Non-operative orthobiologic use for rotator cuff disorders and glenohumeral osteoarthritis: A systematic review.

BACKGROUND: Shoulder pain from rotator cuff pathology and glenohumeral osteoarthritis is a common entity encountered in musculoskeletal practices. Orthobiologic agents are being increasingly used as a treatment option and understanding their safety and efficacy is necessary. OBJECTIVE: To systematically evaluate the available evidence for orthobiologic use in rotator cuff and glenohumeral pathology. METHODS: A systematic review was undertaken following PRISMA guidelines. Randomized clinical trials (RCTs) and prospective cohort studies evaluating non-operative treatment with prolotherapy, platelet-rich plasma (PRP), or medicinal signaling cells (MSCs) for rotator cuff pathology and glenohumeral osteoarthritis were included. Bias risk assessments used were the Cochrane tool and Newcastle-Ottawa score. RESULTS: The search yielded 852 potential articles, of which 20 met the inclusion criteria with a breakdown of 5 prolotherapy, 13 PRP, and 2 MSC. Sixteen studies were RCTs and 4 were cohort studies. Six studies were deemed "low risk of bias or good quality". Efficacy results were mixed, and no serious adverse events were reported from orthobiologic treatment. CONCLUSIONS: Orthobiologics offer a relatively safe management option with inconclusive evidence for or against its use for rotator cuff pathology. No studies on glenohumeral osteoarthritis met the inclusion criteria. Adoption of standardized preparation reporting and consistent use of functional outcome measures is imperative for future studies to consider.

Association of Both Scapular Upward Rotation and Scapulothoracic Muscle Lengths With Shoulder Pain, Function, and Range of Movement.

OBJECTIVE: Our aim was to analyze whether shoulder pain is related to scapular upward rotation (SUR) or to the lengths of the pectoralis minor and levator scapulae muscles. METHODS: This cross-sectional, observational study was carried out in 3 primary-care centers; 54 individuals with chronic shoulder pain participated. Scapular upward rotation and the lengths of the pectoralis minor and levator scapulae muscles were assessed. RESULTS: The level of association was small between shoulder pain and function and (1) the lengths of the pectoralis minor (r = 0.08, P = .93) and levator scapulae (r = -0.01, P = .57) muscles and (2) SUR at 45° (r = 0.17, P = .21), 90° (r = 0.08, P = .57), and 135° (r = 0.10, P = 0.45) of shoulder elevation. CONCLUSION: The relationship was small between shoulder pain and function and (1) SUR (45°, 90°, and 135° of shoulder elevation) and (2) the lengths of the pectoralis minor and levator scapulae muscles. Thus, the use of SUR and pectoralis minor and levator scapulae lengths in shoulder assessment should be undertaken with caution. Other factors such as psychological factors, central/peripheral sensitization, and intrinsic properties of the tissue have to be taken into account.

Shoulder pain and scapular dyskinesis associated with lower trapezius dysplasia - A case report.

BACKGROUND: Scapular dyskinesis (SD) has been associated with shoulder soft-tissue tightness as well scapular muscle strength and/or activation deficits. Inadequate development of the trapezius muscle (trapezius dysplasia) is a relatively rare condition inconsistently associated with shoulder dysfunction. CASE DESCRIPTION: a 24-year old male complaining of left scapular area pain associated with SD and scapular muscle weakness was noted to present with a smaller ipsilateral lower trapezius (LT). Further inquiry including electromyography, rehabilitative ultrasound imaging (RUSI) and magnetic resonance imaging ruled out nerve palsy and demonstrated a hypoplastic left LT. This led to a greater emphasis on serratus anterior (SA) training along with the addition of neuromuscular electrical stimulation of the LT. OUTCOMES: Following 12 sessions over a 5-month period the patient reported no pain or functional deficits, and was able to resume all recreational activities. The patient's subjective shoulder value increased from 55% to 80%, and LT strength was markedly improved. DISCUSSION: Scapular muscle dysplasia may represent a less recognized cause of SD. A more thorough inspection of scapular muscle shape and orientation, possibly augmented by RUSI may be indicated in patients presenting with SD. Neuromuscular electrical stimulation is a potentially useful modality for addressing scapular muscle activation and strength deficits and future research into its efficacy under these circumstances may be warranted.

