Abstract The pathomechanism of the shoulder impingement syndrome has been under debat. Two main theories of the pathogenesis of the disease exists; mechanical (extrinsic) and degenerative (intrinsic) theory. The purpose of this work was to evaluate the pathogenesis of impingement syndrome with five studies that consentrate to aspects related to ethiopathology as outcome and recovery after surgery, radiological diagnosis, immunohisto- and histopathology of subacromial bursa, and subacromial mechanical pressures. The good results of 14 shoulders of 96 operated with an open acromioplasty turned painful after an average of 5 (2 - 10) years postoperatively and had developed 6 full-thickness and 4 partial rotator cuff tears. Initially good result is not permanent in all cases, suggesting that a degenerative process is involved in the pathogenesis of impingement syndrome. Shoulder muscle strengths of 48 patients, who had undergone an open acromioplasty, restored to near normal within one year after open acromioplasty, suggesting that mechanical compression plays a role in the pathogenesis of impingement syndrome. Variation in the shape of the acromion, evaluated in 111 patients and their matched controls by a routine supraspinatus outlet view, is associated with impingement syndrome, but this association is weak. Validity of this radiograph in the diagnosis of impingement syndrome is therefore a minor adjunct to the other diagnostic methods. The role of subacromial bursa in impingement syndrome was studied in 62 patients (33 tendinitis, 11 partial and 18 full-thickness RC tear) suffering from a unilateral impingement syndrome and 24 controls. Tenascin-C proved to be a more general indicator of bursal reaction compared to the conventional histological markers, being especially pronounced at the more advanced stages of impingement. The local subacromial contact pressures measured in 14 patients and 8 controls with a piezoelectric probe were elevated in the impingement syndrome, supporting the mechanical theory. On the basis of this study, both mechanical and degenerative factors are involved in the pathogenesis of impingement syndrome.

Thesis (MHSc--Health Science) -- AUT University, 2009. / Includes bibliographical references. Also held in print ( leaves : ill. ; 30 cm.) in the Archive at the City Campus (T 617.572044 HAR)

Syftet med avhandlingen var att beskriva diagnostiken och utvärdera handläggningen i primärvård av patienter med subacromial smärta. Avhandlingen omfattar fyra studier. I den första studien användes ett frågeformulär och resultaten beskriver hur distriktsläkare och distriktssjukgymnaster i ett svenskt län diagnosticerar och handlägger primärvårdspatienter med subacromial smärta. Den andra studien beskriver distriktsläkares och distriktssjukgymnasters tilltro till effekten av olika behandlingsmetoder för dessa patienter. Med utgångspunkt från de tilltrodda behandlingsmetoderna genomfördes en systematisk litteraturöversikt. Den tredje studien utvärderar intra- och interbedömar reliabilitet för ett styrketest som ingår i ett utvärderingsinstrument ‘the Constant-Murley shoulder assessment’. Den avslutande studien är en randomiserad klinisk studie som utvärderar och jämför effekten av två behandlingsstrategier, akupunktur och ultraljud, båda i kombination med hemträning. Distriktsläkare och distriktssjukgymnaster visade sig använda en likartad diagnostik. Det troligaste valet av behandling för distriktsläkare var antiinflammatoriska läkemedel och kortisoninjektion i den subacromiala bursan och för distriktssjukgymnaster rörelseträning samt ergonomiska åtgärder. Dock var de flesta behandlingsalternativen troliga val, vilket tolkas som en osäkerhet om behandlingarnas effekt. Med utgångspunkt från de behandlingsmetoder som distriktsläkare och distriktssjukgymnaster tilltrodde som effektiva för patienter med subacromial smärta, genomfördes en systematisk kritisk litteraturöversikt. Fyrtio studier inkluderades och deras evidensnivå utvärderades. Endast kortisoninjektion i den subacromiala bursan visade sig ha definitiva bevis för effekt. Akupunktur visade sig ha troliga bevis för effekt och ultraljudsbehandling konkluderades som ineffektivt för patienter med subacromial smärta. Det förelåg en låg grad av samstämmighet mellan tilltro och tillgängliga vetenskapliga bevis. En digital dynamometer kan ersätta den konventionella fjädervågen i det standardiserade styrketestet. En nästan perfekt överensstämmelse vad gäller både intra- och interbedömarreliabilitet vid test av unga skulderfriska personer, oberoende av om en ”håll emot-” eller ”dragteknik” användes eller om medel- eller maxvärden användes vid beräkningen av överensstämmelse. I den randomiserade kliniska studien inkluderades 85 patienter. Tre utvärderingsinstrument, kombinerade i resultatanalysen, utvärderade förändringen under en uppföljningsperiod på 12 månader tillsammans med patienternas subjektiva skattning av resultatet. Resultaten visade att akupunktur i kombination med hemträning är att föredra. Båda behandlingsgrupperna förbättrades signifikant och fortsatte förbättras över tid oberoende av behandling. De flesta patienter uppnådde ett tillfredställande behandlingsresultat efter 12 månader. Åtminstone tre fjärdedelar i varje behandlingsgrupp skattade sig mycket förbättrade eller helt återställda. Detta