Ultrasound assessment of the inferior glenohumeral capsule in normal shoulders-a study of measurement variables and reliability

OBJECTIVES

To establish the reliability of a standardised ultrasound protocol to measure normal inferior glenohumeral capsule (IGHC) thickness and to investigate the effects of age, sex, hand dominance and angles of abduction on the thickness.

METHODS

IGHC images were obtained at 60^o, 90^o and 180^o abduction angles of 151 asymptomatic shoulders in supine position. Following the proposed guidelines, three sonographers blindly measured the IGHC thicknesses for intra- and interrater reliability assessments.

RESULTS

The intrarater reliability was excellent (intraclass correlation coefficient value = 0.95; 95% CI = 0.92-0.97). The interrater reliability was moderate (intraclass correlation coefficient value = 0.74; 95% CI = 0.60-0.83). The mean IGHC thickness values in mm ± SD at 60^o, 90^o and 180^o abduction angles for males were 3.3 ± 0.93, 3.0 ± 0.80 and 2.6 ± 0.55 and those for females were 2.7 ± 0.86, 2.4 ± 0.7 and 2.0 ± 0.56 respectively. Although males had thicker IGHC, the rate at which the thickness reduced with increased abduction was same in both males and females. Age and hand dominance had no effect.

CONCLUSION

The normal IGHC thickness varies with sex and the abduction angle of the arm at which it is measured. A large variation of IGHC thickness exists in the normal population.

ADVANCES IN KNOWLEDGE

The results of this study discourage the use of a single value of IGHC thickness and emphasise the importance of comparing the thickness of the symptomatic side to that of the asymptomatic side of the same subject at the same abduction level. The guidelines provided in this study can be used in clinical practice and in future research studies.

Ultrasound Features for the Diagnosis of Adhesive Capsulitis/Frozen Shoulder: A Systematic Review

While ultrasound has become a preferred tool for musculoskeletal imaging, differing ultrasound findings that have been reported in patients with adhesive capsulitis can create confusion and misconceptions. This systematic review was aimed at summarizing all the ultrasound features currently described in the literature and providing a critical analysis of the sources to allow the readers to make a well-informed decision on the reliability of these features in the diagnosis of this condition. Databases were searched for original studies up to August 2021. Twenty-three studies were included. The QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool was used to assess the quality of each selected article. Fourteen ultrasound features were identified. A quality analysis of all ultrasound features was performed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework. All studies exhibited considerable heterogeneity in investigated ultrasound features and methodologies employed; therefore, meta-analysis was not considered to be appropriate. Hence, narrative synthesis was performed. The overall quality of each ultrasound outcome was found to be of "low" to "very low" level, and the generalisability of the results was also thought to be limited. Cautious interpretation and clinical correlation are recommended while applying these ultrasound features in clinical practice.

Does participatory ergonomics reduce musculoskeletal pain in sonographers? A mixed methods study

Introduction

Sonographers in the Western New South Wales Local Health District (WNSWLHD) reported a musculoskeletal pain prevalence rate of 95%. Participatory ergonomics, where workers are consulted about improving work conditions, was utilised to identify work-related musculoskeletal disorder (WMSD) risks and potential solutions. The aim of this study was to compare the prevalence of WMSD in a cohort of sonographers before and after implementation of ergonomic changes that were driven by recommendations from a participatory ergonomics approach.

Methods

This observational mixed methods study analysed the impact of participatory ergonomic-driven interventions on changes on musculoskeletal pain in a cohort of sonographers employed within the WNSWLHD. A retrospective analysis of 10 sonographer WMSD pain surveys over five sites was completed, along with semi-structured interviews regarding which interventions were perceived as useful, which interventions were not implemented and any barriers to implementation.

Results

Installation of patient monitors, use of ergonomic scanning techniques and job rotation were perceived as responsible for decreased musculoskeletal pain. Taking lunch breaks and microbreaks, use of antifatigue mats and having two sonographers perform mobile exams were not fully implemented. No interventions were perceived as responsible for increased pain.

