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To evaluate the efficacy of distention arthrography (DA) alone and in combination with translational mobilization (TM) for treatment of patients with frozen shoulder (FS).
Eighty-five patients diagnosed with unilateral FS (freezing or frozen stage) were included. Forty-one patients were treated with DA and TM (group 1) and 44 patients with DA alone (group 2). Clinical assessments including visual analogue scale (VAS), Cyriax stage, and shoulder passive range of motion (PROM) including forward flexion, abduction, external rotation, and internal rotation were measured at baseline, 1 month, and 3 months following treatment.
There were no significant differences in gender, side affected, symptom duration, presence of diabetes mellitus, VAS score, Cyriax stage, or shoulder PROM between the two patient groups at baseline. Compared with baseline metrics, patients in both groups demonstrated significantly improved outcome parameters at two post-treatment time points. However, mean all shoulder PROMs were significantly greater, and mean VAS score and Cyriax stage were lower in patients treated with DA and TM than in those treated with DA alone group at two post-treatment time points. At these times, mean interval change of all outcome parameters was significantly greater with DA and TM than DA alone. No serious complications were observed following treatment in either patient group.
Compared with DA alone, DA combined with TM more effectively alleviates shoulder pain and increases PROM in patients with freezing or frozen stage FS.
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To investigate the causes and characteristics of golf-related shoulder injuries in Korean amateur golfers.
Golf-related surveys were administered to, and ultrasonography were conducted on, 77 Korean amateur golfers with golf-related shoulder pain. The correlation between the golf-related surveys and ultrasonographic findings were investigated.
The non-dominant shoulder is more likely to have golf-related pain and abnormal findings on ultrasonography than is the dominant shoulder. Supraspinatus muscle tear was the most frequent type of injury on ultrasonography, followed by subscapularis muscle tear. Investigation of the participants' golf-related habits revealed that only the amount of time spent practicing golf was correlated with supraspinatus muscle tear. No correlation was observed between the most painful swing phases and abnormal ultrasonographic findings. Participants who had not previously visited clinics were more likely to present with abnormal ultrasonographic findings, and many of the participants complained of additional upper limb pain.
Golf-related shoulder injuries and pain are most likely to be observed in the non-dominant shoulder. The supraspinatus muscle was the most susceptible muscle to damage. A correlation was observed between time spent practicing golf and supraspinatus muscle tear.
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To propose and evaluate the effectiveness of a telerehabilitation platform designed for patients with rotator cuff (RC) tears.
During the first study phase, a virtual service platform that included information on RC tear pathology, joint care, and a series of instructions regarding therapeutic exercise was designed and created. Subsequently, in the clinical phase, a quasi-experimental study was performed. The platform was tested on patients and evaluated at baseline and at 1, 2, 3, and 6 months with respect to their pain levels and functionality on the Constant-Murley (CM) scale.
Eleven patients were included, 5 women and 6 men, with a median age of 55 years (range, 42–68 years). Pain diminished from a baseline value of 64 mm (range, 40–80 mm) to 16 mm (range, 0–30 mm) at 6 months (p<0.001). Points on the CM scale rose from a baseline value of 54 points (range, 51–66 points) to 85 points (range, 70–100 points) at 6 months (p=0.001). Functionality in daily living and work activities, movement, and strength exhibited significant changes at 6 months (p<0.05).
Significant changes were observed in pain and functionality in this group of participants who used a telerehabilitation platform. To the best of our knowledge, this is the first study that included a specific program for RC tears.
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To evaluate the beneficial effect of botulinum toxin A (Botox) injection into the subscapularis muscle on intractable hemiplegic shoulder pain.
Six stroke patients with intractable hemiplegic shoulder pain were included. Botulinum toxin A was injected into the subscapularis muscle. Intractable hemiplegic shoulder pain was evaluated using an 11-point numerical rating scale. Pain-free range of motion was assessed for shoulder abduction and external rotation. The spasticity of the shoulder internal rotator was measured using the modified Ashworth scale. Assessments were carried out at baseline and at 1, 2, 4, and, if possible, 8 weeks.
Intractable hemiplegic shoulder pain was improved (p=0.004) after botulinum toxin injection into the subscapularis muscle. Restricted shoulder abduction (p=0.003), external rotation (p=0.005), and spasticity of the shoulder internal rotator (p=0.005) were also improved. Improved hemiplegic shoulder pain was correlated with improved shoulder abduction (r=–1.0, p<0.001), external rotation (r=–1.0, p<0.001), and spasticity of the internal rotator (r=1.0, p<0.001).
Botulinum toxin A injection into the subscapularis muscle appears to be valuable in the management of intractable hemiplegic shoulder pain.
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To investigate the effect of radial extracorporeal shock wave therapy (rESWT) on hemiplegic shoulder pain (HSP) syndrome.
In this monocentric, randomized, patient-assessor blinded, placebo-controlled trial, patients with HSP were randomly divided into the rESWT (n=17) and control (n=17) groups. Treatment was administered four times a week for 2 weeks. The visual analogue scale (VAS) score and Constant-Murley score (CS) were assessed before and after treatment, and at 2 and 4 weeks. The Modified Ashworth Scale and Fugl-Meyer Assessment scores and range of motion of the shoulder were also assessed.