Interrater and Intrarater Reliability and Minimum Detectable Change of Ultrasound for Active Myofascial Trigger Points in Upper Trapezius Muscle in Individuals With Shoulder Pain.

OBJECTIVE: We sought to investigate the interrater and intrarater reliability of ultrasound and the minimum detectable change (MDC) for the trigger points (TrPs) active in the upper trapezius (UT) muscle in individuals with shoulder pain. METHODS: Forty individuals with shoulder pain were investigated for the presence of active TrPs in the UT muscle by means of ultrasound for the parameters of gray scale, muscle thickness of UT muscle at rest, and contraction and area of TrPs. The intrarater reliability was performed on 2 days, and interrater reliability on the same day. For the gray scale, the reliability was evaluated using the kappa coefficient (κ), while the other parameters were measured by the intraclass correlation coefficient (ICC), standard error of measurement (SEM), and MDC. RESULTS: For the gray scale, the intrarater agreement was almost perfect (κ = 1.00) and the interrater agreement was substantial (κ = 0.75). The intrarater and interrater reliability were excellent for most of the parameters, except for the area of TrPs (intrarater: ICC = 0.71, substantial; interrater: ICC = 0.52, substantial). The MDC for intrarater reliability varied between 0.04 and 0.05 (SEM% between 2.4% and 38.87%), and that for interrater reliability ranged from 0.05 to 0.07 (SEM% between 3.18% and 55.10%), with a higher value for area. CONCLUSION: Parameters such as gray scale, resting muscle thickness, and muscle contraction of the UT muscle, obtained through ultrasound, showed excellent intrarater and interrater reliability with low SEM%. The intrarater and interrater reliability for the area deserves a caveat regarding their use.

Relationship Between Intensity of Neck Pain and Disability and Shoulder Pain and Disability in Individuals With Subacromial Impingement Symptoms: A Cross-Sectional Study.

OBJECTIVE: This study aimed to verify a possible relationship between shoulder disability and shoulder pain intensity and the variables related to cervical-spine dysfunction, and determine which of these can differentiate moderate to severe shoulder pain (>4 on a numerical rating scale [NRS]) from mild shoulder pain (≤4 on the NRS) in individuals with subacromial impingement symptoms. METHODS: One hundred and forty volunteers with shoulder pain were evaluated. Demographic information and variables related to the shoulder and neck were collected. Self-reported pain and disability of the shoulder and cervical spine were measured using the Shoulder Pain and Disability Index (SPADI) and Neck Disability Index (NDI) questionnaires, respectively. An NRS was used to measure pain in the shoulder and cervical spine. A purposeful modeling strategy was used to determine the best model to predict shoulder disability and shoulder pain (dependent variables). Multiple logistic regression analysis followed by receiver operating curve analysis was used to determine which variables better differentiated moderate to severe shoulder pain from mild shoulder pain. RESULTS: Variables such as Neck Disability Index (NDI) score (ß = 1.09, P = .00) and age (ß = -0.19, P = .03) were associated with the total SPADI score. Neck pain was significantly associated with shoulder pain (ß = 0.40, P = .00). The combination of variables predicting moderate to severe shoulder pain was total SPADI score (odds ratio [OR] = 1.15, P = .003), neck pain (OR = 3.20, P = .04), and age (OR = 1.01, P = .05). CONCLUSION: Our results demonstrate the important connection between shoulder- and neck-related symptoms in individuals with subacromial impingement symptoms.

Different Degree Centrality Changes in the Brain after Acupuncture on Contralateral or Ipsilateral Acupoint in Patients with Chronic Shoulder Pain: A Resting-State fMRI Study.

