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1.  Hydrodilatation, corticosteroids and adhesive capsulitis: A randomized controlled trial 
Background
Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated.
Methods
In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial.
Results
The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0–100 scale. T-tests did not demonstrate any significant between-group differences in range of motion.
Conclusion
This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone.
Trial registration
The study is registered in Current Controlled Trials with the registration number ISRCTN90567697.
doi:10.1186/1471-2474-9-53
PMCID: PMC2374785  PMID: 18423042
2.  Lessons learnt from the painful shoulder; a case series of malignant shoulder girdle tumours misdiagnosed as frozen shoulder 
Adhesive capsulitis or frozen shoulder is a common condition characterized by shoulder pain and stiffness. In patients in whom conservative measures have failed, more invasive interventions such as arthrographic or arthroscopic distension can be very effective in relieving symptoms and improving range of movement. However, absolute contraindications to these procedures include the presence of neoplasia around the shoulder girdle. We present five cases referred to our institution where the diagnosis of shoulder joint malignancy was delayed, following prolonged, ineffective treatment for frozen shoulder. These cases highlight the importance of careful review of the radiology and the need for reconsideration of the diagnosis in refractory "frozen shoulder".
doi:10.1186/1477-7800-2-2
PMCID: PMC546198  PMID: 15647117
Frozen shoulder; adhesive capsulitis; hydrodilatation; distension; tumour
3.  Shoulder pain 
BMJ Clinical Evidence  2010;2010:1107.
Introduction
Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. About 1% of adults aged over 45 years consult their GP with a new presentation of shoulder pain every year in the UK. The aetiology of shoulder pain is diverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment, topical drug treatment, local injections, non-drug treatment, and surgical treatment? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 71 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, arthroscopic subacromial decompression, autologous whole blood injection, corticosteroids (oral, subacromial injection, or intra-articular injection), electrical stimulation, excision of distal clavicle, extracorporeal shock wave therapy, ice, laser treatment, manipulation under anaesthesia, suprascapular nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, physiotherapy (manual treatment, exercises), platelet-rich plasma injection, rotator cuff repair, shoulder arthroplasty, and ultrasound.
Key Points
Shoulder pain encompasses a diverse array of pathologies and can affect as many as one quarter of the population depending on age and risk factors. Shoulder pain may be due to problems with the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, or other soft tissues around the shoulder.
Rotator cuff problems are the most common source of shoulder pain, accounting for more than two-thirds of cases. Rotator cuff disorders are associated with musculoskeletal problems that affect the joints and muscles of the shoulder, cuff degeneration due to ageing and ischaemia, and overloading of the shoulder.
Frozen shoulder (adhesive capsulitis) accounts for 2% of cases of shoulder pain. Risk factors for frozen shoulder include female sex, older age, shoulder trauma and surgery, diabetes, and cardiovascular, cerebrovascular, and thyroid disease.
In many people, the cornerstone of treatment is achieving pain control to permit a return to normal functional use of the shoulder and encourage this with manual exercises. In people with acute post-traumatic tear, an early surgical option is warranted.
We don't know whether topical NSAIDs, oral corticosteroids, oral paracetamol, or opioid analgesics improve shoulder pain, although oral NSAIDs may be effective in the short term in people with acute tendonitis/subacromial bursitis. If pain control fails, the diagnosis should be reviewed and other interventions considered.
Physiotherapy may improve pain and function in people with mixed shoulder disorders compared with placebo.
Intra-articular corticosteroid injections may reduce pain in the short term compared with physiotherapy and placebo for people with frozen shoulder, but their benefit in the long term and when compared with local anaesthetic is unclear.
Platelet-rich plasma injections may improve the speed of recovery in terms of pain and function in people having open subacromial decompression for rotator cuff impingement, but further evidence is needed.
Acupuncture may not improve pain or function in people with rotator cuff impingement compared with placebo or ultrasound.
Extracorporeal shock wave therapy may improve pain in calcific tendonitis.
We found some evidence that suprascapular nerve block, laser treatment, and arthroscopic subacromial decompression may be effective in some people with shoulder pain.
We don't know whether autologous blood injections, intra-articular NSAID injections, subacromial corticosteroid injections, electrical stimulation, ice, ultrasound, rotator cuff repair, manipulation under anaesthesia, or shoulder arthroplasty are effective as we found insufficient evidence on their effects.
PMCID: PMC3217726  PMID: 21418673
4.  Frozen shoulder: A systematic review of therapeutic options 
World Journal of Orthopedics  2015;6(2):263-268.
Frozen shoulder is a common disease which causes significant morbidity. Despite over a hundred years of treating this condition the definition, diagnosis, pathology and most efficacious treatments are still largely unclear. This systematic review of current treatments for frozen shoulder reviews the evidence base behind physiotherapy, both oral and intra articular steroid, hydrodilatation, manipulation under anaesthesia and arthroscopic capsular release. Key areas in which future research could be directed are identified, in particular with regard to the increasing role of arthroscopic capsular release as a treatment.
doi:10.5312/wjo.v6.i2.263
PMCID: PMC4363808  PMID: 25793166
Frozen shoulder; Adhesive capsulitis; Bursitis; Shoulder; Arthroscopic capsular release; Arthrographic distension; Physiotherapy; Steroid; Hydrodilatation
5.  Responsiveness of the Shoulder Pain and Disability Index in patients with adhesive capsulitis 
Background
Instruments designed to measure the subjective impact of painful shoulder conditions have become essential in shoulder research. The Shoulder Pain and Disability Index (SPADI) is one of the most extensively used scales of this type. The objective of this study was to investigate reproducibility and responsiveness of the SPADI in patients with adhesive capsulitis.
Methods
SPADI test-retest reproducibility was estimated by the "intraclass correlation coefficient" (ICC) and the "smallest detectable difference" (SDD). Responsiveness was assessed by exploring baseline and follow-up data recorded in a recently reported clinical trial regarding hydrodilatation and corticosteroid injections in 76 patients with adhesive capsulitis. "Standardized response mean" (SRM) and "reliable change proportion" (RCP) for SPADI were compared with corresponding figures for shoulder range-of-motion (ROM). The relationship between SPADI and ROM change scores was investigated through correlation and linear regression analyses.
