Rotator Interval vs Posterior Approach Ultrasound-guided Corticosteroid Injections in Primary Frozen Shoulder: A Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS). DATA SOURCES: A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted. STUDY SELECTION: Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS. DATA EXTRACTION: The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD). DATA SYNTHESIS: A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks. CONCLUSION: The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.

Use of Botulinum Toxin as a Treatment of Hemiplegic Shoulder Pain Syndrome: A Randomized Trial.

OBJECTIVE: The primary objective of this paper is to assess whether the use of 200 units of abobotulinum in the pectoralis major and subscapularis muscles modifies the pain complaint assessed using the visual analog scale in subjects with shoulder pain after the onset of spastic hemiplegia due to cerebrovascular disease when compared to the application of a placebo to the same muscles. DESIGN: A prospective, double-blind, randomized, and placebo-controlled clinical trial study in two different rehabilitation centers. SETTING: Two distinct outpatient neurological rehabilitation services. PARTICIPANTS: Patients older than 18 years who were included presented upper limb spasticity resulting from ischemic or hemorrhagic stroke and a diagnosis of Painful Hemiplegic Shoulder Syndrome (PHSS) that was independent of motor dominance. INTERVENTIONS: Patients were divided into two groups, one of them underwent the application of botulinum toxin (TXB-A) in the pectoralis major and subscapularis muscles, at a total dose of 400 U. MAIN OUTCOME MEASURE: Patients were assessed for a change in pain using the Visual Analog Scale (VAS) for at least 13 mm. RESULTS: An improvement in pain and spasticity levels in both groups, more intense in the toxin group, but without statistical significance. The comparison between the groups showed a reduction in pain by VAS (p = 0.52). CONCLUSIONS: The use of botulinum toxin in the subscapularis and pectoralis major muscles resulted in a reduction in shoulder pain in spastic hemiplegic patients without statistical significance.

Post Hoc Subgroup Analysis of the BCause Study Assessing the Effect of AbobotulinumtoxinA on Post-Stroke Shoulder Pain in Adults.

Botulinum toxin type A is approved for the focal treatment of spasticity; however, the effectiveness of abobotulinumtoxinA (aboBoNT-A) in patients with shoulder pain who have set reduced pain as a treatment goal is understudied. In addition, some patients encounter delays in accessing treatment programs; therefore, the suitability of aboBoNT-A for pain reduction in this population requires investigation. These factors were assessed in aboBoNT-A-naive Brazilian patients in a post hoc analysis of data from BCause, an observational, multicenter, prospective study (NCT02390206). Patients (N = 49, n = 25 female; mean (standard deviation) age of 60.3 (9.1) years; median (range) time since onset of spasticity of 16.1 (0-193) months) received aboBoNT-A injections to shoulder muscles in one or two treatment cycles (n = 47). Using goal attainment scaling (GAS), most patients achieved their goal of shoulder pain reduction after one treatment cycle (72.1%; 95% confidence interval: 57.2-83.4%). Improvements in GAS T-score from baseline, clinically meaningful reductions in pain score at movement, and clinically meaningful increases in passive shoulder abduction angle further improved with repeated treatment more than 4 months later, despite treatment starting at a median of 16.1 months after the onset of spasticity. These findings support the further investigation of aboBoNT-A injections in chronic post-stroke shoulder pain.

Effectiveness of subacromial injections in rotator cuff lesions: systematic review and meta-analysis protocol.

INTRODUCTION: Subacromial injections are therapeutic options for rotator cuff injuries, with consistent results not well established yet for each drug applied. The objective of this systematic review and meta-analysis is to analyse the effectiveness of the substances used in subacromial injections for the treatment of rotator cuff injuries and shoulder impingement syndrome, considering the functional gain and pain improvement of the shoulder. METHODS AND ANALYSIS: Beginning in November 2022, we will perform a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant grey literature (reference lists, conference abstracts and academic papers) will also be included.Two reviewers will independently screen and extract the information from the literature. Bias and quality of the included studies will be evaluated using the risk of bias assessment tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4 software. ETHICS AND DISSEMINATION: Approval and patient informed consent are not required because we will only include published literature. The results of this research will be disseminated in a peer-reviewed journal and likely through other scientific events. PROSPERO REGISTRATION NUMBER: CRD42020199292.

Anterior scalene plane block at the superior trunk level relieves referred shoulder pain after liver radiofrequency ablation: a technical report.

We report the first case of using an anterior scalene plane block at the superior trunk level achieving phrenic nerve blockade to treat intolerable referred shoulder pain after liver Radiofrequency Ablation (RFA) of a diaphragm-abutting liver tumor despite prevention with a full-dose non-steroidal anti-inflammatory drug. The anterior scalene plane block rapidly alleviated pain without significant complications.

The myofascial component of the pain in the painful shoulder of the hemiplegic patient.

