Rehabilitative ultrasound imaging (RUSI) in the physical evaluation of patients with shoulder pain

La presente tesis, con título “Exploración ecográfica en la valoración músculo esquelética en pacientes con hombro doloroso” ha sido realizada en régimen de cotutela entre la Universidad de Málaga y la Universidad de Amberes, Bélgica. A continuación, se expone un resumen en castellano sobre el contenido de la misma. El primer capítulo sirve de introducción general, a través de un marco conceptual donde se abordan conceptos generales de la ecografía y su uso dentro de la valoración del hombro, utilizado en la clínica diaria. El segundo y tercer capítulos justifican el motivo de la tesis y enumeran los objetivos del presente proyecto, que estudia el uso de la ecografía en la valoración del hombro. En el tercer capítulo, se desarrolla el primer objetivo de la tesis, a través del estudio bajo el título “Efectos a corto plazo del kinesio taping en el espacio acromiohumeral en sujetos sanos: un ensayo controlado aleatorizado”. En dicho estudio, reclutamos sesenta y dos participantes sin dolor de hombro, y fueron evaluados para su inclusión en el estudio. Finalmente, cuarenta y nueve sujetos fueron incluidos. Se investigó si el kinesio taping puede aumentar la DAH en sujetos asintomáticos en comparación con el tape placebo. Los participantes fueron asignados aleatoriamente entre los grupos 1 y 3. Al grupo 1 (KT1) se le aplicó kinesio taping de la forma tradicional, de anterior a posterior. Al grupo 2 (KT2) se le aplicó el kinesio taping de posterior a anterior, y al grupo 3 (KT3) se le aplicó kinesio taping placebo. A todos los participantes se les aplicó el kinesio taping el día después del examen inicial y se les midió la DAH antes y después de la aplicación del kinesio taping, en 0 y 60 grados de elevación activa del hombro en el plano escapular. Los resultados demostraron que la DAH, medida por ecografía, puede ser incrementada por el kinesio taping significativamente. Nuestros resultados también sugieren que no hay diferencia respecto a la aplicación del kinesio tape, si es de anterior a posterior o viceversa. E el capítulo 4 se desarrolla el estudio realizado con el título “¿Realmente importa la distancia acromiohumeral en el hombro doloroso crónico?”, en el que se investiga el nivel de asociación entre la DAH, dolor, funcionalidad y ROM del hombro en pacientes con dolor crónico de hombro, antes de recibir un tratamiento de fisioterapia. Por tanto, el estudio sigue un diseño transversal. Una muestra comprendida por 110 pacientes con dolor de hombro crónico (más de 3 meses de duración) fue reclutada en tres centros de atención primaria diferentes, de los que 97 fueron incluidos finalmente. Nuestros resultados mostraron una relación estadísticamente significativa pero débil entre la DAH en 0 grados de elevación del hombro, dolor y funcionalidad medido a través del SPADI: a mayor dolor y discapacidad del paciente, menor tamaño aparente de la DAH. Cuando fue analizado el ROM activo de elevación del hombro, no se encontró correlación con DAH en 0 y 60 grados. Los resultados mostraron una fiabilidad intraobservador excelente para ambas medidas de la DAH. Si la perpetuación de los síntomas en etapas avanzadas (cronicidad) es asociada con un descenso de la DAH mantenida permanece incierta, por lo tanto, es crucial establecer la asociación entre DAH, dolor y discapacidad, así como ROM activo libre de dolor en el hombro crónico. Futuros estudios deberían determinar el alcance real de la DAH en la práctica clínica, analizando sus cambios tras la aplicación de distintos tratamientos de fisioterapia, en pacientes que sufren de dolor de hombro crónico. Además, se necesita más investigación para determinar qué cantidad de incremento en la DAH podría ser funcional y clínicamente importante en esta población. En el capítulo 5 desarrollamos el estudio con el título “El espacio coracohumeral en el dolor crónico anterior de hombro. ¿Está asociado con el dolor, función y rango de movimiento?”. Una muestra comprendida por 102 pacientes con dolor crónico anterior de hombro fue reclutada de tres centros diferentes de atención primaria. Un número de 87 sujetos fueron finalmente incluidos en el estudio, siguiendo un diseño transversal, y evaluados antes de recibir tratamiento de fisioterapia. El primer objetivo del estudio fue determinar la fiabilidad intraobservador de la DCH medida por ecografía en pacientes con dolor crónico anterior del hombro. Los resultados muestran una excelente fiabilidad tanto en 0 como 60 grados de elevación del hombro. El segundo objetivo fue analizar el nivel de asociación entre la DCH y el dolor de hombro, la función y ROM libre de dolor. No existió ninguna correlación entre todas las mediciones. Desde nuestro conocimiento, este es el primer y mayor estudio mostrando mediciones de la DCH en pacientes con dolor crónico anterior de hombro medido por ecografía. Este estudio proporciona resultados en respuesta a la falta de estudios de calidad en el campo de la fiabilidad de la DCH medido por ecografía. El auténtico rol de la DCH en la explicación de la severidad del dolor, alteración de la función y limitación del ROM en pacientes con dolor crónico anterior de hombro, aún no está claro. Por tanto, futuros estudios deberían centrarse en determinar la importancia tanto de los factores extrínsecos como de los intrínsecos, y determinar si la DCH puede considerarse como factor pronóstico y predictor en la prevención y manejo del hombro crónico doloroso, y si podría ser el factor clave para direccionar hacia un tratamiento de fisioterapia y/o quirúrgico. Finalmente en el capítulo 6 presentamos una discusión general de la tesis, así como sus limitaciones y prospectivas para futuras investigaciones

