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The association of metabolic syndrome markers with adhesive capsulitis
Abstract
Background
Research has associated adhesive capsulitis with diabetes mellitus but suggests that glucose-mediated injury may begin before diabetes is diagnosed. The period preceding diabetes is often marked by metabolic syndrome.
Methods
We investigated the relationship between metabolic syndrome components (insulin resistance, hypertension, dyslipidemia, and obesity) and the development of adhesive capsulitis using a case-control study. We retrospectively reviewed 150 consecutive adhesive capsulitis patient charts to determine the prevalence of obesity and of medications used for treating metabolic syndrome elements and compared these with previously reported nationwide values.
Results
The prevalence of anti-hyperglycemia medications in the adhesive capsulitis cohort was 18.4% (95% confidence interval [CI], 12.9%-25.7%), twice the national rate of diagnosed diabetes of 7.6% (95% CI, 6.7%-8.5%). In the 20- to 39-year-old group, the prevalence of anti-hyperglycemic medications, 26.3% (95% CI, 11.8%-48.8%), was over 10 times the nationwide rate. The overall prevalence of hypertensive medication use in the adhesive capsulitis group, 33.1% (95% CI, 25.9%-41.2%), was notably higher than the nationwide rate, 21.6% (95% CI, 19.8%-23.4%). In the 40- to 64-year-old group, the prevalence of hypertensive medication use, 36.8% (95% CI, 28.6%-46.0%), was notably higher than the nationwide rate of 24.5% (95% CI, 22.2%-27.0%). The prevalence of anti-lipid medications and obesity was similar between the groups.
Conclusions
The relationship between adhesive capsulitis and metabolic syndrome remains unclear. Our results confirm previous work associating hyperglycemia with adhesive capsulitis. We have also shown a possible association of hypertension, part of metabolic syndrome and a proinflammatory condition, with adhesive capsulitis, which has not been previously described.
... The course of FS and its impact on physical wellbeing, mental health, together with a sustained loss of productivity and global economy has been shown (Bouaicha et al., 2020). Although a common opinion about the pathophysiology exists (the abovementioned cascade), the disparity of results observed in the literature regarding the etiology of FS, suggests that there remain mechanistic lagunes in the pathophysiology and etiology of FS (Austin et al., 2014). ...
... The prevalence of FS in the entire population is 2%-5% (Dias et al., 2005;Hand et al., 2008;Austin et al., 2014). Most patients suffering from FS are women (70%) (Hannafin and Chiaia, 2000) with the most frequent age range being between 40 and 60 (Hand et al., 2008). ...
... FS has been clearly demonstrated to be associated with diabetes (Thomas et al., 2007;Austin et al., 2014;Chan et al., 2017), with type 1 diabetes being the most frequent risk factor for its development. Its incidence in the diabetic population is 10%-36% higher than in the general population, which indicates that poor glucose control is related to the development of FS in the long term (Thomas et al., 2007). ...
Frozen shoulder (FS), also known as adhesive capsulitis of the shoulder (FS), is a fibrotic inflammatory process of unknown etiology whose main symptoms are pain, stiffness and the loss of joint mobility. These symptoms may be associated with pathologies such as diabetes, Dupuytren’s syndrome and the prevalence of today’s sedentary lifestyle. This literature review provides an overview of the epidemiology and pathogenesis of this pathology, as well as the mechanisms of lowgrade chronic inflammation and infection, insulin resistance, and omics-science associated with it. We also propose a new hypothesis related to the possibility that the GABAergic system could play a decisive role in the development of frozen shoulder and that therefore diabetes type 1, endocrinological autoimmune disorders and frozen shoulder are connected by the same pathophysiological mechanisms. If that is true, the combined presence of psycho-emotional stress factors and pathogenic immune challenges could be the main causes of frozen shoulder syndrome. Finally, we propose a series of possible intervention strategies based on a multifactorial etiological and mechanistic concept.
... Most patients can recover within 2 years, but some patients cannot tolerate the disability of shoulder joint due to pain and limited range of motion and seek for surgical treatment. [10] Comorbidities such as diabetes mellitus or thyroid disorders are known to be associated with AC. [11][12][13][14] A cohort study from Taiwan reported that diabetic patients had a 32.1% higher risk of acquiring AC within 3-year follow-up, compared with nondiabetic patients. [11] Austin et al investigated the association between metabolism syndrome markers and AC and they confirmed that hyperglycemia was associated with AC. ...
... They also found possible associations between hypertension, proinflammatory condition, certain metabolic syndrome, and AC. [14] To date, only a few studies have investigated the demographic and clinical characteristics of AC in Asian populations meaning that the data may not be applicable to western subjects due to influence from changing environmental and social factors. [15] However, the evidence of difference in AC between Asian and non-Asian countries is inconclusive. ...
... [15] However, the evidence of difference in AC between Asian and non-Asian countries is inconclusive. [15,16] In addition, medical comorbidities (e.g., diabetic mellitus, hypertension, or thyroid disease) [11][12][13][14] or shoulder diseases (e.g., calcified tendinitis or rotator cuff diseases [10] ) have been noted in patients with AC. However, the magnitude of these factors was not well evaluated using robust methods for observational data. ...
Adhesive capsulitis (AC) is a common chronic disorder for adult patients; however, whether a history of pre-existing shoulder diseases may affect the development of AC is still not fully understood. We aimed to investigate the incidence and prevalence of AC and to assess the association of pre-existing shoulder diseases and traumatic injuries of the shoulder with the development of AC in adults.
This retrospective population-based cohort and nested case-control study used data from the National Health Institute Research Database of Taiwan. A total of 24,414 patients aged 20 years or older and with a diagnosis of AC were identified between 2000 and 2013. We calculated the incidence of AC for each year during the study period. In addition, these AC patients were matched with controls (n = 97,656) in a ratio of 1:4 based on age, gender, and index date. Univariate and multivariate logistic regression models were performed to identify variables associated with AC.
Females and patients aged 50 to 69 years had higher age-gender standardized incidence and prevalence of AC than their counterparts. Multivariate analyses showed that after adjusting for relevant covariates, pre-existing shoulder diseases of calcific tendinitis (odds ratio [OR] = 8.74, 95% confidence interval [CI] = 5.66–13.5), biceps tendinitis (OR = 7.93, 95% CI = 5.33–11.79), rotator cuff syndrome (OR = 6, 95% CI = 5.26–6.85), osteoarthritis (OR = 4.27, 95% CI = 3.44–5.3), and impingement syndrome (OR = 3.13, 95% CI = 2.64–3.71), as well as fracture (OR = 4.51, 95% CI = 3.82–5.34) and dislocation (OR = 3.57, 95% CI = 2.35–5.45) of the shoulder were significantly associated with AC risk.
Higher odds of AC were observed among patients with pre-existing shoulder conditions. This study highlights the need to consider differences in AC risk among patients with various types of shoulder diseases and traumatic injuries of the shoulder.
... However, there is no study in the relevant literature investigating the potential relationship between metabolic syndrome and kinesiophobia in patients with SAPS. Metabolic syndrome has been investigated in different shoulder pathophysiologies such as shoulder arthroplasty [36,37], reverse shoulder arthroplasty [38], adhesive capsulitis [39], and posterosuperior rotator cuff tears [40]. A systematic review has suggested an association between metabolic syndrome and SAPS, however, the included studies had low to moderate quality of evidence [21]. ...
... Goodson et al. highlighted the increased prevalence of severe chronic pain in people with metabolic syndrome [46]. Based on these findings, the association between metabolic syndrome and high level of kinesiophobia may stem from increased shoulder pain and impaired tendon structure, and thus increased fear of movement [36][37][38][39][40][41][42][43][44][45][46]. VAS at rest and VAS during activity with cut-off values of ≥ 5.2 and ≥ 7.1, respectively, were found to be associated with higher level of SAPS-related kinesiophobia in the current study. ...
IntroductionAlthough the negative effects of kinesiophobia on functional status in subacromial pain syndrome (SAPS) patients are clearly demonstrated, no study examines the risk factors of kinesiophobia in individuals with SAPS from a biopsychosocial perspective. The present study aims to determine the risk factors of kinesiophobia in individuals with SAPS using a biopsychosocial approach. This study also aims to explore the compounding effects of multiple associative risk factors by developing a clinical prediction tool to identify SAPS patients at higher risk for kinesiophobia.Materials and methodsThis cross-sectional study included 549 patients who were diagnosed with SAPS. The Tampa-Scale of Kinesiophobia (TSK) was used to assess kinesiophobia. Visual analog scale (VAS), The Shoulder Pain and Disability Index (SPADI), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the presence of metabolic syndrome, using any non-steroidal anti-inflammatory drugs, Pain Catastrophizing Scale (PCS), Illness Perception Questionnaire-revised (IPQ-R), Hospital Anxiety and Depression Scale (HADS), behavioral pattern of the patient, sociodemographic characteristics, and treatment expectancy were outcome measures.ResultsThirteen significant risk factors of having kinesiophobia were: VASat rest (≥ 5.2), VASduring activity (≥ 7.1), DASH (≥ 72.1), presence of metabolic syndrome, PCShelplessness (≥ 16.1), IPQ-Rpersonal control (≤ 17.1), IPQ-Rtreatment control (≤ 16.3), HADSdepression (≥ 7.9), avoidance behavior type, being female, educational level (≤ high school), average hours of sleep (≤ 6.8), and treatment expectancy (≤ 6.6). The presence of seven or more risk factors increased the probability of having high level of kinesiophobia from 34.3 to 51%.Conclusions
It seems necessary to address these factors, increase awareness of health practitioners and individuals.Level of evidenceLevel IV.
... Some authors have suggested that in ammation associated with metabolic syndrome, not just type 2 diabetes, could initiate the development of frozen shoulder and requires more research [6,28]. The other components of metabolic syndrome (hyperlipidaemia, hypertension, obesity) have been shown to be prevalent amongst people with frozen shoulder [29][30][31], but longitudinal analysis of the association between metabolic syndrome and frozen shoulder is scarce. The call for more research on the association between metabolic syndrome and frozen shoulder motivated the second objective of this study, which was to investigate whether the increased in ammation associated with metabolic syndrome could mediate the effect of type 2 diabetes on frozen shoulder. ...
