Arthrographic distension for adhesive capsulitis (frozen shoulder)

BACKGROUND

Adhesive capsulitis (frozen shoulder or painful stiff shoulder) is characterised by spontaneous onset of shoulder pain accompanied by progressive stiffness and disability. It is usually self-limiting but often has a prolonged course over two to three years.

OBJECTIVES

To determine the effectiveness and safety of arthrographic distension of the glenohumeral joint in the treatment of adults with adhesive capsulitis.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Review Group Register, CENTRAL, MEDLINE, CINAHL, and EMBASE to November 2006, unrestricted by date or language.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials comparing arthrographic distension with placebo or other interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Five trials with 196 people were included. One three-arm trial (47 participants) compared arthrographic distension using steroid and air to distension using air alone and to steroid injection alone. One trial (46 participants) compared arthrographic distension using steroid and saline to placebo. Two trials (45 and 22 participants) compared arthrographic distension using steroid to steroid injection alone. One trial (36 participants) compared arthrographic distension using steroid and saline plus physical therapy to physical therapy alone. Trials included similar study participants, but quality and reporting of data were variable. Only one trial was at low risk of bias. No meta-analysis was performed.The trial with low risk of bias demonstrated that distension with saline and steroid was better than placebo for pain (number needed to treat to benefit (NNTB) = 2), function (NNTB = 3) and range of movement at three weeks. This benefit was maintained at six and 12 weeks only for one of two scores measuring function (NNT = 3). A second trial with high risk of bias also reported that distension combined with physical therapy improved range of movement and median percent improvement in pain (but not pain score) at eight weeks compared to physical therapy alone. Three further trials, all at high risk of bias, reported conflicting, variable effects of arthrographic distension with steroid compared to distension alone, and arthrographic distension with steroid compared to intra-articular steroid injection. The trials reported a small number of minor adverse effects, mainly pain during and after the procedure.

AUTHORS' CONCLUSIONS

There is "silver" level evidence that arthrographic distension with saline and steroid provides short-term benefits in pain, range of movement and function in adhesive capsulitis. It is uncertain whether this is better than alternative interventions.

Oral steroids for adhesive capsulitis

BACKGROUND

This review is one in a series of Cochrane reviews of interventions for shoulder pain in adults.

OBJECTIVES

To determine the efficacy and safety of oral steroids for adhesive capsulitis.

SEARCH STRATEGY

Searches of the Cochrane Library including CENTRAL, Issue 4, 2005, Cochrane Musculoskeletal Review Group Register, MEDLINE, EMBASE, CINAHL were conducted in November 2005, unrestricted by date or language.

SELECTION CRITERIA

Only studies described as randomised controlled trials studying participants with adhesive capsulitis, frozen shoulder, stiff painful shoulder or periarthritis and interventions of oral steroids compared to placebo, no treatment, or any other treatment were included.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed methodological quality of each included trial and extracted data. Standard Cochrane methodology was used to analyse the extracted data.

MAIN RESULTS

Five small trials were included: two trials (30 and 49 participants) of oral steroids or placebo; one trial (40 participants) of oral steroids or no treatment; one trial (28 participants) of oral or intra-articular steroids; and one trial (32 participants) of manipulation under anaesthesia and intraarticular steroid injection with or without oral steroids. Study participants were similar across trials, but no trial used the same oral steroid regimen or dosage. Trials were of variable quality (only one of high quality) and some were poorly reported. No meta-analyses could be performed as no raw data could be extracted from one placebo-controlled trial and three trials used different comparators. One trial reported significant short-term benefits of oral steroids versus placebo: 48% more participants reported success (RR = 2 (95% CI 1.3 to 3.1, NNT=2); overall improvement in pain 2.7 (95% CI 1.4 to 4.0) on a 0 to 10 point scale; total shoulder abduction increased by 23.3 degrees (95% CI 11.3 to 35.3); Shoulder Pain and Disability Index (SPADI) score improved by 18.1 (95% CI 7.6 to 28.6) on a 0 to 100 point scale. But benefits were not maintained at 6 weeks. A second trial reported no significant differences between oral steroid and placebo in pain or range of movement but it suggested improvement occurred earlier in the steroid treated group. A third trial reported that oral steroids provided a more rapid initial improvement in pain compared to no treatment but negligible differences by five months. There were minimal adverse effects reported.