Results
Results for test-retest reproducibility indicated a smallest detectable difference of 17 points on the 0–100 scale, and an intraclass correlation coefficient of 0.89. The SPADI was generally more responsive than ROM. Weak to moderately strong associations were identified between SPADI and ROM change scores. According to the regression model, the three variables baseline SPADI, baseline active ROM and change in active ROM together explained 60% of the variance in SPADI improvement.
Conclusion
This study supports the use of SPADI as an outcome measure in similar settings.
doi:10.1186/1471-2474-9-161
PMCID: PMC2633286  PMID: 19055757
6.  Comparison of Sono-guided Capsular Distension with Fluoroscopically Capsular Distension in Adhesive Capsulitis of Shoulder 
Objective
To investigate the short-term effects and advantages of sono-guided capsular distension, compared with fluoroscopically guided capsular distension in adhesive capsulitis of shoulder.
Method
In this prospective, randomized, and controlled trial, 23 patients (group A) were given an intra-articular injection of a mixture of 0.5% lidocaine (9 ml), contrast dye (10 ml), and triamcinolone (20 mg); they received the injection once every 2 weeks, for a total of 6 weeks, under sono-guidance. Twenty-five patients (group B) were treated similarly, under fluoroscopic guidance. Instructions for the self-exercise program were given to all subjects, without physiotherapy and medication. Effects were then assessed using a visual numeric scale (VNS), and the shoulder pain and disability index (SPADI), as well as a range of shoulder motion examinations which took place at the beginning of the study and 2 and 6 weeks after the last injection. Incremental cost-effective ratio (ICER), effectiveness, preference, and procedure duration were evaluated 6 weeks post-injection.
Results
The VNS, SPADI, and shoulder motion range improved 2 weeks after the last injection and continued to improve until 6 weeks, in both groups. However, no statistical differences in changes of VNS, SPADI, ROM, and effectiveness were found between these groups. Patients preferred sono-guided capsular distension to fluoroscopically guided capsular distension due to differences in radiation hazards and positional convenience. Procedure time was shorter for sono-guided capsular distension than for fluoroscopically guided capsular distension.
Conclusion
Sono-guided capsular distension has comparable effects with fluoroscopically guided capsular distension for treatment of adhesive capsulitis of the shoulder. Sono-guided capsular distension can be substituted for fluoroscopic capsular distension and can be advantageous from the viewpoint of radiation hazard mitigation, time, cost-effectiveness and convenience.
doi:10.5535/arm.2012.36.1.88
PMCID: PMC3309313  PMID: 22506240
Sono-guided; Fluoroscopically; Capsular distension; Adhesive capsulitis
7.  Treatment of myofascial trigger points in common shoulder disorders by physical therapy: A randomized controlled trial [ISRCTN75722066] 
Background
Shoulder disorders are a common health problem in western societies. Several treatment protocols have been developed for the clinical management of persons with shoulder pain. However available evidence does not support any protocol as being superior over others. Systematic reviews provide some evidence that certain physical therapy interventions (i.e. supervised exercises and mobilisation) are effective in particular shoulder disorders (i.e. rotator cuff disorders, mixed shoulder disorders and adhesive capsulitis), but there is an ongoing need for high quality trials of physical therapy interventions. Usually, physical therapy consists of active exercises intended to strengthen the shoulder muscles as stabilizers of the glenohumeral joint or perform mobilisations to improve restricted mobility of the glenohumeral or adjacent joints (shoulder girdle). It is generally accepted that a-traumatic shoulder problems are the result of impingement of the subacromial structures, such as the bursa or rotator cuff tendons. Myofascial trigger points (MTrPs) in shoulder muscles may also lead to a complex of symptoms that are often seen in patients diagnosed with subacromial impingement or rotator cuff tendinopathy. Little is known about the treatment of MTrPs in patients with shoulder disorders.
The primary aim of this study is to investigate whether physical therapy modalities to inactivate MTrPs can reduce symptoms and improve shoulder function in daily activities in a population of chronic a-traumatic shoulder patients when compared to a wait-and-see strategy. In addition we investigate the recurrence rate during a one-year-follow-up period.
Methods/Design
This paper presents the design for a randomized controlled trial to be conducted between September 2007 – September 2008, evaluating the effectiveness of a physical therapy treatment for non-traumatic shoulder complaints. One hundred subjects are included in this study. All subjects have unilateral shoulder pain for at least six months and are referred to a physical therapy practice specialized in musculoskeletal disorders of the neck-, shoulder-, and arm.
After the initial assessment patients are randomly assigned to either an intervention group or a control-group (wait and see). The primary outcome measure is the overall score of the Dutch language version of the DASH (Disabilities of Arm, Shoulder and Hand) questionnaire.
Discussion
Since there is only little evidence for the efficacy of physical therapy interventions in certain shoulder disorders, there is a need for further research. We found only a few studies examining the efficacy of MTrP therapy for shoulder disorders. Therefore we will perform a randomised clinical trial of the effect of physical therapy interventions aimed to inactivate MTrPs, on pain and impairment in shoulder function in a population of chronic a-traumatic shoulder patients. We opted for an intervention strategy that best reflects daily practice. Manual high velocity thrust techniques and dry-needling are excluded. Because in most physical therapy interventions, blinding of the patient and the therapist is not possible, we will perform a randomised, controlled and observer-blinded study.
Trial Registration
This randomized clinical trial is registered at current controlled trials ISRCTN75722066.
doi:10.1186/1471-2474-8-107
PMCID: PMC2246010  PMID: 17983467
8.  Shoulder pain 
BMJ Clinical Evidence  2006;2006:1107.
Introduction
Shoulder pain covers a wide range of problems and affects up to 20% of the population. It is not a specific diagnosis. Shoulder pain can be caused by problems with the acromioclavicular joint, shoulder muscles, or referred pain from the neck. Rotator cuff problems account for 65-70% of cases of shoulder pain.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment; topical drug treatment; local injections; non-drug treatment; and surgical treatment? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2006 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 53 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: arthroscopic laser subacromial decompression, corticosteroid injections (intra-articular), corticosteroids (oral, subacromial injection), electrical stimulation, extracorporeal shock wave therapy, guanethidine (intra-articular), ice, laser treatment, manipulation under anaesthesia (plus intra-articular injection in people with frozen shoulder), multidisciplinary biopsychosocial rehabilitation, nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, phonophoresis, physiotherapy (manual treatment, exercises), surgical arthroscopic decompression, transdermal glyceryl trinitrate, ultrasound.
