Effectiveness of Gyejibongnyeong-Hwan for shoulder pain: study protocol for a randomised, wait-list controlled pilot trial.

BACKGROUND: Shoulder pain is an uncomfortable feeling in the muscle around the shoulder. The cause of myalgia is the accumulation of lactic acid in muscles and impaired blood circulation, which is called blood stasis in traditional East Asian medicine. This study aimed to explore the therapeutic effect of Gyejibongnyeong-Hwan (GBH) for shoulder discomfort related to blood stasis before and after treatment. METHODS/DESIGN: This study will be a double-centre, randomised, wait-list controlled pilot trial. Participants with shoulder pain and with a visual analogue scale score of 4 or higher out of 10, blood stasis score of 9 or higher, and triglyceride level of ≥150 mg/dl or total cholesterol level of ≥200 mg/dl will be recruited from two university hospitals. A total of 40 participants will be assigned to the immediate and waiting treatment groups. The immediate treatment group will receive GBH for 8 weeks on enrolment while the waiting treatment group will receive GBH for 8-16 weeks after 8 weeks of controlled waiting. The primary outcome is shoulder pain, and the secondary outcomes are the blood stasis score, blood pressure, ankle-brachial pressure index, brachial-ankle pulse wave velocity, body mass index, waist circumference, indexes of oximetry, and levels of blood lipid, blood sugar, resistin, C-reactive protein, serum amyloid P, and D-dimer. DISCUSSION: The results of this pilot trial will be the bases for a full-scale clinical trial of GBH. TRIAL REGISTRATION: Clinical Research Information Service, KCT0003837. Registered on 23 April 2019. https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=14258.

Impact of different intraoperative CO2 pressure levels (8 and 15 mmHg) during laparoscopic hysterectomy performed due to benign uterine pathologies on postoperative pain and arterial pCO2 : a prospective randomised controlled clinical trial.

OBJECTIVE: To compare the effects of two different intraoperative CO2 pressures (8 and 15 mmHg) during laparoscopic hysterectomy for benign uterine pathologies in terms of postoperative abdominal and shoulder pain, laparoscopy-mediated vegetative alterations, pain medication requirement, arterial CO2 pressure (pCO2 ), surgical parameters, and safety. DESIGN: Prospective randomised controlled study. SETTING: German university hospital. POPULATION: Female patients undergoing laparoscopic hysterectomy for benign uterine pathologies. METHODS: Patients were randomised to a standard pressure (SP; 15 mmHg, control) or low-pressure (LP; 8 mmHg, experimental) group. MAIN OUTCOME MEASURES: Primary outcomes were postoperative abdominal and shoulder pain intensities, measured via numeric rating scale (NRS) and vegetative parameters (fatigue, nausea, vomiting, bloating) at 3, 24, and 48 hours postoperatively. Secondary outcomes were pain medication requirement (mg) and arterial pCO2 (mmHg). Surgical parameters and intra- and postoperative complications were also recorded. RESULTS: In total, 178 patients were included. Patients in the LP group (n = 91) showed significantly lower postoperative abdominal and shoulder pain scores, fewer vegetative alterations, lower pain medication requirements, a shorter postoperative hospitalization, and lower intra- and postoperative arterial pCO2 values compared with the SP group (n = 87; P ≤ 0.01). No differences in intra- and postoperative complications were observed between groups. CONCLUSIONS: Low-pressure laparoscopy seems to be an effective and safe technique for the reduction of postoperative pain and laparoscopy-induced metabolic and vegetative alterations following laparoscopic hysterectomy for benign indications. TWEETABLE ABSTRACT: Low-pressure laparoscopy seems to be an effective and safe technique for reduction of pain following laparoscopic hysterectomy.

Intramuscular pain modulatory substances before and after exercise in women with chronic neck pain.