AUTHORS' CONCLUSIONS

Available data from two placebo-controlled trials and one no-treatment controlled trial provides "Silver" level evidence (www.cochranemsk.org) that oral steroids provides significant short-term benefits in pain, range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks.

Shock wave therapy for lateral elbow pain

BACKGROUND

This review is one in a series of reviews of interventions for lateral elbow pain.

OBJECTIVES

To determine the effectiveness and safety of extracorporeal shock wave therapy (ESWT) for lateral elbow pain.

SEARCH STRATEGY

Searches of the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2004), MEDLINE, EMBASE, CINAHL, and Science Citation Index (SCISEARCH) were conducted in February 2005, unrestricted by date.

SELECTION CRITERIA

We included nine trials that randomised 1006 participants to ESWT or placebo and one trial that randomised 93 participants to ESWT or steroid injection.

DATA COLLECTION AND ANALYSIS

For each trial two independent reviewers assessed the methodological quality and extracted data. Methodological quality criteria included appropriate randomisation, allocation concealment, blinding, number lost to follow up and intention to treat analysis. Where appropriate, pooled analyses were performed. If there was significant heterogeneity between studies or the data reported did not allow statistical pooling, individual trial results were described in the text.

MAIN RESULTS

Eleven of the 13 pooled analyses found no significant benefit of ESWT over placebo. For example, the weighted mean difference for improvement in pain (on a 100-point scale) from baseline to 4-6 weeks from a pooled analysis of three trials (446 participants) was -9.42 (95% CI -20.70 to 1.86) and the weighted mean difference for improvement in pain (on a 100-point scale) provoked by resisted wrist extension (Thomsen test) from baseline to 12 weeks from a pooled analysis of three trials (455 participants) was -9.04 (95% CI -19.37 to 1.28). Two pooled results favoured ESWT. For example, the pooled relative risk of treatment success (at least 50% improvement in pain with resisted wrist extension at 12 weeks) for ESWT in comparison to placebo from a pooled analysis of two trials (192 participants) was 2.2 (95% CI 1.55 to 3.12). However this finding was not supported by the results of four other individual trials that were unable to be pooled. Steroid injection was more effective than ESWT at 3 months after the end of treatment assessed by a reduction of pain of 50% from baseline (21/25 (84%) versus 29/48 (60%), p<0.05). Minimal adverse effects of ESWT were reported. Most commonly these were transient pain, reddening of the skin and nausea and in most cases did not require treatment discontinuation or dosage adjustment.

AUTHORS' CONCLUSIONS

Based upon systematic review of nine placebo-controlled trials involving 1006 participants, there is "Platinum" level evidence that shock wave therapy provides little or no benefit in terms of pain and function in lateral elbow pain. There is "Silver" level evidence based upon one trial involving 93 participants that steroid injection may be more effective than ESWT.

Corticosteroid injections for shoulder pain

BACKGROUND

While many treatments, including corticosteroid injections in and around the shoulder, are advocated to be of benefit for shoulder pain, few are of proven efficacy. This review of corticosteroid injections for shoulder pain is one in a series of reviews of varying interventions for shoulder disorders.

OBJECTIVES

To determine the efficacy and safety of corticosteroid injections in the treatment of adults with shoulder pain.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, Central and Science Citation Index were searched up to and including June 2002.

SELECTION CRITERIA

Randomised and pseudo-randomised trials in all languages of corticosteroid injections compared to placebo or another intervention, or of varying types and dosages of steroid injection in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica and fracture.

DATA COLLECTION AND ANALYSIS

Trial inclusion and methodological quality was assessed by two independent reviewers according to predetermined criteria. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis.

MAIN RESULTS

Twenty-six trials met inclusion criteria. The number, site and dosage of injections varied widely between studies. The number of participants per trial ranged from 20 to 114 (median 52 participants). Methodological quality was variable. For rotator cuff disease, subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no benefit of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials. For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling of any of the trials. One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term (success at seven weeks RR=1.66 (1.21, 2.28).

REVIEWER'S CONCLUSIONS

Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain. Other important issues that remain to be clarified include whether the accuracy of needle placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.

