IDIOPATHIC ADHESIVE CAPSULITIS: A Prospective Functional Outcomee Study of Nonoperative Treatment.
The Journal of Bone and Joint Surgery, 82-A October 2000
Griggs MD, Sean
Ahn MD, Anthony
Green MD, Andrew

ABSTRACT
The purpose of this study was to measure the outcomes of a stretching exercise program provided to patients with phase-II idiopathic adhesive capsulitis. The patients were taught the following 4 exercises: Self passive ER, flexion, horizontal adduction, and IR, along with pendulum exercises. The patients were instructed to perform these stretches 5 times per day, only to the point of tolerable discomfort. The patients were also referred to physical therapy.
The mean follow up time was 22 months, with a range of 12-41 months. One patient died, 3 were lost, and 59 had "complete follow ups, including physical examination and outcome assessment". 14 additional patients finished their evaluation questionnaires but did not physically participate in the examination. One group of patients, consisting of 66 patients, did not receive manipulation or capsular release under anesthesia. Another group of 5 patients did.

RESULTS

1. DM and male gender were the only variables associated with greter limitations of final motion
2. There was not a significant relationship between the gains in ROM and outcome for pain or DASH score
3. The initial pain, during activity, for the exercise group was related to a greater DASH score at the end
4. Overall, patients gained ROM, but the final ROM was still significantly less than uninvolved side
5. At the end, 20 could not throw a ball 30 yards overhand, 11 could not lift 8 lbs shoulder level with an extended elbow, 11 could not carry 20 lbs at their side and 8 could not toss a soft ball underhand 30 ft.
6. Of the original 71 were not satisfied with the results of the protocol and elected to undergo a procedure to increase motion
7. When compared to the general population, the patients displayed a significantly higher mental health score.
8. The limitations at the end of the study were acceptable to most of the patients and did not appear to affect their general health.
9. At the end, 10% still had pain at rest, and 27% had pain with activity. The DASH questionnaire showed that while satisfied, 40% still had abnormal shoulder function
10. Patients with the worst perception at the beginning of the study had the worst outcomes
11. When the protocol failed, the results of a following manipulation or release were limited

COMMENTS
The above results comprise only about 25 percent of the conclusions made by the authors, but I chose the ones that I felt most affect a typical PT. This study verifies what most of us already know, that a stretching program will benefit the patient. This study takes the next step to quantify the results in relation to the opposite shoulder and the patients perception of their shoulder.

The authors note that they sent the patients to formal PT to be taught the exercises, but "Unfortunately, we had little control over the actual number of formal sessions, which tended to be determined by the individual therapists". I would like to know if there was variability in the treatments provided by the therapists, i.e. did some just perform heat, US, massage while others performed skilled manual therapy? How many different PT's were utilized? Why didn't the physicians mandate the PT's follow a protocol?

I remember reading a few years ago, in a medical journal, a study on adhesive capsulitis that implied physical therapy was a waste of money to treat the condition, as the average time of treatment was 9 months!! I still regret that I did not write the physican and indicate he needs to find a more proficient therapist. The mean duration of follow up for the above study was 22 months, and I find the outcomes to be poor. I think that with the appropriate level of manual stretching, modalities as needed, and a home program, the results should be obtained in an average of 2 months, based on the results at my practice.

INTRAMUSCULAR CORTICOSTEROID INJECTION FOR HAMSTRING INJURIES: A 13 Year Experience in the NFL.
The American Journal of Sports Medicine, June 2000 Vol. 28, Number 3
William Levine, MD, John Bergfeld, MD, William Tessendorf, ATC, Claude Moorman III, MD

ABSTRACT
This study found that between January 1985 and January 1998, 431 NFL football players suffered a hamstring injury requiring treatment. 13% suffered severe injuries, with a palpable defect in the muscle, and were treated with an IM injection of a corticosteroid and anesthetic. There were no complications, no strength deficits, the ability to generate normal power was normal, as was the muscle bulk and tone. There was no control study, and the authors conclude that IM corticosteroid injection decreases the amount of practice and game time missed, and speeds recovery safely. The authors also create a grading system to classify the injuries:

Type I: Proximal tendon and may involve the ischial tuberosity

Type II: Muscle and musculotendinous junction

A: Diffuse, with no palpable defect
B. Palpable lesion

Type III Distal tendon insertion.

The athletes with Type IIb were used for this study, most within 72 hours of injury. Dexamethasone Sodium Phosphate was used as the corticosteroid. Players also received treatment in the training room, and were placed on NSAID's

The authors acknowledge that this is a retrospective study with no control, and that isokinetic testing was not done to test muscle function, although no functional deficits were found.

COMMENT
I reviewed this study primarily because some therapists have a concern when using dexamethasone iontophoresis with this type of injury. With the ionto dosage being only 15-20% that of an injection, I consider the above study to support the idea that this is a good treatment alternative for this type of injury, and that safety concerns may be overstated. I would like to see a double-blind study with this type of athletic population testing the efficacy and safety of iontophoresis and hamstring injuries.

APPLICATION OF NUCLEUS PULPOSUS TO THE NERVE ROOM SIMULTANEOUSLY REDUCES BLOOD FLOW IN THE DORSAL ROOT GANGLION AND CORRESPONDING HINDPAW IN THE RAT.
Shoji Yabuki, MD, DMSc, Tamaki Igarashi, MD, and Shinichi Kikuchi, MD, DMSc. Spine, Volume 25, Number 12, June 15, 2000.

ABSTRACT
In this study, 16 rats had nucleus pulposis (NP) applied to the L5 nerve root in order to clarify the effects on the dorsal root ganglion (DRG) and hindpaws. For the control group, the same volume of muscle tissue was applied. Blood flow to the DRG, and hindpaws was measured with a 2 channel laser Doppler flowmeter.

The results are as follows:

1. Only the NP-treated nerve roots showed blood flow reduction and edema formation in the DRG
2. NP also affected the blood flow to the corresponding hindpaw.

The authors consider the following hypothesis: NP causes increased endoneurial fluid pressure and decreased blood flow to the DRG. This may cause sympathetic activity and ectopic firing in the DRG. The sympathetic activity may cause even further decreased blood flow in the DRG, and cause a vasocontriction via a somatosympathetic reflex, inducing decreased blood flow in the hindpaw. This could explain the decreased temperature that can sometimes be seen or reported in HNP cases. This activity could also explain the etiology of radicular pain

COMMENT
While this study may not directly affect treatment, it helps the clinician better understand the pathogenesis of HNP patients, and may give the clinician more information to explain to the patient exactly what may be happening, and why the pain may be occurring.