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1.  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".
PMCID: PMC546198  PMID: 15647117
Frozen shoulder; adhesive capsulitis; hydrodilatation; distension; tumour
2.  Hydrodilatation, corticosteroids and adhesive capsulitis: A randomized controlled trial 
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.
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.
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.
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.
PMCID: PMC2374785  PMID: 18423042
3.  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.
PMCID: PMC3785028  PMID: 24082974
Frozen shoulder; adhesive capsulitis; arthroscopic release
4.  Responsiveness of the Shoulder Pain and Disability Index in patients with adhesive capsulitis 
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.
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 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.
This study supports the use of SPADI as an outcome measure in similar settings.
PMCID: PMC2633286  PMID: 19055757
5.  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.
PMCID: PMC1001346  PMID: 6742897
6.  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
7.  Hydrodilatation (distension arthrography): a long‐term clinical outcome series 
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.
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.
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.
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.
PMCID: PMC2465214  PMID: 17178772
8.  Chiropractic management of shoulder pain and dysfunction of myofascial origin using ischemic compression techniques 
Shoulder pain and dysfunction is a chief complaint commonly presenting to a chiropractor's office. The purpose of this article is to review the most common etiologies of shoulder pain, focusing on those conditions of a myofascial origin. In addition to a review of the literature, the author draws upon his own clinical experience to describe a method to diagnose and manage, patients with shoulder pain of myofascial origin using ischemic compression techniques. This hands-on therapeutic approach conveys several benefits including: positive therapeutic outcomes; a favorable safety profile and; it is minimally strenuous on the doctor and well tolerated by the patient.
PMCID: PMC2504982
shoulder pain; dysfunction; myofascial pain syndromes; ischemic compression; chiropractic
9.  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
10.  Shoulder pain 
Clinical Evidence  2010;2010:1107.
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).
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.
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
11.  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.
PMCID: PMC2485523
active release techniques; adhesive capsulitis; adult; chiropractic; frozen shoulder; manipulation; rehabilitation; racquest sports injury
12.  Chiropractic Management of a 46-Year-Old Type 1 Diabetic Patient with Upper Crossed Syndrome and Adhesive Capsulitis 
Journal of Chiropractic Medicine  2004;3(4):138-144.
To discuss the treatment of a patient with type 1 diabetes presenting with chronic neck and shoulder pain by using chiropractic manipulation and an active rehabilitation program with emphasis on correcting postural imbalances.
Clinical Features
A 46-year-old insulin dependant (type1) diabetic female presented with neck and right shoulder pain of 6 to 8 months duration. Her history included similar left-sided complaints 2 years prior at which time she underwent 3 months of rehabilitation at a local medical center, which improved her condition. Over time her pain resolved but the residuals of restricted left shoulder range of motion remained. The patient had postural changes consisting of forward head posture, rounded shoulders and internally rotated arms.
Intervention and Outcome
Treatment included spinal manipulation, ultrasound and active rehabilitation consisting of at home exercises initially and followed with in office low-tech rehabilitation. Rehabilitation was primarily aimed at improving postural abnormalities, muscle imbalances and abnormal movement patterns. The patient improved with this course of treatment.
Chiropractic care including active rehabilitation may be helpful in treating diabetic patients suffering from chronic neck and shoulder problems.
PMCID: PMC2647023  PMID: 19674636
Manipulation, Chiropractic; Neck Pain; Shoulder Pain; Diabetes; Posture, Rehabilitation
13.  Comparison of Sono-guided Capsular Distension with Fluoroscopically Capsular Distension in Adhesive Capsulitis of Shoulder 
To investigate the short-term effects and advantages of sono-guided capsular distension, compared with fluoroscopically guided capsular distension in adhesive capsulitis of shoulder.
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.
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.
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.
PMCID: PMC3309313  PMID: 22506240
Sono-guided; Fluoroscopically; Capsular distension; Adhesive capsulitis
14.  Chiropractic management of frozen shoulder syndrome using a novel technique: a retrospective case series of 50 patients 
Journal of Chiropractic Medicine  2012;11(4):267-272.
The purpose of this case series is to describe the treatment and outcomes of a series of patients presenting with frozen shoulder syndrome who received a novel chiropractic approach (OTZ Tension Adjustment).