Chronic shoulder pain (CSP) is the third most common musculoskeletal problem. For maximum treatment effectiveness, most acupuncturists usually choose acupoint in the nonpainful side, to alleviate pain or improve shoulder function. This method is named opposite needling, which means acupuncture points on the right side are selected for diseases on the left side and vice versa. However, the underlying neural mechanisms related to treatment are currently unclear. The purpose of this study was to determine whether different mechanisms were observed with contralateral and ipsilateral acupuncture at Tiaokou (ST 38) in patients with unilateral CSP. Twenty-four patients were randomized to the contralateral acupuncture group (contra-group) and the ipsilateral acupuncture group (ipsi-group). The patients received one acupuncture treatment session at ST 38 on the nonpainful or painful sides, respectively. Before and after acupuncture treatment, they underwent functional magnetic resonance scanning. The treatment-related changes in degree centrality (DC) maps were compared between the two groups. We found alleviated pain and improved shoulder function in both groups, but better shoulder functional improvement was observed in the contra-group. Increased DC in the anterior/paracingulate cortex and decreased DC in bilateral postcentral gyri were found in the contra-group, while decreased DC in the bilateral cerebellum and right thalamus was observed in the ipsi-group. Furthermore, the DC value in the bilateral anterior/paracingulate cortex was positively correlated with the treatment-related change in the Constant-Murley score. The current study reveals different changes of DC patterns after acupuncture at contralateral or ipsilateral ST 38 in patients with CSP. Our findings support the hypothesis of acupoint specificity and provide the evidence for acupuncturists to select acupoints for CSP.

The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain.

BACKGROUND: Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population. METHODS: This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist. DISCUSSION: This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.

Absolute and Relative Reliability of Pressure Pain Threshold Assessments in the Shoulder Muscles of Participants With and Without Unilateral Subacromial Impingement Syndrome.

OBJECTIVE: The purpose of this study was to determine the relative and absolute reliability of the pressure pain threshold (PPT) in the shoulder muscles of participants with and without unilateral subacromial impingement syndrome. METHODS: Study of intraday intra- and interrater and interday intrarater reliability. Fifty-two participants symptomatic for unilateral subacromial impingement syndrome were divided into 2 groups (SG1 and SG2) of 26 participants each, and 26 participants asymptomatic for shoulder pain took part in the study. Two raters assessed the PPT in 4 shoulder muscles. Each rater assessed symptomatic (SG1) and asymptomatic participants twice on the same day, and one of the raters on 2 different days (SG2). The intraclass correlation coefficient, standard error of measurement (SEM95% and SEM%), and minimum detectable change (MDC95% and MDC%) were calculated. RESULTS: Relative reliability was good or excellent for all assessments, as well as for both groups and raters (intraclass correlation coefficient: 0.87-0.98). The SEM95% values for intra- and interday intrarater measures were between 0.43 and 1.50 kgf/cm2 and SEM% between 6.76 and 12.86%, whereas MDC95% values ranged from 0.60 to 2.12 kgf/cm2 and MDC% from 9.56 to 18.18%. In interrater measures, SEM95% was between 0.58 and 0.77 kgf/cm2 and SEM% between 10.10% and 13.71%, whereas MDC95% varied from 0.82 to 1.08 kgf/cm2 and MDC% from 14.29% to 19.39%. CONCLUSION: Relative reliability was good or excellent. This study presents absolute reliability values that could be used as a reference in the clinical use of PPT.

The application of the Neurac technique vs. manual therapy in patients during the acute phase of subacromial impingement syndrome: A randomized single-blinded controlled trial.

BACKGROUD: Although the effect of exercise in patients during the subacute and/or chronic subacromial impingement syndrome has been reported, only a few studies have examined the effect of pain free exercise in the acute phase of this disorder. OBJECTIVE: To compare the effect of training using the Neurac technique which combines body segments suspension and vibration vs. manual therapy, on various relevant outcome parameters in patients with acute subacromial impingement syndrome (PASIS). METHOD: Twenty-six patients underwent a 4 week intervention program. Using random assignment, half of the patients were treated using the Neurac device while the other half was treated using manual therapy. The outcome parameters consisted of shoulder pain, shoulder function, range of motion (ROM) and the isokinetic strength of the external and internal rotators at 60 and 180∘/s. RESULTS: Following either modes of interventions, the pain, function, and ROM improved significantly compared to pre-intervention levels in both groups. Time-by-group interaction was observed for the rotational strength which increased significantly and exclusively in the Neurac group. CONCLUSIONS: Given its positive effect on shoulder pain, function, ROM and the isokinetic strength of the external and internal rotators, we recommend the application of the Neurac technique in PASIS.

