Guideline for diagnosis and treatment of subacromial pain syndrome

Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears

High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain

Background: Shoulder pain is reported to be highly prevalent and tends to be recurrent or persistent despite medical treatment. The pathophysiological mechanisms of shoulder pain are poorly understood. Furthermore, there is little evidence supporting the effectiveness of current treatment protocols. Although myofascial trigger points (MTrPs) are rarely mentioned in relation to shoulder pain, they may present an alternative underlying mechanism, which would provide new treatment targets through MTrP inactivation. While previous research has demonstrated that trained physiotherapists can reliably identify MTrPs in patients with shoulder pain, the percentage of patients who actually have MTrPs remains unclear. The aim of this observational study was to assess the prevalence of muscles with MTrPs and the association between MTrPs and the severity of pain and functioning in patients with chronic non-traumatic unilateral shoulder pain. Methods: An observational study was conducted. Subjects were recruited from patients participating in a controlled trial studying the effectiveness of physical therapy on patients with unilateral non-traumatic shoulder pain. Sociodemographic and patient-reported symptom scores, including the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, and Visual Analogue Scales for Pain were compared with other studies. To test for differences in age, gender distribution, and education level between the current study population and the populations from Dutch shoulder studies, the one sample T-test was used. One observer examined all subjects (n = 72) for the presence of MTrPs. Frequency distributions, means, medians, standard deviations, and 95% confidence intervals were calculated for descriptive purposes. The Spearman's rank-order correlation (rho) was used to test for association between variables. Results: MTrPs were identified in all subjects. The median number of muscles with MTrPs per subject was 6 (active MTrPs) and 4 (latent MTrPs). Active MTrPs were most prevalent in the infraspinatus (77%) and the upper trapezius muscles (58%), whereas latent MTrPs were most prevalent in the teres major (49%) and anterior deltoid muscles (38%). The number of muscles with active MTrPs was only moderately correlated with the DASH score. Conclusion: The prevalence of muscles containing active and latent MTrPs in a sample of patients with chronic non-traumatic shoulder pain was high

Treatment of myofascial trigger points in common shoulder disorders by physical therapy: A randomized controlled trial [ISRCTN75722066]

Contains fulltext : 52454.pdf (publisher's version ) (Open Access

A mobile NMR sensor and relaxometric method to nondestructively monitor the dynamics of water and dry matter content in leaves, stems and developing seeds

Fresh weight, water content and dry matter content are some of the most basic plant traits, but are exceptionally difficult to measure non-invasively. Nuclear Magnetic Resonance (NMR) relaxometry may fill this methodological gap. It allows non-invasive detection of protons in liquids and solids, and on the basis of these measures, can be used to monitor and quantify the liquid and dry matter content of seeds and plants. Unfortunately, most existing NMR relaxometers are large, unwieldy, and not at all suitable to measure intact plants or to be used under field conditions. In addition, currently the appropriate NMR relaxometric methods are poorly suited for non-expert use.In this contribution we present a novel approach to overcome these drawbacks. We demonstrate that a basic NMR relaxometer with the capability to accept intact plants, in combination with straightforward NMR and data processing methods, can be used as an NMR plant sensor to continuously, quantitatively and non-invasively monitor changes in water and dry matter content. This can be done in vivo, in situ, and with high temporal resolution.We validate the method showing that measured liquid and solid proton densities accurately reflect fresh weight, water content and dry matter content of a wide range of reference samples. We demonstrate the utility of the non-invasive NMR plant sensor in an experimental context by monitoring water content of leaves of intact plants (rice and mangrove saplings) exposed to osmotic stimuli, and by monitoring seed filling from anthesis to mature ripe stage in grain crops such as wheat, barley and common bean. We further demonstrate how leaf water potential can be monitored non-invasively on the basis of changes in leaf water content as measured by the NMR sensor

Old year rings may provide water storage capacity by cavitating first

The sapwood of temperate trees comprises many year rings. Conduits in the current year ring commonly are assumed to conduct most flow. Those in older rings, conversely, are assumed to be less efficiently connected to new leaves, and may have become more susceptible to cavitation. We hypothesize that older year rings thus will hold more dead-end conduits, conduct less flow and cavitate before the current year xylem does, releasing stored water. To test this hypothesis we used MRI relaxometry and flowmetry, utilizing both a traditional high field imager and a mobile, battery driven one. MRI cannot always resolve singular xylem conduits, especially if it is a mobile device. We here propose and demonstrate MRI methods to nonetheless detect water filled conduits and quantify the flow conducting area – or loss thereof. Large beech trees were exposed to drought. Initially, all xylem regions that contained water filled vessels also exhibited flow. Stagnant water in old or current year rings could not be detected. Cavitation did however start in the oldest year rings first, supporting our hypothesis. Observations in beech and spruce saplings confirmed this observation. However, release of water from old year rings did not appear to slow the spread of cavitation

Monitoring changes in water- and dry matter content of leaves, fruits and stems by means of a mobile NMR sensor (NMRS)

Dry weight, fresh weight, dry matter content and water content are some of the most basic parameters to describe plant growth and water status. They have in common that they are easy to determine gravimetrically and destructively, but are remarkably difficult to measure and monitor in the living plant. In this context, Nuclear Magnetic Resonance (NMR) may help: it can directly and quantitatively detect protons in water and organic compounds, and is able to distinguish between liquids and solids. Unfortunately, NMR is known to be expensive, useful only in the laboratory, and difficult to use. Or is it? In this contribution we introduce a novel class of affordable, mobile NMR device that in their simplest form can be used as an on-line sensors to measure water- and dry matter content, in objects varying in size from pine needles and cereal leaves, to tree trunks and fruit. The devices can be operated in the field, and allow automated, uninterrupted measurements over periods of weeks, with a time resolution of less than a minute. With the addition of some hardware they can also be turned into mobile NMR imagers, capable of measuring flow. We will demonstrate these measurement modalities by means of experiments on a number of model subjects and problems: water storage in the stems and leaves of mangrove exposed to shock wise changes in soil salinity; the dynamics of dry matter deposition and seed water relations during the course of seed filling, and in imaging mode, the detection of air embolism formation in trees exposed to drought