OBJECTIVES: Poststroke shoulder pain occurs very frequently and compromises function and quality of life. Because treatment depends on a multidisciplinary approach, it is desirable to optimize effectiveness. Myofascial pain syndrome is defined by the presence of trigger points that can also be found in spastic stroke patients. The aim of this study was to evaluate the frequency of myofascial pain in the shoulder girdle muscles in patients with poststroke shoulder pain and to document the clinical and functional results obtained with specific treatment for this condition. METHODS: Spastic stroke hemiplegic patients undergoing rehabilitation at the Rehabilitation Center of the Hospital das Clínicas of the Ribeirão Preto Medical School of the University of São Paulo were evaluated regarding the intensity and characteristics of shoulder pain, previous therapeutic interventions, shoulder goniometry and the presence of trigger points. Patients underwent trigger point blockade by intramuscular infiltration of 1% lidocaine. The evaluation and treatment procedures were repeated in the subsequent 3 weeks as long as the pain intensity was greater than 5 on a visual analog scale (VAS). In the fourth week, the evaluation procedures were repeated. Patients who were in a multiprofessional rehabilitation program were instructed to continue the treatment, and the others received complementary therapeutic advice if necessary to initiate it. The evaluations were performed at 0, 1, and 3 weeks and after 4 months. RESULTS: Twenty-one patients (13 men; age=67.8±10.2 years; right hemiparesis: 11) participated in the study, and there was a reduction in pain assessed by VAS from baseline (7.6±2.7) to the first week (5.8±3.6; p<0.05) through the end of the third week (5.2±3.5; p<0.05), but not at the end of four months (6.6±2.9; p=0.11). Good responders had significantly lower pain levels after the third week and presented with a larger range of motion for passive abduction by the end of 4 months. These results demonstrate that the myofascial component of pain should be considered in poststroke shoulder pain and that its treatment may be a pathway for the rapid and long-lasting relief of symptoms. CONCLUSION: Trigger point blockade with lidocaine can reduce pain perception in spastic hemiplegic shoulder in as much as 50% of stroke survivors for four months.

The myofascial component of the pain in the painful shoulder of the hemiplegic patient

OBJECTIVES: Poststroke shoulder pain occurs very frequently and compromises function and quality of life. Because treatment depends on a multidisciplinary approach, it is desirable to optimize effectiveness. Myofascial pain syndrome is defined by the presence of trigger points that can also be found in spastic stroke patients. The aim of this study was to evaluate the frequency of myofascial pain in the shoulder girdle muscles in patients with poststroke shoulder pain and to document the clinical and functional results obtained with specific treatment for this condition. METHODS: Spastic stroke hemiplegic patients undergoing rehabilitation at the Rehabilitation Center of the Hospital das Clínicas of the Ribeirão Preto Medical School of the University of São Paulo were evaluated regarding the intensity and characteristics of shoulder pain, previous therapeutic interventions, shoulder goniometry and the presence of trigger points. Patients underwent trigger point blockade by intramuscular infiltration of 1% lidocaine. The evaluation and treatment procedures were repeated in the subsequent 3 weeks as long as the pain intensity was greater than 5 on a visual analog scale (VAS). In the fourth week, the evaluation procedures were repeated. Patients who were in a multiprofessional rehabilitation program were instructed to continue the treatment, and the others received complementary therapeutic advice if necessary to initiate it. The evaluations were performed at 0, 1, and 3 weeks and after 4 months. RESULTS: Twenty-one patients (13 men; age=67.8±10.2 years; right hemiparesis: 11) participated in the study, and there was a reduction in pain assessed by VAS from baseline (7.6±2.7) to the first week (5.8±3.6; p<0.05) through the end of the third week (5.2±3.5; p<0.05), but not at the end of four months (6.6±2.9; p=0.11). Good responders had significantly lower pain levels after the third week and presented with a larger range of motion for passive abduction by the end of 4 months. These results demonstrate that the myofascial component of pain should be considered in poststroke shoulder pain and that its treatment may be a pathway for the rapid and long-lasting relief of symptoms. CONCLUSION: Trigger point blockade with lidocaine can reduce pain perception in spastic hemiplegic shoulder in as much as 50% of stroke survivors for four months.

[Subacromial sodium hyaluronate injection for the treatment of chronic shoulder pain: A prospective series of eighty patients]. / Infiltración subacromial de ácido hialurónico en el tratamiento del dolor crónico de hombro. Serie prospectiva de 80 pacientes seguidos durante un año.

