Predicting the outcome of conservative treatment with physiotherapy in adults with shoulder pain associated with partial-thickness rotator cuff tears - a prognostic model development study

Hyaluronate Acid Plus Platelet-Rich Plasma Is Superior to Steroids for Pain Relief Less Than 6 Months Using Injection Therapy of Partial Rotator Cuff Tears: A Systematic Review and Network Meta-analysis

PURPOSE

To compare the efficacy of steroid injections to other injectable therapies in partial-thickness rotator cuff (RC) tears.

METHODS

A systematic literature search was performed until October 25, 2021, in 3 databases (Cochrane Central Register of Controlled Trials, Embase, MEDLINE). Eligible studies compared the efficacy of steroid, hyaluronic acid (HA), platelet-rich plasma (PRP), the combination of HA and PRP (HA + PRP), and adipose-derived regenerative cells in RC tears. The primary outcomes were the visual analog scale (VAS), Constant-Murley Shoulder Outcome Score (CMS) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. Using paired and network meta-analysis, we calculated pooled mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

We included a total of 7 articles in the quantitative synthesis. In shorter periods, the HA + PRP combination was superior to the other substances we investigated (HA + PRP: VAS [0-4 weeks]: MD: -0.99 [95% CI, -1.62 to -0.36]; CMS [0-3 months]: 20.56 [95% CI, 16.18 to 24.94]. This combination was followed by the use of HA or PRP alone, depending on the duration of follow-up and the outcome being studied. In our study, short-term results suggest that saline is superior to steroids for partial tears, but this trend is reversed at 6-month follow-up.

CONCLUSIONS

The HA and PRP combination is currently the most effective in partial RC tear treatment in the short term. After 6 months, there is no meaningful difference, so the benefits of the combination are short term.

LEVEL OF EVIDENCE

Level II, including Level I to II studies.

Ultrasound findings and prognosis of shoulder pain: A role for Doppler signal?

PURPOSE

To find ultrasound prognostic factors for shoulder pain.

METHODS

This was an observational, prospective study, comparing the evolution of ultrasound findings with clinical outcomes, in patients with shoulder pain. Data were collected in two appointments, from February 2018 to March 2021. Two-tailed non-parametric statistics were used, and p values <0.05 were considered significant.

RESULTS

A total of 79 participants were included in this study (median age 59 years, range 24-70, 61 women). A positive Doppler signal on tendons (p = 0.002) and absent tendon heterogeneity (p = 0.01) were associated with the patient's self-reported improvement. Tendon calcifications with poorly defined contours (p = 0.03) and sparse distribution (p = 0.001) were associated with VAS improvement. A reduction in the number of calcifications (p = 0.004), in the supraspinatus tendon thickness (p = 0.01), in subacromial effusions (p = 0.03), and in color Doppler grade (p = 0.02), between initial and follow-up exams, was found in patients with an improved DASH outcome.

CONCLUSION

A positive Doppler signal on shoulder tendons can be a marker for a better prognosis in shoulder pain. Poorly defined and sparsely distributed calcifications can also indicate a better course of the disease.

Association between changes in pain or function scores and changes in scapular rotations in patients with subacromial shoulder pain: a prospective cohort study

Background

Scapular dyskinesis is reported as one of the potential factors contributing to the presentation of pain in subacromial shoulder pain. In clinical practice, the evaluation and control of scapular dyskinesis is considered important for managing the subacromial shoulder pain. The aim is to determine the association between changes in pain or function and changes in scapular rotations in participants with subacromial shoulder pain.

Method

Pain, function and scapular rotations were measured in 25 participants with subacromial shoulder pain at baseline and after 8 weeks. Pain was measured with Numeric Pain Rating Scale (NPRS) and function was measured with Patient Specific Functional Scale (PSFS). Scapular rotations were measured with a scapular locator at 60°, 90° and 120° of scapular arm elevation. Spearman rank correlations (r_s) were used to assess the association between variables.

