Short Term Effects of Classic Massage Compared to Connective Tissue Massage on Pressure Pain Threshold and Muscle Relaxation Response in Women With Chronic Neck Pain: A Preliminary Study

Objective

The purpose of this study was to evaluate the short-term effects of classic massage (CM) and connective tissue massage (CTM) on pressure pain threshold and muscle relaxation response in women with chronic neck pain.

Methods

Participants included 45 female volunteers (ages between 25 and 45 years) presenting to the Köroglu State Hospital Neurosurgery Polyclinic who had experienced neck pain for 3 to 6 months. The volunteers were randomly assigned to 2 groups (CM or CTM to the thoracic spine and the neck). Each treatment was carried out for 1 session. Outcome measures were obtained before and after treatment, which included pressure pain threshold that was measured with an algometer and muscle relaxation response that was evaluated with electromyography biofeedback (EMG-BF).

Results

Pressure pain threshold of the sternocleidomastoid muscle was significantly different for the CM (P < .05) group. The EMG-BF values were significantly different for the CTM group (P < .05). Comparing the results of CM and CTM, EMG-BF averages favored the CTM group (P < .05).

Conclusion

For the group of women with chronic neck pain that were included in this study, 1 treatment of CTM demonstrated relaxation responses and 1 treatment of CM demonstrated pain reduction.     

In vivo three-dimensional evaluation of the functional length of glenohumeral ligaments

Background

Glenohumeral ligaments play an important role in stabilizing the shoulder. However, it is impossible to know how they function in vivo during shoulder motion. To help elucidate this stabilizing role, we studied the in vivo three-dimensional kinematics of the normal shoulder joint using a markerless bone-registration technique.

Methods

Our technique utilized image registration to determine corresponding relations between several image volumes represented at different coordinates. Magnetic resonance images of 14 shoulder joints of seven healthy volunteers were acquired for seven isometric abduction orientations between 0° and 180°. We then calculated three-dimensional shortest path between the origin and insertion of each ligament based on anatomical study in each abduction orientation.

Findings

At 0° of abduction, the posterior band of the coracohumeral ligament displayed the maximum length. At 30° of abduction, the superior glenohumeral ligament displayed the maximum length. At 60° of abduction, the anterior band of the coracohumeral ligament and the middle glenohumeral ligament displayed the maximum length. At 120° of abduction, the anterior band of the inferior glenohumeral ligament displayed the maximum length.

Interpretation

Based on progressive abduction of the arm, each ligament had different pattern in change of length. At different arm orientation of abduction, each ligament displayed the maximum length. We think that each ligament might play an important role in stabilizing the shoulder at different arm orientation.     

Biomechanical properties of the glenohumeral joint capsule in hemiplegic shoulder pain

Background

Although many hemiplegic shoulder patients have been suffering from limited range of motion, it is not fully established whether the pathologic biomechanics are same in hemiplegic shoulder pain and adhesive capsulitis. Therefore we aimed to investigate biomechanical properties of glenohumeral joint capsules of hemiplegic shoulder pain with limited range of motions.

Methods

Participants were 14 patients with hemiplegic shoulder pain, 10 controls, and 42 adhesive capsulitis patients matched with the hemiplegic shoulder pain group for sex, age, and range of motion. Demographic data, clinical variables, and sonographic findings were comparable between hemiplegic shoulder pain and adhesive capsulitis groups. We compared capsular capacity, maximal pressure, and capsular stiffness of glenohumeral joint capsule among the 3 groups.

Findings

Hemiplegic shoulder pain and adhesive capsulitis groups had smaller capsular capacity and higher maximal pressure than controls. The capsular stiffness of hemiplegic shoulder pain group was higher than that of controls (P = 0.001) but lower than that of adhesive capsulitis group (P < 0.001).

Interpretation

The stiffness of glenohumeral joint capsules in hemiplegic shoulder pain and adhesive capsulitis patients was substantially higher than that in controls, suggesting that hemiplegic shoulder pain patients had stiffer capsules as adhesive capsulitis patients did although the severities were different. This finding implicates that hemiplegic shoulder pain may share common pathologic properties of tighter capsules with adhesive capsulitis. However, there may be additional mechanisms contributing to range of motion limitation in hemiplegic shoulder pain because capsular stiffness in those patients was not as severe as that in adhesive capsulitis patients with similar range of motion limitation.     