Effect of Balance Taping Using Kinesiology Tape and Cross Taping on Shoulder Impingement Syndrome: A Case Report.

Background and objectives: Shoulder impingement syndrome (SIS) is the most common disorder among people with shoulder pain. The purpose of this case report was to investigate the effect of the combined application of balance taping using kinesiology tape and cross taping on a part-time worker with SIS. Case Report: Combined balance taping and cross taping was applied for 3 weeks (average, 16 hours per day) on a part-time worker with severe pain and a limited range of motion (ROM) in the shoulder who had visual analogue scale (VAS) pain scores of 7 and 8 out of 10 for shoulder flexion and abduction, respectively, and pain and disability scores of the Shoulder Pain Disability Index (SPADI) of 37 out of 50 and 29 out of 80, respectively. After the combined application of balance taping and cross taping, the VAS pain scores for shoulder flexion and abduction decreased from 7 to 0 and from 8 to 0, respectively, and the ROM increased to a normal range. The SPADI pain score decreased from 37 to 2, and the disability score decreased from 29 to 1. Shoulder activity level also increased, and the patient was able to return to his part-time job. Conclusions: We suggest combined application of balance taping and cross taping as an effective treatment for part-time workers with SIS.

Kinesiology taping with exercise does not provide additional improvement in round shoulder subjects with impingement syndrome: A single-blinded randomized controlled trial.

OBJECTIVE: Round shoulder posture (RSP) may exaggerate symptoms of subacromial impingement. The effects of kinesiology taping with exercise on posture, pain, and functional performance were investigated in subjects with impingement and RSP. DESIGN: This study was a single-blinded randomized controlled trial. SETTING: An outpatient rehabilitation clinic in a university hospital. PARTICIPANTS: Thirty-four subjects with subacromial impingement and RSP. INTERVENTIONS: Kinesiology taping with and without tension was applied 2 times per week for 4 weeks. Both groups also performed strengthening and stretching exercises 3 times per week for 4 weeks. MAIN OUTCOME MEASUREMENTS: The pain level, shoulder angle and self-reported score were evaluated at pre-intervention, 2-week post-intervention and 4-week post-intervention time points. RESULTS: Functional performance improved after intervention in both groups (p = 0.027). A greater decrease in pain level was related to better functional performance of the shoulder in both groups (r = -0.760 and -0.674; p < 0.010). Moderate correlations were found for posture and functional performance of the shoulder in the intervention group (0.48). CONCLUSION: Four weeks of strengthening and stretching exercises with or without kinesiology taping improved functional performance in subjects with impingement and RSP. Improvement in clinical symptoms was related to better performance of posture.

Psychometric Properties of Pressure Pain Thresholds Measured in 2 Positions for Adults With and Without Neck-Shoulder Pain and Tenderness.

OBJECTIVE: The purpose of this study was to determine the psychometric properties of pressure pain threshold (PPT) testing in adults with and without neck-shoulder pain and tenderness and to compare the differences in PPT measurements between the seated and prone positions. METHODS: Thirty asymptomatic adults and 30 symptomatic patients with intermittent neck-shoulder pain and tenderness completed the study. A pressure algometer was used to assess PPTs at specific points on the middle deltoid, levator scapulae, and upper trapezius muscles of the dominant side of the asymptomatic individuals and the painful side of the patients. Four trials were performed on each muscle in both the seated and prone positions. To determine between-day reliability, a subset of the participants returned to repeat the testing. RESULTS: The intraclass correlation coefficients showed good to excellent within-session reliability and fair to excellent between-day reliability of PPT measurements in both the seated and prone positions for both groups. There were significant differences between groups for all muscles in both positions (P < .05) except for the upper trapezius muscle in the prone position. In addition, significant differences were found between the 2 testing positions for the middle deltoid and upper trapezius muscles in the symptomatic group and for the middle deltoid muscle in the asymptomatic group. CONCLUSION: The results of the study suggest that PPT testing could be useful for distinguishing individuals with and without neck-shoulder pain and tenderness. Further, the patient's position should be considered when testing PPT, specifically at the middle deltoid or upper trapezius muscles.

