How long does tendinopathy last if left untreated? Natural history of the main tendinopathies affecting the upper and lower limb: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Natural history of disease refers to the progression of a disease process in an individual over time, in the absence of treatment. Understanding natural history of tendinopathies is key for clinicians to make accurate prognostic predictions and design effective intervention studies. OBJECTIVE: To quantify the natural history of the main tendinopathies regarding pain and function and to compare outcomes between untreated individuals and those receiving treatment. METHODS: A systematic literature search was conducted until February 2023, across PubMed, Cochrane, Embase and Scopus databases. Selection criteria included randomized controlled trials (RCTs) with a "wait-and-see" group and cohort studies with ≥3 months of follow-up reporting on pain and function-related outcomes. Standardized mean differences (SMDs) of "wait-and-see" groups were pooled using a random-effects inverse-variance model. Risk of bias was assessed using Cochrane Risk-of-Bias (RoB2), and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: Six RCTs were included, encompassing 518 subjects with tendinopathy. Pooled results demonstrated significant pain (SMD = 0.30, 95%CI: 0.19-0.41) and physical function improvement (SMD = 0.38, 95%CI: 0.28-0.48). These estimates remained consistent regardless of age or follow-up duration. In rotator cuff tendinopathy, untreated individuals improved but did not fully recover at one year, with similar outcomes to other interventions (e.g., surgery). Subjects with lateral elbow, patellar and achilles tendinopathies when untreated, did not fully resolve symptoms within 12-16 weeks. CONCLUSIONS: This review provides limited conclusions about natural history of tendinopathies. Future studies should incorporate true no-intervention groups to accurately reflect tendinopathy's natural progression.

Specific versus non-specific exercises for the neck extensor muscles in women with chronic idiopathic neck pain: A randomized controlled trial.

BACKGROUND: Structural and functional impairments of the cervical extensor muscles have been demonstrated in people with neck pain. A global exercise approach targeting all neck extensor muscles has shown positive effects in this population. However, to date, the efficacy of exercises specifically targeting the deep neck extensors has neither been tested nor compared to global exercises for the neck extensors. OBJECTIVES: To compare the effects on pain and disability of a specific lower deep neck extensors (SLDNE) versus a general neck extensor (GNE) exercise program in women with chronic idiopathic neck pain. METHODS: Fourty-three women with chronic idiopathic neck pain were randomly allocated to either a six-week SLDNE or a GNE exercise program. As primary outcome, neck disability was measured with the Neck Disability Index (NDI). Secondarily, pain intensity (VAS), cervical ROM, pressure pain thresholds (PPTs), cervical and thoracic posture and self-perceived benefit of treatment (GROC) were also measured. Every outcome was measured at baseline and immediately after treatment, except NDI, which was also measured at 6-months follow-up. The GROC was only assessed post-intervention. RESULTS: Both exercise programs lead to reduced neck disability immediately post-intervention (within-group mean difference [MD] = -6.09; 95% Confidence Interval [CI]: 7.75, -4.42 and -4.73; 95%CI: 6.57, -2.91 respectively) and at the 6-months follow-up (-4.47; 95%CI: 6.41, -2.53 and -4.74; 95%CI: 6.50, -2.97), but with no between group differences. Similar results were found for pain intensity post-intervention, with no between group interaction (within-group MD = -20.87 mm; 95% CI: 28.55, -13.19 and -18.00 mm; 95%CI: (-26.24, -9.76) for SLDNE and GNE groups, respectively). GROC improved after both interventions without any between-group difference. CONCLUSIONS: A six-week exercise program specifically targeting the lower deep neck extensors lead to comparable outcomes as a general neck extensor exercise program in women with chronic idiopathic neck pain.

Should Exercises be Painful or not? Effects on Clinical and Experimental Pain in Individuals with Shoulder Pain.

