Analgesic consumption in a large sample of people in musculoskeletal rehabilitation: A descriptive study.

BACKGROUND: Consumption of opioids is increasing worldwide in people with chronic non-cancer pain, although their effectiveness is debated. OBJECTIVES: The aim of the current study was to evaluate analgesic consumption and its association with different variables (demographic variables, pain, anxiety/depression, catastrophism, and kinesiophobia), in the field of musculoskeletal rehabilitation, where no data are available. METHODS: This was a retrospective study over a period of 8 years on people hospitalised for rehabilitation after injury. Participants were classified into 3 categories: no analgesics (NA), non-opioid analgesics (NOA), and opioid analgesics (OPA). ANOVA or chi-squared tests were used to compare the 3 groups. RESULTS: A total of 4,350 people (84% men; mean [SD] age, 44 [11] years) were included. In total, 20% were taking OPA, 40% NOA and 40% NA. In the OPA group, tramadol was mainly used, and the morphine equivalent median dose was 8.3 mg/day. In the NOA group, paracetamol and ibuprofen were mostly used. Symptoms increased progressively across the 3 groups (NA/NOA/OPA), with increased levels of pain severity/interference, anxiety/depression and catastrophizing, and a higher prevalence of neuropathic pain in the OPA group versus the others. CONCLUSIONS: These results are consistent with those found in groups of people with chronic pain taking larger doses of opioids and following opioid reduction or cessation programs. Opioid prescription did not increase over the 8 years, which was reassuring. These factors are important to emphasise because they can be modified in the rehabilitation setting with interdisciplinary management. REGISTRATION: Our database was registered on Mendeley Data.

Acute myopericarditis and left shoulder capsulitis following second dose of mRNA SARS-CoV-2 Moderna vaccination.

Vaccination against mRNA SARS-CoV-2 has been administered on a very large scale and various side effects have been described. The increased risk of myopericarditis is known, and only a few cases of shoulder capsulitis have been reported after vaccination. These two pathologies have never been reported in the same patient after vaccination. Our article presents the history of a man in his 40s who presented with myopericarditis a few days after vaccination against SARS-CoV-2 with mRNA(Messenger RNA) Moderna® vaccine and who at the same time developed shoulder capsulitis. His cardiovascular symptoms resolved rapidly, and his shoulder symptoms improved/resolved within 1 year. This case should make physicians aware of the possibility of several concomitant side effects following vaccination against SARS-CoV-2.

Should we separately measure the pain parameter of the Constant-Murley score in patients with chronic shoulder pain?

BACKGROUND: The Constant-Murley Score (CMS) is a relatively unique shoulder assessment tool because it combines patient-reported outcomes (pain and activity), performance measurement and clinician-reported outcomes (strength and mobility). With these characteristics, the effect of patient-related psychological factors on the CMS remains debated. We aimed to investigate which parameters of the CMS are influenced by psychological factors by assessing the CMS before and after rehabilitation for chronic shoulder pain. METHODS: This retrospective study screened all patients (18-65 years old) who were admitted for interdisciplinary rehabilitation for chronic shoulder pain (≥ 3 months) between May 2012 and December 2017. Patients with unilateral shoulder injuries were eligible. Exclusion criteria were shoulder instability, concomitant neurological injuries, complex regional pain syndrome (including Steinbrocker syndrome), heavy psychiatric issues, and missing data. The Hospital Anxiety and Depression Scale, Pain Catastrophizing scale, and Tampa Scale of Kinesiophobia were administered before and after treatment. Regression models were used to estimate associations between psychological factors and the CMS. RESULTS: We included 433 patients (88% male, mean age 47±11 years) with a median duration of symptoms of 392.2 days (interquartile range: 266.5-583.5). Rotator cuff issue was present in 71% of patients. During interdisciplinary rehabilitation, patients were followed for a mean of 33.6±7.5 days. The mean CMS at entry was 42.8 ±15.5. The mean gain in CMS after treatment was 10.6 ±10.9. Before treatment, psychological factors were significantly associated with only the pain CMS parameter: -0.37 (95% CI: -0.46 to -0.28), p <0.001. After treatment, psychological factors were associated with the evolution of the four CMS parameters: -0.12 (-0.23 to -0.01) to -0.26 (95% CI: -0.36 to -0.16), p<0.05. CONCLUSIONS: This study raises the question of a distinct assessment of pain when assessing shoulder function with CMS in patients with chronic shoulder pain. The separation of the "pain parameter" from the overall CMS score seems illusory with this tool that is used worldwide. However, clinicians should be aware that psychological factors can negatively influence the evolution of all CMS parameters during follow-up, which argues for a biopsychosocial approach to patients with chronic shoulder pain.

