Psychometric properties of the Disability of Arm Shoulder and Hand (DASH) in subjects with frozen shoulder: a reliability and validity study.

BACKGROUND: Frozen Shoulder (FS) is a painful condition characterized by severe pain and progressive restriction of shoulder movement, leading to functional impairment and reduced quality of life. While different Patient Reported Outcome Measurements (PROMs) tools exist for assessing shoulder diseases, few specific PROMs are validated for FS patients. PURPOSE: This study aims to assess the psychometric properties of the Disability of Arm, Shoulder, and Hand (DASH) questionnaire in FS patients. METHODS: One hundred and twenty-four subjects (mean ± SD age = 55.4 ± 7.9 years; 55.6% female) diagnosed with FS were included and completed the DASH questionnaire, the Numerical Pain Rating Scale (NPRS), the Shoulder Pain and Disability Index (SPADI), and the Short-Form Health Survey 36 (SF-36). Floor or ceiling effects were investigated. Structural validity was analysed through a unidimensional Confirmatory Factor Analysis (CFA), internal consistency through Cronbach's alpha, test-retest reliability through the Intraclass Correlation coefficient (ICC), measurement error through the Standard Error of Measurement (SEM), and the Minimum Detectable Change (MDC), and construct validity through the hypothesis testing with the correlation with the other outcome measures used. RESULTS: No floor or ceiling effects were observed. CFA confirmed a one-factor structure after addressing local item dependency (Root Mean Square Error of Approximation = 0.055; Standardized Root Mean Square Residual = 0.077; Comparative Fit Index = 0.970; Tucker-Lewis Index = 0.968). Cronbach's alpha was high (= 0.951), and test-retest reliability was excellent (ICC = 0.999; 95% CI: 0.998-1.000). SEM was equal to 0.5 points, and MDC to 1.5 points. Construct validity was considered satisfactory as 80% of the a-priori hypotheses were met. CONCLUSION: The DASH questionnaire demonstrated good psychometric properties in FS patients, supporting its use as a valuable tool for assessing the impact of FS in clinical and research settings.

Deep learning model for classifying shoulder pain rehabilitation exercises using IMU sensor.

BACKGROUND: Artificial intelligence is being used for rehabilitation, including monitoring exercise compliance through sensor technology. AI classification of shoulder exercise wearing an IMU sensor has only been reported in normal (i.e. painless) subjects. To prove the feasibility of monitoring exercise compliance, we aimed to classify 11 types of shoulder rehabilitation exercises using an AI (artificial intelligence) algorithm in patients with shoulder pain. We had the patients wear an IMU-based sensor, collected data during exercise, and determined the accuracy of exercise classification. METHODS: Data were collected from 58 patients (27 males, 31 females, age range 37-82 years) diagnosed with shoulder diseases such as adhesive capsulitis and rotator cuff disease. 11 types of shoulder pain rehabilitation exercise programs were developed and repeated each exercise ten times per session while wearing an IMU sensor. The study applied the Rectified Linear Unit (ReLU) and the SoftMax as the activation function for hidden layers, the output layer. RESULTS: The acquired data was used to train a DNN model using the multilayer perceptron algorithm. The trained model was used to classify 11 types of shoulder pain rehabilitation exercises. The training accuracy was 0.975 and the test accuracy was 0.925. CONCLUSION: The study demonstrates that IMU sensor data can effectively classify shoulder pain rehabilitation exercises, providing more appropriate feedback for patients. The model can be utilized to establish a system for remotely monitoring patients' exercise performance. The use of deep learning in patient monitoring and rehabilitation has significant potential to bring innovative changes to healthcare service delivery.

Effects of manual therapy in addition to stretching and strengthening exercises to improve scapular range of motion, functional capacity and pain in patients with shoulder impingement syndrome: a randomized controlled trial.