tolkas som en behandlingseffekt i kombination med naturalförloppet. Avhandlingen har beskrivit handläggningen i primärvård av patienter med subacromial smärta och har bidragit med vetenskapliga bevis för distriktsläkare att behandla med kortisoninjektion i subacromiala bursan och för distriktssjukgymnaster att behandla med akupunktur kombinerat med hemträning. / The aim of the thesis was to describe the diagnostic approach and evaluate primary care management of patients with subacromial pain. The thesis includes four different studies, a questionnaire study describing attitudes among general practitioners and physiotherapists in a Swedish county toward the diagnostic approach and management of primary care patients with subacromial pain; a combination of a systematic review and general practitioners and physiotherapists beliefs in interventions for patients with subacromial pain; a study of intra- and inter-observer reliability for the strength test in the Constant-Murley shoulder assessment; and a randomised clinical trial to evaluate and compare the efficacy of two treatment strategies for patients with subacromial pain, acupuncture combined with home exercises and continuous ultrasound combined with home exercises. In the questionnaire study we described that general practitioners and physiotherapists have a uniform diagnostic approach. The most probable choice of treatment was non-steroidal anti-inflammatory drugs and corticosteroid injection into the subacromial bursa for general practitioners and movement exercises together with ergonomics/adjustments at work for physiotherapists, but most treatments were probable choices, reflecting an uncertainty about their effectiveness. The treatments trusted by general practitioners and physiotherapists were systematically reviewed. Forty studies were included and the level of evidence was summarised. Only corticosteroid injections into the subacromial bursa, had definitive evidence for efficacy. Acupuncture had tentative evidence for efficacy and therapeutic ultrasound was concluded as ineffective for patients with subacromial pain. The association between trusted treatments and available scientific evidence was weak. A digital dynamometer can replace the conventional spring-balance in the standardised strength test. An almost perfect agreement was found for intra- and inter-observer reliability in young shoulder-healthy persons, regardless of whether a 'resisted-force' or a 'pull-force' was used or if calculated with mean or maximum values. Eighty-five patients were included in the randomised clinical trial. Three shoulder scores, combined in the analysis, measure change during a 12 months follow-up together with a ‘patient self-evaluation’ of the experienced result. The results favoured acupuncture combined with home exercises. Both groups improved significantly and continued to improve over time independent of treatment and most of the patients reached a satisfactory result at 12 months. At least three fourths of the patients, in each treatment group, reported large improvements or felt completely recovered. This is interpreted as a combination of treatment effect and the natural course. This thesis has described the primary care management of patients with subacromial pain and provided scientific evidence for general practitioners to use corticosteroid injection and for physiotherapists to use acupuncture combined with home exercises, when treating these patients. / On the day of the defence date the status on article III was Accepted and article IV was Submitted.

Diss. (sammanfattning) Umeå : Umeå universitet, 2009. / Härtill 5 uppsatser. Även tryckt utgåva.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2015. / Background: The most common shoulder complaint seen by physicians is shoulder impingement syndrome. There has been limited success with the current conservative treatment that has been provided for this condition. Thoracic spine and rib manipulation is purported to aid in the treatment of this condition; however there is a paucity of controlled investigations. The purpose of this study was to determine the short term efficacy of thoracic and prone rib manipulation on shoulder impingement syndrome. Methods: A randomised, placebo controlled pre-test post-test experimental design was used. Informed consent was obtained and 30 participants were recruited according to inclusion criteria and allocated to either a placebo or intervention group. Intervention consisted of thoracic spinal and rib manipulation. Data was collected, pre and post the first treatment and at a 48 hours follow up. SPSS was used to analyse the data with a p value of 0.05. Results: No statistically significant differences were seen between the groups for pain rating, range of motion of the glenohumeral joint, lateral scapula slide test or scapula isometric pinch test. The shoulder pain and disability index (SPADI) showed significant (p = 0.04) differences between the groups in terms of disability scores, with the intervention group having a great improvement in disability. No clinically significant differences were observed between the groups. Conclusion: Thoracic spine and rib manipulation appears to improve the disability associated with shoulder impingement syndrome, however further research is required with a larger sample size.