Simple clinical tools improve ability-to-work predictions for individuals 3-24 months after upper limb injury.

BACKGROUND: Despite numerous previous studies, predicting the ability to work (ATW) after an upper limb injury (ULI) remains difficult for those still not working 3-24 months after their initial injury. OBJECTIVES: We aimed to identify simple prognostic characteristics that were associated with the long-term ATW for individuals who remained unable to work several months after the accident that caused their ULI. METHODS: A single-center prospective observational study in a rehabilitation center in the French-speaking part of Switzerland. We included participants who were 18-60 years old, still unable to work because of persistent pain/disability 3-24 months after an ULI, and who were referred to our rehabilitation center for a 1-month intensive interdisciplinary treatment. Data were collected on personal characteristics, body function/structure variables, activity limitations/participation restrictions, and environmental factors. Participants' evolution during rehabilitation was assessed using functional tests/questionnaires and the 7-level self-reported Patient's Global Impression of Change (PGIC) assessment at discharge. Participant outcomes after 1 year were categorized as either able (ATW>0%) or unable (ATW=0%) to work. The best prognostic characteristics were selected by logistic regression analysis. RESULTS: Among the 317 participants, 202 (64%) had an ATW>0% at 1 year. A grip strength ≥16 kg (Jamar Hand Dynamometer score - affected side) and "(I) do not take pain medicine" were independent predictors. Overall, 96% (26/27) of participants with these 2 characteristics had an ATW>0% at 1 year. The simultaneous absence of these characteristics predicted an unfavorable prognosis in 50% (59/119) of participants. For those who also had a positive PGIC score then 100% (25/25) of participants with these 3 characteristics had an ATW>0%; for those without, only 42% (19/45) had an ATW>0%. CONCLUSIONS: Grip strength (≥16 kg) and not taking pain medicine are favorable prognostic factors for an ATW after an ULI. Their absence is associated with a poor ATW prognosis for half of people with ULI and should alert caregivers to risk of long-term absenteeism ("red flags"). Including data from a PGIC further improves the ATW prediction. We recommend that these 3 criteria be systematically evaluated.

Healthcare Costs, Time to Fitness for Work, and Related Factors in Chronic Complex Regional Pain Syndrome: A Comparative and Longitudinal Study of 5-Year Follow-Up.

Purpose: To assess and compare the healthcare costs, time to fitness for work (TFW) between chronic complex regional pain syndrome (CRPS) and non-CRPS; and identify factors associated with these outcomes in a comparative longitudinal study. Patients and Methods: 148 patients with chronic CRPS of the hand and 273 patients with chronic hand impairments but without CRPS (non-CRPS) were admitted at a Swiss rehabilitation clinic between 2007 and 2016. Healthcare costs and TFW were retrieved from insurance data over 5 years after the accident. Socio-demographic factors, biopsychosocial complexity measured by means of the INTERMED questionnaire, pain intensity and DASH disability scores were collected during rehabilitation. Generalized estimation equations and Cox proportional-hazards models were used to identify factors associated with outcomes. Results: Healthcare costs were increased by 20% for the CRPS versus non-CRPS group (coefficient = 1.20, 95% CI = 1.08-1.35, p<0.001). The median TFW was longer for CRPS than non-CRPS patients (816 vs 672 days, p = 0.02). After adjusting for covariates, TFW did not differ between the two groups (hazard ratio = 0.94, 95% CI = 0.73-1.21, p=0.61). For CRPS patients, higher healthcare costs were associated with severe or moderate initial injury, high INTERMED or DASH disability scores. Longer TFW were associated with severe initial injury, low educational level, no work contract, and high INTERMED or DASH disability scores. Conclusion: Overall, the healthcare costs were higher for CRPS than non-CRPS patients, but the TFW was comparable. We demonstrated also the significant associations of disability and biopsychosocial factors with the healthcare costs and TFW in CRPS patients.

Development and Validation of Short Forms of the Pain Catastrophizing Scale (F-PCS-5) and Tampa Scale for Kinesiophobia (F-TSK-6) in Musculoskeletal Chronic Pain Patients.

