This week in Physical Medicine & Rehabilitation

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Welcome to This Week in Physical Medicine & Rehabilitation. This week we're covering 10 notable papers spanning the stiff and painful shoulder, adjuncts for spasticity and motor recovery after neurological injury, and the systemic factors that shape recovery, from swallowing to the ventilator. Let's dive in.

The shoulder dominated the week, with two network meta-analyses on frozen shoulder and an observational study on post-stroke shoulder pain. In the BMJ, Meng and colleagues pooled 189 randomised trials covering nearly thirteen thousand participants and 59 different interventions for adhesive capsulitis [1]. Roughly seven in ten of the trials feeding the main outcomes were at high risk of bias, and that shapes everything that follows. With moderate certainty, extracorporeal shockwave therapy probably reduced short-term pain by about two points on a ten-point scale compared with usual care, and manipulation under anaesthesia, with or without an intra-articular steroid injection, probably improved short-term flexion by roughly 25 to 35 degrees. The apparent gains from shockwave in function and range of motion were low certainty and undermined by disagreement between direct and indirect evidence. Mid-term effects were mostly low or very low certainty, and comparative safety could not be judged because adverse events were so poorly reported; the authors stress that an absence of reported harm is not evidence of no harm. Narrowing the lens, Lei and colleagues in the American Journal of Physical Medicine and Rehabilitation compared hydrodilatation strategies across 20 trials and about fourteen hundred patients [2]. Corticosteroid hydrodilatation through the anterior rotator interval ranked highest for pain relief and external rotation, while anterior intra-articular corticosteroid hydrodilatation combined with an additional steroid injection ranked highest for flexion and abduction, improving abduction by around thirty degrees. Plain anterior hydrodilatation was associated with worse pain, and an isolated suprascapular nerve block may have reduced internal rotation. These rankings rest on modest trial numbers and indirect comparisons, so they suggest that approach and steroid content matter rather than settling a preferred technique. It is worth noting that the much broader BMJ network did not place hydrodilatation among its moderate-certainty findings, a reminder that the two analyses answer different questions at different resolutions. Hemiplegic shoulder pain is a separate problem, and Erol Durgun and colleagues, also in the American Journal of Physical Medicine and Rehabilitation, followed 26 consecutive stroke survivors with chronic shoulder pain who received an ultrasound-guided suprascapular nerve block with either triamcinolone 40 milligrams and lidocaine or 70 percent ethanol neurolysis [3]. Both groups improved in pain and range of motion with no between-group differences. At six months, gains in night pain and range of motion persisted only in the alcohol group, and two alcohol-treated patients had a transient post-procedural flare. This was a small, non-randomised service evaluation, so the signal of more durable benefit from neurolysis is hypothesis-generating and the authors call for adequately powered randomised trials.

A second cluster asked whether add-on technologies improve spasticity and motor recovery. Shockwave, which looked promising for frozen shoulder pain, did not show added value in a small randomised trial by Akbulut and Erhan in the American Journal of Physical Medicine and Rehabilitation [4]. Twenty children with spastic cerebral palsy all received botulinum toxin to the plantar flexors, and half of the children also had three weekly shockwave sessions. At twelve weeks spasticity scores were numerically lower with the combination, but the difference on the primary endpoint was not statistically significant, and nor were differences in gait, pain, or ankle range. With twenty children the trial was likely underpowered, so this is an absence of demonstrated benefit rather than proof of no effect. In the Journal of Spinal Cord Medicine, Alashram reviewed whole-body vibration for spasticity after spinal cord injury and found only seven studies [5]. Vibration may reduce spasticity compared with control interventions, but certainty ranged from very low to low, and protocols and outcome measures varied, so the evidence frames vibration as a candidate complementary strategy rather than an established one. On the upper limb after stroke, Wang and colleagues in the Archives of Physical Medicine and Rehabilitation ran a network meta-analysis of 103 trials with more than five thousand participants [6]. Compared with usual care, robot-assisted training alone added about four points on the Fugl-Meyer upper extremity scale, robot training with low-frequency electrical stimulation added about seven and a half, and robot training with repetitive transcranial magnetic stimulation added close to ten. The magnetic stimulation combination ranked first, but once predictive uncertainty was built in, its chance of truly being best fell to little better than a coin toss. Heterogeneity was substantial, head-to-head trials were sparse, and certainty was very low to moderate, so the authors decline to declare a definitive hierarchy.

The third theme looks beyond the injured system to the whole patient. Choi and colleagues, in the American Journal of Physical Medicine and Rehabilitation, analysed 1,286 stroke survivors with dysphagia from a single centre [7]. Among the patients alive at six months, about 60 percent regained full oral intake with multiple consistencies. After adjusting for stroke severity, cognition, aphasia, lesion characteristics, and comorbidities, lower odds of recovery were associated with low skeletal muscle mass, weak grip, nutritional risk, deep penetration or aspiration on videofluoroscopy, and moderate or severe pharyngeal residue, each carrying roughly a quarter to two fifths lower odds. The study is retrospective, so it shows that muscle and nutrition markers add prognostic information alongside the swallow study, not that correcting them improves swallowing. In the Journal of Spinal Cord Medicine, van Oort and colleagues used 24-hour ambulatory blood pressure monitoring in 34 people with subacute motor incomplete spinal cord injury, with a mean age of 61 [8]. At admission to inpatient rehabilitation, about four in five participants lacked normal nocturnal dipping, and nearly six in ten had nighttime hypertension, even though daytime pressure looked normal in most participants. All but one person had at least one blood pressure risk factor, and none of these patterns changed by discharge. It is a small single-centre cohort without outcome data, but it suggests that daytime readings may miss persistent autonomic dysregulation with potential long-term cardiovascular consequences in this group.

Two final papers extend rehabilitation into the intensive care unit and the dizziness clinic. Ren and colleagues, in the American Journal of Physical Medicine and Rehabilitation, pooled 19 randomised trials of diaphragmatic neuromuscular electrical stimulation in nearly fifteen hundred mechanically ventilated patients [9]. Stimulation was associated with better diaphragm thickening, excursion, and inspiratory pressure, about two fewer days on the ventilator, about two fewer days in intensive care, and roughly a third higher relative chance of weaning success. However, most outcomes were rated low or very low certainty because of heterogeneity and high risk of bias, so these are encouraging signals that larger trials need to confirm. In Disability and Rehabilitation, Micarelli and colleagues randomised 81 adults with cervicogenic dizziness to ten sessions of low-dose paraspinal lidocaine injections or saline over five weeks [10]. Dizziness handicap improved by about seven points more with lidocaine, a large standardised effect but below the 11-point threshold for a minimal important change, and most secondary outcomes also favoured lidocaine. Side effects were mostly mild. Participant blinding was not verified and there was no long-term follow-up, so the authors describe a modest short-term benefit that needs confirmation.

If you only have time for one paper this week, make it the BMJ network meta-analysis on adhesive capsulitis [1]. It maps nearly two hundred trials onto a single framework and shows how few frozen shoulder treatments rest on even moderate-certainty evidence, while flagging how little is known about comparative harms.

That's your roundup for This Week in Physical Medicine & Rehabilitation. The full transcript and references are available on the episode page. See you next week.

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