OBJECTIVE: Our purpose was to assess the effectiveness of hyaluronic acid infiltrations for chronic shoulder pain as an alternative to the non-surgical and surgical treatments that are currently available. MATERIAL AND METHODS: This is a prospective study of 80 consecutive patients suffering from chronic shoulder pain followed for twelve months. Five subacromial hyaluronic acid injections on five consecutive weeks were administrated to all patients. RESULTS: A significant improvement within the whole group after six months was observed. Constant score improved by 7.7 points, DASH questionnaire decreased by 5 points and Visual Analog Scale for pain decreased by 1.6 points. Patients with history of less than 24 months of pain responded better to treatment. Females responded better. Patients with decreased subacromial space or cuff tear in the MRI improved but patients diagnosed by the MRI of acromioclavicular osteoarthritis worsened in all scales assessed. DISCUSSION: Subacromial hyaluronic acid injections are specially effective in patients with history of less than 24 months of pain, a decreased subacromial space or partial or total cuff tear but, in our experience, its result is not good in patients with acromioclavicular osteoarthritis.

OBJETIVO: Nuestro objetivo fue evaluar la efectividad de las infiltraciones subacromiales de ácido hialurónico en el tratamiento del dolor crónico de hombro como alternativa a los tratamientos quirúrgicos y no quirúrgicos actualmente disponibles. MATERIAL Y MÉTODOS: Estudio prospectivo de 80 pacientes consecutivos con dolor crónico de hombro seguidos durante 12 meses. Se realizaron cinco infiltraciones subacromiales con ácido hialurónico durante cinco semanas consecutivas y se analizaron los resultados clínicos obtenidos. RESULTADOS: La puntuación en la escala de Constant mejoró en 7.7 puntos, el cuestionario DASH disminuyó en cinco puntos y la puntuación en la escala visual analógica para el dolor disminuyó 1.6 puntos por término medio. Los pacientes que presentaban dolor de menos de 24 meses de evolución respondieron mejor al tratamiento. Las mujeres respondieron mejor. Los pacientes con disminución del espacio subacromial o lesión del manguito rotador según la resonancia magnética mejoraron, pero los pacientes que mostraron signos de artrosis acromioclavicular en la resonancia empeoraron en todas las escalas evaluadas. DISCUSIÓN: Las infiltraciones subacromiales de ácido hialurónico son especialmente efectivas en el tratamiento del dolor crónico de hombro de menos de 24 meses de evolución, con disminución del espacio subacromial o lesión parcial o total del manguito rotador, pero en nuestra experiencia, su resultado no es bueno en pacientes con artrosis acromioclavicular.

Clinical Applications of Ultrasonography in the Shoulder and Elbow.

In the past 30 years, the use of ultrasonography in the field of orthopaedics has evolved. As ultrasonography has been refined, smaller machines with higher fidelity and better transducers have become available at a lower cost. Diagnostic and therapeutic applications of ultrasonography in the shoulder and elbow have expanded imaging options and provided alternatives to surgical management. Ultrasonography is a dynamic tool that affords immediate diagnostic assessment for clinical correlation and can be used for serial examinations and image guidance during therapeutic procedures. This imaging modality is highly reliable and accurate and may limit the need for costly imaging referrals, particularly in geographic areas where advanced imaging is not readily available. However, clinical expertise is paramount for ultrasonography, which is an operator-dependent modality. Ultrasonography is an effective educational resource; therefore, the curriculum in orthopaedic residency training programs should include education on this modality as the use of ultrasonography increases among orthopaedic surgeons.

Infiltración subacromial de ácido hialurónico en el tratamiento del dolor crónico de hombro. Serie prospectiva de 80 pacientes seguidos durante un año / Subacromial sodium hyaluronate injection for the treatment of chronic shoulder pain: A prospective series of eighty patients

Resumen: Objetivo: Nuestro objetivo fue evaluar la efectividad de las infiltraciones subacromiales de ácido hialurónico en el tratamiento del dolor crónico de hombro como alternativa a los tratamientos quirúrgicos y no quirúrgicos actualmente disponibles. Material y métodos: Estudio prospectivo de 80 pacientes consecutivos con dolor crónico de hombro seguidos durante 12 meses. Se realizaron cinco infiltraciones subacromiales con ácido hialurónico durante cinco semanas consecutivas y se analizaron los resultados clínicos obtenidos. Resultados: La puntuación en la escala de Constant mejoró en 7.7 puntos, el cuestionario DASH disminuyó en cinco puntos y la puntuación en la escala visual analógica para el dolor disminuyó 1.6 puntos por término medio. Los pacientes que presentaban dolor de menos de 24 meses de evolución respondieron mejor al tratamiento. Las mujeres respondieron mejor. Los pacientes con disminución del espacio subacromial o lesión del manguito rotador según la resonancia magnética mejoraron, pero los pacientes que mostraron signos de artrosis acromioclavicular en la resonancia empeoraron en todas las escalas evaluadas. Discusión: Las infiltraciones subacromiales de ácido hialurónico son especialmente efectivas en el tratamiento del dolor crónico de hombro de menos de 24 meses de evolución, con disminución del espacio subacromial o lesión parcial o total del manguito rotador, pero en nuestra experiencia, su resultado no es bueno en pacientes con artrosis acromioclavicular.

