Physical Therapy Interventions for the Management of Biceps Tendinopathy: An International Delphi Study

Recommendations for use of extracorporeal shockwave therapy in sports medicine: an international modified Delphi study

OBJECTIVES

While extracorporeal shockwave therapy (ESWT) may be an efficacious adjunctive treatment option for musculoskeletal injuries, current research is limited by significant heterogeneity within treatment protocols. This study aims to establish international expert consensus recommendations on ESWT terminology, parameters, procedural considerations, contraindications and side effects in the application of ESWT to sports injuries.

METHODS

A systematic literature search was performed on the use of ESWT for musculoskeletal and sports medicine injuries to identify potential panellists, followed by the development of a steering committee-led questionnaire. A three-stage, modified Delphi questionnaire was provided to a panel of 41 international clinical and research experts across 13 countries. Panellists had the opportunity to suggest edits to existing statements or recommend additional statements in Round 1. Consensus was defined as≥75% agreement.

RESULTS

All 41 panellists completed Rounds 1, 2 and 3. Consensus was reached on 69/118 statements (58.5%), including recommendations on terminology and fundamental concepts, indications for use, procedural aspects for tendinopathy and bone pathologies, treatment correlations with imaging, periprocedural and postprocedural considerations, absolute and relative contraindications and potential side effects. Of the 49 statements that did not reach consensus, 17/49 (34.7%) were related to procedural aspects of bone pathology.

CONCLUSION

This international panel presents recommendations on ESWT terminology, indications and treatment considerations to guide ESWT use and decision-making by sports medicine clinicians. While our panel supported the use of ESWT in the treatment of bone pathologies, certain procedural aspects of ESWT specific to these injuries did not reach consensus and require further investigation.

Hip joint kinematic assessment in chronic non-specific low back pain patients. A Delphi study

BACKGROUND

Chronic nonspecific low back pain (CNSLBP) has been associated with movement impairment (MI) of the hip joint. However, evidence supporting this is inconsistent. Agreement from experts may provide rationale and recommendations for the assessment of the hip joint in the management of CNSLBP patients.

OBJECTIVE

Gain expert consensus on whether hip MIs are related to CNSLBP, whether they should be assessed and which movement types and directions they recommend.

METHODS

Through a three-round e-Delphi process, international experts in the field rated levels of agreement for generated themes pertaining to assessing proposed hip joint MI in individuals with CNSLBP and underlying rationales. Consensus was defined a priori as ≥75% ratings on Likert scales with an IQR≤ 1.

RESULTS

International expert panel consisted of a mix of researchers and clinicians with the majority involved in both. Response for round I was 27, round 2 was 21 and round III was 26 individuals. Consensus was achieved for the association of active and passive hip joint MI in CNSLBP and their assessment. 100% agreement was achieved for the rationale regarding compensatory movement of the lumbar spine, and the assessment of passive hip movements, in particular extension. Consensus was also achieved for assessing hip passive flexion, extension, rotations, and abduction, active flexion, extension, and abduction. No agreement was attained regarding passive accessory movement.

CONCLUSION

The assessment of active and passive hip joint MI is regarded by experts as appropriate and informative in the management of and research pertaining to CNSLBP.

Ultrasound guided ultra-minimally invasive long head of the biceps tendon release: Anatomic and cadaver study

PURPOSE

The aim of this study was to describe in volunteers and cadavers the location of the vascular structures at risk for performing a new safe and effective ultra-minimally invasive ultrasound guided long head of the biceps tendon (LHBT) release.

METHODS

First, with Doppler ultrasound, we defined the position of the acromial artery from our distal cutting point, on the posterior margin of the LHBT. Second, we performed an ultra-minimally invasive ultrasound guided LHBT release in cadavers. We described the stump and reported safety (no rotator cuff, vascular, or articular damages) and efficacy (tendon release rate).

RESULTS

In 20 volunteers, the mean distance from the distal cutting point to the acromial artery was 0.9 ± 0.1 cm (range, 0.3-1.6). Ultra-minimally invasive LHBT release was safe and fully effective in the eight specimens. The proximal stump measured a mean of 2.8 cm (range, 1.9-4). There were no complications.

CONCLUSIONS

A safe and effective ultra-minimally invasive ultrasound guided LHBT release in cadavers is feasible through an anterior approach.

Pain, function and peritendinous effusion improvement after dry needling in patients with long head of biceps brachii tendinopathy: a single-blind randomized clinical trial

INTRODUCTION

Long head of biceps brachii tendinopathy, a frequent source of anterior shoulder pain, may lead to discomfort and diminished function. The objective of this study is to assess the efficacy of dry needling and transcutaneous electrical nerve stimulation in these patients.

PATIENTS AND METHODS

Thirty patients were randomized into dry needling and transcutaneous electrical nerve stimulation groups and assessed before treatment, 8 and 15 days after treatment using a visual analogue scale, shoulder pain and disability index, pressure pain threshold, tissue hardness, and biceps peritendinous effusion.

RESULTS

Both treatments significantly reduced the visual analogue scale in immediate (p < 0.001), short-term (p < 0.01), and medium-term effects (p < 0.01). Dry needling outperformed transcutaneous electrical nerve stimulation for the pain (p < 0.01) and disability (p < 0.03) subscales of the shoulder pain and disability index in the short-term and medium-term effects, respectively. Pressure pain threshold increased after both treatments but didn't last beyond 8 days. Neither treatment showed any improvements in tissue hardness of the long head of biceps brachii muscle. Notably, only the dry needling group significantly reduced biceps peritendinous effusion in both short-term and medium-term effects (p < 0.01).