BACKGROUND: The current study aimed to measure the effectiveness of manual therapy in addition to stretching and strengthening exercises in patients with shoulder impingement syndrome to improve functional capacity, pain, and scapular range of motion. METHODS: This is a single-blinded randomized controlled trial. Thirty-two participants with chronic shoulder impingement syndrome were randomly allocated into two groups. Both groups received stretching and strengthening exercises while the treatment group was given manual therapy additionally. Treatment was started after the patients signed an informed consent form. The data were collected from the University of Lahore Teaching Hospital between March 2022 and December 2022. The study aimed to measure pain using a numeric pain rating scale, functional capacity was assessed by the disability of the arm and shoulder, and goniometry was used for scapular ranges, i.e., scapular protraction and upward rotation. Each treatment session lasted 45 min for the treatment group and 30 min for the control group. The treatment comprised five days a week for four weeks, after which post-intervention measurements were taken. RESULTS: Thirty-two participants were enrolled in the study, and 16 were divided into each group. The mean age of the participants in the treatment group was 38.19 ± 7.31 while the comparison group was 35.69 ± 7.98. An independent sample t-test was run on the data with a 95% confidence interval, statistically significant results were obtained, i.e., p-value < 0.05, post-intervention in the treatment group. Both groups have significantly improved functional capacity and scapular protraction (p < 0.005), however, pain and scapular upward rotation were not found statistically significant in the control group (p > 0.05). CONCLUSION: The addition of manual therapy along with exercise therapy showed clinical and statistical significant results for pain, functional capacity, and scapular range of motion. It demonstrated superior effects than exercise therapy alone for the chronic condition of SIS. TRIAL REGISTRATION: The trial was registered in the Iranian Registry of Clinical Trials ( https://www.irct.ir/ ) with the registration number: IRCT20230526058291N1, (Date: 12/08/2023).

To allow or avoid pain during shoulder rehabilitation exercises for patients with chronic rotator cuff tendinopathy-Study protocol for a randomized controlled trial (the PASE trial).

BACKGROUND: Rotator cuff (RC) tendinopathy is the most reported shoulder disorder in the general population with highest prevalence in overhead athletes and adult working-age population. A growing body of evidence support exercise therapy as an effective intervention, but to date there are no prospective randomized controlled trials addressing pain as an intervention variable. METHODS: A single-site, prospective, pragmatic, assessor-blinded randomized controlled superiority trial. Eighty-four patients aged 18-55 years with chronic (symptom duration over 3 months) RC tendinopathy are randomized 1:1 to receive shoulder exercise during which pain is either allowed or avoided. The intervention period lasts 26 weeks. During that period, participants in both groups are offered 8 individual on-site sessions with an assigned sports physiotherapist. Participants perform home exercises and are provided with a pain and exercise logbook and asked to report completed home-based exercise sessions and reasons for not completing sessions (pain or other reasons). Patients are also asked to report load and the number of sets and repetitions per sets for each exercise session. The logbooks are collected continuously throughout the intervention period. The primary and secondary outcomes are obtained at baseline, 6 weeks, 26 weeks, and 1 year after baseline. The primary outcome is patient-reported pain and disability using the Shoulder PAin and Disability Index (SPADI). Secondary outcomes are patient-reported pain and disability using Disability Arm Shoulder and Hand short-form (Quick DASH), and shoulder pain using Numeric Pain Rating Scale. Objective outcomes are shoulder range of motion, isometric shoulder muscle strength, pain sensitivity, working ability, and structural changes in the supraspinatus tendon and muscle using ultrasound. DISCUSSION: The results of this study will contribute knowledge about the treatment strategies for patients with RC tendinopathy and help physiotherapists in clinical decision-making. This is the first randomized controlled trial comparing the effects of allowing pain versus avoiding pain during shoulder exercises in patients with chronic RC tendinopathy. If tolerating pain during and after exercise proves to be effective, it will potentially expand our understanding of "exercising into pain" for this patient group, as there is currently no consensus. TRIAL REGISTRATION: ClinicalTrials.gov NCT05124769. Registered on August 11, 2021.

The comparative effectiveness of combined hydrodilatation/corticosteroid procedure with two different quantities for adhesive capsulitis.