Purpose: Chronic pain is a complex phenomenon. Understanding its multiple dimensions requires the use of a combination of several patient-reported outcome measures (PROMs). However, completing multiple PROMs is time-consuming and can be a burden for patients. The objective of our study was to simultaneously reduce the French versions of the Pain Catastrophizing Scale (PCS) and Tampa Scale for Kinesiophobia (TSK) questionnaires to enable their use in an ambulatory and clinical settings. Patients and Methods: We conducted a clinical study between May 2014 and August 2020 in our rehabilitation center. 1428 chronic musculoskeletal pain patients (CMSP) were included. The originality of our approach is that the reduction method included qualitative as well as quantitative analyses. The study was divided into two parts: 1) reduction of the questionnaires (n=1363) based on internal consistency (item-to-total correlation), principal component analysis (item loadings), Rasch analysis (infit/outfit), floor and ceiling effect (quantitative analyses) and expert judgment of items (qualitative analysis), and 2) validation of the reduced questionnaires (n=65), including test-retest reliability (intraclass correlation coefficient [ICC]), homogeneity (Cronbach α), criterion validity (Pearson correlation [r] with the long-version score), determination of the pathological cutoff and Minimal Clinically Important Difference (MCID). The two full-length questionnaires include 30 items in total. Results: The reduction resulted in a 5-item PCS (score 0-20) and 6-item TSK (score 0-24). Psychometric properties of the reduced questionnaires were all acceptable as compared with other version (α=0.89 and 0.71, ICC=0.75 and 0.60, r=0.86 and 0.70, MCID=2 and 2 for PCS and TSK, respectively) while keeping the structure and coherence of the long versions. Conclusion: The two reduced versions of the PCS and TSK can be used in CMSP patient. As their administration only requires a few minutes, they can be implemented in outpatient consultation as well as in clinical settings.

Going toe-to-toe with a rare case of a complex regional pain syndrome limited to the hallux.

We report the first case of a complex regional pain syndrome (CRPS) limited to the hallux using the Budapest criteria. Limited forms of CRPS are scarce in the literature and probably overlooked. There is currently no consensus to define these forms. Due to the particular metameric topography, common to the hand and the foot, we suggest the term 'metameric' CRPS to describe them. A uniform nomenclature would promote future research to study its prevalence and specific treatment in more detail.

Development and validation of a short version of the French Hand Function Sort questionnaire in vocational rehabilitation.

BACKGROUND: The Hand Function Sort (HFS) is a pictorial self-administered questionnaire with 62 items. It is a valid and reliable scale focused on the physical function of the upper limbs. It is used to predict the return to work. OBJECTIVES: We aimed to develop and validate a short version of the French version of the HFS (HFS-F) to simplify its use in clinical practice. METHODS: We included patients with upper-limb chronic pain hospitalised for vocational rehabilitation from 2012 to 2019. Vocational rehabilitation aims to improve the autonomy of patients to regain their previous working capacity. The 62 items of the HFS-F were analysed in terms of patient and expert assessments, floor/ceiling effect, item-to-total correlation, principal component analysis, and Rasch analysis. A short HFS-F was developed. Thereafter, we assessed its internal consistency, test-retest reliability, criterion validity with the full-length HFS-F, construct validity with different scales (Disabilities of the Arm, Shoulder, and Hand [DASH]; Brief Pain Inventory [BPI]; Hospital Anxiety and Depression [HAD]), standard error of measurement (SEM), and minimal detectable change (MDC). RESULTS: Six experts were consulted, 34 patients were interviewed, and 629 questionnaires were analysed. Among the items, 25 were selected after the final round with the six experts. The internal consistency and test-retest reliability were excellent (Cronbach α=0.95, intraclass correlation coefficient=0.92, 95% confidence interval [95% CI] 0.87 to 0.95). The correlation coefficient between scores of the short and full-length HFS-F was 0.841 (95% CI: 0.752 to 0.897, P<10-4), and those between the short HFS-F score and the DASH, BPI, HAD-Anxiety, and HAD-Depression scores were -0.816 (95% CI: -0.714 to -0.881, P<10-4), -0.529 (95% CI: -0.338 to -0.674, P<10-4), -0.451 (95% CI: -0.244 to 0.614, P=0.0001), and -0.360 (95% CI: -0.140 to -0.542, P=0.0018), respectively. The SEM and MDC values were estimated at 6/100 and 17/100, respectively. CONCLUSIONS: A short version of the HFS-F was developed and validated. We named this questionnaire the 25 HFS-F.

