Neural Correlates of Clinical Scores in Patients with Anterior Shoulder Apprehension

Latarjet procedure restores range of motion at 6 months postoperatively: a prospective cohort study using motion capture analysis

BACKGROUND

There is a common concern that range of motion (ROM) is negatively affected by the Latarjet procedure. We hypothesize that the Latarjet procedure results in full recovery of ROM postoperatively and significantly improved patient-reported outcome measures.

METHODS

Patient data were prospectively collected from a randomized controlled trial to analyze outcomes after open Latarjet procedure. Inclusion criteria involved a minimum follow-up of 6 months and unilateral shoulder instability. Study outcome was assessed by postoperative ROM at 6 months postoperatively and compared to the preoperative ROM of the ipsilateral shoulder as well as the ROM of the unaffected contralateral shoulder. All ROM measurements were performed using a motion capture system to ensure consistent and reliable measurements.

RESULTS

The study included a total of 84 patients. ROM was measured in external rotation with the shoulder adducted (ER1), external rotation with the shoulder abducted 90° (ER2), internal rotation with the arm abducted 90° (IR2), and active forward elevation (AE). The mean difference in ROM between the operated arm vs. the contralateral healthy arm at 6 months postoperatively was 3.4° in ER1 (P = .19), 4.2° in ER2 (P = .086), 2.2° in IR2 (P = .36), and 2.4° in AE (P = .045). Subanalysis of patients with and without sling use revealed no significant difference in ROM between the operated shoulder and the contralateral shoulder at 6 months in either group, with the exception of ER2 in the sling group. In this latter group, ROM was 71° in the operated arm and 79° in the contralateral arm (P = .0094). Mean preoperative pain score was 25.7 (95% CI 21.4-30.1) vs. 13.0 postoperatively at 6 months (95% CI 9.50-16.5) (P < .00001). Mean preoperative Single Assessment Numeric Evaluation instability was 42.9 (95% CI 38.4-47.3) vs. 86.2 postoperatively at 6 months (95% CI 83.6-88.7) (P < .00001). Mean preoperative Rowe score was 38.5 (95% CI 34.3-42.7) vs. 84.3 at postoperative month 6 (95% CI 81.1-87.4) (P < .00001).

CONCLUSIONS

Latarjet procedure performed for anterior instability using a capsular repair results in complete ROM recovery in ER1, ER2, and IR2 at 6 months postoperatively, with only a slight discrepancy in active elevation. Sling use after the Latarjet procedure results in no benefit over postoperative recovery without the use of a sling. Sling use negatively affects the ROM in ER2, taking as reference the contralateral arm of the same patient, when compared to patients who did not use a sling postoperatively.

Developing a Rehabilitation Guideline (REGUIDE) for Patients Undergoing an Arthroscopic Bankart Repair After Traumatic Anterior Shoulder Dislocation, Focusing on Managing Apprehension: An International Delphi-Based Consensus Study

OBJECTIVE: We aimed to develop a consensus-based rehabilitation guideline specifically designed to reduce apprehension following arthroscopic Bankart repair after traumatic anterior shoulder dislocation. DESIGN: Delphi-based consensus. METHOD: A comprehensive list of interventions for potential inclusion in a postoperative rehabilitation guideline was developed. American and European physiotherapists and orthopedic surgeons were invited to participate in a Delphi panel, engaging in 3 survey rounds. The health professionals were surveyed about their level of agreement on both initially listed and newly suggested interventions. Consensus was established when a "critical-to-include" rating was given in ≥70% of all responses. Ten former patients were consulted to identify the intervention during standard care rehabilitation that had the most impact on reducing postoperative apprehension following ABR. Any interventions not initially listed in the first round were added to the second survey round of the Delphi process. RESULTS: Forty-four health professionals reached consensus on a set of 27 interventions for managing apprehension after arthroscopic Bankart repair. New interventions included gradual exposure to shoulder positions eliciting apprehension, training in anterior stability-provoking positions, and education addressing the impact of psychosocial factors. Former patients identified specific interventions that were effective in reducing postoperative apprehension following ABR. These interventions encompassed medicine ball throws, active-assisted wall slides, and kinetic chain exercises in anterior stability-provoking positions. CONCLUSION: Our Delphi process informed expert recommendations for various interventions aimed at addressing apprehension associated with ABR. The recommendations were the foundation for developing a rehabilitation guideline (REGUIDE). The REGUIDE integrates principles from cognitive-behavioral therapy to improve rehabilitation and mitigate apprehension. J Orthop Sports Phys Ther 2024;54(5):1-13. Epub 20 March 2024. doi:10.2519/jospt.2024.12106.

