Effectiveness of combined extracorporeal shock-wave therapy and hyaluronic acid injections for patients with shoulder pain due to rotator cuff tendinopathy: a person-centered approach with a focus on gender differences to treatment response

Background Rotator cuff (RC) tendinopathy is a common shoulder pain condition. Extracorporeal shockwave therapy (ESWT) and hyaluronic acid peritendinous injection are viable treatment options for RC tendinopathy. The aim of this study is to evaluate the response in two different therapeutic rehabilitative approaches, the combined treatment ESWT plus hyaluronic acid injections (E + Hy) compared to ESWT alone (ESWT-al), in a cohort of patients with RC tendinopathy according to gender differences. Methods This is a retrospective longitudinal cohort study of patients with painful RC tendinopathy. Patients that had received a clinical evaluation, a shoulder ultra sound examination, as well as the Shoulder Pain and Disability Index (SPADI) questionnaire, and the Numerical Rating Scale (NRS) for pain at baseline, 1-month (T1) and 2-month follow-ups (T2) were included. Results Medical records of 53 patients were analyzed. In the comparison between baseline to T1 and similarly from baseline to T2, a statistically significant reduction has been reported in the NRS (p < 0.001) and in the SPADI (p < 0.001) in the entire study group. At T1, patients in the E + Hy compared to ESWT-al group, showed a slight but statistically significant reductions in both NRS and SPADI score, while these changes were more evident at T2 (p < 0.001). Interestingly, a gender dimorphism in NRS and in SPADI was found, with female patients that apparently responded better to the combined E + Hy compared to ESWT-al approach. Conclusion This retrospective cohort study suggests that the combination of ESWT plus HyA injections seems to be more effective than ESWT alone in RC tendinopathy in both genders. Moreover, in ESWT alone treatment, male patients reported better outcomes compared to females. However, further randomized controlled trials should be structured to confirm and enforce these conclusions

Effectiveness of High-Intensity Laser Therapy Plus Ultrasound-Guided Peritendinous Hyaluronic Acid Compared to Therapeutic Exercise for Patients with Lateral Elbow Tendinopathy

Lateral elbow tendinopathy (LET) is a common painful musculoskeletal disorder. Several treatments have been proposed to provide pain reduction and functional recovery, including laser therapy, hyaluronic acid peritendinous injection (Hy-A), and therapeutic exercise (TE). Our study aims to assess the effectiveness of a combined approach with high-intensity laser therapy (HILT) and Hy-A injections compared to TE on pain, muscle strength, and disability in patients with painful LET. A retrospective longitudinal study was carried out by consulting the medical records of patients with a diagnosis of painful LET formulated by clinical and instrumental findings that received functional evaluations, including the Patient-Rated Tennis Elbow Evaluation (PRTEE) and muscle strength measurement at least four times: T0 (“baseline”), 1-month (T1), 3-month (T2), and 6-month follow-ups (T3). Medical records of 80 patients were analyzed. In the HILT + HyA group, the Peak-strength (p < 0.001) and mean strength (p < 0.001) significantly increased compared to the TE group between study times. For the PRTEE-total-score as for the subscales, the HILT + HyA group reported statistically significant reductions only for the comparisons of baseline versus T1 and baseline versus T2. No serious adverse events occurred. Our findings suggest that Hy-A associated with HILT might be more effective than TE for people with LET in the short–medium term

Gender Medicine and Physiotherapy: A Need for Education. Findings from an Italian National Survey

Background: Gender medicine permeates all sectors of medicine, from prevention to treatment and rehabilitation; it aims to customize the care path, ensuring equity in the access to health care system services. It is unclear to what extent physiotherapists’ treatment choices align with gender medicine principles. The aim of this survey is to detect the need of Italian physiotherapists to deepen knowledge in gender medicine. Materials and methods: An 18-item survey assessed the characteristics of responders about knowledge of gender medicine. An online survey was performed in 2020 using SurveyMonkey Software. Data were analyzed by statistical regression. Results: A total of 617 physiotherapists voluntarily participated in the study (53.84% of the target population). The majority of responders (68.4%) declared having general information about gender medicine, but 55.43% of them claimed to have heard of it but did not know properly what gender medicine was about; 92.38% of the physiotherapists believed that they needed training to acquire knowledge in gender medicine. Conclusions: Gender equity matters for health. Moderate knowledge of gender medicine’ principles and modest application of these findings were used in clinical practice of physiotherapy. Physiotherapists declared that they need training in gender medicine