Findings

No association was observed between changes in pain or function scores with changes in scapular upward/downward rotations (r_s = 0.03 to 0.27 for pain and − 0.13 to 0.23 for function) and scapular anterior/posterior tilt (r_s = − 0.01 to 0.23 for pain and − 0.13 to 0.08 for function) of arm at 60°, 90° and 120° elevation. Data associated with scapular internal/external rotation was not reported due to low reliability.

Conclusion

These findings reject associations between changes in pain or function scores and scapular rotations. Future observational study is warranted using a multifactorial approach to understand potential factors that contribute to the presentation of subacromial shoulder pain.

Clinical short-term outcomes of articular-sided and bursal-sided partial-thickness rotator cuff tears of less than 50% in a single surgeon series: A protocol of randomized controlled trial

BACKGROUND

There have been no published randomized clinical trial to assess the clinical outcomes between the articular-sided and bursal-sided tears. Therefore, a comparative analysis of evaluating and comparing the functional outcomes following arthroscopic repair of bursal-sided versus articular-sided partial-thickness rotator cuff tearsis essential.

METHODS

This study is a present randomized controlled trial which is conducted in our hospital. Consecutive patients with symptomatic articular-sided or bursal-sided partial-thickness rotator cuff tears underwent arthroscopic repair between June 2020 and January 2022. The institutional review board approved the study proposal (with number 10012030), and informed consent was obtained from all patients. Inclusion criteria were existence of an articular- or bursal-sided tear involving <50% of the tendon thickness-confirmed intraoperatively and treated with arthroscopic debridement with or without other decompression surgery (acromioplasty/distal clavicle resection)-and a minimum follow-up of 2 years. All patients followed the same postoperative rehabilitation program. The patients were assessed at baseline preoperatively, and at 1 year and 2 years postoperatively. Outcome parameters were measured at each respective follow-up, which included active range of motion in forward flexion and abduction of the affected shoulder, pain score as measured on the Numeric Pain Rating Scale, as well as outcome scores in terms of the Constant-Murley Score, and Oxford Shoulder Score.

RESULTS

Table 1 and Table 2 describe the data indicators that this article wants to evaluate and collect.

CONCLUSIONS

We hypothesize that both groups of patients will show improvement in range of motion, functional outcome scores, and pain at 2 years, and that results would be similar between the two groups.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6496).

Conservative management in a patient with massive rotator cuff tear and rheumatoid arthritis

BACKGROUND

Shoulder pain is one of the most common problems affecting people older than 60 years. Among the shoulder pathologies, the disorders of the periarticular soft tissue (e.g. rotator cuff) are considered to be the most common; moreover, these disorders are found in approximately 75% of patients with seropositive rheumatoid arthritis. The incidence of structural rotator cuff tendon pathology, including full-thickness rotator cuff tendon tears, increases with age. Recent researchers suggested that non-operative treatment of full-thickness rotator cuff tears could be successful in some patients; furthermore, in rheumatoid arthritis patients, there was a greater possibility of developing surgical complications compared with non-rheumatoid arthritis patients.

MATERIALS AND METHODS

A case report of a woman, 72 years old, with rheumatoid arthritis, shoulder pain and pseudo-paralytic arm presented with a massive tear of Supraspinatus and Infraspinatus tendon. In accordance with evidence, the case was managed using pain education and exercise therapy for 2.5 months. The shoulder pain, the function and the range of motion improved following a physiotherapy program.

CONCLUSION

Pain education in combination with exercise therapy was effective for improving pain and function in a full-thickness tear of Supraspinatus and Infraspinatus tendon in a patient also suffering from rheumatoid arthritis.

A new pathophysiology of atraumatic rotator cuff tears: adduction restriction of the glenohumeral joint

Background

The pathophysiology of atraumatic rotator cuff tears (ATTs) has not been fully understood. Adduction restriction of the glenohumeral joint can cause pain and disability in patients with ATTs. We aimed to use our adduction test (pushing the humerus toward the side in the coronal plane with scapular fixation) to fluoroscopically measure the glenohumeral adduction angle (GAA) and to assess the effectiveness of adduction manipulation.