Objective
Estimate the effect of type 2 diabetes on the development of frozen shoulder and investigate whether the effect is mediated by other metabolic factors.
Methods
Primary care medical record-based cohort study containing 43,977 patients newly diagnosed with type 2 diabetes and 43,977 without diabetes. Variables were identified using established Read codes. A weighting approach with Cox regression was used to decompose the total effect into the direct effect and indirect effect, mediated by metabolic health (which was defined as the number of metabolic factors developed during follow-up). Estimates were expressed as hazard ratios (HR). Confounders were identified using a DAG. Sensitivity to unmeasured confounding, extreme weights, and missing data were tested.
Results
The total effect of type 2 diabetes on the development of frozen shoulder was HR = 4.38 (95% CI: 3.70–5.21), the natural indirect effect (mediated through metabolic health) was HR = 0.98 (95% CI: 0.93–1.03) and the natural direct effect was HR = 4.46 (95% CI: 3.68–5.41). Results were robust to unmeasured confounding, extreme weights, and missing data.
Conclusions
This study suggests that type 2 diabetes may be a cause of frozen shoulder but does not support the hypothesis that the effect is mediated by metabolic health. Clinicians should remain alert that shoulder pain in patients with diabetes could be indicative of a frozen shoulder. This study should raise awareness that, despite often being overlooked, musculoskeletal conditions can be complications of diabetes and should be considered during clinical conversations with patients.
... This study supports the co-incidence of diabetes and dyslipidemia among patients with adhesive capsulitis, as reported by Austin et al. (10) and Park et al. ( Lee et al. (14) study reported the diagnostic value of inferior joint capsule thickness measured by Ultrasound for the diagnosis of frozen shoulder and assessed the changes in the thickness of the inferior joint capsule depending on position of the arm. A cutoff value of 3.2 mm for Inferior joint capsule thickness on Ultrasound had a good diagnostic accuracy for frozen shoulder with a sensitivity and specificity of 73.2% and 77.5%, respectively. ...
... (2) Aunque su etiología no está clara, estudios realizados han establecido la importante relación con la diabetes mellitus tipo 1 y 2. (3) Otros autores han demostrado que la enfermedad de Dupuytren, los trastornos tiroideos y otras enfermedades metabólicas también son factores de riesgo relacionados al SCHC. (4) Se estima que la prevalencia del SCHC oscila entre el 2 % -5 % de la población, (5) sin embargo, durante la pandemia las cifras mostraron un aumento significativo, de 2,41 veces en relación con el año anterior. (6) Así mismo, dentro de la población general, las mujeres tienen mayor probabilidad de presentar SCHC en comparación con los hombres (10,1 y 8,2 respectivamente), (7) siendo la edad entre 40 y 60 la más afectada. ...
Frozen shoulder contracture syndrome is a pathological condition that involves contracture of the joint capsule of the glenohumeral joint, generating pain, restriction of both active and passive range of motion, and impaired function. Various treatments have been proposed and investigated to solve this condition. On the one hand, there are surgical treatments, and on the other, non-surgical ones. Regarding surgical procedures, arthroscopic capsular release and manipulation under anesthesia stand out. The latter consists of mobilizing the shoulder in different directions to break the adhesions of the joint capsule, all this under anesthesia. In relation to the most used non-surgical treatments, there is the prescription of medications, corticosteroid injections, arthrographic hydrodilation and physical therapy. The modalities of physical therapy are an option of easy access, low cost and with varied options. Despite multiple alternatives being presented, there is no consensus on which is the best treatment option, and specifically it remains unclear whether manipulation under anesthesia is a better option than physiotherapy treatment.
... (2) Aunque su etiología no está clara, estudios realizados han establecido la importante relación con la diabetes mellitus tipo 1 y 2. (3) Otros autores han demostrado que la enfermedad de Dupuytren, los trastornos tiroideos y otras enfermedades metabólicas también son factores de riesgo relacionados al SCHC. (4) Se estima que la prevalencia del SCHC oscila entre el 2 % -5 % de la población, (5) sin embargo, durante la pandemia las cifras mostraron un aumento significativo, de 2,41 veces en relación con el año anterior. (6) Así mismo, dentro de la población general, las mujeres tienen mayor probabilidad de presentar SCHC en comparación con los hombres (10,1 y 8,2 respectivamente), (7) siendo la edad entre 40 y 60 la más afectada. ...
El síndrome de contractura del hombro congelado es
una condición patológica que involucra a la
contractura de la cápsula articular de la articulación
glenohumeral, generando dolor, restricción del
rango de movimiento tanto activo como pasivo y
alteración de la función. Diversos tratamientos se
han propuesto e investigado para dar solución a esta
condición. Por una parte, se encuentran los
tratamientos quirúrgicos, y por otra, los no
quirúrgicos. En relación a los quirúrgicos, destacan
la liberación capsular artroscópica y la manipulación
bajo anestesia. Esta última consiste en movilizar el
hombro en distintas direcciones para lograr romper
las adherencias de la cápsula articular, todo esto
bajo anestesia. En relación a los tratamientos no
quirúrgicos más utilizados, se encuentra la
prescripción de medicamentos, inyecciones de
corticoides, la hidrodilatación artrográfica y la
terapia física. Las modalidades de terapia física
resultan una opción de fácil acceso, de bajo costo y
con variadas opciones. A pesar de que se presentan
múltiples alternativas, no existe consenso sobre cuál
es la mejor opción de tratamiento, y
específicamente sigue sin estar claro si la
manipulación bajo anestesia es una mejor opción
que el tratamiento de fisioterapia
... To determine which factors may influence improvement in PROMs, we evaluated a multitude of factors including previously reported risk factors for primary IAC. [1][2][3]6,12,14,15,18,20,21,24,25,28,30,33,34,36 Existing literature revealed prior trauma, HLA-B27 positivity, age more than 40 years, female sex, thyroid disease, obesity, and autoimmune diseases to be predisposing risk factors for developing IAC. 13,20,23,26,32,35,36 We in turn evaluated age, gender, body mass index (BMI), PROMIS scores and ROM at initial consultation (flexion, internal rotation, and external rotation), concomitant medical conditions (hypertension, hyperlipidemia, hypothyroidism, diabetes, anxiety, and depression), smoking status, marital status, ethnicity, manual versus nonmanual labor, dominant arm involvement, number of corticosteroid injections received, and time from symptom onset to first visit as these factors could all be ascertained from patient medical records and were investigated for a possible impact on the investigated outcomes. ...
Background:
The purpose of this study was to identify prognostic factors that are associated with improvements in patient-reported outcomes measures (PROMs) related to upper extremity function and pain in those suffering from idiopathic adhesive capsulitis.
Methods:
All patients treated conservatively for primary idiopathic adhesive capsulitis were identified from our institutional database between 2019 and 2021. Exclusion criteria included any patients treated surgically, follow-up less than one year, or incomplete survey results. PROMs including Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test Version 2.0 (P-UE), Pain Interference (P-Interference), Pain Intensity (P-Intensity), and visual analog scale (VAS) pain scores. They were obtained at initial consultation and at one year to assess patient-perceived impact of their condition. Multiple linear and multivariable logistic regressions were performed to identify factors associated with improvement in patient-perceived pain and shoulder function using final PROM scores and difference in PROM scores from initial consultation. An independent t-test was used to compare baseline and one-year minimum follow-up PROMs. Odds ratios and their 95% confidence intervals were calculated for each factor; a P value of < .05 was considered statistically significant.
Results:
A total of 56 patients (40 females and 16 males) were enrolled in the study with an average age of 54.7 ± 7.7 years. A significant improvement (P < .001) was demonstrated at one-year minimum outcomes for P-UE, P-Interference, P-Intensity, and VAS scores. With respect to comorbid conditions, hypothyroidism [P-UE (β: 9.57, P = .006)] was associated with greater improvements in PROMs, while hyperlipidemia [P-UE (β: -4.13, P = .01) and P-Intensity (β: 2.40, P = .02)] and anxiety [P-UE (β: -4.13, P = .03)] were associated with poorer reported changes in PROMs. Female sex [P-UE (β: 4.03, P = .007) and P-Interference (β: -2.65, P = .04)] and employment in manual labor professions [P-Interference (β: -3.07, P = .01), P-Intensity (β: -2.92, P = .006), and VAS (β: -0.66, P = .03)] were associated with significantly better patient-perceived outcomes. Hispanic heritage was associated with higher reported changes of P-Intensity (β: 8.45, P = .004) and VAS (β: 2.65, P = .002).
Conclusion:
Patient-perceived improvements in PROMIS score during the natural history of adhesive capsulitis are likely multifactorial, with anxiety, hyperlipidemia, increased body mass index, and Hispanic heritage associated with reduced improvement in PROMIS scores.
... These conditions are associated with chronic low-grade inflammation 19 , which has no mechanism of injury and is marked by elevated levels of active pro-inflammatory cytokines but the absence of the increased neutrophil abundance associated with acute inflammation 82 . The influence of hyperglycaemia on the risk of developing FS is mediated by pro-inflammatory cytokines, which are elevated in the capsule and synovium of patients with FS 83 . Raised levels of serum cholesterol and pro-inflammatory lipoproteins have also been detected in FS and are risk factors for cardiovascular disorders 64 . ...
Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition. Frozen shoulder is a fibroproliferative disorder of the shoulder characterized by pain and progressive loss of shoulder mobility. In this Primer, Millar et al. provide an overview of the epidemiology, pathophysiology, diagnosis and treatment of frozen shoulder, as well as how it affects patients’ quality of life.
... Inclusion criteria were age between 40 and 60 years, only females, shoulder pain for more than three months and limitation of external rotation ≤ 60 degrees. Patients were excluded if they exhibited any red flags (malignancy, 15 metabolic diseases, 16 rheumatoid arthritis, 17 osteoporosis, prolonged history of steroid use, etc.), neurological involvement, 18 history of recent shoulder trauma; fracture of humerus, scapula or clavicle, rotator cuff injuries, previous surgery, recurrent dislocation or subluxation of shoulder, and severe pain unrelieved by resting the joint. 19 The socio-demographic variables of the two groups were compared showing that both the groups were equal (Table 1). ...