VAS scores improved post-intervention and at the 2-week and 4-week follow-up in the intervention group (p<0.05). Respective differences in VAS scores between baseline and post-intervention in the intervention and control groups were –1.69±1.90 and –0.45±0.79, respectively (p<0.05), between baseline and 2-week follow-up in the intervention and control groups were –1.60±1.74 and –0.34±0.70, respectively (p<0.05), and between baseline and 4-week follow-up in the intervention and control groups were –1.61±1.73 and –0.33±0.71, respectively (p<0.05). Baseline CS improved from 19.12±11.02 to 20.88±10.37 post-intervention and to 20.41±10.82 at the 2-week follow-up only in the intervention group (p<0.05).
rESWT consisting of eight sessions could be one of the effective and safe modalities for pain management in people with HSP. Further studies are needed to generalize and support these results in patients with HSP and a variety conditions, and to understand the mechanism of rESWT for treating HSP.
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Interventions for Post-Stroke Shoulder Pain: An Overview of Systematic Reviews
To compare quantitative muscle activation between erect and slouched sitting postures in the muscles around the scapula, and to investigate the correlation between the angle of thoracic kyphosis and the alteration of muscle activity depending on two different sitting postures.
Ten healthy males participated in the study. Unilateral surface electromyography (SEMG) was performed for serratus anterior, middle trapezius (MT), and lower trapezius (LT), which are scapular stabilizer muscles, as well as latissimus dorsi. Participants elevated their shoulders for 3 seconds up to 90° abduction in the scapular plane, tilting 30° anterior in the coronal plane. They were told to hold the position for 10 seconds and voluntary isometric contractions were recorded by SEMG. These movement procedures were conducted for three times each for erect and slouched sitting postures and data were averaged.
Activities of MT and LT increased significantly more in the slouched sitting posture than in the erect one. There was no significant correlation between kyphotic angle and the area under curve of each muscle.
Because MT and LT are known as prime movers of scapular rotation, the findings of this study support the notion that slouched sitting posture affects scapular movement. Such scapular dyskinesis during arm elevation leads to scapular stabilizers becoming overactive, and is relevant to muscle fatigue. Thus, slouched sitting posture could be one of the risk factors involved in musculoskeletal pain around scapulae.
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Type 2 superior labral anterior to posterior (SLAP) lesion is a common cause of shoulder pain requiring surgical operation. SLAP tears are often associated with paralabral cysts, but they rarely cause nerve compression. However, we experienced two cases of type 2 SLAP-related paralabral cysts at the spinoglenoid notch which were confirmed as isolated nerve entrapment of the infraspinatus branch of the suprascapular nerve by electrodiagnostic assessment and magnetic resonance imaging. In these pathological conditions, comprehensive electrodiagnostic evaluation is warranted for confirmation of neuropathy, while surgical decompression of the paralabral cyst combined with SLAP repair is recommended.
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To investigate whether an audible cracking sound during shoulder manipulation following distention arthrography is clinically significant in patients with adhesive capsulitis of the shoulder.
A total of 48 patients (31 women, 17 men) with primary adhesive capsulitis of the shoulder completed the study. All participants underwent C-arm-guided arthrographic distention of the glenohumeral joint with injections of a corticosteroid and normal saline. After distention, we performed flexion and abduction manipulation of the shoulder. The patients were grouped into sound and non-sound groups based on the presence or absence, respectively, of an audible cracking sound during manipulation. We assessed shoulder pain and disability based on a Numeric Rating Scale (NRS), the Shoulder Pain and Disability Index (SPADI), and passive range of motion (ROM) measurements (flexion, abduction, internal and external rotation) before the procedure and again at 3 weeks and at 6 weeks after the intervention.
The patients were divided into two groups: 21 were included in the sound group and 27 in the non-sound group. In both groups, the results of the NRS, SPADI, and ROM assessments showed statistically significant improvements at both 3 and 6 weeks after the procedure. However, there were no significant differences between the two groups except with respect to external rotation at 6 weeks, at which time the sound group showed a significant improvement in external rotation when compared with the non-sound group (p<0.05).
These findings showed that manipulation following distention arthrography was effective in decreasing pain and increasing shoulder range of motion. In addition, the presence of an audible cracking sound during manipulation, especially on external rotation, was associated with better shoulder range of motion.
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To translate, adapt, and test the reliability, validity, and responsiveness of the Korean version of the Shoulder Disability Questionnaire (SDQ) and the Shoulder Rating Questionnaire (SRQ).
The international guideline for the adaptation of questionnaires was referenced for the translation and adaptation of the original SDQ and SRQ. Correlations of the SDQ-K and SRQ-K with the Shoulder Pain and Disability Index (SPADI) and the Numeric Rating Scale (NRS) were assessed to determine the reliability and validity of the questionnaires. To evaluate reliability, surveys were performed at baseline and a mean of 6 days later in 29 subjects who did not undergo any treatment for shoulder problems. To evaluate responsiveness, assessments were performed at baseline with 4-week intervals in 23 subjects with adhesive capsulitis who were administered triamcinolone injection into the glenohumeral joint.
Fifty-two subjects with shoulder-related problems were surveyed. Cronbach alpha for internal consistency was 0.82 for the summary SDQ-K and 0.75 for the summary SRQ-K. The test-retest reliability of the SDQ-K, SRQ-K, and domains of the SRQ-K ranged from 0.84 to 0.95. The SDQ-K and SRQ-K summary scores correlated well with the SPADI and NRS summary scores. Generally, the effect sizes and standardized response means of the summary scores of the SDQ-K, SRQ-K, and domains of the SRQ-K were large, reflecting their responsiveness to clinical changes after treatment.