Abstract: Objective: Our purpose was to assess the effectiveness of hyaluronic acid infiltrations for chronic shoulder pain as an alternative to the non-surgical and surgical treatments that are currently available. Material and methods: This is a prospective study of 80 consecutive patients suffering from chronic shoulder pain followed for twelve months. Five subacromial hyaluronic acid injections on five consecutive weeks were administrated to all patients. Results: A significant improvement within the whole group after six months was observed. Constant score improved by 7.7 points, DASH questionnaire decreased by 5 points and Visual Analog Scale for pain decreased by 1.6 points. Patients with history of less than 24 months of pain responded better to treatment. Females responded better. Patients with decreased subacromial space or cuff tear in the MRI improved but patients diagnosed by the MRI of acromioclavicular osteoarthritis worsened in all scales assessed. Discussion: Subacromial hyaluronic acid injections are specially effective in patients with history of less than 24 months of pain, a decreased subacromial space or partial or total cuff tear but, in our experience, its result is not good in patients with acromioclavicular osteoarthritis.

[Evaluation of the pain in older people]. / Evaluación del dolor en el adulto mayor.

OBJECTIVE: To compare the information obtained of the percentage of improvement declared orally with the improvement marked in the visual analogical scale (VAS) in patients under and over 65 years of age. PATIENTS AND METHODS: Ninety-five individuals with acute shoulder pain (enthesitis) were evaluated. The subjects were requested to mark the pain intensity in the VAS before a treatment with corticosteroid injection in the shoulder and were evaluated again through the VAS one week after the procedure. They were also requested to declare orally the pain intensity. Then, the information was compared between patients aged under and over 65 years of age. RESULTS: 29.8% of those younger than 65 years, and 60.95% of those older than that age presented more than 10% difference between orally stated and calculated pain relief percentage based on the VSA. CONCLUSION: The difference between the orally stated and the calculated pain relief percentage based on the VSA was significantly higher in the group of those older than 65 years. This finding proved that the VAS is a poor method to evaluate pain relief in the senior population.

Comparar las informaciones obtenidas del porcentaje verbal de mejoría declarada verbalmente con la escala visual analógica (EVA) en personas con edad menor y mayor o igual de 65 años.

Evaluación del dolor en el adulto mayor / Evaluation of the pain in older people

Resumen: Objetivo: Comparar las informaciones obtenidas del porcentaje verbal de mejoría declarada verbalmente con la escala visual analógica (EVA) en personas con edad menor y mayor o igual de 65 años. Pacientes y métodos: Fueron evaluados 95 individuos con dolor agudo en el hombro (entesitis). Fue solicitado en cada uno de ellos medir la intensidad del dolor a través de la EVA tras un tratamiento médico con infiltración de corticosteroide en el hombro; fueron examinados una semana después, con una nueva medición de la intensidad del dolor verbalmente. Enseguida, las informaciones fueron comparadas entre pacientes con edad mayor o igual y menor de 65 años. Resultados: Se utilizó una diferencia de hasta 10% en módulo (valor absoluto) entre el porcentaje verbalmente declarado y el calculado con base en las medidas declaradas en la EVA. En los sujetos < 65 años, la frecuencia de casos donde la variación entre el porcentaje de mejoría verbalmente declarado y el calculado excede 10% fue de 29.8%; entre las personas ≥ 65 años la discrepancia ocurrió en 60.95%. Conclusión: El análisis de este estudio utilizó distintos métodos descriptivos e inferenciales para investigar las hipótesis levantadas; dentro de las herramientas empleadas, una confirma la hipótesis sobre los individuos ≥ 65 años y nos lleva a recomendar que el uso de la EVA para este grupo etario sea realizado con cautela y orientación.

Abstract: Objective: To compare the information obtained of the percentage of improvement declared orally with the improvement marked in the visual analogical scale (VAS) in patients under and over 65 years of age. Patients and methods: Ninety-five individuals with acute shoulder pain (enthesitis) were evaluated. The subjects were requested to mark the pain intensity in the VAS before a treatment with corticosteroid injection in the shoulder and were evaluated again through the VAS one week after the procedure. They were also requested to declare orally the pain intensity. Then, the information was compared between patients aged under and over 65 years of age. Results: 29.8% of those younger than 65 years, and 60.95% of those older than that age presented more than 10% difference between orally stated and calculated pain relief percentage based on the VSA. Conclusion: The difference between the orally stated and the calculated pain relief percentage based on the VSA was significantly higher in the group of those older than 65 years. This finding proved that the VAS is a poor method to evaluate pain relief in the senior population.