Exercise training improves insulin-mediated capillary recruitment in association with glucose uptake in rat hindlimb

Exercise training is considered to be beneficial in the treatment and prevention of insulin insensitivity, and much of the effect occurs in muscle. We have recently shown that capillary recruitment by insulin in vivo is associated with and may facilitate insulin action to increase muscle glucose uptake. In the present study, we examined the effect of 14 days of voluntary exercise training on euglycemic-hyperinsulinemic clamped (10 mU. min(-1). kg(-1) for 2 h), anesthetized rats. Whole-body glucose infusion rate (GIR), hindleg glucose uptake, femoral blood flow (FBF), vascular resistance, and capillary recruitment, as measured by metabolism of infused 1-methylxanthine (1-MX), were assessed. In sedentary animals, insulin caused a significant (P < 0.05) increase in FBF (1.6-fold) and capillary recruitment (1.7-fold) but a significant decrease in vascular resistance. In addition, hindleg glucose uptake was increased (4.3-fold). Exercise training increased insulin-mediated GIR (24%), hindleg glucose uptake (93%), and capillary recruitment (62%) relative to sedentary animals. Neither capillary density nor total xanthine-oxidase activity in skeletal muscle were increased as a result of the training regimen used. We concluded that exercise training improves insulin-mediated increases in capillary recruitment in combination with augmented muscle glucose uptake. Increased insulin-mediated glucose uptake may in part result from the improved hemodynamic control attributable to exercise training.

Heterogeneity of laser Doppler flowmetry in perfused muscle indicative of nutritive and nonnutritive flow

Laser Doppler flowmetry (LDF) signal responses have been compared with metabolic changes using both a surface macroprobe and randomly placed implantable microprobes in muscles of the constant-flow-perfused rat hindlimb. Changes in response to total flow and to vasoconstrictors that are known to increase (norepinephrine, NE) or decrease (serotonin, 5-HT) hindlimb oxygen uptake were assessed. The surface macroprobe (anterior end of biceps femoris) identified only one type of LDF response characterized by increased signal in response to NE and decreased signal in response to 5-HT. Implanted microprobes (tibialis, gastrocnemius, vastus, or bicep femoris) identified sites that gave three LDF responses of differing character. These responses were where the LDF signal increased with NE and decreased with 5-HT (56.7%), where the LDF signal decreased with NE and increased with 5-HT (16.5%), or where there was no net response to either vasoconstrictor (24.7%). The data are consistent with discrete regions of nutritive and nonnutritive flow in muscle where flow in each as controlled by vasoconstrictors relates directly to the metabolic behavior of the tissue.

Acute impairment of insulin-mediated capillary recruitment and glucose uptake in rat skeletal muscle in vivo by TNF-alpha

The vascular actions of insulin may contribute to the increase in glucose uptake by skeletal muscle. We have recently shown that when capillary recruitment by insulin is blocked in vivo, an acute state of insulin resistance is induced. Another agent that may have vascular effects is the inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha), which has been reported to play an important role in the insulin resistance of obesity, type 2 diabetes, and sepsis in both animals and humans. Thus, in the present study, we have investigated the effect of an intravenous 3-h TNF treatment (0.5 microg x h(1) x kg(-1)) in control and euglycemic-hyperinsulinemic-clamped (10 mU x min(-1) x kg(-1) for 2 h) anesthetized rats. Hind-leg glucose uptake, muscle uptake of 2-deoxyglucose (2-DG), femoral blood flow (FBF), vascular resistance (VR), and capillary recruitment as measured by metabolism of infused 1-methylxanthine (1-MX) were assessed. Insulin alone caused a significant (P < 0.05) increase in FBF (1.7-fold) and capillary recruitment (2.5-fold), with a significant decrease in VR. In addition, hind-leg glucose uptake was increased (fourfold), as was 2-DG uptake in the soleus and plantaris muscles. TNF completely prevented the insulin-mediated changes in FBF, VR, and capillary recruitment and significantly reduced (P < 0.05) the insulin-mediated increase in total hind-leg glucose uptake (by 61%) and muscle 2-DG uptake (by at least 50%). TNF alone had no significant effect on any of these variables. It is concluded that acute administration in vivo of TNF completely blocks the hemodynamic actions of insulin on rat skeletal muscle vasculature and blocks approximately half of the glucose uptake by muscle. It remains to be determined whether these two effects are interdependent.

