Evaluación de la rehabilitación intensiva con bloqueo continuo del nervio supraescapular para el tratamiento de la capsulitis adhesiva refractaria de hombro. Serie de casos / Evaluation of intensive rehabilitation under continuous suprascapular nerve blockade for the treatment of refractory adhesive shoulder capsulitis. Case series

Introducción: El tratamiento de la capsulitis adhesiva refractaria de hombro es difícil. Este estudio observacional retrospectivo evaluó la efectividad a largo plazo del protocolo de fisioterapia intensiva con bloqueo periférico continuo del nervio supraescapular (BNSE). Método: Revisamos 29 historias clínicas de pacientes con capsulitis adhesiva y les tratamos con fisioterapia intensiva con BNSE durante 10 días. Se registraron los resultados del cuestionario de la escala DASH (Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire) y los movimientos de hombro al inicio, a los 10 días de la infusión de anestésico local y transcurridos tres meses del procedimiento. Resultados: Veintiséis pacientes mejoraron los movimientos de hombro transcurridos 10 días de tratamiento. Se realizó seguimiento completo de 16 pacientes transcurridos tres meses del programa de rehabilitación. El rango de cuatro movimientos de hombro, compatible con una vida diaria normal, fue adquirido por nueve pacientes transcurridos tres meses. No se observó diferencia significativa en términos de movimiento de hombro entre la infusión de AL y transcurridos tres meses. Al finalizar la infusión, la puntuación DASH se redujo significativamente a 59,3 (n=26), y transcurridos tres meses se mantuvo en 42,1 (n=16). A los tres meses, el 33% de la población inicial alcanzó objetivamente los cuatro objetivos, compatibles con una calidad de vida correcta. Conclusión: La rehabilitación con BNSE está asociada a una mejora significativa a largo plazo en términos de movimiento de hombro y calidad de vida en los pacientes con capsulitis adhesiva. Son necesarios ensayos controlados aleatorizados para demostrar nuestros resultados alentadores.(AU)

Introduction: Treatment of refractory adhesive shoulder capsulitis is a challenge. This observational retrospective study evaluated the long-term effectiveness of intensive physiotherapy protocol under a continuous peripheral blockade of the suprascapular nerve (cSSNB). Method: We reviewed 29 medical records of patients suffering from adhesive capsulitis and treated with intensive physiotherapy under cSSNB during 10 days. The “disabilities of the arm, shoulder and hand” outcome questionnaire (DASH score) and shoulder movements were recorded at the beginning, 10 days after local anesthetic infusion and three months after. Results: Twenty six patients significant improved shoulder movements after 10 days of treatment. Sixteen patients were followed completely until 3 months after rehabilitation program. Range of four shoulder motion compatible with a normal daily life was acquired in nine patients at three months. There is no significant difference in shoulder motion between the end of LA infusion and at three months. At the end of infusion, DASH score is significantly decreased to 59.3 (n=26), and persists three months 42.1 (n=16). At three months, 33% of the initial population objectively reach the 4 goals, compatible with a correct quality of life. Conclusion: Rehabilitation under cSSNB is associated with a significant long term improvement in shoulder motion and quality of life in patients with adhesive capsulitis. Randomized controlled trials will be necessary to demonstrate our encouraging results.(AU)

Evaluation of intensive rehabilitation under continuous suprascapular nerve blockade for the treatment of refractory adhesive shoulder capsulitis. Case series.

INTRODUCTION: Treatment of refractory adhesive shoulder capsulitis is a challenge. This observational retrospective study evaluated the long-term effectiveness of intensive physiotherapy protocol under a continuous peripheral blockade of the suprascapular nerve (cSSNB). METHOD: We reviewed 29 medical records of patients suffering from adhesive capsulitis and treated with intensive physiotherapy under cSSNB during 10 days. The "disabilities of the arm, shoulder and hand" outcome questionnaire (DASH score) and shoulder movements were recorded at the beginning, 10 days after local anesthetic infusion and three months after. RESULTS: Twenty six patients significant improved shoulder movements after 10 days of treatment. Sixteen patients were followed completely until 3 months after rehabilitation program. Range of four shoulder motion compatible with a normal daily life was acquired in nine patients at three months. There is no significant difference in shoulder motion between the end of LA infusion and at three months. At the end of infusion, DASH score is significantly decreased to 59.3 (n = 26), and persists three months 42.1 (n = 16). At three months, 33% of the initial population objectively reach the 4 goals, compatible with a correct quality of life. CONCLUSION: Rehabilitation under cSSNB is associated with a significant long term improvement in shoulder motion and quality of life in patients with adhesive capsulitis. Randomized controlled trials will be necessary to demonstrate our encouraging results.