The reliability, validity, and responsiveness of the SDQ-K and SRQ-K were excellent. The SDQ-K and SRQ-K are feasible for Korean patients with shoulder pain or disability.
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To investigate the effects of glenohumeral internal rotation deficit (GIRD) on the isokinetic strength, body pain, and the quality of life in male high school baseball players of Korea.
Fifty-six male high school baseball players were divided into either group A (GIRD≥20°, n=12) or group B (GIRD<20°, n=44). The range of motion in the shoulder and the isokinetic strength were measured. Questionnaires were administered regarding the body pain location by using the visual analogue scale, and the quality of life was measured by using the SF-36 Form.
All subjects had increased external rotation range of motion and decreased internal rotation in the throwing shoulder. The incidence of GIRD (≥20°) was 21.43% in the present study. In the isokinetic strength test, a significantly weaker muscular state at an angular velocity of 180°/s was observed in group A, compared to group B. For the comparison of the pain, the frequency of shoulder pain was higher (33.93%) than other body pain, among the study subjects.
GIRD is one of the main risk factors of glenohumeral joint damage, and it is correlated with reduced isokinetic strength and quality of life. High school baseball players will need appropriate shoulder rehabilitation programs for the improvement in their quality of life and performance.
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To evaluate the effects of repeated steroid injection at subacromial bursa with different interval for patient with periarticular shoulder disorder.
Group A (n=10) received subacromial bursa injection only on their first visit, group C (n=10) received the injection on their first visit and one week later, and group B (n=10) received the injection on their first visit and two weeks later. All injections were done with a combination of 40 mg (1.0 mL) of triamcinolone and 5.0 mL 0.5% lidocaine (6 mL total). We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at baseline at 1, 2, and 4 weeks after the initial injection.
In VAS, comparing the changes in VAS between groups, group B showed significant improvements compared with group A or C at 4 weeks after the initial injection (p<0.05). In SDQ, comparing the changes in SDQ between the groups, group B and C showed more improvement than group A at 4 weeks after the initial injection, but these results were not statistically significant (p>0.05). In AROM, comparing the changes in AROM of external rotation between groups, group B and C showed significant improvement compared with group A at 4 weeks after the initial injection (p<0.05).
It may be more effective in pain relief for patients with periarticular disorder to receive subacromial bursa injections twice with 2-week interval, as opposed to once.
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To assess the efficacy of trigger point injection into brachialis muscle for rotator cuff disease patients with upper arm pain.
A prospective, randomized, and single-blinded clinical pilot trial was performed at university rehabilitation hospital. Twenty-one patients clinically diagnosed with rotator cuff disease suspected of having brachialis myofascial pain syndrome (MPS) were randomly allocated into two groups. Effect of ultrasound (US)-guided trigger point injection (n=11) and oral non-steroidal anti-inflammatory drug (NSAID) (n=10) was compared by visual analog scale (VAS).
US-guided trigger point injection of brachialis muscle resulted in excellent outcome compared to the oral NSAID group. Mean VAS scores decreased significantly after 2 weeks of treatment compared to the baseline in both groups (7.3 vs. 4.5 in the injection group and 7.4 vs. 5.9 in the oral group). The decrease of the VAS score caused by injection (ДVAS=-2.8) was significantly larger than caused by oral NSAID (ДVAS=-1.5) (p<0.05).
In patients with rotator cuff disease, US-guided trigger point injection of the brachialis muscle is safe and effective for both diagnosis and treatment when the cause of pain is suspected to be originated from the muscle.
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To assess the relative effectiveness of three injections methods suprascapular nerve block (SSNB) alone, intra-articular steroid injection (IAI) alone, or both-on relief of hemiplegic shoulder pain.
We recruited 30 patients with hemiplegic shoulder pain after stroke. SSNB was performed in 10 patients, IAI in 10 patients, and a combination of two injections in 10 patients. All were ultrasonography guided. Each patient's maximum passive range of motion (ROM) in the shoulder was measured, and the pain intensity level was assessed with a visual analogue scale (VAS). Repeated measures were performed on pre-injection, and after injection at 1 hour, 1 week, and 1 month. Data were analyzed by Kruskal-Wallis and Friedman tests.
All variables that were repeatedly measured showed significant differences in shoulder ROM with time (p<0.05), but there was no difference according injection method. In addition, VAS was statistically significantly different with time, but there was no difference by injection method. Pain significantly decreased until a week after injection, but pain after a month was relatively increased. However, pain was decreased compared to pre-injection.
The three injection methods significantly improved shoulder ROM and pain with time, but no statistically significant difference was found between them.
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To evaluate effects of subacromial bursa injection with steroid according to dosage and to investigate whether hyaluronidase can reduce steroid dosage.
Thirty patients with periarticular shoulder disorder were assigned to receive subacromial bursa injection once a week for two consecutive weeks. Ten patients (group A) underwent subacromial bursa injection with triamcinolone 20 mg; another group of ten patients (group B) with hyaluronidase 1,500 IU and triamcinolone 20 mg; and the other ten patients (group C) with triamcinolone 40 mg. We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at study entry and every week until 1 week after the 2nd injection.
