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PEMF MEDICAL STUDIES 

This section of the website will profile short reviews of important recent PEMF studies. 

Click Links Below for Details on Medical Work on PEMF Tech

Age-associated Memory Impairment Reversed with PEMF Therapy

Diabetic Foot Ulcer Infections – Combining Therapy with PEMF and Laser

Essential Tremor and Treatment with PEMF Devices

PEMF for Microcirculation & Increasing Blood Flow

PEMFs and Brain Recovery After Stroke

PEMFs for Healing Diabetic Foot Ulcers

PEMFs Reduce Progression of Arteriosclerosis

PEMFs Reverse The Muscle Damage From Cholesterol Lowering Drugs (statins)

Pulsed Electromagnetic Fields Help with Muscle Soreness After Exercise

SAFETY OF USING IUDS WITH PEMFS

More Studies Below:

Pulsed Electromagnetic Field and Pulsed Low-Intensity Ultrasound Therapy

Pulsed electromagnetic field therapy has been extensively studied by Hannemann et al. (see Chapter 23).20 With regard to pulsed low-intensity ultrasound therapy, Mayr et al. performed a single-blind randomized controlled trial with patients sustaining scaphoid fractures type B1 or B2 (Herbert classification). 29 patients (30 fractures) were divided into two groups; all patients were treated with a below-elbow cast with immobilization of the thumb until radiologic consolidation occurred. The intervention group additionally underwent a pulsed low-intensity ultrasound treatment of 20 min daily. The consolidation was assessed by a CT scan every 2 weeks. The time until consolidation was 43.2 ± 10.9 days in the intervention group, compared with 62 ± 19.2 days in the placebo group, a significant difference (P = .0055). Limitations of this study include the small groups, lacking sample size calculation, a single-blinded design, and more importantly the imprecision and unreliability of the primary outcome time until consolidation, despite the fact that evaluation by a CT-scan was performed every 2 weeks.21 No further publications considering both subjects have been found in the literature.

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Effects of Mechanical and Electrical Stimulation on Fracture Repair

Electromagnetic Therapy

Areas of active bone growth and regeneration or areas of bone deposition during physiologic bone remodeling are electronegative with respect to less active areas; thus, electric fields may be part of the normal process of bone development and regeneration.

Direct electrical currents have been used to treat nonunion fractures and osteotomies, as first described in 1971, which are reported to respond well to applications of either cathodal current or electromagnetic fields.

Bone regeneration can be accelerated in osteotomies made 3.5–4.5 cm distal to the head of the fibula in dogs. A voltage field was induced in the fibula by inductively coupling pulsed electromagnetic fields of low frequency and strength directly to the bone across the skin. Not only did the stimulated osteotomies heal faster than control osteotomies but also the regenerated bone was more highly organized and stronger than control regenerated bone, even though the mass of callus formed was less than in controls. This method has been used to successfully treat tibial pseudoarthroses in young patients. Pseudoarthrosis is a rare, local bone dysplasia that has a very low probability of correction by conventional techniques. Pulsed electromagnetic fields have also been used as a noninvasive postoperative treatment for lumbar vertebral fusion.

The use of electromagnetic fields has been advocated to promote the synthesis of extracellular matrix proteins of bone cells and the secretion of growth factors from osteoblasts to stimulate angiogenesis and new bone formation. Pulsed electromagnetic field therapy may enhance angiopoietin-2 expression. It may also affect several membrane receptors and stimulate osteoblasts to secrete several growth factors such as BMPs 2 and 4, TGF-β, and FGF2. These anabolic effects of electromagnetic fields on bone formation contribute to the enhancement of fracture repair.

Silent Pulses and Rhythmic Entrainment

James L. Oschman PhD, in Energy Medicine (Second Edition), 2016

Medical Use of Electricity and Magnetism

Should you fracture a bone in an arm or leg, and it fails to heal in 3–6 months, there is a good chance that your orthopedic surgeon will prescribe an energy method called pulsed electromagnetic field (PEMF) therapy. Your prescription is for a small battery-powered pulse generator (Figure 15.1B) connected to a coil that you will place next to your injury for 8–10 h/day, or you will have an electrical stimulator implanted near the fracture (Figures 15.1C and 15.2). The PEMF device produces a magnetic field that induces currents to flow in nearby tissues.

The idea of jump-starting a healing process is familiar to anyone who has practiced energetic bodywork or movement therapies. It is fascinating to follow the saga of how the energetic approach to bone healing was discovered, accepted as a therapy, rejected, and reinstated by the medical community.

Modern use of energy fields to stimulate bone repair actually began shortly after the discovery of ‘animal electricity’ at the end of the eighteenth century. By the mid-1800s, the preferred method for treating slow-healing fractures was to pass electricity through needles surgically implanted in the fracture region (Figure 15.1A). The technique was banished from medical practice, along with unproven electrotherapies, early in the 1900s (see Chapter 4).

