Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: a systematic review

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Bibliometric and visualized analysis of scientific publications on rehabilitation of rotator cuff injury based on web of science

Background

Since the discovery of rehabilitation as an intervention for rotator cuff injury, its impact on the recovery of rotator cuff injury has attracted crucial attention, and the number of related studies is increasing worldwide. There were no bibliometric and visualized analysis studies in this field. This study aimed to investigate the research hotpots and trends in the rehabilitation of rotator cuff injury via bibliometric and visualized analysis and to identify the future development of clinical practice.

Method

The publications regarding rehabilitation of rotator cuff injury from inception to December 2021 were obtained from the Web of Science Core Collection database. The trends of publications, co-authorship and co-occurrence analysis and visualized analysis were carried out using Citespace, VOSviewer, Scimago Graphica software, and R Project.

Results

A total of 795 publications were included in this study. The number of publications significantly increased yearly. The United States published the highest number of related papers and the papers published by the United States had the highest citations. The University of Laval, the University of Montreal and Keele University were the top 3 most contributive institutions. Additionally, the Journal of Shoulder and Elbow Surgery was the journal with the highest number of publications. The most common keywords were "rotator cuff", "rehabilitation", "physical therapy", "management", and "telerehabilitation".

Conclusion

The total number of publications has shown a steady upward trend. The cooperation between countries globally was still relatively lacking, and therefore it is necessary to strengthen cooperation between different countries and regions to provide conditions for multi-center, large sample, and high-quality research. In addition to the relatively mature rehabilitation of rotator cuff injury such as passive motion or exercise therapy, telerehabilitation has also attracted much attention with the progress of science.

Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: Clinical Practice Guideline Methods

OBJECTIVES: To present the methods used to develop a clinical practice guideline (CPG) with recommendations endorsed by key stakeholders for assessing, managing, and supporting return to work for adults with rotator cuff disorders. DESIGN: Clinical practice guideline development. METHODS: A steering committee composed of the research team of this project led the development of this CPG in 5 phases, which followed the standards of the NICE and AGREE II collaborations. During the preparation phase (I), a multidisciplinary working committee of experts in managing rotator cuff disorders (n = 20) determined the scope and objectives of the CPG. The recommendations development phase (II) included initial knowledge synthesis, development of preliminary recommendations, systematic consultations with a multidisciplinary panel of key stakeholders (n = 51) using a modified three-round Delphi approach and drafting of the original CPG. In the external evaluation phase (III), an external committee of experts evaluated the original CPG using the AGREE II tool. In the dissemination phase (IV), the strategy for disseminating the CPG was developed and implemented. During the update phase (V), the CPG was revised based on an update of the initial knowledge synthesis. RESULTS: Seventy-three preliminary recommendations were developed from the initial knowledge synthesis. During the Delphi consultation, all of these recommendations were endorsed, and one new recommendation was proposed by panelists. The original CPG received an overall AGREE II score of 83% from the external evaluators. In 2021, an update of the initial 2017 knowledge synthesis was conducted and 13 recommendations were revised. CONCLUSION: The 5-phase consensus methods approach guided the development of a high-quality CPG on assessing, managing, and supporting return to work for adults with rotator cuff disorders. J Orthop Sports Phys Ther 2022;52(10):665-674. Epub: 27 July 2022. doi:10.2519/jospt.2022.11307.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Periarticular Neurofascial Dextrose Prolotherapy Versus Physiotherapy for the Treatment of Chronic Rotator Cuff Tendinopathy: Randomized Clinical Trial

BACKGROUND/OBJECTIVE

Rotator cuff tendinopathy is a common cause of shoulder pain. We aimed to compare periarticular (neurofascial) dextrose prolotherapy versus physiotherapy for treatment of chronic rotator cuff tendinopathy in the short term.