Diss. (sammanfattning) Linköping : Univ., 2004. / Härtill 4 uppsatser.

Made available in DSpace on 2016-06-02T20:19:21Z (GMT). No. of bitstreams: 1 5121.pdf: 13124971 bytes, checksum: 6e287fe7f29cdce25264d37ed5bc3045 (MD5) Previous issue date: 2013-02-21 / Financiadora de Estudos e Projetos / Background: There is a lack of studies that evaluated within day and between day reliabilities of 3-D scapular kinematics during elevation and lowering of the arm in different shoulder conditions, as well as studies about low-amplitude and high-velocity thoracic spine manipulation (TSM) effects on scapular kinematics in subjects with shoulder dysfunctions. Objective: To establish within day and between day reliability of scapular motion during elevation and lowering of the arm and at rest position and to evaluate the immediate effects of a TSM on pain and scapular kinematics during elevation and lowering of the arm, both in subjects with and without shoulder impingement syndrome (SIS). Methods: Kinematic data were collected using Flock of Birds® electromagnetic device. Subjects were divided in 2 groups: control and impingement. For reliability kinematic data were collected during elevation and lowering of the arm and at rest position on 2 different occasions separated by 3 to 5 days. Forty-nine subjects were tested for within day reliability. Forty-three subjects were reassessed for between day reliability. For kinematic evaluation pre- and ppost-manipulation, scapular kinematics was collected during elevation and lowering of the arm before and immediately after the intervention. Numeric pain rating scale was used to assess shoulder pain during arm movement at pre- and post- intervention. Fifty subjects (31.76 ± 10.91 years) with SIS and 47 subjects (25.76 ± 5.01 years) asymptomatic for shoulder dysfunctions were randomly assigned to one of the groups: manipulation or sham. Results: There was very good within day reliability for assessing scapular internal and upward rotations and tilt from both groups during elevation and lowering of the arm (ICC=0.92-0.99). In general, there was good between day reliability for assessing scapular motion during elevation and lowering of the arm from both groups (ICC=0.54-0.88). There was also good and very good between day reliability for assessing scapular rest position in both groups (ICC=0.66-0.95). Study 2: Subjects with SIS experienced reduced shoulder pain (from 3.29 to 2.45, p<0.01) during arm movement immediately after TSM. Subjects with and without SIS who received TSM and asymptomatic subjects who received sham intervention showed significant increase in scapular upward rotation at post-intervention. Increase in scapular anterior tilt at postmanipulation was also observed in asymptomatic subjects who received TSM. Conclusion: Flock of Birds® electromagnetic tracking system is a reliable device for measuring 3-D scapular motion during elevation and lowering of the arm and at rest position in subjects with and without impingement symptoms over time. TSM is associated with improved shoulder pain and scapular upward rotation in subjects with SIS. Although with questionable clinical relevance, TSM may not be immediately favorable to scapular tilt in asymptomatic subjects. / Além da escassez de evidências a respeito da confiabilidade entre repetições e dias da avaliação cinemática 3-D da escápula durante a elevação e descida do braço em diferentes condições do ombro, estudos sobre os efeitos da manipulação torácica de alta velocidade e baixa amplitude (MT) na cinemática escapular em sujeitos assintomáticos e portadores de disfunções no ombro também são bastante escassos. Objetivo: Determinar a confiabilidade entre repetições e entre dias das medidas do movimento 3-D da escápula durante a elevação e descida do braço e na posição de repouso e avaliar os efeitos imediatos de uma MT na dor e na cinemática da escápula durante a elevação e descida do braço, ambos em sujeitos assintomáticos e portadores da síndrome do impacto (SI). Métodos: Para a avaliação cinemática foi utilizado o dispositivo eletromagnético Flock of Birds®. Os sujeitos foram divididos