Optimising the use of physiotherapy resources after manipulation under anaesthetic for frozen shoulder

INTRODUCTION

Manipulation under anaesthetic (MUA) is a successful treatment for frozen shoulder (FS), and the recovery period and recurrence rates may be reduced by postoperative physiotherapy. This study evaluates two physiotherapy pathways for patients undergoing MUA for FS.

METHODS

Between 2016 and 2018, 248 age- and sex-matched patients presented to either a NHS secondary care upper limb service or the lead author's independent practice with a diagnosis of FS. The patients had differential access to postprocedure physiotherapy based on which service they presented to. In Group 1, physiotherapy advice only was given to the patient. In Group 2, supervised hydrotherapy and physiotherapy occurred postoperatively. Pre- and postprocedure Oxford Shoulder Scores (OSS) were collected for each group. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on postoperative OSS.

RESULTS

Group 2 showed a significantly greater improvement in postprocedure OSS when compared with Group 1 (18.2 vs 16.7) p<0.001). The estimated maximum effect of physiotherapy on postoperative OSS was an increase of 3.2.

CONCLUSION

Following MUA for FS, a statistically significant increase in OSS was detected in patients receiving postprocedure physiotherapy compared with advice alone. There was no difference in recurrence rates. The increase in OSS (3.2) is below the minimal clinically important difference, raising questions regarding the relative importance of postprocedure physiotherapy in a resource-limited environment.

1419 Targeted Use of Physiotherapy Resources in The COVID Era: How Does Face to Face Physiotherapy Compare with Simple Advice Sheets After Manipulation Under Anaesthetic for Frozen Shoulder?

Introduction

This study compares two pathways for patients undergoing MUA for FS, one where physiotherapy advice is only given to the patient (Group 1), and the other where supervised hydrotherapy and physiotherapy occur post operatively (Group 2).

Method

A descriptive analysis of pre- and post-operative Oxford Shoulder Scores and change scores were performed. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on post-operative OSS, with pre-operative OSS as the only covariate.

Results

The results for post-operative OSS were significantly greater for Group 2 than for Group 1 (40.7 for NHS and 44.7 for private, improvement of 17.32 for NHS and 18.23 for Private). The effect of physiotherapy was significant (p &lt; 0.001). The estimated effect of physiotherapy on postoperative OSS was an increase of 3.2 (95% confidence interval 1.5 – 4.8).

Conclusions

We detected a statistically significant increase in post-operative OSS in patients treated for frozen shoulder with MUA + physiotherapy compared with patients receiving MUA plus advice alone. These results suggest that physiotherapy does confer a real benefit, however the increased OSS is below the clinically significant level. Therefore, in a resource poor environment, such as may exist during and after COVID in many health care systems, MUA plus physio advice alone gives an excellent outcome for the treatment of FS.

18 Manipulation Under Anaesthetic for Frozen Shoulder: Does Post-Operative Supervised Physiotherapy Affect the Outcome?

Introduction

This study compares two pathways for patients undergoing MUA for FS, one where physiotherapy advice is only given to the patient (Group 1), and the other where supervised hydrotherapy and physiotherapy occur post operatively (Group 2).

Method

A descriptive analysis of pre- and post-operative Oxford Shoulder Scores and change scores were performed.

Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on post-operative OSS, with pre-operative OSS as the only covariate.

Results

The results for post-operative OSS were significantly greater for Group 2 than for Group 1 (40.7 for NHS and 44.7 for private, improvement of 17.32 for NHS and 18.23 for Private). The estimated effect of physiotherapy on postoperative OSS was an increase of 3.2 (95% confidence interval 1.5 – 4.8).

Conclusions

We detected a statistically significant increase in post-operative OSS in patients treated for frozen shoulder with MUA + physiotherapy compared with patients receiving MUA plus advice alone. These results suggest that physiotherapy does confer a real benefit, however the increased OSS is below the clinically significant level. Therefore, in a resource poor environment, such as may exist after COVID in many health care systems, MUA plus physio advice alone gives an excellent outcome for the treatment of FS.