Resultados funcionales de la aplicación de toxina botulínica tipo A contra antiinflamatorios orales en la rehabilitación de síndrome de hombro doloroso por lesión del mango de los rotadores / Functional results of type a botulinum toxin versus oral antiinflammatory agents in the rehabilitation of painful shoulder syndrome caused by rotator cuff lesion

Las enfermedades del mango de los rotadores se caracterizan por signos inespecíficos, síntomas y alteraciones de la anatomía, su etiología es multifactorial y pueden abarcar desde tendinitis hasta rupturas masivas de espesor completo del tendón del manguito de los rotadores, las cuales comprometen la biomecánica normal del hombro afectado. Normalmente suceden en mayores de 40 años; sin embargo, el asociado a trauma depende del mecanismo de lesión y no tiene relación directa con la edad de aparición de los síntomas. Se han descrito factores vasculares en el daño al tendón del manguito de los rotadores, en patologías que afectan a la microcirculación; sin embargo, estudios recientes no han demostrado que el tendón bajo observación directa presente datos de hipovascularidad. La toxina botulínica tipo A realiza su acción mediante bloqueo de la liberación de acetilcolina en la placa neuromuscular; en las articulaciones provoca liberación de la tensión capsular así como la disminución de factores pro inflamatorios tales como la interleucina-1; aunque existen pocos artículos sobre su utilidad intraarticular, en los grupos musculares y tendinosos, además de tener un efecto miorrelajante existen diversas publicaciones que apoyan su utilidad en el manejo del dolor y su utilidad en la rehabilitación de este grupo de pacientes; en dosis bajas, ha sido ampliamente utilizada. Material y métodos: Se trata de un estudio prospectivo, experimental y longitudinal en el cual se realizó seguimiento a 24 pacientes con diagnóstico de síndrome de hombro doloroso demostrado por pruebas clínicas y de gabinete debido a lesiones del mango de los rotadores, sin criterios de reparación quirúrgica inmediata, o ya reparados, a los cuales a 12 pacientes se les aplicará toxina botulínica tipo A en el espacio subacromial de forma peri-tendón del tendón conjunto del manguito de los rotadores, así como en puntos de dolor y contractura muscular en hombro, con una dosis total de 200 UI de toxina botulínica tipo A, mientras que al grupo control, de 12 pacientes, se le administraron antiinflamatorios vía oral por seis semanas, tipo Cox 2, Celecoxib 100 mg cápsulas una cada 12 horas; a los dos grupos se les sometió a un programa de rehabilitación ya establecido, el cual fue supervisado cada dos semanas y hasta las seis semanas de evolución; se realizaron valoraciones subjetivas y objetivas valorando la presencia de dolor, el nivel funcional y la movilidad posible mediante la escala de valoración funcional de hombro de Constant y la escala visual análoga. Resultados: Grupo de Celecoxib Promedio de escala de Constant inicial fue de 60 puntos, el inmediato a la primera dosis se mantuvo en 60 puntos, a las dos semanas de tratamiento con Celecoxib se encontró un puntaje de Constant promedio de 66 puntos y a las seis semanas el promedio fue de 70.33 puntos, siendo el valor de la p > 0.005. Grupo de toxina botulínica 200 UI máximo en hombro afectado, 50 UI subacromial y 150 en puntos de dolor además de asociarlo a programa de ejercicios de rehabilitación supervisados en consultorio. El promedio de la escala de Constant inicial fue de 58 puntos, el inmediato a la primera dosis se elevó a 70.83 puntos, a las dos semanas posteriores a infiltración y seguimiento de ejercicios en consultorio fue de puntaje Constant promedio de 77.16 puntos y a las seis semanas el promedio fue de 78.5 puntos, siendo el valor de la p < 0.005 (p = 0.00045). En cuanto a la escala visual análoga se observó que en el grupo de Celecoxib existió una disminución de dicha escala a las seis semanas con una p < 0.005.

Rotator cuff conditions are characterized by unspecific signs, as well as anatomic alterations and symptoms. They have a multifactorial etiology and may include everything from tendinitis to massive, full thickness tears of the rotator cuff tendon that compromise the normal biomechanics of the involved shoulder. They usually occur in people over 40 years of age but lesions resulting from trauma may vary according to the mechanism of injury and are not directly related with the age at onset of symptoms. Vascular factors have been described as related with rotator cuff tendon damage in conditions affecting the microcirculation. However, recent studies have not proven that the tendon under direct observation shows hypovascularity. Type A botulinum toxin acts by blocking the release of acetylcholine in the neuromuscular plate; in the joints it releases capsular tension and reduces proinflammatory factors such as interleukin-1 (IL-1). There are only a few papers on its intraarticular benefit; in muscle and tendon groups it not only has a muscle relaxant effect, but several publications support its utility for pain management. It has been widely used in the rehabilitation of this group of patients at low doses. Material and methods: Prospective, investigational and longitudinal study involving the follow-up of 24 patients with a diagnosis of painful shoulder syndrome proven clinically and with imaging tests, and caused by rotator cuff lesions. The patients either did not meet the criteria for immediate surgical repair or had already undergone such a repair. Type A botulinum toxin was applied to 12 patients in the subacromial space around the rotator cuff conjoint tendon, as well as in the painful spots and in the muscle contracture in the shoulder. The total dose of Type A botulinum toxin was 200 IU. The control group, also composed of 12 patients, was given a COX-2 oral antiinflammatory agent for 6 weeks (Celecoxib, 100 mg BID). Both groups followed a pre-established rehabilitation program for a total of 6 weeks and were supervised every 2 weeks. Subjective and objective assessments were made including pain, performance level and possible mobility, using Constant's functional shoulder assessment and the visual analog scale (VAS). Results: Celecoxib group: Mean initial Constant scale score was 60; after the first dose it remained unchanged. After 2 weeks of treatment with Celecoxib the mean Constant score was 66; by 6 weeks it was 70.33, with p > 0.005. The botulinum toxin group received a maximum dose of 200 IU in the affected shoulder, 50 IU were administered subacromially and 150 in the painful spots. This treatment was combined with rehabilitation exercises supervised at the doctor's office. The mean initial Constant scale score was 58; immediately after the first dose it went up to 70.83. Two weeks after the injection and the supervision of rehabilitation exercises at the office, the mean Constant scale score was 77.16; at six weeks it was 78.5, with p < 0.005 (p = 0.00045). The VAS in the Celecoxib group decreased at six weeks with p < 0.005.