All groups showed statistically significant improvements in VAS after 1st and 2nd injections. When comparing the degree of improvement in VAS, there were statistically significant differences between groups C and A or B, but not between groups A and B. SDQ was statistically significantly improved only in groups B and C, as compared to pre-injection. There were statistically significant differences in improvement of SDQ after the 2nd injection between groups C and A or B. Statistically significant improvements in AROM were shown in abduction (groups B and C) and in flexion (group C only).
Repeated high-dose (40 mg) steroid injection was more effective in terms of pain relief and functional improvements of shoulder joint than medium-dose (20 mg) steroid injection in periarticular disorder. Hyaluronidase seems to have little additive effect on subacromial bursa injection for reducing the dosage of steroid.
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To investigate the relationship between the rotator cuff tear (RCT) and the muscle strength in hemiplegic side, and the effects of paralysis on the affected shoulders in hemiplegic patients.
A cross-sectional observational study performed in a university hospital was presented. The study enrolled 55 participants with hemiplegia of diverse degree of motor paresis, excluding those with bilateral lesions, history of major trauma or other co-existing musculoskeletal disorders of the shoulder. The main outcome measurements were muscle strength of the affected upper extremity (based on Medical Research Council scale), RCTs of the bilateral shoulders (by ultrasonography), and presence of shoulder pain, subluxation of the glenohumeral joint, passive range of motions, and subacromial spurs.
Comparing each side of the shoulders, the prevalence of shoulder pain and supraspinatus muscle tear was higher (p<0.0001, p=0.007), and the range of motion was restricted (p<0.0001, p<0.0001, p<0.0001, p<0.0001) in the affected side. There was a significant trend toward higher prevalence of RCT and shoulder subluxation in the weaker shoulder (p=0.019, p<0.0001). In a multivariate analysis, Manual Muscle Test grade of less than three was an independent risk factor for RCT (p=0.025).
RCT in hemiplegia had a linear trend with muscle weakness in the affected side and the degree of weakness was an independent risk factor for the occurrence of RCT. In addition, shoulder pain, limitation of range of motions, and RCT were more frequent on the hemiplegic side of the shoulders. It is the first study to reveal a linear trend between RCT and upper extremity weakness and will provide physicians an insight to the management of RCTs in hemiplegic patients.
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To investigate whether or not indirect ultrasound guidance could increase the accuracy of the glenohumeral joint injection using the superior approach.
Twelve shoulders from 7 adult cadavers were anatomically dissected after a dye injection had been performed, while the cadavers were in the supine position. Before the injection, a clinician determined the injection point using the ultrasound and the more internal axial arm rotation was compared to how it was positioned in a previous study. Injection confidence scores and injection accuracy scores were rated.
The clinician's confidence score was high in 92% (11 of 12 shoulders) and the injection accuracy scores were 100% (12 of 12 shoulders). The long heads of the biceps tendons were not penetrated.
Indirect ultrasound guidance and positioning shoulder adducted at 10° and internally rotated at 60°-70° during the superior glenohumeral joint injection would be an effective method to avoid damage to the long head of biceps tendons and to produce a highly accurate injection.
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To explore the relationship between a number of clinically relevant variables and sonographic imaging data in respect to the level of impairment experienced in the affected and unaffected shoulders of hemiplegic stroke patients.
Fifty-one hemiplegic stroke patients (32 males, 19 females; 29 right-sided hemiplegics, 22 left-sided hemiplegics) participated in this study. A musculoskeletal radiologist conducted a sonographic exam on both the affected and unaffected shoulders of all patients and two physicians classified the severity of the injury on a six-point rating scale. Clinical variables including age, sex, duration of injury, spasticity and muscle power of the hemiplegic side, and level of functional activity of the shoulder were assessed.
The sonographic rating scores of hemiplegic shoulders were positively correlated with age (p<0.01) and negatively correlated with level of muscle spasticity (p<0.05). The sonographic rating scores of unaffected shoulders were positively correlated with duration of injury (p<0.01). Affected shoulders received sonographic rating scores that reflected significantly more impairment than those of unaffected shoulders (p<0.001), and pre-morbid handedness did not affect the relationship between impairment rating and shoulder injury status.
Hemiplegic stroke influences not only affected shoulders, but also unaffected sides. Proper management of spasticity, enhancement of motor recovery, and avoidance of unaffected shoulder overuse should be considered to prevent shoulder problems following strokes which result in hemiplegia.
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Candida species inhabit the skin and mucous membranes of healthy individuals with low virulence, and osteomyelitis due to candida is very rare. However, the incidence of invasive candidal infection caused by intravenous drug use, broad-spectrum antibiotics, and indwelling central venous catheter is increasing. A 73-year old man visited the outpatient clinic complaining of right shoulder pain that radiated to the right acromioclavicular joint. He had undergone multiple injection procedures followed by nonsteroidal anti-inflammatory drug therapy for several weeks. The ultrasonographic findings showed a heterogeneous mass around the right acromioclavicular joint, while the right shoulder MRI and the overall findings of the body bone scan were suggestive of osteomyelitis. Pathologic findings of ultrasonographically guided joint aspiration fluid showed acute and chronic nonspecific inflammation, while the tissue culture and staining revealed Candida parapsilosis.