Editorial Commentary: Shoulder Arthroscopic Dynamic Anterior Stabilization Is Effective for Anteroinferior Shoulder Instability With Limited Anterior Bone Loss

Shoulder dynamic anterior stabilization (DAS) is an efficient and well-established glenohumeral stabilization technique, offering an arthroscopic alternative to Latarjet and glenoid reconstruction with distal tibial allograft or the iliac crest autograft. DAS is essentially an augmented Bankart procedure and can be performed using transfer of either the long head of the biceps tendon or the conjoined tendon. Both result in similar and acceptable rates of recurrences, complications, return to sport, and subjective shoulder function. However, the effectiveness of Bankart repair on shoulder stability decreases significantly over time, so long-term follow-up evaluations of DAS are required. The best indication for DAS may be anteroinferior shoulder instability with limited anterior bone loss.

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial

BACKGROUND

There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction.

METHODS

This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded.

DISCUSSION

This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction.

TRIAL REGISTRATION

The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.

Patients with recurrent anterior shoulder instability exhibit altered glenohumeral and scapulothoracic joint kinematics during upper limb movement: A prospective comparative study

BACKGROUND

Altered shoulder kinematics in patients with recurrent anterior shoulder instability remains poorly understood. This prospective study aimed to quantify in vivo glenohumeral and scapulothoracic joint kinematics and joint-contact positions in patients with shoulder instability and healthy controls.

METHODS

Twenty patients with recurrent anterior shoulder instability (mean 28 years) and five patients without shoulder pathology (mean 39 years) were scanned using open CT in six static upper limb positions including 90° of abduction, combined abduction and external rotation, 90° of flexion, lift-off position (i.e. reaching behind the back) and the neutral shoulder with external rotation. Image datasets were digitally reconstructed to quantify shoulder joint kinematics and glenohumeral translation.

FINDINGS

At 90° of abduction, instability patients demonstrated significantly less glenohumeral abduction and a reciprocal increase in upward scapulothoracic rotation compared to controls (mean difference: 13.3°, p = 0.038). With the shoulder in combined abduction and external rotation, instability patients showed a significant increase in glenohumeral rotation and a reciprocal decrease in scapulothoracic rotation compared to controls (mean difference: 5.0°, p = 0.042). There were no significant differences in humeral head translation in the sagittal plane (anterior-posterior axis) for all motions tested (p > 0.05).

INTERPRETATION

Scapulothoracic and glenohumeral kinematics are significantly different between patients with recurrent anterior shoulder instability and those with a healthy shoulder. Instability patients compensate for reduced glenohumeral function during abduction by increasing scapular rotation. With the shoulder in combined abduction and external rotation position, greater glenohumeral joint angles without significantly increased humeral head translation suggest altered neuromuscular control in the unstable shoulder.

Functional cortical changes associated with shoulder instability - a systematic review

BACKGROUND

Glenohumeral joint instability is associated with structural deficits and/or alterations in sensory and motor processing; however, a proportion of patients with glenohumeral joint instability fail to respond to surgical and rehabilitative measures. This systematic review aimed to establish if functional cortical changes occur in patients with glenohumeral joint instability.