em 2 grupos (controle e impacto). Os dados cinemáticos para a confiabilidade foram coletados durante a elevação e descida do braço e na posição de repouso em duas ocasiões diferentes separadas por 3 a 5 dias. Quarenta e nove sujeitos foram avaliados para a confiabilidade entre repetições e quarenta e três sujeitos foram avaliados para a confiabilidade entre dias. Para a avaliação pré e pós-manipulação os dados cinemáticos foram coletados durante a elevação e descida do braço antes e imediatamente após a intervenção. A escala numérica de dor mediu a dor durante o movimento do braço antes e após a intervenção. Cinquenta sujeitos (31,76 ± 10,91 anos) com SI e 47 sujeitos (25,76 ± 5,01 anos) assintomáticos para disfunções no ombro foram aleatoriamente designados a um dos seguintes grupos : manipulação ou sham. Resultados: A confiabilidade das medidas entre as repetições foi excelente para as rotações medial e superior e para a inclinação da escápula em ambos os grupos durante a elevação e a descida do braço (CCI=0,92-0,99). No geral, confiabilidade entre dias para avaliar os movimentos escapulares durante a elevação e a descida do braço para ambos os grupos foi boa (CCI=0,54-0,88). A confiabilidade entre dias também foi boa e excelente para as rotações escapulares durante a posição de repouso em ambos os grupos (ICC=0,66-0,95). Houve melhora significativa da dor nos sujeitos com SI (de 3,29 para 2,45, p<0,01) durante o movimento do braço imediatamente após a MT. Os sujeitos com e sem SI que receberam a MT e os sujeitos assintomáticos que receberam a intervenção sham apresentaram significativo aumento na rotação superior da escápula após a intervenção. O aumento na inclinação anterior após a manipulação também foi observado nos sujeitos assintomáticos que receberam a MT. Conclusão: O Flock of Birds® é um dispositivo eletromagnético confiável para medir ao longo do tempo o movimento 3-D da escápula durante a elevação e descida do braço e na posição de repouso em sujeitos assintomáticos e portadores de SI ao longo do tempo. A MT está associada com a melhora da dor e da rotação superior da escápula nos sujeitos com SI. E, apesar da questionável relevância clínica, a MT pode não ser imediatamente favorável para a inclinação escapular nos sujeitos assintomáticos.

Made available in DSpace on 2016-06-02T20:19:23Z (GMT). No. of bitstreams: 1 5783.pdf: 3013658 bytes, checksum: 554232e857a534b5beaacd869958f849 (MD5) Previous issue date: 2014-02-27 / Universidade Federal de Minas Gerais / Background: Shoulder pain is one of the most common and disabling complaints, and shoulder impingement syndrome (SI) is one of the most common causes of this symptom. Recently, several records of pressure pain threshold become useful tools as topographical pressure pain sensitivity maps to assess the state of awareness on various musculoskeletal conditions. However, there are no studies that have proposed topographic maps to assess shoulder sensitivity. Objective: To develop topographical pressure pain sensitivity maps of the shoulder in subjects with SI as compared with healthy subjects, and to analyze the intra-rater reliability of the topographic maps of the shoulder in healthy and asymptomatic subjects. Methods: Initially, 29 predetermined points and 4 points in fixed anatomical locations have been identified on both shoulders of 25 patients with SI and 25 healthy and asymptomatic subjects. The map was determined from anatomical landmarks and anthropometric measurements of each individual. Of all 32 points assessed, 11 are located in bony structures, 11 in muscle bellies, 9 in tendons, 1 on the coracoacromial ligament and 1 over the acromioclavicular joint. The pressure pain threshold was evaluated at all points in the dominant and nondominant side of healthy subjects and in the symptomatic and asymptomatic sides in subjects with SI. The sides and points were randomized prior to the evaluation. The pressure pain threshold was assessed 3 times on each point (20 s of rest), and the mean of each measure was considered for analysis. Results: The methodology used allowed us to characterize a topographic map for