Movement and pain patterns in early stage primary/idiopathic adhesive capsulitis: a factor analysis

Objectives

To evaluate patients clinically diagnosed with early stage primary/idiopathic adhesive capsulitis to determine the existence of any pattern of movement loss and associated pain that may facilitate early recognition.

Design

Cross-sectional study.

Setting

Private upper limb specialty clinic, Newcastle, Australia.

Participants

Fifty-two patients clinically diagnosed with early stage adhesive capsulitis by a medical practitioner or physiotherapist.

Main outcome measures

Percentage loss of active and passive ranges of eight shoulder movements and the pain level at the end of each movement. The reason for limitation of movement was also recorded.

Results

Factor analysis clearly identified two groups for percentage loss of active range of movement. Notably external rotation movements grouped separately from other movements. A single group emerged for percentage loss of passive range of movement suggesting a non-specific global loss. For both pain at the end of active range of movement and passive range of movement two groups emerged, however the delineation between the groups was less clear than for percentage loss of active range of movement suggesting a pattern of end range pain may be less useful in identifying patients in this stage.

Conclusions

External rotation movements in neutral and abduction generally group together and behave differently to other shoulder movements in patients clinically diagnosed with early stage primary/idiopathic adhesive capsulitis. In particular external rotation in abduction has emerged as the most painfully limited movement in this sample. This study provides preliminary evidence of patterns of range of movement and end range pain that require testing in a population of mixed shoulder diagnoses to determine their diagnostic utility for early stage adhesive capsulitis.     

Effects of Massage Therapy and Occlusal Splint Therapy on Mandibular Range of Motion in Individuals With Temporomandibular Disorder: A Randomized Clinical Trial

Objective

The purpose of this study was to investigate the effects of massage therapy compared with occlusal splint therapy on mandibular range of motion (ROM) in individuals with temporomandibular disorder (TMD) and compare the results with ROM obtained in a group of individuals without this disorder.

Methods

A blinded randomized clinical trial was conducted. Twenty-eight volunteers with TMD were randomly distributed into either a massage therapy group or an occlusal splint group. Both treatments were provided for 4 weeks. Fourteen individuals without TMD were consecutively allocated to a comparison group. Fonseca anamnestic index was used to characterize TMD and allocate the volunteers to either of the intervention groups or asymptomatic comparison group. Mandibular ROM was evaluated before and after treatment using a digital caliper. Two-way repeated-measures analysis of variance with a post hoc Bonferroni testing was used for intergroup and intragroup comparisons (level of significance was set to 5%). Cohen d was used to calculate the effect size.

Results

In the intragroup analysis, significant increases in ROM were found for all measures in both the massage and occlusal splint groups (P < .05). A small to moderate clinical effect of treatment with the occlusal splint was found regarding right and left lateral excursion in comparison with the massage therapy and asymptomatic comparison groups (0.2 < d < 0.5).

Conclusion

Massage therapy on the masticatory muscles and the use of an occlusal splint lead to an increase in mandibular ROM similar to that of the asymptomatic comparison group with regard to maximum active mouth opening and both right and left excursion in individuals with TMD.     

Effectiveness of Home Exercise on Pain,Function, and Strength of Manual Wheelchair Users With Spinal Cord Injury: A High-Dose Shoulder Program With Telerehabilitation

Objective

To test the effectiveness of a high-dose home exercise/telerehabilitation program for manual wheelchair users who have a spinal cord injury (SCI) by determining whether the intervention would reduce pain and increase function, as we hypothesized.

Design

A pre-post trial with outcomes measured at 3 time points: baseline, postintervention (12wk), and follow-up (>24 wk).

Setting

Subjects performed an exercise program at their homes using telerehabilitation for therapist monitoring of technique and exercise advancement. Baseline and postintervention data were collected at a motion analysis laboratory in a tertiary medical center.

Participants

A convenience sample of manual wheelchair users (N=16, 3 women; average age, 41y; average time in a wheelchair, 16y) with shoulder pain (average pain duration, 9y) and mechanical impingement signs on physical examination.

Interventions

A 12-week home exercise program of rotator cuff and scapular stabilization exercises was given to each participant. The program included a high dose of 3 sets of 30 repetitions, 3 times weekly, and regular physical therapist supervision via videoconferencing.