Rotator CUFF disorders: A survey of current physiotherapy practice in Belgium and the Netherlands.

BACKGROUND: Disorders of the rotator cuff are a common musculoskeletal pain presentation in the general population, and treatment by a physiotherapist is often prescribed. In 2011, 2016, surveys of physiotherapy practice in the United Kingdom (UK) were performed, which reported that advice and exercise were the most common treatment strategies used. The aim of this current survey was to examine current physiotherapy practice in Belgium and The Netherlands, with consideration of differences between physiotherapists who were members of a shoulder network and physiotherapists who were not. METHODS: During February/March 2018, a cross-sectional online survey was conducted in Belgium and The Netherlands. RESULTS: 505 physiotherapists completed the survey. Advice (n = 362/505), isotonic exercises (n = 302/505) and scapular stabilisation exercises (n = 359/505) were the most common treatment modalities for patients with rotator cuff disorders. Physiotherapists not part of a shoulder network group more commonly integrated mobilization (n = 66/254 SN, n = 125/251 N-SN), electrotherapy (n = 1/254 SN, n = 19/251 N-SN) and massage (n = 48/254 SN, n = 89/251 N-SN) compared to those who were member of the group. CONCLUSION: Advice and exercise were the most common treatment prescriptions, which aligns with recommendations from current research evidence. Practice differs between physiotherapists involved with a shoulder network group compared to those who are not.

Effect of Kinesiology Taping on Upper Torso Mobility and Shoulder Pain and Disability in US Masters National Championship Swimmers: An Exploratory Study.

OBJECTIVE: The purpose of this study was to observe changes in shoulder pain and upper-extremity functional movement after kinesiology taping (KT) in competitive swimmers. METHODS: Seventy-six healthy participants competing in the US Masters Swimming 2017 National Championship participated in the study. Participants performed functional movement of shoulder flexion along with Disabilities of the Arm, Shoulder, and Hand index assessments for the shoulder before and 30 minutes after application of KT. RESULTS: A change in the functional movement assessment was observed after KT application when compared to the pre-KT application (33.56 ± 1.39 cm vs 35.35 ± 1.52 cm, P < .001). A statistical significant change for pain and disability scores of 2.17 was observed (12.29 ± 1.22 vs 10.12 ± 1.16, P < .01). CONCLUSION: For the participants in this study, KT changed shoulder pain and active functional movement scores significantly in swimmers.

The effectiveness of trigger point treatment in rotator cuff pathology: A randomized controlled double-blind study.

BACKGROUND: Studies have emphasized the importance of the presence of myofascial trigger points (MTrPs) in patients with rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles. OBJECTIVE: Evaluate the effectiveness of the treatment of active MTrPs in patients with rotator cuff pathologies. METHODS: Fifty-three patients with rotator cuff tear were randomized into two groups. All patients received the same standard conservative treatment twice a week for 6 weeks. Patients in Group 1 additionally received ischemic compression (IC) of MTrPs. Pain, range of motion (ROM), function, and anxiety and depression were assessed. MTrPs in rotator cuff muscles were assessed manually, and the number of MTrPs on the shoulder complex was counted. RESULTS: There were no significant differences between the groups in terms of changes in resting/activity/night pain, ROM, function, or anxiety and depression (p> 0.05). Pain scores improved only in Group 1. However, the total number of MTrPs was significantly decreased in Group 1 (p= 0.001). CONCLUSION: A six-week course of IC helps treat active MTrPs. A standard conservative treatment program reduced pain and increased function; the addition of MTrP treatment did not improve clinical outcomes in patients with rotator cuff pathologies.

Effect of manual physiotherapy in homogeneous individuals with subacromial shoulder impingement: A randomized controlled trial.