BACKGROUND: In peripheral tissue, several substances influence pain and pain modulation. Exercise has been found to decrease pain and improve function for chronic pain conditions, but how and why exercise produces beneficial effects remains unclear. This study investigates whether aspects of pain and concentrations of substances with algesic, analgesic and metabolic functions differ between women with chronic neck shoulder pain (CNSP) and healthy women (CON) and whether changes are found after an exercise intervention for CNSP. METHODS: Forty-one women with CNSP and 24 CON subjects were included. The participants attended two microdialysis sessions with 4-6 months between the experiments. During this period, the CNSP subjects underwent an exercise intervention. Expression levels of substance P, beta-endorphin, cortisol, glutamate, lactate and pyruvate as well as pain intensity and pressure pain thresholds were analysed. RESULTS: At baseline, higher concentrations of glutamate and beta-endorphin and lower concentrations of cortisol in CNSP than CON were found. After exercise, decreased levels of substance P and possibly of glutamate, increased levels of beta-endorphin and cortisol as well as decreased pain intensity and increased pain pressure thresholds were found for CNSP. CONCLUSIONS: The findings at baseline indicated algesic and analgesic alterations in the painful trapezius muscles. The findings for CNSP after the exercise intervention, with changes in peripheral substances and decreased pain intensity and sensitivity, could reflect a long-term physiological effect of the exercise.

Inflammatory biomarkers in serum in subjects with and without work related neck/shoulder complaints.

BACKGROUND: Although it has recently been recognised that inflammation is important in the development of work-related musculoskeletal disorders (MSDs), the exact pathophysiological pathways are unknown. METHODS: We investigated serum concentrations of inflammatory cytokines in 35 female supermarket cashiers with repetitive work tasks and work related neck/shoulder complaints, compared with those from 25 women without MSDs (6 supermarket cashiers and 19 middle-school teachers or faculty staff). None of the subjects were pregnant or lactating, and showed no signs of rheumatoid arthritis, systemic lupus erythematosus, cancer, diabetes, coronary artery disease or inadequately controlled hypertension. Serum levels of IL-1α, IL-1ß, IL-6, IL-8, IL-10, IL-12, MCP-1, MIP-1α, MIP-1ß, TNF-α, GM-CSF, CTGF and CRP were analysed. RESULTS: The women with pain related to MSD had higher serum concentrations of MIP-1ß (median, 25th-75th percentile: 90.0 pg/mL, 62.5-110 vs. 73.1 pg/mL, 54.6-88.3; p = 0.018), IL-12 (0.26 pg/mL, 0.26-0.26 vs. 0.26 pg/mL, 0.26-0.26; p = 0.047) and CRP (0.5 mg/L, 0.5-1.6 vs. 0.5 mg/L, 0.5-0.5; p = 0.003), than control subjects. Levels of MIP-1α, MIP-1ß and CRP were correlated with the reported intensity of neck/shoulder pain (r = 0.29, p = 0.03 for MIP-1α; r = 0.29, p = 0.02 for MIP-1ß and r = 0.43, p = 0.001 for CRP). No statistically significant differences in serum levels were found for the remaining cytokines. CONCLUSIONS: Otherwise healthy females with ongoing work-related neck/shoulder pain showed higher serum concentrations of MIP-1ß, IL-12 and CRP than controls, and the levels of MIP-1α, MIP-1ß and CRP were correlated to pain intensity. These results support previous findings that inflammatory processes play a part in work related MSDs.

Shoulder pain and dysfunction in 150 type 2 diabetes mellitus patients.

OBJECTIVE: To study the prevalence of shoulder pain and dysfunction in patients from Southern Brazil with diabetes mellitus (DM) and to evaluate the association of pain and dysfunction with diabetes control and epidemiological factors. SUBJECTS AND METHODS: We studied 150 patients with type 2 DM for pain and shoulder dysfunction with the UCLA-m (modified University of California at Los Angeles Shoulder Rating Scale); for epidemiological and treatment data, values of Hb A(1C) and plasma glucose were analyzed. RESULTS: Pain was present in 63.4%, and dysfunction in 53.4% of the studied sample; 26.6% of the patients rated shoulder performance as bad. No association was found between Hb A(1C) or plasma glucose and joint function, except for active flexion of the shoulder and fasting glucose (p = 0.026). Women had worse shoulder performance (p = 0.0043), as did elderly patients (p < 0.0001). CONCLUSIONS: Shoulder pain and dysfunction is highly prevalent in patients with type 2 diabetes; these disorders affect more women and the elderly.

