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PubMed1999

Wound infiltration and drain lavage with ropivacaine after major shoulder surgery.

UNLABELLED: Subcutaneous infiltration and wound lavage with ropivacaine is an alternative to opioids after major shoulder surgery. However, the efficacy and potential toxicity of this method remain unclear. We therefore evaluated plasma ropivacaine concentrations after shoulder infiltration and wound lavage. We subsequently quantified the efficacy of two ropivacaine concentrations. Patients undergoing major shoulder surgery were anesthetized with alfentanil and propofol. The initial patients (n = 18) received ropivacaine 7.5 mg/mL and ropivacaine plasma concentrations were measured in 15-min intervals. The subsequent 45 patients were randomly assigned to: 1) isotonic saline, 2) 3.75 mg/mL ropivacaine, or 3) 7.5 mg/mL ropivacaine. Ten milliliters of each solution was administered subcutaneously and 20 mL was injected into the wound drain which was clamped for 10 min. Supplemental postoperative pain relief was provided by patient-controlled anesthesia using the opioid piritramid (3.5-mg boluses, 6-min lock-out). Postoperative pain scores were recorded on a 100-mm visual analog scale for 4 h in the initial patients and for 10 h in the second part of the study. Unbound ropivacaine plasma concentrations peaked after 15 min at 0.08+/-0.09 microg/mL; the maximum was 0.30 microg/mL, compared with a toxic threshold of 0.6 microg/mL. In the second part of the study, pain scores were significantly lower after 3.75 mg/mL (20+/-15 mm) or 7.5 mg/mL (10+/-9 mm) ropivacaine than saline (35+/-10 mm). Piritramid requirements differed significantly in the three groups, being highest with saline and lowest with ropivacaine 7.5 mg/mL. We conclude that wound infiltration and lavage with 30 mL ropivacaine 7.5 mg/mL after major shoulder surgery resulted in very low pain scores and opioid requirement. IMPLICATIONS: Wound infiltration and lavage with 30 mL ropivacaine 7.5 mg/mL after major shoulder surgery resulted in very low pain scores and opioid requirement.

Amides↗
PubMed1993

Manual palpation and pain threshold in female office employees with and without neck-shoulder symptoms.

OBJECTIVE: The aim of this study was to quantify myofascial tenderness by using manual palpation and the dolorimeter on female office employees with disturbing neck-shoulder symptoms (DS) and no or occasional neck-shoulder symptoms (NOS). The association among neck-shoulder symptoms, pain threshold, and age was also analyzed. DESIGN: The cross-sectional study of female office employees selected on a voluntary basis from two offices. SETTING: The manual palpation of neck-shoulder muscles was analyzed at 16 palpation points defined before the examination. The pain threshold (PT) was measured at four trigger areas of trapezius and levator muscles. PATIENTS: 160 female office employees with mean age 41 (21-60) years; height was 163 (149-178) cm; and weight was 62 (45-115) kg. MAIN OUTCOME MEASURES: Manual palpation findings of neck-shoulder muscles at 16 defined palpation points and PT measurement of trigger areas in trapezius and levator muscles by a dolorimeter. RESULTS: The mean number of tender points was 7.25 (SD, 4.5) in subjects with DS and 3.44 (SD, 3.8) in subjects with NOS; the difference was significant (p < 0.0001). Suboccipital and trapezius muscles were tender in most cases in both symptom groups. The PTs of trapezius and levator muscles were significantly lower in subjects with DS than in subjects with NOS (p < 0.0001-0.0005). The PT of the trapezius muscles in subjects > or = 39 years old with DS was significantly lower than in those with NOS (p < 0.0007-0.0402). The PT of subjects with DS was lower in subjects 39 years old and older than in younger subjects, while the PT in subjects with NOS was higher in older subjects than in younger ones; the differences were statistically nonsignificant. CONCLUSIONS: Suboccipital and trapezius muscles are often tender in subjects with DS and in those with NOS. The finding that the PT of the trapezius muscle in older subjects with DS decreases while the PT in subjects with NOS increases is interesting and needs further investigation.

Adult↗
PubMed1998

Electromyographic analysis of shoulder joint function of the biceps brachii muscle during isometric contraction.