[Neuromusculoskeletal disorders related to musical playing - a review of the literature]. / Les pathologies neuro-musculo-squelettiques en lien avec la pratique musicale. Une revue de la littérature.

The prevalence of pathologies associated with musical playing are high among professional musicians. While hearing injuries appear to be the most commonly disorder, instrumentalists are also prone to numerous neurological and musculoskeletal problems. Despite the increasing number of recent clinical studies, an appropriate identification of these problems by health practitioners remains difficult and the implementation of an adequate treatment is almost inexistent in a population of musicians with several disorders affecting the ability to play their instrument.

Les pathologies en lien avec la pratique musicale sont fréquentes dans une population de musiciens professionnels. Alors que les lésions auditives restent peut-être les seules connues du grand public, les musiciens sont aussi sujets à de nombreux troubles neurologiques et musculo-squelettiques. Malgré une augmentation récente des études cliniques, l'identification de ces troubles par les praticiens de la santé reste difficile et la mise en place de traitement est presque inexistante dans une population de musiciens présentant de nombreux troubles interférant avec la pratique de leur instrument.

[Pathologies of the musculoskeletal system in diabetes mellitus]. / Les complications musculo-squelettiques du diabète.

Diabetes mellitus causes several micro- (nephropathy, neuropathy and retinopathy) and macro-vascular (coronary insufficiency, stroke, lower limb arteriopathy) complications. Some complications are less widely known, particularly the ones involving the musculoskeletal system. Even though diabetes is not specifically linked to these complications, it increases both their incidence and severity. The objective of this paper is to review the main musculoskeletal complications associated to diabetes. It describes the pathophysiology, symptomatology and treatments of these complications.

Le diabète sucré entraîne toute une série de complications micro- (néphropathie, rétinopathie et neuropathie) et macro-vasculaires (coronopathie, accident vasculaire cérébral et artériopathie des membres inférieurs). Certaines complications sont moins connues, notamment celles qui touchent le système musculo-squelettique. Ces pathologies ne sont pas spécifiques du diabète, mais celui-ci en augmente fortement, non seulement, l'incidence, mais aussi la sévérité. Le but du présent article est de revoir les principales complications musculo-squelettiques que l'on peut rencontrer chez les personnes diabétiques, en décrire la physiopathologie, la symptomatologie et le traitement à préconiser.

Using platelet-rich plasma to treat jumper's knees: Exploring the effect of a second closely-timed infiltration.

OBJECTIVES: Some clinical series have evaluated the effect of platelet-rich plasma (PRP) in the treatment of proximal patellar tendinopathy. Although it is possible that a single infiltrative administration may prove to be an effective treatment for this indication, most of the existing studies evaluated the effects of two or three successive infiltrations. The aim of this study was to evaluate whether two infiltrations of PRP proves more effective than a single treatment. DESIGN: Prospective, randomized and comparative study of level 2. METHODS: Twenty patients suffering from chronic proximal patellar tendinopathy were enrolled into the study and split into two randomized groups (one or two infiltrations of PRP, respectively). The 3-month follow-up evaluation consisted of VAS, IKDC and VISA-P scores, along with algometer, isokinetic and ultrasounds evaluations. After 1 year, subjects were contacted to define their functional evolution. RESULTS: The concentration of the PRP used for each infiltration was similar in both groups, and contained no red or white cells. Results revealed no difference in treatment efficacy between the groups. CONCLUSIONS: The comparison between one or two infiltrations of PRP did not reveal any difference between the two groups at short to mid term. A second closely-timed infiltration of PRP to treat proximal patellar tendinopathies is not necessary to improve the efficacy of this treatment in the short term.

Gender effect on the scapular 3D posture and kinematic in healthy subjects.