A sample of 34 patients was randomly assigned to two Groups A and B (17 in each group). Positional release of subscapularis technique to Group A participants and Proprioceptive Neuromuscular Facilitation (PNF) (hold-relax) and anterior mobilisation technique were simultaneously applied to Group B participants. Data was collected from Nusrat Abdul Rauf Centre for Enablement and Faisal Hospital, Faisalabad, from August 30, 2018 to November 27, 2018. The duration of the treatment was four weeks with three sessions per week. The main outcome measures were Numeric Pain Rating Scale (NPRS), Shoulder Pain and Disability Index (SPADI), and shoulder external rotation range of motion. The differences between Ola Grimsby group (Group B) and subscapularis release group (Group A) were statistically significant for pain, disability and shoulder range of motion (p-value<0.05) with higher mean values for Ola Grimsby group. This study concluded that the sequential effects of Ola Grimsby technique are better as compared to positional release of subscapularis in terms of reducing pain and improving shoulder external rotation range of motion. Keywords: Pain, Frozen Shoulder
... Several authors have hypothesized an association with a chronic state of low grade inflammation which might predispose to the development of FS [79]. Several association studies support this theory [38,40,48]. Fasting serum cholesterol, triglycerides and plasma glucose levels are often elevated in FS [6,80]. ...
Purpose
The pathophysiology of frozen shoulders is a complex and multifactorial process. The purpose of this review is to scope the currently available knowledge of the pathophysiology of frozen shoulders.
Methods
A systematic search was conducted in Medline, Embase and the Cochrane library. Original articles published between 1994 and October 2020 with a substantial focus on the pathophysiology of frozen shoulders were included.
Results
Out of 827 records, 48 original articles were included for the qualitative synthesis of this review. Glenohumeral capsular biopsies were reported in 30 studies. Fifteen studies investigated were classified as association studies. Three studies investigated the pathophysiology in an animal studies. A state of low grade inflammation, as is associated with diabetes, cardiovascular disease and thyroid disorders, predisposes for the development of frozen shoulder. An early immune response with elevated levels of alarmins and binding to the receptor of advance glycation end products is present at the start of the cascade. Inflammatory cytokines, of which transforming growth factor-β1 has a prominent role, together with mechanical stress stimulates Fibroblast proliferation and differentiation into myofibroblasts. This leads to an imbalance of extracellular matrix turnover resulting in a stiff and thickened glenohumeral capsule with abundance of type III collagen.
Conclusion
This scoping review outlines the complexity of the pathophysiology of frozen shoulder. A comprehensive overview with background information on pathophysiologic mechanisms is given. Leads are provided to progress with research for clinically important prognostic markers and in search for future interventions.
Level of evidence
Level V.
... 34 One study showed that MetS was not associated with adhesive capsulitis, although associations with type II DM and hypertension were identified. 35 Shoulder pain is a common MSK complaint in clinical practice with point prevalence ranging between 7% and 26%. 36 37 Symptoms associated with the rotator cuff and related tissues have been defined as rotator cuff-related shoulder pain (RCRSP). ...
... 34 One study showed that MetS was not associated with adhesive capsulitis, although associations with type II DM and hypertension were identified. 35 Shoulder pain is a common MSK complaint in clinical practice with point prevalence ranging between 7% and 26%. 36 37 Symptoms associated with the rotator cuff and related tissues have been defined as rotator cuff-related shoulder pain (RCRSP). ...
Objectives Rotator cuff-related shoulder pain (RCRSP) is a common upper limb complaint. It has been suggested that this condition is more common among people with cardiometabolic risk factors. This systematic review has synthesised evidence from case–control, cross-sectional and cohort studies on the association between metabolic syndrome (MetS) and RCRSP.
Design and data sources Five medical databases (MEDLINE, EMBASE, SCOPUS, CINAHL and AMED) and reference checking methods were used to identify all relevant English articles that considered MetS and RCRSP. Studies were appraised using the Newcastle-Ottawa Scale (NOS). Two reviewers performed critical appraisal and data extraction. Narrative synthesis was performed via content analysis of statistically significant associations.
results Three cross-sectional, two case–control and one cohort study met the inclusion criteria, providing a total of 1187 individuals with RCRSP. Heterogeneity in methodology and RCRSP or MetS definition precluded a meaningful meta-analysis. Four of the included studies identified associations between the prevalence of MetS and RCRSP. Studies consistently identified independent cardiometabolic risk factors associated with RCRSP. All studies were level III evidence.
summary and conclusion The low-moderate quality evidence included in this review suggests an association between MetS and RCRSP. Most studies demonstrated moderate quality on appraisal. The direction of association and cardiometabolic factors influencing should be investigated by longitudinal and treatment studies. These preliminary conclusions and clinical utility should be treated with caution due to limitations of the evidence base.
... (2012), [27] Austin DC et al. (2014) [28] . The inflammation and capsular fibrosis seen in AC is precipitated by metabolic syndrome (DM) and chronic low grade inflammation. ...
Background and Objectives: Adhesive Capsulitis (AC) is commonly known as Frozen Shoulder Syndrome (FSS) is a condition characterized by intense shoulder pain, gradual fibrosis of the glenohumeral joint that causes a limited range of motion, and contracture of the glenohumeral joint capsule. The disease peaks between 40 and 70 years of age and 10 to 36% of the individuals with Diabetes mellitus are mostly affected followed by Hypothyroidism and Hyperthyroidism. In conventional medicine it is being treated with pharmacologically, non-pharmacologically and with surgery. In Unani system of medicine AC is considered as a type of articular disease and treated according to the principles of Amraz-e-Mafasil with drugs and regimens. In this study a Unani formulation and Roghan-e-Dahtura is selected to validate its indication as effective in painful joints. Methods: This study was conducted as an open labeled interventional without control pre and post analysis on 30 patients with oral Unani formulation (Sibr, Halela Zard, Suranjan Sheerin, Saqmooniya and Aabe Mako) and local application of Roghan-e-Dhatura for 28 days with follow ups on, 7 th , 14 th , 21 th and 28 th day. The pre and post treatment effects were assessed objectively with VAS, SPADI. Results: The study outcome measured with mean and standard deviation in VAS, before treatment 8.33±0.55 and after treatment 2.23±0.73, with p value < 0.001 and SPADI 76.51±2.80 and 16.61±6.87, found statistically highly significant with p value <0.001 with Tukey-Kramer Multiple comparisons and Kruskal-Wallis tests. Interpretation & Conclusion: This study shows clinically and statistically significant difference in ameliorating the symptoms of adhesive capsulitis without any adverse effect. Therefore, it can be concluded that the test drugs are safe and effective in management of adhesive capsulitis symptoms.
Purpose: The aim of the study is to evaluate the prediction of adhesive capsulitis in the preoperative period of rotator cuff tear (RCT) by neutrophil-lymphocyte (NLR), platelet-lymphocyte (PLR), neutrophil-monocyte (NMR), lymphocyte-monocyte (LMR) ratios. Methods: This study was designed as a retrospective case-control study. After ethical approval, preoperative hemogram and biochemistry data of 128 patients who were operated on for RCT were collected from the archive of hospitale. Among the patients who underwent arthroscopy due to RCT, those with signs of adhesive capsulitis in the intraoperative period were included in the RCT+Adhesive capsulitis group. Age, blood glucose, CRP, sedimentation, white blood cell, neutrophil, monocytes, lymphocytes, platelets, fasting blood glucose, hemoglobin and hematocrit values, and NLR, PLR, NMR, and LMR ratios were compared between healthy control and RCT+Adhesive capsulitis. Logistic regression analysis of the ratios was also performed. Results: A total of 64 healthy RCT (group 1) and 64 patients with RCT+Adhesive capsulitis (group 2) were included in the study. Fasting blood glucose, lymphocyte, CRP values, and NMR and LMR were found to be higher in patients with adhesive capsulitis (p
Background
This study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and shoulder adhesive capsulitis (AC) using a large-scale, nationwide, population-based cohort in the Republic of Korea.
Methods
A total of 3,471,745 subjects aged over 20 years who underwent a National Health Insurance Service medical checkup between 2009 and 2010 were included in this study, and followed from the date of their medical checkup to the end of 2018. Subjects were classified into the following four groups based on the presence of dysglycemia and history of diabetes medication: normal, prediabetes, newly diagnosed T2DM (new-T2DM), and T2DM (claim history for antidiabetic medication). The endpoint was new-onset AC during follow-up. The incidence rates (IRs) in 1,000 person-years and hazard ratios (HRs) of AC for each group were analyzed using Cox proportional hazard regression models.
Results
The IRs of AC were 9.453 (normal), 11.912 (prediabetes), 14.933 (new-T2DM), and 24.3761 (T2DM). The adjusted HRs of AC in the prediabetes, new-T2DM, and T2DM groups were 1.084 (95% confidence interval [CI], 1.075 to 1.094), 1.312 (95% CI, 1.287 to 1.337), and 1.473 (95% CI, 1.452 to 1.494) compared to the normal group, respectively. This secular trend of the HRs of AC according to T2DM status was statistically significant (P<0.0001).
Conclusion
This large-scale, longitudinal, nationwide, population-based cohort study of 3,471,745 subjects confirmed that the risk of AC increases in prediabetic subjects and is associated with T2DM status.
Objective
Summarise longitudinal observational studies to determine whether diabetes (types 1 and 2) is a risk factor for frozen shoulder.
Design
Systematic review and meta-analysis.
Data sources
MEDLINE, Embase, AMED, PsycINFO, Web of Science Core Collection, CINAHL, Epistemonikos, Trip, PEDro, OpenGrey and The Grey Literature Report were searched on January 2019 and updated in June 2021. Reference screening and emailing professional contacts were also used.