METHODS

AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Medline, PEDro, Pubmed, PsychINFO and Scopus were searched from inception to 17 March 2021. Randomised controlled trials and non-randomised trials were included and quality was appraised using the Downs and Black tool.

RESULTS

One thousand two hundred seventy-nine records were identified of which five were included in the review. All studies showed altered cortical function when comparing instability patients with healthy controls and included areas associated with higher cortical functions.

DISCUSSION

The findings of this systematic review offer some insight as to why interventions addressing peripheral pathoanatomical factors in patients with glenohumeral joint instability may fail in some cases due to functional cortical changes. However, data are of moderate to high risk of bias. Further high-quality research is required to ascertain the degree of functional cortical changes associated with the type and duration of glenohumeral joint instability.

Kinesiophobia could affect shoulder function after repair of rotator cuff tears

Purpose

Kinesiophobia (fear of movement) is a major limiting factor in the return to pre-injury sport level after surgery of rotator cuff tears. The study aims to gain insights into how kinesiophobia affects shoulder pain and function after the repair of full-thickness rotator cuff tears.

Methods

A prospective study was conducted to evaluate patients who underwent rotator cuff repair between January 2019 and December 2019 in our institution. The patients were divided into a trial group with a high kinesiophobia (Tampa Scale for Kinesiophobia [TSK], TSK > 37) and a control group with a low kinesiophobia (TSK ≤ 37). The indicators of interest included the Constant-Murley scores, numerical rating scale (NRS), visual analogue scale (VAS), Oxford Shoulder Score (OSS), and the American shoulder and elbow score (ASES), shoulder function and strength, and range of motion (ROM) at 3 days, 6 weeks, and 12 months after repair of full-thickness rotator cuff tears.

Results

In total, 49 patients who underwent repair of full-thickness rotator cuff tears were enrolled, which was divided into a trial group involving 26 patients (mean TSK 52.54) and a control group involving 23 patients (mean TSK 33.43). There were no statistically significant differences in basic information such as age, gender, and length of stay in the two groups. The preoperative and early postoperative functional scores and the Tampa Scale for Kinesiophobia were statistically significant differences between the two groups. However, long-term postoperative follow-up showed no statistically significant difference in ASES, and Constant-Murley scores, OSS, and VAS scores between the two groups as the kinesiophobia changed from positive to negative.

Conclusion

Degree of kinesiophobia reduced during post-operative rehabilitation of rotator cuff repair patients, but high kinesiophobia is still present in a large portion of the patients after rotator cuff repair. Patients after rotator cuff repair will benefit from early recognition and prevention of kinesiophobia.

Structural and Functional Asymmetry in Precentral and Postcentral Gyrus in Patients With Unilateral Chronic Shoulder Pain

Objective

The purpose of this study was to explore the structural and functional asymmetry of precentral and postcentral gyrus in patients with unilateral chronic shoulder pain (CSP) utilizing MRI.

Patients and Methods

We collected structural and resting-state functional MRI (rs-fMRI) data in 22 left-sided, 15 patients with right-sided CSP, and 24 healthy controls (HCs). Here, we performed the structural asymmetry and seed-based functional connectivity (FC) analyses. We extracted regional cortical thickness and surface area measurements from T1-weighted MRI images, using asymmetry indexes (AIs) to assess asymmetries. We used Data Processing and Analysis for Brain Imaging software for seed-based FC analysis and selected unilateral-precentral and postcentral as the regions of interest. Then, we performed group comparisons of the neuroimaging metrics, and also explored the relationships between brain asymmetry and clinical variables.

Results

We found significant differences in surface area AIs of the precentral among three groups, the AI values were negatively correlated with the visual analog scale score and positively correlated with Constant–Murley scores (CMS) in the left-sided CSP group. Further, FC of left postcentral with cingulate gyrus and left paracentral lobule showed significant group differences; FC of right postcentral with left caudate, left paracentral, and left postcentral were different among groups; FC of right precentral with the cingulate gyrus, precuneus, and left paracentral revealed significant group differences. Besides, there was a positive correlation between right precentral-cingulate gyrus FC and CMS in the right-sided CSP group.

