Diagnosis, level 2b.

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BackgroundThere is no consensus about the optimal treatment strategy for frozen shoulders (FS). Conservative treatment consisting of intra-articular corticosteroid infiltrations and physiotherapy are considered appropriate for most patients. However, with a conservative strategy, patients experience a prolonged rehabilitation period with a considerable amount of pain and disabilities in daily life. Also, at long term, a residual amount of pain and restriction of range of motion is frequently reported. Manipulation under anesthesia is a short and relative simple procedure with the potential to rapidly reduce symptoms and restore the range of motion. The objective of this trial is to evaluate the effectiveness of MUA followed by a PT program compared to a PT program alone, in the treatment of patients with a stage two FS. We hypothesize that the course of the disease can be shortened with MUA with a quicker functional recovery.MethodsThis is a prospective, single center, randomized controlled trial. Eligible patients will be allocated to either the manipulation (MUA) group or the physiotherapy alone (PT) group. In the MUA group manipulation will be performed under interscalene block, directly followed by an intensive physiotherapy treatment protocol, with the goal to maintain the obtained range of motion. Patients allocated to the PT group are given advice and education and receive a written protocol to hand out to their physical therapist based on the recent guideline of the Dutch Shoulder Network for the treatment of frozen shoulders. Descriptive statistics will be used to describe the sample size, patients demographics, presence of diabetes mellitus, range of motion, duration of symptoms till randomization and will be presented for each treatment group. The SPADI is used as primary functional outcome parameter. Secondary outcome parameters are; OSS, NPRS, EQ-5D 3-L, passive range of motion, WORQ-UP, duration of symptoms, usage of analgesics and adverse events. A sample size of 41 subjects in each group was calculated. Follow up is planned after 1,3 and 12 months. The length of physiotherapy treatment in both groups is variable, depending on individual progression. Differences between groups in outcome parameters will be analysed using the linear mixed modelling and the restricted maximum likelihood ratio technique for estimating the model parameters.DiscussionSuccessful completion of this trial will provide evidence on the best treatment strategy for patients with a stage two frozen shoulder. The results of this study can lead to a better understanding for the role of manipulation in the treatment of frozen shoulders.Trial registrationThis trial is registered in the Dutch Trial Register under the number NTR6182 on the 20th of February 2017.

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Introduction Range of motion (ROM) is closely monitored before and after surgery for stiff elbow and during rehabilitation. Measurements in the home environment may be helpful to increase involvement and adherence of the patient. Therefore, our objective is to investigate the validity and inter- and intraobserver reliability of 3 alternative methods to assess the ROM by the patient in a home-based situation, in comparison to the universal goniometer (UG). We hypothesize that all 3 alternative methods will be valid alternatives and show a level of reliability equivalent to UG. Methods Goniometric measurements of elbow flexion, extension, pronation and supination using photography, movie, and a smartphone application were obtained. The validity of these measurement methods was compared to UG. The interobserver and intraobserver reliability were calculated for all measurement methods. Results Photography and movie based goniometry of the elbow showed good validity in flexion and extension. The interobserver and intraobserver reliability were found to be good to excellent for photo and movie but moderate to poor for UG and the smartphone application. Conclusions Photo or movie based goniometry seems to be a useful option for initial and follow-up measurement of the elbow ROM, both in the outpatient clinic and in a home environment. Based on our study, the smartphone application we used is not recommended.

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BackgroundThe elbow is prone to stiffness after trauma. To regain functional elbow motion several conservative- and surgical treatment options are available. Conservative treatment includes physical therapy, intra-articular injections with corticosteroids and a static progressive or dynamic splinting program. If conservative treatment fails, an operative release of the posttraumatic stiff elbow is often performed. The best Evidence-Based rehabilitation protocol for patients after an operative release is unknown to date and differs per surgeon, hospital and country. Options include early- or delayed motion supervised by a physical therapist, immediate continuous passive motion (CPM), (night) splinting and a static progressive or dynamic splinting program.Methods/designThe SET-Study (Stiff Elbow Trial) is a single-centre, prospective, randomized controlled trial. The primary objective of this study is to compare the active Range of Motion (ROM) (flexion arc and rotational arc) twelve months after surgery between three groups. The first group will receive in-hospital CPM in combination with early motion Physical Therapy (PT) supervised by a physical therapist, the second group will receive only in-hospital early motion PT supervised by a physical therapist and the third group will receive outpatient supervised PT from postoperative day seven till ten. Secondary outcome measures will be Patient Reported Outcome Measures (PROMs) including the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), the quick Disabilities of Arm, Shoulder and Hand (qDASH) score, Visual Analogue pain Scale in rest and activity (VAS), Pain Catastrophizing Scale (PCS), the Short Form (SF)-36, the Centre for Epidemiological Studies Depression Scale Revised (CESD-R) and the Work Rehabilitation Questionnaire (WORQ) for the upper limb.DiscussionA successful completion of this trial will provide evidence on the best rehabilitation protocol in order to (re)gain optimal motion after surgical release of the stiff elbow.Trial registrationThe trial is registered at the Dutch Trial Register: NTR6067, 31–8-2016.

Reasons for performing study Normal radiographic anatomy of the juvenile donkey foot has not been reported previously. Objectives To provide a radiographic survey of the anatomical development of the donkey foot from 0 to 2 years of age. Study design Radiographic survey. Methods The right front foot of 9 donkey foals born in the spring of 2012, housed and fed in the same conditions, were radiographed every month for the first 6 months of age and every 3 months for the following 18 months. Latero‐medial radiographs with and without barium markers at the coronary band and anterior‐posterior radiographs of both front feet were obtained during weightbearing. Radiographs were obtained at 55 kV and 3 mAs with mobile x‐ray equipment (Gierth RHF 200 ML, Examion DR810). Results The distal physis of the metacarpus (McIII) was closed at the mean age of 17.8 months (SD: 11.5, 21). The proximal physis of the proximal phalanx was closed at the mean age of 15.5 months (SD: 11.5, 21). The distal physis appeared as a clear radiolucent line at 2 weeks of age and was still visible subtly at 24 months. The proximal physis of the middle phalanx was closed at the mean age of 10.7 months (SD: 11.5, 19). The distal physis was visible at birth but closed at 4 days. Conclusions Based on our results, it seems that physes close at an older age in the donkey foal than in the horse. Ethical animal research: The study was approved by the Ethics committee of the Vrije Universiteit Brussel (VUB), Brussels, Belgium. (VUB/14‐272‐2). Owners gave informed consent for their horses' inclusion in the study. Source of funding: The authors acknowledge Vtrade Belgium for the logistic assistance. Competing interests: None declared.