Eligibility criteria
Longitudinal observational studies that estimated the association between diabetes and developing frozen shoulder.
Data extraction and synthesis
Data extraction was completed by one reviewer and independently checked by another using a predefined extraction sheet. Risk of bias was judged using the Quality In Prognosis Studies tool. For studies providing sufficient data, random-effects meta-analysis was used to derive summary estimates of the association between diabetes and the onset of frozen shoulder.
Results
A meta-analysis of six case–control studies including 5388 people estimated the odds of developing frozen shoulder for people with diabetes to be 3.69 (95% CI 2.99 to 4.56) times the odds for people without diabetes. Two cohort studies were identified, both suggesting diabetes was associated with frozen shoulder, with HRs of 1.32 (95% CI 1.22 to 1.42) and 1.67 (95% CI 1.46 to 1.91). Risk of bias was judged as high in seven studies and moderate in one study.
Conclusion
People with diabetes are more likely to develop frozen shoulder. Risk of unmeasured confounding was the main limitation of this systematic review. High-quality studies are needed to confirm the strength of, and understand reasons for, the association.
PROSPERO registration number
CRD42019122963.
IntroductionThe purpose of this study is to calculate the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Testing v2.0 (UE), Pain Interference (P-Interference), and Pain Intensity (P-Intensity) in patients treated nonoperatively for idiopathic adhesive capsulitis (IAC).Methods
The anchor-based MCID, SCB, and PASS were calculated as the change in PROMIS scores representing the optimal cutoff for a ROC curve with an area under the curve (AUC) analysis. The distribution-based MCID was calculated as a range between the average standard error of measurement multiplied by two different constants: 1 and 2.77. Effect sizes and standardized response means (SRM) were calculated to assess the responsiveness of each PROMIS instrument while regression analyses were performed to identify factors associated with achieving these thresholds.ResultsThis study enrolled 115 patients. The anchor-based MCID for PROMIS UE, P-Interference, and P-Intensity was 5.11, 4.16, and 8.16, respectively. The respective SCB was 8.44, 6.65, and 10.05. The respective PASS was 8.47, 7.01, and 10.41. The odds of achieving MCID values in adhesive capsulitis were negatively affected by gender (male), higher forward elevation at the time of presentation, higher pain scores (P-Interference), need for ≥ 2 corticosteroid injections, and a concomitant diagnosis of diabetes.Conclusion
The MCID, SCB, and PASS parameters for PROMIS scores can be utilized to determine the clinical meaningfulness of patient-reported improvements in these instruments during the nonoperative treatment and as a research tool to compare the efficacy of new treatments for adhesive capsulitis.Level of evidenceLevel III, basic science study, validation of outcome instruments.
Key points
• This is the first study to calculate the mini
mal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the Patient-Reported Outcome Measurement Information System (PROMIS) Upper Extremity and Pain instruments in patients with idiopathic adhesive capsulitis (IAC) of the shoulder.• This study determined the impact of symptom severity, demographics, and comorbidities on achieving the MCID, SCB, and PASS for PROMIS instruments in IAC patients treated nonoperatively.
Background
Diabetic patients have a greater incidence of adhesive capsulitis (AC) and a more protracted disease course as compared to patients with idiopathic AC. The purpose of this study was to compare gene expression differences between AC with and without diabetes mellitus.
Methods
Shoulder capsule samples were prospectively obtained from diabetic or non-diabetic patients who presented with shoulder dysfunction and underwent arthroscopy (n=16). Shoulder samples of AC with and without diabetes (n=8) were compared to normal shoulder samples with and without diabetes as the control group (n=8). Shoulder capsule samples were subjected to whole transcriptome RNA-sequencing (RNA-seq) and differential expression analyzed with EdgeR. Only genes with a False Discovery Rate (FDR) less than 5% were included for further functional enrichment analysis.
Results
The sample population had a mean age of 47 years (range 24–62 years) and the mean HbA1C level for non-diabetic and diabetic patients was 5.18% and 8.71%, respectively. RNA-seq analysis revealed 66 genes were found to be differentially expressed between diabetic patients and non-diabetic patients with AC, while only 3 genes were differentially expressed when comparing control patients with and without diabetes. Furthermore, 286 genes were differentially expressed in idiopathic AC and 61 genes were differentially expressed in diabetic AC. On gene clustering analysis, idiopathic AC was enriched with multiple structural and muscle related pathways, such as muscle filament sliding, whereas diabetic AC included a greater number of hormonal and inflammatory signaling pathways, such as cellular response to corticotropin releasing factor.
Conclusions
Whole transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC to idiopathic AC, suggesting that these conditions are distinct clinical entities. The new genes expressed explain the differences in disease course and suggest new therapeutic targets which may lead to different treatment paradigms in these two subsets.
Background:
Studies on the effects of manipulation under anesthesia (MUA) for primary stiff shoulder when different comorbidities are present are lacking. Our aim was to assess how comorbidities influence the recovery speed and clinical outcomes after MUA.
Methods:
Between April 2013 and September 2018, 281 consecutive primary stiff shoulders in the frozen phase treated with MUA were included in this study. We investigated the comorbidities of patients and divided them into the control (n=203), diabetes mellitus (DM) (n=32), hyperlipidemia (n=26), and thyroid disorder (n=20) groups. The range of motion (ROM) and clinical scores for each group before MUA and 1 week, 6 weeks, and 3 months after MUA were comparatively analyzed. We identified the ROM recovery time after MUA and the responsiveness to MUA. Then, subjects were subdivided into early and late recovery groups based on their recovery time and into successful and non-successful MUA groups based on their responsiveness to MUA.
Results:
Significant improvements in ROM and clinical scores at 3 months after MUA were observed in all groups. Significant differences in ROM among the four groups were also observed during follow-up (P<.05). The DM group had significantly lower ROM values, even at 3 months after MUA, compared to the control group. The ROM recovery speed after MUA was slowest in the DM group, followed by the thyroid disorder, hyperlipidemia, and control groups. Most (90.6%) of the DM group experienced late recovery. The proportion of non-successful MUA was higher in the DM and thyroid disorder groups than that in the control and hyperlipidemia groups (P=.004). During follow-up, there were no differences among groups regarding the visual analogue scale, University of California at Los Angeles shoulder, and Constant scores CONCLUSION: The ROM recovery speed and responsiveness to MUA for primary stiff shoulder were poorer for the DM and thyroid disorder groups than for the control group. In particular, compared to any other disease, outcomes were poorer when the comorbidity was DM. If patients have comorbidities, then they should be informed before MUA that the comorbidity could affect the outcomes of treatment.
Background
Hyperglycemia is the most commonly cited risk factor for adhesive capsulitis. However, no study has established whether fasting glucose levels within the normoglycemic range are associated with idiopathic adhesive capsulitis (IAC). This study hypothesized that increments of fasting glucose levels within the normoglycemic range are linked to IAC. This study investigated any association between normoglycemic fasting glucose levels and IAC.
Methods
This case-control study comprised a group of 151 IAC patients without intrinsic shoulder lesions, extrinsic causes, or known metabolic risk factors such as diabetes, dyslipidemia, and thyroid dysfunction. The control group comprised 453 age- and sex-matched persons seeking general check-ups at the authors’ health promotion center during the same period as the case group. Control subjects had normal shoulder function, no previous diagnosis of adhesive capsulitis or of metabolic disease, and no history of trauma or of shoulder surgery. The studied variables were body mass index (BMI), serum lipid profiles, thyroid hormone levels, fasting glucose levels, glycosylated hemoglobin A1c, and high-sensitivity C-reactive protein (hs-CRP). Fasting glucose levels were studied as scale data and categorical data (< 85, 85-89, 90-94, and 95-99 mg/dl). Multivariable conditional logistic regression analysis evaluated the matched sets of subjects. Odds ratios (ORs) and 95% confidence intervals (CIs) were determined for various potentially associated factors.
Results
Fasting glucose level, hyper-cholesterolemia, and hs-CRP were significantly associated with IAC (P ≤ .030). Fasting glucose levels in the <85 mg/dl quartile were significantly negatively associated with IAC (P ≤ .001). In contrast, fasting glucose levels in the 90-94 mg/dl quartile or higher were significantly positively associated with IAC (P ≤ .034).
Conclusion
IAC is positively associated with fasting glucose levels of 90-99 mg/dl, which are currently considered normoglycemic.
Background:
Chronic inflammation is implicated in the development of idiopathic adhesive capsulitis (IAC), whose association with high-sensitivity C-reactive protein (CRP), an inflammation marker, is undetermined. This study's purposes were to investigate the association between high-sensitivity CRP levels and IAC and to determine the metabolic factors associated with high-sensitivity CRP.
Methods:
This case-control study examined a group of 202 patients with IAC and without intrinsic shoulder lesions or extrinsic causes and a control group of 606 age and sex-matched persons seeking general check-ups at our health promotion center during the same period as the case group. Control subjects had normal shoulder function and no previously diagnosed adhesive capsulitis; no medication for diabetes, dyslipidemia, and thyroid abnormalities; and no history of trauma or of shoulder surgery. The studied variables were body mass index; diabetes; thyroid abnormalities; dyslipidemias; triglyceride/high-density lipoprotein (TG/HDL) >3.5; serum levels of thyroid hormone, fasting glucose, and glycosylated hemoglobin A1c (HbA1c); and high-sensitivity CRP >1.0 mg/L. Multivariable conditional logistic regression analysis evaluated the matched sets of subjects. Odds ratios (ORs) and 95% confidence intervals (CIs) were determined for the studied variables possibly affecting IAC.
Results:
Serum high-sensitivity CRP >1.0 mg/L was significantly associated with IAC (OR, 2.47 [95% CI, 1.65 to 3.70]) after adjusting for diabetes, fasting glucose level, HbA1c, dyslipidemia, TG/HDL >3.5, and thyroid-stimulating hormone (p ≤ 0.031). Diabetes (OR, 1.71 [95% CI, 1.09 to 3.33]), fasting glucose level (OR, 1.54 [95% CI, 1.12 to 2.12]), HbA1c (OR, 2.00 [95% CI, 1.25 to 3.22]), hypertriglyceridemia (OR, 1.70 [95% CI, 1.03 to 3.41]), hypo-high-density lipoproteinemia (OR, 1.98 [95% CI, 1.04 to 3.79]), and TG/HDL >3.5 (OR, 1.37 [95% CI, 1.06 to 1.88]) were significantly associated with high-sensitivity CRP >1.0 mg/L in patients with IAC (p ≤ 0.039).