Shoulder pain and dysfunction in 150 type 2 diabetes mellitus patients / Dor e disfunção do ombro em 150 pacientes com diabetes melito tipo 2

OBJECTIVE: To study the prevalence of shoulder pain and dysfunction in patients from Southern Brazil with diabetes mellitus (DM) and to evaluate the association of pain and dysfunction with diabetes control and epidemiological factors. SUBJECTS AND METHODS: We studied 150 patients with type 2 DM for pain and shoulder dysfunction with the UCLA-m (modified University of California at Los Angeles Shoulder Rating Scale); for epidemiological and treatment data, values of Hb A1C and plasma glucose were analyzed. RESULTS: Pain was present in 63.4%, and dysfunction in 53.4% of the studied sample; 26.6% of the patients rated shoulder performance as bad. No association was found between Hb A1C or plasma glucose and joint function, except for active flexion of the shoulder and fasting glucose (p = 0.026). Women had worse shoulder performance (p = 0.0043), as did elderly patients (p < 0.0001). CONCLUSIONS: Shoulder pain and dysfunction is highly prevalent in patients with type 2 diabetes; these disorders affect more women and the elderly.

OBJETIVO: Estudar a prevalência de dor e disfunção do ombro em pacientes com diabetes melito (DM) do sul do Brasil e verificar a possível associação com controle glicêmico e fatores epidemiológicos. SUJEITOS E MÉTODOS: Estudaram-se 150 pacientes com DM tipo 2 para dor e disfunção do ombro pelo instrumento UCLAm (University of California at Los Angeles Shoulder Rating Scale modificada), dados epidemiológicos e de tratamento, valores de Hb A1C e glicemia de jejum. RESULTADOS: Verificou-se que havia dor em 63,4% e disfunção em 53,4% da amostra estudada. Em 26,6% dos pacientes, o desempenho do ombro foi considerado ruim. Não se encontrou associação de Hb A1C e glicemia de jejum com dor e disfunção do ombro salvo pela associação entre flexão ativa dessa articulação com glicemia de jejum (p = 0,026). As mulheres tinham pior desempenho do ombro (p = 0,0043), assim como os mais idosos (p < 0,0001). CONCLUSÕES: Existe uma prevalência muito alta de dor e disfunção do ombro em pacientes com DM tipo 2, sendo maior em mulheres e idosos.

[Analgesic and anti-inflammatory effects of balance acupuncture on experimental scapulohumeral periarthritis in rabbits].

OBJECTIVE: To investigate therapeutic effects of balance acupuncture on scapulohumeral periarthritis (SP)and the mechanisms. METHODS: Thirty male New Zealand rabbits were randomly divided into a blank group (group B), a model group (group M) and a balance acupuncture group (group BA) with 10 rabbits in each group. SP model was established by using persistent mechanical strain and ice compress. Balance acupuncture at "Jiantong" point was applied in the animals in group BA, but not in the rabbits of the other two groups. Joint movement and pathological changes in tissues around the affected shoulder joint were observed, and interleukin-1beta (IL-1beta), 5-hydroxytryptamine (5-HT) in plasma and the affected surrounding tissues, and DNA contents in tendon of supraspinatus muscle were measured. RESULTS: The content of plasma 5-HT in group BA [(18.16 +/- 4.44) ng/mL] was significantly lower than that in group M [(23.28 +/- 5.89) ng/mL] (P < 0.05), but without obvious difference in IL-1beta content between the two groups (P > 0.05). Compared with group M, the contents of IL-1beta, 5-HT in affected surrounding tissues, and DNA expression in tendon of supraspinatus muscle were significantly lowered to va rious extent in group BA (P < 0.01, P < 0.05). CONCLUSION: Balance acupuncture can effectively improve local and systemic pathological situation induced by SP by way of reducing pain-producing factors, inflammatory factors and DNA expression to alleviate local organization and adhesions in rabbits with experimental SP.

Noradrenaline and cortisol changes in response to low-grade cognitive stress differ in migraine and tension-type headache.