Exercise can reduce pain, however the effect of painful versus non-painful exercises is uncertain. The primary aim of this randomized crossover study was to compare the effect of painful versus nonpainful isometric shoulder exercises on pain intensity after exercise in individuals with rotator cuff-related shoulder pain. Secondary exploratory aims were to describe the effects on pressure pain thresholds (PPTs), conditioned pain modulation (CPM) and muscle strength. On separate days, 35 individuals performed painful isometric shoulder exercises (external rotation; 20% above pain threshold), nonpainful isometric shoulder exercises (external rotation; 20% below pain threshold), and a rest condition, in randomised order. Shoulder pain intensity, PPTs, CPM, and external rotation strength were assessed before, immediately after and 45 minutes after conditions. No significant differences were observed between painful and nonpainful exercises. Visual analogue scale scores increased immediately after both painful and non-painful exercises compared with rest (P = .047, partial ƞ2 = .07), but were similar to preexercise levels after 45 minutes. No changes in PPTs, CPM, or muscle strength after exercises compared with rest were observed. Painful and non-painful isometric exercises caused a moderate but short-lasting increase in shoulder pain in individuals with RCRSP. Isometric exercises had no effect on pain sensitivity and shoulder muscle strength or CPM. PERSPECTIVE: This study evaluated for the first time in individuals with rotator cuff-related shoulder pain the effects of painful versus non-painful isometric exercises on different pain-related outcome measures. Both painful and non-painful isometric exercises caused a moderate but relatively short-lasting increase in shoulder pain in individuals with rotator cuff-related shoulder pain. Trial registration number: (ClinicalTrials.gov) NCT03675399.

The effect of vibration therapy on neck myofascial trigger points: A randomized controlled pilot study.

BACKGROUND: The purpose of this study was to evaluate the effect of low-frequency self-administered vibration therapy into myofascial trigger points in the upper trapezius and levator scapulae on patients with chronic non-specific neck pain. METHODS: Twenty-eight patients with chronic non-specific neck pain were randomly assigned into a vibration group, receiving 10 self-applied sessions of vibration therapy in the upper trapezius and levator scapulae trigger points; or a control group, receiving no intervention. Self-reported neck pain and disability (Neck Disability Index) and pressure pain threshold were assessed at baseline and after the first, fifth and 10th treatment sessions. FINDINGS: Significant differences were found in the vibration group when compared to the control group after the treatment period: the vibration group reached lower Neck Disability Index scores (F = 4.74, P = .033, η2 = 0.07) and greater pressure pain threshold values (F = 7.56, P = .01, η2 = 0.10) than the control group. The vibration group reported a significant reduction in Neck Disability Index scores (χ2 = 19,35, P = .00, Kendall's W = 0.28) and an increase in pressure pain threshold (χ2 = 87,10, P = .00, Kendall's W = 0.73) between the assessment times over the course of the treatment. The mean increase in pressure pain threshold in the vibration group after the 10 sessions was 8.54 N/cm2, while the mean reduction in Neck Disability Index scores was 4.53 points. INTERPRETATION: Vibration therapy may be an effective intervention for reducing self-reported neck pain and disability and pressure pain sensitivity in patients with chronic non-specific neck pain. This tool could be recommended for people with non-specific neck pain.

Laterality judgement and tactile acuity in patients with frozen shoulder: A cross-sectional study.

BACKGROUND: Disrupted tactile acuity and poor laterality judgement have been shown in several chronic musculoskeletal pain conditions. Whether they are impaired in people with frozen shoulder (FS) remains unknown. OBJECTIVES: To determine whether there is impairment in tactile acuity and laterality judgement in subjects with FS. METHODS: Thirty-eight subjects with idiopathic FS and 38 sex and age-matched healthy controls were enrolled. The two-point discrimination threshold (TPDT) over the affected and unaffected shoulder of patients with FS and shoulder of healthy controls was evaluated. In addition, all participants performed a left/right judgment task (LRJT). Independent and dependent t-tests were used to compare group means. Pearson-product moment coefficient correlations between pain intensity and duration and LRJT and TPDT were calculated for the FS group. RESULTS: The TPDT over the affected shoulder was significantly increased compared to the unaffected shoulder (mean difference, 3.82 mm; 95% confidence interval [CI]:0.53, 7.10; p = .02) and controls (mean difference, 5.80 mm; 95% CI: 1.09, 10.52; p = .02). Patients with FS were less accurate (mean difference, 5.90%; 95% CI: 0.36, 11.43; p = .03) and slower (mean difference, -0.26 s; 95% CI: 0.06, 0.45; p = .01) responding to images of their affected shoulder compared to their unaffected shoulder. No associations were found between pain intensity and duration and either TPDT or laterality judgement. CONCLUSIONS: Participants with FS demonstrated reduced tactile acuity and impaired laterality judgement over their affected shoulder compared to their unaffected shoulder. When compared to controls, subjects with FS showed reduced tactile acuity. TRIAL REGISTRATION CLINICALTRIALS. GOV IDENTIFIER: NCT03320200.