Conclusion

This small study provides preliminary evidence that a participatory ergonomics approach facilitated identification of occupation and site-specific risks for WMSD in the WNSWLHD, allowing implementation of ergonomic changes to be tailored to the workplace, resulting in a safer work environment for sonographers.

Effectiveness of workshops to teach a home-based exercise program (BEST at Home) for preventing falls in community-dwelling people aged 65 years and over: a pragmatic randomised controlled trial

Background

Falls are a significant public health issue. There is strong evidence that exercise can prevent falls and the most effective programs are those that primarily involve balance and functional exercises, however uptake of such programs is low. Exercise prescribed during home visits by health professionals can prevent falls however this strategy would be costly to deliver at scale. We developed a new approach to teach home exercise through group-based workshops delivered by physiotherapists. The primary aim was to determine the effect of this approach on the rate of falls among older community-dwelling people over 12 months. Secondary outcomes included the proportion of people falling, fear of falling, physical activity, lower limb strength, balance and quality of life.

Methods

A randomised controlled trial was conducted among community-dwelling people aged ≥65 in New South Wales, Australia. Participants were randomised to either the intervention group (exercise targeting balance and lower limb strength) or control group (exercise targeting upper limb strength).

Results

A total of 617 participants (mean age 73 years, +SD 6, 64% female) were randomly assigned to the intervention group (n = 307) or control group (n = 310). There was no significant between-group difference in the rate of falls (IRR 0.91, 95% CI 0.64 to 1.29, n = 579, p = 0.604) or the number of participants reporting one or more falls (IRR 0.99, 95% CI 0.76 to 1.29, n = 579, p = 0.946) during 12 month follow-up. A significant improvement in the intervention group compared to control group was found for fear of falling at 3, 6 and 12 months (mean difference 0.50, 95% CI 0.2 to 0.8, p = 0.004; 0.39, 95% CI 0.001 to 0.8, p = 0.049; 0.46, 95% CI 0.006 to 0.9, p = 0.047, respectively), and gait speed at 3 months (mean difference 0.09 s, 95% CI 0.003 to 0.19, p = 0.043). No statistically significant between-group differences were detected for the other secondary outcomes.

Conclusions

There was no significant intervention impact on the rate of falls, but the program significantly reduced fear of falling and improved gait speed. Other exercise delivery approaches are needed to ensure an adequate intensity of balance and strength challenge and dose of exercise to prevent falls.

A comparison between measurement properties of four shoulder-related outcome measures in Nepalese patients with shoulder pain

Purpose

The Patient-Specific Functional Scale (PSFS), Disability of the Arm, Shoulder and Hand (DASH), Quick-DASH, and Shoulder Pain and Disability Index (SPADI) are frequently used instruments in shoulder functional assessment. They are available in Nepali and all but the PSFS has been validated for shoulder assessment. Therefore, the aim of this study was to validate the Nepali PSFS in shoulder pain patients and to compare validity, reliability, and responsiveness of all four instruments to provide a recommendation for their use.

Method

Patients attending physiotherapy completed the Nepali PSFS at baseline and follow-up (1–3 weeks). It was tested for reliability using internal consistency (Cronbach’s α), intraclass correlation coefficient (ICC), construct validity by hypothesis testing and responsiveness by anchor-based method using Area Under the Curve (AUC). The instruments were compared based on reported measurement properties and patients’ preference.

Results

156 patients enrolled at baseline and 121 at follow-up. The PSFS showed sufficient reliability (α = 0.70, ICC = 0.82), construct validity (all three hypotheses met) and responsiveness (AUC = 0.83). Measurement property comparison demonstrated adequate reliability and validity, while PSFS was the most responsive instrument. Patients favoured the verbal rating scale of the DASH/Quick-DASH. The DASH had a lower completion rate for ‘culturally sensitive’ and ‘uncommon’ activities.

Conclusion

The Nepali PSFS is a reliable, valid, and responsive instrument in shoulder functional assessment. The combined use of the Quick-DASH or SPADI with the PSFS is recommended for a comprehensive assessment of Nepali shoulder pain patients in clinical and research settings. They are shorter, more appropriate to the Nepali context and provide balanced self-evaluation.