OBJECTIVE: To assess the efficacy of injecting various amounts of fluid into the shoulder joints for capsule distension in patients with adhesive capsulitis. DESIGN: A randomized controlled trial. SETTING: Outpatient clinic of a tertiary care centre. PARTICIPANTS: Eighty-four patients with adhesive capsulitis underwent a baseline (time0), 6 weeks (time1), and 12 weeks (time2) follow-up after hydrodilitation. INTERVENTION: Group 1 (n = 42) received 20 ml of lidocaine, steroid, and saline hydrodilatation via posterior glenohumeral recess, while Group 2 (n = 42) received 10 ml of lidocaine, steroid, and saline hydrodilitation. MAIN MEASURES: The primary outcome was the visual analogue scale for pain. The secondary outcomes were shoulder pain and disability index (SPADI) and ROM of the shoulder. RESULTS: There was a significant reduce in VAS scores for pain, SPADI scores, and increased shoulder ROM in both groups over time; however, the group-by-time interactions for any of the outcomes between groups were not significant except VAS pain in motion. Post-hoc pairwise analysis of the marginal effect of time and group showed that the significant difference of VAS in motion is due to time effect: time1 vs time0 (95% CI -4.09 to -2.68), time2 vs time0 (-4.21 to -2.77), and time2 vs time1 (-0.83 to 0.63), without between-group difference: group 1 vs group 2 (-0.38 to 0.59). CONCLUSION: Our study suggests hydrodilatation achieved an optimal effect at time1 for patients with adhesive capsulitis in both groups, and adding more saline offers additional benefits in flexion and external roatation until time2.

Arthroscopic capsular release is more effective in pain relief than conservative treatment in patients with frozen shoulder.

BACKGROUND: Frozen shoulder is a common medical condition, but the ideal therapeutic method is yet to be determined. Our aim was to analyze the pain-relieving effect of different treatment options used for the management of this disease. METHODS: Medical records of 59 patients (22 male, 37 female, average age: 55.5 years ±9.9) with early stage primary frozen shoulder were evaluated, their demographic data, physical examination, concomitant diseases and treatment specific data were registered. Life quality and the level of pain were assessed using the Oxford Shoulder Score (OSS) and Numeric Rating Scale (NRS). Different treatment modalities and their effect on pain relief were recorded. Any existing correlation between life quality, pain and demographic data, concomitant diseases or the therapeutic method used was investigated. RESULTS: The level of pain measured on NRS improved from 7.9 ± 1.6 to 1.9 ± 2.2. The most effective therapeutic method in terms of pain relief was surgery, followed by physiotherapy and intraarticular steroid injection (NRS score after treatment: 2 - p < 0.0001; 3.3 - p < 0.0001; 4.9 - p < 0.0001, respectively). Non-steroidal anti-inflammatory drugs (NSAIDs) did not reduce pain significantly. OSS improved from 24 to 43.6 and was not affected by the investigated variables, time to recovery was not influenced by the demographic data, the type of treatment or concomitant diseases. CONCLUSIONS: Arthroscopic capsular release, physiotherapy and intraarticular steroid injection outperformed physical therapy and NSAID treatment in terms of pain relief. Despite of slight but persistent post-therapeutic pain found in half of the cases, treatment was considered satisfactory by the patients. Nor patient specific neither therapy specific data had a significant effect on the course of the disease.

High frequency neuronavigated repetitive transcranial magnetic stimulation in post-stroke shoulder pain: A double-blinded, randomized controlled study.

OBJECTIVE: This study aimed to determine the effect of 5Hz neuronavigated repetitive transcranial magnetic stimulation (rTMS) to the affected primary motor cortex (M1) on pain, the effect of pain on activities of daily living, disability, mood, neurophysiological parameters and passive shoulder joint range of motion in patients with post-stroke shoulder pain. DESIGN: Twenty two patients were randomized into an experimental group (rTMS, n=7) who received daily rTMS 5Hz 1000 pulses, five times/week for three weeks (15 sessions) to the affected M1 and a control group (n=11) who received sham stimulation. Outcome measures were Numeric Rating Scale (NRS), Brief Pain Inventory (BPI), Disabilities of the arm, shoulder, and hand questionnaire (Quick DASH), Hospital Depression Anxiety Scale (HADS), joint range of motion (ROM) measurements, neurophysiological parameters. Selected outcome measures were performed before treatment (T0), after the 5th session (T1) of rTMS treatment, after the 10th session (T2), after the 15th session (T3), and four weeks after the end of the treatment (T4). In the analysis of the outcomes, within-group comparisons were performed by using the Wilcoxon or Friedman test and between-group comparisons were performed by using the Mann-Whitney U test. RESULTS: There was no statistically significant difference between and within groups in terms of change- and followup scores in the NRS measurements (p>0.05). BPI scale was found to be lower in rTMS group at T0 and T3 (p= 0.010). Quick-DASH scores at T4 were found to be significantly lower in rTMS group (p= 0.032). However, no difference was found within each group over time (p>0.05) and there was no statistical difference between the groups in terms of change scores (T3-T0 and T4-T0) (p>0.05) for BPI and Quick-DASH. In rTMS group, there was a statistically significant difference in shoulder external rotation at T3 compared to the baseline (T0) (p=0.039). However, the magnitude of external rotation change (T3-T0) with the treatment was comparable in the groups. No statistically significant change occurred in both treatment groups in other range of motion measurements. CONCLUSION: High frequency neuronavigated rTMS to the affected M1 did not show any significant beneficial effect on pain, activities of daily living, disability, anxiety and depression, neurophysiological measurements and passive ROM over sham stimulation.