CONCLUSIONS

Dry needling showed non-inferior results to transcutaneous electrical nerve stimulation in reducing pain and disability and demonstrated even superior results in reducing biceps peritendinous effusion (see Graphical Abstract).

TRIAL REGISTRATION

The Institutional Review Board of the China Medical University Hospital (CMUH107-REC2-101) approved this study, and it was registered with Identifier NCT03639454 on ClinicalTrials.gov.

Physical Therapy Utilization Prior to Biceps Tenodesis or Tenotomy for Biceps Tendinopathy

Introduction

Surgery for the management of individuals with long head of the biceps tendon (LHBT) tendinopathy is common. Little is known about physical therapy (PT) utilization prior to surgery. The purpose of this review was to investigate the use of PT prior to biceps tenodesis and tenotomy surgeries by assessing the number of visits and the types of interventions. A secondary objective was to report on themes of PT interventions.

Methods

A retrospective observational cohort study design was used to analyze medical records and report on patient visits, procedure codes based on active or passive interventions, and themes of interventions utilized by PT.

Results

Patient records (n=308) were screened for eligibility, n=62 (20.1%) patients attended PT prior to surgery. The median number of PT visits was four (IQR=3.5), and 39/62 (63%) patients had four or more visits to PT. Active interventions were used in 54.5% (533/978) of the codes billed; passive interventions were used in 45.5% (445/978) of the codes. There was high utilization of therapeutic exercise [93.4% (498/533) of active procedure codes] including muscle performance/resistance, functional activity, motor control and stretching. Manual therapy [84.3% (375/445) of passive procedure codes] included soft tissue mobilization, non-thrust manipulation (glenohumeral joint and cervical spine) and thrust manipulation (thoracic spine).

Conclusions

PT was not commonly utilized prior to undergoing biceps tenodesis and tenotomy surgery. Further research is needed to understand the reasons for low utilization.

Level of Evidence

3b.

Effect of extracorporeal shock wave combined with Kinesio taping on upper limb function during individuals with biceps brachii tendinopathy：protocol for a double-blind, randomised controlled trial

INTRODUCTION

Long head of biceps brachii tendinopathy (LHBT) is characterised by persistent pain and disability of shoulder joint, impairing patients' quality of life. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment, which promotes tissue regeneration and repair. However, ESWT has a side effect that often causes short-term pain and swelling in the treatment area. It is known that the effects of Kinesio taping (KT) on relieving swelling and pain. Due to insufficient clinical evidence from current limited studies, this randomised controlled study aims to explore the effects of ESWT combined with KT on upper limb function during individuals with LHBT.

METHODS AND ANALYSIS

A 2×2 factorial design, double-blind, randomised controlled trial will be conducted. A total of 144 participants will be randomly allocated into one of four groups (KT+ESWT, KT+sham ESWT, sham KT+ESWT or sham KT+sham ESWT) to participate in a 4-week treatment programme. Measurements will be taken at pretreatment (baseline), immediately after treatment and 6 weeks after treatment. The primary endpoint will be the Constant-Murley score (CMS), the secondary endpoints will include the pain Numerical Rating Scale, range of motion, pressure pain threshold and soft tissue hardness of biceps, speed test and global rating of change. Repeated measures analysis of variance will be used to compare differences among the effects of different interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. In addition to international conference reports, findings will be disseminated through international publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100051324.

Physical therapy interventions used to treat individuals with biceps tendinopathy: a scoping review

BACKGROUND

Shoulder pain related to pathology of the long head of the biceps tendon (LHBT) can be debilitating. Chronic LHBT tendinopathy is a common condition that is difficult to treat. Little consensus exists regarding the optimal approach to treating individuals with LHBT tendinopathy.

OBJECTIVE

To systematically scope the literature to identify and present the available information regarding physical therapist interventions used for the management of individuals with LHBT tendinopathy including types of interventions used or recommended.

METHODS

A scoping review of physical therapist interventions used to treat LHBT was conducted of the CINAHL, Embase, Medline, and SportDiscus databases. Full text records reporting physical therapist-based interventions in individuals with proximal LHBT pathology were included. Articles not written in English were excluded.

RESULTS

Of the 4059 records identified, 14 articles met the inclusion criteria. Interventions used to treat LHBT tendinopathy identified in quantitative studies included: extracorporeal shock wave therapy, polarized light, ultrasound, low-level laser, iontophoresis, general exercise, eccentric training, stretching, dry needling, and joint mobilization. Interventions described in literature reviews, clinical commentaries, and a Delphi study included: therapeutic modalities, manual therapy, exercise, dry needling, and patient education.

CONCLUSION

This scoping review reported interventions primarily based on therapeutic modalities in quantitative studies while literature reviews, clinical commentaries, and a Delphi study described the addition of manual therapy, patient education, exercise, and dry needling. Overall, there is a dearth of evidence detailing the conservative management of LHBT tendinopathy.

Congenital absence of the bilateral long heads of the biceps brachii tendons in a patient with Silver-Russell syndrome

Agenesis of the long head of biceps tendon (LHBT) is a congenital anomaly not commonly reported in the literature, and bilateral absence of the LHBT is even more rare. Most cases of LHBT agenesis are found incidentally at arthroscopy or are diagnosed by magnetic resonance imaging after a history of insidious shoulder pain or anterior shoulder instability. We present the magnetic resonance imaging findings of bilateral congenital absence of the LHBT in a 37-year-old male with Silver-Russell syndrome who presented with progressive, bilateral anterior shoulder pain after failing conservative treatment strategies. This case report describes bilateral agenesis of the LHBT in association with a congenital growth disorder that has not been described previously in the literature. We provide a description of key MR imaging findings to assist in making the diagnosis, along with a discussion of potential differential diagnoses, and a review of the current literature on this topic.