scholarly journals Factors Affecting the Outcomes of Arthroscopic Capsular Release for Idiopathic Adhesive Capsulitis

2019 ◽  
Vol 7 (9) ◽  
pp. 232596711986762 ◽  
Author(s):  
Syed M. Rizvi ◽  
Ahmed J. Harisha ◽  
Patrick H. Lam ◽  
George A.C. Murrell
Keyword(s):  
Range Of Motion ◽  
Internal Rotation ◽  
External Rotation ◽  
Adhesive Capsulitis ◽  
Linear Regression Analysis ◽  
Frozen Shoulder ◽  
Level Of Evidence ◽  
Duration Of Symptoms ◽  
Capsular Release ◽  
Arthroscopic Capsular Release

Background: Arthroscopic capsular release has been shown to provide excellent short- and long-term outcomes in patients with idiopathic frozen shoulder. Some surgeons delay surgery in the belief that operating in the early stages of adhesive capsulitis results in a poorer prognosis. However, it is unclear which factors, particularly the stage of the disorder, affect the surgical outcome of this procedure. Hypothesis: Patients who undergo capsular release during the early symptomatic stage of idiopathic adhesive capsulitis would have less improvement in range of motion compared with those who undergo surgery at a later stage. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 189 shoulders with idiopathic adhesive capsulitis that underwent arthroscopic capsular release were evaluated. All patients completed a L’Insalata questionnaire and had their range of motion and strength tested prior to surgery and at 1, 6, and 12 weeks and 6 months post–capsular release. Post hoc, patients were grouped by whether they had symptoms lasting <10 months (shorter symptoms group; n = 131) or ≥10 months (longer symptoms group; n = 38). Multiple linear regression analysis was performed to determine which preoperative factors were independently associated with a favorable outcome. Results: Patients in the shorter symptoms group were more restricted prior to surgery than were those in the longer symptoms group (mean ± SEM: external rotation, 17° ± 2° vs 27° ± 4° [ P = .04]; abduction, 78° ± 3° vs 92° ± 6° [ P = .04]; internal rotation, S3 ± 1 vs S1 ± 1 [ P = .03]). The shorter symptoms group had greater postoperative improvement in internal rotation (from S3 ± 1 preoperatively to T12 ± 1 vertebral levels) compared with the longer symptoms cohort (from S1 ± 1 to L2 ± 1) ( P = .02). Conclusion: Patients with a frozen shoulder and a duration of symptoms <10 months made greater improvements in internal rotation and had similar final results for flexion, abduction, and external rotation following arthroscopic capsular release when compared with patients who had a longer duration of symptoms, so there is no reason to delay surgery.

Shoulder hydrodilatation for primary, post-traumatic and post-operative adhesive capsulitis

2020 ◽  
pp. 175857322097717
Author(s):  
Daoud Makki ◽  
Mustafa Al-Yaseen ◽  
Fayaz Almari ◽  
Puneet Monga ◽  
Lennard Funk ◽  
...  
Keyword(s):  
Range Of Motion ◽  
Outcome Measures ◽  
Glenohumeral Joint ◽  
External Rotation ◽  
Adhesive Capsulitis ◽  
Frozen Shoulder ◽  
Capsular Release ◽  
Arthroscopic Capsular Release ◽  
Number Of Patients ◽  
Post Traumatic