Impact of Surgical Positioning on the Occurrence of Postoperative Ipilateral Shoulder Pain After Lung Resection by Video-Assisted Thoracoscopy: A Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate the impact of the ipsilateral arm position on ipsilateral shoulder pain after lung cancer resection by video-assisted thoracic surgery. DESIGN: A prospective randomized controlled trial. SETTING: A single academic center study. PARTICIPANTS: Patients undergoing video-assisted thoracic surgery pulmonary resection for cancer at the Institut Universitaire de Cardiologie et de Pneumologie de Québec from May 2020 to May 2022 were included. INTERVENTIONS: Patients randomly were assigned with a 1:1 ratio to a supported or suspended ipsilateral arm position. MEASUREMENTS AND MAIN RESULTS: Ipsilateral shoulder pain incidence, pain score, and opioid use were recorded in the postanesthesia care unit (PACU) on postoperative days 1 and 2. One hundred thirty-three patients were randomized, 67 in the suspended-arm group and 66 in the supported-arm group. Of the patients, 31% reported ipsilateral shoulder pain in the PACU with no difference between groups (19/67 [28.4%] v 22/66 patients (33.3%), p = 0.5767). There was no significant difference between the pain score in the PACU (3 [0-6] v 4 [0-6], p = 0.9055) at postoperative day 1 (4 [2-6] v 3 [2-5], p = 0.4113) and at postoperative day 2 (2 [0-5] v 2 [1-4], p = 0.9508). Ipsilateral shoulder pain score decreased rapidly on postoperative day 2. There was no statistical difference in opioid and gabapentinoid use between the groups. CONCLUSIONS: Ipsilateral arm position seems to have no impact on ipsilateral shoulder pain.

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block.

BACKGROUND: Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC. MATERIALS AND METHODS: A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved. RESULTS: Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness. CONCLUSIONS: In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Linking patient reported shoulder outcomes to the international classification of functioning, disability and health.

PURPOSE: To link the items from shoulder-specific Patient Reported Outcome Measures (PROMs) to the International Classification of Functioning, Disability and Health (ICF) domains and categories, and to determine if the items fit into the ICF framework. MATERIALS AND METHODS: The Brazilian versions of the Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST) and Western Ontario Rotator Cuff Index (WORC) were linked to the ICF by two researchers independently. Agreement between raters was determined by calculating the Kappa Index. RESULTS: Fifty-eight items from the PROMs were linked to eight domains and 27 categories of ICF. The PROMs covered components of body functions, activities, and participation. Components of body structure and environmental factors were not covered by any of the PROMs. ​There was substantial agreement between raters when linking the OSS (Kappa index = 0.66), SPADI (Kappa index = 0.92), SST (Kappa index = 0.72) and WORC (Kappa index = 0.71). CONCLUSIONS: WORC and SST were the PROMs that covered the highest number of ICF domains (seven and six, respectively). However, SST is short and may be less time consuming in a clinical assessment. Clinicians can benefit from this study to decide which shoulder-specific PROM may be more adequate according to the clinical demand.Implications For RehabilitationWestern Ontario Rotator Cuff Index was the shoulder-specific Patient Reported Outcome Measure (PROM) that best showed a broader view of functionality through the International Classification of Functioning, Disability and Health (ICF) domains that can influence shoulder pain and disability.Simple Shoulder Test seems to be the most recommended shoulder-specific PROM considering the number of domains covered by the ICF and the clinical evaluation time consumption.Shoulder Pain and Disability Index fails to provide a broader view of functioning through other ICF domains that may influence shoulder pain and disability.