Nutritive and non-nutritive blood flow: rest and exercise

There is growing evidence to support the notion of two vascular routes within, or closely associated with skeletal muscle. One route is in intimate contact with muscle cells (hence is known as 'nutritive') and the other functions as a vascular shunt (and has had the interesting misnomer of 'non-nutritive'). Recent findings suggest that the 'non-nutritive' route may, in part, be those vessels in closely associated (interlacing?) connective tissue that nourishes attached fat cells, and may form the basis of 'marbling' of muscle in obesity. In addition, embolism studies using various size microspheres indicate that the 'non-nutritive' vessels are likely to be capillaries fed by terminal arterioles that branch from the same transverse arterioles as those supplying terminal arterioles of the muscle capillaries (i.e. two vascular systems operating in parallel). The proportion of flow distributed between the two routes is tightly regulated and controls muscle metabolism and contraction by regulating hormone and substrate delivery as well as product removal. Because a high proportion of nutritive flow may elevate the set point for basal metabolism, a low proportion of nutritive flow in muscle at rest confers an evolutionary advantage, particularly when food is scarce. In addition, the proportion of flow that is carried by the non-nutritive routes at rest affords a flow reserve that can be switched to the nutritive route to amplify nutrient supply during exercise. Alternatively the non-nutritive route may allow flow to escape when active muscle contraction compresses its nutritive capillaries. Thus rhythmic oscillation of blood flow between the non-nutritive and nutritive networks may aid the muscle pump.

Increased metabolism of infused 1-methylxanthine by working muscle

Exogenous substrates for capillary endothelial enzymes have potential as markers for changes in capillary recruitment (albeit nutritive flow). The metabolism of infused 1-methylxanthine (1-MX) to 1-methylurate (1-MU) by capillary endothelial xanthine oxidase of the constant-flow perfused rat hindlimb was shown previously to decrease with oxygen uptake (VO2) when nutritive flow was decreased. In the present study, the metabolism of 1-MX was investigated under conditions when VO2 and nutritive flow are known to increase during muscle contraction. The constant-flow red blood cell-perfused rat hindlimb at 37 degrees C was used with sciatic nerve stimulation, and perfusate samples from whole hindlimb and working muscles taken for analysis of oxygen, lactate, 1-MX and 1-MU. Flow to muscle was assessed separately using fluorescent microspheres and was found to increase 2.3-fold to the working muscles while flow to the non-working leg muscles decreased to compensate. The activity of xanthine oxidase of whole muscle extracts was not altered by contraction. Samples from the vein draining the working muscles, and microsphere measurements of flow, indicated increased VO2 (5.5-fold to 249.2 +/- 43.1 micromol h-1 g-1, P < 0.001), and 1-MX conversion (2.5-fold to 1.87 +/- 0.25 micromol h-1 g-1, P < 0.01) (SEM are shown). It is concluded that as 1-MX metabolism parallels VO2, this substrate may be a useful indicator of changes in capillary (nutritive) surface area in muscle.

Reduced glycogen phosphorylase activity in denervated hindlimb muscles of rat is related to muscle atrophy and fibre type

Changes in the activity of muscle glycogen synthase or phosphorylase (GP) may be responsible for the deregulation of glycogen synthesis and storage which occurs in diabetes mellitus. To clarify the relationship between muscle atrophy, fibre type, insulin-stimulated glucose uptake and GP activity during insulin resistance, we used sciatic nerve severance to induce insulin resistance in rat hindlimb muscles and compared the above parameters in muscles with a range of fibre types. Changes were analysed by comparison with the contralateral hindlimb, which bears more weight due to denervation of the opposing limb, as well as the sham-operated and contralateral limb of a separate rat. Denervation caused a decrease in insulin-stimulated glucose uptake by 1 day after denervation and a decline of GP activity after 7 days in all muscles investigated. GP activity decreased by 73% in soleus, 36% in red gastrocnemius, 35% in tibialis and 13% in white gastrocnemius, which was related to the degree of muscle atrophy and inversely related to the overall GP activity in non-denervated muscles. GP activity in muscles of the contralateral limb from the denervated rat did not differ from either hindlimb of the sham-operated rat. We conclude that the fibre-type related reduction in insulin-stimulated glucose uptake of denervated muscle determines the change in its metabolism and it is this metabolic change which determines the mechanism, rate and degree of muscle atrophy, which is directly related to the decline in GP activity.