Background Adhesive capsulitis (frozen shoulder) is characterised by pain and loss of range of motion of the glenohumeral joint. It can be present as primary (idiopathic) or secondary to surgery, trauma or other conditions that restrict the use of the shoulder joint. Various treatment options have been adopted including physiotherapy, manipulation under anaesthetic, hydrodilatation and arthroscopic or open capsular release but the optimal form of management remains uncertain. Objectives The purpose of the study was to assess the clinical outcome of glenohumeral hydrodilatation in three cohorts of patients with different aetiologies with adhesive capsulitis. Study design & methods We carried out a retrospective study of patient who underwent hydrodilatation for adhesive capsulitis between 2013 and 2015. The procedure was performed by a specialist musculoskeletal radiologist under radiological guidance. The injection consisted of steroids, local anaesthetics and NaCl solution with a target volume around 35 mL. Our outcome measures were range of motion, and pre- and post-operative pain. Patients were divided into three groups based on the presumed cause of their stiffness: idiopathic, post-traumatic and post-surgical. Results Two hundred fifty patients were included, with a mean age of 59 years (range: 20–79). Of these, 180 had idiopathic primary adhesive capsulitis (27 were diabetic), 23 were post-traumatic, and 20 following surgical procedures. Thirty-four required further intervention following initial hydrodilatation with 8 undergoing repeat hydrodilatation, and 26 requiring arthroscopic capsular release. The diabetic group accounted for 16 capsular releases and 4 repeat procedures, while the idiopathic group accounted for 9 and 4, respectively. One patient required capsular release in the surgical group. An improvement was recorded in ROM in all groups with mean abduction improving from 59° to 110°, flexion from 50° to 120° and external rotation from 20° to 50°. With regards to pain, the majority showed an improvement from severe or moderate pain to no or mild pain. Conclusions Results show that hydrodilatation resulted in an improvement in all outcome measures, with only a small number of patients, especially those with diabetes, needing further procedures or showing no improvement in range of motion and pain. There was no difference between the post-traumatic and post-surgical groups.

Effectiveness of arthroscopic management of idiopathic shoulder stiffness: A meta-analysis

2021 ◽  
pp. 1-8
Author(s):  
Ya-Dong Wang ◽  
Yu-Xiang Ming ◽  
Yong-Hua Pang ◽  
Wei-Nan Chen ◽  
Xu-Hua Zong ◽  
...  
Keyword(s):  
Range Of Motion ◽  
External Rotation ◽  
Meta Analysis ◽  
Eligibility Criteria ◽  
Shoulder Stiffness ◽  
Capsular Release ◽  
Shoulder Range Of Motion ◽  
Arthroscopic Capsular Release ◽  
Shoulder Range

BACKGROUND: Persisting shoulder stiffness adversely affects quality of life by causing pain and motion restrictions especially in patients with diabetes. OBJECTIVE: The aim of this study was to evaluate the outcomes of arthroscopic capsular release in patients with idiopathic shoulder stiffness. METHOD: A literature search was conducted in electronic databases and studies were selected by following precise eligibility criteria. Random-effects meta-analyses were performed to estimate the changes at latest follow-up in scores of the Constant, American Shoulder and Elbow Surgeons (ASES), and University of California at Los Angelis (UCLA) scales, Visual Analogue Scale (VAS), and shoulder range of motion. RESULTS: Nineteen studies were included. The follow-up duration was 42 months [95% confidence interval (CI): 32, 51]. Improvements in scores of the Constant, ASES, UCLA scales, and VAS were 48.3 [95% CI: 38.0, 58.6], 44.6 [95% CI: 24.6, 64.6], 19.3 [95% CI: 16.6, 22.0], and -6.1 [95% CI: -6.9, -5.4] respectively (P< 0.05 all). Improvements in the shoulder range of motion were: abduction 82.0 [95% CI: 65.0, 98.9]; forward flexion 75.9 [95% CI: 59.7, 92.1]; external rotation 43.2 [95% CI: 37.5, 49.0]; and internal rotation 25.4 [95% CI: 15.2, 35.5] degrees; P< 0.05 all). CONCLUSION: Arthroscopic capsular release effectively improves shoulder function in patients with idiopathic shoulder stiffness.

scholarly journals Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation

2014 ◽  
Vol 96 (1) ◽  
pp. 55-60 ◽  
Author(s):  
CD Smith ◽  
P Hamer ◽  
TD Bunker
Keyword(s):  
Pain Relief ◽  
Range Of Motion ◽  
Frozen Shoulder ◽  
Stage Ii ◽  
Capsular Release ◽  
Oxford Shoulder Score ◽  
Arthroscopic Capsular Release ◽  
Good Pain Relief ◽  
The Mean ◽  
Shoulder Score