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To evaluate the additive effects of hyaluronidase combined with steroids in patients with peri-articular shoulder disorder.
Thirty patients with peri-articular shoulder disorder were given subacromial bursa injections once a week for three consecutive weeks. Fifteen patients (Group A) underwent subacromial bursa injections with hyaluronidase 1,500 IU, triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). Another fifteen patients (Group B) underwent the same injections with triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). We examined the active range of motion (AROM) in the shoulder, used a visual analogue scale (VAS) for measurement, and administered a shoulder disability questionnaire (SDQ) at the commencement of the study and then every week until one week after the third injection.
There were no significant difference between group A and B before the injections took place (p>0.05). Statistically significant improvement was seen in the VAS, SDQ, and AROM of flexion, abduction, internal rotation at one week after the first and second injections compared with the parameters measured at previous visits in both groups (p<0.05), except the SDQ between one week after the first and second injections in group B (p>0.05). Improvement in all parameters measured at one week after the third injection compared with the measurement values at one week after the second injection were not statistically significant in both groups (p>0.05). However, group A (the hyaluronidase group) showed significantly greater improvements than group B in terms of their SDQ and AROM of internal rotation scores one week after the three injections had taken place (p<0.05).
Peri-articular shoulder disorder patients who underwent subacromial bursa injections using hyaluronidase and steroids showed greater functional improvements than those who were given only steroid injections.
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To investigate the relationship between the shoulder gradient and acromiohumeral interval of both shoulders in patients with unilateral shoulder impingement syndrome.
Using the angulometer, we measured the shoulder gradient in patients with unilateral shoulder impingement syndrome in a standing position. Using the radiography, we measured the acromiohumeral interval and the angle between a vertical line and a line connecting a superior angle with an inferior angle of the scapula.
In patients with unilateral shoulder impingement syndrome, the frequency of shoulder impingement syndrome was 76.2% (16 of 21) on the side of the relatively lower shoulder. The mean acromiohumeral interval on the side of the lower shoulder was 10.03±1.28 mm, compared with 10.46±1.50 mm for the higher shoulder. The angle between a vertical line and a line connecting a superior angle with an inferior angle of the scapular of the side of the lower shoulder was -0.31±3.73 degrees, compared with 3.85±4.42 degrees for the higher shoulder.
The frequency of shoulder impingement syndrome was significantly higher on the side of the relatively lower shoulder, and there is no significant difference in the acromiohumeral interval between the side of the lower shoulder and that of the higher shoulder. In patients with unilateral shoulder impingement syndrome, the scapular on the side of lower shoulder was more rotated downward than on the side of the higher shoulder.
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To investigate the additive effect of sono-guided subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders.
This prospective randomized controlled trial involved 26 patients who had shoulder pain. Group A, consisting of 13 patients, was treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml), followed by injection with sodium hyaluronate (2 ml) once a week for 3 weeks. The other 13 patients (Group B) were treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml) once a week for 3 weeks. The effects were assessed using a visual analogue scale (VAS) of shoulder pain, active range of motion (AROM), shoulder function assessment scale (SFA), shoulder disability questionnaire (SDQ) at study entry and every week from first injection until 4 weeks after the 1st injection (= 2 weeks after 3rd injection).
(1) Demographic features and all parameters measured before injection did not show a significant difference between the 2 groups. (2) Statistically significant improvements were shown in VAS, SFA, SDQ during the 1st, 2nd, and 4th week after the first injection in both groups (p<0.05). (3) SFA showed significant improvement at 1 week after injection only in group A (p<0.05). (4) AROM of internal rotation showed significant improvement at week 4 after the 1st injection only in group A (p<0.05).
Subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders has additive effects on functional improvement of the affected shoulder, including the AROM of internal rotation.
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Objective: In adhesive capsulitis, assessment of the mobility of the shoulder are likely to have intrinsic error because of the altering scapulohumeral rhythm and extrinsic error. For more objective and the precise assessment of shoulder mobility in adhesive capsulitis, we observed proper glenohumeral movement, the change of scapulohumeral angle, the scapulohumeral rhythm were evaluated with radiography and compared with clinical measurement of shoulder range of motion (ROM).
Method: The subjects were 19 patients (21 shoulder) with adhesive capsulitis of the shoulder and undertook combination treatment of distention arthrography, per os medication of non-steroid anti- inflammatory drug, stellate ganglion block, physical therapy including exercise. We assessed change in visual analogue scale (VAS), joint space capacity, shoulder mobility by measurement of ROM, and scapulohumeral angle in active shoulder abduction under the fluroscopy.
Results: All the subjects experienced pain relief, increased shoulder mobility and restoration of scapulohumeral rhythm. The improvement of the shoulder extension and scapulohumeral angle is well correlated with the change of VAS and joint capacity. However, the improvement of the shoulder flexion, abduction, external rotation and internal rotation were poor correlated with them.
Conclusion: We propose the measurement of scapulohumeral angle with active shoulder abduction in shoulder AP view as an assessment method for shoulder mobility in adhesive capsulitis.