Surface electromyography was performed for both heads of the biceps brachii in 11 healthy men while the muscles were under 30% maximum isometric shoulder flexion and abduction. Elbow related biceps activity was minimized by using a brace locked in neutral forearm rotation. Electromyographic activity was normalized as a percentage of maximal muscle contraction during 24 shoulder motions. Electromyographic activity was detected in all motions examined, suggesting that the biceps muscle acts as a flexor and an abductor of the shoulder. Both heads of the biceps muscle had higher activities during external rotation than during internal rotation for most motions. Activities of both heads increased with arm elevation, but showed little dependence on elbow position. The long head was still active during internal rotation of the shoulder. These findings also suggest that the biceps muscle is a flexor and an abductor of the shoulder, and that the long head can act as a humeral head stabilizer in superior and anterior directions. Muscle fatigue of the biceps and the deltoid muscle also was determined at 30% of maximum isometric flexion. All muscles had significantly decreased mean power frequency and turns count, and increased amplitude and integrated electromyography. The rate of decrease in mean power frequency was larger for the biceps than for the deltoid muscle, and the rate of increase in amplitude was larger for the long head of the biceps than for the short head or for the deltoid muscle. These findings suggest that the long head of the biceps must increase its mechanical output to keep the arm in elevation to a greater extent than do the short head and the deltoid muscle. This may be one of the causes of tendinitis or rupture of the long head.

Adolescent↗
PubMed1998

Shoulder joint kinetics during the push phase of wheelchair propulsion.

The purpose of this investigation was to quantify the forces and moments at the shoulder joint during free, level wheelchair propulsion and to document changes imposed by increased speed, inclined terrain, and 15 minutes of continuous propulsion. Data were collected using a six-camera VICON motion analysis system, a strain gauge instrumented wheel, and a wheelchair ergometer. Seventeen men with low level paraplegia participated in this study. Shoulder joint forces and moments were calculated using a three-dimensional model applying the inverse dynamics approach. During free propulsion, peak shoulder joint forces were in the posterior (46 N) and superior directions (14 N), producing a peak resultant force of 51 N at an angle of 185 degrees (180 degrees = posterior). Peak shoulder joint moments were greatest in extension (14 Newton-meters [Nm]), followed by abduction (10 Nm), and internal rotation (6 Nm). With fast and inclined propulsion, peak vertical force increased by greater than 360%, and the increase in posterior force and shoulder moments ranged from 107% to 167%. At the end of 15 minutes of continuous free propulsion, there were no significant changes compared with short duration free propulsion. The increased joint loads documented during fast and inclined propulsion could lead to compression of subacromial structures against the overlying acromion.

Acceleration↗
PubMed2000

Magnetic resonance-based motion analysis of the shoulder during elevation.

Changes in shoulder motion patterns are relevant in various shoulder diseases, but no in vivo information exists about the relative positions in vivo of the shoulder girdle bones and the supraspinatus muscle in three-dimensional space. Thus, the objective of this study was to perform a motion analysis of these structures during passive arm elevation using open magnetic resonance imaging and three-dimensional image processing. Fourteen volunteers were examined in five positions of abduction (30 degrees-150 degrees) with an open magnetic resonance system. After segmentation and three-dimensional reconstruction, the axis of the supraspinatus, humerus, clavicle, and the plane of the glenoid were determined, and the relative movements were calculated. The ratio for glenohumeral to scapulothoracic motion was 1.5:1 at 60 degrees and 2.4:1 at 120 degrees abduction. At 30 degrees, the axis of the supraspinatus was nearly horizontal, and during abduction a continuous elevation (+123 degrees at 150 degrees abduction) was measured. In the transverse plane, the angle between the supraspinatus and the clavicle axes became larger during abduction because of an increasing retroversion of the clavicle. The study shows specific three-dimensional motion patterns for each bone of the shoulder girdle and the supraspinatus muscle during passive elevation. The technique and results can be used for future studies in patients with pathologic changes of shoulder girdle motion.

Adult↗
PubMed2004

Role of the coracoacromial ligament as restraint after shoulder hemiarthroplasty.