The effectiveness of EMG-driven neuromusculoskeletal model calibration is task dependent

Calibration of neuromusculoskeletal models using functional tasks is performed to calculate subject-specific musculotendon parameters, as well as coefficients describing the shape of muscle excitation and activation functions. The objective of the present study was to employ a neuromusculoskeletal model of the shoulder driven entirely from muscle electromyography (EMG) to quantify the influence of different model calibration strategies on muscle and joint force predictions. Three healthy adults performed dynamic shoulder abduction and flexion, followed by calibration tasks that included reaching, head touching as well as active and passive abduction, flexion and axial rotation, and submaximal isometric abduction, flexion and axial rotation contractions. EMG data were simultaneously measured from 16 shoulder muscles using surface and intramuscular electrodes, and joint motion evaluated using video motion analysis. Muscle and joint forces were calculated using subject-specific EMG-driven neuromusculoskeletal models that were uncalibrated and calibrated using (i) all calibration tasks (ii) sagittal plane calibration tasks, and (iii) scapular plane calibration tasks. Joint forces were compared to published instrumented implant data. Calibrating models across all tasks resulted in glenohumeral joint force magnitudes that were more similar to instrumented implant data than those derived from any other model calibration strategy. Muscles that generated greater torque were more sensitive to calibration than those that contributed less. This study demonstrates that extensive model calibration over a broad range of contrasting tasks produces the most accurate and physiologically relevant musculotendon and EMG-to-activation parameters. This study will assist in development and deployment of subject-specific neuromusculoskeletal models.

The effectiveness of ergonomics interventions in reducing upper limb work-related musculoskeletal pain and dysfunction in sonographers, surgeons and dentists: a systematic review

The aim of this systematic review was to summarise the effects of ergonomics interventions on work-related upper limb musculoskeletal pain and dysfunction, and on productivity in sonographers, surgeons and dentists. A total of 31 studies were included. All studies reported effects on upper limb pain. Nine studies reported effects on dysfunction and only two studies reported effects on productivity. Moderately strong evidence in reducing upper limb pain was found for instigation of microbreaks into long duration surgical procedures, and the use of wider, lighter handles in dental instruments. Moderate evidence was also found for use of prismatic glasses and favourable positioning in reducing upper limb pain. Weak, inconsistent or no evidence was found for all other ergonomics interventions in reducing upper limb pain and dysfunction and increasing productivity. The lack of high quality research, particularly in sonographers and in the outcome of productivity, should be addressed. Practitioner summary: This systematic review investigates the effectiveness of ergonomics interventions on upper limb pain, dysfunction and productivity in sonographers, dentists and surgeons. Instigation of microbreaks during long duration procedures and the use of wider, lighter instrument handles were most effective in reducing upper limb work-related pain. Abbreviations: ANOVA: analysis of variance; CLS: conventional laparoscopic surgery; DMAIC: define, measure, analyze, improve and control; GRADE: grading of recommendations, assessment, development and evaluations; HD: high definition; PRISMA: preferred reporting items for systematic reviews and meta-analyses; PROSPERO: The International Prospective Register of Systematic Reviews; RCT: randomised control trial; SILS: single incision laparoscopic surgery; VITOM: video telescopic operative microscope; WNSWLHD: Western New South Wales Local Health District; WMSD: work related musculoskeletal disorder.

Role of the kinetic chain in shoulder rehabilitation: does incorporating the trunk and lower limb into shoulder exercise regimes influence shoulder muscle recruitment patterns? Systematic review of electromyography studies

OBJECTIVE

To investigate the influence of trunk and lower limb motion on electromyography (EMG) muscle activity and recruitment patterns around the shoulder.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, PEDro, AMED, PubMed, Cochrane Central Register of Controlled trials, Cochrane Database of Systematic reviews, SportsDiscuss and PROSPERO.

ELIGIBILITY CRITERIA

Studies investigating both multiregional kinetic chain (KC) shoulder exercises and localised non-kinetic chain (nKC) shoulder exercises in healthy subjects under the same experimental conditions were included in this review.