Main Outcome Measures

Primary outcomes of pain and function were measured with the Wheelchair User's Shoulder Pain Index (WUSPI), Disabilities of Arm, Shoulder, and Hand (DASH) Index, and Shoulder Rating Questionnaire (SRQ). Secondary outcomes of strength were measured with isometric strength tests of scapulothoracic and glenohumeral muscles, and a static fatigue test of the lower trapezius.

Results

Pain was reduced and function improved after the intervention. There was a significant main effect for pain and function between the 3 time points based on the Friedman signed-ranked test, WUSPI (χ²₂=5.10, P=.014), DASH Index (χ²₂=5.41, P=.012), and SRQ (χ²₂=23.71, P≤.001). Wilcoxon signed-rank tests demonstrated that isometric strength measurements of the serratus anterior and scapular retractors increased after the exercise intervention ([t=2.42, P=.04] and [t=4.67, P=.003], respectively). Muscle impulse produced by the lower trapezius during a fatigue task also improved (t=2.2, P=.02). No differences were measured in isometric strength for the lower trapezius, glenohumeral rotators, and abductors between the baseline and 12-week time points.

Conclusions

A high-dose scapular stabilizer and rotator cuff strengthening program using telerehabilitation for supervision holds promise for shoulder pain treatment in manual wheelchair users with SCI. Additional work is needed to determine the effectiveness compared with other interventions, as well as the potential for earlier intervention to prevent development of shoulder pain.     

Analysis of the influence of rotator cuff impingements on upper limb kinematics in an elderly population during activities of daily living

Background

Despite a high prevalence of rotator cuff impingements or tears in the elderly population, little research has focused on how this injured population adapts to perform tasks of daily living. The current study investigated the influence of rotator cuff impingements in this population on kinematics and shoulder loading differences, while completing activities of daily living.

Methods

Upper limb and trunk movement was measured for thirteen asymptomatic elderly and ten elderly subjects with rotator cuff impingements during five range of motion tasks and six activities of daily living. Thoracohumeral kinematics was derived from this data.

Findings

Symptomatic populations showed significantly decreased ranges of flexion/extension, abduction and internal and external rotation when compared to the asymptomatic population. The asymptomatic population had a 44% larger range of angle of elevation than the symptomatic population. Task was found to be a main effect for most variables examined including angle of elevation. Participants with impingements had significantly lower ranges of humeral rotations during the tasks with ranges of 40° (SD 40°) and 51° (SD 36°) respectively. Perineal care, hair-combing and reaching tasks were the most demanding in terms of the required range of motion. The reaching tasks resulted in the highest shoulder moment.

Interpretation

Developing adaptations for perineal care, hair-combing and reaching tasks should be prioritized when working with persons with rotator cuff impingements, as these tasks demanded the largest ranges of motion while producing high shoulder moments. Substantial differences existed between the experimental groups for a number of kinematic measures.     

Importance of the subscapularis muscle after total shoulder arthroplasty

Background

The rotator cuff muscles are the main stabilizer of the glenohumeral joint. After total shoulder arthroplasty using anterior approaches, a dysfunction of the subscapularis muscle has been reported. In the present paper we tested the hypothesis that a deficient subscapularis following total shoulder arthroplasty can induce joint instability.

Methods

To test this hypothesis we have developed an EMG-driven musculoskeletal model of the glenohumeral joint. The model was based on an algorithm that minimizes the difference between measured and predicted muscular activities, while satisfying the mechanical equilibrium of the glenohumeral joint. A movement of abduction in the scapular plane was simulated. We compared a normal and deficient subscapularis. Muscle forces, joint force, contact pattern and humeral head translation were evaluated.

Findings

To satisfy the mechanical equilibrium, a deficient subscapularis induced a decrease of the force of the infraspinatus muscle. This force decrease was balanced by an increase of the supraspinatus and middle deltoid. As a consequence, the deficient subscapularis induced an upward migration of the humeral head, an eccentric contact pattern and higher stress within the cement.

Interpretation

These results confirm the importance of the suscapularis for the long-term stability of total shoulder arthroplasty.     

Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective,randomised study

Background

Stress relaxation and static progressive stretch are techniques used for non-surgical restoration of shoulder range of motion for patients with adhesive capsulitis.

Objectives

To compare a static progressive stretch device plus traditional therapy with traditional therapy alone for the treatment of adhesive capsulitis of the shoulder.

Design

Prospective, randomised controlled trial.

Participants

Sixty patients with adhesive capsulitis of the shoulder were assigned at random to an experimental group or a control group.