METHODS

We carried out a randomized clinical trial with 2 arms at a university hospital. In total, 66 patients with chronic rotator cuff tendinopathy, proven by magnetic resonance imaging, were randomly allocated to 2 groups. The outcomes were change in shoulder pain intensity (primary) and disability (secondary) index using a questionnaire for Shoulder Pain and Disability Index. For physiotherapy, participants received superficial heat, transcutaneous electrical nerve stimulation, and pulsed ultrasound. Also, they carried out an exercise program, 10 sessions of 30 minutes for 3 weeks. For prolotherapy, we used 8 mL of 12.5% dextrose and 40 mg of 2% lidocaine. The mixture was injected 2 times with 1-week interval superficially around the shoulder joint and to tender points along the suprascapular nerve.

RESULTS

Neurofascial dextrose was more effective than physiotherapy for alleviating pain in 2 weeks (p < 0.001), and they were similar 3 months after the interventions (p = 0.055). For disability, dextrose was more effective than physiotherapy 2 weeks and 3 months (both p < 0.001) after the interventions. However, the changes in the physiotherapy group seemed to be more sustained.

CONCLUSIONS

Both interventions are effective for the short-term management of rotator cuff tendinopathy. However, prolotherapy is more successful as the initial treatment. Besides, the treatment time is much shorter for dextrose prolotherapy compared with physiotherapy.

Do we need to improve the reporting of evidence in tendinopathy management? A critical appraisal of systematic reviews with recommendations on strength of evidence assessment

Objective

To critically appraise the quality of published systematic reviews (SRs) of randomised controlled trials (RCTs) in tendinopathy with regard to handling and reporting of results with special emphasis on strength of evidence assessment.

Data sources

Medline from inception to June 2020.

Study eligibility

All SRs of RCTs assessing the effectiveness of any intervention(s) on any location of tendinopathy.

Data extraction and synthesis

Included SRs were appraised with the use of a 12-item tool devised by the authors arising from the Preferred Reporting Items in Systematic Reviews and Meta-Analyses statement and other relevant guidance. Subgroup analyses were performed based on impact factor (IF) of publishing journals and date of publication.

Results

A total of 57 SRs were included published in 38 journals between 2006 and 2020. The most commonly used risk-of-bias (RoB) assessment tool and strength of evidence assessment tool were the Cochrane Collaboration RoB tool and the Cochrane Collaboration Back Review Group tool, respectively. The mean score on the appraisal tool was 46.5% (range 0%–100%). SRs published in higher IF journals (>4.7) were associated with a higher mean score than those in lower IF journals (mean difference 26.4%±8.8%, p=0.004). The mean score of the 10 most recently published SRs was similar to that of the first 10 published SRs (mean difference 8.3%±13.7%, p=0.54). Only 23 SRs (40%) used the results of their RoB assessment in data synthesis and more than half (n=30; 50%) did not assess the strength of evidence of their results. Only 12 SRs (21%) assessed their strength of evidence appropriately.

Conclusions

In light of the poor presentation of evidence identified by our review, we provide recommendations to increase transparency and reproducibility in future SRs.

Subacromial corticosteroid injection versus subcutaneous 5% dextrose in patients with chronic rotator cuff tendinopathy: A short-term randomized clinical trial

Aim

The aim of this study is to compare subcutaneous 5% dextrose versus subacromial corticosteroid injection for the treatment of chronic rotator cuff tendinopathy.

Methods

We carried out a randomized clinical trial with two parallel groups at a university hospital. Overall, 57 (32 women) were included in two groups of corticosteroid (n = 29) and dextrose (n = 28). The mean pain score was 6.6 (1.0). We used a visual analog scale for pain and goniometry for the range of motion. The measurements were repeated 1 month after the interventions. For corticosteroid, a single injection of triamcinolone and 1% lidocaine, and for dextrose, a mixture of 5% dextrose and 2% lidocaine three times weekly were prescribed.

