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

Mobile NMR for the plant sciences: engineering for sensor-like, outdoor use

Plant breeding was revolutionized by the advent of genetic methods: it has become cheap and easy to generate scores of new genotypes. The bottleneck now has become to test which of the genotypes perform best, and under what conditions. Traditional screening methods test for growth velocity in very young plants by means of photography and image recognition. These methods are fast, but have little predictive value for yield. To test for yield production, currently no methods are available other than the old fashioned way: to grow the crop to maturity and harvest it, a process that takes many months and hectares of field space. In this contribution we demonstrate how mobile NMR enables measurements of yield production way before harvest, while the plant is still growing. The most important indicators of plant performance and yield are water content, dry matter content and sap flow. All of these parameters are exceedingly difficult to measure non-invasively by conventional botanical methods - yet are fairly straightforward to measure by means of relaxometry, MR imaging and MR velocimetry [1-3]. Despite the exciting developments in mobile NMR in the last decade, the application of NMR on plants has mostly remained restricted to the laboratory. Some of the largest challenges of bringing NMR into the field pertain to the hardware. The magnet needs to be light and small enough to be mobile, yet should have a homogeneous region that is large enough to contain the object of interest, and be open or openable in order to fit on or around a stem, branch or fruit. The RF coil, the gradient set (if applicable) and the shielding should be open or openable as well. It further should be possible to mount the system in an arbitrary position in, under or around the plant part of interest. The most challenging factor is temperature. Not only the magnet should be either temperature controlled or temperature stable, but the spectrometer as well. The temperature of the sample on the other hand should if possible be allowed to change in unison with the environment, but should be measured and recorded in order to compensate for temperature induced changes in the Boltzmann equilibrium. In this contribution we present a number of approaches to address these challenges and bring mobile NMR into the field. We tested a number of magnet concepts and explored their suitability for use in simple, sensor-like NMR devices or mobile MRI. To emulate sensor-like applications that could be run on even the simplest of spectrometers we used basic relaxometry to estimate water- and solid content. Such measurements could be done in a highly automated fashion, either leaving the spectrometer to run autonomously for days or control it remotely, and were found to produce data of surprisingly high information content on subjects ranging from the filling of a single rice grain to the daily growth of the trunk of an oak tree