Intra-articular lidocaine for reduction of shoulder dislocation.

Anterior shoulder dislocation is the most common joint dislocation seen in the emergency department. Although emergency medicine providers use several techniques for reduction, each method is associated with potential discomfort for the patient. In addition, pain from the dislocated shoulder causes muscle spasm that impedes reduction. Therefore, both analgesia and procedural sedation are often used to reduce pain and enable reduction. Intra-articular injection of lidocaine has demonstrated efficacy in reduction of pain and facilitation of shoulder reduction compared with analgesia and sedation. Intra-articular lidocaine may also reduce time to successful reduction of shoulder dislocations.

[Functional results of type A botulinum toxin versus oral anti-inflammatory agents in the rehabilitation of painful shoulder syndrome caused by rotator cuff lesion]. / Resultados funcionales de la aplicación de toxina botuínica tipo A contra antiinflamatorios orales en la rehabilitación de síndrome de hombro doloroso por lesión del mango de los rotadores.

UNLABELLED: Rotator cuff conditions are characterized by unspecific signs, as well as anatomic alterations and symptoms. They have a multifactorial etiology and may include everything from tendinitis to massive, full thickness tears of the rotator cuff tendon that compromise the normal biomechanics of the involved shoulder. They usually occur in people over 40 years of age but lesions resulting from trauma may vary according to the mechanism of injury and are not directly related with the age at onset of symptoms. Vascular factors have been described as related with rotator cuff tendon damage in conditions affecting the microcirculation. However, recent studies have not proven that the tendon under direct observation shows hypovascularity. Type A botulinum toxin acts by blocking the release of acetylcholine in the neuromuscular plate; in the joints it releases capsular tension and reduces proinflammatory factors such as interleukin-1 (IL-1). There are only a few papers on its intraarticular benefit; in muscle and tendon groups it not only has a muscle relaxant effect, but several publications support its utility for pain management. It has been widely used in the rehabilitation of this group of patients at low doses. Material and methods: Prospective, investigational and longitudinal study involving the follow-up of 24 patients with a diagnosis of painful shoulder syndrome proven clinically and with imaging tests, and caused by rotator cuff lesions. The patients either did not meet the criteria for immediate surgical repair or had already undergone such a repair. Type A botulinum toxin was applied to 12 patients in the subacromial space around the rotator cuff conjoint tendon, as well as in the painful spots and in the muscle contracture in the shoulder. The total dose of Type A botulinum toxin was 200 IU. The control group, also composed of 12 patients, was given a COX-2 oral antiinflammatory agent for 6 weeks (Celecoxib, 100 mg BID). Both groups followed a pre-established rehabilitation program for a total of 6 weeks and were supervised every 2 weeks. Subjective and objective assessments were made including pain, performance level and possible mobility, using Constant's functional shoulder assessment and the visual analog scale (VAS). RESULTS: Celecoxib group: Mean initial Constant scale score was 60; after the first dose it remained unchanged. After 2 weeks of treatment with Celecoxib the mean Constant score was 66; by 6 weeks it was 70.33, with p > 0.005. The botulinum toxin group received a maximum dose of 200 IU in the affected shoulder, 50 IU were administered subacromially and 150 in the painful spots. This treatment was combined with rehabilitation exercises supervised at the doc tor's office. The mean initial Constant scale score was 58; immediately after the first dose it went up to 70.83. Two weeks after the injection and the supervision of rehabilitation exercises at the office, the mean Constant scale score was 77.16; at six weeks it was 78.5, with p < 0.005 (p = 0.00045). The VAS in the Celecoxib group decreased at six weeks with p < 0.005.