Short- and long-term effects of whole-body photobiomodulation on pain, functionality, tissue quality, central sensitisation and psychological factors in a population suffering from fibromyalgia: protocol for a triple-blinded randomised clinical trial

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research has been funded by THOR Photomedicine by providing the equipment needed.Background: The development of an integral and global treatment to improve the quality of life in those with fibromyalgia syndrome (FMS) is challenging. The aim of this study is to investigate the impact of whole-body photobiomodulation (PBM) on pain perception, functionality, quality of soft tissue, central sensitisation and psychological factors in patients suffering with FMS. Methods: This study is a randomised, placebo-controlled clinical trial. A total of 44 participants will be recruited in a private care practice and randomised to receive either a whole-body PBM therapy programme or placebo in the same care centre. The parameters of the PBM programme are as follows: wavelengths of red and near-infrared LEDs 50:50 ratio with 660–850 nanometers; fluence of 25.2 J/cm2; treatment time of 1200 s and a total power emitted of 967 W. Treatment sessions will be 3 times weekly for a period of 4 weeks, totalling 12 treatment sessions. Primary outcome will be pain (Numeric Pain Rating Scale; Widespread Pain Index; Symptom Severity Score). Secondary outcomes will be functionality (Fibromyalgia Impact Questionnaire; the Leisure Time Physical Activity Instrument), quality of soft tissue (elastography), central sensitisation (pain pressure threshold and the Autonomic Symptom Profile) and psychological factors (Pain Catastrophising scale, Tampa Scale, Self-Efficacy questionnaire). Assessments will be at baseline (T1), after session 6 (T2), after treatment (T3) and 2 weeks (T4), 3 (T5) and 6 (T6) month follow-up. Discussion: PBM therapy has been shown to reduce pain and inflammation and to increase the rate of tissue repair for a wide range of conditions, but its potential use as a whole-body treatment in FM is yet to be explored. This trial will investigate whether whole-body PBM therapy is effective at reducing pain intensity, improving functionality, quality of soft tissue, central sensitisation symptoms and psychological measurements. Furthermore, 3- and 6-month follow-up will investigate long-term efficacy of this treatment.THOR Photomedicin