In the 1950s and 1960s, there was a resurgence of medical interest in electric and magnetic therapy. After considerable effort by scientists at a number of research centres (Bassett et al., 1982; Brighton et al., 1981), both electric and magnetic therapy for fracture ‘non-unions’ were granted the ‘safe and effective’ classification by the U.S. Food and Drug Administration. To obtain this status, many studies were done to document the success, lack of side effects, and mechanisms of energy field methods.

Not surprisingly, the scientific evidence is that PEMF therapy is effective because it conveys ‘information’ that triggers specific repair activities within the body. The currents induced in tissues by PEMF mimic the natural electrical activities created within bones during movements. Pulsing magnetic fields initiate a cascade of activities, from the cell membrane to the nucleus and on to the gene level, where specific changes take place (Bassett, 1995).

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Multiple Sclerosis

Bradly Jacobs MD, MPH, ABOIM, Surya Pierce MD, in Integrative Medicine (Fourth Edition), 2018

Magnet Therapy

Magnetic therapy is simply the therapeutic application of magnets and can be delivered in many forms. In a 12-week, randomized trial, subjects with MS laid down on a metal mat for 8 minutes twice daily. The device delivered low-frequency, pulsed electromagnetic field therapy. Another study had subjects with MS wear wristwatch-size, magnetic pulsing devices called Enermed for 10 to 24 hours daily for 2 months. Another device also delivered low-frequency magnetic stimulations at 37.5 mT and a sequence of pulses at 4 to 7 Hz three times weekly for 2 months. These studies demonstrated consistent benefits in reducing fatigue but no benefit for depression in subjects with MS.53

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Biomarkers of compromised implant fixation

Reshid Berber, ... Andrew Manktelow, in Biomarkers of Hip Implant Function, 2023

5.4.3 Biophysical stimulation

Biophysical stimulation represents a non-invasive and locally applied strategy to enhance bone healing. Two methods of biophysical stimulation have been used in orthopaedic practice: pulsed electromagnetic fields (PEMFs) and low-intensity pulsed ultrasound (LIPUS). In the case of PEMF therapy, the positive effect on bone ingrowth is primarily linked to improved vascular function secondary to the release of angiogenic factors, such as IL-8, βFGF, and VEGF (Dimitriou and Babis, 2007). LIPUS, on the other hand, is a form of mechanical energy that is transmitted through living tissue as acoustic pressure waves and absorbed at a rate proportional to the density of the tissues it passes through. It has been hypothesised that the micromechanical strains produced by LIPUS in biological tissues result in biochemical events that stimulate fracture healing (Dimitriou and Babis, 2007). Although both techniques were initially developed, and are currently employed, to stimulate bone regeneration during fracture healing, their positive clinical outcomes and safety highlight their potential as adjunct therapies to enhance implant osseointegration. There is a paucity of data on the impact of biophysical stimulation on osseointegration of prosthetic implants, but some advantages in terms of early recovery have been described in patients treated with these procedures, suggesting that biophysical stimulation could reduce bone oedema, pain, and bone reabsorption around femoral stems following THA (Massari et al., 2015).

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Nonoperative Treatment of Shoulder Impingement

Michael A. Keirns, Julie M. Whitman, in The Athlete's Shoulder (Second Edition), 2009

Conservative Treatment of Nondisplaced and Minimally Displaced Scaphoid Waist Fractures

Joris P. Commandeur MD, ... Frank J.P. Beeres MD, PhD, in Scaphoid Fractures: Evidence-Based Management, 2018

Decreasing the Inflammatory Process

Adjuncts in diminishing the chemical reaction of the inflammatory process are rest, therapeutic modalities, and nonsteroidal anti-inflammatory agents. When the inflammatory mechanism is inhibited, the patient should experience an associated decrease in pain and swelling. Success in achieving these goals has been accomplished through an array of modalities to include laser, microcurrent, pulsed electromagnetic field therapy, iontophoresis, and phonophoresis.117 My (MAK) anecdotal choice of modalities to treat the acute inflamed shoulder include cryotherapy and low-frequency transcutaneous electrical nerve stimulation (TENS).

Cold applications diminish the inflammatory condition by acting as vasoconstrictors and reducing metabolic activity.118,119 Cooling also diminishes discomfort associated with the acute shoulder injury by increasing the threshold of pain in stimulated nerve fibers.120,121 Through this cold-induced analgesia, normal shoulder motion can be facilitated.122 Cold therapy can be effective with ice massage for 15 to 20 minutes with the arm positioned in abduction (Fig. 41-8).

Classically, TENS has been used for the purpose of pain alleviation. Low-frequency TENS has also been found effective to increase microcirculation and facilitate the absorption of calcific deposits in the shoulder tendons.123,124 The most effective treatment points are believed to be associated with stimulation of the acupuncture points.125 Figure 41-9 displays a possible electrode placement using acupuncture sites. The points used in this arrangement include Jianjing (GB 21), Binao (LI 14), Juga (LI 16), and Jianya (LI 15).126 Any physical modality is only an adjunct in a physical therapy clinic and should be used with prudence.