Key Points
Shoulder pain covers a wide range of problems and affects up to 20% of the population. It is not a specific diagnosis. Shoulder pain can be caused by problems with the acromioclavicular joint, shoulder muscles, or referred pain from the neck.
Rotator cuff problems account for 65-70% of cases of shoulder pain. Rotator cuff disorders are associated with musculoskeletal problems that affect the joints and muscles of the shoulder, cuff degeneration due to ageing and ischaemia, and overloading of the shoulder.
Adhesive capsulitis (frozen shoulder) accounts for 2% of cases of shoulder pain. Risk factors for frozen shoulder include female sex, older age, shoulder trauma and surgery, diabetes, and cardiovascular, cerebrovascular and thyroid disease.
In many people, the cornerstone of treatment is achieving pain control to allow appropriate physiotherapy to proceed. In people with acute post traumatic tear, an early surgical option is warranted.
We don't know whether oral or topical NSAIDs, oral paracetamol, opioid analgesics or transdermal glyceryl trinitrate improve shoulder pain. If pain control fails, the diagnosis should be reviewed and other interventions considered.
Physiotherapy improves pain and function in people with mixed shoulder disorders compared with placebo or sham laser treatment. Physiotherapy seems to be of similar efficacy to intra-articular or sub-acromial corticosteroid injections or surgical arthroscopic decompression over 6-12 months.
Intra-articular injections may be beneficial but only if accurately sited. Intra-articular corticosteroid injections may reduce pain in the short term compared with physiotherapy, but their benefit compared with placebo or local anaesthetic is unclear.Clinical outcome correlates with accuracy of injection, but even experienced clinicians may fail to locate the correct site in the majority of cases.
Suprascapular nerve blocks improve pain at 1 month in people with adhesive capsulitis and degenerative disease but we don't know whether it improves shoulder pain from other causes.
Extracorporeal shock wave therapy may improve pain in calcific tendonitis, and manipulation under anaesthesia may reduce symptoms of adhesive capsulitis, but neither intervention is beneficial in rotator cuff lesions.
PMCID: PMC2907630
9.  Adhesive capsulitis: a case report 
Adhesive capsulitis or frozen shoulder is an uncommon entity in athletes. However, it is a common cause of shoulder pain and disability in the general population. Although it is a self limiting ailment, its rather long, restrictive and painful course forces the affected person to seek treatment. Conservative management remains the mainstay treatment of adhesive capsulitis. This includes chiropractic manipulation of the shoulder, therapeutic modalities, mobilization, exercise, soft tissue therapy, nonsteroidal anti-inflammatory drugs, and steroid injections. Manipulation under anesthesia is advocated when the conservative treatment fails. A case of secondary adhesive capsulitis in a forty-seven-year-old female recreational squash player is presented to illustrate clinical presentation, diagnosis, radiographic assessment and conservative chiropractic management. The patient’s shoulder range of motion was full and pain free with four months of conservative chiropractic care.
Images
PMCID: PMC2485523
active release techniques; adhesive capsulitis; adult; chiropractic; frozen shoulder; manipulation; rehabilitation; racquest sports injury
10.  Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. 
BMJ : British Medical Journal  1998;316(7128):354-360.
OBJECTIVE: To review the efficacy of common interventions for shoulder pain. DESIGN: All randomised controlled trials of non-steroidal anti-inflammatory drugs, intra-articular and subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, and surgery for shoulder pain that were identified by computerised and hand searches of the literature and had a blinded assessment of outcome were included. MAIN OUTCOME MEASURES: Methodological quality (score out of 40), selection criteria, and outcome measures. Effect sizes were calculated and combined in a pooled analysis if study population, end point, and intervention were comparable. RESULTS: Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5-22). Selection criteria varied widely, even for the same diagnostic label. There was no uniformity in the outcome measures used, and their measurement properties were rarely reported. Effect sizes for individual trials were small (range -1.4 to 3.0). The results of only three studies investigating "rotator cuff tendinitis" could be pooled. The only positive finding was that subacromial steroid injection is better than placebo in improving the range of abduction (weighted difference between means 35 degrees (95% confidence interval 14 to 55)). CONCLUSIONS: There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable, and responsive in affected people.
PMCID: PMC2665551  PMID: 9487172
11.  The Frozen Shoulder: Myths and Realities 
Frozen shoulder is a common, disabling but self-limiting condition, which typically presents in three stages and ends in resolution. Frozen shoulder is classified as primary (idiopathic) or secondary cases. The aetiology for primary frozen shoulder remains unknown. It is frequently associated with other systemic conditions, most commonly diabetes mellitus, or following periods of immobilisation e.g. stroke disease. Frozen shoulder is usually diagnosed clinically requiring little investigation. Management is controversial and depends on the phase of the condition. Non-operative treatment options for frozen shoulder include analgesia, physiotherapy, oral or intra-articular corticosteroids, and intra-articular distension injections. Operative options include manipulation under anaesthesia and arthroscopic release and are generally reserved for refractory cases.
doi:10.2174/1874325001307010352
PMCID: PMC3785028  PMID: 24082974
Frozen shoulder; adhesive capsulitis; arthroscopic release
12.  Frozen shoulder: an arthrographic and radionuclear scan assessment. 
Annals of the Rheumatic Diseases  1984;43(3):365-369.
The diagnostic criteria and nomenclature used to describe the painful stiff shoulder remain confused. Arthrographic features of capsulitis have come to be accepted as characteristic of the frozen shoulder. Increased technetium uptake has also been noted. Both features have been considered to have possible prognostic and therapeutic importance. During a therapeutic study of strictly defined clinical frozen shoulder 35 of 38 patients showed increased technetium diphosphonate uptake in the affected shoulder in comparison with the opposite side. Of 36 patients who had arthrography 15 showed evidence of capsulitis, 11 rupture of the rotator cuff, and five no abnormality. Five tests failed owing to technical difficulty. There was no association between the technetium uptake and the arthrographic features, and neither was useful in predicting the rate or extent of recovery. Frozen shoulder of traumatic onset behaved no differently from that which arose spontaneously. We do not therefore consider that arthrography or technetium diphosphonate scanning performed at presentation contributes to the assessment of the painful stiff shoulder.