assessing shoulder pain sensitivity in subjects with SI. There was no difference between the SI and healthy groups (p> 0,05). However, the symptomatic side of subjects with SI showed higher sensitization (p <0.05), in some locations (points 6 and 7, located on the spine of the scapula and point 10, located on the infraspinatus muscle). The tendons were the most sensitive structures, followed by the bones for both groups. There was excellent intra-rater reliability between the trials of pressure pain threshold for each point (non-dominant side of healthy subjects, ICC: 0.86-0.98; dominant side of healthy subjects, ICC: 0.89-0.96). The standard error of measurement and minimal detectable change presented range, respectively, 28.4-55.9kPa and 66.7-131.4kPa (non-dominant side), 29.4-60.8kPa and 69.6-142.2kPa (dominant side). Conclusion: The proposed topographical pressure pain sensitivity maps of the shoulder was useful for detecting the state of peripheral hyperalgesia in different anatomical structures (bones, muscles and tendons) in subjects with SI, and was reliable for assessing pressure pain sensitivity on the shoulder in healthy subjects. / Contextualização: A dor no ombro é uma das queixas mais comuns e incapacitantes, e a síndrome do impacto do ombro (SI) é uma das causas mais comuns desta sintomatologia. Recentemente, mapas topográficos com vários registros de limiar de dor à pressão tornaram-se ferramentas úteis para avaliar o estado de sensibilização em diversas condições musculoesqueléticas. No entanto, não há ainda estudos que tenham proposto mapas topográficos para avaliar a sensibilidade dolorosa no ombro. Objetivo: Propor e caracterizar um mapa topográfico de sensibilidade dolorosa à pressão no ombro em indivíduos com SI e comparar a indivíduos saudáveis, e analisar a confiabilidade intra-examinador do mapa topográfico de sensibilidade dolorosa à pressão no ombro em indivíduos saudáveis e assintomáticos. Métodos: Inicialmente, 29 pontos pré-determinados e 4 pontos em localizações anatômicas fixas, foram identificados em ambos os ombros de 25 portadores da SI e 25 indivíduos saudáveis e assintomáticos no ombro. O mapa foi determinado a partir de pontos anatômicos e medidas antropométricas de cada indivíduo. De 32 pontos avaliados, 11 se localizam em estruturas ósseas, 11 em ventres musculares, 9 sobre tendões ou junções miotendíneas, 1 sobre o ligamento coracoacromial e 1 sobre a articulação acrômioclavicular. O limiar de dor à pressão foi avaliado em todos os pontos, nos lados dominante e não dominante dos indivíduos saudáveis e, nos lados sintomático e assintomático dos indivíduos com SI do ombro. Os lados e os pontos a serem avaliados foram randomizados antes da coleta de dados. O limiar de dor à pressão foi examinado 3 vezes sobre cada ponto (intervalo 20 s), e a média entre cada medida foi considerada para a análise. Resultados: A metodologia utilizada permitiu caracterizar um mapa topográfico para a avaliação da sensibilidade dolorosa do ombro em indivíduos com SI. Não houve diferença entre os grupos SI e saudáveis (p>0.05). No entanto, o lado sintomático dos indivíduos com SI apresentou maior sensibilização (p<0.05) em algumas localizações (pontos 6 e 7, localizados sobre a espinha da escápula e ponto 10, localizado sobre o músculo infraespinal). Os tendões foram as estruturas mais sensíveis, seguido dos ossos, para ambos os grupos SI e indivíduos saudáveis. Houve excelente confiabilidade intra-examinador, entre as repetições de limiar de dor á pressão para cada ponto (lado não dominante dos indivíduos saudáveis, ICC: 0.86-0.98; lado dominante dos indivíduos saudáveis, ICC: 0.89-0.96). O erro padrão da medida e a mínima diferença detectável apresentaram amplitude, respectivamente, 28.4-55.9kPa e 66.7- 131.4kPa (lado não dominante); 29.4-60.8kPa e 69.6-142.2kPa(lado dominante). Conclusão: O mapa topográfico proposto foi útil para detectar o estado de hiperalgesia periférica em diferentes estruturas anatômicas (ossos, músculos e tendões) em indivíduos com SI, e mostrou-se confiável para avaliar a sensibilidade dolorosa à pressão no ombro em sujeitos saudáveis.