Interventions

Both groups received three traditional therapy sessions per week for 4 weeks. In addition, the experimental group used a static progressive stretch device for 4 weeks.

Main outcome measures

The primary outcome measure was shoulder range of motion (active and passive shoulder abduction, and passive shoulder external rotation). The secondary outcome measures were function [measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire] and pain [measured using a visual analogue scale (VAS)].

Results

At baseline, there were no differences between the two groups. However, after the intervention, there were significant (P < 0.05) differences between the groups for all outcome parameters: 0.3 for mean VAS scores [95% confidence interval (CI) −0.6 to 1.1], −10.1 for DASH scores (95% CI −21.0 to 0.9), 21.2° for shoulder passive external rotation (95% CI 16.8 to 25.7), 26.4° for shoulder passive abduction (95% CI 17.4 to 35.3), and 27.7° for shoulder active abduction (95% CI 20.3 to 35.0). At 12-month follow-up, the differences between the groups were maintained and even increased for mean shoulder range of motion, VAS scores and DASH scores, with significant differences (P < 0.001) between the groups: −2.0 for VAS scores (95% CI −2.9 to −1.2), −53.8 for DASH scores (95% CI −64.7 to −42.9), 47.9° for shoulder passive external rotation (95% CI 43.5 to 52.3), 44.9° for shoulder passive abduction (95% CI 36.0 to 53.8), and 94.3° for shoulder active abduction (95% CI 87.0 to 101.7).

Conclusion

Use of a static progressive stretch device in combination with traditional therapy appears to have beneficial long-term effects on shoulder range of motion, pain and functional outcomes in patients with adhesive capsulitis of the shoulder. At 12-month follow-up, the experimental group had continued to improve, while the control group had relapsed.     

Effect of Interferential Current Stimulation in Management of Hemiplegic Shoulder Pain

Objective

To study the immediate effects of interferential current stimulation (IFC) on shoulder pain and pain-free passive range of motion (PROM) of the shoulder in people with hemiplegic shoulder pain (HSP).

Design

Double-blind, placebo-controlled clinical trial.

Setting

Institutional physical therapy clinic, neurologic rehabilitation center.

Participants

A population-based sample of people with HSP (N=30) was recruited.

Intervention

Participants were divided into 2 groups—an IFC group and a placebo group—by using a match-paired method (age, sex, and Brunnstrom motor recovery stage). In the IFC group, participants received IFC for 20 minutes with an amplitude-modulated frequency at 100Hz in vector mode. The current intensity was increased until the participants felt a strong tingling sensation.

Main Outcome Measures

Pain intensity and pain-free PROM of the shoulder until the onset of pain were measured at baseline and immediately after treatment.

Results

Participants reported a greater reduction in pain during the most painful movement after treatment with IFC than with placebo (P<.05). The IFC group showed a greater improvement in posttreatment pain-free PROM than the placebo group in shoulder flexion (P<.01), abduction (P<.01), internal rotation (P<.01), and external rotation (P<.01).

Conclusions

This study provides evidence that IFC is effective for the relief of pain during movement and also increases the pain-free PROM of the shoulder in people with HSP.     

In vitro quantitative assessment of total and bipolar shoulder arthroplasties: A biomechanical study using human cadaver shoulders

Background

Glenohumeral arthroplasty has produced results far inferior to those seen with hip and knee joint procedures. Therefore, the objective of this study was to evaluate the biomechanical parameters of the glenohumeral joint before and after total shoulder arthroplasty and bipolar hemiarthroplasty in 12 different positions simulating overhead activities.

Methods

Six matched pairs of cadaveric shoulders were used with a custom shoulder testing system to quantify the joint reactive force, contact areas, contact patterns and contact pressures in 12 different positions simulating overhead activities. The entire study was performed for the anatomic glenohumeral joint and following total shoulder arthroplasty on one side, and for the anatomic glenohumeral joint and following bipolar shoulder hemiarthroplasty on the contra-lateral side.

Findings

There was a significant increase in posterior force following total shoulder arthroplasty in two positions of horizontal adduction (P < 0.05). In positions of increased glenohumeral abduction and horizontal adduction, the contact pressures and patterns were greatly altered following both total shoulder arthroplasty and bipolar hemiarthroplasty procedures compared to the anatomic state.