Conclusion

Surface area and FC patterns asymmetry exist in precentral and postcentral gyrus in patients with unilateral CSP. Asymmetry trend is associated with pain severity and shoulder joint function impairment. Brain structural and functional asymmetry may be an important indicator for understanding the potential mechanism of chronic pain.

Single Assessment Numeric Evaluation for instability as an alternative to the Rowe score

BACKGROUND

Several functional outcome scores have been proposed for the evaluation of shoulder instability. Most are multiple-item questionnaires, which can be time-consuming and difficult for patients to understand, as well as leading to lack of compliance. The Single Assessment Numeric Evaluation (SANE) score is a single question that has recently gained widespread acceptance based on its simplicity and correlation with more complex scoring systems. The purpose of this study was to assess the correlation of a new modified version of the SANE score, the SANE-instability score, with the Rowe score after treatment for shoulder instability.

MATERIALS AND METHODS

We prospectively evaluated a consecutive series of 253 patients (268 shoulders) treated surgically or nonoperatively for shoulder instability between November 2017 and November 2019, for whom the Rowe and SANE-instability scores were collected before treatment and/or after treatment. The SANE-instability score was assessed with the following question: "What is the overall percent value of your shoulder if a completely stable shoulder represents 100%?" Correlations were tested using the Pearson coefficient (r) and interpreted as very high (r = 0.90-1.00), high (r = 0.70-0.89), moderate (r = 0.50-0.69), low (r = 0.30-0.49), or negligible (r = 0.00-0.29). Subgroup analyses were also performed to observe correlation variations according to follow-up length (before treatment and at 6, 12, 26, 52, and 104 weeks after treatment), patient age (<20, 20-29, 30-39, or ≥40 years), and type of treatment (nonoperative or surgical).

RESULTS

The overall correlation between the SANE-instability and Rowe scores was high (r = 0.85, P < .001). Subgroup analyses revealed that the correlation between the 2 scores was high before treatment (r = 0.74); moderate at 6 and 12 weeks after treatment (r = 0.66 and r = 0.57, respectively); and then high at 26, 52, and 104 weeks after treatment (r = 0.75, r = 0.75, and r = 0.78, respectively) (P < .001). The correlation was high across all types of treatment (r = 0.76-0.85), high for patients aged ≥ 20 years (r = 0.80-0.86), and very high for patients aged < 20 years (r = 0.93) (P < .001).

CONCLUSION

This study demonstrated a significant correlation between the SANE-instability and Rowe scores before and after treatment, as well as across all patient age groups and treatments. Owing to its high simplicity, the SANE-instability score could be used as an alternative to the Rowe score for patient follow-up at various time points.

The immediate and subsequent impact of a first-time traumatic anterior shoulder dislocation in people aged 16-40: Results from a national cohort study

BACKGROUND

Limited evidence exists which details changes in quality of life, shoulder activity level, kinesiophobia, shoulder pain and disability following a first-time traumatic anterior shoulder dislocation (FTASD) in people treated non-operatively. This study had three objectives: (1) to examine quality of life, pain, disability and kinesiophobia after an FTASD within 12 weeks, (2) to examine whether these variables were different in people with and without recurrent shoulder instability and (3) to assess how these variables changed over 12 months.

METHODS

A prospective cohort study was undertaken in people with an FTASD aged between 16 and 40 years. Measures of quality of life, kinesiophobia, shoulder activity, shoulder pain and disability were recorded within 12 weeks of an FTASD and at 3, 6, 9 and 12 months.

RESULTS

An FTASD negatively impacted quality of life, shoulder pain and function and these variables improved over time. People with recurrent shoulder instability had poorer quality of life 12 months after an FTASD. Across the entire cohort, kinesiophobia did not significantly change across time in people following an FTASD.

