Chronic Shoulder Research Articles

Neglected posterior shoulder dislocation treated with anatomic reconstruction for bipolar bone defects of humeral head and posterior glenoid: A case report and literature reviews

Treatment of chronic posterior shoulder dislocation remains difficult. Currently, there is no consensus on how to treat these cases. In this report, we present a uncommon case of a 42-yearold man with neglected posterior shoulder dislocation, a reverse Hill-Sachs lesion, and a defect of the posterior glenoid. We show our treatments and reviews articles about posterior shoulder dislocations.

Acute Splenic Sequestration Crisis in a 70-Year-Old Patient With Hemoglobin SC Disease.

A 70-year-old African American female with a past medical history significant for chronic bilateral shoulder pain and reported sickle cell trait presented with acute-onset bilateral thoracolumbar pain radiating to her left arm. Two days after admission, Hematology was consulted for severely worsening microcytic anemia and thrombocytopenia. Examination of the patient’s peripheral blood smear from admission revealed no cell sickling, spherocytes, or schistocytes. Some targeting was noted. A Coombs test was negative. The patient was eventually transferred to the medical intensive care unit in respiratory distress. Hemoglobin electrophoresis confirmed a diagnosis of hemoglobin SC disease. A diagnosis of acute splenic sequestration crisis complicated by acute chest syndrome was crystallized, and red blood cell exchange transfusion was performed. Further research is necessary to fully elucidate the pathophysiology behind acute splenic sequestration crisis, and the role of splenectomy to treat hemoglobin SC disease patients should be better defined.

Posterior bone block: a reliable method to treat recurrent nonlocked posterior shoulder dislocation with engaging reverse Hill–Sachs lesion

Background Posterior shoulder dislocation was first reported in 1839 by Sir Astley Cooper. Hill and Sachs, in 1940, stated that with any dislocation event the soft bone of the humeral head impacts against the harder, sharper edge of the glenoid, leading to an impression fracture of the posterosuperior head in recurrent anterior dislocation. A reverse Hill–Sachs lesion is an impression fracture in the anterosuperior head in recurrent posterior dislocation. In 1952, McLaughlin described his surgical technique to treat an anterior impression fracture of the humerus after recurrent posterior shoulder dislocation. Hypothesis Our hypothesis is to prove that posterior bone block augmentation of the posterior glenoid is a safe and reliable line of treatment in cases of recurrent posterior instability with engaging reverse Hill–Sachs lesion. Patients and methods Between March 2009 and March 2011 five cases were referred to us with chronic recurrent posterior shoulder dislocation with engaging reverse Hill–Sachs lesion. The mean age of the patients was 28 years (range: 20–36 years). There were two left and three right shoulders. All patients were male. All patients were manual workers. All sustained traumatic dislocations through nonathletic accidents. None of the patients had epileptic fits before. Preoperatively, the mean active forward elevation was 140° (range: 130°–150°) and external rotation with the arm at the side was 35° (range: 20°–50°). Preoperative constant score average was 40 points (range: 30–50 points). The mean time interval between injury and surgery was 12 months (range: 8–16 months). All cases had engaging reverse Hill–Sachs lesion. None of the cases had significant posterior glenoid bone loss. All patients were treated with open posterior bone block augmentation of the posterior glenoid harvested from the anterior iliac crest. Results Patients were evaluated at 3, 6, 12, and 24 months. Range of motion was recorded and follow-up radiographs were taken to evaluate graft incorporation. The mean follow-up time for the five patients was 30 months (range: 24–36 months). At 6 months postoperatively, the mean forward elevation was 165° (range: 160°–170°) and external rotation with the arm at the side was 55° (range: 40°–70°). Patients were evaluated postoperatively according to the constant score system (maximum: 100 points). We found a mean postoperative constant score of 87.5 points (range: 80–95 points), a fairly good result considering the nature of bone loss. Conclusion The posterior bone block can successfully restore the stability and function of the shoulder in patients with recurrent posterior dislocations with significant engaging reverse Hill–Sachs lesion in which arthroscopic soft-tissue reconstruction is not a reasonable option. This technique can be used for combined soft tissue and bony defects as well as for revisions after previous soft-tissue reconstructions.

Late radiation side effects, cosmetic outcomes and pain in breast cancer patients after breast-conserving surgery and three-dimensional conformal radiotherapy : Risk-modifying factors.