An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report

BACKGROUND: Shoulder pain (SP) may originate from both musculoskeletal and visceral conditions. Physiotherapists (PT) may encounter patients with life-threatening pathologies that mimic musculoskeletal pain such as Acute Myocardial Infarction (AMI). A trained PT should be able to distinguish between signs and symptoms of musculoskeletal or visceral origin aimed at performing proper medical referral.CASE PRESENTATION: A 46-y-old male with acute SP lasting from a week was diagnosed with right painful musculoskeletal shoulder syndrome, in two successive examinations by the emergency department physicians. However, after having experienced a shift of the pain on the left side, the patient presented to a PT. The PT recognized the signs and symptoms of visceral pain and referred him to the general practitioner, which identified a cardiac disease. The final diagnosis was acute myocardial infarction.CONCLUSION: This case report highlights the importance of a thorough patient screening examination, especially for patients treated in an outpatient setting, which allow distinguishing between signs and symptoms of musculoskeletal from visceral diseases

Tumour Hidden behind Thoracic Spine Pain: A Rare Case of Neuroblastoma in a Young Mother—A Case Report

Background: Neuroblastoma (NB) is the most common form of paediatric malignancy, responsible for up to 15% of cancer deaths in children, whereas in adults, its onset is a rarer event, despite being characterized by greater lethality. The purpose of this case report was to describe the clinical presentation, physical examination, and clinical decision-making process in a patient with Neuroblastoma mimicking thoracic spine pain of musculoskeletal origin. Methods: a thirty-two-year-old mother complained of thoracic spine pain on her left vertebral side and in her left periscapular muscles; her pain was constant, deep, and worse at night; she also experienced pain during physical exertion of her upper limbs; the patient also reported pain in her left breast. Results: the physiotherapist’s anamnesis and physical examination led him to suspect the need for an extra-expertise pathology and to refer his patient to another medical specialist; the subsequent investigations revealed a poorly differentiated Neuroblastoma ALK + (IIC) in the posterior mediastinum on the left; the patient underwent surgery excision after 4 months. Conclusions: differential screening should be a physiotherapist’s fundamental skill in their patients’ clinical management, especially in direct access cases; the physiotherapist has an ethical and moral duty to conduct differential screening, in order to rule out extra-expertise pathologies—both when patients self-refer for rehabilitation assessment, and when they are referred by other practitioners

Rehabilitation following shoulder arthroplasty: a survey of current clinical practice patterns of Italian physiotherapists

Abstract Background The incidence of Total Shoulder Arthroplasty (TSA) and Reverse Total Shoulder Arthroplasty (RTSA) is constantly increasing. As a result, the interest in post-surgical rehabilitation has grown, since it is crucial in order to achieve full recovery and successful outcomes. The first aim of this study is to investigate the Italian physiotherapists (PTs) clinical practice in the management of patients with TSA and RTSA and to compare it with the best evidence available in the literature. The second purpose of this study is to assess any existing difference between the survey answers and the different sample subgroups. Materials and methods This cross-sectional observation study was designed following the CHERRIES checklist and the STROBE guidelines. A 4-sections survey with a total of 30 questions was developed for investigating post-surgery rehabilitation management in patient with TSA and RTSA. The survey was sent to Italian PTs from December 2020 until February 2021. Results Six-hundred and seven PTs completed the survey regarding both TSA and RTSA; 43.5% of participants (n = 264/607) stated that TSA is more likely to dislocate during abduction and external rotation. Regarding reverse prosthesis, 53.5% (n = 325/607) affirmed RTSA is more likely to dislocate during internal rotation, adduction and extension. In order to recover passive Range of Motion (pROM), 62.1% (n = 377/607) of participants reported that they gain anterior flexion, abduction, internal rotation, external rotation up to 30°, with full pROM in all directions granted at 6–12 weeks. Regarding the active ROM (aROM), 44.2% (n = 268/607) of participants stated that they use active-assisted procedures within a range under 90° of elevation and abduction at 3–4 weeks and higher than 90° at 6–12 weeks, with full recovery at a 3-month mark. Sixty-five point seven percent of the sample (n = 399/607) declared that, during the rehabilitation of patients with TSA, they tend to focus on strengthening the scapular and rotator cuff muscles, deltoid, biceps and triceps. Conversely, 68.0% (n = 413/607) of participants stated that, for the rehabilitation of patients with RTSA, they preferably focus on strengthening the periscapular and deltoid muscles. Finally, 33.1% (n = 201/607) of participants indicated the instability of the glenoid prosthetic component as the most frequent complication in patients with TSA, while 42.5% (n = 258/607) of PTs identified scapular neck erosion as the most frequent post-RTSA surgery complication. Conclusions The clinical practice of Italian PTs effectively reflects the indications of the literature as far as the strengthening of the main muscle groups and the prevention of movements, which may result in a dislocation, are concerned. Some differences emerged in the clinical practice of Italian PTs, regarding the restoration of active and passive movement, the starting and progression of muscle strengthening and the return to sport (RTS). These differences are actually quite representative of the current knowledge in post-surgical rehabilitation for shoulder prosthesis in the rehabilitation field. Level of evidence