The goal of this study was to explore the relationship between indicators of sympathoneural, sympathomedullar and hypothalamic-pituitary-adrenocortical (HPA) activity and stress-induced head and shoulder-neck pain in patients with migraine or tension-type headache (TTH). We measured noradrenaline, adrenaline and cortisol levels before and after low-grade cognitive stress in 21 migraineurs, 16 TTH patients and 34 controls. The stressor lasted for 60 min and was followed by 30 min of relaxation. Migraine patients had lower noradrenaline levels in blood platelets compared to controls. Pain responses correlated negatively with noradrenaline levels, and pain recovery correlated negatively with the cortisol change in migraineurs. TTH patients maintained cortisol secretion during the cognitive stress as opposed to the normal circadian decrease seen in controls and migraineurs. There may therefore be abnormal activation of the HPA axis in patients with TTH when coping with mental stress, but no association was found between pain and cortisol. A relationship between HPA activity and stress in TTH patients has to our knowledge not been reported before. In migraine, on the other hand, both sympathoneural activation and HPA activation seem to be linked to stress-induced muscle pain and recovery from pain respectively. The present study suggests that migraineurs and TTH patients cope differently with low-grade cognitive stress.

Management of chronic pain in whiplash injury.

We investigated the response of chronic neck and shoulder pain to decompression of the carpal tunnel in 38 patients with whiplash injury. We also determined the plasma levels of substance P (SP) and calcitonin gene-related peptide (CGRP), which are inflammatory peptides that sensitise nociceptors. Compared with normal control subjects, the mean concentrations of SP (220 v 28 ng/l; p < 0.0001) and CGRP (400 v 85 ng/l; p < 0.0005) were high in patients with chronic shoulder and neck pain before surgery. After operation their levels fell to normal. There was resolution of neurological symptoms with improvement of pain in 90% of patients. Only two of the 30 with chronic neck and shoulder pain who had been treated conservatively showed improvement when followed up at two years. In spite of having neuropathic pain arising from the median nerve, all these patients had normal electromyographic and nerve-conduction studies. Chronic pain in whiplash injury may be caused by 'atypical' carpal tunnel syndrome and responds favourably to surgery which is indicated in patients with neck, shoulder and arm pain but not in those with mild symptoms in the hand. Previously, the presence of persistent neurological symptoms has been accepted as a sign of a poor outcome after a whiplash injury, but our study suggests that it may be possible to treat chronic pain by carpal tunnel decompression.

Endocrine and immunologic parameters indicative of 6-month prognosis after the onset of low back pain or neck/shoulder pain.

STUDY DESIGN: Prospective study. OBJECTIVES: To evaluate the prognosis of spine disease by investigating biologic parameters reflecting different physiologic or psychophysiological systems in men and women with acute onset of low back or neck/shoulder complaints. SUMMARY OF BACKGROUND DATA: Psychosocial factors may be of importance to the etiology and prognosis of musculoskeletal disorders. The possible mechanisms, however, remain unclear. Stress-induced long-lasting energy mobilization resulting in inhibited anabolism has been discussed. Using a theoretical framework within stress physiology, such psychophysiological processes were recorded by measures of substances representing the anabolic, catabolic, immunologic, and opioid systems. METHODS: The study comprised 67 working men and women 21 to 59 years of age seeking care by any caregiver for acute low back and/or neck/shoulder pain. Blood samples were taken and analyzed for 3 methyl 5hydroxy phenylethylene glycol (MHPG, reflecting sympathoadrenomedullary activity), DHEA-s (anabolism), immunoglobulin E, interleukin 6 (immune activity), and beta-endorphin (pain regulation). The participants were followed up for 6 months after the blood samples had been drawn. RESULTS: In women, low MHPG, low DHEA-s, and low beta-endorphin predicted persistent disability due to low back complaints. Few significant findings were made for self-reported pain, for neck/shoulder complaints, and for men. CONCLUSION: Disturbances of the regulation of certain biologic parameters might be indicators of a prolonged course of low back disease in women. Prospective studies are necessary to enable causal conclusions.