The files of 50 consecutive patients who presented to a private chiropractic practice with frozen shoulder syndrome were reviewed retrospectively. Two primary outcomes were extracted from the files for initial examination and at final evaluation: (1) the 11-point numeric pain rating scale and (2) the percentage change in shoulder abduction. Each patient received a series of chiropractic manipulative procedures that focused on the cervical and thoracic spine.
Of the case files reviewed, 20 were male and 30 were female; and all were between the ages of 40 and 70 years. The median number of days under care was 28 days (range, 11 to 51 days). The median change in Numeric Pain Rating Scale score was − 7 (range, 0 to − 10). Of the 50 cases, 16 resolved completely (100% improvement), 25 showed 75% to 90% improvement, 8 showed 50% to 75% improvement, and 1 showed 0% to 50% improvement.
Most patients with frozen shoulder syndrome in this case series appeared to improve with the chiropractic treatment.
PMCID: PMC3706702  PMID: 23843759
Shoulder; Adhesive capsulitis; Chiropractic; Musculoskeletal manipulations
15.  Hallux rigidus: A case report of successful chiropractic management and review of the literature 
To describe a common musculoskeletal disorder from a chiropractic management prospective, subsequently to stimulate further research into the chiropractic therapeutic effects on such cases and to contribute to chiropractic literature.
Clinical Features
A 27-year-old, 76” male student often involved in athletic activities, had a sudden onset of continuous localized pain in the medial aspect of the mid and forefoot on the right side for 1-and-a half months. The onset of pain was related to an accidental injury while playing basketball. The pain worsened every time during and after playing basketball and other weight-bearing activities such as walking upstairs and is palliated with physical rest. He tried Biofreeze and ice application for several times immediately after the injuries which help to some extent to relieve pain and swelling, but he did not seek any other professional care. The condition had been improving slowly even before he came to the clinic although the patient described the pain as 5/10 on the Borg pain scale when he came to the clinic for the first time. The characteristic local findings were a mildly hyper-pronated right foot, mildly asymmetric soft-tissue and bony contours, tenderness, stiffness and decreased range of motion (ROM) at the first metatarsophalangel and adjacent joints on the medial aspect of the midfoot decreased fluid motions in the concerned joints on the chiropractic evaluation and some abnormal wearing in the shoes.
Intervention and Outcome
He was managed with chiropractic manipulation combined with other conservative measures. Range of motion (ROM), Borg Pain Scale and an orthopedic test (Morton's Test) were used as the outcome measures. The subject showed a favorable response to the conservative (chiropractic) care.
Although hallux rigidus is one of the most common musculoskeletal degenerative conditions, our conservative management received a favorable response but there has been little discussion about it in chiropractic literature. It can be hypothesized that the progress of Hallux Rigidus (HR) can be reversed or halted by chiropractic management provided it is started at the early stage of the disease.
PMCID: PMC2646982  PMID: 19674618
Hallux Rigidus; Degenerative Joint Disease; First Metatarsophalangeal Disorders; Chiropractic Manipulation; Rehabilitation
16.  Magnetic resonance imaging in glenohumeral instability 
World Journal of Radiology  2011;3(9):224-232.
The glenohumeral joint is the most commonly dislocated joint of the body and anterior instability is the most common type of shoulder instability. Magnetic resonance (MR) imaging, and more recently, MR arthrography, have become the essential investigation modalities of glenohumeral instability, especially for pre-procedure evaluation before arthroscopic surgery. Injuries associated with glenohumeral instability are variable, and can involve the bones, the labor-ligamentous components, or the rotator cuff. Anterior instability is associated with injuries of the anterior labrum and the anterior band of the inferior glenohumeral ligament, in the form of Bankart lesion and its variants; whereas posterior instability is associated with reverse Bankart and reverse Hill-Sachs lesion. Multidirectional instability often has no labral pathology on imaging but shows specific osseous changes such as increased chondrolabral retroversion. This article reviews the relevant anatomy in brief, the MR imaging technique and the arthrographic technique, and describes the MR findings in each type of instability as well as common imaging pitfalls.