Although injections can be a useful tool in decreasing the inflammatory process and differentiating the impingement diagnoses, caution must be exercised in recommending steroid injections. Steroid injection in or near the cuff and biceps tendons can produce tendon atrophy or can reduce the capability of damaged tendon to repair itself.127–129 Kennedy and Willis130 concluded that collagen necrosis occurred with steroid injection. Controlled studies have been performed showing minimal effectiveness alone with the use of steroid injections.131,132

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Osteonecrosis of the Knee

Andreas Gomoll, Brian Chilelli, in Evidence-Based Management of Complex Knee Injuries, 2022

Treatment

The treatment options for patients with SONK include operative and nonoperative options and depend on the stage of the disease, associated structural abnormalities and symptoms. The size of the lesion, which is taken by measuring the greatest width in the AP radiograph and the greatest length in the lateral radiograph, can also help guide management.17 Small lesions (<3.5 cm2) have a high potential to respond well to nonoperative management and heal.18 On the other hand, larger lesions (>5 cm2) have a higher likelihood of failure with nonoperative treatment and tend to progress to advanced osteoarthritis.19 Another method to assess size involves calculating the width of the lesion in the AP radiograph as a percentage of the entire affected condyle width.16 With this method Lotke et al.16 determined that small lesions involving 32% of the condyle responded well to conservative treatment, whereas large lesions involving more than 50% of the condyle progressed rapidly to collapse and required arthroplasty.

Nonsurgical management

The initial management for most small precollapse lesions consists of rest, activity modification, antiinflammatory medications, physical therapy, protected weightbearing and bracing. Unloader braces function to redistribute joint reaction forces and create a more favourable biomechanical environment for healing of the subchondral bone to occur. Pharmacological agents such as vitamin D and bisphosphonates should be considered to maximise the healing potential of the subchondral region. Vitamin D deficiencies need to be restored to normal levels. Bisphosphonates are thought to decrease the resorption of bone while allowing healing to occur and reducing the chances of subchondral collapse. The goals of nonoperative treatment are to control symptoms and reduce stress on the subchondral bone to maximize healing. Nonsurgical management has been associated with favourable results when initiated during the early precollapse stages of small lesions with greater than 80% of patients in most studies experiencing success without progression of the disease process.16,18,20 However, Nakayama et al20 did find that the presence of varus deformity was significantly associated with a poor prognosis resulting in progressive deformity and prolonged disability.

Other areas of nonoperative management being studied are hyperbaric oxygen chamber therapy (HBOT) and pulsed electromagnetic field (PEMF) therapy. Increased levels of reactive oxygen species occur with HBOT and trigger a set of responses that lead to increased vascularisation and the modulation of impaired proinflammatory cytokine productions.21 A retrospective study of 37 SONK patients treated with HBOT documented improved Oxford Knee scores in 86% of patients after 30 sessions and in 100% of patients after 50 sessions.22 In addition, MRI 1 year after HBOT completion demonstrated resolution of oedema at the femoral condyle in all but 1 patient. In another study, 28 patients with symptomatic Kashino stage 1 SONK were treated with local electromagnetic field therapy and followed for 24 months.23 The patients were treated 6 hours daily for 90 days. At final follow-up, visual analogue scale (VAS), Tegner and EuroQol-5D (EQ-5D) scores and Knee Society Score (KSS) results all significantly improved compared with baseline. Furthermore, MRI evaluation at 6 months was favourable, with a significant reduction of mean total Whole-Organ Magnetic Resonance Imaging Score (WORMS) and mean femoral bone marrow lesion area. Only 4 of the 28 patients (14.3%) required total knee arthroplasty within 24 months of ending PEMF therapy because of persistent pain and symptoms.

Surgical Management

Surgical intervention should be considered for patients who have failed 12 weeks of nonoperative treatment and for patients with large lesions that are at high risk for advanced collapse. Joint-preserving procedures include arthroscopy, core decompression, bone grafting, subchondroplasty and osteochondral allograft/autograft transplantation. Unicompartmental and total knee arthroplasty are reserved for failed joint-preserving procedures and advanced collapse disease.

Arthroscopy allows for management of associated intraarticular abnormalities and has been described to facilitate decompression of the subchondral lesion. Loose chondral flaps can be debrided and meniscal pathological conditions may be addressed. Meniscus root repair restores meniscus function and unloads the medial compartment, allowing for subchondral healing. Akgun et al.24 performed arthroscopic debridement and microfracture on 26 patients with SONK and followed them for a mean of 27 months. All patients failed nonoperative management before surgical intervention, and the average lesion size was 1.62 cm2. The authors reported a statistically significant improvement in Lysholm score at mean follow-up, and 71% of patients were able to return to strenuous sports with no or minimal limitation. Of note, 14 of the 26 patients (53.8%) were found to have meniscus tears, and partial meniscectomy was performed in those cases.