Results

Both interventions were effective in decreasing pain compared to the baseline (both p < 0.001). The difference in pain between the two groups was nearly significant 1-month post-intervention (p = 0.052). The comparison of the two groups in considerable pain reduction (≥2.8) was in favor of dextrose (p = 0.046). The differences in the range of motion were not conclusive. None of the participants reported an important adverse effect.

Conclusion

The 5% dextrose treatment is at least as effective as corticosteroid for reducing pain in patients with rotator cuff tendinopathy.

Physical therapy for tendinopathy: An umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs).

METHODS

Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool. Studies scoring 9 points or higher were further analyzed using GRADE principles.

RESULTS

40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I² = 1.9%, p = 0.361) on visual analogue scale, and grip strength of 9.59 kg; 95% CI, [5.90, 13.27].

CONCLUSIONS

Moderate-quality evidence may support these following interventions: LLLT revealed a statistically and potentially clinically significant improvement in pain and function on the short-term. Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was supported by qualitative evidence only. Caution is advised when interpreting results due to possible pathological differences in tendinopathy at each region.

Short-wave diathermy in the clinical management of musculoskeletal disorders: a pilot observational study

Musculoskeletal disorders are the most common cause of pain and functional limitation in the general population. The study aim was  to evaluate short-wave diathermy (SWD) effects on pain and quality of life in people with musculoskeletal disorders. Eighty participants (31 men, mean age 56 ± 12.49 years) were enrolled, recruiting from outpatient clinics at the Rehabilitation Unit, University Hospital, Padova. Inclusion criteria were pain lasting more than 15 days, pain visual analog scale (VAS) score higher than 50/100 mm, and a diagnosis of osteoarthritis, neck/back pain, or tendinopathies. All participants underwent ten sessions of percutaneous SWD, 3 times/week. Each session lasted 15-20 min, with frequencies of 4 or 8 MHz and heat intensity between 40 and 60 W. Outcomes were assessed before and after treatment. Primary outcome was pain reduction, evaluated by short form McGill pain questionnaire, which includes VAS and present pain intensity (PPI). Secondary outcome was improvement in social and work-related activity limitations. Participants were grouped based on classification of pain [nociceptive and neuropathic pain (group A) vs nociceptive only (group B)]. VAS and PPI improved significantly (p < 0.01). No difference in pain reduction (VAS and PPI) emerged between the groups. Limitations due to pain in work-related and non-work-related activities decreased (p < 0.01); use of pain medications was reduced at T1 vs T0 (p < 0.01). Our results suggest that SWD is effective in reducing musculoskeletal pain in the short term, providing relief and improving quality of life.

Effect of Exergaming on Muscle Strength, Pain, and Functionality of Shoulders in Cancer Patients

Objective: To compare the strength of the middle deltoid muscle by means of dynamometry and the Shoulder Pain and Disability Index (SPADI) in participants in treatment for cancer after the practice of an exergaming protocol. Materials and Methods: We conducted a randomized controlled clinical trial. Thirty-eight voluntary participants were divided into two groups: cancer group (n = 19; age = 61.46 ± 8.79 years; body mass index [BMI] = 28.36 ± 4.94 kg/m³) and control group (n = 19; age = 57.62 ± 7.57 years; BMI = 28.06 ± 3.74 kg/m³), and they participated in the study. All participants performed an exergame protocol by using Xbox 360 Kinect^® (Microsoft, Redmond) with the game Your Shape Fitness Evolved 2012 two to three times per week for 20 sessions. They were evaluated through the isometric dynamometer in the middle deltoid muscle and the SPADI at three moments: preintervention (EV1), after 10 sessions (EV2), and after 20 sessions (EV3). Results: The cancer group scored higher on both the disability index, in all three evaluations, and the pain index, in EV2 and EV3, when compared with the control group. There was a significant reduction in the disability score in EV2 and EV3 when compared with EV1 in the cancer group, whereas pain was lower in EV2 and EV3 when compared with EV1 in the control group. There were no significant interevaluation or intergroup differences in the maximal isometric voluntary contraction of the deltoid muscle of both upper limbs. Conclusion: At the end of the exergaming, protocol reduced the disability of the shoulder joint of the cancer group and decreased the differences between the groups for disability and pain scores, without changing isometric force.