PMCID: PMC3194043  PMID: 22007285
Shoulder joint; Instability; Magnetic resonance imaging; Magnetic resonance arthrogram
17.  A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder 
BMJ Open  2013;3(9):e003452.
To elucidate the experiences and perceptions of people living with primary frozen shoulder and their priorities for treatment.
Qualitative study design using semistructured interviews.
General practitioner (GP) and musculoskeletal clinics in primary and secondary care in one National Health Service Trust in England.
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.
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.
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.
PMCID: PMC3787409  PMID: 24078753
Pain Management
18.  A proposed protocol for hand and table sanitizing in chiropractic clinics and education institutions 
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.
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.
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.
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.
PMCID: PMC2697580  PMID: 19646384
Infection control; Primary prevention; Hand disinfection; Chiropractic
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.
PMCID: PMC1754915  PMID: 14962967
20.  The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends 
Chiropractors, physiotherapists, and osteopaths receive training in the diagnosis and management of musculoskeletal conditions. As a result there is considerable overlap in the types of conditions that are encountered clinically by these practitioners. In Australia, the majority of benefits paid for these services come from the private sector. The purpose of this article is to quantify and describe the development in service utilization and the cost of benefits paid to users of these healthcare services by private health insurers. An exploration of the factors that may have influenced the observed trends is also presented.
A review of data from the Australian Bureau of Statistics, Australian Health Practitioner Regulation Agency, and the Australian Government Private Health Insurance Administration Council was conducted. An analysis of chiropractic, physiotherapy and osteopathic service utilisation and cost of service utilisation trend was performed along with the level of benefits and services over time.
In 2012, the number of physiotherapists working in the private sector was 2.9 times larger than that of chiropractic, and 7.8 times that of the osteopathic profession. The total number of services provided by chiropractors, physiotherapists, and osteopaths increased steadily over the past 15 years. For the majority of this period, chiropractors provided more services than the other two professions. The average number of services provided by chiropractors was approximately two and a half times that of physiotherapists and four and a half times that of osteopaths.
This study highlights a clear disparity in the average number of services provided by chiropractors, physiotherapists, and osteopaths in the private sector in Australia over the last 15 years. Further research is required to explain these observed differences and to determine whether a similar trend exists in patients who do not have private health insurance cover.
PMCID: PMC3896731  PMID: 24428934
Chiropractic; Physiotherapy; Osteopathy; Allied health; Healthcare utilisation
21.  Attitudes of clinicians at the Canadian Memorial Chiropractic College towards the chiropractic management of non-musculoskeletal conditions 
The objective of this study was to determine the attitudes of clinical faculty during the 2009–2010 academic year at the Canadian Memorial Chiropractic College towards the treatment of various non-musculoskeletal disorders.
A confidential survey was distributed to the clinical faculty via email. It consisted of several questions polling the demographic of the respondent such as years in clinical practice, and a list of 29 non-musculoskeletal conditions. Clinicians were asked to indicate their opinions on each condition on rating scale ranging from strongly agree to strongly disagree.
Twenty of 22 clinicians responded. The conditions garnering the greatest positive ratings include: asthma, constipation, chronic pelvic pain, dysmenorrhea, infantile colic, and vertigo. The options regarding vertigo and asthma, while demonstrating an overall positive attitude towards the benefits of chiropractic care, were stratified amongst clinicians with varying years in clinical practice.
This study suggests clinicians at this college are moderately open towards the chiropractic treatment of some non-musculoskeletal disorders.
PMCID: PMC3095585  PMID: 21629463
non-musculoskeletal; chiropractic; treatment; CMCC; non-musculosquelettique; chiropratique; traitement; CMCC
22.  Surveillance case definitions for work related upper limb pain syndromes 
OBJECTIVES: To establish consensus case definitions for several common work related upper limb pain syndromes for use in surveillance or studies of the aetiology of these conditions. METHODS: A group of healthcare professionals from the disciplines interested in the prevention and management of upper limb disorders were recruited for a Delphi exercise. A questionnaire was used to establish case definitions from the participants, followed by a consensus conference involving the core group of 29 people. The draft conclusions were recirculated for review. RESULTS: Consensus case definitions were agreed for carpal tunnel syndrome, tenosynovitis of the wrist, de Quervain's disease of the wrist, epicondylitis, shoulder capsulitis (frozen shoulder), and shoulder tendonitis. The consensus group also identified a condition defined as "non-specific diffuse forearm pain" although this is essentially a diagnosis made by exclusion. The group did not have enough experience of the thoracic outlet syndrome to make recommendations. CONCLUSIONS: There was enough consensus between several health professionals from different disciplines to establish case definitions suitable for use in the studies of several work related upper limb pain syndromes. The use of these criteria should allow comparability between studies and centres and facilitate research in this field. The criteria may also be useful in surveillance programmes and as aids to case management.