CONCLUSIONS

Quality of life was significantly affected by an FTASD in people with recurrent shoulder instability. Across the entire cohort of people with an FTASD, kinesiophobia remained elevated in people following an FTASD.

LEVEL OF EVIDENCE

Level 1 prognostic study.

Handedness-related outcome following arthroscopic shoulder stabilization

INTRODUCTION

Bankart's repair technique represents a standard procedure for arthroscopic shoulder stabilization with excellent functional outcomes. Information concerning handedness-related outcome is missing. Here, we compare the postoperative outcome following arthroscopic shoulder stabilization in relation to handedness, taking sex and age as covariates into account.

PATIENTS AND METHODS

Our retrospective dual-cohort study included 36 patients with dominant side shoulder instability (mean follow-up 33 months) and 31 patients with non-dominant side shoulder instability (mean follow-up 41 months), who underwent arthroscopic shoulder stabilization due to traumatic anterior-inferior shoulder instability. All had experienced recurrent dislocations preoperatively. The impact of handedness, and of age and sex as covariates on postoperative outcome was evaluated by the Rowe score, the apprehension test and self-reported VAS.

RESULTS

Postoperatively, the Rowe score of the dominant side (mean 81.8, median 97.5) and the non-dominant side (mean 84.8, median 100) was not different (P = 0.718). Likewise, the univariate analysis for handedness (P = 0.806), sex (P = 0.627) and age (P = 0.929) as well as multivariate analysis for handedness (P = 0.721), sex (P = 0.583) and age (P = 0.898) showed no difference. The apprehension test for dominant versus non-dominant side operated patients was not different (P = 0.194). The univariate and multivariate analysis for handedness (P = 0.202 and P = 0.387, respectively) and age (P = 0.322 and P = 0.310, respectively) revealed no difference. However, the univariate and multivariate analysis for sex (P = 0.007 and P = 0.013, respectively) showed a difference. In relation to handedness, the results for the validated self-reported pain (rest pain P = 0.696, load-dependent pain P = 0.332) and surgery outcome satisfaction (P = 0.912) VAS were not different.

CONCLUSIONS

Patients with shoulder instability, who underwent arthroscopic Bankart repair for stabilization of their dominant or non-dominant shoulder showed no handedness-related difference in postoperative outcome based on Rowe score, apprehension test and self-reported VAS. For the orthopedic practice, this suggests that handedness is not a risk factor for patients outcome.

LEVEL OF EVIDENCE

Level IV, cohort study.

The Responsiveness of Patient- Reported Outcome Tools in Shoulder Surgery Is Dependent on the Underlying Pathological Condition

BACKGROUND

Given the high number of available patient-reported outcome (PRO) tools for patients undergoing shoulder surgery, comparative information is necessary to determine the most relevant forms to incorporate into clinical practice.

PURPOSE

To determine the utilization and responsiveness of common PRO tools in studies involving patients undergoing arthroscopic rotator cuff repair or operative management of glenohumeral instability.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of rotator cuff and instability studies from multiple databases was performed according to PRISMA guidelines. Means and SDs of each PRO tool utilized, study sample sizes, and follow-up durations were collected. The responsiveness of each PRO tool compared with other PRO tools was determined by calculating the effect size and relative efficiency (RE).