Images
PMCID: PMC1001346  PMID: 6742897
13.  General Practitioner Management of Shoulder Pain in Comparison with Rheumatologist Expectation of Care and Best Evidence: An Australian National Survey 
PLoS ONE  2013;8(4):e61243.
Objectives
To determine whether current care for common shoulder problems in Australian general practice is in keeping with rheumatologist expectations and the best available evidence.
Methods
We performed a mailed survey of a random sample of 3500 Australian GPs and an online survey of all 270 rheumatologists in Australia in June 2009. Each survey included four vignettes (first presentation of shoulder pain due to rotator cuff tendinopathy, acute rotator cuff tear in a 45 year-old labourer and early and later presentation of adhesive capsulitis). For each vignette, GPs were asked to indicate their management, rheumatologists were asked to indicate appropriate primary care, and we determined best available evidence from relevant Cochrane and other systematic reviews and published guidelines.
Results
Data were available for at least one vignette for 614/3500 (17.5%) GPs and 64 (23.8%) rheumatologists. For first presentation of rotator cuff tendinopathy, 69% and 82% of GPs and 50% and 56% rheumatologists would order a shoulder X-ray and ultrasound respectively (between group comparisons P = 0.004 and P<0001). Only 66% GPs and 60% rheumatologists would refer to an orthopaedic surgeon for the acute rotator cuff tear. For adhesive capsulitis, significantly more rheumatologists recommended treatments of known benefit (e.g. glucocorticoid injection (56% versus 14%, P<0.0001), short course of oral glucocorticoids (36% versus 6%, p<0.0001) and arthrographic distension of the glenohumeral joint (41% versus 19%, P<0.0001).
Conclusions
There is a mismatch between the stated management of common shoulder problems encountered in primary care by GPs, rheumatologist expectations of GP care and the available evidence.
doi:10.1371/journal.pone.0061243
PMCID: PMC3628939  PMID: 23613818
14.  Randomized Controlled Trial for Efficacy of Capsular Distension for Adhesive Capsulitis: Fluoroscopy-Guided Anterior Versus Ultrasonography-Guided Posterolateral Approach 
Annals of Rehabilitation Medicine  2014;38(3):360-368.
Objective
To find the most effective procedure to treat adhesive capsulitis of the shoulder, we evaluated the clinical effects of an ultrasonographic-guided anterior approach capsular distension and a fluoroscopy-guided posterolateral approach capsular distension. We expected the anterior approach to be better than the posterolateral approach because the rotator interval, a triangular anatomic area in the anterosuperior aspect of the shoulder, which is considered an important component of the pathology of adhesive capsulitis.
Methods
Participants were randomly assigned to two groups: 27 patients in group A were injected by an anterior approach with 2% lidocaine (5 mL), contrast dye (5 mL), triamcinolone (40 mg), and normal saline (9 mL) under fluoroscopic guidance in the operating room. Twenty-seven patients in group B were injected using a posterolateral approach with 2% lidocaine (5 mL), triamcinolone (40 mg), and normal saline (14 mL) under ultrasonographic guidance. After injection, all patients received physiotherapy four times in the first postoperative week and then two times each week for eight more weeks. Treatment effects were assessed using the shoulder pain and disability index (SPADI), visual numeric scale (VNS), passive range of motion (PROM), hand power (grip and pinch) at baseline and at one week, five and nine weeks after injection.
Results
SPADI, VNS, PROM, and hand power improved in one week, five and nine weeks in both groups. Statistically significant differences were not observed in SPADI, VNS, PROM, or hand power between groups.
Conclusion
Ultrasonography-guided capsular distension by a posterolateral approach has similar effects to fluoroscopy-guided capsular distension by an anterior approach.
doi:10.5535/arm.2014.38.3.360
PMCID: PMC4092177  PMID: 25024960
Adhesive capsulitis; Injection
15.  Recurrent Dislocation of the Shoulder Joint 
Dr. Anthony F. DePalma is shown. Photograph provided with kind permission of the Art Committee of Thomas Jefferson University, Philadelphia, PA.
Dr. DePalma was the first editor of Clinical Orthopaedics and Related Research, established by the recently formed Association of Bone and Joint Surgeons. The idea of forming the Association of Bone and Joint surgeons had been conceived by Dr. Earl McBride of Oklahoma City in 1947, and organized by a group of twelve individuals (Drs. Earl McBride, Garrett Pipkin, Duncan McKeever, Judson Wilson, Fritz Teal, Louis Breck, Henry Louis Green, Howard Shorbe, Theodore Vinke, Paul Williams, Eugene Secord, and Frank Hand) [9]. The first organizational meeting was held in conjunction with the 1949 Annual Meeting of the AAOS [9] and the first annual meeting held April 1–2, 1949 in Oklahoma City. Drs. McBride and McKeever invited Dr. DePalma to attend that meeting and join the society. According to DePalma, “Even at this small gathering, there were whisperings of the need of another journal to provide an outlet for the many worthy papers written on clinical and basic science subjects” [7]. The decision to form a new journal was finalized in 1951, and Drs. DePalma and McBride signed a contract with J.B. Lippincott Company. Dr. DePalma was designated Editor-in-Chief, and the journal became a reality in 1953 with the publication of the first volume. From the outset he established the “symposium” as a unique feature, in which part of the articles were devoted to a particular topic. Dr. DePalma served as Editor for 13 years until 1966, when he resigned the position and recommended the appointment of Dr. Marshall R. Urist. At his retirement, Clinical Orthopaedics and Related Research was well established as a major journal.