Psychiatric Comorbidity and Complex Regional Pain Syndrome Through the Lens of the Biopsychosocial Model: A Comparative Study.

PURPOSE: To compare the prevalence of psychiatric comorbidity between patients with complex regional pain syndrome (CRPS) of the hand and non-CRPS patients and to assess the association between biopsychosocial (BPS) complexity profiles and psychiatric comorbidity in a comparative study. PATIENTS AND METHODS: We included a total of 103 patients with CRPS of the hand and 290 patients with chronic hand impairments but without CRPS. Psychiatric comorbidities were diagnosed by a psychiatrist, and BPS complexity was measured by means of the INTERMED. The odds ratios (OR) of having psychiatric comorbidities according to BPS complexity were calculated with multiple logistic regression (adjusted for age, sex, and pain). RESULTS: Prevalence of psychiatric comorbidity was 29% in CRPS patients, which was not significantly higher than in non-CRPS patients (21%, relative risk=1.38, 95% CI: 0.95 to 2.01 p=0.10). The median total scores of the INTERMED were the same in both groups (23 points). INTERMED total scores (0-60 points) were related to an increased risk of having psychiatric comorbidity in CRPS patients (OR=1.46; 95% CI: 1.23-1.73) and in non-CRPS patients (OR=1.21; 95% CI: 1.13-1.30). The four INTERMED subscales (biological, psychological, social, and health care) were correlated with a higher risk of having psychiatric comorbidity in both groups. The differences in the OR of having psychiatric comorbidity in relation to INTERMED total and subscale scores were not statistically different between the two groups. CONCLUSION: The total scores, as well as all four dimensions of BPS complexity measured by the INTERMED, were associated with psychiatric comorbidity, with comparable magnitudes of association between the CRPS and non-CRPS groups. The INTERMED was useful in screening for psychological vulnerability in the two groups.

Prospective multicentre validation study of a new standardised version of the 400-point hand assessment.

BACKGROUND: Hand rehabilitation needs valid evaluation tools; the 400-point Hand Assessment (HA) is an exhaustive but not standardised tool. The aim of this study was to validate a standardised version of this test. METHODS: A modified version and a standardised prototype was made for this prospective validation study (four centres, three countries). Psychometric properties studied: reliability (intra-rater and inter-rater, standard error of measurement [SEM], minimum detectable change [MDC],internal consistency); content validity, construct validity with Jebsen Taylor hand function test, QuickDASH, MOS-SF 36 and pain; responsiveness, using an anchor-based approach (ROC curve with area under curve, mean response change) with calculation of MCID. For SEM, MDC and responsiveness, QuickDASH was used for comparison. RESULTS: One hundred and seventy-six patients with hand/wrist injuries were included between May 2013 and February 2015. One hundred and seventy were available for final analysis: 67% men; mean age 43.4 ± 13.2 years; both manual and office workers (46, 5% of each); 37% had a hand or wrist fracture. Reliability: ICC intra-rater = 0.967 [0.938-0.982]; inter-rater = 0.868 [0.754-0.932]. Distribution-based approach: for 400-point HA/QuickDASH: SEM = 3.48/4.52, MDC = 9.065/12.53, internal consistency of 400-point HA: Cronbach α = 0.886. VALIDITY: Content validity was good according to COSMIN guidelines. Construct validity: correlation coefficient: Jebsen-Taylor hand function test = - 0.573 [- 0.666-0.464], QuickDASH = - 0.432 at T0 [- 0.545-0.303], - 0.551 at T3 [- 0.648-0.436]; MOS-SF 36 physical component = 0.395 [0.263-0.513]; no correlation with MOS-SF 36 mental component = 0.142 [- 0.009 + 0.286] and pain = - 0.166 [- 0.306 + 0.018]. Responsiveness: Anchor-based approach: AUC Δ400-point HA = 0.666 [0.583-0.749], AUC ΔQuickDASH = 0.556 [0.466-0.646]. MCID (optimal ROC curve cut-off): 6.07 for 400-point HA, - 2.27 for QuickDASH. MCID with mean response change + 12.034 ± 9.067 for 400-point HA and - 8.03 ± -9.7 for QuickDASH. The patient's global impression of change was only correlated with the Δ400-point HA. CONCLUSIONS: The 400-point HA standardised version has good psychometric properties. For responsiveness, we propose an MCID of at least 12.3/100. However, these results must be confirmed in other populations and pathologies. TRIAL REGISTRATION: This study was retrospectively registered into ISCTRN registry (Number ISRCTN25874481) the 07/02/2019.

