metabolic Control, Obesity, Antidiabetic Treatment and Demographic Characteristics in Adults with Type 1 or 2 Diabetes from the DPV Registry

AIMS

To examine the association of frozen shoulder (FS) with demographic and diabetes-related outcomes in individuals with type 1 (T1D) or type 2 (T2D) diabetes aged ≥30 years.

MATERIALS AND METHODS

Multivariable logistic regression models, adjusted for demographics were used to calculate the proportion of FS in association with age, gender, diabetes duration, body mass index (BMI), haemoglobin A1C (HbA1c) and diabetes treatment.

RESULTS

The unadjusted percentage of FS was higher in T1D compared to T2D (0.22% vs. 0.06%). In T1D, adjusted regression models revealed higher prevalence of FS in women than men (0.26 [0.20-0.34] % vs. 0.15 [0.11-0.21] %, p=0.010). No significant relationship of age and BMI with FS was found in both diabetes types. Longer diabetes duration was associated with a higher proportion of FS in T1D (p<0.001) and T2D (p=0.004). In T1D, HbA1c >7% was related to a higher proportion of FS compared to HbA1c ≤7% (0.25 [0.19-0.32] vs. 0.12 [0.08-0.20] %, p=0.007), while an inverse relationship was found in T2D (HbA1c ≤7%: 0.08 [0.07-0.10] vs. HbA1c >7%: 0.05 [0.04-0.06] %, p=0.001).

CONCLUSIONS

Different associations of FS with gender and HbA1c were observed for T1D and T2D; however, longer diabetes duration increases the risk for FS independent of diabetes type. Musculoskeletal diseases are still underreported in individuals with diabetes and awareness should be raised for FS as a specific diabetes complication.

Exercise Therapy is Effective for Improvement in Range of Motion, Function, and Pain in Patients With Frozen Shoulder: A Systematic Review and Meta-analysis

OBJECTIVE(S)

To determine (1) the effect of exercise therapy alone or in combination with other interventions compared with solely exercises and programs with or without exercises and (2) what kind of exercise therapy or combination with other interventions is most effective.

DATA SOURCES

PubMed, Web of Science and Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Studies were screened in a 2-phase approach by 2 independent reviewers (M.M. and L.M.). Reference lists of included studies and interesting systematic reviews were hand searched.

DATA EXTRACTION

Two independent reviewers (M.M. and L.M.) extracted information about origin, characteristics of study participants, eligibility criteria, characteristics of interventions, outcome measures and main results in a pre-defined template.

DATA SYNTHESIS

Thirty-three studies were included in the qualitative and 19 in the meta-analysis. Preliminary evidence was found for supervised exercises to be more beneficial than home exercises for ROM and function. Multimodal programs comprising exercises may result in little to no difference in ROM compared to solely exercises. Programs comprising muscle energy techniques show little to no difference in ROM when compared with programs with other exercises. Adding stretches to a multimodal program with exercises may increase ROM. There is uncertain evidence that there is a difference between those programs regarding function and pain. Preliminary evidence was found for several treatment programs including exercises to be beneficial for improvement in both passive and active ROM, function, pain, and muscle strength. No studies used patient satisfaction as an outcome measure.

CONCLUSIONS

ROM, function, and pain improve with both solely exercises and programs with exercises, but for ROM and pain there was little to no difference between programs and for function the evidence was uncertain. Adding exercises improve active ROM compared with a program without exercises, whereas adding physical modalities has no beneficial effect. Muscle energy techniques are a beneficial type of exercise therapy for improving function compared with other types of exercise. Unfortunately, no conclusion can be drawn about the results in the long-term and most effective dose of exercise therapy.

The puzzling pathophysiology of frozen shoulders - a scoping review

Purpose

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

Methods

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

Results

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

Conclusion

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

Level of evidence

Level V.

Effectiveness of surgical and non-surgical interventions for managing diabetic shoulder pain: a systematic review

PURPOSE

This systematic review evaluated and compared the effectiveness of non-surgical and surgical interventions for managing shoulder pain in patients with diabetes.

METHODS

PubMed, Scopus, CINAHL, EMBASE, Sport Discus, and Cochrane library were searched for studies published in the last 20 years. Randomized clinical trials (RCTs) and cohort studies that assessed shoulder pain in patients with diabetes and implemented one or a combination of non-surgical and surgical interventions were eligible for inclusion. The quality of the included studies was assessed using the Structured Effectiveness Quality Evaluation Scale (SEQES) tool. Data extracted from the eligible studies included study design, patient characteristics, duration of symptoms, type of interventions, outcome measures used to assess pain, follow-up intervals, and research findings.

