Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

Disparities in Receipt of Early Intervention Services by Toddlers with Autism Diagnoses: an Intersectional Latent Class Analysis of Demographic Factors

We examined receipt of general early intervention services and autism-specific specialized services across demographic groups among toddlers with autism diagnoses who were receiving Part C Early Intervention (EI). Latent class analysis (n = 508) identified five demographically distinct subgroups associated with intersecting marginalization and privilege. Analyses of longitudinal parent interviews (n = 225) revealed service receipt disparities across these demographically distinct latent classes; children from White, U.S. born, English-proficient parents with incomes above poverty level received more EI services (M = 12.0 h/week) than other subgroups, with children from Latiné immigrant families receiving the fewest hours (M = 6.9 h/week). Across all groups, average intervention hours were 8.8 h/week. Despite early identification, racial, ethnic, and other sociodemographic disparities were evident in receipt of Part C Early Intervention services, indicating the need to address barriers to equitable care.

Similar outcomes between arthroscopic capsular release and manipulation under anesthesia for frozen shoulder: A meta-analysis

To compared the arthroscopic capsular release (ACR) with manipulation under anaesthesia (MUA) for the surgical treatment of frozen shoulder (FS) based on postoperative outcomes and complications. PubMed, Cochrane Library, Embase, and Web of Science were searched on October 2, 2023 to retrieve eligible studies that compared ACR with MUA in terms of clinical outcomes (pain visual analogue scale, external rotation, forward flexion and adverse events) for patients with FS. Mean differences (MD) were calculated for continuous outcomes and odds ratios (OR) were calculated for dichotomous outcomes. Six papers, including 5 clinical studies (a total of 690 shoulders), were included in the final meta-analysis. The forward flexion was found to be larger in the ACR group at 3 months (MD, 2.73; 95%CI, 0.42-5.04; I2 = 44%; P = 0.02) and 6 months (MD, 2.36; 95%CI, 1.29-3.44; I2 = 0%; P < 0.0001). Except for this, ACR was comparable with MUA in terms of pain visual analogue scale at 3, 6 and 12 months (p = 0.25, p = 0.11, p = 0.28, respectively), external rotation at 3, 6 and 12 months (p = 0.15, p = 0.52, p = 0.23, respectively), and forward flexion at 12 months (p = 0.08). There were no differences in complication rates between the two groups (OR, 0.82; 95%CI, 0.47-1.44; I2 = 0%; P = 0.50). In comparison with MUA, ACR demonstrated better outcomes for forward flexion at 3 and 6 months, while there were no significant differences between ACR and MUA in terms of pain visual analogue scale, external rotation and adverse events.

A multi-center, single-blinded, randomized, parallel-group, superiority study to compare the efficacy of manipulation under anesthesia versus intra-articular steroid injection in the treatment of patients with frozen shoulder and a diagnosis of rotator cuff injury or tear by MRI: study protocol for a randomized controlled trial

BACKGROUND

Frozen shoulder (FS) is a common condition that can cause severe pain and limited range of motion in the shoulder joint. While intra-articular steroid injection has been shown to be an effective treatment for FS, manipulation under anesthesia (MUA) is an alternative treatment that has gained popularity in recent years. However, there is a lack of evidence regarding the effectiveness of MUA on FS patients with concomitant rotator cuff injury or tear. Though a few studies have shown that MUA is not associated with rotator cuff tears, and will not exacerbate the injury, more high-quality studies with bigger sample sizes are needed. Therefore, the aim of this multi-center, single-blinded, randomized, parallel-group, superiority study is to compare the efficacy of MUA versus intra-articular steroid injection in the treatment of FS patients with a diagnosis of rotator cuff injury or tear by MRI.