RESULTS

KC exercises produced greater EMG activation levels in 5 of 11 studies for the lower trapezius. Of the remaining studies, five found no difference between the exercise types and one favoured nKC exercises. KC exercises produced greater EMG activation levels in 5 of 11 studies for the serratus anterior. Of the remaining studies, three reported the opposite and three found no significant difference between the exercise types. nKC exercises produced greater EMG activation in infraspinatus in three of four studies. KC exercises produced the lowest trapezius muscle ratios in all studies. Studies investigating the upper trapezius, middle trapezius, supraspinatus, subscapularis, biceps brachii, latifissimus dorsi, pectoralis major, deltoid, and trapezius and serratus anterior ratios showed inconsistency.

CONCLUSION

This review found evidence that integrating the KC during shoulder rehabilitation may increase axioscapular muscle recruitment, produce lower trapezius muscle ratios and reduce the demands on the rotator cuff. Stepping appears preferable to squatting.

PROSPERO REGISTRATION NUMBER

CRD42015032557, 2015.

Nepali translation, cross-cultural adaptation and measurement properties of the Shoulder Pain and Disability Index (SPADI)

Background

The Shoulder Pain and Disability Index (SPADI) is a 13-item shoulder-specific patient-reported outcome measure (PROM). The English version is easy to use and has demonstrated excellent measurement properties for both clinical and research settings. The availability of the SPADI in Nepali would facilitate shoulder research and enhance management of patients with shoulder pain in Nepal. Therefore, the purpose of this study was to translate and cross-culturally adapt the SPADI into Nepali (SPADI-NP) and evaluate its measurement properties.

Methods

The translation and adaptation process followed international guidelines. Participants completed SPADI-NP on two assessments (N = 150 at initial and 119 at follow-up assessment). A Nepali version of the Global Rating of Change score was completed at follow-up. Assessment of measurement properties included analysis of internal consistency (Cronbach’s α), minimal detectable change (MDC) with standard error of measurement (SEM), test-retest reliability (intraclass correlation coefficient; ICC), validity (factor structure, construct using Pearson’s correlation with the Disability of Arm and Hand [DASH]) and responsiveness (area under the curve; AUC) with minimal important change (MIC).

Results

Minor changes were integrated in the adaptation process to improve cultural relevance such as dress items. Items were largely loaded under two factors (pain and disability), internal consistencies were good for the pain construct (α = 0.82) and disability (α = 0.88) and test-retest reliability was excellent (pain = 0.89, disability = 0.96). MDC was 5.7 (out of 100) with SEM = 2.1. Strong associations with the DASH (r = 0.63 pain, r = 0.81 disability) demonstrated its construct validity. The AUC was 0.68 and MIC was 12.3 (out of 100).

Conclusion

The Nepali version of the SPADI demonstrated excellent reliability and validity. It can be used for the assessment of shoulder pain and disability in patients with shoulder pain in Nepal in both clinical practice and research.

Cross-cultural adaptation and measurement properties of the Nepali version of the DASH (disability of arm, shoulder and hand) in patients with shoulder pain

Background

Patient-reported outcome measures (PROMs) are important tools in both clinical practice and research. However, no upper extremity PROM to assess physical disability is available in Nepali. The most commonly used and recommended questionnaire for the shoulder is the Disability of Arm, Shoulder and Hand (DASH). Therefore, the aim of the study was to translate and cross-culturally adapt the DASH into Nepali and determine its measurement properties.

Methods

The translation and cultural adaptation process followed international standard procedures. The translated Nepali version of the questionnaire (DASH-NP) was completed by 156 patients with shoulder pain from three Nepali hospitals at an initial assessment and by 121 at follow-up. A Nepali version of Global Rating of Change (GROC-NP) was completed at follow-up to dichotomise improved and stable participants. Measurement properties testing included: internal consistency (Cronbach's alpha), test-retest reliability (Intraclass Correlation Coefficient, ICC), Minimal Detectable Change (MDC), construct validity - factor analysis, hypothesis testing with the Shoulder Pain and Disability Index (SPADI) (Pearson Correlation = r) and responsiveness - Area Under the Curve with minimal important change.