Materials and methods

Fifty-five patients with ATTs were included in the study. The GAAs of the patients vs. healthy subjects without ATTs were measured fluoroscopically and compared. During the test, patients showed restriction and expressed pain. The visual analog scale (VAS) score, passive range of motion (ROM), and the American Shoulder and Elbow Surgeons score at the initial visit were compared with those after adduction manipulation.

Results

Of the patients, 41 (75%) had positive adduction test results. A higher percentage of positive adduction test results was observed in smaller tears. The average GAA was –21.4° on the affected side, which was smaller than that on the unaffected side, at –2.8° (P < .001), and that in healthy subjects, at 4.8° (P < .001). After manipulation, the GAA was –0.8° (P < .001) and the VAS score, the American Shoulder and Elbow Surgeons score, and all ROM values significantly improved up to the level on the unaffected side.

Conclusion

Adduction restriction of the glenohumeral joint was identified in 75% of all the patients with ATTs. Adduction manipulation significantly reduces the VAS score and restores the ROM. Adduction restriction is considered a crucial pathophysiology of ATTs.

Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review

OBJECTIVE

To systematically scope the reported advice and education in physical therapy management of patients with subacromial shoulder pain, and to define key themes of the advice and education.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched MEDLINE, Scopus, Web of Science, and CINAHL, with publication dates from 2007 to September 2019.

STUDY SELECTION CRITERIA

We included quantitative and qualitative research that reported on physical therapy interventions for subacromial shoulder pain.

DATA SYNTHESIS

We performed a qualitative synthesis that identified items included in patient advice and education.

RESULTS

Of 89 original studies included, there were 61 randomized controlled trials; 5 prospective studies; 16 nonrandomized observational intervention studies or case series; and 7 surveys, audits of physical therapy patient records, and focus groups with physical therapists. We identified 7 key themes for advice and education: exercise intensity and pain response, activity modification advice, posture advice, pain self-management advice, pathoanatomical and diagnosis information, behavioral approaches, and pain biology advice.

CONCLUSION

While advice focused predominantly on the local tissue pathology model, 10% of studies included information about pain neuroscience education, psychosocial factors, motor imagery, or behavior change. J Orthop Sports Phys Ther 2020;50(6):285-293. doi:10.2519/jospt.2020.9152.

The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review

Objective:

To examine the predictive, moderating and mediating role of cognitive, emotional and behavioral factors on pain and disability following shoulder treatment.

Data sources:

Electronic databases (PubMed, Web of Science, Embase and PsycINFO) were searched until 14 January 2019.

Study selection:

Studies including persons with musculoskeletal shoulder pain that describe the predictive, moderating or mediating role of baseline cognitive, emotional or behavioral factors on pain or disability following treatment were selected.

Results:

A total of 23 articles, describing 21 studies and involving 3769 participants, were included. Three studies had a high risk of bias. There was no predictive role of baseline depression, anxiety, coping, somatization or distress on pain or disability across types of shoulder treatment. No predictive role of fear-avoidance beliefs was identified in patients receiving physiotherapy, which contrasted to the results found when surgical treatment was applied. Baseline catastrophizing was also not predictive for pain or disability in patients receiving physiotherapy. After conservative medical treatments, results on the predictive role of catastrophizing were inconclusive. Treatment expectations and baseline self-efficacy predicted pain and disability in patients receiving physiotherapy, which was not the case in patients receiving conservative medical treatment. Finally, there was a moderating role for optimism in the relationship between pain catastrophizing and disability in patients receiving physiotherapy.

Conclusion:

There is evidence that expectations of recovery and self-efficacy have a predictive role and optimism a moderating role on pain and/or disability following physiotherapy for musculoskeletal shoulder pain. After surgical treatment, fear-avoidance is a predictor of pain and disability.