Affectivity during social behaviour in a schizophrenic-like rat

Introduction

Rats are social animals that produce high-frequency whistles said to reflect their underlying affective state. Injecting rats with a glutamate agonist (domoic acid) at a sensitive period of brain development, models aspects of schizophrenia. This is known as the neonatal DOM model.

Aims

We investigated whether DOM rats display altered social behaviour – as seen in patients with schizophrenia – using their high-frequency whistles as a proxy for the emotional valence of social situations.

Methods

We used 19 male Sprague Dawley rats, injected with either a low-dose of domoic acid or saline at postnatal days 8 to 14. The social behaviour of the rats was investigated at four levels:

– anticipation of social interaction;

– dyadic encounter;

– three-chamber test;

– tickling.

Tests were carried out at postnatal days 34 to 40 and 50 to 56. Rat whistles were recorded on all days of testing.

Results

In progress.

Conclusions

The interest in rat whistles as a supplement to traditional behavioural tests has increased. New software allows for detailed qualitative analysis of the whistle subtypes and thus new complexity to their interpretation. This study can help unravel information encoded in the whistles and shed light on the social behaviour of the DOM rat thus investigating it is applicability as a model of schizophrenia.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Effect of silencing the two major tomato fruit pectin methylesterase isoforms on cell wall pectin metabolism

Post-harvest storage is largely limited by fruit softening, a result of cell wall degradation. Pectin methylesterase (PE) (EC 3.1.1.11) is a major hydrolase responsible for pectin de-esterification in the cell wall, a response to fruit ripening. Two major PE isoforms, PE1 and PE2, have been isolated from tomato (Solanum lycopersicon) pericarp tissue and both have previously been down-regulated using antisense suppression. In this paper, PE1 and PE2 double antisense tomato plants were successfully generated through crossing the two single antisense lines. In the double antisense fruit, approximately 10% of normal PE activity remained and ripening associated pectin de-esterification was almost completely blocked. However, double antisense fruit softened normally during ripening. In tomato fruit, the PE1 isoform was found to contribute little to total PE activity and have little effect on the degree of esterification of pectin. In contrast, the other dominant fruit isoform, PE2, has a major impact on de-esterification of total pectin. PE2 appears to act on non-CDTA-soluble pectin during ripening and on CDTA-soluble pectin before the start of ripening in a potentially block-wise fashion.

Shoulder arthroplasty. Part 2: normal and abnormal radiographic findings

Frequently, the decision made by general practitioners or musculoskeletal triage assessment services to refer patients for specialist review is initiated by a radiological report. Following shoulder arthroplasty it is important to ensure that any patient with asymptomatic evidence of a failing prosthesis is referred for review so that revision surgery can be contemplated and planned before the situation becomes unsalvageable. The first paper in this series described the various types of shoulder arthroplasty and indications for each. This follow-up paper will concentrate on their modes of failure and the associated radiographic features, and is aimed at radiology trainees and non-musculoskeletal specialist radiologists.

Shoulder arthroplasty. Part 1: Prosthesis terminology and classification

Shoulder arthroplasty is the third most common joint replacement procedure in the UK, and there are a number of different implant options available to surgeons to treat a variety of shoulder disorders. With an increasing burden placed on clinical follow-up, more patients are remaining under the care of their general practitioners and musculoskeletal triage assessment services and are not necessarily being seen by specialists. Referrals to orthopaedic specialists are therefore often prompted by radiological reports describing evidence of implant failure. This article is the first of two reviews on shoulder arthroplasty, concentrating on implant features and the indications for their use. The second article will address the modes of failure of shoulder arthroplasty and describe the relevant associated radiological features.