The purpose of this work was to identify parameters influencing the risk of late radiation side effects, fair or poor cosmetic outcomes (COs) and pain in breast cancer patients after breast-conserving therapy (BCT) and three-dimensional conformal radiotherapy (3D-CRT). Between 2006 and 2013, 159 patients were treated at the Hannover Medical School. Physician-rated toxicity according to the LENT-SOMA criteria, CO and pain were assessed by multivariate analysis. LENT-SOMA grade 1-4 toxicity was observed as follows: fibrosis 10.7 %, telangiectasia 1.2 %, arm oedema 8.8 % and breast oedema 5.0 %. In addition, 15.1 % of patients reported moderate or severe breast pain, and 21.4 % complained about moderate or severe pain in the arm or shoulder. In multivariate analysis, axillary clearing (AC) was significantly associated with lymphoedema of the arm [odds ratio (OR) 4.37, p = 0.011, 95 % confidence interval (CI) 1.4-13.58]. Breast oedema was also highly associated with AC (OR 10.59, p = 0.004, 95 % CI 2.1-53.36), a ptosis grade 2/3 or pseudoptosis and a bra size ≥ cup C (OR 5.34, p = 0.029, 95 % CI 1.2-24.12). A ptosis grade 2/3 or pseudoptosis and a bra size ≥ cup C were the parameters significantly associated with an unfavourable CO (OR 3.19, p = 0.019, 95 % CI 1.2-8.4). Concerning chronic breast pain, we found a trend related to the prescribed radiation dose including boost (OR 1.077, p = 0.060, 95 % CI 0.997-1.164). Chronic shoulder or arm pain was statistically significantly associated with lymphoedema of the arm (OR 3.9, p = 0.027, 95 % CI 1.17-13.5). Chronic arm and breast oedema were significantly influenced by the extent of surgery (AC). Ptotic and large breasts were significantly associated with unfavourable COs and chronic breast oedema. Late toxicities exclusive breast pain were not associated with radiotherapy parameters.

A Combined Surgery For Chronic Locked Anterior Shoulder Dislocation: Case Report and Review of the Literature

Omuz cikiklari siklikla eger 3 haftadan daha eski ise kronik olarak adlandirilmaktadirlar. Bu cikiklarin coguna buyuk Hill-Sachs lezyonlari, glenoid kavite kemik kayiplari ve norolojik yaralanmalar eslik edebilir. Bizim olgumuz 66 yasinda bir bayan ve dusme sonucu basvurdugu merkezde sadece Radius alt uc kirigi olarak tedavi edilmis, one omuz cikigi atlanmis. Kronik kilitli one omuz cikiginin sonucu olarak buyuk bir Hill-Sachs lezyonu oldugu saptandi. Yaralanmadan yetmis gun sonra hastanin omuz rahatsizligindan (agri ve hareket kisitliligi) dolayi hastaya tedavi olarak; acik reduksiyon, Latarjet Proseduru ve proksimal humeral ice dondurme osteotomisi uygulandi. Bu tedavi kombinasyonu kronik omuz cikigi icin Ingilizce literaturde bir ilktir. Bir yil sonra hasta ameliyat sonucundan oldukca memnun kalmistir. Hasta fonksiyonel omuz hareketini kazanmis ve omzunun instabilite olmadan agrisiz oldugu saptanmistir. Buyuk Hill-Sachs lezyonlari yasli hastalarda genel olarak hemiartroplasti ile tedavi edilmektedir ancak hastanin kendi kemigi korunarak da basarili sonuc alinabilir.

The intra- and inter-observer reliability of the CT-scan based X index to quantify glenoid bone loss in chronic anterior shoulder instability and its impact on decision making.