Analysis of (210)Pb in water samples with plastic scintillation resins.

(210)Pb is a radioactive lead isotope present in the environment as member of the (238)U decay chain. Since it is a relatively long-lived radionuclide (T1/2 = 22.2 years), its analysis is of interest in radiation protection and the geochronology of sediments and artwork. Here, we present a method for analysing (210)Pb using plastic scintillation resins (PSresins) packaged in solid-phase extraction columns (SPE cartridge). The advantages of this method are its selectivity, the low limit of detection, as well as reductions in the amount of time and reagents required for analysis and the quantity of waste generated. The PSresins used in this study were composed of a selective extractant (4',4″(5″)-Di-tert-butyldicyclohexano-18-crown-6 in 1-octanol) covering the surface of plastic scintillation microspheres. Once the amount of extractant (1:1/4) and medium of separation (2 M HNO3) were optimised, PSresins in SPE cartridges were calibrated with a standard solution of (210)Pb. (210)Pb could be fully separated from its daughters, (210)Bi and (210)Po, with a recovery value of 91(3)% and detection efficiency of 44(3)%. Three spiked water samples (one underground and two river water samples) were analysed in triplicates with deviations lower than 10%, demonstrating the validity of the PS resin method for (210)Pb analysis.

Does pre-surgical central modulation of pain influence outcome after total knee replacement? A systematic review.

The aim of this study is to systematically review whether the presence of altered central pain modulation pre-surgical influences outcome after total knee replacement (TKR) in patients with knee osteoarthritis (OA), and if so which indices of central pain modulation predict poor outcome after TKR. To identify relevant articles, PubMed and Web of Science were searched. The search strategy was a combination of key words related to "Knee Osteoarthritis and Total Knee Replacement", "Central Pain Modulation" and "Post-Surgical Outcome Measures". Articles fulfilling the inclusion criteria were screened for methodological quality and results were analyzed and summarized. Sixteen prospective cohort studies were included. Strong evidence is available that presence of catastrophic thinking and poor coping strategies predict more pain after TKR and that there is no association between fear of movement and post-surgical pain or function. Evidence on other psychosocial influences is limited or conflicting. Literature on the influence of other signs of altered central pain modulation on post-surgical outcome is scarce. It is plausible that pre-surgical signs of altered central pain modulation, such as joint pain at rest or widespread pain sensitization, predict more post-surgical pain. Surgeons should be attentive for patients with signs of altered central pain modulation before surgery as they might be at risk for unfavorable outcome. A broader therapeutic approach aiming to desensitize the central nervous system can be adapted in these patients. Further research is however needed to identify the influence of central pain modulation pre-surgical in predicting outcome after TKR.

Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review.

It has been suggested that differential diagnosis of headaches should consist of a robust subjective examination and a detailed physical examination of the cervical spine. Cervicogenic headache (CGH) is a form of headache that involves referred pain from the neck. To our knowledge, no studies have summarized the reliability and diagnostic accuracy of physical examination tests for CGH. The aim of this study was to summarize the reliability and diagnostic accuracy of physical examination tests used to diagnose CGH. A systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in four electronic databases (MEDLINE, Web of Science, Embase and Scopus). Full text reports concerning physical tests for the diagnosis of CGH which reported the clinometric properties for assessment of CGH, were included and screened for methodological quality. Quality Appraisal for Reliability Studies (QAREL) and Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) scores were completed to assess article quality. Eight articles were retrieved for quality assessment and data extraction. Studies investigating diagnostic reliability of physical examination tests for CGH scored poorer on methodological quality (higher risk of bias) than those of diagnostic accuracy. There is sufficient evidence showing high levels of reliability and diagnostic accuracy of the selected physical examination tests for the diagnosis of CGH. The cervical flexion-rotation test (CFRT) exhibited both the highest reliability and the strongest diagnostic accuracy for the diagnosis of CGH.

Inter-and intra-tester reliability of a battery of cervical movement control dysfunction tests.