The purpose of this study is to compare the effectiveness of the Rolyan, hemisling, remodified Bobath, and the newly designed triangular Bobath slings. Sixteen patients with a shoulder subluxation were evaluated by the simple shoulder AP X-rays with and without slings. The hemisling was applied with the elbow flexed at 90 and 120 degrees. The radiologic evaluation for the detection of shoulder subluxation was done by measuring the vertical and horizontal displacement on a plain AP view. The mean value of vertical displacement without a sling application was 5.21 cm which was reduced to 4.30 cm by a triangular Bobath sling application and 4.32 cm by a hemisling application at 120°elbow flexion. These two slings significantly corrected the vertical displacement, but other were not. In nine of sixteen patients, the triangular Bobath sling was the best sling for the vertical correction. All slings except a hemisling increased the horizontal displacement even though it was not statistically significant. The triangular Bobath sling improved the discomfort of the axilla better than the remodified Bobath sling.
The results support that the triangular Bobath sling was the best among 4 slings for the correction of shoulder subluxation, although a reduction in lateral displacement and an improvement in applicability need to be explored further.
Objective: The aim of this study is to know the usefulness of ultrasonographic evaluation of hemiplegic shoulder pain.
Method: For 20 hemiplegic patients with shoulder pain, the shoulder was evaluated by simple radiographic findings, physical examinations, visual analogue scale (VAS), manual muscle test (MMT), and finally the ultrasonographic examination to define shoulder pain nature. The ultrasonographic results were compared to the simple radiography, physical examination, VAS, and MMT.
Results: The ultrasonographic findings were variable. The positive ultrasonographic findings were 10 joint fluid collections, 3 tendinous thickenings, 4 high echogenic findings, 4 tendon surface defects, 2 tendinous gracilings, and 1 joint surface irregularity. The ultrasonographic interpretative conclusion included 6 tendon (or muscle) tears, 2 degenerative changes, 5 nonspecific simple joint fluid collections, and 7 normal shoulder joints. In comparison of ultrasonographic findings and subluxation, VAS, and fluid collection, VAS showed relatively higher correlation.
Conclusion: The ultrasonography is very useful as a non-invasive, inexpensive, painless, and rapid screening diagnostic method for the evaluation of painful hemiplegic shoulder.
Objective: To evaluate the effects of intra-articular injection of shoulder and subscapularis motor point block on painful hemiplegic shoulder.
Method: Thirty painful hemiplegic shoulder of recent onset stroke were divided randomly into three groups, i.e. group I: range of motion (ROM) exercise only, group II: intra-articular injection with ROM exercise, group III: subscapularis motor point block with ROM exercise. The intra-articular injection of shoulder was done with 20 ml of normal saline, 5 ml of 1% lidocaine, and 40 mg of triamcinolone. The subscapularis motor point block was done with 5 ml of 5% phenol under electromyographic guide. The ROM in external rotation and simple X-ray of shoulder in full abduction were checked in three groups at pre-treatment and post-treatment 3 week, and the glenohumeral abduction and scapulohumeral rhythm were obtained from the shoulder X-ray.
Results: There were significant (p＜0.05) improvements of glenohumeral abduction, external rotation, and scapulohumeral rhythm of shoulder in group II and III, but improvement of only glenohumeral abduction was significant in group I. Angular increment of glenohumeral abduction and external rotation was most significant in group III compared with other two groups.
Conclusion: These results suggest that the intra-articular injection of shoulder and subscapularis motor point block are potentially useful techniques in the prevention and management of the painful hemiplegic shoulder.
Objective: To compare intraarticular steroid injection with and without capsular distension in the treatment of adhesive capsulitis of the shoulder
Method: Fifty-five cases those were clinically diagnosed as adhesive capsulitis of the shoulder were randomly assigned to one of two treatment groups. 28 cases were treated by intraarticular steroid injection with capsular distension (group 1) and 27 cases by steroid injection alone (group 2). They were evaluated by visual analogue scales, Cyriax stages of arthritis, and active shoulder range of motion (flexion, abduction, external rotation and internal rotation). Follow up assessments were made one week and one month after injection.
Results: There were no statistically significant differences in Cyriax stages and VAS between two groups. But in the group 1, shoulder range of motion showed significant improvement in flexion and internal rotation at one week, and flexion at one month.
Conclusion: Intraarticular steroid injection with cspsular distension had no advantage over steroid injection alone in pain reduction, but can help the patients to achieve better range of motion, especially flexion and internal rotation, in treatment of adhesive capsulitis of the shoulder.
Measurements of local shoulder muscle function during shoulder abduction are of a great interest in biomechanics research and in ergonomic applications. There have been so many opinions that the supraspinatus muscle acts in synergy with the deltoid muscle as a single unit throughout the shoulder abduction. However the specific actions of deltoid and supraspinatus muscles have been subjects of controversy. Electromyography is an established evaluation method of biomechanical study. It reflects the electrical activity at the muscle membrane level and indirectly the mechanical output of the muscle. The purpose of this study was to evaluate the role of deltoid and supraspinatus muscles during shoulder abduction by the comparison of motor unit action potentials using a quantitative electromyographic analysis method, to provide a good insight into the biomechanics of shoulder abduction.