Results

Significant adaptations such as changing measurement units, activities and terminology were incorporated to improve cultural relevance. Internal consistency (α = 0.92) and test-retest reliability (ICC = 0.97, 95% CI: 0.94–0.98, p < 0.001) were excellent. The MDC was 11 out of 100 points. There were moderate-high positive correlations with the SPADI pain and disability items (rs = 0.63 and 0.81, P < 0.001). Four factor solution was retrieved for the DASH-NP. The Area Under the Curve was 0.69 (95% CI: 0.57 - 0.81, p < 0.001) with minimal important change of 11.2/100 points.

Conclusions

The Nepali translation of the DASH is comprehensible, easy to administer via self-report or interview. It is found to be a reliable, valid, and responsive measure in patients with shoulder pain in Nepal. The DASH-NP can be used to assess shoulder pain related disability in Nepal for clinical practice or research.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1105-1) contains supplementary material, which is available to authorized users.

Trial Protocol: Home-based exercise programs to prevent falls and upper limb dysfunction among community-dwelling older people: study protocol for the BEST (Balance Exercise Strength Training) at Home randomised, controlled trial

INTRODUCTION

Falling when older is a major public health issue. There is compelling evidence to show that specific exercise programs can reduce the risk and rate of falls in community-dwelling older people. Another major health issue for older people living in the community is upper limb dysfunction, including shoulder pain. Home-based exercise programs appeal to some older people, due to their convenience.

RESEARCH QUESTIONS

This trial aims to determine the effectiveness and cost-effectiveness of a home-based lower limb exercise program compared with a home-based upper limb exercise program to prevent falls and upper limb dysfunction among community-dwelling people aged 65+ years.

DESIGN

Randomised, controlled trial.

PARTICIPANTS AND SETTING

A total of 576 community-dwelling people will be recruited from the Illawarra and Shoalhaven regions of New South Wales, Australia.

INTERVENTION

Participants will be randomised to either a home-based lower limb exercise intervention or a home-based upper limb exercise intervention. The lower limb program is designed to improve balance and strength in the lower limbs. The upper limb program is designed to improve upper limb strength and mobility. Participants will attend three group-based instruction sessions to learn and progress the exercises, and will be instructed to perform the exercises three times per week at home for 12 months.

OUTCOME MEASURES

The two primary outcomes will be fall rates, recorded with monthly calendars for a 12-month period, and upper limb dysfunction, measured with the Disability of the Arm, Shoulder and Hand questionnaire. Secondary outcomes will include: lower limb strength and balance; shoulder strength and mobility; physical activity; quality of life; attitudes to exercise; proportion of fallers; fear of falling; and health and community service use. The cost-effectiveness of both exercise programs from a health and community service provider perspective will be evaluated.

ANALYSIS

Negative binomial regression models will be used to estimate the between-group difference in fall rates. Modified Poisson regression models will be used to compare groups on dichotomous outcome measures. Linear regression models will be used to assess the effect of group allocation on the continuously scored measures, after adjusting for baseline scores. Two economic evaluations will be conducted: the first will assess cost-effectiveness of the lower limb program compared with the upper limb program; and the second will assess cost-effectiveness of the upper limb program compared with the lower limb program.

DISCUSSION

If effective, the trial will provide a model for both upper limb and lower limb exercise programs that can be performed at home and implemented at scale to community-dwelling older adults.

Evaluation of a buckle force transducer for measuring tissue tension

A buckle force transducer, suitable for measuring forces in biological materials in situ, was investigated in order to establish its reliability as a force measuring instrument. Eleven separate materials varying in shape, size and mechanical properties, were tested. Each material was repeatedly loaded and unloaded. Calibration lines, relating the applied force and the output voltage, were calculated for each loading-unloading trial. For each material, deviations between trials were calculated as a percentage of the range of voltages recorded in the first trial of that material. These data were analysed to evaluate four parameters: test-retest reliability, the effect of skewed alignment, linearity of the instrument, and amount of hysteresis present. Results indicate that the buckle force transducer used is a highly reliable and consistent measuring instrument, which behaves in a linear manner and demonstrates acceptably small hysteresis. The implications for measuring forces in biological materials are discussed.