Patients with an irreparable rotator cuff tear and glenohumeral degeneration often are treated with hemiarthroplasty. This procedure has proven effective as long as the coracoacromial ligament remained intact. The ligament reportedly acts as a restraint against anterosuperior dislocation. The purpose of the current study was to test the role of the coracoacromial ligament as an anterosuperior restraint after hemiarthroplasty in shoulders from cadavers with simulated irreparable rotator cuff tears. Six fresh-frozen shoulders were dissected to mimic a massive rotator cuff tear. After a hemiarthroplasty was done, each shoulder was mounted in a fixture, which was attached to a materials testing device. Using this device, the role of the coracoacromial ligament was evaluated by loading the shoulders in various positions and then measuring displacement before and after excision of the ligament. The mean difference in anterosuperior displacement was 3.44 mm. In all shoulders, subjective observation revealed that the humeral head often becomes wedged between the coracoid and the acromion during axial loading after excision of the coracoacromial ligament. Therefore, the coracoacromial ligament should be preserved to enhance the stability of the joint and to preserve the superior fulcrum.

Adult↗
PubMed1999

Localized muscle fatigue decreases the acuity of the movement sense in the human shoulder.

PURPOSE: The purpose of this study was to investigate alterations in the movement sense acuity during localized muscle fatigue in the human dominant shoulder. METHODS: Fourteen healthy volunteers (8 males and 6 females) with a mean age 23 +/- 2 yr participated in the study. The subjects' ability to discriminate movement velocity relative to a reference velocity imposed over the dominant shoulder was tested following two experimental conditions: 1) Light exercise (LE), repetitive isokinetic horizontal flexion/extensions at the shoulder, ranging from 85 degrees to 20 degrees relative to the frontal plane, at 10% of maximal voluntary contraction (MVC) and 2) Hard exercise (HE), same movements as in LE, but performing MVC to fatigue. RESULTS: The results showed that subjects had a lower probability of distinguishing between different movement velocities following HE as compared with those during the LE condition (P < 0.001). When genders were compared, female subjects had a lower probability of distinguishing correctly than male subjects (P < 0.001). CONCLUSIONS: The acuity of the movement sense in the dominant shoulder is reduced in the presence of shoulder muscle fatigue. The possible influence of muscle fatigue via peripheral muscle receptors on movement sense is discussed.

Adult↗
PubMedDate not supplied

Posterior shoulder (glenohumeral) dislocation.

While shoulder dislocations are a common injury, dislocation in the posterior direction is unusual and often missed clinically. A traumatic posterior shoulder dislocation can be caused by a direct blow to the anterior shoulder or if a posteriorly directed force is axially applied through the forward flexed arm. A posterior shoulder dislocation can occur after a violent muscle contraction induced by an electrical shock or grand mal seizure. Posterior shoulder dislocations are commonly associated with posterior glenoid rim fractures and anterior compression fractures of the humeral head. This diagnosis should not be missed if a complete physical and radiographic exam are properly performed.

Adult↗
PubMed1998

Determinants of self-reported neck-shoulder and low back symptoms in a general population.

STUDY DESIGN: A combined cross-sectional and longitudinal design. OBJECTIVES: To investigate relation between, on one hand, self-reported neck-shoulder symptoms and, on the other hand, low back symptoms and self-reported work-related physical load, psychosocial factors, and individual characteristics and to study the influence of physical capacity in adolescence on neck-shoulder and low back symptoms in adulthood. SUMMARY OF BACKGROUND DATA: Heavy physical work and exposure to vibration constitute risk factors for low back problems, and repetitive and static work are risk factors for neck-shoulder symptoms in many jobs. The interplay between individual factors and work-related psychosocial and physical exposure, however, is not well documented. This study addresses effects of adolescent capacity on this interplay in a general population. METHODS: A random sample of 425 Swedish students was investigated when the students were 16 years and 34 years of age. Sixty-five percent participated in both examinations; only those who worked > or = 16 hours/week at the follow-up period, 148 men and 90 women, were included in these analyses. Data about musculoskeletal symptoms, work, and sociodemographic and individual characteristics were collected at the age of 34 years; physical performance data were collected at the ages of 16 years and 34 years. RESULTS: Among the men, self-employment and worry were associated with neck-shoulder symptoms; among the women, monotonous work and high decision latitude were associated with neck-shoulder symptoms. Low back problems were related to monotonous work among men and women and to exposure to vibration among men. Performance in certain fitness tests at the ages of 16 years and 34 years was negatively associated with musculoskeletal symptoms. CONCLUSIONS: The inverse relationships between performance at the age of 16 years and adult musculoskeletal symptoms may imply benefits of early fitness training.