[Complex regional pain syndrome]. / Syndrome douloureux régional complexe.

The Complex Regional Pain Syndrome (previously algodystrophy) is a rare affliction that usually affects a distal extremity (hand, foot). It occurs most frequently within weeks following a traumatic injury or stroke. It is a syndromic entity whose diagnosis is based on precise criteria, known as the Budapest criteria, excluding any disease that better explains the symptoms. The treatment must be given early. Functional restoration (physiotherapy, occupational therapy) is at the heart of the treatment, along with psychoeducation. Inappropriate disuse and avoidance, often encountered, must be combated. Bisphosphonates or steroids are first-line drugs at early stages. The evolution is often long, but the prognosis is favorable in about 75 % of cases (≤ 1 year).

Le syndrome douloureux régional complexe (anciennement algodystrophie) est une affection rare qui touche préférentiellement une extrémité (main, pied). Il se développe le plus souvent dans les semaines qui suivent un traumatisme ou un accident vasculaire cérébral. Il s'agit d'une entité syndromique dont le diagnostic repose sur des critères précis, dits de Budapest, excluant toute atteinte expliquant mieux les symptômes. Le traitement doit être précoce. La restauration fonctionnelle en est le cœur (physiothérapie, ergothérapie), associée à une psychoéducation. L'immobilisation inappropriée et l'évitement, souvent rencontrés, doivent être combattus. Bisphosphonates ou corticoïdes sont les médicaments de premier choix des formes précoces. L'évolution est souvent longue, mais le pronostic favorable dans environ 75 % des cas (≤ 1 an).

Determining the minimal clinically important difference of the hand function sort questionnaire in vocational rehabilitation.

OBJECTIVE: To estimate the Minimal Clinically Important Difference (MCID) of the French version of the Hand Function Sort questionnaire (HFS-F). As a comparison, the MCID of the Disabilities of the Arm, Shoulder, and Hand (DASH) was also estimated. MATERIALS AND METHODS: We included French-speaking patients hospitalized in a multidisciplinary rehabilitation program for chronic pain of the upper limb after an accident. HFS-F and DASH scores were collected at admission and discharge; the Patient Global Impression of Change measure (PGIC; 7 levels) was collected at discharge. The MCID was estimated by 2 methods: the anchor-based method (receiver operating characteristic [ROC], delta (Δ) mean of scores) and the objective method based on the distribution of scores (standard error of measurement, SEM). RESULT: We included 225 patients. By the anchor-based method, the MCID for the HFS-F and DASH was +26 (SD 35) (P<10-4) and -13 (SD 13) (P<10-4), respectively, and by the ROC curve, it was +10 to +12 for the Δ-HFS-F and -7.5 to -5 for the Δ-DASH. The area under the ROC curve (AUC) was 0.726 [0.638-0.781] for Δ-HFS-F and 0.768 [0.701-0.83] for Δ-DASH. The correlations between the anchor and delta scores were>0.38 (P<10-4). The SEM was 16.2 for the HFS-F and -4.3 for the DASH. CONCLUSIONS: Values below the SEM must be rejected. Our anchor was significantly correlated with the outcome. Therefore, we propose an MCID for the HFS-F of 26, corresponding to approximately 10% progression of the score.

Immediate and short-term effects of kinesiotaping on muscular activity, mobility, strength and pain after rotator cuff surgery: a crossover clinical trial.