Conclusions:
Serum high-sensitivity CRP >1.0 mg/L is an independent associated marker for IAC. Dyslipidemia, insulin resistance, and hyperglycemia, which are recognized factors associated with IAC, are also associated with high-sensitivity CRP >1.0 mg/L in these patients, supporting the interaction of chronic systemic inflammation in IAC.
Level of evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objective:
Glenohumeral joint hydrodilatation with corticosteroids has been proposed as an effective secondary therapeutic procedure for primary adhesive capsulitis (AC). However, little is known about which subgroup of patients would benefit from this procedure. This study aimed to identify covariates associated with improved prognosis in patients receiving ultrasound-guided hydrodilatation with corticosteroid injection.
Design:
This was a cohort study. Data on baseline demographic characteristics, disease status, past medical conditions, and initial ultrasonographic findings were collected. Linear and logistic regression analyses were performed to determine the prognostic factors associated with better clinical outcomes.
Results:
Fifty-three patients (54 shoulders) were included. Linear regression analysis showed that coracohumeral ligament (CHL) thickness <3 mm, use of analgesics before hydrodilatation, and female sex were associated with good improvement in the Shoulder Pain and Disability Index (SPADI) score. Multivariate logistic regression analysis showed that CHL thickness <3 mm on ultrasound was associated with a strong tendency (p=0.054) of reaching the minimal detectable change. Additionally, capsule rupture did not play a role in determining the clinical efficacy of hydrodilatation.
Conclusion:
In patients with primary AC, CHL thickness <3 mm is correlated with greater short-term improvement in the SPADI score after ultrasound-guided hydrodilatation with steroid injection is performed.
Background:
Although numerous studies have suggested that frozen shoulder (FS) is a self-limiting disease with most patients recovering within 2 years, its long-term outcome is still controversial. The aims of this study were to evaluate the clinical outcomes after conservative treatment for FS and to determine the predictors of its clinical outcome.
Methods:
This study included 234 shoulders of 215 patients who received conservative treatment for FS. The mean follow-up period was 41.8 months (range 27-117 months). Initial evaluation included demographics, detailed medical history, and clinical assessments of shoulder status. Questionnaires, which included the Visual Analogue Scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV) and satisfaction grading for the current shoulder status were assessed at the final follow-up.
Results:
The mean VAS pain score, ASES score, and SSV significantly improved from 6.7, 37.0, and 40.1% at the time of initial evaluation to 1.5, 87.6, and 85.0% at the final follow-up evaluation (all p < 0.001). According to satisfaction grading, the shoulder status at the final follow-up was very satisfied in 101 shoulders (43.2%), satisfied in 68 (29.1%), fair in 37 (15.8%), unsatisfied in 20 (8.5%), and very unsatisfied in 8 (3.4%). Univariate analysis revealed that gender, diabetes, simultaneous bilateral involvement, overall bilateral involvement and duration of symptoms were associated with clinical outcomes at the final follow-up. Multivariate analysis revealed that duration of symptoms (p = 0.002) was an independent risk factor for unsuccessful outcome.
Conclusions:
At the mean follow-up period of 41.8 months, 72.3% of patients revealed subjective satisfaction for the current shoulder status. Duration of symptoms was an independent risk factor for poor prognosis.
Frozen shoulder is a condition of loss of active and passive motion as result of inflammatory contracture and fibrosis of the joint capsule. We hypothesize that genetic variants in genes involved in these processes such as genes that play a role in extracellular matrix homeostasis (collagens, glycoproteins, genes involved in TGFβ signaling, and metalloproteinases and its inhibitors) may contribute to the susceptibility to frozen shoulder. We evaluated eighteen SNPs of genes involved in extracellular matrix homeostasis in 186 cases (Nfemales = 114; Nmales = 72) of frozen shoulder and 600 age‐matched controls (Nfemales = 308; Nmales = 292). Multivariate logistic regressions were carried out with age, gender, genetic ancestry and common comorbidities as covariates. Carriers of the C allele of MMP13 rs2252070 and G/G MMP9 (rs17576 A > G/rs17577 G > A) haplotype may have an increased risk of frozen shoulder (p = 0.002, OR = 1.64, 95%CI = 1.20–2.26 and p = 0.046, OR = 1.40, 95%CI = 1.01–1.95, respectively), especially in females (p = 0.005, OR = 1.91, 95%CI = 1.22–2.99 and p = 0.046, OR = 1.59, 95%CI = 1.01–2.51, respectively). In females, the G allele of MMP9 rs17576 tended to contribute to the susceptibility to the studied disease (p = 0.05, OR = 1.51, 95%CI = 0.97–2.33). In contrast, the presence of the C allele of TGFB1 rs1800470 seems to be associated with a reduced risk (p = 0.04, OR = 0.47, 95%CI = 0.23–0.96) while the GG‐genotype of TGFBR1 rs1590 was associated with increased risk (p = 0.027, OR = 4.11, 95%CI = 1.17–14.38) to frozen shoulder development in males. Thus, we identified genetic variants that were independent risk factors that can aid in the risk assessment of frozen shoulder reinforcing the involvement of MMP and TGFβ signaling in disease development.This article is protected by copyright. All rights reserved
Shoulder stiffness is associated with diabetes mellitus. It is characterized by pain and restriction of active and passive range of motion. Like other complications of diabetes (e.g., arterial stiffness, pancreatic or renal fibrosis), shoulder stiffness is due to a fibrotic process. The clinical course is generally benign, but it can last for months, with remaining disabilities in the long term. Several possibilities of treatment are being used. The practitioner should be aware of this complication, its natural history, and the current treatments available in order to adequately tailor the best treatment to the patient, sometimes combining more than one option.
Adhesive capsulitis is often referred to as frozen shoulder, among other terms, and has long been a topic of debate and interest in orthopaedic surgery. Despite descriptions and research on the condition dating back to the first half of the nineteenth century, much about this disease remains unknown. Patients with frozen shoulder present with limited motion, particularly external rotation, substantial pain, and decreased function. Most cases are self-limited and improve with conservative measures, but an increasing body of work identifies a subset of patients with frozen shoulder who endure long-term sequelae, and who may also benefit from earlier or more aggressive interventions. Once these patients have exhausted conservative management, arthroscopic and other surgical options become the only means of treatment. Specific medical interventions are lacking, largely due to our limited understanding of the underlying pathophysiology. This disorder is strongly associated with trauma, diabetes, thyroid disease and other conditions. Understanding these associations may bring greater insight into the fundamental pathophysiology of frozen shoulder. Here we will review the history, epidemiology, diagnosis, pathophysiology, evidence-based treatments, and outcomes associated with this complex and burdensome disease.
Range of motion testing is a necessary component of the shoulder examination. The concepts and techniques described in this chapter are meant to provide a foundation upon which clinicians can conduct individualized examinations according to the patient’s suspected pathology. Specific findings can then narrow the differential diagnosis and direct the clinician towards the performance of various provocative testing maneuvers. In addition, an understanding of each topic is necessary to aid in the interpretation of various clinical studies in the literature.
Adhesive capsulitis (AC) is very poorly understood, particularly it’s underlying etiology. Obesity and metabolic syndrome, which are strongly associated with chronic low grade inflammation, are becoming increasingly understood to underlie a raft of morbid states including upper limb pain syndromes, diabetes (DM), cardiovascular disease (CVD), cancer and central nervous system dysfunction and degeneration. Notwithstanding age, two of the strongest established risk factors for AC are DM and CVD. The hypothesis argues that similar to DM and CVD, the inflammation and capsular fibrosis seen in AC is precipitated by metabolic syndrome and chronic low grade inflammation. These pathophysiological mechanisms are highly likely to be perpetuated by upregulation of pro-inflammatory cytokine production, sympathetic dominance of autonomic balance, and neuro-immune activation. The hypothesis predicts and describes how these processes may etiologically underpin and induce each sub-classification of AC. An improved understanding of the etiology of AC may lead to more accurate diagnosis, improved management, treatment outcomes, and reduce or prevent pain, disability and suffering associated with the disease. The paper follows on with a discussion of similarities between the pathophysiology of AC to general systemic inflammatory control mechanisms whereby connective tissue (CT) fibrosis is induced as a storage depot for leukocytes and chronic inflammatory cells. The potential role of hyaluronic acid (HA), the primary component of the extracellular matrix (ECM) and CT, in the pathophysiology of AC is also discussed with potential treatment implications. Lastly, a biochemical link between physical and mental health through the ECM is described and the concept of a periventricular-limbic central driver of CT dysfunction is introduced.
Primary frozen shoulder is considered a diagnosis for all cases for which an underlying etiology or associated condition cannot be identified. The secondary types of frozen shoulder include all the associated condition that can be identified as diabetes, hyperthyroidism, hypothyroidism, hypoadrenalism, previous ipsilateral breast surgery, cervical radiculopathy chest wall tumor, previous cerebrovascular accident, or more local extrinsic problems, including previous humeral shaft fracture, scapulothoracic abnormalities, acromioclavicular arthritis, or clavicle fracture.
Frozen shoulder is a condition of unknown etiology that results in a progressive decrease in shoulder range of motion. Multiple interventions have been implemented to minimize the duration of symptoms, including physiotherapy, pain medication, and surgical treatment. The epidemiology of frozen shoulder is not completely understood, and intervention results vary by study and population. Some relevant literature is reviewed here and data from the Brazilian population are presented.
To compare the prevalence in metabolic syndrome (MetSyn) between 1988-1994 and 1999-2006 among U.S. adults of different races or ethnicities.