Core decompression has been described to help facilitate healing of the subchondral bone and prevent additional surgical treatment in precollapse disease. This technique typically involves extraarticular drilling under fluoroscopic guidance. It is meant to decrease intraosseous pressure and enhance microcirculation to the affected area of subchondral pathological conditions. Forst et al.25 achieved clinical improvement in 15 of 16 patients with early-stage SONK treated with core decompression. They reported improved mean KSSs at a mean follow-up of 35 months and normalisation of bone marrow signalling on MRI.

Subchondroplasty (SBC; Zimmer Knee Creations; West Chester, PA, USA) is a proprietary term to describe the technique of surgically injecting calcium phosphate into the trabeculae of subchondral cancellous bone.26 It is meant to reinforce the subchondral region and stabilise insufficiency fractures. A literature review reported on 164 patients from eight studies with bone marrow lesions who went on to surgical subchondral calcium phosphate injection.27 All studies demonstrated significant functional improvements despite 25% of patients in one of the studies with some type of persistent pain complaint. Furthermore, the largest series included in the review acknowledged a 70% reduction in conversion to total knee arthroplasty (TKA) at 2 years.28 Despite optimism regarding the technique, there is a lack of long-term outcome data.

Osteochondral autograft transfer (OAT) is a technique in which one or multiple osteochondral cylinders are harvested from a nonweightbearing area of the knee and implanted within the SONK lesion. This procedure is often limited to small lesions and can result in donor site morbidity. Duany et al.29 reported success in nine patients treated with this technique at a mean follow-up of 42 months.

Fresh osteochondral allograft (OCA) transplantation has demonstrated excellent efficacy in treating large SONK lesions of the knee. This procedure is a viable option for cases of early or late collapse without associated diffuse osteoarthritis. The disrupted chondral surface and abnormal subchondral bone are replaced with an appropriately sized and matched OCA. A case series of seven patients treated with OCA for large SONK lesions (mean 4.6 cm2) of the medial femoral condyle reported no failures and improved subjective outcome scores at an average follow-up of 7.1 years.30 In addition, all patients were extremely satisfied with the results of the procedure.

High tibial osteotomy (HTO) is a common surgical procedure for the treatment of degenerative conditions of the medial compartment and can be used to treat SONK. It facilitates unloading of the lesion and can be combined with concomitant drilling or bone grafting. Takeuchi et al.31 followed 30 patients with SONK of the medial femoral condyle who underwent HTO combined with curetting and drilling of the lesion to a mean follow-up of 40 months. At final follow-up, American Knee Society Score and Function Score increased from 51 to 93 and 58 to 93, respectively. Osteotomy hardware was removed in 24 patients, and arthroscopic findings at that time revealed complete fibrocartilage fill of the previous SONK lesions.

Unicompartmental knee arthroplasty (UKA) may be an appropriate option for patients with advanced collapsed disease isolated to a single condyle or compartment. It can also be used as a salvage option after failed joint preservation surgery. Chalmers et al.32 reported a 5- and 10-year survivorship of 93% in 41 patients treated with UKA for primary osteonecrosis of the knee. Similarly, Heyse et al.33 revealed a survival rate of 93.1% at 10 years and 90.6% at 15 years, with 97.3% of patients reporting feeling satisfied (21.6%) or very satisfied (75.7%). TKA is the treatment of choice for advanced disease affecting more than one compartment.

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Fracture Healing

Jiliang Li, ... David L. Stocum, in Basic and Applied Bone Biology (Second Edition), 2019

Low-Intensity Pulsed Ultrasound

Low-intensity pulsed ultrasound (LIPUS) has been shown to have significant beneficial skeletal effects. Ultrasound refers to a high-frequency nonaudible acoustic energy that travels in the form of longitudinal mechanical waves. Traditionally used by physical therapists to intervene in injuries to soft tissues, it is most commonly used with intensity in the range of 0.5–2.0 W/cm2. In comparison, to intervene in injuries to hard tissues (such as bone) pulsed-wave ultrasound with a spatially averaged, temporally averaged intensity (ISATA) of below 0.1 W/cm2 is preferred. ISATA refers to the average ultrasound power over the area of the ultrasound beam (spatial average) and the average of this intensity over a complete pulse cycle (ultrasound “on” and “off” period; temporal average). Pulsed-wave ultrasound with an ISATA below 0.1 W/cm2 is termed LIPUS and is preferred in the intervention of fracture healing, as its low ISATA significantly reduces the risk of any thermal or cavitational tissue damage—LIPUS has US FDA approval to be applied to bone.