BACKGROUND: Apart from the cranio-cervical flexion test and the deep neck flexor endurance test, evidence related to reliability of cervical movement control dysfunction tests is lacking. OBJECTIVES: This study investigated the inter- and intra-tester reliability of a battery of cervical movement control dysfunction tests and the effect of clinician experience on reliability in 15 patients with chronic neck pain and 17 non-neck pain controls. In addition, it explored whether impaired performance on this battery of tests was more frequently observed in the neck pain group. DESIGN: Inter and intra-tester reliability study. METHOD: Participants were videotaped while performing a battery of nine active cervical movement control dysfunction tests. Two physiotherapists, with different levels of experience, independently rated all tests on two occasions two weeks apart. They were masked to participants' neck pain or non-neck pain status. RESULTS: Inter-tester reliability for the complete battery of tests was substantial (κ = 0.69; 95% CI: 0.62, 0.76). Intra-rater reliability values for the expert (κ = 0.86; 95% CI: 0.79, 0.92) and novice (κ = 0.76; 95% confidence intervals (CI): 0.68, 0.84) were overall comparable suggesting that novices can achieve good accuracy with the battery of tests if trained. The frequency of impaired performances in cervical movement control dysfunction tests was low and comparable between groups. Only two tests achieved a greater number of impaired ratings in the patient group. CONCLUSIONS: Although reliable, further research in larger neck pain populations is required to explore this battery of tests, in order to establish their diagnostic accuracy for identifying clinically relevant cervical movement control dysfunction.

Effect of manual therapy techniques on headache disability in patients with tension-type headache. Randomized controlled trial.

BACKGROUND: Tension-type headache (TTH) is the most common type of primary headache however there is no clear evidence as to which specific treatment is most effective or whether combined treatment is more effective than individual treatments. AIM: To assess the effectiveness of manual therapy techniques, applied to the suboccipital region, on aspects of disability in a sample of patients with tension-type headache. DESIGN: Randomized Controlled Trial. SETTING: Specialized centre for headache treatment. POPULATION: Seventy-six (62 women) patients (age: 39.9 ± 10.9 years) with episodic chronic TTH. METHODS: Patients were randomly divided into four treatment groups: 1) suboccipital soft tissue inhibition; 2) occiput-atlas-axis manipulation; 3) combined treatment of both techniques; 4) control. Four sessions were applied over 4 weeks and disability was assessed before and after treatment using the Headache Disability Inventory (HDI). Headache frequency, severity and the functional and emotional subscales of the questionnaire were assessed. Photophobia, phonophobia and pericranial tenderness were also monitored. RESULTS: Headache frequency was significantly reduced with the manipulative and combined treatment (P<0.05), and the severity and functional subscale of the HDI changed in all three treatment groups (P<0.05). Manipulation treatment also reduced the score on the emotional subscale of the HDI (P<0.05). The combined intervention showed a greater effect at reducing the overall HDI score compared to the group that received suboccipital soft tissue inhibition and to the control group (both P<0.05). In addition, photophobia, phonophobia and pericranial tenderness only improved in the group receiving combined therapy (P<0.05). CONCLUSION: When given individually, suboccipital soft tissue inhibition and occiput-atlas-axis manipulation resulted in changes in different parameters related to the disability caused by TTH. However, when the two treatments were combined, effectiveness was noted for all aspects of disability and other symptoms including photophobia, phonophobia and pericranial tenderness. CLINICAL REHABILITATION IMPACT: Although individual manual therapy treatments showed a positive change in headache features, measures of photophobia, photophobia and pericranial tenderness only improved in the group that received the combined treatment suggesting that combined treatment is the most appropriate for symptomatic relief of TTH.

Evidence for central sensitization in patients with osteoarthritis pain: a systematic literature review.

Hyperexcitability of the central nervous system (CNS) has been suggested to play an important role in the chronic pain experienced by osteoarthritis (OA) patients. A systematic review following PRISMA guidelines was performed to evaluate the existing evidence from the literature related to the presence of central sensitization (CS) in patients with OA.Electronic databases PubMed and Web of Science were searched to identify relevant articles using pre-defined keywords regarding CS and OA. Full-text clinical reports addressing studies of CS in human adults with chronic complaints due to osteoarthritis were included and screened for methodological quality by two independent reviewers. From the 40 articles that were initially eligible for methodological quality assessment, 36 articles achieved sufficient scores and therefore were discussed. The majority of these studies were case-control studies and addressed OA of the knee joint. Different subjective and objective parameters considered manifestations of CS, which have been previously reported in other chronic pain conditions such as whiplash or rheumatoid arthritis, were established in subjects with OA pain. Overall results suggest that, although peripheral mechanisms are involved in OA pain, hypersensitivity of the CNS plays a significant role in a subgroup of subjects within this population. Although the majority of the literature provides evidence for the presence of CS in chronic OA pain, clinical identification and treatment of CS in OA is still in its infancy, and future studies with good methodological quality are necessary.