Comparative Study of Pain Relief in Two Non-Pharmacological Treatments in Patients with Partial Rotator Cuff Tears: A Randomized Trial

Background

Pain induction is the primary characteristic of a rotator cuff tear while muscle weakness appears as a secondary feature, leading to further disability.

Objectives

The study aimed to determine the effectiveness of physiotherapeutic interventions through transcutaneous electrical nerve stimulation (TENS) or microcurrent electrical nerve stimulation (MENS) in conjunction with kinesiotherapy in patients with partial thickness rotator cuff tear.

Methods

This was a blinded randomized prospective study. The study recruited 42 outpatients with partial rotator cuff tear under conservative treatment selected from the 401 General Military Hospital of Athens and the University General Hospital ‘Attikon’ during 2015 - 2017. Patients were assessed for pain and disability using the SPADI (shoulder pain and disability index), a numerical rating scale (NRS) for pain, and the EuroQoL-5 questionnaire for the evaluation of the quality of life. The first group received TENS and kinesiotherapy while the second group received MENS and kinesiotherapy. Three measurements were recorded. The first assessment was performed during the initial patient visit; the second after completion of the physiotherapeutic sessions, and the third one three months after the initial assessment. A follow-up ultrasound scan was performed three months after the completion of the therapeutic sessions to assess the anatomical healing of the rotator cuff tear.

Results

Repeated measurements analysis indicated a significant improvement in pain scores, functionality, and patients’ quality of life (P value < 0.001). Comparison of the two treatment methods did not reveal any significant differences (P value > 0.05) despite the fact that the MENS was associated with a greater improvement in pain intensity and TENS with a greater improvement in functionality and quality of life.

Conclusions

Using MENS and TENS appears to be equally effective in terms of pain relief, functional improvement, and quality of life enhancement in patients.

Effect of Psychomotricity in Combination With 3 Months of Active Shoulder Exercises in Individuals With Chronic Shoulder Pain: Primary Results From an Investigator-Blinded, Randomized, Controlled Trial

OBJECTIVE

To evaluate whether psychomotor therapy (PMT) in combination with usual care active exercise (AE) rehabilitation for the shoulder is superior to merely AE.

DESIGN

The trial was a single-center, stratified (by corticosteroid injection [yes or no]), randomized, and controlled superiority trial.

SETTING

Shoulder unit of the orthopedic department at Hospital Lillebaelt, Vejle Hospital.

PARTICIPANTS

Eligible participants (N=87) were adults aged 18-75 years with shoulder complaints lasting for at least 3 months, in addition to a score equal to or below 3 on the Multidimensional Assessment of Interoceptive Awareness score. Furthermore, patients had at least a visual analog scale pain score of 2 at rest, 3 at night, and 5 in activity (range: 0-10).

INTERVENTIONS

Patients were randomized to 12 weeks of AE (control group) or in combination with 5 PMT sessions (intervention group).

MAIN OUTCOME MEASURE

The primary outcome was the patient-reported outcome score Disability of the Arm, Shoulder and Hand questionnaire. The primary endpoint was 12 weeks after baseline.

RESULTS

There was no between-group difference in function between the intervention group and control group.

CONCLUSIONS

Our results showed no additional benefit on patient-reported function and pain from PMT over usual care in patients with long-lasting shoulder pain and low body awareness. This finding suggests that PMT adds no additional benefit to patients' recovery in relation to pain and active function in comparison to standard care.

The effect of Mulligan mobilization on pain and life quality of patients with Rotator cuff syndrome: A randomized controlled trial

BACKGROUND

Mulligan mobilization techniques cause pain and affect the function in patients with Rotator cuff syndrome.