OBJECTIVE: To compare the effect of specific interventions aimed at (1) the upper thoracic spine (passive mobilization) and (2) the posterior shoulder (massage, passive mobilization, and stretching) to (3) an active control intervention in a homogeneous group with extrinsic subacromial shoulder impingement (SSI). STUDY DESIGN: Single-centre, prospective, double-blinded, randomized controlled trial. METHOD: Eligible individuals with clearly defined extrinsic SSI were randomized to each group. Treatment duration was 12 consecutive weeks consisting of nine treatments over 6 weeks, followed by 6 weeks when one home exercise was performed daily. Outcomes included (1) active thoracic flexion/extension range of motion, (2) passive glenohumeral internal rotation and posterior shoulder range, (3) pain rating, and (4) shoulder pain and function disability index. Data were analysed at baseline, 6 and 12 weeks. Shoulder pain and function disability index scores were investigated via email 6 months after commencement of treatment. RESULTS: Twenty participants completed treatment in each group. No differences were identified between groups at baseline. Upper thoracic and posterior shoulder interventions, with a targeted home exercise, both significantly decreased pain and increased function scores and increased posterior shoulder range compared with active control at 12 weeks, and 6 months following cessation of the trial. CONCLUSION: Manual therapy treatment that addresses these extrinsic factors, of thoracic spine or posterior shoulder tightness, decreases the signs and symptoms of SSI. The trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR; 12615001303538).

Pain, fatigue, function and participation among long-term manual wheelchair users partnered with a mobility service dog.

PURPOSE: To assess the effects of a mobility service dog (MSD) on pain, fatigue, wheelchair-related functional tasks, participation and satisfaction among manual wheelchair users over a nine-month period. METHOD: A longitudinal study with repeated assessment times before and three, six and nine months after intervention was achieved. Intervention consisted in partnering each participant with a MSD. The setting is a well-established provincial service dog training school and participants homes. A convenience sample of 24 long-term manual wheelchair users with a spinal cord injury was involved. Outcome measures were: Wheelchair User's Shoulder Pain Index (WUSPI), Rate of Perceived Exertion (RPE), vitality scale from the SF-36, grip strength, Wheelchair Skills Test (WST), Canadian Occupational Performance Measure (COPM), Reintegration to Normal Living Index (RNLI), Life Space Assessment, Psychosocial Impact of Assistive Devices Scale (PIADS) and Quebec User Evaluation of Satisfaction with assistive Technology (QUEST 2.0). RESULTS: Shoulder and wrist pain as well as fatigue decreased significantly over time with the use of a MSD as evidenced by scores from WUSPI, RPE and SF-36 (feeling less worn out). Manual wheelchair propulsion skills (steep slopes, soft surfaces and thresholds) improved significantly over time as confirmed by the WST. Participation increased significantly over time as revealed by the COPM (for five occupations) and the RNLI (for five items). Satisfaction with the MSD was high over time (QUEST: nine items) and with a high positive psychosocial impact (PIADS: 10 items). CONCLUSION: MSD represents a valuable mobility assistive technology option for manual wheelchair users. IMPLICATIONS FOR REHABILITATION For manual wheelchair users partenered with mobility service dog  â€¢ Shoulder pain and fatigue significantly decreased and continued to decrease between the third and sixth month and the ninth month. • Performance with propelling the wheelchair up steep slopes increased from 41 to 88% and on soft surfaces increased from 53 to 100% after 3 months, respectively. • Occupational performance satisfaction was significantly increased for mobility in relation with the transfers, navigating in a natural environment and picking up objects. • High satisfaction towards psychosocial competency, psychosocial adequacy and self-esteem were reported at months three, six and nine.

Dry needling in addition to standard physical therapy treatment for sub-acromial pain syndrome: a randomized controlled trial protocol.