Domoic acid neurotoxicity in hippocampal slice cultures

The neurotoxicity of domoic acid was studied in 2-3 week old rat hippocampal slice cultures, derived from 7 day old rat pups. Domoic acid 0.1-100 microM was added to the culture medium for 48 hrs, alone or together with the glutamate receptor antagonists NS-102 (5-Nitro-6,7,8,9-tetrahydrobenzo[G]indole-2,3-dione-3-oxime), NBQX (2,3-dihydroxy-6-nitro-7-sulphamoyl-benzo(F)quinoxaline) or MK-801 ((+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]-cyclohepten-5,10-imine hydrogen maleate), followed by transfer of the cultures to normal medium for additional 48 hrs. Neuronal degeneration in the fascia dentata (FD), CA3 and CA1 hippocampal subfields was monitored and EC(50) values estimated by densitometric measurements of the cellular uptake of propidium iodide (PI). The CA1 region was most sensitive to domoic acid, with an EC(50) value of 6 microM domoic acid, estimated from the PI-uptake at 72 hrs. Protective effects of 10 microM NBQX against 3 and 10 microM domoic acid were observed for both dentate granule cells and CA1 and CA3c pyramidal cells. NS102 and MK 801 only displayed protective effects when combined with NBQX. MK801 significantly increased the combined neuroprotective effect of NBQX and NS102 against 10 microM domoic acid in both CA1 and FD, but not in CA3. We conclude, that domoic acid neurotoxicity in CA3 and in hippocampal slice cultures in general primarily involves AMPA/kainate receptors. At high concentrations (10 microM domic acid) NMDA receptors are, however, also involved in the toxicity in CA1 and FD.

MRI AFTER OPERATIVE REDUCTION FOR DEVELOPMENTAL DYSPLASIA OF THE HIP

We performed MRI on 13 infants after operative reduction for developmental dysplasia of the hip (DDH). Using an axial gradient-echo sequence, MRI accurately depicted the acetabular anatomy and confirmed adequate reduction in 12 patients. The one patient with redislocation after surgery was correctly identified. MRI can be carried out quickly, inexpensively and without risk of radiation and is the investigation of choice to confirm adequate reduction in DDH.

MRI after operative reduction for developmental dysplasia of the hip

We performed MRI on 13 infants after operative reduction for developmental dysplasia of the hip (DDH). Using an axial gradient-echo sequence, MRI accurately depicted the acetabular anatomy and confirmed adequate reduction in 12 patients. The one patient with redislocation after surgery was correctly identified. MRI can be carried out quickly, inexpensively and without risk of radiation and is the investigation of choice to confirm adequate reduction in DDH.

Morphine differentially affects domoic acid and kainic acid toxicity in vivo

The effect of systemic injections of morphine on behavioural toxicity and hippocampal (CA3 region) damage produced by both domoic and kainic acids was investigated in mice. Low doses of morphine (2.0 and 4.0 mg kg-1), but not higher doses, significantly antagonized the toxic response to a previously determined TD50 of domoic acid. By contrast, low doses of morphine had either minimal or no effect on the response to an equitoxic dose of kainic acid (TD50), but higher doses (6.0 and 8.0 mg kg-1) resulted in significant potentiation of kainate toxicity. These results provide the first evidence of a pharmacological dissociation between the mechanisms of domoic acid and kainic acid toxicity in vivo, suggesting that these two toxins produce behavioural and hippocampal toxicity via overlapping but non-identical mechanisms.

Mussel culture and the accumulation of domoic acid

The cultured mussel industry of Prince Edward Island had never experienced a toxic disease problem until November of 1987. With the successful use of the long-line culture system, the yearly production of fresh mussels to the gourmet food market had risen to close to 3.2 million pounds (1.46 million kg) of product. The physiology of this sessile bivalve and its method of feeding and location in the estuary leave it prone to the accumulation of a widely distributed biotoxin. Eastern Prince Edward Island became the epicentre of domoic acid-intoxicated mussels as early as 10 November 1987 (retrospective samples) during an intense bloom of the diatom Nitzschia. Mussels were able to accumulate large amounts of the domoic acid with little effect on their own well-being. Despite being in low water temperatures (below 4 degrees C) and under thick ice cover, the levels of the toxin decreased and were undetectable in about 6 weeks. The following year the toxin was detected in much smaller amounts, and the levels of toxin accumulation demonstrated a variable lag time with the increase in concentration of Nitzschia available in the water column. The sales of Prince Edward Island cultured mussels have rebounded to about 140% of the pre-domoic acid crisis.