RESULTS

After a full-text review of 238 rotator cuff articles and 110 instability articles, 81 studies and 29 studies met the criteria for final inclusion, respectively. In the rotator cuff studies, 25 different PRO tools were utilized. The most commonly utilized PRO tools were the Constant (50 studies), visual analog scale (VAS) for pain (44 studies), American Shoulder and Elbow Surgeons (ASES; 39 studies), University of California, Los Angeles (UCLA; 20 studies), and Disabilities of the Arm, Shoulder and Hand (DASH; 13 studies) scores. The ASES score was found to be more responsive than all scores including the Constant (RE, 1.94), VAS for pain (RE, 1.54), UCLA (RE, 1.46), and DASH (RE, 1.35) scores. In the instability studies, 16 different PRO tools were utilized. The most commonly used PRO tools were the ASES (13 studies), Rowe (10 studies), Western Ontario Shoulder Instability Index (WOSI; 8 studies), VAS for pain (7 studies), UCLA (7 studies), and Constant (6 studies) scores. The Rowe score was much more responsive than both the ASES (RE, 22.84) and the Constant (RE, 33.17) scores; however, the ASES score remained more responsive than the Constant (RE, 1.93), VAS for pain (RE, 1.75), and WOSI (RE, 0.97) scores.

CONCLUSION

Despite being frequently used in the research community, the Constant score may be less clinically useful as it was less responsive. Additionally, it is a greater burden on the provider because it requires objective strength and range of motion data to be gathered by the clinician. In contrast, the ASES score was highly responsive after rotator cuff repair and requires only subjective patient input. Furthermore, separate PRO scoring methods appear to be necessary for patients undergoing rotator cuff repair and surgery for instability as the instability-specific Rowe score was much more responsive than the ASES score.

Shoulder apprehension: A multifactorial approach

Shoulder apprehension is related to changes in functional cerebral networks induced by dislocations, peripheral neuromuscular lesions and persistent mechanical glenohumeral instability consisting of micro-motion.All the damage to the osseous and soft-tissue stabilizers of the shoulder, as well as neurologic impairment persisting even after stabilization, must be properly identified in order to offer the best possible treatment to the patient.There is growing evidence supporting the use of a global multimodal approach, involving, on the one hand, shoulder 'reafferentation', including proprioception, mirror therapy and even cognitive behavioural approaches, and, on the other hand, surgical stabilization techniques and traditional physical therapy in order to minimize persistent micro-motion, which may help brain healing. This combined management could improve return to sport and avoid dislocation arthropathy in the long term. Cite this article: EFORT Open Rev 2018;3:550-557. DOI: 10.1302/2058-5241.3.180007.

Eccentric cross-exercise after anterior cruciate ligament reconstruction: Novel case series to enhance neuroplasticity

OBJECTIVES

Substantial changes in neural function are historically present after anterior cruciate ligament reconstruction (ACLR), and are not rectified with traditional rehabilitation. Cross-exercise is a potential means to enhance neural excitability and improve recovery after ACLR. Hence our purpose, was to detail changes in brain activation, neural excitability and patient-reported outcomes in a cohort that completed an 8-week quadriceps-focused eccentric cross-exercise training program immediately following ACLR.

DESIGN

Case series.

SETTING

University.

PARTICPANTS

Five patients participated in an 8-week (24-session) eccentric cross-exercise intervention after ACLR.

MAIN OUTCOME MEASURES

Brain activation, neural activity and patient-reported outcomes were evaluated within 2 weeks post-ACLR and again at 10-weeks post-ACLR after the intervention. Each cross-exercise session consisted of 4 sets of 10 isokinetic eccentric contractions at 60 deg/sec with the noninvolved limb.

RESULTS

Following the intervention, patients demonstrated a facilitated spinal reflexive and muscle activity response from the motor cortex during a time when these measures are known to be depressed. Patients also demonstrated a reduce dependence on frontal cortex activity to generate quadriceps contractions. Further patients reported significant reductions in pain and symptoms and greater knee function.

CONCLUSIONS

Eccentric cross-exercise after ACLR helps to facilitate positive adaptations in neural function and patient reported outcomes.