Dr. Anthony F. DePalma was born in Philadelphia in 1904, the son of immigrants from Alberona in central Foggia, Italy [1]. He attended the University of Maryland for his premedical education, then Jefferson Medical College, from which he graduated in 1929. He then served a two-year internship (common at the time) at Philadelphia General Hospital. Jobs were scarce owing to the Depression, and he felt fortunate to obtain in 1931 a position as assistant surgeon at the Coaldale State Hospital, in Coaldale, Pennsylvania, a mining town. However, he became attracted to orthopaedics and looked for a preceptorship (postgraduate training in specialties was not well developed at this time before the establishments of Boards). In the fall of 1932, he was appointed as a preceptor at the New Jersey Orthopaedic Hospital, an extension of the New York Orthopaedic Hospital. In 1939 he acquired Board certification (the first board examination was offered in 1935 for a fee of $25.00 [2]) and was appointed to the NJOH staff [1].
Dr. DePalma volunteered for military service in 1942, and served first at the Parris Island Naval Hospital in South Carolina, then on the Rixey, a hospital ship. In addition to serving to evacuate casualties to New Zealand, his ship was involved in several of the Pacific island assaults (Guam, Leyte, Okinawa). In 1945, he was assigned to the Naval Hospital in Philadelphia [1].
On his return to Philadelphia, he contacted staff members at Jefferson Medical College, including the Chair, Dr. James Martin, and became good friends with Dr. Bruce Gill (a professor of Orthopaedics at the University of Pennsylvania, and one of the earliest Presidents of the AAOS). After he was discharged from the service, he joined the staff of the Department of Orthopaedic Surgery at Jefferson, where he remained the rest of his career. He succeeded Dr. Martin as Chair in 1950, a position he held until 1970 when he reached the mandatory retirement age of 65. He closed his practice and moved briefly to Pompano Beach, Florida, but the lure of academia proved too powerful, and in January, 1971, he accepted the offer to develop a Division of Orthopaedics at the New Jersey College of Medicine and became their Chair. He committed to a five-year period, and then again moved to Pompano Beach, only to take the Florida State Boards and open a private practice in 1977. His practice grew, and he continued that practice until 1983 at the age of nearly 79. Even then he continued to travel and lecture [1].
We reproduce here four of his many contributions on the shoulder. The first comes from his classic monograph, “Surgery of the Shoulder,” published by J. B. Lippincott in 1950 [2]. In this article he describes the evolutionary development of the shoulder, focusing on the distinction between various primates, and relates the anatomic changes to upright posture and prehensile requirements. The remaining three are journal articles related to frozen shoulder [1], recurrent dislocation [3], and surgical anatomy of the rotator cuff [6], three of the most common shoulder problems then and now. He documented the histologic inflammation and degeneration in various tissues including the coracohumeral ligaments, supraspinatus tendon, bursal wall, subscapularis musculotendinous junction, and biceps tendon. Thus, the problem was rather more global than localized. He emphasized, “Manipulation of frozen shoulders is a dangerous and futile procedure.” For recurrent dislocation he advocated the Magnuson procedure (transfer of the subscapularis tendon to the greater tuberosity) to create a musculotendinous sling. All but two of 23 patients he treated with this approach were satisfied with this relatively simple procedure. (Readers will note the absence of contemporary approaches to ascertain outcomes and satisfaction. The earliest outcome musculoskeletal measures were introduced in the 60s by Larson [11] and then by Harris [10], but these instruments were physician-generated and do not reflect the rather more rigorously validated patient-generated outcome measures we use today. Nonetheless, the approach used by Dr. DePalma reflected the best existing standards of reporting results.) Dr. DePalma’s classic article, “Surgical Anatomy of the Rotator Cuff and the Natural History of Degenerative Periarthritis,” [6] reflected his literature review and dissections of 96 shoulders from 50 individuals “unaware of any (shoulder) disability” and mostly over the age of 40. By the fifth decade, most specimens began to show signs of rotator cuff tearing and he found complete tears in nine specimens from “the late decades.” He concluded,
“Based on the…observations, one can reasonably construct the natural history of periarthritis of the shoulder. It is apparent that aging is an important etiological factor, and with aging certain changes take place in the connective tissue elements of the musculotendinous cuff…it is also apparent that in slowly developing lesions of this nature compensating adjustments in the mechanics of the joint take place so that severe alterations in the mechanics of the joint do not appear. However, one must admit that such a joint is very vulnerable and, if subjected to minor trauma, the existing degenerative lesion would be extended and aggravated.”
Thus, he clearly defined the benign effects of rotator cuff tear in many aging individuals, but also the potential to create substantial pain and disability.
Dr. DePalma was a prolific researcher and writer. In addition to his “Surgery of the Shoulder,” he wrote three other books, “Diseases of the Knee: Management in Medicine and Surgery” (published by J.B. Lippincott in 1954) [4], “The Management of Fractures and Dislocations” (a large and comprehensive two volume work published by W.B. Saunders in 1959, and going through 5 reprintings) [5], and “The Intervertebral Disc” (published by W.B. Saunders in 1970, and written with his colleague, Dr. Richard Rothman) [8]. PubMed lists 62 articles he published from 1948 until 1992.
We wish to pay tribute to Dr. DePalma for his vision in establishing Clinical Orthopaedics and Related Research as a unique journal and for his many contributions to orthopaedic surgery.
References
DePalma A. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193–204.DePalma AF. Origin and comparative anatomy of the pectoral limb. In: DePalma AF, ed. Surgery of the Shoulder. Philadelphia: JB Lippincott; 1950:1–14.DePalma AF. Recurrent dislocation of the shoulder joint. Ann Surg. 1950;132:1052–1065.DePalma AF. Diseases of the Knee: Management in Medicine and Surgery. Philadelphia, PA: JB Lippincott Company; 1954.DePalma AF. The Management of Fractures and Dislocations—An Atlas. Philadelphia: WB Saunders Company; 1959.DePalma AF. Surgical anatomy of the rotator cuff and the natural history of degenerative periarthritis. Surg Clin North Am. 1963;43:1507–1520.DePalma AF. A lifetime of devotion to the Janus of orthopedics. Bridging the gap between the clinic and laboratory. Clin Orthop Relat Res. 1991;265:146–169.DePalma AF, Rothman RH. The Intervertebral Disc. Philadelphia: WB Saunders Company; 1970.Derkash RS. History of the Association of Bone and Joint Surgeons. Clin Orthop Relat Res. 1997;337:306–309.Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.
doi:10.1007/s11999-007-0105-3
PMCID: PMC2505210  PMID: 18264840
16.  Hydrodilatation (distension arthrography): a long‐term clinical outcome series 
Objectives
To describe and compare the medium to long‐term effectiveness of hydrodilatation and post‐hydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology.