Adolescent↗
PubMed2001

Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group.

STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To evaluate the effectiveness of multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. SUMMARY OF BACKGROUND DATA: Multidisciplinary biopsychosocial rehabilitation programs for neck and shoulder pain require substantial staff and financial resources. They are widely used, despite questionable evidence of their effectiveness. METHODS: The reviewed randomized controlled and controlled trials appraising the effectiveness of biopsychosocial rehabilitation for working age patients with neck and shoulder pain were identified by searching electronic bibliographic databases, checking references, and consulting experts in the rehabilitation field. Four blinded reviewers selected the trials. Two specialists on rehabilitation evaluated the clinical relevance. Two other blinded reviewers extracted the data and assessed the main results and the methodologic quality of the studies. A qualitative analysis was performed to evaluate the level of scientific evidence. RESULTS: After 1808 abstracts and the references of 65 reviews were screened, only two relevant studies were found that satisfied the criteria. One of these was considered a methodologically low-quality randomized controlled trial, and the other was a methodologically low-quality controlled clinical trial. The clinical relevance of included studies was satisfactory. The level of scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain was limited. CONCLUSIONS: There appears to be little scientific evidence for the effectiveness on neck and shoulder pain of multidisciplinary biopsychosocial rehabilitation compared with other rehabilitation methods. There is an urgent need for high-quality trials in this field.

Adult↗
PubMed2000

An alternative slump reduction technique of anterior shoulder dislocations: a 3-year prospective study.

OBJECTIVE: To describe an alternative method of dislocated shoulder reduction and to investigate its success rate when used at a ski resort setting. DESIGN: A prospective observational study. SETTING: Medical center at Australia's largest ski resort during the ski seasons of 1994, 1995, and 1996 (June through early October). The center is a primary care private practice. PATIENTS: There were 199 patients with anterior dislocated shoulders who presented to the center. One patient was excluded from the study because of spontaneous reduction during clothing removal. INTERVENTIONS: Patients had upper body clothing removed, were seated in a chair, and supported in a slumped position by an assistant. The medical officer then performed the reduction once relaxation was achieved. Patients were always offered Entenox (nitrous oxide). MAIN OUTCOME MEASURES: Successful reduction of the anterior dislocated shoulder with or without analgesia. Any complications such as fractures and nerve damage were recorded. RESULTS: The data were recorded by the treating medical officer. 93.2% of the subjects were successfully treated using the "slump" reduction method. The success rate on first attempt using the slump method was 85.6%. Of the remainder, four subjects were reduced by an alternative method and five were sent to hospital for reduction under general anesthesia. Four of these subjects had fractures. CONCLUSION: The slump method of reduction for anterior dislocated shoulders compares favorably with previously documented methods. It would seem to be a particularly useful method when parenteral analgesia is either not available or relatively contraindicated. There were no complications resulting from the use of this method, and it is a method that is easy to learn. The slump method is a safe and effective addition to the primary care physician's options in reducing an anteriorly dislocated shoulder.

Adult↗
PubMed2003

Questionnaire reveals variations in the management of acute first time shoulder dislocations in the Netherlands.

AIM: To collect information about the management of patients with acute first time shoulder dislocation by (orthopaedic) surgeons in the accident and emergency departments of Dutch hospitals. DESIGN: Questionnaires were sent to 131 (orthopaedic) surgeons of 74 Dutch hospitals. METHOD: We enquired whether patients with acute first time shoulder dislocation are managed according to protocols in accident and emergency departments; which radiographs are deemed necessary before and after reduction; which reduction methods are generally performed; and what kind of pain relief or sedatives are generally administered. Furthermore, we enquired into the method and duration of immobilization after reduction. RESULTS: The response rate was 73%. Sixty-five per cent of the hospitals are used to managing acute first time shoulder dislocation according to protocols. Making prereduction and postreduction radiographs is standard practice in almost all hospitals. The most favoured methods of reduction are those according to Kocher and Hippocrates. In 85% of cases sedatives are administered before reduction, and in addition to that systemic analgesia is administered in 30%, whereas intra-articular analgesia is preferred in 25% of cases. CONCLUSION: Apparently, a protocol for the management of acute first time shoulder dislocation is not standardly available in all hospitals. On the basis of current literature and the results of this questionnaire it may be useful to establish a guideline for diagnostic procedures and the management of acute first time shoulder dislocation in accident and emergency departments.