Populations considered for shoulder analysis are often composed of various ratios of men and women. It is consequently hypothesized that gender has no significant effect on the joint kinematic. However, the literature reports, for the shoulder, differences in the range of motion between genders. The specific influence of gender on the scapulo-thoracic kinematics has not been studied yet. The dominant shoulder of two populations of men and women composed of 11 subjects each were evaluated in three dimensions for three distinct motions: flexion in the sagittal plane, abduction in the frontal plane and gleno-humeral internal/external rotation with the arm abducted at 90°. Posture, kinematics and range of motion were studied separately. For flexion and abduction and with regard to the scapular kinematic, external rotation was significantly larger for women than men. The differences were of at least 5° at 120° of humeral elevation. Upward rotations were identical. Women also showed larger average active humero-thoracic range of motion. The mean differences were of 13°, 7°, 12° and 5° for abduction, flexion, internal rotation and external rotation, respectively. No difference was observed between the scapular resting positions of both populations. The observed differences concerning both the scapular and humeral patterns would indicate that the shoulder behaviour of men and women should not be expected to be similar.

[Critical analysis of classical conservative treatments of tendinopathies]. / Analyse critique des traitements conservateurs classiques des tendinopathies.

Classic "passive" therapeutics (anti-inflammatory drugs, infiltrations of corticosteroids...) of tendinopathies, which are used relatively empirically, reduce pain and inflammation, without fundamentally changing the tendon structure. The eccentric rehabilitation has been applied to chronic tendinopathies, not only due to the failure of conventional therapies but also due to a better pathophysiological understanding of tendinopathies. Various studies underscore the effectiveness of eccentric rehabilitation which, after 20-30 sessions, leads to healing and especially prevents the risk of chronicity. Shockwave therapy, amending the tendinous structure, would lead to a long term healing.

[New conservative treatments of chronic tendinopathies]. / NOUVEAUX TRAITEMENTS CONSERVATEURS DES TENDINOPATHIES CHRONIQUES.

The pathophysiological mechanisms of tendinopathies integrate various intrinsic and extrinsic factors. Classic "passive" therapeutics have a limited action. Because of a better pathophysiological understanding of tendinopathies, more recent treatments (injections of various compounds, infiltrations of platelet-rich plasma, stem cells) would lead to a long-term healing. In case of failure of conservative managements and depending on the anatomical site, a surgical approach may be considered.

One injection of platelet-rich plasma associated to a submaximal eccentric protocol to treat chronic jumper's knee.

AIM: Jumper's knee is a frequent chronic overuse syndrome of the proximal part of the patellar tendon. Platelets contain lots of growth factors which could enhance the healing process of tendons. The aim of this study was to clarify the possible efficacy of one injection of Platelet-rich plasma (PRP) in cases of rebel jumper's knees. METHODS: Twenty patients with chronic proximal patellar tendinopathy were enrolled. Assessments were made before infiltration of PRP, and 6 weeks and 3 months after the infiltration, using a 10-point visual analogic scale of pain, clinical examinations with a pressure algometer, algofunctional scores (IKDC and VISA-P), functional assessments (isokinetic and optojump evaluations) and imagery (ultrasounds and MRI). The PRP was obtained with an apheresis system (COMTEC®, Fresenius-Kabi, Bad Homburg, Germany). Six millilitres of PRP were injected without local anesthetic. One week after infiltration, patients started a standardized sub-maximal eccentric reeducation. RESULTS: During daily activities pain significantly decreased with time. At functional evaluation, it decreased as well, but without significant functional improvement. No improvements in the imagery measurements were observed. Younger patients seemed to be more susceptible to have an improvement of pain by the PRP infiltration. CONCLUSION: This study demonstrates that a local infiltration of PRP associated with a submaximal eccentric protocol can improve symptoms of chronic jumper's knee in patients non-responsive to classical conservative treatments.

Isokinetic intervention in microtraumatic shoulder instability: an update.

AIM: Aim of the present study was to carry out a critical analysis of the use of isokinetic dynamometers for evaluation and rehabilitation in microtraumatic shoulder instability. METHODS: A non-systematic literature review was conducted on Medline using the following key words: "isokinetics", "shoulder instability", "evaluation", "rehabilitation". We also analyzed the related articles, and compiled a database of expert opinion. RESULTS: Despite a lack of consensus on testing modalities, lateral and medial rotator muscle strength can be safely and reliably assessed on isokinetic devices in subjects presenting with microtraumatic instability of the shoulder, before and after rehabilitation and/or surgery. There is considerable inter-individual variability in the results, leading to consider isokinetic testing as a useful examination before individualized rehabilitation. Its use as a muscle strengthening method in a global rehabilitation program seems interesting in order to correct rotator muscle strength deficiencies and/or asymmetries, which may be infra-clinical, even though strong scientific evidence is still lacking. CONCLUSION: Isokinetics is a safe tool for evaluation and seems to be effective in rehabilitation for microtraumatic instability of the shoulder. It would, however, be necessary to standardize practices thanks to rigorous clinical studies, so as to determine precisely the indications of this technique in the comprehensive management of shoulder instability.

