Non-operative management of shoulder osteoarthritis: Current concepts.

Glenohumeral osteoarthritis (OA) is one of the most common causes of shoulder pain. Conservative treatment options include physical therapy, pharmacological therapy, and biological therapy. Patients with glenohumeral OA present shoulder pain and decreased shoulder range of motion (ROM). Abnormal scapular motion is also seen in patients as adaptation to the restricted glenohumeral motion. Physical therapy is performed to (1) decrease pain, (2) increase shoulder ROM, and (3) protect the glenohumeral joint. To decrease pain, it should be assessed whether the pain appears at rest or during shoulder motion. Physical therapy may be effective for motion pain rather than rest pain. To increase shoulder ROM, the soft tissues responsible for the ROM loss need to be identified and targeted for intervention. To protect the glenohumeral joint, rotator cuff strengthening exercises are recommended. Administration of pharmacological agents is the major part next to physical therapy in the conservative treatment. The main aim of pharmacological treatment is the reduction of pain and diminution of inflammation in the joint. To achieve this aim, non-steroidal anti-inflammatory drugs are recommended as first-line therapy. Additionally, the supplementation of oral vitamin C and vitamin D can help to slow down cartilage degeneration. Depending on the individual comorbidities and contraindications, sufficient medication with good pain reduction is thus possible for each patient. This interrupts the chronic inflammatory state in the joint and, in turn, enables pain-free physical therapy. Biologics such as platelet-rich plasma, bone marrow aspirate concentrate, and mesenchymal stem cells have gathered increased attention. Good clinical outcomes have been reported, but we need to be aware that these options are helpful in decreasing shoulder pain but neither stopping the progression nor improving OA. Further evidence of biologics needs to be obtained to determine their effectiveness. In athletes, a combined approach of activity modification and physical therapy can be effective. Oral medications can provide patients with transient pain relief. Intra-articular corticosteroid injection, which provides longer-term effects, must be used cautiously in athletes. There is mixed evidence for the efficacy of hyaluronic acid injections. There is still limited evidence regarding the use of biologics.

Hyperalgesia and sensitization of dorsal horn neurons following activation of NK-1 receptors in the rostral ventromedial medulla.

Neurons in the rostral ventromedial medulla (RVM) project to the spinal cord and are involved in descending modulation of pain. Several studies have shown that activation of neurokinin-1 (NK-1) receptors in the RVM produces hyperalgesia, although the underlying mechanisms are not clear. In parallel studies, we compared behavioral measures of hyperalgesia to electrophysiological responses of nociceptive dorsal horn neurons produced by activation of NK-1 receptors in the RVM. Injection of the selective NK-1 receptor agonist Sar9,Met(O2)11-substance P (SSP) into the RVM produced dose-dependent mechanical and heat hyperalgesia that was blocked by coadministration of the selective NK-1 receptor antagonist L-733,060. In electrophysiological studies, responses evoked by mechanical and heat stimuli were obtained from identified high-threshold (HT) and wide dynamic range (WDR) neurons. Injection of SSP into the RVM enhanced responses of WDR neurons, including identified neurons that project to the parabrachial area, to mechanical and heat stimuli. Since intraplantar injection of capsaicin produces robust hyperalgesia and sensitization of nociceptive spinal neurons, we examined whether this sensitization was dependent on NK-1 receptors in the RVM. Pretreatment with L-733,060 into the RVM blocked the sensitization of dorsal horn neurons produced by capsaicin. c-Fos labeling was used to determine the spatial distribution of dorsal horn neurons that were sensitized by NK-1 receptor activation in the RVM. Consistent with our electrophysiological results, administration of SSP into the RVM increased pinch-evoked c-Fos expression in the dorsal horn. It is suggested that targeting this descending pathway may be effective in reducing persistent pain.NEW & NOTEWORTHY It is known that activation of neurokinin-1 (NK-1) receptors in the rostral ventromedial medulla (RVM), a main output area for descending modulation of pain, produces hyperalgesia. Here we show that activation of NK-1 receptors produces hyperalgesia by sensitizing nociceptive dorsal horn neurons. Targeting this pathway at its origin or in the spinal cord may be an effective approach for pain management.

Discordance Between Patient and Clinician Experiences and Priorities in Rural Interhospital Transfer: A Mixed Methods Study.