CT and MRI Correlations in Patients with Suspected Cholesteatoma after Surgery.

The study of postoperative ear cavities in patients who underwent surgery for cholesteatoma is a difficult challenge for radiologists. In our study we make a correlation between CT and MRI findings, useful tools in patients with suspected residual or recurrent cholesteatoma. The use of different MRI sequences especially DWI can help radiologists to discriminate between cholesteatoma and other different processes.

Hipovitaminosis B12 y psicopatología: a propósito de tres casos / Of three cases of hypotaminosis B12 and psychopatology

Este trabajo pretende revisar el estado actual de los conocimientos acerca de las manifestaciones psiquiátricas de la deficiencia de vitamina B12. Los trabajos previos en este campo ha distinguido la existencia de tres grandes grupos sindrómicos: psicosis, depresión y déficits neurocognitivos. Se presenta un caso de cada uno de estos diagnósticos y se discute su relación con el déficit vitamínico. (AU)

[Nasal rhinosporidiosis]. / Rinosporidiosis nasal.

Rhinosporidiosis is a granulomatous disease of uncertain mycotic origin that is characterized by polypoid lesions, predominantly of the nasal mucous membrane and conjunctiva. It is endemic to India and Sri Lanki, but occasionally occurs in other regions of the world. We report a case in Spain. The modes of infection and transmission, as well as treatment, are discussed.

[Synchronous intestinal, tonsillar and pulmonary tuberculosis]. / Tuberculosis intestinal, amigdalar y pulmonar sincrónicas.

OBJECTIVES: To emphasize the unusual synchronous presentation of intestinal, pulmonary and tonsillar tuberculosis in the same patient. CLINICAL CASE: A 43 years old male consults for abdominal pain and alternating episodes of diarrhoea-constipation. Based on radiologic, endoscopic and pathologic studies the diagnosis of Crohn's ileo-cecal disease is achieved and a treatment with salazosulphapyridine and corticosteroid is started. Two months later the patient presents with a tonsilar ulceration that is diagnosed as tuberculosis on biopsy material. At the same time, chest x-rays film reveal active tuberculous lesions, and tuberculous bacili are seen in the sputum. Simultaneously the intestinal disease worsens and complicates with incomplete occlusion that requires a right hemicolectomy. Pathologic study of the specimen shows evident tuberculous lesions. Specific treatment for tuberculosis is started, and the patient remains free of disease one year later. CONCLUSIONS: Due to the increase in the prevalence of tuberculous diseases, we must keep it in mind in the differential diagnosis of intestinal strictures, even though they are suggestive of Crohn's disease, and a radical surgical procedure must also be evaluated.

Implications of tumour in resection margins following surgical treatment of squamous cell carcinoma of the head and neck.

Presence of tumour at the resection margin following primary surgical treatment for squamous cell carcinoma of the head and neck is thought to adversely affect prognosis. To confirm this we performed a review of 478 patients treated by primary surgery for squamous cell carcinoma of the head and neck and sub-divided them into those exhibiting positive margins and those with negative margins following resection. Uni-variate and multi-variate statistical methods were used to analyse survival figures and a variety of parameters associated with the presence of positive resection margins. We found 5-year survival was decreased if resection margins were found to be positive (P < 0.025). The presence of positive resection margins was also significantly associated with time to tumour recurrence (P < 0.001) and survival with nodal recurrence (P < 0.001). Other factors which were significantly associated with survival using Cox's multi-variate analysis were site of tumour (P < 0.005), nodal extracapsular rupture (P < 0.05), histology (P < 0.05) and pathological T-stage (P < 0.05). Uni-variate analysis revealed no significant associations between the presence of positive margins and the patient's age, sex, tumour site, degree of tumour differentiation, and nodal status, though using multiple logistic regression, the general condition of the patient (P < 0.01) and the tumour site P < 0.05) were significantly related. The results support the concept that every effort should be made to obtain negative resection margins when undertaking primary ablative surgery for squamous cell carcinoma of the head and neck.