A number of in vitro studies have shown LIPUS to have direct effects on osteoblasts, including alteration of transmembrane ion transfer, stimulation of immediate-early response genes, elevation of mRNA levels for bone matrix proteins, such as osteocalcin and BSP, and increased synthesis of cytokines and growth factors, including c-Fos, COX-2, IGF-I, nitric oxide, p38/MAPK, PGE2, PI3-K, and VEGF. These changes are consistent with a bone-forming response. This bone-forming response is supported by studies using bone rudiments. In 17-day-old fetal mouse metatarsal bone rudiments, LIPUS treatment for 21 min/day over a period of 7 days was found to stimulate a threefold increase in the average length of the calcified diaphysis, when compared with control rudiments.

LIPUS stimulates bone union. The initial benefit of LIPUS on the skeleton in vivo is the induction of bone repair in fractures displaying either delayed union or nonunion. In a fracture nonunion model in rodents, 6 weeks of LIPUS treatment stimulated union in 50% of fractures. This is compared with a 0% union rate in contralateral fractures treated with inactive-LIPUS (placebo). Clinically, LIPUS stimulates union in more than 85% of fractures that have otherwise failed to heal.

In addition to its benefits on fractures displaying a failed healing response, LIPUS can substantially accelerate the rate of repair of fresh fractures. LIPUS also promotes greater bone content in fracture callus, more rapid endochondral ossification, and quicker recovery of stiffness in ovariectomy-induced osteoporotic, as well as diabetic, rats. In humans, LIPUS can reduce the time for recovery of clinical and radiographic union by 30%–38%. This represents a reduction in healing time of 58, 37, and 19 days in tibial diaphyseal, distal radius, and scaphoid fractures, respectively.

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Case studies in a musculoskeletal out-patients setting

Adrian Schoo, ... James Selfe, in Clinical Case Studies in Physiotherapy, 2009

Case Study 8

1.  Rotator cuff condition with symptoms of supraspinatus tendon impingement and subscapularis involvement.

2.  Painful arc on abduction with audible click, pain and weakness on resisting subscapularis as well as supraspinatus activity.

3.  Within the domain of shoulder pain, rotator cuff conditions can be caused by an inter-relationship between soft tissue laxity (i.e. ligament) resulting in glenohumeral laxity, impingement (e.g. due to bursitis or osteophytes) resulting in tendon compression and cuff lesions (Allingham & McConnell 2003). Therefore, treatment is likely to be more effective when all possible factors that can cause laxity, impingement or lesion of the cuff are considered. These include:

a.  Poor mobility of the thoracic spine

b.  Muscle imbalance (tightness and or weakness)

c.  Poor posture (e.g. hyperkyphosis, protracted or depressed shoulders) that result in abnormal scapular movement and subacromial impingement or

d.  Degenerative changes of the acromioclavicular joint due to trauma and or osteoarthritis.

4.  As with back pain each of the possible contributing factors need to be examined and included in the treatment plan as appropriate (Kent et al 2005). This means that instead of lumping groups of symptoms together (e.g. rotator cuff symptoms) it has been suggested to split and recognise factors that cause laxity, impingement and/or lesion and provide treatment as the clinician sees fit. So far:

a.  an exercise programme that includes stabilisation exercises of the scapula, functional shoulder exercises and thoracic mobilisation is likely to be effective in short-term recovery and longer-term functioning of rotator cuff disease

b.  the combination of exercise and mobilisation has shown to enhance outcomes

c.  ultrasound and pulsed electromagnetic field therapy has shown to only improve pain in case of calcific tendinitis, and laser therapy only symptoms associated with adhesive capsulitis (Green et al 2003).

Allingham and McConnell (2003) described the various components of a rehabilitation programme that can be individualised to address the multiplicity factors that can be involved in the aetiology of shoulder pain.

5.  Common shoulder problems that can cause pain are strain or tendinopathy of the rotator cuff (supraspinatus, subscapularis, infraspinatus and teres minor), glenoid labral tear, glenohumeral instability or dislocation, acromioclavicular sprain and/or fractured distal end of the clavicle, and muscle strain or tear of the pectoralis major or long head of the biceps. Other common causes of shoulder pain can be based on referred pain from the cervical or thoracic spine, or pathology of the brachial plexus.

Less common causes of shoulder pain are suprascapular or long thoracic nerve entrapment. Problems not to be missed include thoracic outlet syndrome (e.g. cervical rib), circulation problems (e.g. axillary vein thrombosis), bone tumour, or referred pain from diaphragm or organs (e.g. heart, gallbladder, spleen, apex of the lungs, or duodenum) (Brukner et al 2001e).

Although adhesive capsulitis of the glenohumeral joint, calcification tendinopathy or tear in one of the muscles of the rotator cuff, or a fracture of the neck of humerus, coracoid process or scapula are less common in sports medicine (Brukner et al 2001e), they can be more common in middle-aged and older people.