PURPOSE: Rural emergency department (ED) patients require interhospital transfer for definitive care at nearly 6 times the national rate, yet transfer decision-making is variable. The goal of this study was to understand patient experiences, preferences, and decision-making in the rural interhospital transfer process, and to measure the concordance between patient opinions and provider perceptions. METHODS: Ours is a mixed methods study of patients transferred to a 711-bed Midwestern academic medical center and the emergency physicians in community hospitals. Qualitative interviews were conducted by a single research assistant with admitted patients transferred from an ED, and a corresponding survey was distributed to community emergency physicians. Standardized scenarios were posed to both groups to understand transfer priorities. FINDINGS: Seventy-nine patients and 40 physicians participated in this study. Patients and physicians cited proximity to home, medical expertise, a personal relationship with a health care provider, health insurance, privacy concerns, and patient choice as the primary factors that influenced patient transfer priorities. Compared with patient respondents, physicians overestimated the patient-perceived importance of proximity to home (P = .015) and being cared for by a personal physician (P = .049), but they underestimated the value of receiving treatment in a comprehensive medical center (P = .002). In standardized scenarios, physicians agreed with patients in transfer preferences for conditions requiring neurosurgical consultation, but they underestimated patients' desire for transfer for pneumonia requiring mechanical ventilation. CONCLUSION: Patients and physicians recognize similar factors that influence patient preferences in interhospital ED transfer, but physicians may overestimate the value of nonmedical influences on decision-making priorities.

Interhospital Transfer Delays Appropriate Treatment for Patients With Severe Sepsis and Septic Shock: A Retrospective Cohort Study.

OBJECTIVE: To test the hypothesis that interhospital transfer causes significant delays in the administration of appropriate antibiotics and compliance with the completion of Surviving Sepsis Bundle elements. DESIGN: Single-center retrospective cohort study. SETTING: A comprehensive 60,000-visit emergency department at a 711-bed Midwestern academic medical center. PATIENTS: Patients with severe sepsis and septic shock treated between 2009 and 2014 were identified by International Classification of Diseases,9th Revision, Clinical Modification, codes, then divided into two cohorts: 1) transfer patients who arrived at the tertiary academic center after receiving care in a local community hospital and 2) control patients who presented directly to the tertiary academic center emergency department. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: One hundred ninety-three patients were included. Transfer patients were more likely to require surgery in the hospital (p < 0.001) and require ICU care (p = 0.001) but had similar illness severity based on (Acute Physiology and Chronic Health Evaluation II, 17.7 vs 17.5; p = 0.662). Antibiotic administration at 1 and 3 hours was comparable between the two cohorts, but initial antibiotic appropriateness was lower in transfer patients (34% vs 79%; p < 0.001). Transfer patients were less likely to have fluid resuscitation started by 3 hours (54% vs 89%; p < 0.001), but they were not less likely to receive an adequate fluid bolus (30 mL/kg) by the time of hospital admission (p = 0.056). There were no differences in ICU length of stay or mortality. CONCLUSIONS: Interhospital transfer significantly delays administration of appropriate initial antibiotics and resuscitation therapy. Future studies are needed to identify strategies of providing regional sepsis care prior to transfer to tertiary centers and to continue care pathways during the interhospital transfer process.

Activation of rostral ventromedial medulla neurons by noxious stimulation of cutaneous and deep craniofacial tissues.

The rostral ventromedial medulla (RVM) projects to the medullary and spinal dorsal horns and is a major source of descending modulation of nociceptive transmission. Traditionally, neurons in the RVM are classified functionally as on, off, and neutral cells on the basis of responses to noxious cutaneous stimulation of the tail or hind paw. On cells facilitate nociceptive transmission, off cells are inhibitory, whereas neutral cells are unresponsive to noxious stimuli and their role in pain modulation is unclear. Classification of RVM neurons with respect to stimulation of craniofacial tissues is not well defined. In isoflurane-anesthetized male rats, RVM neurons first were classified as on (25.5%), off (25.5%), or neutral (49%) cells by noxious pinch applied to the hind paw. Pinching the skin overlying the temporomandibular joint (TMJ) altered the proportions of on (39.2%), off (42.2%), and neutral (19.6%) cells. To assess the response of RVM cells to specialized craniofacial inputs, adenosine triphosphate (ATP; 0.01-1 mM) was injected into the TMJ and capsaicin (0.1%) was applied to the ocular surface. TMJ and ocular surface stimulation also resulted in a reduced proportion of neutral cells compared with hind paw pinch. Dose-effect analyses revealed that on and off cells encoded the intra-TMJ concentration of ATP. These results suggest that somatotopy plays a significant role in the functional classification of RVM cells and support the notion that neutral cells likely are subgroups of on and off cells. It is suggested that a portion of RVM neurons serve different functions in modulating craniofacial and spinal pain conditions.