INTRODUCTION The aim of this prospective study was to assess the immediate and long-term effectiveness of arthroscopic capsular release in a large cohort of patients with a precise and isolated diagnosis of stage II idiopathic frozen shoulder. METHODS All patients underwent a preoperative evaluation. Patients with secondary frozen shoulder and those with concurrent pathology at arthroscopy were excluded. This left 136 patients with a stage II arthroscopically confirmed idiopathic frozen shoulder. At each postoperative attendance, a record was made of pain, function and range of motion. At 12 months, the Oxford shoulder score was calculated, and pain and range of motion were assessed. RESULTS Fifty per cent achieved good pain relief within a week and eighty per cent within six weeks of arthroscopic capsular release. The mean preoperative visual analogue scale pain score was 6.6 and the mean postoperative score was 1.0. The mean time to achieving good pain relief was 16 days following surgery. No patient could sleep through the night prior to surgery while 90% reported having a complete night’s sleep at a mean of 12 days after surgery. The mean postoperative Oxford shoulder score was 38/48 and the mean improvement was 19.2. CONCLUSIONS This large series demonstrates that arthroscopic capsular release is a safe procedure, with rapid improvement in pain and a marked improvement in range of motion.

scholarly journals Restriction of Passive Glenohumeral Abduction Combined With Normal Passive External Rotation Is a Diagnostic Feature of Calcific Tendinitis

2018 ◽  
Vol 6 (2) ◽  
pp. 232596711775290 ◽  
Author(s):  
Anna Jungwirth-Weinberger ◽  
Christian Gerber ◽  
Glenn Boyce ◽  
Thorsten Jentzsch ◽  
Simon Roner ◽  
...  
Keyword(s):  
Range Of Motion ◽  
External Rotation ◽  
Adhesive Capsulitis ◽  
Salient Feature ◽  
Supraspinatus Tendon ◽  
Calcific Tendinitis ◽  
Diagnostic Feature ◽  
Inclusion Criteria ◽  
Level Of Evidence ◽  
Standardized Protocol

Background: Passive glenohumeral range of motion may be characteristically limited to specific shoulder pathologies. While pain associated with loss of range of passive external glenohumeral rotation is recognized as a salient feature in adhesive capsulitis, restriction of glenohumeral range of motion in calcific tendinitis of the supraspinatus tendon has never been studied. Hypothesis: On the basis of clinical observation, we hypothesized that calcific tendinitis of the supraspinatus tendon is associated with loss of passive glenohumeral abduction without loss of external rotation. Study Design: Cohort study; Level of evidence, 3. Methods: Ranges of passive glenohumeral rotation and abduction, which are measured with a standardized protocol in our institution, were retrospectively reviewed and compared for patients diagnosed with either adhesive capsulitis or calcific tendinitis of the supraspinatus tendon. A total of 57 patients met the inclusion criteria for the calcific tendinitis, and 77 met the inclusion criteria for the adhesive capsulitis group. Results: When compared with the contralateral, unaffected shoulder, glenohumeral abduction in the calcific tendinitis group was restricted by a median of 10° (interquartile range [IQR], –20° to –5°) as opposed to glenohumeral external rotation, which was not restricted at all (median, 0°; IQR, 0° to 0°). The adhesive capsulitis group showed a median restriction of glenohumeral abduction of 40° (IQR, –50° to –30°) and a median restriction of passive glenohumeral external rotation of 40° (IQR, –60° to –30°). Conclusion: Calcific tendinitis of the supraspinatus does not typically cause loss of external rotation but is frequently associated with mild isolated restriction of abduction. This finding can be used to clinically differentiate adhesive capsulitis from calcific tendinitis.

scholarly journals Current Concepts in the Treatment of adhesive capsulitis of the Shoulder

2019 ◽  
Vol 6 (03) ◽  
pp. 4354-4357
Author(s):  
Luciano Andrés Rossi ◽  
Maximiliano Ranalletta
Keyword(s):  
Corticosteroid Injection ◽  
Adhesive Capsulitis ◽  
Postoperative Rehabilitation ◽  
Duration Of Symptoms ◽  
Capsular Release ◽  
Daily Life Activities ◽  
Nonsurgical Management ◽  
Arthroscopic Capsular Release ◽  
History Of ◽  
High Level

Adhesive capsulitis is characterized by chronic inflammation of the capsular subsynovial layer, which produces capsular fibrosis, contracture, and adherence of the capsule to itself and to the anatomic neck of the humerus. Physical therapy is the mainstay of treatment, regardless of stage. Based on the natural history of the disease, early corticosteroid injection has a role in shortening the overall duration of symptoms allowing patients to move faster in the stages of rehabilitation and thus return to their daily life activities more rapidly. Most patients will see complete resolution of symptoms with nonsurgical management. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. There is a lack of high level studies comparing different techniques for capsular release. Both circumferential and limited release have proven to be effective. Regarding postoperative rehabilitation, arthroscopic release should be followed by early, diligent, and directed therapy to prevent recurrent stiffness.