BACKGROUND: Kinesiotape (KT) is widely used in musculoskeletal rehabilitation as an adjuvant to treatment, but minimal evidence supports its use. The aim of this study is to determine the immediate and short-term effects of shoulder KT on muscular activity, mobility, strength and pain after rotator cuff surgery. METHODS: Thirty-nine subjects who underwent shoulder rotator cuff surgery were tested 6 and 12 weeks post-surgery, without tape, with KT and with a sham tape (ST). KT and ST were applied in a randomized order. For each condition, the muscular activity of the upper trapezius, three parts of the deltoid and the infraspinatus were measured during shoulder flexion, and range of motion (ROM) and pain intensity were assessed. At 12 weeks, the isometric strength at 90° of shoulder flexion, related muscular activity and pain intensity were also measured. Subjects maintained the last tape that was applied for three days and recorded the pain intensity at waking up and during the day. RESULTS: Modifications in muscle activity were observed with KT and with ST. Major changes in terms of decreased recruitment of the upper trapezius were observed with KT (P < 0.001). KT and ST also increased flexion ROM at 6 weeks (P = 0.004), but the differences with the no tape condition were insufficient to be clinically important. No other differences between conditions were found. CONCLUSIONS: Shoulder taping has the potential to decrease over-activity of the upper trapezius, but no clinical benefits of KT on ROM, strength or pain were noted in a population of subjects who underwent rotator cuff surgery. TRIAL REGISTRATION: The study was retrospectively registered on ClinicalTrials.gov PRS ( NCT03379636 ) on 21st December 2017.

Heartbeat-enhanced immersive virtual reality to treat complex regional pain syndrome.

OBJECTIVES: To develop and test a new immersive digital technology for complex regional pain syndrome (CRPS) that combines principles from mirror therapy and immersive virtual reality and the latest research from multisensory body processing. METHODS: In this crossover double-blind study, 24 patients with CRPS and 24 age- and sex-matched healthy controls were immersed in a virtual environment and shown a virtual depiction of their affected limb that was flashing in synchrony (or in asynchrony in the control condition) with their own online detected heartbeat (heartbeat-enhanced virtual reality [HEVR]). The primary outcome measures for pain reduction were subjective pain ratings, force strength, and heart rate variability (HRV). RESULTS: HEVR reduced pain ratings, improved motor limb function, and modulated a physiologic pain marker (HRV). These significant improvements were reliable and highly selective, absent in control HEVR conditions, not observed in healthy controls, and obtained without the application of tactile stimulation (or movement) of the painful limb, using a readily available biological signal (the heartbeat) that is most often not consciously perceived (thus preventing placebo effects). CONCLUSIONS: Next to these specific and well-controlled analgesic effects, immersive HEVR allows the application of prolonged and repeated doses of digital therapy, enables the automatized integration with existing pain treatments, and avoids application of painful bodily cues while minimizing the active involvement of the patient and therapist. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that HEVR reduces pain and increases force strength in patients with CRPS.

[Adhesive capsulitis of the shoulder : Update 2017]. / La capsulite rétractile de l'épaule : mise au point en 2017.

A century and a half after its first description, adhesive capsulitis (frozen shoulder) has revealed only part of its secrets. Its definition remains clinical since the imaging technology we have at our dis-posal is insufficiently sensitive and specific. Next to its idiopathic form, the most frequent and the most characteristic, there are numerous situations inducing a functional limitation of the glenohumeral joint and of its environment. The clinical course inexorably takes place in one to two years, and develops in 3 phases where successively pain, retraction, and then recovery, as a rule complete recovery, dominate. No treatment is likely to shorten it. In the absence of clearly established proof, our therapeutic approach must be prudent and conservative.

Un siècle et demi après sa première description, la capsulite rétractile de l'épaule n'a dévoilé qu'une partie de ses secrets. Sa définition reste clinique puisqu'on ne dispose d'aucune méthode d'imagerie suffisamment sensible et spécifique. A côté de la forme idiopathique, la plus fréquente et la mieux caractérisée, il existe une multitude de situations induisant une limitation fonctionnelle de l'articulation gléno-humérale et de son environnement. L'évolution se déroule inexorablement sur un à deux ans et comporte trois phases où dominent successivement la douleur, la rétraction puis la récupération en principe complète. Aucun traitement n'est susceptible de l'écourter. En l'absence de preuve clairement établie, l'approche thérapeutique doit être prudente et conservatrice.

Role of pain in measuring shoulder strength abduction and flexion with the Constant-Murley score.