METHODS

A parallel, single-blinded, multi-center randomized controlled trial of 320 patients will be conducted at three hospitals of China. Eligible patients with frozen shoulder and rotator cuff injury or tear diagnosed by MRI will be randomly assigned to, in equal proportions, the manipulation under anesthesia group and the intra-articular steroid injection group via a central randomization system, undergoing a corresponding operation on day one and a sequent physical exercise for 14 days. The primary outcome is the comprehensive efficacy evaluation (total effective rate) and the change of Constant-Murley Score. Outcome assessors and data analysts will be blinded, and participants will be asked not to reveal their allocation to assessors.

DISCUSSION

This study aims to explore the superiority of manipulation under anesthesia in reducing pain and improving shoulder function in frozen shoulder patients accompanied with rotator cuff injury. To provide a scientific basis for the dissemination and application of manipulation under anesthesia, and a better knowledge for the role of MUA in the treatment of frozen shoulder accompanied with rotator cuff injury.

TRIAL REGISTRATION

Chictr.org.cn ChiCTR2200067122 . Registered on 27 December 2022. ChiCTR is a primary registry of the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) network and includes all items from the WHO Trial Registration data set in Trial registration.

Comparative analysis of scaphoid nonunion treatment with screw fixation and angular stable plate

INTRODUCTION

Scaphoid fractures represent 5-10% of nonunion rate and the treatment options consist of an open reduction with correction of deformity, restoration of the scaphoid length with autologous wedge grafting and fixation. However, there is still no consensus in the literature on the best fixation method. Therefore, the purpose of the study is to compare plate fixation and screw fixation in treating scaphoid nonunion with humpback deformity and carpal instability.

METHODS

Prospective, non-randomised study comparing the treatment of two groups of patients with scaphoid nonunion. A total of 19 patients were included in the study, the first ten patients were included in group 1 (plate fixation), subsequently nine patients were included in group 2 (screw fixation). The nonunion duration was longer than 6 months and patients did not present type III Scaphoid Nonunion Advanced Collapse (SNAC). Clinical evaluations included pain intensity, range of motion, grip strength, pinch test and functional scales Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Wrist Score. Radiographic evaluations consisted of radiographs of both wrists in AP, AP with ulnar deviation, lateral and oblique views. Patients further underwent a tomography of the affected wrist for bone deformity, carpal collapse and later consolidation evaluation.

RESULTS

According to post-operative measurements, group 1 showed a significant improvement in the scapholunate angle (p = 0.011) and in the intrascaphoid angle (p = 0.002). Group 2 only showed an improvement in the scapholunate angle (p = 0.011). All patients in group 1 achieved consolidation in 8 weeks, while group 2 patients had a slower consolidation, with a mean of 14 weeks and standard deviation (SD) of 4.2, with statistical significance (p = 0.006).

CONCLUSION

Our prospective study, despite the limitations, contributes to the literature for demonstrating a better fixation using plate, with a better correction of humpback deformity and Dorsal Intercalated Segment Instability (DISI) and a faster consolidation.

LEVEL OF EVIDENCE

II, therapeutics studies; prospective comparative study.

Reliability and validity of the Shoulder Pain and Disability Index in a sample of patients with frozen shoulder

BACKGROUND

The Shoulder and Pain Disability Index (SPADI) is a widely used outcome measure. The aim of this study is to explore the reliability and validity of SPADI in a sample of patients with idiopathic frozen shoulder.

METHODS

The SPADI was administered to 124 patients with idiopathic frozen shoulder. A sub-group of 29 patients were retested after 7 days. SPADI scores were correlated with other outcome measures (i.e., Disabilities of the Arm, Shoulder and Hand Questionnaire - DASH; Numerical Pain Rating Scale-NPRS; and 36-item Short Form Health Survey-SF-36) to examine construct validity. Structural validity was assessed by a Two-Factors Confirmatory Factor Analysis (CFA). Internal consistency, test-retest reliability, and measurement error were also analyzed.