Motor unit action potentials of deltoid muscle were seen earlier than those of supraspinatus muscle at the time of initiation of shoulder abduction. The Root Mean Square (RMS) voltage of deltoid muscle was increased gradually from 0o to 90o of shoulder abduction, and then decreased gradually above 90o to 180o of shoulder abduction. The RMS voltages of deltoid muscle were significantly higher than those of supraspinatus muscle at each degree of shoulder abduction wholly. There was no differences in the RMS voltages of deltoid muscle, during shoulder abduction between the loading of 1 kg and without loading. However, the RMS voltages of supraspinatus muscle were significantly higher in the loading state than without loading. The Mean Rectified Voltages (MRV) were similar to the RMS voltages of deltoid and supraspinatus muscles during shoulder abduction.
Based on these results, we concluded that the deltoid muscle was not only an initiator but also a major contributor in shoulder abduction, where as the supraspinatus muscle acts as a secondary muscle for the initiation of shoulder abduction and a supporting muscle when there is a resistance against shoulder abduction.
Objective: Shoulder pain in hemiplegia is common and serious problem, but is not completely understood and somewhat controversial. This preliminary study attempt to evaluate the effect and usefulness of subacromial massage in the management of hemiplegic shoulder.
Method: In this ramdomized controlled trial, twenty nine hemiplegic patients with shoulder pain and limitation of motion were treated with either subacromial massage (treatment group) or massage on the supra-acromial area (control group). Outcome measurement of pain intensity, and range of motion were obtained by blinded assessment.
Results: After massage, in treatment group, mean active range of shoulder motion was increased by 14.3o in abduction, 9.0o in flexion, 10.3o in external rotation and 13o in internal rotation versus 3.9o in abduction, 7.5o in flexion, 4.3o in external rotation and 6.4o in internal rotation in control group. The mean pain intensity decreased from VAS 5.47 to 3.8 in treatment group and from VAS 4.57 to 3.71 in control group. This result was statistically significant, except in increment of active range of motion of flexion and external rotation of shoulder joint.
Conclusion: Subacromial massage was used in an effort to increase shoulder motion and to reduce shoulder pain in hemiplegic patients. There were increase in shoulder motion especially abduction, and decrease shoulder pain in study group compared with control group. Further investigation in the form of long term follow up studies is needed. (J Korean Acad Rehab Med 2002; 26: 385-390)
Objective: To study the acromial type, acromial angle, acromial tilt and subacromial distances which known as extrinsic factors of subacromial impingement syndrome in groups of subacromial impingement syndrome and normal control.
Method: The radiography of shoulder named shoulder series composed of AP view, arch view and impingement view was performed in thirty patients with subacromial impingement syndrome and ninety persons with normal adult and we measured the acromial type, acromial angle, acromial tilt, subacromial distances and subacromial spur.
Results: Mean subacromial distances of impingement group were 11.3⁑2.4 mm in AP view, 11.1⁑2.5 mm in arch view and those of normal control group were 11.1⁑2.2 mm in AP view, 10.4⁑1.9 mm in arch view. Incidences of acromial type I,II,III in impingement group were 15 (50%), 10 (33.3%), 5 (16.7%) respectively and those in normal control group were 20 (22.2%), 46 (51.1%), 24 (26.7%) respectively. Incidence of subacromial spur was 19 (63.3%) in impingement group and 52 (57.8%) in normal control group.
Mean subacromial spur size was 10.0⁑5.4 mm in impingement group and 12.4⁑4.5 mm in normal control group. Mean acromial angle was 27.1⁑8.3 degree in impingement group and 29.1⁑8.7 degree in normal control group. Mean acromial tilt was 28.0⁑6.39 degree in impingement group and 31.8⁑3.4 degree in normal control group.
Conclusion: No significant statistical difference between subacromial impingement syndrome group and normal control group in acromial type, acromial angle, acromial tilt and subacromial distance known as extinsic factors of subacromial impingement syndrome
Objective: 1. To determine the difference of scapulohumeral rhythm (SHR) between the affected and unaffected side in hemiplegic patients. 2. To discover the influencing factors on altered scapulohumeral rhythm of affected side in hemiplegic patients.
Method: Fifteen hemiplegic subjects, 18 to 54 years of age, participated in this study.
Subjects were divided into two groups according to muscle tone on the basis of modified Ashworth scale (MAS). Plain X-ray of the shoulders were taken in neutral, 90 degree abduction, and full elevation of the arm in both affected and unaffected side. The arm angle, scapula angle, and glenohumeral angle were recorded for each individual in each of the three positions.
Result: In the unaffected shoulders of hemiplegic patients, the mean values of SHRs from neutral to the 90o and from neutral to the 180o were 1：1.82 and 1：2.12, respectively. In the affected shoulders, the mean values of SHRs between 0∼90o abduction and 0 to full abduction were 1：2.35 and 1：2.25, respectively. The mean value of SHRs from neutral to 90 degree of affected side was significantly decreased than unaffected side in the low tone group and increased in the high tone group (p＜0.05). In addition, the SHRs of hemiplegic shoulders were significantly increased in the high tone group than the low tone group (p＜0.05).
Conclusion: Spasticity tends to result in decreased motion of scapula, which alters the SHR. A glenohumeral-to-scapulothoracic ratio of hemiplegic shoulder could be affected by spasticity and presence of subluxation.
Objective: MRI findings of adhesive capsulitis (AC) have been rarely documented even though the disease is a rather common disorder. To find reliable MRI parameters, we studied MRI findings of the patients with arthrographically-proven AC.