Submitted by Bruna Rodrigues (bruna92rodrigues@yahoo.com.br) on 2016-10-03T12:59:30Z No. of bitstreams: 1 TeseMNH.pdf: 1453015 bytes, checksum: dc886893af7e51ac61e4ea5fdd4b63b6 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-10-10T14:22:00Z (GMT) No. of bitstreams: 1 TeseMNH.pdf: 1453015 bytes, checksum: dc886893af7e51ac61e4ea5fdd4b63b6 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-10-10T14:22:09Z (GMT) No. of bitstreams: 1 TeseMNH.pdf: 1453015 bytes, checksum: dc886893af7e51ac61e4ea5fdd4b63b6 (MD5) / Made available in DSpace on 2016-10-10T14:22:17Z (GMT). No. of bitstreams: 1 TeseMNH.pdf: 1453015 bytes, checksum: dc886893af7e51ac61e4ea5fdd4b63b6 (MD5) Previous issue date: 2015-11-18 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Background: Shoulder impingement syndrome (SIS) is a common cause of shoulder pain complains and numerous treatment strategies are available in the clinic. Questions remain regarding the effects of Thoracic Spinal Manipulation (TSM) on SIS and concerning the efficacy of available techniques on the treatment of this population. Objectives: In a clinical trial, the objective was to evaluate short-term effects of a TSM on pain, function, scapular kinematics and scapular muscle activity in individuals with SIS. In a systematic review, the objective was to summarize current evidence regarding effectiveness of physical therapy to improve pain, function and range of motion in this population. Methods: In the clinical trial, participants were randomly allocated to TSM group (n=30) or sham-TSM group (n=31) and attended 2 intervention sessions over a 1-week period. Shoulder pain, shoulder function (DASH and WORC questionnaires), scapular kinematics and scapular muscle activity were measured. A blinded assessor evaluated the outcomes at day 1, day 2-pre, day 2-post and day 3. In the review, Pubmed, Web of Science, CINAHL Cochrane, Embase, Lilacs, Ibecs and Scielo databases were searched up to April 2015. Randomized controlled trials investigating different modalities of physical therapy in the treatment of patients with SIS on pain, function/disability or range of motion were included. Results: In the clinical trial, TSM group improved pain (1.1 points) and tended to improve function (5.0 points on WORC) over the sham-TSM group after 2 intervention sessions. Scapular upward rotation increased 4.0°, 5.3° and 3.3° at day 2-pre, day 2-post and day 3, respectively, in the TSM group during lowering of the arm. Changes in scapular internal rotation and tilt were not different between groups. Upper and lower trapezius activity decreased in the TSM group and both groups, respectively, during elevation and lowering of the arm. Serratus anterior activity increased in the sham-TSM group. In the review, sixty-two RCTs were included. The majority had a low to moderate risk of bias. Exercise therapy provided high evidence of improvements to the treatment in the short, mid or long-term. Dynamic humeral centering, proprioceptive exercises and manual therapy associated with conventional exercises enhance the improvements in the short-term. Low-level laser, ultrasound, pulsed electromagnetic field and kinesio taping provided moderate and high evidence level towards no benefits to the treatment of SIS. Microwave diathermy, transcutaneous electrical nerve stimulation and isolated manual therapy or acupuncture provided limited evidence of benefits. Conclusion: TSM may be worthy to achieve short-term reduction of shoulder pain, increase of scapular upward rotation and decrease of upper trapezius activity facilitating the application of other movement-based interventions in individuals with SIS. Exercise therapy should be used as the first choice to improve pain, function and range of motion, and the association of manual therapy should be the best choice to accelerate symptoms decrease and progress exercise therapy quickly. Low-level laser therapy, ultrasound, pulsed electromagnetic field