Changes in Circadian Variations in Blood Pressure, Pain Pressure Threshold and the Elasticity of Tissue after a Whole-Body Photobiomodulation Treatment in Patients with Fibromyalgia: A Tripled-Blinded Randomized Clinical Trial

This study analysed circadian variation changes in blood pressure (BP), the pain pressure threshold (PPT) and the elasticity of tissue in patients with fibromyalgia (FM) after a whole-body photobiomodulation (PBM) treatment. This was a tripled-blinded randomized clinical trial including forty participants with FM. Participants using validated self-measurement BP devices attained readings that were used to calculate the circadian variation. Additionally, a standard pressure algometer of 1cm2 was used to assess 13 tender points by exerting a pressure of up to 4 kg, and strain elastography assessed the elasticity of tissue. Circadian variations in BP showed significant differences after the PBM intervention (p = 0.036). When comparing PPT between groups, statistically significant differences were found in the occiput (p = 0.039), low cervical (p = 0.035), trapezius (p = 0.037), second rib (p < 0.001) and medial epicondyle points (p = 0.006). Furthermore, there were statistically significant differences in both the trapezius and the forearm at the distal dorsal third SEL values (p <= 0.001) when comparing groups. Whole-body PBM produces changes in circadian blood pressure, the pain pressure threshold and the elasticity of tissue after a treatment program was carried out. However, more studies are needed to corroborate our findings as well as to better understand the underlying mechanisms

Short-Term Effects of Whole-Body Photobiomodulation on Pain, Quality of Life and Psychological Factors in a Population Suffering from Fibromyalgia: A Triple-Blinded Randomised Clinical Trial

Background: Fibromyalgia (FM) is a multifunctional chronic musculoskeletal pain condition characterised by sensory hypersensitivity. Photobiomodulation (PBM) has shown a positive impact on relieving pain; however, no studies to our knowledge have analysed a whole-body PBM intervention in subjects with FM. The aims of the study were to compare the effects of whole-body PBM with placebo PBM on pain, functionality and psychological symptoms in patients suffering from FM. Methods: Forty-two subjects were recruited from a private care practice. The design of the study is a randomised, triple-blinded, placebocontrolled clinical trial. Participants received 12 treatment sessions. Pain, quality of life, level of physical activity and psychological factors were assessed at baseline (T0), after session 6 (T1), after treatment (T2) and at 2-week (T3) followup. Results: There were statistically significant differences in pain at 4 weeks (p B 0.001) (T2) and the 2-week follow-up (T3) (p B 0.001). In relation to the quality of life, there were statistically significant improvements after session 6 (p B 0.001) (T1), immediately after treatment (p B 0.001) (T2) and at the 2-week (T3) follow-up (p B 0.001). Kinesiophobia presented significant differences between groups immediately after treatment (p B 0.001) (T2) and at the 2-week (T3) follow-up (p B 0.001), with self-efficacy only showing significant differences between groups 2 weeks after the treatment (p = 0.01) (T2). There were no differences between groups when comparing pain catastrophising at any time. Conclusion: Whole-body PBM resulted in a significant reduction in pain and an improvement in quality of life in those participants suffering from FM after receiving 4 weeks of treatment. Furthermore, psychological factors such as kinesiophobia and self-efficacy were also improved. Thus, a whole-body PBM treatment is presented as a possible new multifactorial treatment with potential benefits for those with FM and more studies are needed to corroborate our findings

Patellar and Achilles Tendon Thickness Differences among Athletes with Different Numbers of Meals per Day: A Cross-Sectional Study