Effectiveness of Pulse Electromagnetic Field Therapy in Patients With Subacromial Impingement Syndrome: A Double-Blind Randomized Sham Controlled Study.

OBJECTIVES: To evaluate the 3-month effects of pulsed electromagnetic field therapy (PEMF) in the treatment of subacromial impingement syndrome (SIS). DESIGN: Planned analysis of a randomized controlled trial with 4- and 12-week follow-ups. SETTING: Physical medicine and rehabilitation clinic, treatment unit. PARTICIPANTS: Of the 250 individuals screened for eligibility, participants with a diagnosis of SIS (N=80) were randomized to intervention or control groups. INTERVENTION: The first group received PEMF + exercise and the second group received sham PEMF + exercise 5 days a week for a total of 20 sessions. MAIN OUTCOME MEASURES: Visual Analog Scale (VAS), Constant Murley Score (CMS), Shoulder Pain and Disability Index (SPADI), Short Form-36 (SF-36) Quality of Life Questionnaire, and shoulder muscle strength measurement with an isokinetic dynamometer. Evaluations were performed before treatment (T0), after treatment (T1), and 12th week (T2). RESULTS: Evaluation at T1 and T2 showed improvement in most parameters in both groups compared with baseline. In the comparison between the 2 groups at T1 and T2, more improvement was found in the PEMF group in most parameters. CONCLUSIONS: In our study, PEMF was found to be superior to sham PEMF in terms of pain, ROM, functionality, and quality of life at the first and third months.

Does the psychological profile of a patient with frozen shoulder predict future outcome? A systematic review.

BACKGROUND AND PURPOSE: Frozen shoulder (FS) is defined as a condition characterised by functional restriction and daily and nightly pain. As in other shoulder pathologies, the manifestation of psychological factors is recognised in FS; however, from a psychological point of view, only few studies have reported its prognostic value. The aim of this systematic review is to investigate, in patients with FS, the prognostic value of psychological factors on pain, function, disability, health-related quality of life, return to work and time to recovery. MATERIALS AND METHODS: This systematic review was reported following the Preferred Reporting Items for Systematic reviews and Meta-Analysis-PRISMA 2020 guideline. The authors followed the Cochrane Handbook for Systematic review of Intervention as methodological guidance. The Quality in Prognostic Studies-QUIPS tool was used to assess the risk of bias. RESULTS: Pain-related fear and depression could be prognostic regarding patient-reported outcome measures assessing shoulder function, disability, and pain; instead, pain catastrophizing could have a prognostic value assessed by the disability of the arm shoulder and hand -DASH scale. Anxiety would appear to impact on disability and pain. DISCUSSION AND CONCLUSIONS: As widely reported in numerous musculoskeletal conditions, also in FS psychological factors influence the physical dimension such as pain, disability and function. Therefore, clinicians should be encouraged to identify these factors through a comprehensive assessment of the bio-psychological profile of each individual with FS. Perhaps, patients with FS that show such psychological prognostic factors could benefit from a comprehensive and shared approach with other dedicated professionals.

Spanish Cross-Cultural Adaptation and Validation of the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score.

CONTEXT: There are no available questionnaires in Spanish that assess the function and performance of shoulder and elbow in overhead sports. The Kerlan-Jobe Orthopaedic Clinic (KJOC) score is a reference tool for this purpose. We aimed to cross-culturally adapt and investigate its measurement properties in Spanish overhead athletes. DESIGN: Cross-cultural adaptation followed the steps of direct translation, back translation, comprehensibility analysis, and review by the Committee of Experts. Then, symptomatic and asymptomatic overhead athletes were invited to complete an electronic version of the Spanish adaptation (KJOC-Sp). The structural validity was evaluated through an exploratory factor analysis with principal axis factoring. Hypotheses were tested for known-groups and convergent validity, studying the correlation with the Shoulder Pain and Disability Index and the Disabilities of the Arm, Shoulder, and Hand Sports Module questionnaires in symptomatic athletes. Cronbach alpha was calculated for internal consistency and intraclass correlation coefficient (ICC)2,1 for test-retest reliability. Floor and ceiling effects and time to completion were also calculated. RESULTS: The KJOC-Sp maintained the content of the original version and was adapted to the new population. One hundred participants (41 females and 59 males) with a mean age of 22.4 (5.9) years participated in the study of measurement properties. The factor analysis revealed a 1-factor solution. Symptomatic participants scored significantly lower than asymptomatic, with a large effect size (P < .001; r = .67). Correlations were of -.60 (P < .05) with the Shoulder and Pain Disability Index questionnaire and -0.66 (P < .05) with the Disabilities of the Arm, Shoulder, and Hand Sports Module questionnaire. Cronbach alpha was .98 (95% confidence interval, .97-.98) and the ICC2,1 was .96 (95% confidence interval .93-.98). No floor or ceiling effects were observed among the symptomatic athletes, while mean time to completion was 121 seconds. CONCLUSION: The KJOC-Sp is equivalent to the original score, aside from valid and reliable, without floor or ceiling effects in symptomatic athletes and with a low time consumption.