The X index is a measure of the antero-inferior glenoid bone loss on unilateral 2D CT-scans in the preoperative analysis of chronic anterior shoulder instability. Recurrence rate was shown to be higher after stabilization surgery if X index is superior or equal to 0.4. The objective of this study was to assess the intra- and inter-observer reliability of the X index. Sixty patients with an X index ≥0.4 were included retrospectively. The X index was measured twice by two independent evaluators, 15 days apart. The measurement was performed on a unilateral 2D CT-scan by dividing the length of the antero-inferior glenoid defect over the maximal antero-posterior diameter of the glenoid. Reliability of X index was assessed with intra-class correlation coefficient (ICC, ρ). Two points were added to the ISIS calculation if its glenoid criterion was "zero" and we compared this modified score to the original one. The intra-observer reliability of the X index measurement was "excellent" (ρ = 0.95 ± 0.01, p < 0.0001) while the inter-observer reliability was "good" (ρ = 0.59 ± 0.08, p < 0.0001). In patients with a glenoid bone loss visualized by the X index, 48.3 % had a negative sclerotic glenoid line sign. This proportion significantly decreased with the augmentation of the X index, p = 0.02. The average original ISIS score was 3.4 ± 1.9 and became 4.3 ± 1.7 (p < 0.00001) when the X index was incorporated. The X index is a reliable and simple unilateral 2D CT-scan measurement. AP shoulder radiographs significantly underestimated glenoid bony lesions.

Arthroscopic treatment of recurrent anterior shoulder instability with augmentation

Chronic anterior shoulder instability was found in cases with little soft tissue on the anterior portion of the joint, especially the anterior bundle of the inferior glenohumeral ligament (AIGHL) complex. Low volume and quality of the AIGHL complex tissue can lead to limitation of external rotation and difficulties to return to activities of daily living and overhead throwing sports. A new approach for the augmentation of chronic Bankart repair was developed for these cases based on a pilot study using polyglycolic acid sheets (PGA sheet). Favorable functional results without recurrence were obtained using the PGA sheet for augmentation of the AIHGL complex without any side effects. A long-term follow-up is necessary.

慢性的な肩関節の夜間痛に対する経動脈的微小血管塞栓療法の有効性

慢性的な肩関節の夜間痛に対する経動脈的微小血管塞栓療法の有効性

Pulsed Radiofrequency for the Suprascapular Nerve for Patients With Chronic Headache

Chronic shoulder or suprascapular pain is a disabling phenomenon. Chronic headache is also a disabling phenomenon for many patients. Once it was believed that chronic headache that is attributed to the cervical spine originates from the upper cervical nerve roots (C0-C3). Currently, it is suggested by some authors that the reason for headache in many patients is attributed to the lower cervical nerve roots in the cervical spine. The suprascapular nerve originates from the C5 and C6 nerve roots and supplies the suprascapular and shoulder region. Pulsed radiofrequency (PRF) has gained popularity over recent years as a good clinical tool in treating patients with shoulder/suprascapular pain. It is usually considered as a treatment option after conservative treatment has failed. The purpose of this study was to evaluate whether PRF for the suprascapular nerve has also beneficial effect for patients that have also chronic headache that is attributed to the lower cervical nerve roots. Sixty-nine patients with a follow-up of 1 year who had chronic shoulder/suprascapular pain and chronic headache were examined after they underwent PRF procedures to the suprascapular nerve (either unilateral or bilateral). Forty patients (58%) reported long-term pain relief (1-y follow-up) for the shoulder/suprascapular pain and 31 patients (45%) reported long-term pain relief for the headache. This pain relief was defined as reduction of Visual Analogue Score by at least 30%. No complications were found in this study except for mild discomfort in the treated area which spontaneously resolved up to 3 weeks after the procedure. PRF for the suprascapular nerve is a safe and an effective procedure for patients who suffer from shoulder/suprascapular pain and also for headache that is attributed to the lower cervical nerve roots. It should be tried after conservative treatment has failed.

ARTHROSCOPIC FINDINGS AND FUNCTIONAL OUTCOME OF SHOULDER INJURY IN THE YOUNG OVERHEAD ATHLETES

Research background and hypothesisOverhead athletes are having higher risk to suffer from acute and chronic shoulder injuries.Research aimto evaluate shoulder complex functional characteristics of the overhead and non-overhead young athletes...

Coffee intake and development of pain during computer work

BackgroundThe present study sought to determine if subjects who had consumed coffee before performing a simulated computer office-work task found to provoke pain in the neck and shoulders and forearms and wrists exhibited different time course in the pain development than the subjects who had abstained from coffee intake.FindingsForty eight subjects all working fulltime, 22 with chronic shoulder and neck pain and 26 healthy pain-free subjects, were recruited to perform a computer-based office-work task for 90 min. Nineteen (40%) of the subjects had consumed coffee (1/2 -1 cup) on average 1 h 18 min before start. Pain intensity in the shoulders and neck and forearms and wrists was rated on a visual analogue scale every 15 min throughout the work task.During the work task the coffee consumers exhibited significantly lower pain increase than those who abstained from coffee.ConclusionsSubjects who had consumed coffee before starting a pain provoking office work task exhibited attenuated pain development compared with the subjects who had abstained from coffee intake. These results might have potentially interesting implications of a pain-modulating effect of caffeine in an everyday setting. However, studies with a double blind placebo controlled randomized design are needed.