Acute Disease↗
PubMed2005

Radiographic comparison of two glenoid preparation techniques in total shoulder arthroplasty.

We compared the prevalence of periglenoid radiolucencies between two glenoid component preparation techniques used in total shoulder arthroplasties. Seventy-two consecutive patients with primary osteoarthritis had total shoulder arthroplasties using one prosthetic system with flat-back keeled polyethylene glenoid components. Thirty-seven shoulders had glenoid implants that were cemented after standard curettage preparation of the keel slot. Thirty-five shoulders had glenoid implants that were cemented after using bone compaction to prepare the keel slot. The immediate postoperative and 2-year postoperative radiographs were examined to evaluate the presence and progression of periglenoid radiolucencies. The curettage group had a higher rate (38%) of keel radiolucencies than the compaction group (11%) seen on the immediate postoperative radiographs. Both groups had progression of periglenoid radiolucencies with time. Progression of the radiolucent lines was worse in the curettage group 2 years after arthroplasty. Preparation of the glenoid component keel slot with the bone compaction technique seems to achieve better fixation of flat-back keeled polyethylene glenoid components in total shoulder arthroplasties.

Adult↗
PubMed2005

A salvage procedure for refractory shoulder instability.

We present the case of a patient with symptomatic refractory multidirectional shoulder instability who was treated with staged bilateral anterior and posterior glenoid bone augmentation after previous failed arthroscopic and open procedures. The patient was pain free postoperatively and has not had symptoms of instability in either shoulder. At her most recent followup, 24 months after surgery, she had nearly full symmetric shoulder range of motion without anterior or posterior apprehension signs. Her Constant-Murley scores were 77 and 79 on the right and left, respectively, with UCLA scores of 29 on the right and the left shoulders. Her Short Form-36 overall score was 105, indicating overall satisfaction. Currently, the patient states that she can do all daily activities without restrictions. In carefully selected patients, the use of anterior and posterior glenoid bone augmentation may be effective as a salvage procedure in rare cases of refractory multidirectional shoulder instability.

Adult↗
PubMed2005

Measurement of shoulder activity level.

There are many measurement tools for assessing patients' shoulder symptoms (pain) and function (what patients can do), but they do not measure activity (how often a patient engages in activity). This is relevant because activity level can have an important impact on a patient's outcome. Our goal was to develop a short, easy to administer measure of shoulder activity which could be used to predict outcome of shoulder disorders. The activity scale was developed using established principles: item generation, item reduction, pretesting, and reliability and validity testing. The activity rating is a numerical sum of scores for five activities rated on a five-point frequency scale from never performed (0 points) to daily (4 points). Patients were scored on the following criteria: carrying an object 8 lb or heavier by hand, handling objects overhead, weight training with arms, swinging motion (ie, hitting tennis or golf ball), and lifting objects 25 lb or heavier. Two additional multiple choice questions provide a score assessing participation in contact and overhead sports. The activity scale showed excellent reliability and construct validity. It can be completed quickly and used in conjunction with patient-based measures of shoulder outcome to define patient populations for cohort studies, and to assess activity level as a prognostic factor in patients with shoulder disorders.

Activities of Daily Living↗
PubMed2005

Predictors of outcome in neck and shoulder symptoms: a cohort study in general practice.