Interpretation

The alterations in joint reaction force, contact pressure and contact patterns following shoulder arthroplasty suggest a possible etiology for glenoid component edge loading in patients following total shoulder arthroplasty. This edge loading may lead to a rocking phenomenon of the glenoid component and subsequent loosening.     

Gene expression profiles of fatigued fibromyalgia patients with different categories of pain and catastrophizing: A preliminary report

Background

Fibromyalgia (FM) is a chronic condition characterized by diffused musculoskeletal pain and overwhelming fatigue.

Purpose

To compare the gene expression profiles of fatigued FM women with different levels of pain and catastrophizing.

Methods

Nine women with FM enrolled in an active Medstar Research Institute protocol were included in the gene expression analyses of peripheral blood RNA via Affymetrix GeneChip Human Genome U133 Plus 2.0 array (Santa Clara, CA). Scores from Brief Pain Inventory, Pain Catastrophizing Scale, and Multidimensional Fatigue Inventory categorized the nine participants into pain (high, n = 3; low, n = 6) and catastrophizing groups (high, n = 5; low, n = 4).

Discussion

Differential expression of 107 genes between the high and low pain groups and 139 genes between the high and low catastrophizing groups (over 2.0-fold change, p < .05) were observed. Network analyses showed interferon signaling and interferon regulatory activation factor pathways distinguished between the pain groups whereas dendritic cell maturation delineated between the catastrophizing groups.

Conclusion

Findings provide preliminary evidence that specific physiological pathways may possibly delineate pain and catastrophizing mechanisms. Further investigation via the use of a larger and more homogenous sample is warranted.     

Influence of Foot Orthotics Upon Duration of Effects of Spinal Manipulation in Chronic Back Pain Patients: A Randomized Clinical Trial

Objective

The purpose of this study was to investigate the effects of 4 weeks of custom foot orthotics on pain, disability, recurrence of spinal fixation, and muscle dysfunction in adult low back pain patients receiving limited chiropractic care.

Methods

Adult volunteers with low back pain of greater than or equal to 1 month's duration were randomized to receive custom orthotics (group A) or a flat insole sham (group B) with limited chiropractic care in 5 visits over 4 weeks. Primary outcome measures are as follows: Quadruple Numerical Pain Rating Scale (for back), the Roland-Morris Disability Questionnaire, the number of muscles grade 4 or lower on manual muscle testing, and the number of spinal fixations detected by motion palpation and vertebral challenge at intake (B1), 2 weeks later before treatment began and orthotic use was initiated (B2) and before each subsequent treatment at approximately days 3, 10, 17, and 24 after B2. Secondary outcome measures are correlations of all primary outcomes.

Results

Both groups improved on all Numerical Pain Rating Scale, Roland-Morris Disability Questionnaire, and the number of muscles from intake (B1) to final visit. Only group B yielded significant improvements in the number of spinal fixations. No outcome measures showed statistical difference between groups at any time point; however, those who wore custom orthotics longer each day showed trends toward greater improvements in some outcome measures.

Conclusions

Both groups improved with chiropractic care including spinal manipulation; however, there were no statistical differences shown between sham and custom orthotic groups. Future studies should formally measure the time that orthotics or shams are worn in a weight-bearing capacity each day.     

Patterns of hip flexion motion predict frontal and transverse plane knee torques during a single-leg land-and-cut maneuver

Background

Impulsive frontal plane knee joint torques directly strain the anterior cruciate ligament and therefore may contribute to injury risk. Because deleterious torques may in part be related to aberrant kinematic movement patterns the primary purpose of this study was to establish a prediction model for frontal plane knee joint torques based on motion characteristics derived from Principal Component Analysis.

Methods

Eighteen healthy NCAA Division I female athletes performed a single-leg land-and-cut maneuver (n = 5 trials) with their dominant limb. Ensemble average lower extremity joint angles for the hip, knee, and ankle along with normalized external knee abduction torques were calculated for the entire stance phase. The ensemble kinematic data were individually submitted to a Principal Component Analysis. Principal component scores were used in a forward step-wise regression model to establish a prediction equation for peak ensemble-averaged knee abduction torque.

Findings

Approximately 31% of the variance in knee abduction torque was explained by a principal component that captured relative magnitudes of hip flexion motion during early stance. Likewise, approximately 32% of the variance in knee internal rotation torque was explained by a principal component that captured overall hip flexion during stance.