PMCID: PMC1757569  PMID: 9624281
23.  Pregnancy and chiropractic: a narrative review of the literature 
The purpose of this article is to review the literature on the topic of chiropractic care during pregnancy.
A PubMed search was performed using the terms pregnancy and chiropractic. Sources were cross-referenced to obtain further articles and research information after reviewing the articles obtained through the search.
Thirty-three references were used for this review. The current literature reports favorable results on the use of chiropractic care throughout pregnancy.
Chiropractic evaluation and treatment during pregnancy may be considered a safe and effective means of treating common musculoskeletal symptoms that affect pregnant patients. The scarcity of published literature warrants further research.
PMCID: PMC2647084  PMID: 19674697
24.  Manipulative assessment and treatment of the shoulder complex: case reports 
Journal of Chiropractic Medicine  2003;2(4):145-152.
To describe a unique method of evaluation and a conservative management plan for patients with shoulder dysfunction of mechanical origin. Possible causes for this clinical presentation and a brief review of the literature are offered.
Clinical Features
In the 3 cases described here, symptoms included acute shoulder pain, limitation of movement, positive orthopedic tests, palpable tenderness, muscle spasm and muscle weakness. The 3 cases all resulted in differing diagnoses.
Intervention and Outcome
Following the use of a proposed joint dysfunction isolation test, thrusting forms of manual adjusting procedures, electrical modalities and soft tissue therapy were applied. Three cases representing different common shoulder problems (an acute episode of a chronic problem, a progressive problem resulting in capsulitis, and a occult problem associated with a motor vehicle accident) responded favorably to treatment.
There is the need for a non-surgical, conservative approach to treatment of shoulder problems before considering the more aggressive treatment approaches that carry greater iatrogenic risks. The patients’ signs and symptoms responded to a unique method of evaluation and manipulative therapy when other approaches had failed. The risk/benefit ratio suggests that conservative care be considered a potential option for similar conditions.
PMCID: PMC2646976  PMID: 19674612
Shoulder; Chiropractic Manipulation; Muscle Testing
25.  Hip Capsule Dimensions in Patients With Femoroacetabular Impingement: A Pilot Study 
Joint-preserving hip surgery, either arthroscopic or open, increasingly is used for the treatment of symptomatic femoroacetabular impingement (FAI). As a consequence of surgery, thickening of the joint capsule and intraarticular adhesions between the labrum and joint capsule and between the femoral neck and the joint capsule have been observed. These alterations are believed to cause persistent pain and reduced range of motion. Because the diagnosis is made with MR arthrography, knowledge of the normal capsular anatomy and thickness on MRI in patients is important. To date there is no such information available.
The purpose of this study was to establish thickness, length of the hip capsule, and the size of the perilabral recess in patients with FAI.
We reviewed the preoperative MR arthrography of 30 patients (15 men) with clinical symptoms of FAI. We measured capsular thickness and made observations on the perilabral recess.
The joint capsule was thickest (6 mm) anterosuperiorly between 1 and 2 o’clock. The average length from the femoral head-neck junction to the femoral insertion of the capsule ranged from 19 to 33 mm. A perilabral recess was present circumferentially, even across the acetabular notch, where the labrum is supported by the transverse acetabular ligament. The shortest recess occurred superiorly.
Knowledge of the capsular anatomy in patients with FAI before surgery is important to judge the postoperative changes and to plan potential further therapy including arthroscopic treatment of intraarticular adhesions.
PMCID: PMC3492636  PMID: 22810156

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