and kinesio taping do not provide significant effects to the therapy and therefore could be avoided. More studies are necessary to improve evidence concerning effects of diacutaneous fibrolysis, microwave diathermy, transcutaneous electrical stimulation, acupuncture and isolated manual therapy techniques in the treatment of SIS. / Introdução: A Síndrome do Impacto (SI) é uma causa comum de dor no ombro e inúmeras estratégias de tratamento estão disponíveis na clínica. Os efeitos da manipulação torácica e a eficácia de muitas técnicas de tratamento da SI ainda não estão claros na literatura. Objetivos: Em um ensaio clínico, os objetivos foram avaliar os efeitos a curto-prazo de uma manipulação torácica na dor, função, cinematica scapular e atividade muscular em indivíduos portadores de SI. Em uma revisão sistemática, o objetivo foi sintetizar a atual evidência a respeito da efetividade da fisioterapia para melhorar a dor, função e amplitude de movimento nessa mesma população. Métodos: No ensaio clínico, os participantes foram distribuídos aleatoriamente ao grupo manipulação (n=30) ou grupo sham (n=31) e receberam 2 sessões de intervenção durante 1 semana. Foram medidos dor e função do ombro (questionários DASH e WORC), cinematica e atividade muscular da escápula. Um avaliador cego coletou as variáveis no dia 1, dia 2-pré intervenção, dia 2 pós-intervenção e no dia 3. Na revisão sistemática, as buscas foram realizadas nas bases de dados Pubmed, Web of Science, CINAHL Cochrane, Embase, Lilacs, Ibecs e Scielo até abril de 2015. Foram incluídos ensaios clínicos randomizados controlados que investigaram o efeito de diferentes modalidades fisioterapêuticas no tratamento de pacientes com SI na dor, função e amplitude de movimento. Resultados: No ensaio clínico, o grupo manipulação apresentou diminuição da dor (1.1 pontos) e uma tendência de melhora na função (5.0 pontos no WORC) comparado ao grupo sham após 2 intervenções. A rotação superior da scapula aumentou 4.0°, 5.3° e 3.3° no dia 2 pré-intervenção, dia 2 pós-intervenção e no dia 3, respectivamente durante a descida do braço. As mudanças na rotação interna e na inclinação da scapula não foram diferentes entre os grupos. Atividade do trapézio superior e trapézio inferior diminuiu no grupo manipulação e em ambos grupos, respectivamente. A atividade do serrátil anterior aumentou no grupo sham. Na revisão sistemática, 62 estudos controlados randomizados foram incluídos. A maioria dos estudos apresentou baixo risco de vies. Os exercícios terapêuticos apresentaram alta evidência de melhora no tratamento a curto, médio e longo prazo. Os exercícios proprioceptivos e a terapia manual associada com exercícios convencionais aumentam as melhoras a curto prazo. O laser de baixa intensidade, ultrassom, campo pulsado eletromagnético e o tape proporcionaram evidência moderada e alta de nenhum benefício ao tratamento. As terapias com ondas curtas, estimulação transcutânea eletromagnética, a terapia manual aplicada de forma isolada e a acupuntura apresentaram evidência limitada de benefícios. Conclusão: A manipulação torácica parece proporcionar a curto prazo redução da dor no ombro, aumento da rotação superior da scapula e diminuição da atividade do trapézio superior facilitando a aplicação de outras terapias focadas no restabelecimento do movimento em pacientes com SI. Os exercícios terapêuticos devem ser utilizados como primeira opção para melhorar a dor, a função e a amplitude de movimento, e a associação dos exercícios com a terapia manual deve ser a melhor opção para acelerar a melhora dos sintomas. O laser de baixa intensidade, ultrassom, campo eletromagnético pulsado e o tape não proporcionam efeitos significativos à terapia, portanto, devem ser evitados. Mais estudos são necessaries para aperfeiçoar a evidência a respeito da terapia com ondas curtas, miofibrólise, estimulação elétrica transcutânea, acupuntura e terapia manual aplicada isoladamente no tratamento da SI.