Methods
Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2‐year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of “normal” function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures.
Results
A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2‐year follow‐up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2‐year follow‐up period. A significant improvement was observed in all outcomes measures over this period (p<0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used.
Conclusions
Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.
doi:10.1136/bjsm.2006.028431
PMCID: PMC2465214  PMID: 17178772
17.  A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder 
BMJ Open  2013;3(9):e003452.
Objectives
To elucidate the experiences and perceptions of people living with primary frozen shoulder and their priorities for treatment.
Design
Qualitative study design using semistructured interviews.
Setting
General practitioner (GP) and musculoskeletal clinics in primary and secondary care in one National Health Service Trust in England.
Participants
12 patients diagnosed with primary frozen shoulder were purposively recruited from a GP's surgery, community clinics and hospital clinics. Recruitment targeted the phases of frozen shoulder: pain predominant (n=5), stiffness predominant (n=4) and residual stiffness predominant following hospital treatment (n=2). One participant dropped out. Inclusion criteria: adult, male and female patients of any age, attending the clinics, who had been diagnosed with primary frozen shoulder.
Results
The most important experiential themes identified by participants were: pain which was severe as well as inexplicable; inconvenience/disability arising from increasing restriction of movement (due to pain initially, gradually giving way to stiffness); confusion/anxiety associated with delay in diagnosis and uncertainty about the implications for the future; and treatment-related aspects. Participants not directly referred to a specialist (whether physiotherapist, physician or surgeon) wanted a faster, better-defined care pathway. Specialist consultation brought more definitive diagnosis, relief from anxiety and usually self-rated improvement. The main treatment priority was improved function, though there was recognition that this might be facilitated by relief of pain or stiffness. There was a general lack of information from clinicians about the condition with over-reliance on verbal communication and very little written information.
Conclusions
Awareness of frozen shoulder should be increased among non-specialists and the best available information made accessible for patients. Our results also highlight the importance of patient participation in frozen shoulder research.
doi:10.1136/bmjopen-2013-003452
PMCID: PMC3787409  PMID: 24078753
Pain Management
18.  The Effectiveness of Intensive Mobilization Techniques Combined with Capsular Distension for Adhesive Capsulitis of the Shoulder 
Journal of Physical Therapy Science  2014;26(11):1767-1770.
[Purpose] The aim of this study was to determine the synergistic effect of intensive mobilization techniques combined with capsular distension for patients with adhesive capsulitis (AC). [Subjects] The subjects were 53 patients with AC (mean age, 56.0 ± 7.6 years). [Methods] Patients were randomized to one of four treatment groups: intensive mobilization after one steroid injection with capsular distension (IMSID); intensive mobilization (IM); one steroid injection with capsular distension (SID); and general physical therapy only (GPT). The IMSID, IM, and SID groups also received general physical therapy for 20 minutes. All treatments were performed twice per week for 4 weeks. Patients were assessed using the Shoulder Pain and Disability Index (SPADI), Constant-Murley Shoulder Function Assessment Score (CS), Active Range of Motion (AROM), and Verbal Numeric Score (VNS). [Results] There were significant post-intervention differences in all the measured values in each of the groups, except for external rotation ROM in the SID group. The IMSID group showed the greatest differences among the groups. There were significant differences among the means of all the groups. [Conclusion] The most effective treatment for AC was the combination of the intensive mobilization and steroid injection with capsular distension, which helped to control inflammation, extend joint space, and recover ROM.
doi:10.1589/jpts.26.1767
PMCID: PMC4242951  PMID: 25435696
Adhesive capsulitis; Intensive mobilization; Capsular distension
19.  Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial 
Annals of the Rheumatic Diseases  2004;63(3):302-309.
Objective: To determine whether arthrographic distension with a mixture of saline and steroid, in patients with painful stiff shoulder for at least 3 months, is better than placebo in improving function, pain, and range of motion at 3, 6, and 12 weeks.
Methods: A randomised, placebo controlled trial with participant and outcome assessor blinding in which shoulder joint distension with normal saline and corticosteroid was compared with placebo (arthrogram). Outcome measures, assessed at 3, 6, and 12 weeks, included a shoulder-specific disability measure (SPADI), a patient preference measure (Problem Elicitation Technique (PET)), pain, and range of active motion.
Results: From 96 potential participants, 48 were recruited. Four withdrew from the placebo group after the 3 week assessment and three subsequently received arthrographic distension with saline and steroid. At 3 weeks, significantly greater improvement in SPADI (p = 0.005), PET, overall pain, active total shoulder abduction, and hand behind back was found in participants in the joint distension and steroid group than in the placebo group. At 6 weeks the results of the intention to treat analysis favoured joint distension, although the between-group differences were only significant for improvement in PET (difference in mean change in PET between groups = 45.9 (95% CI 3.2 to 88.7). Excluding the four withdrawals, the between-group differences for the disability and pain measures significantly favoured distension over placebo. At 12 weeks, both the intention to treat analysis and an analysis excluding the four withdrawals demonstrated a significantly greater improvement in PET score for the distension group.
Conclusions: Short term efficacy of arthrographic distension with normal saline and corticosteroid over placebo was demonstrated in patients with painful stiff shoulder.
doi:10.1136/ard.2002.004655
PMCID: PMC1754915  PMID: 14962967
20.  Assessment of anterior shoulder instability by CT arthrography. 
Computed tomography (CT) immediately after double-contrast shoulder arthrography was taken in twenty-two young male patients with anterior shoulder instability including recurrent dislocation and subluxation. This recently developed technique called CT arthrography can provide significant information about patients with glenohumeral instability which is difficult to obtain by conventional arthrography. Information about glenoid labrum pathology is useful for proper management of the shoulder with instability. Lesions identified in this study include anterior labral defects (attenuation, tear, displacement), anterior capsular distension and/or detachment, Hill-Sachs lesion, anterior glenoid rim compression fracture, and fracture of scapula. This article describes the method used in CT arthrography of the glenohumeral joint, reviews the normal cross-sectional anatomy, and emphasizes the importance of the application of CT arthrography in the shoulder disorder with instability. CT arthrography of the glenohumeral joint is easy to perform, is accurate, and has lower radiation dose than arthrotomography.