scholarly journals The Effect of Straight-Line Long-Toss Versus Ultra-Long-Toss Throwing on Passive Glenohumeral Range of Motion Recovery After Pitching

2021 ◽  
pp. 194173812098001
Author(s):  
T. David Luo ◽  
Aaron D. Sciascia ◽  
Austin V. Stone ◽  
Chukwuweike U. Gwam ◽  
Christopher A. Grimes ◽  
...  
Keyword(s):  
Range Of Motion ◽  
Internal Rotation ◽  
National Collegiate Athletic Association ◽  
External Rotation ◽  
Level Of Evidence ◽  
Left Hand ◽  
Right Hand ◽  
Straight Line ◽  
Significant Difference ◽  
Baseball Pitchers

Background: Repetitive throwing in baseball pitchers can lead to pathologic changes in shoulder anatomy, range of motion (notably glenohumeral internal rotation deficit), and subsequent injury; however, the ideal strengthening, recovery, and maintenance protocol of the throwing shoulder in baseball remains unclear. Two strategies for throwing shoulder recovery from pitching are straight-line long-toss (SLT) throwing and ultra-long-toss (ULT) throwing, although neither is preferentially supported by empirical data. Hypothesis: ULT will be more effective in returning baseline internal rotation as compared with SLT in collegiate pitchers after a pitching session. Study Design: Cohort study. Level of Evidence: Level 3. Methods: A total of 24 National Collegiate Athletic Association Division I baseball pitchers with mean age 20.0 ± 1.1 years were randomized to either the ULT group (n = 13; 9 right-hand dominant, 4 left-hand dominant) or SLT group (n = 11; 10 right-hand dominant, 1 left-hand dominant). Measurements (dominant and nondominant, 90° abducted external rotation [ER], internal rotation [IR], and total range of motion [TROM]) were taken at 5 time points across 3 days: before and immediately after a standardized bullpen session on day 1; before and immediately after a randomized standardized ULT or SLT session on day 2; and before practice on Day 3. Results: ULT demonstrated significantly greater final ER compared with baseline (+10°; P = 0.05), but did not demonstrate significant IR changes. Similarly, SLT demonstrated significantly greater post-SLT ER (+12°; P = 0.02) and TROM (+12°; P = 0.01) compared with baseline, but no significant IR changes. Final ER measurements were similar between ULT (135° ± 14°) and SLT (138° ± 10°) ( P = 0.59). There was also no statistically significant difference in final IR between ULT (51° ± 14°) and SLT (56° ± 8°) ( P = 0.27). Conclusion: The routine use of postperformance, ULT throwing to recover from range of motion alterations, specifically IR loss, after a pitching session is not superior to standard, SLT throwing. Based on these findings, the choice of postpitching recovery throwing could be player specific based on experience and comfort. Clinical Relevance: The most effective throwing regimens for enhancing performance and reducing residual impairment are unclear, and ideal recovery and maintenance protocols are frequently debated with little supporting data. Two strategies for throwing shoulder recovery from pitching are SLT and ULT throwing. These are employed to help maintain range of motion and limit IR loss in pitchers. The routine use of ULT throwing for recovery and to limit range of motion alterations after a pitching session is not superior to SLT throwing.

scholarly journals A comparative study on the effectiveness of Mulligan mobilization versus Positional release therapy technique in patients with Adhesive capsulitis

2021 ◽  
Vol 12 (1) ◽  
pp. 1-5
Author(s):  
Chandrasekaran K ◽  
Sundaram M S ◽  
Senthil Selvam P ◽  
Viswanath Reddy A ◽  
Senthilkumar S ◽  
...  
Keyword(s):  
Range Of Motion ◽  
Internal Rotation ◽  
Functional Activity ◽  
External Rotation ◽  
Adhesive Capsulitis ◽  
Shoulder Range Of Motion ◽  
Release Technique ◽  
Group A ◽  
Group B ◽  
Shoulder Range