Interpretation

Rapid hip flexion motion during the first half of the stance phase of a single-leg land-and-cut maneuver is associated with greater knee abduction joint torques, whereas greater overall flexion during the entire stance phase is associated with smaller internal rotation torques.     

Why do patients with Simple Mechanical Back Pain seek Urgent Care?

Objective

To explore why patients with simple mechanical back pain seek urgent care.

Design

Qualitative Exploratory Inquiry based on the principles of Grounded Theory.

Setting

Urgent Care.

Methods

Data collection by semi-structured interview.

Participants

Eleven patients presenting to urgent care (Accident and emergency, Walk-in Centre and Out of hours service) with back pain.

Results

The study identified eight key motivators of patients with mechanical back pain seeking urgent care: (1) GP access, (2) Pain, (3) Function, (4) Something being different, (5) Something being wrong, (6) Desire for investigation, (7) Third Party Influence and (8) Repeat visits.

Conclusion

This study provides some evidence to support the notion that patients are willing to use primary care services for the treatment of Simple Mechanical Back Pain but that access is frequently limited and untimely. The study concludes that inappropriate attendances at urgent care facilities are frequently a human response to perception of pain severity which is reinforced by functional loss, uncertainty, the need to provide care for others and the encouragement of others. While it is asserted that there is a clear need for mass education in this area, it is also speculated that attendance at urgent care may occur to overtly escalate the need for assistance and illustrate to sceptical significant others the severity of the condition.     

Clinical correlates to laboratory measures for use in non-contact anterior cruciate ligament injury risk prediction algorithm

Background

Prospective measures of high knee abduction moment during landing identify female athletes at high risk for non-contact anterior cruciate ligament injury. Biomechanical laboratory measurements predict high knee abduction moment landing mechanics with high sensitivity (85%) and specificity (93%). The purpose of this study was to identify correlates to laboratory-based predictors of high knee abduction moment for use in a clinic-based anterior cruciate ligament injury risk prediction algorithm. The hypothesis was that clinically obtainable correlates derived from the highly predictive laboratory-based models would demonstrate high accuracy to determine high knee abduction moment status.

Methods

Female basketball and soccer players (N = 744) were tested for anthropometrics, strength and landing biomechanics. Pearson correlation was used to identify clinically feasible correlates and logistic regression to obtain optimal models for high knee abduction moment prediction.

Findings

Clinical correlates to laboratory-based measures were identified and predicted high knee abduction moment status with 73% sensitivity and 70% specificity. The clinic-based prediction algorithm, including (Odds Ratio: 95% confidence interval) knee valgus motion (1.43:1.30–1.59 cm), knee flexion range of motion (0.98:0.96–1.01°), body mass (1.04:1.02–1.06 kg), tibia length (1.38:1.25–1.52 cm) and quadriceps to hamstring ratio (1.70:1.06–2.70) predicted high knee abduction moment status with C statistic 0.81.

Interpretation

The combined correlates of increased knee valgus motion, knee flexion range of motion, body mass, tibia length and quadriceps to hamstrings ratio predict high knee abduction moment status in female athletes with high sensitivity and specificity.

Clinical Relevance

Utilization of clinically obtainable correlates with the prediction algorithm facilitates high non-contact anterior cruciate ligament injury risk athletes' entry into appropriate interventions with the greatest potential to prevent injury.     

Nonsteroidal Anti-Inflammatory Drugs Versus Corticosteroid for Treatment of Shoulder Pain: A Systematic Review and Meta-Analysis

Objective

To compare the treatment efficacy between corticosteroid injection and nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with shoulder pain.

Data Sources

PubMed and EMBASE databases were searched from inception to January 2014. Reference lists of the retrieved studies were additionally scrutinized.

Study Selection

Randomized controlled trials (RCTs) comparing corticosteroid injection with NSAIDs for treatment of shoulder pain were included. The primary outcome was remission, and the secondary outcomes were pain relief and improvement of range of active abduction. Study selection was conducted by 2 researchers independently. Any disagreements were solved by discussion and confirmed by the third reviewer.

Data Extraction

Two reviewers independently conducted data extraction and the quality assessment. Data regarding patients, intervention, control, and outcomes were extracted from the included trials.

Data Synthesis

Six high-quality RCTs of 267 patients meeting the inclusion criteria were included. For an outcome of remission, NSAIDs were less effective than corticosteroid in 4 or 6 weeks (relative risk, .64; 95% confidence interval, .45–.92). NSAIDs did not significantly differ with corticosteroid in pain relief and improvement of range of active abduction.