STUDY DESIGN: An observational prospective cohort study in general practice. OBJECTIVES: To describe the clinical course and to identify predictors of recovery, changes in pain intensity, and changes in functional disability in patients with neck or shoulder symptoms at 3- and 12-month follow-up. SUMMARY OF BACKGROUND DATA: Knowledge on the clinical course and predictors of outcome in neck and shoulder symptoms is limited. Such knowledge would facilitate treatment decisions and may help to inform patients about their prognosis. METHODS: Four hundred and forty-three patients who consulted their general practitioner with neck or shoulder symptoms participated in the study. Baseline scores of pain and disability, symptom characteristics, sociodemographic and psychological factors, social support, physical activity, general health, and comorbidity were investigated as possible predictors of recovery, changes in pain intensity, and changes in functional disability using multiple regression analyses. RESULTS: The recovery rate was low; 24% of the patients reported recovery at 3 months and 32% reported recovery at 12-month follow-up. Duration of the symptoms before consulting the GP and a history of neck or shoulder symptoms increased the probability of an unfavorable outcome. Furthermore, less vitality and more worrying were consistently associated with poorer outcome after 3 and 12 months. The area under the receiver-operator characteristic curve for the model predicting recovery was 0.8 at 3 months and 0.75 at 12 months. The explained variance of the models on pain and functional disability ranged from 43 to 54%. CONCLUSIONS: The results found in this study indicate that besides clinical characteristics, psychological factors also predict the outcome of neck and shoulder symptoms.

Adult↗
PubMed2005

Kinematic alterations in the ipsilateral shoulder of patients with hemiplegia due to stroke.

OBJECTIVE: To evaluate the assumption that shoulder kinematic patterns of the ipsilateral, nonparetic shoulder in hemiplegia are similar to kinematics recorded in a healthy population. DESIGN: Case control study of a convenience sample of ten patients with hemiplegia due to stroke in the subacute phase compared with a control group of similar age. Three-dimensional positions of the scapula and humerus were measured and expressed in Euler angles as a function of active arm elevation in the frontal and sagittal plane and during passive humeral internal/external rotation at an elevation angle of 90 degrees in the frontal and sagittal plane. RESULTS: Compared with controls, in the ipsilateral shoulder of patients, we found both a statistically significant diminished scapular protraction during elevation in the sagittal plane (35 +/- 5 vs. 51 +/- 8 degrees at 110 degrees of humeral elevation) and humeral external rotation during arm elevation in the frontal plane (51 +/- 7 vs. 69 +/- 14 degrees at 110 degrees of humeral elevation). Maximal passive humeral external rotation was found to be impaired in the frontal (64 +/- 13 vs. 98 +/- 14 degrees) and sagittal planes (65 +/- 11 vs. 94 +/- 12 degrees). In addition, there was significantly diminished anterior spinal tilt during humeral internal rotation (-5 +/- 10 vs. -20 +/- 9 degrees) and diminished posterior spinal tilt during external rotation in the frontal plane (-14 +/- 8 vs. -3 +/- 6 degrees). Maximal thoracohumeral elevation in patients was significantly impaired (126 +/- 12 vs. 138 +/- 8 degrees). CONCLUSION: Clear kinematic changes in the ipsilateral shoulder in patients with hemiplegia were found, indicating underlying alterations in muscle contraction patterns. The cause remains speculative. These results suggest that the ipsilateral shoulder should not be considered to function normally beforehand.

Adult↗
PubMed2003

Significance of shoulder function in the reconstruction of prehension with double free-muscle transfer after complete paralysis of the brachial plexus.

Reconstruction of shoulder stability and movement in cases with complete paralysis of the brachial plexus was performed to improve the outcomes for universal function of prehension after double free-muscle transfer (Doi's procedure). In cases in which the C5 or C6 nerve root was available as a donor, neurotization of the supra-scapular nerve was performed with a nerve graft. If the C5 or C6 nerve root was not available, then the contralateral C7 nerve root was chosen as the donor motor nerve and was transferred to the suprascapular nerve by using a vascularized ulnar nerve graft. Seven cases with ipsilateral C4, C5, or C6 nerve root transfer to the suprascapular nerve and one with contralateral C7 transfer were evaluated, and the functional outcomes for the range of shoulder motion were compared with those for patients who had undergone arthrodesis of the humeroscapular joint or had undergone no procedures for shoulder function reconstruction. The patients who underwent supra-scapular nerve repair demonstrated statistically significantly better ranges of motion for flexion and abduction of the shoulder, compared with the other two groups. Shoulder function is important for achieving prehensile function among patients with complete paralysis of brachial function, when they undergo double free-muscle transfer.

Adolescent↗