Does supraspinatus initiate shoulder abduction?

PURPOSE

It is commonly stated that supraspinatus initiates abduction; however, there is no direct evidence to support this claim. Therefore, the aims of the present study were to determine whether supraspinatus initiates shoulder abduction by activating prior to movement and significantly earlier than other shoulder muscles and to determine if load or plane of movement influenced the recruitment timing of supraspinatus.

METHODS

Electromyographic recordings were taken from seven shoulder muscles of fourteen volunteers during shoulder abduction in the coronal and scapular planes and a plane 30° anterior to the scapular plane, at 25%, 50% and 75% of maximum load. Initial activation timing of a muscle was determined as the time at which the average activation (over a 25 ms moving window) was greater than three standard deviations above baseline measures.

RESULTS

All muscles tested were activated prior to movement onset. Subscapularis was activated significantly later than supraspinatus, infraspinatus, deltoid and upper trapezius, while supraspinatus, infraspinatus, upper trapezius, lower trapezius, serratus anterior and deltoid all had similar initial activation times. The effects of load or plane of movement were not significant.

CONCLUSIONS

Supraspinatus is recruited prior to movement of the humerus into abduction but not earlier than many other shoulder muscles, including infraspinatus, deltoid and axioscapular muscles. The common statement that supraspinatus initiates abduction is therefore, misleading.

Playing level achieved, throwing history, and humeral torsion in Masters baseball players

Humeral torsion is thought to be beneficial for throwing. To examine this hypothesis, the throwing and non-throwing arms of 84 Masters baseball players over 35 years of age were measured for humeral torsion, and the highest playing level they achieved and their playing history were recorded. Regression analyses were used to obtain predictors of the highest playing level achieved, throwing arm humeral torsion, and side-to-side difference in humeral torsion. Equations accounting for 36%, 46%, and 12% of the variance respectively were produced. Achieving representative level playing status was associated with the number of seasons played under 16 years of age and having greater throwing arm humeral retrotorsion. Throwing arm humeral retrotorsion was associated with non-throwing arm humeral retrotorsion and an increased number of seasons played before the age of 16 years. A model in which repeated throwing develops an adaptive unilateral bone torsion along with growth in baseball expertise is proposed. Thus dominant arm humeral retrotorsion is a predictor of highest baseball playing level achieved, which in turn is influenced by genetic endowment (as seen in the torsion of the non-throwing arm) and amount of throwing activity, particularly prior to the age of 16.

Indirect ultrasound measurement of humeral torsion in adolescent baseball players and non-athletic adults: reliability and significance

Accurate clinical interpretation of shoulder rotation range requires knowledge of the contribution of humeral torsion. This study compares the reliability of indirectly measuring humeral torsion using ultrasound visualisation with direct palpation and compares the degree of humeral torsion in a non-throwing adult population with a population of elite adolescent baseballers. The reliability of a novel method of indirectly measuring humeral torsion using palpation and ultrasound was established prior to using the ultrasound method to determine the amount of humeral torsion in both humeri of a group of 16 non-throwing subjects and 36 elite adolescent baseball players. Excellent inter-tester reliability was found for the ultrasound method of measuring humeral torsion in each arm (ICC 2,1: 0.98 and 0.94) but poor reliability for the direct palpation method (ICC 2,1: 0.51 and 0.49). Using the ultrasound method, side-to-side differences in humeral torsion ranged from 0 to 13 degrees for the non-throwing group and 0 to 29 degrees for the baseball players. This side-to-side difference was significant in the baseball players (p<0.001) but not significant in the non-throwing group (p=0.43). Whilst side-to-side differences in humeral torsion were noted between all subjects irrespective of arm dominance, only throwers demonstrated consistently greater humeral retrotorsion in their throwing arm. A reliable clinical tool for estimating humeral torsion, such as that employed in this study, will allow for a more valid prescription of interventions for the treatment of shoulder dysfunction.