[Infusional therapy: an alternative for shouder pain post-laparoscopy]. / Terapia infusional: una alternativa en dolor de hombro post laparoscopia

INTRODUCTION: Neuraxial anesthesia in upper abdominal laparoscopic surgery decreases perioperative morbidity and mortality. However, shoulder pain is common and difficult to control. Use of a major opioid (e.g., fentanyl) for the control of this event may depress respiratory function. This is why we believe that a safe and effective therapeutic control of this disease pain is a multimodal analgesic scheme which we have called infusional therapy. OBJECTIVE: To compare various schemes for controlling shoulder pain secondary to pneumoperitoneum. METHODS: Nonrandomized clinical trial with 56 patients ASA I-II divided into four groups undergoing laparoscopic cholecystectomy. Group I (n= 15) managed with ketorolac 1 mg kg, group II (n = 12) ketoprofen 100 mg, group III (n = 14) ketoprofen 50 mg + 50 mg tramadol, and group IV (n = 15) ketoprofen 100 mg + 100 mg tramadol. The following ariables were analyzed: presence and intensity of pain, analgesia rescue and operative time. RESULTS: Group I had more shoulder pain events compared to other groups (p= 0.002) in the same way the group IV required less rescue analgesia (p= 0.034). CONCLUSION: preemptive analgesia to infusional therapy with ketoprofen-tramadol at doses of 100 mg each is safe for laparoscopic surgery.

Antecedentes: en cirugía laparoscópica del hemiabdomen superior la anestesia neuroaxial disminuye la morbilidad y mortalidad perioperatorias; sin embargo, el dolor de hombro es una afección frecuente de difícil control. Puesto que los fármacos opioides mayores (fentanilo) para el control del dolor deprimen la función respiratoria, consideramos que la terapia infusional es un tratamiento seguro y eficaz. Objetivo: comparar diversos esquemas analgésicos para el control del dolor de hombro secundario al neumoperitoneo. Material y método: ensayo clínico no aleatorizado, efectuado en 56 pacientes ASA I-II en cuatro grupos con colecistectomía laparoscópica. El grupo I (n= 15) se trató con ketorolaco 1 mg/kg, el grupo II (n= 12) con ketoprofeno 100 mg, el grupo III (n= 14) con ketoprofeno 50 mg más tramadol 50 mg, y el grupo IV (n= 15) con ketoprofeno 100 mg más tramadol 100 mg. Las variables analizadas fueron: dolor y su intensidad, analgesia de rescate y tiempo quirúrgico. Resultados: en el grupo I hubo más episodios de dolor de hombro que en el resto de los grupos (p= 0.002); el grupo IV requirió menos analgesia de rescate (p= 0.034). Conclusión: la analgesia preventiva con terapia infusional con ketoprofeno-tramadol, a dosis de 100 mg, es segura para pacientes intervenidos mediante cirugía laparoscópica.

[Reduction of omalgia in laparoscopic cholecystectomy: clinical randomized trial ketorolac vs ketorolac and acetazolamide]. / Reducción de omalgia en colecistectomía laparoscópica: ensayo clínico aleatorizado con ketorolaco vs ketorolaco y acetazolamida.

BACKGROUND: Laparoscopy cholecystectomy for the surgical treatment of cholelithiasis has been considered the gold standard. The referred pain to the shoulder (omalgia) may be present to 63% of the patients and limits outpatient management. OBJECTIVE: The study was to evaluate the usefulness of acetazolamide associated with ketorolac for reduction of the omalgia to minimally invasive treatment. METHODS: We performed a clinical trial, randomized, double blind in patients undergoing laparoscopic cholecystectomy to assess the reduction of post-operative omalgia comparing ketorolac and ketorolaco+acetazolamida. 31 patients in each group were studied. The study group: 250 mg of acetazolamide before anesthetic induction and 30 mg of ketorolac in the immediate postoperative period. CONTROL GROUP: one tablet of placebo prior to the anesthetic induction and 30 mg of ketorolac in the immediate postoperative. The presence of omalgia was assessed using the analog visual scale. The variables recorded included: age, sex, flow of carbon dioxide intra-abdominal pressure, surgical time, urgent or elective surgery, omalgia, severity of pain evaluated by analog visual scale, addition analgesia. RESULTS: Both groups were homogeneous and statistical analysis showed no differences in the variables studied. The omalgia in the study group was presented at 9.67% and in the group control was the 58.06% (p < 0.001). CONCLUSION: 250 mg oral acetazolamide associated 30 mg of ketorolac reduces significantly the development of omalgia in patients undergoing laparoscopic cholecystectomy.

