Comparative effect of triamcinolone/lidocaine ultrasonophoresis and injection on pain, disability, quality of life in patients with acute rotator cuff related shoulder pain: a double blinded randomized controlled trial

BACKGROUND

Alleviating inflammation should be considered as one of the first steps of the treatment plan in patients with acute rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To compare the effects of triamcinolone/lidocaine ultrasonophoresis, injection on pain, disability, and quality of life in patients with acute RCRSP.

METHODS

A total of 28 acute RCRSP patients were randomly allocated into two groups of ultrasonophoresis and injection. Both groups received vitamin C and shoulder care education for 10 days and then were subjected to therapeutic interventions. Ultrasonophoresis group received triamcinolone (16 mg) and lidocaine (2mg) using ultrasonophoresis (frequency: 3 MHz, intensity: 1.50 W/Cm2), while the injection group received a single subacromial injection of triamcinolone (80 mg) and lidocaine (10 mg). The main outcomes measures were pain assessed by two scales (visual analog scale), and shoulder pain and disability index (SPADI), disability (SPADI), and quality of life (Western Ontario rotator cuff questionnaire).

RESULTS

Although the main effect of time was statistically significant for all dependent variables (P< 0.01), no significant interaction was found between group and time (P-value (0.12-0.55)). The ultrasonophoresis effect, size for pain, disability, and quality of life were 2.58, 1.43, 1.78, and 1.35, respectively. The injection effect, size for pain, disability, and quality of life were 1.98, 2.02, 1.40, and 1.60, respectively.

CONCLUSIONS

Triamcinolone/lidocaine ultrasonophoresis demonstrated similar outcomes to injection in reducing pain, improving disability, and enhancing quality of life in patients with acute RCRSP in short time. According to our findings, ultrasonophoresis with triamcinolone/lidocaine cream is as effective as triamcinolone/lidocaine injection and can be proposed as a potential adjunctive treatment for patients with acute RCRSP.

The Responsiveness of Three Persian Outcome Measures Following Physiotherapy Intervention in Patients with Chronic Non-Specific Neck Pain

Objectives

A prospective cohort study to evaluate and compare the responsiveness of the Persian version of the neck disability index (NDI), neck pain & disability scale (NPDS), neck outcome score (NOOS), and to determine the minimal clinically important difference (MCID) and minimal detectable change (MDC). To date, no studies have made a direct comparison between the responsiveness of the Persian version of NPDS, NDI, and NOOS questionnaires.

Methods

At the end of the study, 55 patients with chronic non-specific neck pain completed the NPDS, NDI, and NOOS questionnaires at the beginning and end of three weeks of physiotherapy treatment. Additionally, patients completed the global rating of change scale to differentiate between improved and unimproved patients. Comparison of responsiveness was performed using anchor-based methods (receiver operating characteristic (ROC) curve and correlation analysis). MCID and MDC were assessed to investigate relevant changes for each questionnaire.

Results

ROC curves analysis showed areas under the curves of 0.70, 0.64, and 0.43 to 0.63 for the NPDS, NDI, and NOOS subscales, respectively. The correlation coefficients between the global rating of the change scale and the change scores of the NPDS and NDI were 0.38 (P<0.01) and 0.30 (P<0.05), respectively. There were no significant correlations between NOOS subscales and global rating of change score (r=0.001- 0.21, P>0.05). The MCID for the NPDS, NDI, and NOOS subscales were 28.09 (score 0-100), 7.5 (score 0-50), and 13.75 to 28.64 (score 0-100), respectively. The MDCs were found to be in the following order: 47.1 points for NPDS, 36.1 for NDI, and 23.5 to 39.7 for NOOS subscales.

Conclusion

The Persian NPDS seems more responsive than the NDI and NOOS questionnaires. The level of clinically meaningful change in NDI, NPDS, and NOOS questionnaires is in the range of measurement error.