A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders.

OBJECTIVE: To perform a systematic review of clinical practice guidelines (CPGs) covering the management of common shoulder disorders. DATA SOURCES: A systematic search of CPGs on specific shoulder disorders was conducted up to August 2022 in relevant databases. STUDY SELECTION: Twenty-six CPGs on rotator cuff (RC) tendinopathy, RC tear, calcific tendinitis, adhesive capsulitis, glenohumeral (GH) instability, GH osteoarthritis, or acromioclavicular disorders published from January 2008 onward were screened and included. DATA EXTRACTION: CPGs methodological quality was assessed with the AGREE II checklist. All recommendations from CPGs were extracted and categorized by shoulder disorder and care components (evaluation, diagnostic imaging, medical, rehabilitation, and surgical treatments). After semantic analysis of the terminology, recommendations for each shoulder disorders were classified by 2 reviewers into "recommended," "may be recommended," or "not recommended." Disagreements were resolved by discussion until reviewers reached consensus. DATA SYNTHESIS: Only 12 CPGs (46%) were of high quality with major limitations related to the applicability and editorial independence of the guidelines. The initial evaluation of shoulder pain should include patient's history, subjective evaluation focused on red flags, and clinical examination. Magnetic resonance imaging is usually not recommended to manage early shoulder pain, and recommendations for X-rays are conflicting. Acetaminophen, oral non-steroidal anti-inflammatory drugs, and rehabilitation including exercises were recommended or may be recommended to treat all shoulder pain disorders. Guidelines on surgical management recommendations differed; for example, 6 CPGs reported that acromioplasty was recommended or may be recommended in chronic RC tendinopathy, whereas 4 CPGs did not recommend it. CONCLUSIONS: Recommendations vary for diagnostic imaging, conservative vs surgical treatment to manage shoulder pain, although several care components are consensual. The development of evidence-based, rigorous CPGs with a valid methodology and transparent reporting is warranted to improve overall shoulder pain care.

Efficacy of combined ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy in patients with adhesive capsulitis: A randomised controlled trial.

OBJECTIVE: To evaluate the therapeutic effect of combining ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy compared with physical therapy alone in patients with adhesive capsulitis. DESIGN: A prospective, single-blinded, randomised controlled trial. SETTING: Single medical centre. PARTICIPANTS: Patients with adhesive capsulitis (N = 62) were divided into group A: ultrasound-guided hydrodilatation with hyaluronic acid + physical therapy (N = 31) and group B: physical therapy alone (N = 31). INTERVENTIONS: Group A received three doses of ultrasound-guided hydrodilatation with hyaluronic acid-based injectates (20 mL in total). Both groups underwent structured physical therapy. OUTCOME MEASURES: The primary outcome measure was Constant score, while secondary outcomes included Shoulder Pain and Disability Index score, numerical rating scale (at rest, night, and during motion), 36-item Short Form Health Survey, and range of motion of the shoulder. All measurements were collected at baseline, 6 weeks, and 12 weeks post-injection. RESULTS: At week 12, the Constant scores were 68.29 ± 14.55 and 62.77 ± 14.44 for groups A and B, respectively. There was a greater reduction in the Constant score, Shoulder Pain and Disability Index, and numerical rating scale between the baseline and 6 weeks and between the baseline and 12 weeks in group A (Constant score: p < 0.05, Shoulder Pain and Disability Index: p < 0.01, and numerical rating scale: p < 0.05). CONCLUSION: The combination of ultrasound-guided hydrodilatation with hyaluronic acid in conjunction with physical therapy provides additional benefits compared to physical therapy alone for the treatment of adhesive capsulitis at up to 12 weeks. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02708706.