OBJECTIVES: The Constant-Murley score (CS) has been used for more than 25 years to assess shoulder function. Strength by itself accounts for 25% of the total score. The measurement at 90° abduction seems to be sometimes limited by pain, particularly with tendinopathy or subacromial impingement. We compared the assessment of isometric strength in anterior forward flexion and abduction and its effect on pain and total CS. METHODS: Strength was assessed by CS at both 90° forward flexion and abduction in the scapular plane by using an Isobex dynamometer, the first position tested being randomized. Pain was assessed on a 100-mm visual analog scale (VAS) and total CS was assessed. RESULTS: We included 54 patients with unilateral shoulder problems; 50% had rotator cuff injury. Mean strength on the affected side was 4.7±2.5kg in forward flexion and 4.6±2.8kg in abduction. Induced pain and total CS did not differ between the 2 positions tested. CONCLUSIONS: Strength can be measured by the CS in forward flexion or abduction, because the measurement does not affect strength, pain intensity or total score. The choice of direction for measurement should be based on the underlying pathology, related contraindications and patient preference.

Clinician and Patient-reported Outcomes Are Associated With Psychological Factors in Patients With Chronic Shoulder Pain.

BACKGROUND: Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors. QUESTIONS: We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements? METHODS: All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5-15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes. RESULTS: Greater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25-1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, -6.15; 95% CI, -11.09 to -1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021-0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87-0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77-16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, -0.35; 95% CI, -0.58 to -0.12; p = 0.003). CONCLUSIONS: Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score. LEVEL OF EVIDENCE: Level III, prognostic study.

Diagnosis of partial complex regional pain syndrome type 1 of the hand: retrospective study of 16 cases and literature review.

BACKGROUND: The partial form of the complex regional pain syndrome of the hand type 1 (CRPS 1), involving only 1 to 3 fingers, is a rare condition first described in 1972. The aim of the study is to define more precisely the diagnosis workup and the prognosis of this clinical entity. METHODS: Retrospective study of CRPS1 partial form observed during five years in a rehabilitation ward. Application of The Budapest criteria, evaluation of radiological exams, therapeutic results and vocational outcomes. Comparison with cases from literature review. RESULTS: 132 patients were hospitalized with the diagnosis of CRPS type 1 of the hand. 16 partial forms were isolated: 11 men, 5 women with a mean age of 43 years. Among these patients, 14 (88%) met The Budapest criteria and the two remaining cases were diagnosed by using the three phase bone scintigraphy. Only moderate improvement was obtained in the majority of the patients. At the maximal time of follow-up (4 to 9 years), 50% of the patients hadn't returned to work. From the literature review, 19 cases were eligible for clinical comparisons. The main differences between our series and the literature were: more men involved, later diagnosis and worst prognosis in term of return to work. CONCLUSIONS: This is the largest series of consecutive partial form of CRPS. The Budapest criteria are sufficient for the diagnosis in 88% of cases. As in complete form of CRPS1 of the hand, three phase bone scintigraphy should only be used in doubtful cases in the first six months of the illness. Partial form of CRPS1 of the hand is rare and its prevalence remains unknown. Long term prognosis (4 to 9 years) is poor in our series, 50% of patients didn't returned to work.

Akt signalling through GSK-3beta, mTOR and Foxo1 is involved in human skeletal muscle hypertrophy and atrophy.

Skeletal muscle size is tightly regulated by the synergy between anabolic and catabolic signalling pathways which, in humans, have not been well characterized. Akt has been suggested to play a pivotal role in the regulation of skeletal muscle hypertrophy and atrophy in rodents and cells. Here we measured the amount of phospho-Akt and several of its downstream anabolic targets (glycogen synthase kinase-3beta (GSK-3beta), mTOR, p70(s6k) and 4E-BP1) and catabolic targets (Foxo1, Foxo3, atrogin-1 and MuRF1). All measurements were performed in human quadriceps muscle biopsies taken after 8 weeks of both hypertrophy-stimulating resistance training and atrophy-stimulating de-training. Following resistance training a muscle hypertrophy ( approximately 10%) and an increase in phospho-Akt, phospho-GSK-3beta and phospho-mTOR protein content were observed. This was paralleled by a decrease in Foxo1 nuclear protein content. Following the de-training period a muscle atrophy (5%), relative to the post-training muscle size, a decrease in phospho-Akt and GSK-3beta and an increase in Foxo1 were observed. Atrogin-1 and MuRF1 increased after the hypertrophy and decreased after the atrophy phases. We demonstrate, for the first time in human skeletal muscle, that the regulation of Akt and its downstream signalling pathways GSK-3beta, mTOR and Foxo1 are associated with both the skeletal muscle hypertrophy and atrophy processes.