Efficacy of low-level laser therapy on pain, disability, pressure pain threshold, and range of motion in patients with myofascial neck pain syndrome: a systematic review and meta-analysis of randomized controlled trials

Low-level laser therapy (LLLT) is one of recent modalities for treatment of myofascial neck pain (MNP). Several RCTs have been conducted on its effectiveness. The aim of this comprehensive meta-analysis was to evaluate the effectiveness of LLLT on MNP. Electronic databases were searched for identifying eligible studies comparing the effectiveness of LLLT using any wavelength with placebo or active control in myofascial neck pain up to June 2022. Data related to pain intensity, pain pressure threshold (PPT), range of motion (ROM), and disability was analyzed as a pooled estimate of mean difference or standard mean difference (SMD) with 95% confidence intervals (CIs) using random/fixed-effect model. Funnel plot and Egger's linear regression test were also conducted to examine the risk of publication bias. A total of 13 randomized controlled trials were included in this systematic review and meta-analysis. The data assessing laser effectiveness on different outcomes of 556 patients were considered for meta-analysis. Pooled results revealed that LLLT was significantly effective in pain reduction (MD =  - 1.29, 95% CI =  - 2.36; - 0.23, P < 0.001). Also, secondary outcomes including PPT (SMD of 2.63, 95% CI = 0.96; 4.30, P < 0.01) and right bending ROM (SMD of 3.44, 95% CI = 0.64; 6.24, P < 0.01) were improved, while disability (MD of - 7.83, 95% CI =  - 17.1; 0.08, P = 1.34) did not improve significantly after LLLT. Our meta-data revealed that LLLT may reduce myofascial neck pain and its related outcomes. LLLT is suggested to be used by clinicians along with other therapies such as manual and exercise therapy.

Stereoselective pharmacokinetics of flurbiprofen in humans and rats

Flurbiprofen, a 2-arylpropionic acid (2-APA) nonsteroidal anti-inflammatory drug (NSAID), exists as racemate and is used as such. Although the activity of 2-APAs is due mainly to their S-enantiomers, information on the pharmacokinetics of flurbiprofen is usually based on the measurement of total concentrations of S- and R-flurbiprofen. In this work, the pharmacokinetics of flurbiprofen enantiomers following single doses were studied in humans and rats. Upon iv administration of 10 mg/kg of racemic flurbiprofen to male Sprague-Dawley rats, the plasma concentrations were consistently higher for S-flurbiprofen than for R-flurbiprofen (AUC = 134 +/- 39 versus 41 +/- 9 mg.L-1 h). In bile duct-cannulated rats, the biliary excretion contained only 3.6-5.2% of the dose as conjugated flurbiprofen (S:R = 1.2-2.1). After administration of R-flurbiprofen to the rat, both enantiomers were found in plasma [AUC(R):AUC(S) = 0.10-0.16], indicating a limited extent of enantiomeric bioinversion. This is consistent with the previously reported limited extent of flurbiprofen uptake into fat. In healthy volunteers also, significant stereoselectivity was observed in the plasma concentration of the drug after 100-mg oral racemic doses [AUC-(S):AUC(R) = 45.4 +/- 12.7:40.1 +/- 14.3 mg.L-1.h]. As compared with the R-enantiomer, S-flurbiprofen has a smaller volume of distribution (7.23 +/- 1.9 versus 8.41 +/- 3.0 L) and total clearance (1.23 +/- 0.34 versus 1.47 +/- 0.50 L/h), but an equal half-life (4.21 +/- 1.2 versus 4.18 +/- 1.3 h). In urine, on the other hand, the R-configuration was predominant, as greater amounts of the R-enantiomer were found both as conjugated flurbiprofen and as an unidentified metabolite. Negligible amounts of intact flurbiprofen enantiomers were detected in urine. The observed stereoselectivity in humans cannot be attributed to enantiomeric bioinversion, as S-flurbiprofen was not detected in plasma and urine after oral administration of R-flurbiprofen.

Paracervical block with 2-chloroprocaine

Thirty healthy term gravidas in active labor received a paracervical block (PCB) with the ester-type local anesthetic, 2-chloroprocaine (2CP). Good to excellent pain relief resulted in all but 1 case. The duration of action was short (mean 38.9 min), requiring repeat blocks in 6/30 cases. Fetal heart rate and uterine contractions were electronically monitored, and fetal acid-base status was periodically checked by fetal scalp pH measurements. PCB-related fetal bradycardia was observed in 3 cases, but in only 1 case was PCB the only cause for the bradycardia. Fetal acidosis was not observed. No instance of neonatal depression or acidosis as expressed by the 1- and 5-minute Apgar scores and cord blood acid-base evaluation was observed. No maternal complications were observed. It is concluded that paracervical block using 2CP is an effective though short-acting method of pain relief which, when properly monitored, is safe for both mother and fetus.