BACKGROUND: Trigger point dry needling interventions are utilized by physical therapists to manage shoulder pain. Observational studies have shown positive short-term outcomes in patients with subacromial pain syndrome receiving trigger point dry needling. However, little research has been done to evaluate the long-term effectiveness of trigger point dry needling specifically as it compares to other commonly utilized interventions such as exercise and manual therapy. The purpose of this study is to assess the additive short and long-term effectiveness of trigger point dry needling to a standard physical therapy approach of manual therapy and exercise for patients with subacromial pain syndrome. METHODS: This multicenter randomized trial with 3 arms was designed following the standard protocol items for randomized interventional trials. Results will be reported consistent with the consolidated standards of reporting trials guidelines. 130 participants will be randomized to receive standard PT interventions alone (manual therapy and exercise), standard PT and trigger point dry needling or standard PT and sham trigger point dry needling. The primary outcome measures will be the Shoulder Pain and Disability Index and Patient Reported Outcomes Measurement Information Systems (PROMIS-57) scores collected at baseline, 6-weeks, 6-months and one year. Healthcare utilization will be collected for 12 months following enrollment and groups analyzed for differences. DISCUSSION: It is not known if trigger point dry needling provides long-term benefit for individuals with subacromial pain syndrome. This study will help determine if this intervention provides additive benefits over those observed with the commonly applied interventions of exercise and manual therapy. TRIAL REGISTRATION: Identifier: NCT03442894 (https://clinicaltrials.gov/ct2/show/NCT03442894) on 22 February 2018.

The Effects of Needling Therapies on Muscle Force Production: A Systematic Review and Meta-analysis.

BACKGROUND: Needling has been shown to decrease pain in the short term; however, its effects on muscle force production are unclear. OBJECTIVE: To evaluate the evidence regarding the comparative effects of needling on muscle force production. METHODS: In this systematic review, an electronic search was performed using key words related to needling. Methodological quality of articles was appraised and effect sizes were calculated. The strength of evidence was determined, and meta-analysis was performed when similar methods were used in studies for similar conditions. RESULTS: Twenty-one studies were included in this review, of which 9 were deemed to be of high quality (greater than 6/10 on the Physiotherapy Evidence Database [PEDro] scale), 11 of fair quality (5 to 6/10), and 1 of poor quality (less than 5/10). Three meta-analyses were performed. There was moderate strength of evidence and medium effect sizes for needling therapy to enhance force production in those with neck pain, and very low strength of evidence of no effect for individuals with nonspecific and postoperative shoulder pain and those with lateral epicondylalgia. Other studies not included in the 3 meta-analyses demonstrated no significant effect of needling on force production. These studies included individuals with carpal tunnel syndrome, knee osteoarthritis, ankle sprains, knee arthroscopy, or delayed-onset muscle soreness. CONCLUSION: The majority of studies suggest no effect of dry needling on force production. High-quality studies with adequate power that control for the placebo effect and follow accepted reporting standards could make valuable contributions to the literature. This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42017080318). LEVEL OF EVIDENCE: Therapy, level 1a. J Orthop Sports Phys Ther 2019;49(3):154-170. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8270.

Effects of functional electrical stimulation-cycling on shoulder pain and subluxation in patients with acute-subacute stroke: a pilot study.

Functional electrical stimulation (FES)-cycling is a technique used to provide voluntary muscle contraction during a functional task. The aims were primarily to determine the effects of FES-cycling on shoulder pain and subluxation, and secondarily to evaluate the improvement of upper extremity motor function in patients with acute-subacute stroke patient. In this prospective trial, 21 patients with acute-subacute stroke, randomly assigned into the FES-cycling group or the standard rehabilitation program (control group). Analyses of shoulder subluxation were carried out by radiography. The numeric rating scale was used to evaluate the intensity of pain, Fugl-Meyer and Frenchay arm tests for motor function, and functional independence measure for functional status. The outcome data were evaluated at baseline and at the end of 4-week treatment. Intragroup comparisons showed improvement of acromiohumeral distance, Fugl-Meyer assessment, and functional independence measure in both groups after treatment. In intergroup comparison, FES-cycling group exerted better outcomes in shoulder pain compared with the control group (P=0.015). Correlation analyses demonstrated only positive correlation between shoulder subluxation and pain (P=0.022). FES-cycling was superior to standard rehabilitation therapy for shoulder pain relief in patients with acute-subacute stroke. Therefore, combining FES-cycling with a standard rehabilitation program alleviates shoulder pain and may prevent development of shoulder subluxation over time.