PMCID: PMC3053628  PMID: 3268172
21.  A proposed protocol for hand and table sanitizing in chiropractic clinics and education institutions 
Abstract
Objective
By nature, chiropractic is a hands-on profession using manipulation applied to the joints with direct skin-to-skin contacts. Chiropractic tables are designed with a face piece to accommodate the prone patient's head in a neutral position and hand rests to allow for relaxed shoulders and upper spine so treatment is facilitated. The purpose of this article is to present a proposed guideline for hand and treatment table surface sanitizing for the chiropractic profession that is evidence-based and can easily be adopted by teaching institutions and doctors in the field.
Methods
A review of the chiropractic literature demonstrated that pathogenic microbes are present on treatment tables in teaching clinics at multiple facilities, yet no standardized protocols exist in the United States regarding table sanitizing and hand hygiene in chiropractic clinics or education institutions. This article reviews the scientific literature on the subject by using several search engines, databases, and specific reviews of documents pertaining to the topic including existing general guidelines.
Results
The literature has several existing guidelines that the authors used to develop a proposed protocol for hand and table sanitizing specific to the chiropractic profession. Recommendations were developed and are presented on hand hygiene and table sanitizing procedures that could lower the risk of infection for both clinical personnel and patients in chiropractic facilities.
Conclusion
This article offers a protocol for hand and table sanitizing in chiropractic clinics and education institutions. The chiropractic profession should consider adoption of these or similar measures and disseminate them to teaching clinics, institutions, and private practitioners.
doi:10.1016/j.jcm.2008.09.003
PMCID: PMC2697580  PMID: 19646384
Infection control; Primary prevention; Hand disinfection; Chiropractic
22.  Effectiveness of individualized physiotherapy on pain and functioning compared to a standard exercise protocol in patients presenting with clinical signs of subacromial impingement syndrome. A randomized controlled trial 
Background
Shoulder impingement syndrome is a common musculoskeletal complaint leading to significant reduction of health and disability. Physiotherapy is often the first choice of treatment although its effectiveness is still under debate. Systematic reviews in this field highlight the need for more high quality trials to investigate the effectiveness of physiotherapy interventions in patients with subacromial impingement syndrome.
Methods/Design
This randomized controlled trial will investigate the effectiveness of individualized physiotherapy in patients presenting with clinical signs and symptoms of subacromial impingement, involving 90 participants aged 18-75. Participants are recruited from outpatient physiotherapy clinics, general practitioners, and orthopaedic surgeons in Germany. Eligible participants will be randomly allocated to either individualized physiotherapy or to a standard exercise protocol using central randomization.
The control group will perform the standard exercise protocol aiming to restore muscular deficits in strength, mobility, and coordination of the rotator cuff and the shoulder girdle muscles to unload the subacromial space during active movements. Participants of the intervention group will perform the standard exercise protocol as a home program, and will additionally be treated with individualized physiotherapy based on clinical examination results, and guided by a decision tree. After the intervention phase both groups will continue their home program for another 7 weeks.
Outcome will be measured at 5 weeks and at 3 and 12 months after inclusion using the shoulder pain and disability index and patients' global impression of change, the generic patient-specific scale, the average weekly pain score, and patient satisfaction with treatment. Additionally, the fear avoidance beliefs questionnaire, the pain catastrophizing scale, and patients' expectancies of treatment effect are assessed. Participants' adherence to the protocol, use of additional treatments for the shoulder, direct and indirect costs, and sick leave due to shoulder complaints will be recorded in a shoulder log-book.
Discussion
To our knowledge this is the first trial comparing individualized physiotherapy based on a defined decision making process to a standardized exercise protocol. Using high-quality methodologies, this trial will add evidence to the limited body of knowledge about the effect of physiotherapy in patients with SIS.
Trial registration
Current Controlled Trials ISRCTN86900354
doi:10.1186/1471-2474-11-114
PMCID: PMC2889850  PMID: 20534140
23.  Curriculum mapping within an Australian master of chiropractic program: Congruence between published evidence for chiropractic and student assessment tasks 
Objective
This study sought to determine congruence between student assessment tasks within the master of chiropractic curriculum at Macquarie University and 2 separate but related domains: (1) disorders commonly presenting to chiropractors and (2) musculoskeletal conditions for which there is published evidence that chiropractic treatment is effective.
Methods
A literature review was undertaken to determine which musculoskeletal disorders commonly present to chiropractors and the conditions for which there is published evidence that chiropractic treatment is effective. These 2 domains were then mapped to the assessment tasks within the curriculum and analyzed. The proportion of time allocated to theory versus skill acquisition was also determined.
Results
Assessment tasks within the curriculum specifically focus on low back pain, neck pain, lower extremity pain, thoracic pain, and adhesive capsulitis. This curriculum mapping demonstrates congruence between the student assessment tasks and published evidence for chiropractic. The assessments also contain an appropriate balance between theory and skills acquisition.
Conclusion
There is congruence between the assessment tasks within the curriculum and the 2 domains against which it was mapped. Thus, completion of the curriculum provides training relevant to conditions that commonly present to chiropractors and musculoskeletal conditions for which chiropractic treatment is effective.
doi:10.7899/JCE-14-9
PMCID: PMC4360768  PMID: 25162981
Chiropractic; Curriculum; Education; Evaluation; Program
24.  Exercise Protocol for the Treatment of Rotator Cuff Impingement Syndrome 
Journal of Athletic Training  2010;45(5):483-485.
Abstract
Reference/Citation:
Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18(1):138–160.
Clinical Question:
What is the role of exercise in the treatment of rotator cuff impingement syndrome (RCIS), and what evidence-based exercises can be synthesized into a criterion-standard exercise rehabilitation protocol?