Analysis of data on 6,423 adult men and nonpregnant women aged ≥20 years from Third National Health and Nutrition Examination Survey (NHANES III) and 6,962 participants from the combined NHANES 1999-2006 were done. The revised National Cholesterol Education Program Adult Treatment Panel III definition was used to calculate MetSyn.
Both the unadjusted prevalence (27.9 ± 1.1% to 34.1 ± 0.8%, P < 0.001) and age-adjusted prevalence (29.2 ± 1.0% to 34.2 ± 0.7%, P < 0.001) increased from NHANES III to NHANES 1999-2006, respectively. Although MetSyn prevalence was highest in Mexican Americans, significant increases in prevalence occurred among non-Hispanic whites and non-Hispanic blacks, especially among younger women.
The persistent increase of MetSyn among U.S. adults is a serious public health concern because it raises the likelihood of increased prevalence of type 2 diabetes.
The prevalence of obesity increased in the United States between 1976-1980 and 1988-1994 and again between 1988-1994 and 1999-2000.
To examine trends in obesity from 1999 through 2008 and the current prevalence of obesity and overweight for 2007-2008.
Analysis of height and weight measurements from 5555 adult men and women aged 20 years or older obtained in 2007-2008 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population. Data from the NHANES obtained in 2007-2008 were compared with results obtained from 1999 through 2006.
Estimates of the prevalence of overweight and obesity in adults. Overweight was defined as a body mass index (BMI) of 25.0 to 29.9. Obesity was defined as a BMI of 30.0 or higher.
In 2007-2008, the age-adjusted prevalence of obesity was 33.8% (95% confidence interval [CI], 31.6%-36.0%) overall, 32.2% (95% CI, 29.5%-35.0%) among men, and 35.5% (95% CI, 33.2%-37.7%) among women. The corresponding prevalence estimates for overweight and obesity combined (BMI > or = 25) were 68.0% (95% CI, 66.3%-69.8%), 72.3% (95% CI, 70.4%-74.1%), and 64.1% (95% CI, 61.3%-66.9%). Obesity prevalence varied by age group and by racial and ethnic group for both men and women. Over the 10-year period, obesity showed no significant trend among women (adjusted odds ratio [AOR] for 2007-2008 vs 1999-2000, 1.12 [95% CI, 0.89-1.32]). For men, there was a significant linear trend (AOR for 2007-2008 vs 1999-2000, 1.32 [95% CI, 1.12-1.58]); however, the 3 most recent data points did not differ significantly from each other.
In 2007-2008, the prevalence of obesity was 32.2% among adult men and 35.5% among adult women. The increases in the prevalence of obesity previously observed do not appear to be continuing at the same rate over the past 10 years, particularly for women and possibly for men.
We examined the prevalences of diagnosed diabetes, and undiagnosed diabetes and pre-diabetes using fasting and 2-h oral glucose tolerance test values, in the U.S. during 2005-2006. We then compared the prevalences of these conditions with those in 1988-1994.
In 2005-2006, the National Health and Nutrition Examination Survey included a probability sample of 7,267 people aged > or =12 years. Participants were classified according to glycemic status by interview for diagnosed diabetes and by fasting and 2-h glucoses measured in subsamples.
In 2005-2006, the crude prevalence of total diabetes in people aged > or =20 years was 12.9%, of which approximately 40% was undiagnosed. In people aged > or =20 years, the crude prevalence of impaired fasting glucose was 25.7% and of impaired glucose tolerance was 13.8%, with almost 30% having either. Over 40% of individuals had diabetes or pre-diabetes. Almost one-third of the elderly had diabetes, and three-quarters had diabetes or pre-diabetes. Compared with non-Hispanic whites, age- and sex-standardized prevalence of diagnosed diabetes was approximately twice as high in non-Hispanic blacks (P < 0.0001) and Mexican Americans (P = 0.0001), whereas undiagnosed diabetes was not higher. Crude prevalence of diagnosed diabetes in people aged > or =20 years rose from 5.1% in 1988-1994 to 7.7% in 2005-2006 (P = 0.0001); this was significant after accounting for differences in age and sex, particularly in non-Hispanic blacks. Prevalences of undiagnosed diabetes and pre-diabetes were generally stable, although the proportion of total diabetes that was undiagnosed decreased in Mexican Americans.
Over 40% of people aged > or =20 years have hyperglycemic conditions, and prevalence is higher in minorities. Diagnosed diabetes has increased over time, but other conditions have been relatively stable.
To examine the association between shoulder capsulitis and chronic diabetic complications and diseases closely related to diabetes.
A cross sectional study in 291 type I [mean (SD) age 33.2 (9.9) years] and 134 type II [61.1 (12.4) years] diabetic patients. The presence of shoulder capsulitis, Dupuytren disease, and limited joint mobility was sought. The patients were assessed for background and proliferative retinopathy, nephropathy, autonomic neuropathy, and peripheral symmetrical somatic polyneuropathy. Diseases closely related to diabetes (hypertension, history of myocardial infarction, coronary heart disease, and peripheral vascular disease) were also recorded.
Prevalence of shoulder capsulitis was 10.3% in type I and 22.4% in type II diabetic subjects. Shoulder capsulitis was associated with the age in types I (P < 0.01) and II (P < 0.05) diabetic patients, and with the duration of diabetes in type I patients (P < 0.01). Odds ratios for autonomic neuropathy in type I and type II diabetic subjects with shoulder capsulitis were 4.1 (95% confidence interval, 1.6 to 10.9) and 2.7 (95% CI, 1.1 to 7.0), respectively, after controlling for age and duration of diabetes. Odds ratio for history of myocardial infarction in type I diabetic subjects with shoulder capsulitis was 13.7 (95% CI, 1.3 to 139.5) after controlling for age, duration of diabetes, hypertension, and smoking habits. Other associations between shoulder capsulitis and diabetic complications, related diseases, and other hand abnormalities were fully explained by age and the duration of diabetes.
Shoulder capsulitis is common in type I and type II diabetic patients. It is associated with age in type I and II diabetic patients and with the duration of diabetes in type I patients. It is associated with autonomic neuropathy in type I and II diabetic patients and with history of myocardial infarction in type I diabetic patients, independently of time related variables.
Circulating levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) are elevated in diabetic patients. We assessed the role of glucose in the regulation of circulating levels of IL-6, TNF-alpha, and interleukin-18 (IL-18) in subjects with normal or impaired glucose tolerance (IGT), as well as the effect of the antioxidant glutathione.
Plasma glucose levels were acutely raised in 20 control and 15 IGT subjects and maintained at 15 mmol/L for 5 hours while endogenous insulin secretion was blocked with octreotide. In control subjects, plasma IL-6, TNF-alpha, and IL-18 levels rose (P<0.01) within 2 hours of the clamp and returned to basal values at 3 hours. In another study, the same subjects received 3 consecutive pulses of intravenous glucose (0.33 g/kg) separated by a 2-hour interval. Plasma cytokine levels obtained at 3, 4, and 5 hours were higher (P<0.05) than the corresponding values obtained during the clamp. The IGT subjects had fasting plasma IL-6 and TNF-alpha levels higher (P<0.05) than those of control subjects. The increase in plasma cytokine levels during the clamping lasted longer (4 hours versus 2 hours, P<0.01) in the IGT subjects than in the control subjects, and the cytokine peaks of IGT subjects after the first glucose pulse were higher (P<0.05) than those of control subjects. On another occasion, 10 control and 8 IGT subjects received the same glucose pulses as above during an infusion of glutathione; plasma cytokine levels did not show any significant change from baseline after the 3 glucose pulses.
Hyperglycemia acutely increases circulating cytokine concentrations by an oxidative mechanism, and this effect is more pronounced in subjects with IGT. This suggests a causal role for hyperglycemia in the immune activation of diabetes.
The underlying pathophysiology of the metabolic syndrome is the subject of debate, with both insulin resistance and obesity considered as important factors. We evaluated the differential effects of insulin resistance and central body fat distribution in determining the metabolic syndrome as defined by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III. In addition, we determined which NCEP criteria were associated with insulin resistance and central adiposity. The subjects, 218 healthy men (n = 89) and women (n = 129) with a broad range of age (26-75 years) and BMI (18.4-46.8 kg/m2), underwent quantification of the insulin sensitivity index (Si) and intra-abdominal fat (IAF) and subcutaneous fat (SCF) areas. The metabolic syndrome was present in 34 (15.6%) of subjects who had a lower Si [median: 3.13 vs. 6.09 x 10(-5) min(-1)/(pmol/l)] and higher IAF (166.3 vs. 79.1 cm2) and SCF (285.1 vs. 179.8 cm2) areas compared with subjects without the syndrome (P < 0.001). Multivariate models including Si, IAF, and SCF demonstrated that each parameter was associated with the syndrome. However, IAF was independently associated with all five of the metabolic syndrome criteria. In multivariable models containing the criteria as covariates, waist circumference and triglyceride levels were independently associated with Si and IAF and SCF areas (P < 0.001). Although insulin resistance and central body fat are both associated with the metabolic syndrome, IAF is independently associated with all of the criteria, suggesting that it may have a pathophysiological role. Of the NCEP criteria, waist circumference and triglycerides may best identify insulin resistance and visceral adiposity in individuals with a fasting plasma glucose <6.4 mmol/l.
High blood pressure (HBP) has been associated with elevated C-reactive protein (CRP), a marker of chronic mild inflammation. However, the association between HBP and other inflammatory markers, particularly interleukin 6 (IL-6) and tumour necrosis alpha (TNF-alpha), has not been evaluated in well-controlled studies. We examined the cross-sectional relationship between IL-6, TNF-alpha, and CRP and HBP in a random sample of 196 healthy subjects. All markers were measured in duplicate with high-sensitivity ELISA tests. Three blood pressure (BP) measurments were averaged for the analysis, and subjects with systolic BP >or=140 and/or diastolic BP >or=90 mmHg were considered hypertensive. Log binomial regression was used to estimate multivariate-adjusted prevalence ratios (PR) of HBP. Of the subjects, 40% (79) were hypertensive (mean age: 44 years; range 30-64). After adjustment for age, sex, body mass index, family history of HBP, and the level of the other inflammatory markers, subjects in the second (PR: 3.10, P=0.003), third (PR: 2.32; P=0.031), and fourth quartiles (PR: 2.30; P=0.036) of IL-6 were more than twice as likely to be hypertensive than those in the first quartile. Corresponding PR estimates for TNF-alpha levels were 1.41 (P=0.014) for the second; 1.59 (P=0.001) for the third; and 1.61 (P=0.025) for the fourth quartile. The CRP-HBP association was not statistically significant. Our results suggest that TNF-alpha and IL-6 could be independent risk factors for HBP in apparently healthy subjects. Nevertheless, the temporal relationship between elevated inflammation markers and HBP should be ascertained in prospective cohort studies.