RESULTS

The construct validity was satisfactory as seven out of eight of the expected correlations formulated (≥ 75%) for the subscales were satisfied. The CFA showed good values of all indicators for both Pain and Disability subscales (Comparative Fit Index = 0.999; Tucker-Lewis Index = 0.997; Root Mean Square Error of Approximation = 0.030). Internal consistency was good for pain (α = 0.859) and disability (α = 0.895) subscales. High test-retest reliability (Intraclass correlation coefficient [ICC]) was found for pain (ICC = 0.989 [95% Confidence Interval (CI = 0.975-0.995]) and disability (ICC = 0.990 [95% CI = 0.988-0.998]). Standard Error of Measurement values of 2.27 and 2.32 and Minimal Detectable Change values of 6.27 and 6.25 were calculated for pain and disability subscales, respectively.

CONCLUSION

The SPADI demonstrated satisfactory reliability and validity properties in a sample of patients with idiopathic frozen shoulder.

Systematic Review with Meta-Analysis: Efficacy and Safety of Lusutrombopag for Severe Thrombocytopenia in Patients with Chronic Liver Disease Undergoing Invasive Procedures

INTRODUCTION

Lusutrombopag is an oral thrombopoietin receptor agonist (TPO-RA). Clinical trials have shown lusutrombopag's efficacy in reducing need for preoperative platelet transfusion in patients with chronic liver disease (CLD) and severe thrombocytopenia. This analysis assessed efficacy and safety of lusutrombopag in patients with severe thrombocytopenia and CLD undergoing planned invasive procedures.

METHODS

An electronic database search (through 1 December 2020) identified three randomised, placebo-controlled, double-blind clinical trials comparing lusutrombopag with placebo in patients with CLD and platelet count below 50 × 109/L scheduled to undergo a procedure with a perioperative bleeding risk. A random-effects meta-analysis examined treatment effect, with Cochrane Collaboration's tool assessing risk of bias.

RESULTS

The meta-analysis included 343 (lusutrombopag 3 mg, n = 173; placebo, n = 170) patients. More patients met the criteria for treatment response (platelet count at least 50 × 109/L and increase of at least 20 × 109/L from baseline anytime during the study) with lusutrombopag versus placebo (risk ratio [RR] 6.39; 95% confidence interval [CI] 3.69, 11.07; p < 0.0001). The primary efficacy outcome, proportion of patients requiring no platelet transfusion and no rescue therapy for bleeding for at least 7 days post procedure, was achieved by more patients treated with lusutrombopag versus placebo (RR 3.42; 95% CI 1.86, 6.26; p = 0.0001). The risk of any bleeding event was significantly lower with lusutrombopag compared to placebo (RR 0.55; 95% CI 0.32, 0.95; p = 0.03); conversely, thrombosis event rates were similar between lusutrombopag and placebo (RR 0.79; 95% CI 0.19, 3.24; p = 0.74).

CONCLUSION

This meta-analysis showed that treatment of severe thrombocytopenia with lusutrombopag in patients with CLD prior to a planned invasive procedure was efficacious and safe in increasing platelet counts, avoiding the need for platelet transfusions, and reducing risk of bleeding, thereby enhancing the certainty of evidence supporting the efficacy and safety of lusutrombopag.

Positive Effect of Manipulated Virtual Kinematic Intervention in Individuals with Traumatic Stiff Shoulder: A Pilot Study

Virtual reality enables the manipulation of a patient’s perception, providing additional motivation to real-time biofeedback exercises. We aimed to test the effect of manipulated virtual kinematic intervention on measures of active and passive range of motion (ROM), pain, and disability level in individuals with traumatic stiff shoulder. In a double-blinded study, patients with stiff shoulder following proximal humerus fracture and non-operative treatment were randomly divided into a non-manipulated feedback group (NM-group; n = 6) and a manipulated feedback group (M-group; n = 7). The shoulder ROM, pain, and disabilities of the arm, shoulder and hand (DASH) scores were tested at baseline and after 6 sessions, during which the subjects performed shoulder flexion and abduction in front of a graphic visualization of the shoulder angle. The biofeedback provided to the NM-group was the actual shoulder angle while the feedback provided to the M-group was manipulated so that 10° were constantly subtracted from the actual angle detected by the motion capture system. The M-group showed greater improvement in the active flexion ROM (p = 0.046) and DASH scores (p = 0.022). While both groups improved following the real-time virtual feedback intervention, the manipulated intervention provided to the M-group was more beneficial in individuals with traumatic stiff shoulder and should be further tested in other populations with orthopedic injuries.