6.  As explained in the third answer, thoracic mobility (or rather lack of) and poor scapular stability can cause tissue impingement and cause rotator cuff problems. Since poor respiration in asthma can be associated with thoracic dysfunction, it is important to include breathing and thoracic mobilisation exercises if needed.

7.  Although modified duties at work can reduce impingement until scapular movement and stability have improved, it is not always accepted by the employer. Educating the patient, careful monitoring, and liaison with employer can enhance the outcome of the rehabilitation process.

8.  Using outcome measures such as the Upper Extremity Functional Index (Stratford et al 2001) or the Croft Disability Questionnaire (Croft et al 1994) do not measure pain and disability associated with overhead activities as the SPADI does. Although cross-sectional comparison of different shoulder questionnaires can show comparable overall validity and patient acceptability, it is important to include overhead activities since overhead work is an important aspect of her daily work. An additional benefit of the SPADI is that it is responsive to change, quick to complete, and scores are not likely to change in stable subjects (Paul et al 2004).

9.  Corticosteroid injections can be beneficial in reducing symptoms (Green et al 2003). Also, an ultrasound scan can assist with assessing the degree of tendon degeneration as well as showing the presence of bursitis, whereas an X-ray can exclude calcific tendinitis or degenerative joint changes of the acromioclavicular joint. MRI can exclude problems in the glenohumeral joint (e.g. labral tears).

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Rotator Cuff Contusion

Robert A. Arciero MD, ... Kirsten L. Poehling-Monaghan MD, in Shoulder and Elbow Injuries in Athletes, 2018

Treatment

There is currently a lack of guidelines based on randomized, prospective studies to aid the clinician treating partial rotator cuff tears and contusions. Also, most of the available studies lack adequate statistical power. The results of nonoperative management of partial-thickness tears are largely unknown because there are no long-term follow-up studies using a standardized treatment protocol. Nonsurgical treatment is still regarded as the initial management step. The goal of treatment in athletes with a partial rotator cuff tear is to eliminate pain and restore function. Treatment of the athlete with a rotator cuff contusion has the same objective. The goals could evolve if biologic interventions are developed that lead to a true healing response (Ferhat et al, 2016).

Determining whether the injury is traumatic or is related to overuse is the first step to frame the treatment strategies. In the athlete with a trauma history, the initial goal is to control the pain and to restore full shoulder/scapula mobility and strength. The treatment for a partial rotator cuff tear in the overhead throwing athlete centers on the underlying deficiencies seen, such as loss of shoulder motion, scapula dyskinesia, and rotator cuff weakness. Mechanical flaws in the throwing or overhead motion may also need to be corrected.

The majority of patients in the study by Cohen et al (2007) examining rotator cuff contusions showed quick responses to treatment with modalities such as, pulse ultrasound and cuff/scapula strenthening. It was noted that the athletes who had significant subentheseal bone bruises and what the researchers called “chronic tendinopathy” had more prolonged recovery. In the patients who did not demonstrate significant improvement by the third day after injury (23%) a subacromial corticosteroid injection was utilized; this step was described to be of benefit, because only one of the six athletes who received a cortisone injection later needed surgery. Minimal morbidity was noted overall as a result of the contusions but 11% of the patients required later surgical intervention.

Separate Cochrane Systematic Reviews evaluating the benefits of electrotherapy modalities as well as assessing the value of manual therapy and exercise for rotator cuff disease have been performed (Page, Green, McBain, et al, 2016; Page, Green, Mrocki, et al, 2016). Modalities such as transcutaneous electric nerve stimulation, therapeutic ultrasound, low-level laser therapy (LLLT), and pulsed electromagnetic field therapy are examples of the modalities potentially utilized in the electrotherapy evaluation. On the basis of low-quality evidence, therapeutic ultrasound may have short-term benefits for patients with calcific tendinitis, and LLLT may have short-term benefits in patients with rotator cuff disease. The review of the literature identified only 1 of 60 trials to be of high quality regarding manual therapy and exercise, and no benefit was noted.

In the overhead throwing athlete, shoulder rehabilitation should be directed at the underlying deficits, most commonly loss of shoulder internal rotation and poor control of the scapula. A four-phase approach is described by Wilk & Macrina (2014) in the nonoperative treatment of throwing shoulder injuries. In phase 1, the “acute phase,” the primary goals are to diminish pain/inflammation, improve motion, activate the appropriate muscles, create dynamic stability and muscle balance, and restore proprioception. The athlete’s level of activity is adjusted according to symptoms, which usually require the athlete to abstain from activity. Internal rotation motion is addressed; the preferred stretches are the modified sleeper’s stretch and supine horizontal adduction with internal rotation stretch (Fig. 6A.2). A horizontal adduction stretch with manual patient assistance into internal rotation is performed. Assessment of scapula positioning is also recommended, with strengthening of the scapula retractors and the lower trapezius and additional stretching of the pectoralis minor. The primary goals of phase 2, the “intermediate phase,” are to progress the strengthening program, improve the range of motion, and facilitate neuromuscular control. Core strengthening is also initiated during this phase. Kibler et al (2013) have emphasized the need to evaluate and treat the entire system to restore the athlete’s kinetic chain. Phase 3, the “advanced strengthening phase,” involves aggressive strengthening drills to promote power and endurance as well as functional drills, and throwing is gradually introduced. “Return to throwing phase,” phase 4, incorporates the progression of an interval-throwing program. This program controls for distance, intensity, and surface, in that for pitchers, throwing from the mound is the last advancement. It is important to be aware that when athletes are told to throw with 50% effort, they actually throw at 83% of their maximal speed, and when asked to throw at 75% they are actually throwing at 90% of their maximal effort (Fleisig et al, 1996).