Brain activity in the right-frontal pole and lateral occipital cortex predicts successful post-operatory outcome after surgery for anterior glenoumeral instability

Shoulder apprehension is more complex than a pure mechanical problem of the shoulder, creating a scar at the brain level that prevents the performance of specific movements. Surgery corrects for shoulder instability at the physical level, but a re-dislocation within the first year is rather common. Predicting which patient will be likely to have re-dislocation is therefore crucial. We hypothesized that the assessment of neural activity at baseline and follow-up is the key factor to predict the post-operatory outcome. 13 patients with shoulder apprehension (30.03 ± 7.64 years) underwent clinical and fMRI examination before and one year after surgery for shoulder dislocation contrasting apprehension cue videos and control videos. Data analyses included task-related general linear model (GLM) and correlations imaging results with clinical scores. Clinical examination showed decreased pain and increased shoulder functions for post-op vs. pre-op. Coherently, GLM results show decreased activation of the left pre-motor cortex for post-surgery vs. pre-surgery. Right-frontal pole and right-occipital cortex activity predicts good recovery of shoulder function measured by STT. Our findings demonstrate that beside physical changes, changes at the brain level also occur one year after surgery. In particular, decreased activity in pre-motor and orbito-frontal cortex is key factor for a successful post-operatory outcome.

Structural white matter and functional connectivity alterations in patients with shoulder apprehension

Previous functional magnetic resonance imaging (fMRI) findings indicate that shoulder apprehension is more complex than a pure mechanical problem of the shoulder, showing a direct modification in functional brain networks associated with motor inhibition and emotional regulation. The current study extends these findings by investigating further structural alterations in patients with shoulder apprehension compared to controls. 14 aged patients with shoulder apprehension (27.3 ± 2.0 years) and 10 matched healthy controls (29.6 ± 1.3 years) underwent clinical and fMRI examination including fMRI and diffusion tensor imaging (DTI). Tract-based spatial statistics procedure was used to analyze white matter (WM) alterations. Functional images were analyzed investigating resting state network connectivity. DTI results were correlated with different shoulder clinical scores and functional connectivity networks. Fractional anisotropy (FA), representing white matter integrity, is increased in the left internal capsule and partially in the thalamus in patients compared to controls. Moreover, FA correlates negatively with simple shoulder test (SST) scores (p < .05) and positively with a functional connectivity network qualitatively replicating previous results (p < .01). This study extends previous findings, showing that in addition to functional changes, structural white matter changes are also present in patients with shoulder apprehension.

Clinician and Patient-reported Outcomes Are Associated With Psychological Factors in Patients With Chronic Shoulder Pain

BACKGROUND

Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors.

QUESTIONS

We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements?

METHODS

All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5-15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes.

RESULTS

Greater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25-1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, -6.15; 95% CI, -11.09 to -1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021-0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87-0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77-16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, -0.35; 95% CI, -0.58 to -0.12; p = 0.003).

CONCLUSIONS

Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score.

LEVEL OF EVIDENCE

Level III, prognostic study.

Does surgery for instability of the shoulder truly stabilize the glenohumeral joint?: A prospective comparative cohort study

Despite the fact that surgery is commonly used to treat glenohumeral instability, there is no evidence that such treatment effectively corrects glenohumeral translation. The purpose of this prospective clinical study was to analyze the effect of surgical stabilization on glenohumeral translation.Glenohumeral translation was assessed in 11 patients preoperatively and 1 year postoperatively following surgical stabilization for anterior shoulder instability. Translation was measured using optical motion capture and computed tomography.Preoperatively, anterior translation of the affected shoulder was bigger in comparison to the normal contralateral side. Differences were significant for flexion and abduction movements (P < 0.001). Postoperatively, no patients demonstrated apprehension and all functional scores were improved. Despite absence of apprehension, postoperative anterior translation for the surgically stabilized shoulders was not significantly different from the preoperative values.While surgical treatment for anterior instability limits the chance of dislocation, it does not seem to restore glenohumeral translation during functional range of motion. Such persistent microinstability may explain residual pain, apprehension, inability to return to activity and even emergence of dislocation arthropathy that is seen in some patients. Further research is necessary to better understand the causes, effects, and treatment of residual microinstability following surgical stabilization of the shoulder.