Rotator cuff repair vs. nonoperative treatment:a systematic review with meta-analysis

Background: Rotator cuff (RC) tears have been widely studied as many treatment strategies have been recommended. However, optimal management for patients with RC tears is still unclear. Purpose: The main aim of this systematic review was to analyze randomized controlled trials using meta-analysis to compare repair to conservative treatments for patients with any type of RC tear. Methods: MEDLINE, Cochrane Library (CENTRAL database), PEDro, and Scopus databases were used. Two independent reviewers selected randomized controlled trials that compared surgical to conservative treatments for RC tear patients. The studies included were assessed using Cochrane Risk of Bias 2 tools, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and to summarize the study conclusions. Results: Six trials were included. Pooled results showed improvement in function and pain perception in favor of the repair group at 6 months (mean difference 1.26, 95% CI –2.34, 4.85, P = .49; and –0.59, 95% CI –0.84, –0.33, P < .001, respectively), at 12 months (mean difference 5.25, 95% CI 1.55, 8.95, P = .005, for function; and –0.41, 95% CI –0.70, –0.12, P = .006, for pain) and at 24 months (mean difference 5.57, 95% CI 1.86, 9.29, P = .003, for function; and –0.92, 95% CI –1.31, –0.52, P < .001, for pain) in RC tear patients. However, these differences did not reach the minimum clinically important difference. The certainty of evidence ranged from low to moderate because of imprecision in the studies included. Conclusions: Overall analysis showed that in patients with RC tear, repair compared with conservative treatment could result in increased pain reduction and functional improvement at 6, 12, and 24 months. Even if these effects were often statistically significant, their clinical relevance was limited. Moreover, the certainty of body of evidence ranged from low to moderate

Manipulation under Anesthesia versus Non-Surgical Treatment for Patients with Frozen Shoulder Contracture Syndrome: A Systematic Review

Purpose: To investigate the efficacy of manipulation under anesthesia (MUA) compared to other non-surgical therapeutic strategies for patients with frozen shoulder contracture syndrome (FSCS). Methods: A systematic review of literature was conducted. A literature search was performed in MEDLINE, EMBASE, PEDro, Cochrane Central Library and Scopus. Only randomized controlled trials were included and assessed for critical appraisal through the Cochrane Collaborations tools. Results: Five randomized controlled trials were included. The overall risk of bias (RoB) was high in 4 out of 5 of the included studies. MUA was found to be not superior in terms of reduction of pain and improvement of function when compared to cortisone injections with hydrodilatation (mean regression coefficient MUA &minus;2.77 vs. injection &minus;2.75; 95% CI (&minus;1.11 to 1.15)) and home exercise (mean difference 95% CI: 0.2 (&minus;0.64 to 1.02)) in the short term (3 months), and cortisone injections with hydrodilatation (mean regression coefficient MUA 3.13 vs. injection 3.23; 95% CI (&minus;0.90 to 1.11)) in the long term (&gt;6 months). Moreover, if compared to structured physiotherapy, MUA highlighted a higher Oxford Shoulder Score at final 1-year follow up (mean difference 95% CI: 1.05 (&minus;1.28 to 3.39); p = 0.38). Similar results were obtained for disability, with statistically no significant long-term (&gt;12 months) differences between MUA and home exercise (mean difference 95% CI: 0 (&minus;3.2 to 3.2)) or structured physiotherapy (mean difference 95% CI: &minus;0.50 (&minus;5.70 to 4.70); p = 0.85)). Only two trials reported adverse events. Conclusions: This review suggested that limited and inconsistent evidence currently exists on the efficacy of MUA compared to other non-surgical strategies in the management of patients with FSCS. Future research should focus on clinical trials with higher methodological quality