O plasma rico em plaquetas (PRP) tem sido utilizado na ortopedia como método para melhorar a cicatrização tecidual. Existem poucos estudos com alto nível de evidência sobre o seu efeito no reparo do manguito rotador e os resultados são conflitantes, não havendo consenso sobre sua eficácia. O objetivo primário deste estudo foi avaliar o efeito do uso do PRP em pacientes submetidos ao reparo do manguito rotador por via artroscópica através da escala da University of California at Los Angeles (UCLA). A avaliação clínica através da escala de Constant-Murley, de dor através da escala visual analógica (EVA), a presença de rerroturas na análise da ressonância magnética (RM) e a ocorrência de complicações foram considerados desfechos secundários. Estudo prospectivo, randomizado, duplo-cego. Dois grupos com 27 pacientes (Grupo PRP e Grupo Controle) foram submetidos ao reparo artroscópico em fileira simples de âncoras, sendo que, no Grupo PRP, foi aplicado o concentrado de plaquetas ao final do procedimento. O PRP foi obtido por aférese, aplicado na consistência líquida, com adição de trombina autóloga. Foram incluídas apenas roturas de espessura completa do supraespinal com retração inferior a 30 mm. Os procedimentos foram realizados pelo mesmo cirurgião, entre setembro de 2008 e abril de 2012. Os desfechos foram avaliados através das escalas da UCLA, de Constant-Murley, EVA e pela RM, pré-operatoriamente e aos 3, 6 e 12 meses. A EVA foi aplicada adicionalmente no primeiro e sétimo dia. O nível de significância empregado foi de 5%. Os pacientes apresentaram melhora clínica significativa com o procedimento nos dois grupos (p < 0,001). Evoluíram de 13,63 ± 3,639 para 30,04 ± 4,528 no Grupo Controle e de 13,93 ± 4,649 para 32,30 ± 3,506 no Grupo PRP aos 12 meses (p = 0,046) de acordo com a escala da UCLA, com um poder de 84% e tamanho do efeito de 0,56. De acordo com a escala de Constant-Murley, os pacientes evoluíram de 47,37 ± 11,088 para 76,89 ± 13,198 no Grupo Controle e de 46,96 ± 11,937 para 83,26 ± 11,141 no Grupo PRP aos 12 meses (p=0,061). A avaliação aos 3 e 6 meses não demonstrou diferença significativa. A avaliação pela EVA não demonstrou diferença estatística em nenhum dos tempos de seguimento, evoluindo de 7,00 ± 1,939 no Grupo Controle e de 6,67 ± 1,617 no Grupo PRP no pré-operatório para 1,70 ± 2,127 e 1,04 ± 1,808, respectivamente, aos 12 meses (p = 0,220). Na análise pela RM, o Grupo Controle apresentou uma rerrotura completa e quatro parciais, enquanto o Grupo PRP apresentou duas rerroturas parciais (p = 0,42). Ocorreu um caso de rigidez articular em cada grupo (p = 1). O PRP obtido por aférese, aplicado na consistência líquida e com adição de trombina propiciou melhores resultados pela escala da UCLA aos 12 meses de pós-operatório / Platelet-rich plasma (PRP) has been used in orthopedics as a method to enhance tissue healing. There are few studies with a high level of evidence about its effect on rotator cuff repair, and the results are conflicting, with no consensus about its effectiveness. Clinical assessment as measured by the UCLA (University of California at Los Angeles) shoulder rating scale was established as the primary outcome. The secondary outcomes included clinical assessment on the Constant-Murley scale, pain as measured by a visual analog scale (VAS), the retear rate assessed by magnetic resonance imaging (MRI) and the complication rate. A prospective, randomized, doubleblind trial was conducted. Two groups of 27 patients (PRP Group and Control Group) were subjected to arthroscopic single-row repair. Liquid PRP prepared by apheresis was applied to the PRP Group at the end of the surgical procedure, with autologous thrombin. Complete supraspinatus tears with retraction less than 30 mm were included. The procedures were performed by the same surgeon between September 2008 and April 2012. Outcomes were assessed using UCLA and Constant-Murley scales, VAS and magnetic resonance imaging preoperatively and at 3, 6 and 12 months. The VAS was also applied on days one and seven. The significance level was 5%. The two groups of patients exhibited significant clinical improvement (p < 0.001). The score on the UCLA scale increased from 13.63 ± 3.639 to 30.04 ± 4.528 and from 13.93 ± 4.649 to 32.30 ± 3.506 in the Control and PRP groups, respectively, between the preoperative assessment and after 12 months (p=0.046), with a 84% power and a 0.56 effect size. The score on Constant-Murley scale increased from 47.37 ± 11.088 to 76.89 ± 13.198 in the Control Group and from 46.96 ± 11.937 to 83.26 ± 11.141 in the PRP Group (p = 0.061). Assessment at 3 and 6 months did not identify significant differences. The VAS did not statistically differ at any investigated timepoint and varied from 7.00 ± 1.939 and 6.67 ± 1.617 before surgery to 1.70 ± 2.127 and 1.04 ± 1.808 at the 12-month assessment in the Control and PRP groups, respectively (p = 0.220). The Control Group exhibited one case of complete and four of partial retears, and the Group PRP exhibited two cases of partial retears (p = 0.42). PRP prepared by apheresis, applied in the liquid state with thrombin, promoted better results on the UCLA scale 12 months after surgery