Thyroid dysfunction may cause musculoskeletal symptoms. We have evaluated the prevalence of adhesive capsulitis, Dupuytren's contracture, trigger finger, limited joint mobility and carpal tunnel syndrome in a series of patients with various thyroid diseases and differing levels of function.
Patients with euthyroid (diffuse and/or nodular) goitre, Hashimoto's thyroiditis, Graves' disease, toxic nodular goitre, toxic diffuse goitre and patients with goitre who had partial thyroidectomy were included in the study (n = 137). Neurological and musculoskeletal examinations were performed after a standardized symptom questionnaire. The prevalence of musculoskeletal problems was analysed with respect to thyroid function and thyroid autoantibody status.
Serum concentrations of free T3, free T4, TSH and thyroglobulin and thyroperoxidase antibodies were determined. Serum levels of creatine kinase, lactate dehydrogenase, calcium and phosphate along with erythrocyte sedimentation rate were measured to exclude other causes of musculoskeletal complaints.
When the study group (n = 137) was divided according to thyroid status, 30.6% (n = 42) were thyrotoxic, 16.8% (n = 23) had subclinical thyrotoxicosis, 28.5% (n = 39) were euthyroid, 7.3% (n = 10) had subclinical hypothyroidism and 16.8% (n = 23) were hypothyroid. Overall, adhesive capsulitis was found in 10.9% (n = 15), Dupuytren's contracture in 8.8% (n = 12), limited joint mobility in 4.4% (n = 6), trigger finger in 2.9% (n = 4) and carpal tunnel syndrome in 9.5% (n = 13) of the patients. The prevalence of adhesive capsulitis was highest in patients with subclinical thyrotoxicosis (17.4%); Dupuytren's contracture, limited joint mobility and carpal tunnel syndrome were commonest in hypothyroid patients (21.7%, 8.7% and 30.4%, respectively). Trigger finger occurred in 10% of patients with subclinical hypothyroidism. When these prevalences were analysed with respect to thyroid status, carpal tunnel syndrome was significantly more prevalent in the hypothyroid group (P = 0.004). When thyroperoxidase antibody-positive and -negative patients were compared, adhesive capsulitis negatively (P = 0.03, r =-0.18) and trigger finger positively correlated with (P = 0.03, r = 0.21) thyroperoxidase antibody existence.
These results demonstrate that musculoskeletal disorders often accompany thyroid dysfunction. In addition to the well-known observation that these disorders are common in patients with hypothyroidism, they are also observed in patients with thyrotoxicosis. Patients with thyroid dysfunction should be questioned for musculoskeletal complaints and referred to a specialist if necessary.
Fifty-eight patients with the diagnosis of primary frozen shoulder were independently examined by 3 surgeons for evidence of Dupuytren[apos ]s disease. The disease was found in 52% (30/58) of the patients reviewed. These figures were compared with previously reported figures for a population of similar age. This showed that Dupuytren[apos ]s disease is 8.27 (95% CI, 6.25-11.2) times more common in patients with frozen shoulder than in the general population; the difference between the two was highly statistically significant (P [lt ] .001, [chi ]2 test). We discuss the literature on the association between frozen shoulder and Dupuytren[apos ]s disease and the implications of such a high proportion of patients sharing these two conditions. (J Shoulder Elbow Surg 2001;10:149-51.)
The purpose of this study was to test the hypothesis that specific cytokines are involved in the initiation and evolution of the fibrotic process in adhesive capsulitis of the shoulder. After approval from the Institutional Review Board, biopsies of shoulder capsule and synovium were collected during shoulder arthroscopy from 19 patients with adhesive capsulitis, 14 patients with nonspecific synovitis and no fibrosis or clinical evidence of adhesive capsulitis, and seven patients undergoing surgery for another pathology who had a normal capsule and synovium. Immunohistochemical localization with monoclonal antibodies to transforming growth factor-β and its receptor, platelet-derived growth factor and its receptor, basic fibroblast growth factor, interleukin-1β, tumor necrosis factor-α, and hepatocyte growth factor was performed using standard immunoperoxidase techniques. The frequency of cytokine staining was correlated with the clinical diagnosis Synovial cells, fibroblasts, T-cells, and B-cells were identified with specific antibodies, and newly synthesized matrix was examined for type-I and type-III collagen by immunohistochemical staining. The predominant cell types present were synovial cells and fibroblasts. Staining for type-III collagen in adhesive capsulitis tissues indicated new deposition of collagen in the capsule. There was staining for transforming growth factor-β and its receptor, platelet-derived growth factor and its receptor, interleukin-1β, and tumor necrosis factor-α in adhesive capsulitis and nonspecific synovitis tissues, compared with minimal staining in normal capsule. Staining was more frequent in snovial cells than in capsular cells. The frequency of cell and matrix staining for transforming growth factor-β, platelet-derived growth factor, and hepatocyte growth factor was greater in adhesive capsulitis tissues than in those from patients with nonspecific synovitis. No difference in the frequency of staining between primary (idiopathic) and secondary adhesive capsulitis was found. The results of this study indicate that adhesive/capsulitis involves both synovial hyperplasia and capsular fibrosis. Cytokines such as transforming growth factor-β and platelet-derived growth factor may be involved in the inflammatory and fibrotic processes in adhesive capsulitis. Matrix-bound transforming growth factor-β may act as a persistent stimulus, resulting in capsular fibrosis. Understanding the basic pathophysiology of adhesive capsulitis is an important step in the development of clinically useful antifibrotic agents that may serve as novel treatments for patients with this condition.
There is controversy regarding the influence of glycemic control in diabetic patients with frozen shoulder. To determine the relationship between glycemic control and the prevalence of frozen shoulder in diabetic patients, we hypothesized that increased glycosylated hemoglobin A1c (HbA1c) levels would correlate with an increased prevalence of frozen shoulder.
A retrospective analysis with statistical review of 201,513 diabetic patients enrolled in a regional health maintenance organization in 2007 was performed. Analysis included determining the relationship between the prevalence of frozen shoulder and the following factors: HbA1c level, type of diabetes treatment, duration of diabetes treatment, and presence of end-stage diabetic manifestations.
There were 1150 diabetic patients with a diagnosis of frozen shoulder. There was no significant relationship between HbA1c level and the prevalence of frozen shoulder. Insulin-dependent patients who used or did not use oral hypoglycemics were 1.93 times more likely than non-insulin-dependent diabetic patients to have frozen shoulder, and that rate increased to 1.96 times more likely when the results were adjusted for HbA1c level. Patients who were taking oral hypoglycemic drugs were 1.5 times more likely to develop frozen shoulder than those who did not use insulin or take oral hypoglycemic drugs. Duration of diabetes was also associated with the development of frozen shoulder, after controlling for insulin use (odds ratio: 1.85 for duration of more than ten years of use compared with less than five years of use). The prevalence of end-stage diabetic manifestations was increased in patients with frozen shoulder as compared with those without frozen shoulder (p < 0.0001).
There was no association found between HbA1c level and the prevalence of frozen shoulder in this diabetic population.
Diabetes mellitus (DM) is a widespread chronic disease the complications of which affect several different organ systems Characterization of the musculoskeletal complications of DM is derived predominantly from observational studies Although attempts have been made to classify the rheumatic manifestations of DM, pathogenetic mechanisms for many of these conditions have not yet been elucidated their association with DM is based largely on epidemiologic data Although only diabetic muscle infarction has been reported to occur exclusively among patients with DM several other rheumatologic disorders have been observed more frequently among individuals with DM than in the general population In this article the authors discuss those rheumatic disorders that have been associated with DM or the metabolic syndrome and potential pathophysiologic relationships that might link these conditions
An increased prevalence of musculoskeletal disease is recognised in diabetes and is a common source of disability. It is known to predominantly affect the upper limbs especially the hand and shoulder. The relationship with other complications of diabetes and glycaemic control is uncertain. We designed this study to clarify these relationships, and to assess differences between types 1 and 2 diabetes.
We identified a group of 96 people with established diabetes and examined them for the presence of locomotor disease focussing on the upper limbs. We recorded the mean HbA1c and the presence of diabetic complications, together with the health assessment questionnaire (HAQ) score. We explored correlations between locomotor disease and these variables using logistic regression. We compared data between type 1 and type 2 diabetics and contrasted the amalgamated data with that of a matched control population of medical out patients using Students t tests.
Locomotor disease was present in 75% of diabetics with the upper limb the commonest site for abnormalities. This prevalence was significantly higher than that seen in the controls (53%) [p=0.02]. Shoulder capsulitis (25%), carpal tunnel syndrome (20%), tenosynovitis (29%), limited joint mobility (28%) and Dupuytrens contracture (13%) were the most frequent findings and were much commoner than in controls. Capsulitis usually coexisted with other upper limb abnormalities and best predicted the presence of retinopathy and/or neuropathy. The mean HbA1c was significantly higher in patients with combined shoulder and hand problems (9.1%) than in those with no upper limb problems (8.0%) [p=0.018]. The pattern of results was similar in type 1 and type 2 diabetes, although the prevalence of abnormalities and mean HAQ were significantly greater in type 2 patients, which may be in part a function of their greater mean age.
Upper limb locomotor abnormalities are very common in diabetes and are associated with worse glycaemic control and more diabetic complications. Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications.