RESULTS

A narrative synthesis with effect sizes (ES) or between-group differences was conducted. A total of 25 (14 non-surgical and 11 surgical) studies met the inclusion criteria. Six studies addressed physiotherapeutic interventions (three RCTs and three cohorts - ES = 0.07-1.3), three studies assessed the effect of steroid injections (two RCTs and one cohort - ES = 0.2-0.4), two cohorts addressed arthrographic capsular distension (between-group difference of 1.1 on Visual Analogue Scale), two cohorts addressed MUA, and one RCT addressed suprascapular nerve block (ES = 1-6). For the surgical studies, six cohorts addressed arthroscopic capsular release (ES = 0.2), three cohorts addressed arthroscopic rotator cuff repair (ES = 0.05-0.5), and one cohort addressed arthroplasty (ES = 0.3).

CONCLUSION

Moderate- to very-low-quality evidence suggests large effects of physiotherapy modalities plus exercise and suprascapular nerve block, and trivial to small effects for surgical interventions for improving shoulder pain in patients with diabetes. Future well-designed studies are needed to provide accurate estimates of the true effects of these interventions on improving shoulder pain in patients with diabetes.Implications For RehabilitationShoulder pain may lead to disability in patients with diabetes.We recommend the use of physiotherapy interventions to reduce shoulder pain.Corticosteroid injections are recommended for short-term shoulder pain relief.

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

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.

A pilot study of ultrasound-guided acupotomy for the treatment of frozen shoulder

This study retrospectively analyzed the feasible effectiveness of ultrasound-guided acupotomy (USGAP) for the treatment of frozen shoulder (FS). A total of 36 patients with FS were analyzed in this retrospective study. All 36 patients received extracorporeal shock-wave therapy (ESWT). In addition, 18 of them also underwent USGAP intervention and were assigned to a treatment group, while the other 18 patients did not receive such intervention and were assigned to a control group. The primary efficacy endpoint was pain intensity, as measured by the Numeric Rating Scale (NRS). The secondary efficacy endpoint was assessed by the score of shoulder pain and disability index (SPADI). Furthermore, the adverse events were also documented during the treatment period. All efficacy endpoints were measured after the treatment. After treatment, patients who received USGAP exerted better efficacy endpoints in pain relief, as measured by NRS scale (P < .01), and shoulder disorders, as evaluated by SPADI (P < .01), than subjects who did not receive USGAP. Additionally, no adverse events occurred in either group. The results of this study indicated that USGAP may be used for the treatment of FS effectively. More studies are still needed to warrant the present results.

Effectiveness of Nonsurgical Interventions for Managing Adhesive Capsulitis in Patients With Diabetes: A Systematic Review

OBJECTIVE

This systematic review evaluated the effectiveness of nonsurgical interventions for managing adhesive capsulitis (AC) in patients with diabetes on pain, function, and range of motion.

DATA SOURCES

MEDLINE and other databases were searched for studies published in the last 20 years.

STUDY SELECTION

Randomized controlled trials (RCTs) that assessed AC in people with diabetes and implemented 1 or a combination of physiotherapeutic interventions, corticosteroids, and manipulation under anesthesia (MUA) were eligible for inclusion.

DATA EXTRACTION

The Cochrane Risk of Bias was used by 2 independent raters who met to achieve consensus. The quality of trials was assessed using Grading of Recommendations, Assessment, Development and Evaluations. Data extracted from the eligible studies included study design, participant characteristics and duration of symptoms, type of intervention, outcome measures, follow-up intervals, and research findings.

DATA SYNTHESIS

Because of the lack of similar interventions, a narrative synthesis was conducted, and meta-analyses were not performed. The effect sizes or between-group differences of the interventions were reported. A total of 8 RCTs met the inclusion criteria: 4 addressed physiotherapeutic interventions, 3 corticosteroid injections, and 1 MUA. The effect sizes for physiotherapeutic interventions were 0.8-2.0, 0.9-2.0, and 1.0 for ROM, function, and pain, respectively, with the largest effect size (2.0) being reported for joint mobilization plus exercises. The effect sizes for corticosteroids were 0.2-0.5 and 0.1 for ROM and pain. The between-group improvement for MUA was 5.6 points on Constant Shoulder Score.

CONCLUSION

Low-quality evidence suggests large effects of joint mobilization plus exercises on AC in people with diabetes, although confidence in this conclusion is limited due to the high risk of bias. Even weaker support was available for corticosteroid and MUA. Future high-quality RCTs are needed to determine the best intervention for managing AC in patients with diabetes.