Arthroscopic double-loaded single-row repair in chronic traumatic anterior shoulder dislocation

We evaluated the clinical results of arthroscopic double-loaded single-row repair for chronic anterior shoulder dislocation. From January 2007 to December 2008, of the 47 shoulders with chronic anterior shoulder dislocation that consecutively underwent arthroscopic double-loaded single-row repair using bio-absorbable suture anchors containing two non-absorbable braided sutures, 45 shoulders (95.7 %) had successful follow-up for a minimum of 2 years. The mean age of patients was 23.7 years, the mean frequency of dislocations before surgery was 6.8 events, and the mean interval between the initial dislocation and surgery was 47.9 months. Clinical results were evaluated using ASES, Rowe, VAS score, and range of motion before surgery and at the final follow-up. The mean number of suture anchors was 3.38 (range 2-6) and the mean number of stitches was 6.32 (range 4-10). Four of the 45 cases had recurrence (8.9 %). Of these four, three cases underwent re-operation using the same method and the other one case showed no specific discomfort except a one-time dislocation that underwent conservative treatment. The preoperative and the final follow-up ASES and Rowe scores were statistically significantly improved (P < 0.001, each) and instability VAS score was significantly decreased (P < 0.001). No significant difference in forward flexion, extension, abduction, or internal rotation was found (P > 0.05), but external rotation at the side was significantly decreased (P = 0.001). Arthroscopic double-loaded single-row repair using suture anchors, containing two sutures in chronic anterior shoulder dislocation, is a reliable procedure with respect to recurrence rate, range of motion, and shoulder function.

Deep tissue hyperalgesia after computer work

Background and purpose A growing number of people are using computers. Shoulder and neck pain occur commonly during computer work. Peripheral and central sensitization may play a major role in establishing and maintaining several chronic pain conditions. We have previously reported that a 90 min simulated computer office-work induced substantial pain in the shoulders and neck. We hypothesized that the development of pain during the computer work may be related to sensitization. The aim of the present study was to examine if the 90 min computer work induced deep tissue muscle hyperalgesia manifested as altered pressure pain thresholds (PPTs). Methods Twenty-two subjects with chronic shoulder and neck pain (pain group) and 26 healthy and pain free subjects (reference group) performed a standardized computer office-work task with use of a computer-mouse and with time pressure and high precision demands continuously for 90 min. The pressure pain threshold was measured with a pressure algometer in shoulder and forearm muscles (bilaterally in upper trapezius and extensor carpi radialis), and at sternum, before and 15 min and 30 min after the computer work task. Results The PPTs before starting the computer work were not different between the groups at any of the five locations. In both groups, the PPTs in the active and inactive side of the upper trapezius as well as in the extensor carpi radialis of the forearm operating the computer mouse were significantly reduced after the 90 min computer work compared with the pre-work levels. In the pain group, also the PPT in the inactive resting forearm was significantly reduced. The changes seen in PPTs from pre- to post-work were not significantly different between the groups, except for the inactive resting forearm where the groups exhibited different time course. Conclusion A decrease in pressure pain thresholds of involved muscles suggests that computer office-work can induce deep tissue hyperalgesia within 90 min. The development of pain during the computer work indicates peripheral sensitization as the predominant mechanism. Decreased pressure pain thresholds also in sites distant from pain areas may indicate a contribution from central sensitization in the subjects with chronic shoulder and neck pain. Implications The lasting pain after work and the reduced PPTs both in involved and distant musculature may indicate need for frequent pauses during computer work, especially when performed with time pressure and high precision demands, in order to avoid pain to increase and sustain after work, and thus to prevent the possibility of pain to become chronic.