Corticosteroid injections have been commonly utilized in treating rotator cuff disease. Koester et al (2007) performed a systematic review of the literature and analyzed nine randomized controlled studies comparing subacromial corticosteroid injection with placebo. One study demonstrated significant pain relief and two studies showed an increased range of motion in the injection group. No significant complications were identified. In a study comparing a corticosteroid injection with a platelet-rich plasma (PRP) injection for subacromial impingement syndrome, the investigators found the Constant score and VAS for pain to be significantly better at both 6 weeks and 6 months in the corticosteroid-treated group. Good patient candidates for a single subacromial corticosteroid injection to achieve pain control are those with significant night pain or patients who will not tolerate phase 1 rehabilitation because of pain.

PRP injections are being utilized for partial rotator cuff tears. There are mixed results in the literature. A randomized controlled trial (level I evidence) with a 1-year follow-up demonstrated no benefit from a single PRP injection in comparison with placebo (Kesikburun et al, 2013). Biologic type injections may have a role in the treatment of partial rotator cuff tears; however, the exact platelet count and leukocyte concentration in PRP for optimal growth factor activity has yet to be definitively proven in the literature.

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Rotator cuff lesions

Peter A. Huijbregts, Carel Bron, in Neck and Arm Pain Syndromes, 2011

Management

Physical therapy management options for patients with impingement syndrome include education, modalities, exercise, manual therapy, and also taping interventions. Common medical management includes non-steroidal anti-inflammatory medication (NSAID), subacromial steroid infiltration, and arthroscopic or open subacromial decompression surgery.

Considering the role of thoracic flexion on scapulo-thoracic motion, education with regard to appropriate posture seems an obvious component of patient education. Bullock et al (2005) noted a significant increase in patients with impingement for shoulder flexion range although not pain intensity with erect as compared to slouched sitting posture. Visual, manual, and verbal feedback combined with education on faulty movement patterns provided significantly decreased electromyographic activity in the upper and middle trapezius, infraspinatus, serratus anterior, and anterior and middle deltoid muscles of patients with impingement immediately and 24 hours after movement training, whereas trunk, shoulder, and clavicular kinematics improved during and immediately after training, especially in the subset of patients with elevated clavicular position supporting the role of educating patients on correct movement patterns (Roy et al 2009).

Taping patients may support retraining of correct movement patterns. However, using asymptomatic subjects Cools et al (2002) showed that tape application intended to inhibit the upper and facilitate the lower trapezius had no effect on electromyographic activity in the serratus anterior or all three portions of the trapezius with resisted or un-resisted flexion and abduction of the shoulder. The authors suggested altered timing as a possible explanation for the clinically observed effects of taping. In contrast, in patients with subacromial impingement Selkowitz et al (2007) did show that similar taping decreased upper trapezius and increased lower trapezius activity during a functional overhead-reaching task and that it decreased upper trapezius activity during shoulder abduction in the scapular plane. Mechanisms suggested to be involved in taping include facilitation or augmentation of proprioceptive cutaneous input, tension when movement occurs outside of the movement pattern allowed by the taping application, and inhibition or facilitation by taping shortened overactive muscles in a lengthened position, whereas the tape might be used hold lengthened under-active muscles in a shortened position. Various taping techniques appropriate for patients with impingement have been described in the literature (Morrissey 2000, Kneeshaw 2002) (Fig 16.5). Morrissey (2000) suggested that when the positive effect on the movement pattern or on symptoms was maintained, taping could be discontinued.

Laser therapy was not demonstrated to be superior to placebo for patients with rotator cuff tendinopathy (Green et al 2003). Ultrasound (RR 1.81, 95% CI 1.26–2.60) and pulsed electromagnetic field therapy (RR 19, 95% CI 1.16–12.43) resulted in improvement compared to placebo with regard to pain in patients with calcific tendinopathy. There is no evidence of an effect for ultrasound in patients with other tendinopathy. Ultrasound also provides no additional benefit when used in combination with exercise interventions over exercise alone (Green et al 2003). There is strong evidence that extra-corporeal shock-wave therapy is no more effective than placebo in patients with impingement with regard to functional limitations (Faber et al 2006).