Isokinetic assessment of the shoulder rotators: a study of optimal test position.

BACKGROUND: Isokinetic assessment of the shoulder rotator cuff is a common component of shoulder muscles assessment. Nevertheless, the extensive mobility of the shoulder poses great difficulty in finding a consensus protocol for evaluation. OBJECTIVE: To select an optimal protocol, among three, based on the best reproducibility and reliability of strength scores derived from internal and external rotator tests. METHOD: The dominant side external and internal rotator muscles of twelve healthy male subjects were evaluated based on a concentric protocol (60° s(-1) and 240° s(-1) ) in three different test positions: two in lying supine with the arm in either 90° or 45° abduction and one in the seated position with the arm moving in the scapular plane on the dominant shoulder. Subjects were tested twice over 10 days. RESULTS: The two lying installations were associated with the lowest coefficient of variation (7.1-11.8%) and smallest detectable difference (7-15.9 N.m) for peak moment and strength ratios. Consequently, the lying positions were chosen for rotators assessment with 90° of abduction associated with a higher reproducibility for the agonist/antagonist ratios or 45° if some pain was provoked. In any case, the coefficient of variation did not exceed 12%. CONCLUSION: Based on a reproducibility and reliability analysis, we recommend the testing of isokinetic strength of the shoulder rotators to be conducted in supine lying, with the arm at 90° or 45° abduction in the frontal plane.

Shoulder function after latissimus dorsi transfer in breast reconstruction.

BACKGROUND/AIMS: Latissimus dorsi (LD) transfer in the case of breast reconstruction remains frequently used because this muscle provides a good size source of tissue in reconstructive surgery. Given that, the consequences of the LD removal on shoulder function and the actual loss of maximal strength developed must be investigated. METHODS: Twenty women (50 ± 7.5 years old) were evaluated before surgery, 3 and 6 months after an unilateral transfer of a pedicle flap of LD muscle used for breast reconstruction. Women performed a bilateral shoulder isokinetic assessment [for the internal rotators (IRs) and external rotators and for the abductor and adductor (ADD) muscles] allowing the establishment of bilateral muscular deficit status and the study of agonist/antagonist muscle ratios. The algofunctional and clinical status of the shoulders was analysed by the means of Constant score and specific shoulder clinical tests. The women did not perform any specific strengthening of muscle shoulder after surgery. RESULTS: The isokinetic assessment showed a muscle weakness 3 and 6 months after LD transfer, mainly on the ADDs (33 ± 9% at 6 months) and on the IRs (16 ± 11% at 6 months). The Constant score significantly decreased after surgery on the operated shoulder. Women with a Constant score impairment showed pain during specific shoulder clinical tests. We also found a correlation between Constant score impairment and internal rotators weakness or rotator muscle imbalance. CONCLUSION: Given those results, we could advocate a specific shoulder strengthening after LD transfer, focused mainly on the IRs and ADDs.

Effect of the lengthening of the protocol on the reliability of muscle fatigue indicators.

The aim of this study was to examine absolute and relative reliability of fatigue measures calculated from peak torque or total work during 20, 30, 40 and 50 reciprocal maximal concentric contractions performed on an isokinetic dynamometer at 180 degrees x s(-1). Eighteen moderately active men performed 50 reciprocal maximal concentric contractions on three occasions with one 7-10 days recovery between each session. Peak torque and total work were computed for each contraction and subsequently summed to compute cumulated performance after respectively 20, 30, 40 and 50 repetitions. Muscle fatigue was determined after 20, 30, 40 and 50 repetitions by the fatigue index, the percent decrease in performance and the slope. Reliability of average peak torque or average total work was similar and was not affected by the lengthening of the protocol, although a learning effect was evident for knee flexors. Reliability of fatigue measures calculated from peak torque or total work was similar, improved with the lengthening of the protocol and was better for knee extensors. Measuring average peak torque or average total work and the slope during a protocol involving 30 maximal reciprocal concentric contractions appear to represent a better compromise between reliability and physiological interpretability of the data.