Data Sources:
Investigations were identified by PubMed, Ovid, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and Database of Abstracts of Reviews of Effects. The search terms included shoulder, impingement, rotator cuff, rehabilitation, physical therapy, physiotherapy, and exercise. Additional searches were performed with bibliographies of retrieved studies.
Study Selection:
To qualify for inclusion, studies had to be level 1 or level 2 (randomized controlled trials); had to compare rehabilitation interventions, such as exercise or manual therapy, with other treatments or placebo; had to include validated outcome measures of pain, function, or disability; and had to be limited to individuals with diagnosed impingement syndrome. Impingement syndrome was determined by a positive impingement sign per Neer or Hawkins criteria, or both. Articles were excluded if they addressed other shoulder conditions (eg, calcific tendinosis, full-thickness rotator cuff tears, adhesive capsulitis, osteoarthritis), addressed postoperative management, were retrospective studies or case series, or used other outcome measures.
Data Extraction:
An evidence-based journal club of 9 faculty members and fellows reviewed the articles and extracted and tabulated the data. Individual outcomes for pain, range of motion (ROM), strength, and function were organized. Intragroup and between-groups outcomes were assessed for the effectiveness of treatment, and statistical outcomes were recorded when available. Clinical importance was determined when statistical value was P < .05 and the effect size or difference between treatments was 20% or more. Sixa major categories were created to organize the components of the physical therapy programs used in each study: ROM, flexibility and stretching, strengthening techniques, therapist-driven manual therapy, modalities, and schedule. Components from these categories were used to create a synthesized physical therapy program.
Main Results:
The searches identified 80 studies, of which 11 met the inclusion criteria. In 5 studies, the diagnosis of RCIS was confirmed using an impingement test consisting of lidocaine injected into the subacromial space and elimination of pain with the impingement sign. Randomization methods were used in 6 studies, and blinded, independent examiners were involved in follow-up data collection in only 3 studies. Validated outcome measures were used in all studies. Follow-up was very good in 10 studies and was less than 90% in only 1 study. The specific exercise programs varied among studies. However, general treatment principles were identified among the different studies and included frequency, ROM, stretching or flexibility, strengthening, manual therapy (joint and/or soft tissue mobilizations), modalities, and others.
The findings indicated that exercise improves outcomes of pain, strength, ROM impairments, and function in patients with impingement syndrome. In 10 studies, investigators reported improvements in pain with supervised exercise, home exercise, exercise associated with manual therapy, and exercise after subacromial decompression. Of the 6 studies in which researchers compared pre-exercise pain with postexercise pain, 5 demonstrated that exercise produced statistically significant and clinically important reductions in pain. Two studies demonstrated improvements in pain when comparing exercise and control groups. In 1 study, investigators evaluated bracing without exercise and found no difference in pain between the brace and exercise groups. Investigators evaluated exercise combined with manual therapy in 3 studies and demonstrated improvement in pain relief in each study and improvement in strength in 1 study. In most studies, exercise also was shown to improve function. The improvement in function was statistically significant in 4 studies and clinically meaningful in 2 of these studies. In 2 studies, researchers compared supervised exercise with a home exercise program and found that function improved in both groups but was not different between groups. This finding might have resulted from a type II statistical error. In 4 studies, researchers did not find differences between acromioplasty with exercise and exercise alone for pain alone or for outcomes of pain and function.
Conclusions:
Findings indicated that exercise is beneficial for reducing pain and improving function in individuals with RCIS. The effects of exercise might be augmented with implementation of manual therapy. In addition, supervised exercise might not be more effective than a home exercise program. Many articles had methodologic concerns and provided limited descriptions of specific exercises, which made comparing types of exercise among studies difficult. Based on the results, Kuhn generated a physical therapy protocol using evidence-based exercise that could be used by clinicians treating individuals with impingement syndrome. This evidence-based protocol can serve as the criterion standard to reduce variables in future cohort and comparative studies to help find better treatments for patients with this disorder.
doi:10.4085/1062-6050-45.5.483
PMCID: PMC2938321  PMID: 20831395
function; subacromial impingement; rehabilitation
25.  Intra-articular Corticosteroid Injection for the Treatment of Idiopathic Adhesive Capsulitis of the Shoulder 
HSS Journal  2007;3(2):202-207.
Treatment for idiopathic adhesive capsulitis or frozen shoulder of the shoulder is controversial. The hypothesis of the study is that intra-articular corticosteroid injection in the early stages of idiopathic adhesive capsulitis will lead to a razpid resolution of stiffness and symptoms. This is a retrospective cohort study of only patients with stage 1 or stage 2 adhesive capsulitis. The diagnosis was made by history and physical examination and only when other causes of pain and motion loss were eliminated. Stage 1 adhesive capsulitis was defined as significant improvement in pain and normalization of motion following intra-articular injection. Stage 2 included patients who had significant improvement in pain and partial improvement in motion following injection. Seven patients with stage 1 and 53 patients with stage 2 comprised the baseline cohort. The mean age was 52 years (range: 30 to 78); 46 patients were female and nine patients had diabetes mellitus. Patients completed a physical examination as well as a shoulder rating questionnaire for symptoms and disability. Criteria for resolution were defined as forward flexion and external rotation to within 15° of the contralateral side and internal rotation to within three spinal levels of the contralateral side. Forty-four of the patients out of 60 met the criteria for recovery at a mean of 6.7 months. The mode and median time to recovery was 3 months. The mean score at final follow-up for 41 patients using the shoulder-rating questionnaire of L’Insalata was 90 (range 52–100). The mean time to recovery for the stage 1 patients was 6 weeks (range: 2 weeks to 3 months), and it was 7 months for stage 2 patients (range: 2 weeks to 2 years). Glenohumeral corticosteroid injection for early adhesive capsulitis may have allowed patients to recover motion at a median time of 3 months. In many cases, the patients had improvement prior to the 3-month mark; however, that was the routine time for follow-up. Patients with stage 1 disease tended to resolve more rapidly than stage 2 patients. Prompt recognition of stage 1 and stage 2 idiopathic adhesive capsulitis and early injection of corticosteroid with local anesthesia may be both diagnostic and therapeutic.
doi:10.1007/s11420-007-9044-5
PMCID: PMC2504264  PMID: 18751795

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