Exercise therapy interventions for patients with impingement are intended to restore the frontal and transverse plane glenohumeral force couples and normalize scapular motion. Generally they consist of progressive resistive exercises for the rotator cuff and scapular muscles and stretching of tight structures but they should also address the motor control deficits identified in patients with impingement. More detail on shoulder exercises is provided in Chapters 21 and 22. Exercise interventions have been supported in a number of recent randomized trials (Werner et al 2002, Walther et al 2004, Lombardi et al 2008) and systematic literature reviews for producing improvements in both pain and function (Green et al 2003, Trampas & Kitsios 2006, Faber et al 2006). In a Cochrane review (Green et al 2003), exercise was noted as effective in terms of short-term recovery in rotator cuff disease (RR 7.74; 95% CI 1.97–30.32) and for longer-term benefit with regard to function (RR 2.45; 95% CI 1.24–4.86). It should be noted that in patients with Neer stage I–II impingement there are no significant between-group differences (at 6 and 12 weeks) with regard to pain and function for patients treated with a supervised exercise programme or a home programme in which they are instructed by a physical therapist (Werner et al 2002, Walther et al 2004).

The presence and size of a full-thickness rotator cuff tear may limit potential for management with exercise and underscores the importance of correct diagnosis. However, at least in a subset of patients with impingement non-operative management is equally effective as open or arthroscopic decompression (Coghlan et al 2008). Haahr et al (2005) noted no between-group differences at 12 months for pain and function in patients treated with subacromial arthroscopic decompression or 19 sessions of rotator cuff and scapular strengthening augmented by thermotherapy and massage. Faber et al (2006) reported no significant difference between supervised exercise therapy and arthroscopic acromioplasty with regard to return to work status at 6 months and at 2.5 years.

Some systematic reviews (Green et al 2003, Faber et al 2006) have supported a combination of manual therapy and exercise for patients with impingement for improvements in pain and function. Manual therapy interventions may be appropriate for restrictions in the glenohumeral jointshoulder girdle, cervical and thoracic spine, and ribs and are discussed in more detail in Chapters 11, 12, 15 and 20.

Senbursa et al (2007) compared a home programme of rotator cuff and scapular strengthening exercises, active range of motion, and stretching with 12 sessions of glenohumeral soft tissue and joint mobilization, ice application, stretching and strengthening exercises in patients with impingement. At 4 weeks there were significant between group differences with regard to pain and function favouring the manual therapy group. Kachingwe et al (2008) showed significant changes with regard to pain, pain-free range of motion, and function for patients with impingement treated with 6 sessions of supervised exercise only, supervised exercise with glenohumeral grade I–IV glide and traction mobilizations from midrange, supervised exercise with a Mulligan mobilization with movement (MWM) shoulder flexion technique, or a control group receiving only physician advice; there were no between-group differences. Although power in this pilot study was extremely limited, the three intervention groups had a greater improvement in function and both manual therapy groups improved more with regard to pain measures. Active range of motion increased most for the MWM and least for the mobilization group.

Bergman et al (2004) compared medical care (consisting of oral analgesics or NSAID, education, advice, corticosteroid infiltrations and physical therapy referral for exercise, modalities, massage after 6 weeks) to medical care with up to 6 treatments of thrust and non-thrust manipulative interventions to the ribs and cervical-thoracic spine over 12 weeks in patients with shoulder symptoms and dysfunction of cervico-thoracic spine and adjacent ribs. At 12 weeks, 43% of the manipulation group and 21% of the medical care group reported full recovery. A 17-percentage point difference favouring manipulation still existed at 52 weeks. During intervention and follow-up a consistent between-group difference in severity of the main complaint, shoulder pain and disability, and general health favoured the manual therapy group.

Bang & Deyle (2000) showed significant between-group differences on function, pain, and isometric strength of the shoulder in patients with impingement for the group that received thrust and non-thrust techniques to the glenohumeral joint, shoulder girdle, cervical and thoracic spine, and ribs and also manual muscle stretching, massage, and supervised exercise over the group receiving only the exercise intervention. Boyles et al (2009) showed significant within-group improvements at 48 hours for pain with provocative shoulder and resisted tests and functional scores in patients with impingement after only receiving mid-thoracic, cervico-thoracic, and rib thrust manipulation.

With regard to medical management, Green et al (2003) reported that for rotator cuff disease, corticosteroid injections might at times be superior to physical therapy. Buchbinder et al (2003) noted that for rotator cuff disease, subacromial steroid injection demonstrated a small benefit over placebo in some trials. Pooled results of three trials showed no benefit of subacromial steroid injection over NSAIDs. In the context of surgery it should be noted that no significant differences have been reported in outcome between arthroscopic and open subacromial decompression, although four trials did report earlier recovery with arthroscopic decompression (Coghlan et al 2008).

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