The objectives of this study were to examine the trends in the prevalence of type 2 diabetic patients with comorbid hypertension and blood pressure (BP) control rates in the United States and determine factors associated with these outcomes.
We used data from National Health and Nutrition Examination Surveys (NHANES) III (1988-1994) and NHANES 1999-2004, a cross-sectional sample of the noninstitutionalized US populations. Type 2 diabetic patients were identified as patients at least 30 years of age with physician-diagnosed diabetes who were taking insulin or oral antidiabetic drugs to manage the condition. A diagnosis of hypertension was based on physician diagnosis, treatment with antihypertensive medications, or BP at least 140/90 mmHg. BP control was defined as diabetic patients who maintained BP <130/80 mmHg. Logistic regression was used to estimate risks of high BP, and odds of high BP treatment and control rates, after adjusting for demographic and clinical risk factors.
The age-adjusted prevalence of diabetic patients and those with hypertension increased significantly from 5.8 to 7.1% and 3.9 to 4.7%, respectively, from NHANES III to NHANES 1999-2004. Among diabetic patients with hypertension, patients who were treated with medication or lifestyle or behavioral modification therapy have increased significantly from 76.5 to 87.8% during the observation period. The proportion of patients who controlled BP increased from 15.9 to 29.6%, but 70% of patients still did not meet the target BP goal.
Aggressive public health efforts are needed to improve BP control in type 2 diabetic patients with hypertension.
To investigate duration of the period between diabetes onset and its clinical diagnosis.
Two population-based groups of white patients with non-insulin-dependent diabetes (NIDDM) in the United States and Australia were studied. Prevalence of retinopathy and duration of diabetes subsequent to clinical diagnosis were determined for all subjects. Weighted linear regression was used to examine the relationship between diabetes duration and prevalence of retinopathy.
Prevalence of retinopathy at clinical diagnosis of diabetes was estimated to be 20.8% in the U.S. and 9.9% in Australia and increased linearly with longer duration of diabetes. By extrapolating this linear relationship to the time when retinopathy prevalence was estimated to be zero, onset of detectable retinopathy was calculated to have occurred approximately 4-7 yr before diagnosis of NIDDM. Because other data indicate that diabetes may be present for 5 yr before retinopathy becomes evident, onset of NIDDM may occur 9-12 yr before its clinical diagnosis.
These findings suggest that undiagnosed NIDDM is not a benign condition. Clinically significant morbidity is present at diagnosis and for years before diagnosis. During this preclinical period, treatment is not being offered for diabetes or its specific complications, despite the fact that reduction in hyperglycemia, hypertension, and cardiovascular risk factors is believed to benefit patients. Imprecise dating of diabetes onset also obscures investigations of the etiology of NIDDM and studies of the nature and importance of risk factors for diabetes complications.
A patient who presented with bilateral frozen shoulders and unrecognized hyperthyroidism is described. Both frozen shoulder and the related shoulder-hand syndrome may occur in this setting. These poorly understood rheumatic conditions often are complications of stroke, spinal cord injury, or diabetes. Dysfunction of the autonomic nervous system is thought to be of pathogenic importance. It is postulated that the close resemblance of hyperthyroidism to activation of the sympathetic nervous system may underlie its association with frozen shoulder and shoulder-hand syndrome.
Of 935 consecutive patients referred with shoulder pain, 50 fitted the criteria for primary frozen shoulder. Twelve patients who failed to improve after conservative treatment and manipulation had excision of the coracohumeral ligament and the rotator interval of the capsule. The specimens were examined histologically, using special stains for collagen. Immunocytochemistry was performed with monoclonal antibodies against leucocyte common antigen (LCA, CD45) and a macrophage/synovial antigen (PGMI, CD68) to assess the inflammatory component, and vimentin and smooth-muscle actin to evaluate fibroblasts and myofibroblasts. Our histological and immunocytochemical findings show that the pathological process is active fibroblastic proliferation, accompanied by some transformation to a smooth muscle phenotype (myofibroblasts). The fibroblasts lay down collagen which appears as a thick nodular band or fleshy mass. These appearances are very similar to those in Dupuytren's disease of the hand, with no inflammation and no synovial involvement. The contracture acts as a check-rein against external rotation, causing loss of both active and passive movement.
Limited joint mobility (LJM) in childhood insulin-dependent (type 1) diabetes is associated with a substantially increased risk of microvascular complications. Cross-sectional studies have not demonstrated a relationship between LJM and metabolic control. This study was designed to determine whether glycemic control, as measured by glycohemoglobin (hgbA1C) levels from the onset of diabetes, is associated with the occurrence of LJM.
Probands (n = 18) had hgbA1C values and recorded observation of joint function from soon after onset of their diabetes. Controls (n = 40) were matched to probands for gender and age at diagnosis and had follow-up beyond the age at which the proband was found to have LJM.
The odds ratio for occurrence of LJM for the mean hgbA1C from diabetes onset was 1.46, 95% confidence limits 1.07 to 2.00. Thus, for every unit increase in average hgbA1C, there was approximately a 46% increase in the risk of LJM. When hgbA1C was dichotomized, the OR for hgbA1C of more than 8% was 2.55, and the OR was 4.54 if the hgbA1C was greater than 12%. Age at diagnosis and duration of diabetes were not independent prognostic factors for LJM.
Glycemic control from onset of diabetes is strongly associated with occurrence of LJM.
This study was done to examine the association between shoulder adhesive capsulitis and chronic diabetic complications and diseases closely related to diabetes in Akdeniz University Hospital. Shoulder adhesive capsulitis were evaluated in 297 consecutive type II diabetic patients attending an outpatient diabetic clinic. Shoulder adhesive capsulitis was detected in 86 patients (29%). There was a significant association between shoulder adhesive capsulitis and limited joint mobility (p = 0.006), shoulder adhesive capsulitis and Dupuytren's disease (p = 0.003). Odds ratios (OR) for carpal tunnel syndrome, limited joint mobility, and Dupuytren's disease with shoulder adhesive capsulitis were respectively 1.4, 2.1, and 2.4 [95% confidence interval (CI), respectively, 0.7-2.9, 1.2-3.69, and 1.3-4.4]. Also, shoulder adhesive capsulitis was associated with the age of patients (p = 0.000) and the duration of diabetes (p = 0.03). When other associations between shoulder adhesive capsulitis and diabetic complications were compared, it was associated with retinopathy [p = 0.014, OR = 2.2 (95% CI 1.1-4.2)], but there was no association with neuropathy or macroproteinuria. On the other hand, the degrees of passive abduction, internal rotation, external rotation motions of shoulder joints in the all patients were correlated with age of patients, duration of diabetes, neuropathy, and the other hands' problems (Dupuytren's disease, limited joint mobility) (p<0.05). The presence of shoulder adhesive capsulitis may indicate presence of organ involvement.
In recent years, several major organizations have endorsed the concept of the metabolic syndrome and developed working definitions for it. How well these definitions predict the risk for adverse events in people with the metabolic syndrome is only now being learned. The purpose of this study was to summarize the estimates of relative risk for all-cause mortality, cardiovascular disease, and diabetes reported from prospective studies in samples from the general population using definitions of the metabolic syndrome developed by the National Cholesterol Education Program (NCEP) and World Health Organization (WHO).
The author reviewed prospective studies from July 1998 through August 2004.
For studies that used the exact NCEP definition of the metabolic syndrome, random-effects estimates of combined relative risk were 1.27 (95% CI 0.90-1.78) for all-cause mortality, 1.65 (1.38-1.99) for cardiovascular disease, and 2.99 (1.96-4.57) for diabetes. For studies that used the most exact WHO definition of the metabolic syndrome, the fixed-effects estimates of relative risk were 1.37 (1.09-1.74) for all-cause mortality and 1.93 (1.39-2.67) for cardiovascular disease; the fixed-effects estimate was 2.60 (1.55-4.38) for coronary heart disease.
These estimates suggest that the population-attributable fraction for the metabolic syndrome, as it is currently conceived, is approximately 6-7% for all-cause mortality, 12-17% for cardiovascular disease, and 30-52% for diabetes. Further research is needed to establish the use of the metabolic syndrome in predicting risk for death, cardiovascular disease, and diabetes in various population subgroups.
Adhesive capsulitis, or frozen shoulder syndrome, is a condition characterized by gradual loss of active and passive glenohumeral motion. The etiology of adhesive capsulitis is unknown. Treatment methods include supervised benign neglect, physical therapy, intra-articular corticosteroid injections, closed manipulation under anesthesia, arthroscopic capsular release, and open surgical release. Approximately 70% of patients presenting with adhesive capsulitis are women; however, the role of sex in the etiology, development, and outcome of treatment for adhesive capsulitis remains unclear. Individualized treatment is necessary following thorough evaluation of patient symptoms and stage of the disease.
Adhesive capsulitis is characterized by a progressive and painful loss of shoulder motion of unknown etiology. Previous studies have found the prevalence of adhesive capsulitis to be slightly greater than 2% in the general population. However, the relationship between adhesive capsulitis and diabetes mellitus (DM) is well documented, with the incidence of adhesive capsulitis being two to four times higher in diabetics than in the general population. It affects about 20% of people with diabetes and has been described as the most disabling of the common musculoskeletal manifestations of diabetes.
Consented patients presenting with adhesive capsulitis reporting no history of DM had blood testing for diabetes and prediabetes. An anonymous database was analyzed for a diabetic condition.
The prevalence of diabetes in patients with adhesive capsulitis was 38.6% (34 of 88). The prevalence of prediabetes was 32.95% (29 of 88). The total prevalence of a diabetic condition in patients with adhesive capsulitis was 71.5% (63 of 88). Previous literature fails to reveal the incidence of newly diagnosed diabetes, 2 of 88 (2%), and prediabetes, 25 of 88 (28.4%) in patients presenting with adhesive capsulitis. Early diagnosis and effective management of DM reduces the risk of microvascular complications. DM is believed to play a role in the development of musculoskeletal complications.
Awareness of these findings alerts the practitioner to the risk of diabetes and prediabetes in patients presenting with adhesive capsulitis of the shoulder.
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