Adhesive capsulitis is a painful condition in which the movement of the shoulder becomes limited and functional activity is affected. Adhesive capsulitis occurs when the shoulder joint capsule become thick, stiff and inflamed. The aim of the study is to compare the effectiveness of Mulligan movement with mobilization versus Positional release technique on shoulder range of motion and functional activity in patients with adhesive capsulitis. 30 patients were randomly divided into two groups. Group A (N = 15) received Mulligan mobilization technique and Group B (N = 15) received positional release therapy. The shoulder range of motion (Abduction, External rotation, Internal rotation) was measured by goniometer, the functional activity by SPADI questionnaire. The results showed that significant differences in shoulder ROM Abduction (t = 14.18, p = 0.000), Internal rotation (t = 13.80, p = 0.000), External rotation (t = 15.87, p = 0.000) and SPADI questionnaire (t = 13.94, p = 0.000) were observed in group A patients when compared to group B. In conclusion the Mulligan mobilization technique was effective to improve the shoulder ROM and reduce functional disability in patients with adhesive capsulitis compared to Positional release technique.

scholarly journals L-Shaped Arthroscopic Posterior Capsular Release in Frozen Shoulder

2021 ◽  
Vol 1 (2) ◽  
pp. 263502542110000
Author(s):  
Mohamed Gamal Morsy ◽  
Ahmed Hassan Waly ◽  
Mostafa Ashraf Galal ◽  
El Hussein Mohamed Ayman ◽  
Hisham Mohamed Gawish
Keyword(s):  
Radiofrequency Ablation ◽  
Range Of Motion ◽  
Internal Rotation ◽  
Frozen Shoulder ◽  
Axillary Nerve ◽  
Posterior Capsule ◽  
Loss Of Function ◽  
Shoulder Stiffness ◽  
Capsular Release ◽  
Infraspinatus Muscle

Background: The inadequate arthroscopic release of the tight posterior capsule in frozen shoulder may result in limited postoperative shoulder internal rotation. Indication: The purpose of this article is to describe an L-shaped arthroscopic posterior capsular release to overcome the limited internal rotation that may be encountered following the standard longitudinal technique. Operative intervention is indicated in patients with refractory shoulder stiffness with limitation of internal rotation of grade 0, +2, +4 (according to the Constant-Murley Score), after failure of conservative measures for 3 to 6 months. The technique is contraindicated if less than 3 months of physical therapy, shoulder stiffness due to osseous deformity, infection, or cuff tear arthropathy. Technique: After performing a standard anterior capsular release, the scope is shifted to the anterior portal to perform posterior capsular release by introducing the radiofrequency ablation device through the posterior portal. Posterior release begins from the glenoid level down to the 6 o’clock position until the back fibers of the infraspinatus muscle appear. Then the hook-tip part of the radiofrequency ablation device is used to perform a transverse release in the posterior capsule, starting from the beginning of the longitudinal limb. The transverse limb is performed in a stepwise manner going step-by-step laterally but ending before reaching the rotator cuff to avoid any damage of the cuff. After that, the shoulder was manipulated according to Codman technique. Results: A comparative study was performed on 43 patients with primary frozen shoulder to compare the standard longitudinal (22 patients) and L-shaped (21 patients) posterior capsular release. At the final follow-up, there was a statistically significant improvement in the internal rotation range of motion in the L-shaped group ( P < .001). There was no loss of function over time. Moreover, there were no infections, instability, or axillary nerve injury in either group. Discussion/Conclusion: Restriction of internal rotation in frozen shoulder has been attributed to posterior capsular tightness. The L-shaped arthroscopic posterior capsular release in patients with primary frozen shoulder significantly improves the postoperative internal rotation range of motion.

scholarly journals Evaluation of the inter and intraobserver reproducibility of the GRASP method: a goniometric method to measure the isolated glenohumeral range of motion in the shoulder joint

2021 ◽  
Vol 8 (1) ◽  
Author(s):  
Miguel Angel Ruiz Ibán ◽  
Susana Alonso Güemes ◽  
Raquel Ruiz Díaz ◽  
Cristina Victoria Asenjo Gismero ◽  
Alejandro Lorente Gomez ◽  
...  
Keyword(s):  
Range Of Motion ◽  
Internal Rotation ◽  
Glenohumeral Joint ◽  
External Rotation ◽  
Intraclass Correlation ◽  
Correlation Coefficients ◽  
Outpatient Setting ◽  
Interobserver Reproducibility ◽  
Level Of Evidence ◽  
Intraclass Correlation Coefficients