The objective of this study is to analyse differences in the thickness of the patellar (PT) and Achilles tendons (AT) among athletes with different number of meals per day. The design is a cross-sectional, observational study. A total of thirty-six male athletes (with mean age groups ranging from 31 to 40) were recruited and divided into three groups based on the number of daily meals they had (3, 4 or 5 meals). PT and AT were assessed by ultrasound. There were statistically significant differences in PT when comparing groups 1 and 3, at both longitudinal (p < 0.03) and transversal (p < 0.002) planes. There were no differences when comparing groups 1 and 2 or groups 2 and 3. There was a negative correlation between the number of meals per day and tendon thicknesses in both PT (longitudinal plane: r = -0.384; p = 0.02/transversal plane: r = -0.406; p = 0.01) and AT (transversal plane: r = -0.386; p = 0.02). In conclusion, there were patellar tendon thickness differences between participants and the number of daily meals could play a key role in tendon thickness, healing and performance

Mid- and Long-Term Results Using 448 kHz Stimulation on the Elasticity of the Supraspinatus Tendon Measured by Quantitative Ultrasound Elastographyin Badminton Professionals: Prospective Randomized Double-Blinded Clinical Trial with Nine Months of Follow-Up

The aim of this study is to analyse the changes that occur in the elasticity of the supraspinatus tendon after the application of a 448 kHz capacitive resistive monopolar radiofrequency (CRMR) at 3, 6 and 9 months in professional badminton players. A randomized double-blinded clinical trial that included 9 months of follow-up was used. A private care practice was used to recruit the participants of this study. They were randomly assigned either the CRMR treatment (n = 19) or the placebo treatment (n = 19). The experimental group received a total of nine treatments of 448 kHz CRMR divided into three treatments per week. The control group received the same regimen but with no radiofrequency. Quantitative ultrasound strain elastography was used to report the main values for three areas of the supraspinatus tendon. These were measured at the start (T1) and directly after (T2), one week after, (T3), three months after (T4), six months after (T5) and nine months after (T6) the completion of the intervention program. There were statistically significant differences in the supraspinatus tendon elasticity immediately after (p <= 0.001), one week after (p <= 0.001) and three months after (p = 0.01) the intervention program. No significant changes were found six or nine months after the intervention program. A three-week intervention program using 448 kHz produced significant changes in the elasticity of the supraspinatus tendon, with the changes lasting up to approximately three months when compared to the control group

Reliability of coracohumeral distance and subcoracoid tendons in subacromial pain syndrome

This study investigated the intra-rater reliability of a novice ultrasound (US) examiner and the interrater reliability of two examiners (novice, expert) in the measures of coracohumeral distance at rest (CHD) and at 60° of elevation without (CHD60) or with weights (CHD60w), tendon thickness of the long head of the biceps (LHB) and subscapularis (SCP). Twenty-one patients with subacromial pain syndrome (SAPS) and 20 asymptomatic participants were included. Intra and inter-rater reliability were tested with intraclass-correlation-coefficient (ICC), differences between raters were analyzed with Bland–Altman plots. Intra-rater reliability for CHD, CHD60 and CHD60w was excellent (ICC = 0.97– 0.98) in asymptomatic participants, and good-to-excellent (0.88–0.93) in SAPS, while intra-rater reliability for LHB and SCP was good-to-excellent in asymptomatic participants (0.88–0.97) and in SAPS (0.90–0.92). Inter-rater reliability for CHD, CHD60 and CHD60w was moderate-to-good (0.70– 0.90) in asymptomatic participants and good (0.85–0.87) in SAPS, in contrast inter-rater reliability for LHB and SCP was poor in asymptomatic participants (0.10–0.46) and poor-to-moderate (0.49–0.61) in SAPS. Bland–Altman plots revealed systematic and/or proportional bias for tendons’ thickness. A novice showed good-to-excellent intra-rater reliability in all US measures, whereas in comparison to an expert a novice can measure reliably CHD, CHD60 and CHD60w, but not LHB and SCP, where more training is recommended.University of Antwerp (grant number: 37063)Research Foundation Flanders—FWO (grant number: 1158121N

The Relationship between Daily Physical Activity, Psychological Factors, and Vegetative Symptoms in Women with Fibromyalgia: A Cross-Sectional Observational Study