Giant Cell Tumor of the Acromion: Case Report and Literature Review.

BACKGROUND/AIM: Giant cell tumor of bone (GCTB) is a locally aggressive neoplasm that typically occurs in the ends (epiphyses) of long bones of young adults. Flat bones are uncommon sites of involvement. Herein, we describe an unusual case of pathologically proven GCT of the acromion. CASE REPORT: The patient was a 39-year-old woman with no history of trauma who presented with a 3-month history of right posterior shoulder pain. Physical examination revealed mild swelling and tenderness in the posterior aspect of the right shoulder. Plain radiograph showed a purely lytic lesion, suggestive of a bone tumor. Computed tomography demonstrated an intraosseous lytic lesion with associated cortical thinning and lack of periosteal reaction. On magnetic resonance imaging, the lesion exhibited slightly higher signal intensity compared to skeletal muscle on T1-weighted sequences and heterogeneous high signal intensity on T2-weighted sequences. Strong enhancement was observed following gadolinium administration. The lesion was treated by extensive curettage with adjuvant therapy comprising ethanol and the remaining cavity was filled with polymethylmethacrylate bone cement. Histologically, the lesion was composed of round or spindle-shaped mononuclear cells admixed with numerous osteoclast-like giant cells. Immunohistochemically, the mononuclear neoplastic cells were diffusely positive for H3.3 G34W. The patient was asymptomatic and there was no evidence of local recurrence or distant metastasis 5 months after surgery. CONCLUSION: Although rare, acromial GCTB should be considered in the differential diagnosis of posterior shoulder pain, especially in young and early middle-aged adults.

Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial.

BACKGROUND: Despite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT. METHODS: The Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic "add-on" trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes). RESULTS: The average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82). CONCLUSIONS: In patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function. TRIAL REGISTRATION: The trial is registered on ClinicalTrials.gov: NCT03353272 (27/11/2017).

Clinical Diagnosis of Common Overlapping Shoulder and Cervical Spine Disorders: A Review of Current Evidence.

¼ Pain in the shoulder is a common orthopaedic complaint that can be caused by shoulder or neck pathologies.¼ Shoulder and neck pathologies often coexist, among which one may be a predisposing factor for the other.¼ History, physical examination, and diagnostic injections can be used to discern the cause of shoulder pain and guide treatment.

Upper-crossed syndrome and disability in shoulder adhesive capsulitis.

STUDY DESIGN: Cross-sectional analytical study. INTRODUCTION: Adhesive capsulitis (AC) is a long-standing condition with varying extents of disability seen among patients. The role of postural manifestations and contractile tissue involvement in this condition is poorly understood and yet to be explored. PURPOSE: This study aimed to analyze if individuals with adhesive capsulitis demonstrated the characteristics of an upper crossed syndrome (UCS) postural manifestation and whether or not its presence affected the extent of disability experienced by this population. METHODS: Sixty-five individuals with AC were assessed for the presence of UCS. Scapular muscle strength and length alterations, forward head posture (FHP), and disability were assessed and compared between those with and without UCS. Paired T test and an independent T test were utilized to compare means within and between these groups, respectively, while non-parametric measures were utilized for their skewed counterparts. Phi coefficient (φ) was used to determine the strength of association between the descriptive patient characteristics. The correlation between symptom duration and degree of postural involvement was analyzed using Pearson's correlation coefficient. RESULTS: 43.1% of the study population demonstrated UCS and 80% FHP with a significant negative correlation between Cranio Vertebral Angle and chronicity of AC (r = -0.27). Individuals with AC demonstrated significantly decreased scapular muscle strength (p = <.001) and pectoralis minor length on the affected side (p = .03). No differences were seen between groups with and without UCS. The mean SPADI scores between groups demonstrated a more significant level of perceived pain and disability in individuals with UCS (p = .049). CONCLUSIONS: As seen in UCS, individuals with AC demonstrated alterations in movement patterns and posture. UCS was seen to contribute towards the existing disability in AC. This study suggests a careful evaluation and intervention based on these findings to document its effect on pain and dysfunction in AC.