Abstract Purpose To evaluate the intra and interobserver reproducibility of a new goniometric method for evaluating the isolated passive range of motion of the glenohumeral joint in an outpatient setting. Methods This is a prospective observational study on healthy subjects. The Glenohumeral ROM Assessment with Scapular Pinch (GRASP) method is a new method for assessing the isolated range of motion (ROM) of the glenohumeral joint (GH) by a single examiner with a clinical goniometer. It measures the isolated glenohumeral passive abduction (GH-AB), passive external rotation (GH-ER) and internal rotation (GH-IR) with the arm at 45º of abduction. These three GH ROM parameters were measured in both shoulders of 30 healthy volunteers (15 males/15 females, mean age:41.6[SD = 10.3] years). The full shoulder passive abduction, passive external rotation and internal rotation 45º of abduction were measured by the same examiners with a goniometer for comparison. One examiner made two evaluations and a second examiner made a third one. The primary outcome was the intra- and interobserver reproducibility of the measurements assessed with intraclass correlation coefficients (ICC) and the Bland–Altman plot. Results The intra-observer ICC for isolated glenohumeral ROM were: 0.84 ± 0.07 for GH-ABD, 0.63 ± 0.09 for GH-ER, and 0.61 ± 0.14 for GH-IR. The inter-observer ICC for isolated glenohumeral ROM were: 0.86 ± 0.06 for GH-ABD, 0.68 ± 0.12 for GH-ER, and 0.62 ± 0.14 for GH-IR. These results were similar to those obtained for full shoulder ROM assessment with a goniometer. Conclusion The GRASP method is reproducible for quick assessment of isolated glenohumeral ROM. Level of evidence III

scholarly journals MID-LONG TERM RESULTS OF MANIPULATION AND ARTHROSCOPIC RELEASE IN FROZEN SHOULDER

2017 ◽  
Vol 25 (6) ◽  
pp. 270-274 ◽  
Author(s):  
HALUK CELIK ◽  
MUSTAFA FAIK SECKIN ◽  
MEHMET AKIF AKCAL ◽  
ADNAN KARA ◽  
BEKIR ERAY KILINC ◽  
...  
Keyword(s):  
Conservative Treatment ◽  
External Rotation ◽  
Frozen Shoulder ◽  
Case Series ◽  
Long Term Results ◽  
Treatment Level ◽  
Capsular Release ◽  
Arthroscopic Release ◽  
Arthroscopic Capsular Release

ABSTRACT Objective: Surgical treatment options should be discussed in cases of frozen shoulder, which is usually treated in a conservative manner. In this study, we evaluated the efficacy of manipulation and arthroscopic release in cases of frozen shoulder which resisted conservative treatment. Methods: A total of 32 patients who underwent manipulation and arthroscopic capsular release in 34 shoulders were included in the study. The average follow-up period was 49.5 months (range: 24-90 months). No reason for onset could be found in 8 (25%) patients, who were classified as primary frozen shoulder; twenty-four (75%) patients were classified as secondary frozen shoulder due to underlying pathologies. The average pre-operative complaint period was 11 months (range: 3-24 months). After arthroscopic examination, manipulation was performed first, followed by arthroscopic capsular release. The range of motion in both shoulders was compared before the procedure and in the last follow-up visit. Constant and Oxford classifications were used to assess functional results, and the results were assessed statistically. Results: Patient values for passive elevation, abduction, adduction-external rotation, abduction-external rotation, and abduction-internal rotation increased in a statistically significant manner between the preoperative assessment and follow-up evaluation (p<0.01). The average change of 47.97±21.03 units observed in the patients’ values obtained in the control measurements against the pre-op Constant scores was determined to be statistically significant (p<0.01). According to the Oxford classification, 29 shoulders were sufficient. Conclusion: Successful results can be obtained with arthroscopic release performed after manipulation in patients with frozen shoulder resistant to conservative treatment. Level of Evidence IV, Case Series.

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