Bilateral upper extremity motor priming (BUMP) plus task-specific training for severe, chronic upper limb hemiparesis: study protocol for a randomized clinical trial

BACKGROUND

Various priming techniques to enhance neuroplasticity have been examined in stroke rehabilitation research. Most priming techniques are costly and approved only for research. Here, we describe a priming technique that is cost-effective and has potential to significantly change clinical practice. Bilateral motor priming uses the Exsurgo priming device (Exsurgo Rehabilitation, Auckland, NZ) so that the less affected limb drives the more affected limb in bilateral symmetrical wrist flexion and extension. The aim of this study is to determine the effects of a 5-week protocol of bilateral motor priming in combination with task-specific training on motor impairment of the affected limb, bimanual motor function, and interhemispheric inhibition in moderate to severely impaired people with stroke.

METHODS

Seventy-six participants will be randomized to receive either 15, 2-h sessions, 3 times per week for 5 weeks (30 h of intervention) of bilateral motor priming and task-specific training (experimental group) or the same dose of control priming plus the task-specific training protocol. The experimental group performs bilateral symmetrical arm movements via the Exsurgo priming device which allows both wrists to move in rhythmic, symmetrical wrist flexion and extension for 15 min. The goal is one cycle (wrist flexion and wrist extension) per second. The control priming group receives transcutaneous electrical stimulation below sensory threshold for 15 min prior to the same 45 min of task-specific training. Outcome measures are collected at pre-intervention, post-intervention, and follow-up (8 weeks post-intervention). The primary outcome measure is the Fugl-Meyer Test of Upper Extremity Function. The secondary outcome is the Chedoke Arm and Hand Activity Index-Nine, an assessment of bimanual functional tasks.

DISCUSSION

To date, there are only 6 studies documenting the efficacy of priming using bilateral movements, 4 of which are pilot or feasibility studies. This is the first large-scale clinical trial of bilateral priming plus task-specific training. We have previously completed a feasibility intervention study of bilateral motor priming plus task-specific training and have considerable experience using this protocol.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03517657 . Retrospectively registered on May 7, 2018.

Effectiveness of interventions for the management of primary frozen shoulder : a systematic review of randomized trials

AIMS

This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI.

METHODS

MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder.

RESULTS

Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero.

CONCLUSION

The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773-784.

Cost-effectiveness of surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder : an economic evaluation of the UK FROST trial

Aims

A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care.

Methods

A cost utility analysis from the NHS perspective was performed. Differences between manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR), and early structured physiotherapy plus steroid injection (ESP) in costs (2018 GBP price base) and quality adjusted life years (QALYs) at one year were used to estimate the cost-effectiveness of the treatments using regression methods.

Results

ACR was £1,734 more costly than ESP ((95% confidence intervals (CIs) £1,529 to £1,938)) and £1,457 more costly than MUA (95% CI £1,283 to £1,632). MUA was £276 (95% CI £66 to £487) more expensive than ESP. Overall, ACR had worse QALYs compared with MUA (-0.0293; 95% CI -0.0616 to 0.0030) and MUA had better QALYs compared with ESP (0.0396; 95% CI -0.0008 to 0.0800). At a £20,000 per QALY willingness-to-pay threshold, MUA had the highest probability of being cost-effective (0.8632) then ESP (0.1366) and ACR (0.0002). The results were robust to sensitivity analyses.

Conclusion

While ESP was less costly, MUA was the most cost-effective option. ACR was not cost-effective.

Cite this article: Bone Jt Open 2021;2(8):685–695.