Antecedentes: la colecistectomía laparoscópica es el patrón de referencia del tratamiento de la colelitiasis sintomática. El 63% de los pacientes operados sufre dolor postquirúrgico referido al hombro (omalgia), circunstancia que limita el tratamiento ambulatorio. Objetivo: evaluar la utilidad de la acetazolamida asociada con ketorolaco para disminuir la omalgia consecutiva al tratamiento de mínima invasión. Material y métodos: ensayo clínico, aleatorizado, doble ciego realizado en pacientes a quienes se efectuó colecistectomía laparoscópica para evaluar la reducción de la omalgia postoperatoria y comparar el efecto de ketorolaco y ketorolaco más acetazolamida. En cada grupo se estudiaron 31 pacientes. El grupo de estudio recibió 250 mg de acetazolamida antes de la inducción anestésica, y 30 mg de ketorolaco en el postoperatorio inmediato. El grupo control recibió una tableta de placebo antes de la inducción anestésica, y 30 mg de ketorolaco en el postoperatorio inmediato. La omalgia se evaluó con la escala visual análoga. Las variables estudiadas incluyeron: edad, sexo, flujo de dióxido de carbono, presión intrabdominal, tiempo quirúrgico, cirugía electiva o urgente, omalgia, intensidad del dolor evaluada con la escala visual análoga y analgesia de rescate. Resultados: los grupos estudiados fueron homogéneos, el análisis estadístico no mostró diferencias en las variables estudiadas. En el grupo de estudio la omalgia coexistió en 9.67% de los pacientes y en el grupo control en 58.06% (p < 0.001). Conclusión: la administración por vía oral de 250 mg de acetazolamida y 30 mg de ketorolaco redujo significativamente la omalgia en los pacientes a quienes se realizó colecistectomía laparoscópica.

Aplicación de farmacopuntura en afecciones dolorosas del hombro / Application pharmacopuncture in painful affections of the shoulder

Se realizó un estudio experimental, tipo ensayo clínico controlado, en el período comprendido entre enero del 2007 hasta enero del 2008, con el fin de comparar la respuesta al tratamiento con farmacopuntura en el hombro doloroso con respecto al bloqueo del nervio supraescapular y proponer un algoritmo de tratamiento. La muestra quedó constituida por 60 pacientes, los cuales fueron aleatorizados y divididos en dos grupos, a uno se le realizó bloqueo del nervio supraescapular con betametasona y lidocaína al 2 por ciento en dosis habituales y al otro grupo se les aplicó farmacopuntura con pequeñas dosis de betametasona diluida con agua para inyección. El tratamiento fue aplicado dos veces por semana y hasta seis sesiones como máximo. Se evaluaron semanalmente por un equipo de trabajo teniendo en cuenta el criterio del paciente según la escala visual análoga, según criterio médico basado en el examen clínico, explorándose el dolor, la limitación de la movilidad articular y el balance funcional . Se observó una evolución satisfactoria más rápida en los pacientes tratados con farmacopuntura. El tratamiento con farmacopuntura en el hombro doloroso es de alta eficacia frente al bloqueo del nervio supraescapular.

We carried out an experimental, longitudinal and prospective study, at the Provincial Centre for the Development of Natural and Traditional Medicine Dr Mario E Dihigo, during the period from January 2007 to January 2008, with the objective of treating the increased incidence of patients with painful affections of the shoulder, requiring in many cases the usage of long, risk treatments, with results not always satisfactory. The sample was formed by 60 patients who were randomized and divided in two groups. A blockade of the supraescapular nerve with betamethasone and lidocain 2 per cent in habitual doses was applied to one group; the second one received pharmacopuncture with low doses of betamethasone diluted in water for injection. The treatment was applied 2 times a week and up to the maximum of 6 sessions. They were evaluated weakly for a working group, taking into account the patient's criteria according to the visual analogous scale, according to the medical criteria based on the clinical examination looking for pain, joint mobility limitation and functional balance. Among the studied patients there was a predominance of the female sex beginning from the third and fourth decades of life. Tendinitis of the rotator cuff was the most frequent diagnosis. There was a faster satisfactory recovery in patients treated with pharmacopuncture. Pharmacopuncture therapy in painful shoulder is of higher efficacy than the blockade of the supraescapular nerve.

Methylprednisolone versus triamcinolone in painful shoulder using ultrasound-guided injection.

There is little evidence about the comparative efficacy of corticosteroids in the treatment of painful shoulder. The main aim was to compare the efficacy of methylprednisolone (MTP) versus triamcinolone (TMC) in the treatment of painful shoulder using an ultrasound-guided injection. Patients with painful shoulder due to subacromial bursitis and partial or full-thickness rotator cuff tears demonstrated by musculoskeletal ultrasound received a guided-injection of MTP acetate 40 mg (12 patients) or TMC acetonide 40 mg (12 patients). Range of motion and pain visual analogue scale were registered at 10 and 30 min, 1 and 2 weeks postinjection. Two weeks postinjection, both groups reported a mean improvement in range of motion (33%) and relief of pain (61%). Relief of pain of 50% or more was observed in 92% of patients in MTP group and 50% of TMC group (p = 0.02). Two months postinjection, 50% of the patients in MTP group and 25% in TMC group reported total relief of pain (p = 0.3). Patients with painful shoulder receiving an ultrasound-guided injection of MTP or TMC have a rapid and sustained overall response. Relief of pain tends to be more rapid with MTP than TMC.