Conclusions

Current meta-analysis suggests that NSAIDs are less effective than corticosteroid in achieving remission in patients with shoulder pain at 4 or 6 weeks after treatment. Considering the limited number of studies and small size of each trial, the results should be interpreted with caution, and more high-quality RCTs are encouraged.     

Structural stability of different reconstruction techniques following total sacrectomy: a biomechanical study

Background

The biomechanical stability of spino-pelvis structure after varying reconstruction methods following total sacrectomy remains poorly defined. The objective of this study was to compare the structural stability of different reconstruction techniques.

Methods

Six fresh human cadavers (L2-pelvis-femora) were used to compare biomechanical stability after reconstruction using four different techniques: (1) sacral rod reconstruction; (2) bilateral fibular flap reconstruction; (3) four-rod reconstruction; and (4) improved compound reconstruction. After total sacrectomy, the construction was carried out using each method once in each cadaver. Structural stiffness was evaluated by linear and angular ranges of motion. L5 relative shift-down displacement, abduction angle on the coronal plane and rotation angle on the sagittal plane, were calculated based on displacement of the identification point under 500 N axial loading. Overall stiffness was estimated using load displacement curve.

Findings

Improved compound reconstruction resulted in significantly higher stiffness than all three other techniques. The structural stability following bilateral fibular flap reconstruction was superior to that after sacral rod reconstruction. Four-rod reconstruction achieved worst stability due to the lack of anterior bracing applied in three other methods.

Interpretation

Improved compound reconstruction produces optimal structural stability after total sacrectomy. This finding suggests that both anterior bracing and alternation of screw trajectory are important in achieving optimal structural stability.     

Evidence of a pelvis-driven flexion pattern: Are the joints of the lower lumbar spine fully flexed in seated postures?

Background

Seated postures are achieved with a moderate amount of lumbo-sacral flexion and sustained lumbo-sacral spine flexion has been associated with detrimental effects to the tissues surrounding a spinal joint. The purpose of this study was to determine if the lower intervertebral joints of the lumbo-sacral spine approach their end ranges of motion in seated postures.

Methods

Static sagittal digital X-ray images of the lumbo-sacral region from L3 to the top of the sacrum were obtained in five standing and seated postures from 27 participants. Vertebral body bony landmarks were manually digitized and intervertebral joint angles were calculated for the three lower lumbo-sacral joints.

Findings

In upright sitting, the L5/S1 intervertebral joint was flexed to more than 60% of its total range of motion. Each of the lower three intervertebral joints approached their total flexion angles in the slouched sitting posture. These observations were the same regardless of gender. The results support the idea that lumbo-sacral flexion is driven by rotation of the pelvis and lower intervertebral joints in seated postures.

Interpretation

This is the first study to quantitatively show that the lower lumbo-sacral joints approach their total range of motion in seated postures. While not directly measured, the findings suggest that there could be increased loading of the passive tissues surrounding the lower lumbo-sacral intervertebral joints, contributing to low back pain and/or injury from prolonged sitting.     

Comorbidity of Pain and Depression Among Persons With Traumatic Brain Injury

Objective

To assess the prevalence of pain, depression, and comorbid pain and depression among a civilian sample of persons with traumatic brain injury (TBI).

Design

Longitudinal survey design with 1-year follow-up.

Setting

Inpatient rehabilitation and the community.

Participants

Participants (N=158) admitted to inpatient rehabilitation after moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measures

Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); pain was assessed with a numerical rating scale from 0 (no pain) to 10 (worst pain). Participants who reported average pain ≥4 were classified as having pain, and participants with PHQ-9 scores ≥10 were classified as depressed.

Results

Both pain and depression were more prevalent at baseline assessment (pain: 70%; depression: 31%) than at year 1 (pain: 34%; depression: 22%). Comorbid pain and depression declined from 27% at baseline to 18% at year 1. Pain was significantly associated with depression at baseline (relative risk: 2.62, P=.003) and at year 1 (relative risk: 7.98, P<.001).

Conclusions

Pain and depression are common and frequently co-occur in persons with TBI. Although their frequency declined over the first year after injury, the strength of their association increased. Assessment and treatment of both conditions simultaneously may lead to improved outcomes, both early after TBI and over time.