OBJECTIVE

The aim of the study was to investigate the effect of Mulligan mobilization on pain and quality of life in individuals with Rotator cuff syndrome.

METHODS

This study was conducted on 30 patients with Rotator cuff syndrome. The patients were randomized into Mulligan and control group. All the patients participating in this study were treated with conventional physiotherapy. Additionally, the Mobilization with movement (MWM) technique was used in the Mulligan group. Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH), goniometer for the normal range of motion (ROM) and Short Form-36 (SF-36) questionnaires were used for assessment.

RESULTS

Statistically significant improvement was found in the post-treatment VAS, DASH, SF-36, and ROM values significantly improved in both groups (p< 0.05). However, the Mulligan group showed much better results when compared to the control group in ROM, VAS, DASH (p< 0.05). In the SF-36 questionnaire, significant results were obtained for both groups, except the social function parameter. For the SF-36 parameters, both groups performed equally.

CONCLUSIONS

Mulligan mobilization was more effective than general treatment methods for pain as well as normal joint motion, DASH scoring and some parameters of SF-36 compared with general treatment methods.

Long-Term Effect of Pulsed Nd:YAG Laser in the Treatment of Patients with Rotator Cuff Tendinopathy: A Randomized Controlled Trial

OBJECTIVE

The purpose of the present study was to investigate the long-term effect of pulsed Nd:YAG laser on the treatment of rotator cuff tendinopathy.

METHODS

Sixty patients with rotator cuff tendinopathy participated and completed the study. The mean age was 50.2 ± 3.6 years. Participants were randomly assigned to one of two groups: the control group and the treatment group. Both groups were treated with an exercise program, in addition to the pulsed Nd:YAG laser received by the treatment group and the "sham" laser received by the control group, both for three sessions per week for 4 weeks. Outcome measures included pain, assessed by the visual analog scale, and range of motion (ROM), assessed using a traditional goniometer, while the shoulder pain and disability index were used to evaluate the functional recovery of the shoulder joint. Evaluation was carried out before treatment, immediately after treatment, 3 months posttreatment, and 6 months posttreatment. Statistical analyses were used to investigate the effect of interventions and to compare the study groups' pretreatment, posttreatment, and at follow-up points. The significance level was set to p < 0.05.

RESULTS

Pain was significantly decreased after treatment and at follow-up points, while ROM and shoulder functions were significantly improved after treatment and at follow-up intervals in both groups. The improvement was more significant in the treatment group than in the control group posttreatment and at follow-up intervals.

CONCLUSIONS

Pulsed Nd:YAG laser combined with an exercise program seems to be more effective in the treatment of patients with rotator cuff tendinopathy than a sham laser with exercises.

Two Transcutaneous Stimulation Techniques in Shoulder Pain: Transcutaneous Pulsed Radiofrequency (TPRF) versus Transcutaneous Electrical Nerve Stimulation (TENS): A Comparative Pilot Study

Objective

To compare the safety and efficacy of 2 transcutaneous stimulation techniques, transcutaneous pulsed radiofrequency (TPRF) versus transcutaneous electrical nerve stimulation (TENS), in chronic shoulder tendonitis.

Design

A prospective, randomized, and double-blind clinical trial.

Setting

Academic pain service of a city hospital.

Subjects

Fifty patients with sonography-confirmed shoulder tendonitis.

Methods

Fifty patients were randomly allocated into two groups for electrical stimulation treatment with 3-month follow-ups: Group 1 (n=25), TENS and Group 2 (n=25), TPRF. Both groups underwent either treatment for 15 minutes every other day, three times total. Our primary goals were to find any treatment comfort level, adverse event, and changes in Constant-Murley shoulder (CMS) scores. The secondary goals were finding the changes in pain, enjoyment of life, and general activity (PEG) scores.