Nowadays, there is evidence that relates the amount of physical activity, as well as the impact of psychological factors, to the intensity of symptoms present in patients with fibromyalgia (FM). However, there are no studies which correlate the level of association of physical activity, psychological factors and vegetative symptoms in the FM population. The study has a cross-sectional observational design with 41 participants being recruited from a private clinic and rehabilitation service. The Autonomic Symptom Profile (Compass-31) to assess vegetative symptoms, the GODIN questionnaire to evaluate the level of leisure activity, and the pain catastrophizing scale, Tampa Kinesiophobia Scale and Self-Efficacy Scale to assess psychological factors, were used. A low and significant level of association was found between pain catastrophizing (PCS) and Kinesiophobia (r = 0.398; p < 0.01), as well as with catastrophizing and vegetative symptoms (r = 0.428; p < 0.05). Furthermore, a low and significant level of association was also found between self-efficacy and vegetative symptoms (r = 0.397; p < 0.05). No association was found between the level of daily physical activity (measured by the Godin Leisure questionnaire) and vegetative symptoms, nor with any psychological factor studied. There is an association between vegetative symptoms and psychological factors. Nevertheless, more research which takes other factors into account, such as lifestyle and nutritional, is needed.University Chair in Clinical Psychoneuroimmunology (University of Granada)University Chair in Clinical Psychoneuroimmunology (PNI Europe

Understanding the clinical profile of patients with frozen shoulder: a longitudinal multicentre observational study

Introduction There is a large diversity in the clinical presentation of frozen shoulder (FS) and the clinical outcome is not always satisfactory. The aim of the current study was to examine to what extent range of motion (ROM) limitation, metabolic factors (diabetes mellitus and thyroid disorders), autonomic symptoms and pain sensitivity may contribute to the prognosis in terms of shoulder pain and disability and quality of life in patients with FS. Methods Patients with stage 1 or 2 FS were longitudinally followed-up during 9 months after baseline assessment. They completed six questionnaires and underwent quantitative sensory testing (pressure pain thresholds, temporal summation and conditioned pain modulation) and ROM assessment. Results One hundred and forty-nine patients with FS were initially recruited and 121 completed at least one follow-up measurement. Shoulder pain and disability improved over time and diabetes mellitus was found to be a prognostic factor for final outcome. Several domains of quality of life also improved over time and external rotation ROM, diabetes mellitus, thyroid disorder and autonomic symptoms were found to be prognostic factors for final outcome. These prognostic factors explained 2.5%–6.3% of the final outcome of shoulder pain and disability and quality of life. Discussion and conclusion In patients with FS, prognostic variables were able to predict different outcomes, indicating that outcomes in this population can be variable-dependent. Other variables not explored in this study might contribute to the prognosis of patients with FS, which should be investigated in future research. In clinical practice, baseline assessment of prognostic factors and focusing on a more holistic approach might be useful to inform healthcare practitioners about progression of patients with FS during a 9-month period

Is there any benefit of adding a central nervous system–focused intervention to a manual therapy and home stretching program for people with frozen shoulder? A randomized controlled trial

Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion. The aim of this study was to evaluate the effect of adding a central nervous system (CNS)–focused approach to a manual therapy and home stretching program in people with FS. Methods A total of 34 patients with a diagnosis of primary FS were randomly allocated to receive a 12-week manual therapy and home stretching program or manual therapy and home stretching program plus a CNS-focused approach including graded motor imagery and sensory discrimination training. The Shoulder Pain and Disability Index score, self-perceived shoulder pain (visual analog scale score), shoulder range of motion, and the Patient-Specific Functional Scale score were measured at baseline, after a 2-week washout period just before starting treatment, after treatment, and at 3 months’ follow-up. Results No significant between-group differences in any outcome were found either after treatment or at 3 months’ follow-up. Conclusion A CNS-focused approach provided no additional benefit to a manual therapy and home stretching program in terms of shoulder pain and function in people with FS