Method: Eighteen patients with AC (patient group) and eight subjects without AC (control group) were enrolled. Mean age of the former was 55.1 years and that of the latter was 41.4 years. Mean duration of the diseases in patient group was 5.9 months. Oblique coronal and axial MRI images of the shoulder were measured for the thickness of capsule and synovium around the axillary fold (TAF), volume of axillary recess (VAR), and volume of biceps tendon sheath (VBTS), which were com-
pared in both groups using unpaired t-test.
Results: TAF was significantly increased in patient group (p＜0.0001), and the thickened axillary fold greater than 5.1 mm was a useful MRI criterion for the diagnosis of AC with sensitivity of 93% and with specificity of 100%. VBTS was also significantly diminished in patient group (p＜0.05), whereas there was no significant difference in VAR between two groups.
Conclusion: TAF, especially greater than 5.1 mm, and decreased VBTS are useful MRI parameters for the diagnosis of AC of shoulder. (J Korean Acad Rehab Med 2002; 26: 177-181)
Objective: To evaluate the efficacy of intraarticular injection of hyaluronic acid and steroid in adhesive capsulitis of shoulder.
Method: Thirty-nine patients with adhesive capsulitis of shoulder were assigned at random to receive intraarticular injection into the glenohumeral joint. The treatment groups were divided into three: group A, triamcinolone 1 ml and 1% lidocaine 3 ml and normal saline 25 ml; group B, hyaluronic acid 2 ml and 1% lidocaine 3 ml and normal saline 25 ml; group C, hyaluronic acid 2 ml and 1% lidocaine 3 ml. The same physical therapy program was carried out for all patients. Pain was assessed by visual analogue scale (VAS) and range of motion (flexion, abduction, internal rotation and external rotation) was measured before injection, and at 30 minutes, 1 week and 2 weeks after injection.
Results: The shoulder range of motion (ROM) and VAS of three groups were all improved at 30 minutes, 1 week and 2 weeks after injection compared with those of preinjection, but there was no significant difference in ROM and VAS among three groups.
Conclusion: We concluded that intraarticular injection of hyaluronic acid would be a good treatment method in adhesive capsulitis of shoulder, specially in patients with risk of steroid use.
Method: 20 hemiplegic patients (right: 10, left: 10) were evaluated LSST in resting position at three different points (T2-Superior Angle, T3-Scapular Spine, T7-Inferior Angle) in three times of the both shoulder. Muscle power of shoulder, Brunnstrom stages, spasticity, subluxation degrees using X-ray studies and ROM pain degrees using Visual Analog Scale (VAS) were also evaluated to examine the clinical correlation.
Results: This study showed the evidence of positive correlation with LSST and shoulder subluxation, ROM pain degrees using VAS at T7-inferior angle (p＜0.05), and negative correlations with LSST with shoulder abduction muscle power and Brunnstrom stage. But, there were no correlations with shoulder spasticity and hemiplegic side.
Conclusion: This study provided LSST can be a useful predictor of shoulder subluxation and it supposed that the glenoid fossa on the affected side was upward rotated compared to the unaffected side. (J Korean Acad Rehab Med 2003; 27: 819-823)
Method: A cross sectional study in 155 type II diabetic patients was done. The presence of LJM and shoulder adhesive capsulitis was sought. The diseases closely related to diabetes were recorded. The patients were assessed for retinopathy, nephropathy, and neuropathy.
Results: The prevalence of LJM and shoulder adhesive capsulitis in type II diabetic patients was 32.3% and 29.7%, respectively. Development of LJM and shoulder adhesive capsulitis was correlated with age and duration of diabetes. Higher blood HbA1c level was noticed in mild and moderate degree of LJM. The prevalence of shoulder adhesive capsulitis was shown association with LJM. The prevalence of LJM was associated with a history of myocardial infarction and chronic diabetic compli cations. The prevalence of shoulder adhesive capsulitis was associated with retinopathy, carpal tunnel syndrome, and autonomic neuropathy.
Conclusion: According to the results, around 30% of type II DM patients could have hand LJM and should adhesive capsulitis, which suggested more attention and effort to prevent the LJM and shoulder adhesive capsulitis were needed.
Objective: The goal of this study is to investigate the effect of subacromial bursa injection of hyaluronate in patients with adhesive capsulitis of shoulder.
Method: Fifty nine patients with adhesive capsulitis of shoulder were injected with hyaluronate (HyruanⰒ, LG chemical) 2.5 ml to subacromial bursa once a week for 5 weeks and randomly selected twenty eight patients among them were injected with DepomedrolⰒ 20 mg only at first week. The effect of hyaluronate injection was evaluated by pain (Visaul analogue scale), night pain, range of motion of shoulder, functional activities of daily living and patient's self satisfaction at preinjection, every week after first injection until 5th week, 8th and 12th week.
Results: Visual analogue scale and night pain were signi-
ficantly decreased at 5th and 12th week compared with preinjection status. The range of motion of shoulder and functional activities of daily living significantly improved at 5th week and 12th week. Eighty eight percent (N=52) of patients reported as a little improved, improved or much improved at 5th week. No significant serious side effect of injection was found until 12th week.
Conclusion: Hyaluronate injection into subacromial bursa decreased pain and improved shoulder range of motion. It also improved functional activities of daily living of patients with adhesive capsulitis. So it is effective and safe for those patients, especially who cannot receive corticosteroid intraarticular injection. (J Korean Acad Rehab Med 2002; 26: 73-80)
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