Results

For primary goals, no adverse events were noted throughout this study. No differences were found between groups for treatment tolerability (3.20 + 0.87 vs. 2.16 + 0.75). Statistically significant lower PEG scores were noticeable with the TPRF group after the course (12.73 + 5.79 vs. 24.53 + 10.21, p=0.013). Their statistical significance lasted for 3 months although the difference gap diminished after 1 month. CMS scores were significantly higher in the TPRF group (70.84 + 6.74 vs. 59.56 + 9.49, p=0.007) right after treatment course but the significance did not last.

Conclusions

In treating chronic shoulder tendinitis using two transcutaneous stimulation techniques, both TPRF and TENS are safe and effective. TPRF is superior to TENS.

Electrically stimulated acupuncture increases renal blood flow through exosome-carried miR-181

Acupuncture with low-frequency electrical stimulation (Acu/LFES) can prevent muscle atrophy by increasing muscle protein anabolism in mouse models of chronic kidney disease. During the treatment of muscle wasting, we found that Acu/LFES on the gastrocnemius muscle of the leg enhances renal blood flow. We also found that Acu/LFES increases exosome abundance and alters exosome-associated microRNA expression in the circulation. When exosome secretion was blocked using GW4869, the Acu/LFES-induced increase in renal blood flow was limited. This provided evidence that the increased renal blood flow is exosome mediated. To identify how exosomes regulate renal blood flow, we performed microRNA deep sequencing in exosomes isolated from treated and untreated mouse serum and found that the 34 microRNAs are altered by Acu/LFES. In particular, miR-181d-5p is increased in the serum exosome of Acu/LFES-treated mice. In silico searching suggested that miR-181d-5p could target angiotensinogen. Using a luciferase reporter assay, we demonstrated that miR-181 directly inhibits angiotensinogen. When Acu/LFES-treated muscle was excised and incubated in culture medium, we found that the amount of exosomes and miR-181d-5p was increased in the medium providing evidence that Acu/LFES can increase miR-181 secretion. We conclude that Acu/LFES on leg hindlimb increases miR-181 in serum exosome leading to increased renal blood flow. This study provides important new insights about the mechanism(s) by which acupuncture may regulation of muscle-organ cross talk through exosome-derived microRNA.

Comparison of different electrotherapy methods and exercise therapy in shoulder impingement syndrome: A prospective randomized controlled trial

OBJECTIVE

The aim of this study was to assess and compare the effects of different electrotherapy methods and exercise therapy on pain, function and quality of life in shoulder impingement syndrome.

METHODS

Eighty-three patients (66 females, 17 males; mean age: 48.2 ± 7.33 years) with shoulder impingement syndrome were selected and 79 of them were randomly allocated into four groups. Group 1 (n = 19, mean age: 47.89 ± 7.12 years) was given hot pack and exercises, Group 2 (n = 20, mean age: 47.70 ± 6.51 years) was given hot packs, exercises and interferential current, Group 3 (n = 20, mean age: 48.50 ± 8.34 years) was given hot packs, exercises and TENS and Group 4 (n = 20, mean age: 48.55 ± 7.89 years) was given hot packs, exercises and ultrasound three times a week for four weeks. Assessments were made before treatment, right after it and three months after that using the visual analog scale (VAS), Short Form-36 (SF-36) and the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measures.

RESULTS

At the fourth week and third month assessments, all groups showed significant improvements in terms of pain, DASH and SF-36 physical component scores (p < 0.05). In intragroup comparisons, a significant difference between pre- and post-treatment results was found only in SF-36 mental component scores of Group 2. No significant difference was observed between the groups in any stage of the study period (p > 0.05).

CONCLUSION

Application of ultrasound, interferential current and TENS in addition to exercise therapy in shoulder impingement syndrome treatment had similar improvements in terms of pain, function and physical component of quality of life. However, interferential current treatment showed significantly better outcomes for the mental component of quality of life.

LEVEL OF EVIDENCE

Level I, Therapeutic study.