Classificazione ed eziologia delle instabilità di spalla

Shoulder instability includes a wide spectrum of different manifestations ranging from painful hyperlaxity to chronic locked shoulder dislocations. Many different classifications of glenohumeral joint have been proposed, based on aetiology, direction of instability, or on combination thereof. A correct diagnosis and classification is essential to establish an adequate treatment strategy. The correct use of different clinical tests and signs in combination with the corresponding imaging diagnostics allows an explicit classification and therefore the correct choice of treatment regimes in the majority of cases.

Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial

BackgroundShoulder pain is a common musculoskeletal problem that is often chronic or recurrent. Myofascial trigger points (MTrPs) cause shoulder pain and are prevalent in patients with shoulder pain. However, few studies have focused on MTrP therapy. The aim of this study was to assess the effectiveness of multimodal treatment of MTrPs in patients with chronic shoulder pain.MethodsA single-assessor, blinded, randomized, controlled trial was conducted. The intervention group received comprehensive treatment once weekly consisting of manual compression of the MTrPs, manual stretching of the muscles and intermittent cold application with stretching. Patients were instructed to perform muscle-stretching and relaxation exercises at home and received ergonomic recommendations and advice to assume and maintain good posture. The control group remained on the waiting list for 3 months. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score (primary outcome), Visual Analogue Scale for Pain (VAS-P), Global Perceived Effect (GPE) scale and the number of muscles with MTrPs were assessed at 6 and 12 weeks in the intervention group and compared with those of a control group.ResultsCompared with the control group, the intervention group showed significant improvement (P < 0.05) on the DASH after 12 weeks (mean difference, 7.7; 95% confidence interval (95% CI), 1.2 to 14.2), on the VAS-P1 for current pain (mean difference, 13.8; 95% CI, 2.6 to 25.0), on the VAS-P2 for pain in the past 7 days (mean difference, 10.2; 95% CI, 0.7 to 19.7) and VAS-P3 most severe pain in the past 7 days (mean difference, 13.8; 95% CI, 0.8 to 28.4). After 12 weeks, 55% of the patients in the intervention group reported improvement (from slightly improved to completely recovered) versus 14% in the control group. The mean number of muscles with active MTrPs decreased in the intervention group compared with the control group (mean difference, 2.7; 95% CI, 1.2 to 4.2).ConclusionsThe results of this study show that 12-week comprehensive treatment of MTrPs in shoulder muscles reduces the number of muscles with active MTrPs and is effective in reducing symptoms and improving shoulder function in patients with chronic shoulder pain.Trial registration numberISRCTN: ISRCTN75722066

One Case of Video-Assisted Thoracoscopic Removal of Acupuncture Needle in Lung Parenchyma

We report the case of a 32-year-old woman presenting with intermittent chest pain resulted from a migratory acupuncture needle. The patient received acupuncture treatment approximately 3 years prior to this presentation, for the treatment of chronic left shoulder and lumbar pain after delivery. Chest radiography revealed a retained needle in the lingular segmental area. Video-assisted thoracoscopy was then used to remove the migratory acupuncture needle attached between the lingular segmental lobe and the pericardial fat. The patient recovered without complications and was discharged home.

Musculoskeletal Dysfunction and Pain in Adults with Asthma

Background. The mechanical alterations related to the overload of respiratory muscles observed in adults with persistent asthma might lead to the development of chronic alterations in posture, musculoskeletal dysfunction and pain; however, these changes remain poorly understood. Objective. This study aimed to assess postural alignment, muscle shortening and chronic pain in adults with persistent asthma. Methods. This cross-sectional and controlled study enrolled 30 patients with mild (n = 17) and severe (n = 13) persistent asthma. Fifteen non-asthmatic volunteers were also assessed. Asthma was classified by the Global Initiative for Asthma (GINA) guidelines. Postural alignment and muscle shortening were evaluated by head and shoulder positions, chest wall mobility, and posterior (trunk and lower limb) muscle flexibility. In addition, the measures used were previously tested for their reproducibility. Pain complaints were also assessed. Results. In comparison with non-asthmatic subjects, patients with mild or severe persistent asthma held their head and shoulders more forward and had lower chest wall expansion, decreased shoulder internal rotation, and decreased thoracic spine flexibility. Chronic lower thoracic, cervical, and shoulder pain was significantly increased in patients with mild or severe asthma compared with non-asthmatic subjects (p < 0.05). Conclusion. Adults with persistent asthma have musculoskeletal dysfunction and chronic pain that is independent of the severity of their disease but that might be related to their age at the onset of disease symptoms.

Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy

The purpose of this case report is to demonstrate the importance of a thorough patient interview. The case involves a man referred for physical therapy for a musculoskeletal dysfunction; during the patient interview, a psychiatric disorder was recognized that was later identified as schizophrenia. A secondary purpose is to educate physical therapists on the recognizable signs and symptoms of schizophrenia.Client description: A 19-year-old male patient with chronic shoulder, elbow, and wrist pain was referred for physical therapy. During the interview, the patient reported that he was receiving signals from an electronic device implanted in his body.Measures and outcome: The physical therapist's initial assessment identified a disorder requiring medical referral. Further management of the patient's musculoskeletal dysfunction was not appropriate at this time. The patient was referred for further medical investigation, as he was demonstrating signs suggestive of a psychiatric disorder. The patient was diagnosed with schizophrenia by a psychiatrist and was prescribed Risperdal. This case study reinforces the importance of a thorough patient interview by physical therapists to rule out non-musculoskeletal disorders. Patients seeking neuromusculoskeletal assessment and treatment may have undiagnosed primary or secondary psychiatric disorders that require recognition by physical therapists and possible medical referral.

Somatocognitive therapy in the management of chronic gynaecological pain. A review of current approach and historical background

Abstract Introduction We have developed somatocognitive therapy as a hybrid of Mensendieck physiotherapy and cognitive psychotherapy. Womenwith chronic pelvic pain (CPP) and vulvodynia (chronic pain of the vulvae and vestibulum, VD) were recruited into two separate treatment protocols as described. Methods 60 patients with CPP were recruited from the Department of Gynaecology at the Oslo University Hospital into a randomized, controlled intervention study. The patients were randomized into three treatment groups, receiving (1) treatment as usual, (2) somatocognitive therapy, and (3) in addition receiving cognitive therapy. The patients were assessed by means of SMT, Visual Analogue Score of Pain (VAS), and General Health Questionnaire (GHQ-30) at baseline, after three months of out-patient therapy and at 1 year follow-up. 9 women with VD were treated in an outpatient setting by physiotherapy students under senior supervision, each receiving in all 16 therapy sessions over 8 weeks, and scored for motor patterns (SMT) and pain (VAS) before and after therapy. Results In the control group, no significant change was found. In the group receiving somatocognitive therapy, significant reduction in pain score and improvement in motor function were found the end of therapy, and the significant improvement continued through the follow-up period. GHQ scores were significantly improved for the scores representing level of anxiety and coping, and improved for depression. In the group receiving cognitive therapy in addition, the VAS scores were reduced to the same level as the group receiving only somatocognitive therapy, whereas the motor patterns showed slightly less improvement than for those women that did not receive cognitive intervention. In the women with VD somatocognitive therapy resulted in significantly reduction in pain scores (by an average of 66%), and significant improvement of motor patterns, especially for the scores for gait (56%) and respiration (88%). Conclusions Somatocognitive therapy is a new approach that appears to be very promising in the management of chronic gynaecological pain. Short-term out-patient treatment significantly reduces pain scores and improves motor function, especially with respect to respiration, gait and movement (ability to relax). The approach is now being used in a randomized, controlled intervention study including patient with chronic low back, neck and shoulder, and widespread pain.

RE: Fishbain DA, Lewis JE, Gao J, Cole B, Rosomoff RS. Alleged Breaches of “Standards of Medical Care” in a Patient Overdose Death Possibly Related to Chronic Opioid Analgesic Therapy, Application of the Controlled Substances Model Guidelines: Case Report. Pain Med 2009; 10(3): 565–572

April 29, 2009 Dear Editor, I was quite dismayed when I read the case report on alleged breaches of “standards of medical care” in a patient overdose death possibly related to chronic opioid analgesic therapy, application of the controlled substances model guidelines: case report by Dr. David Fishbain. He defended all of the allegations while I agreed with most of them. More importantly, I feel a key element was left out. On page 568, he related the guidelines state that the decision to start chronic opioid analgesic therapy (COAT) should be based on a diagnosis and clear documentation of chronic pain unresponsive to other treatments. Dr. Fishbain glossed over the very important first element, that is, diagnosis. The diagnosis listed was “chronic right shoulder pain.” This is a symptom, not a diagnosis. …