Comparison of Functional Outcome Between Intra-Articular Injection of Corticosteroid Versus Platelet-Rich Plasma in Frozen Shoulder: A Randomized Controlled Trial

Comparative efficacy of platelet rich plasma, hyaluronic acid, and corticosteroid injections in adhesive capsulitis management: A meta-analysis

OBJECTIVE

To compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) against corticosteroid injections in adult patients with adhesive capsulitis (AC), in impacting pain relief and range of motion (ROM).

LITERATURE SURVEY

A systematic review was conducted between January and February 2024 through PubMed and Google Scholar using the following keywords: "PRP," "Hyaluronic Acid," "Bone Marrow Aspirate," "Frozen Shoulder," "Periarthritis," "Adhesive Capsulitis," and "Corticosteroid Injections." Inclusion criteria were studies published between January 2019 and February 2024 and used corticosteroids as a comparison for orthobiologic treatment. The initial search yielded 47 studies, refined to 21 after applying eligibility criteria. Ultimately, six studies were selected.

METHODOLOGY

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, a Cochrane Risk of Bias analysis was performed, and data were independently extracted by multiple authors. A meta-analysis was conducted to compare the efficacy of PRP and HA against corticosteroids measured by visual analog scale (VAS), Shoulder Pain and Disability Index (SPADI), Disabilities of the Arm, Shoulder, and Hand (DASH), and UCLA Shoulder scores.

SYNTHESIS

Qualitatively, studies with 3 months or longer patient follow-ups demonstrated better long-term efficacy in pain reduction and ROM improvement with PRP or HA injections. A 6-month improvement in pain as measured by VAS had a significant standardized mean difference (SMD) of -1.31 (95% confidence interval [CI], -1.56 to 1.04). There were significant improvements in functional outcomes at 6 months in DASH (SMD of -1.23 [95% CI, -1.71 to -0.74]) and UCLA Shoulder scores (SMD of 0.74 [95% CI, 0.47-1.00]): No significant differences were observed in 3-month outcomes: DASH (SMD of -0.12 [95% CI, -0.54 to 0.30]) and SPADI scores (SMD of -0.34 [95% CI, -0.78 to 0.10]). Cochrane analysis identified one study with high risk of bias.

CONCLUSIONS

The review highlights orthobiologics as a promising alternative to corticosteroid injections in managing AC, with PRP providing more long-term pain relief compared to corticosteroid injections. Improvements in shoulder ROM were also seen but require further studies to determine their significance. However, substantial heterogeneity (I2 > 50) was observed, underscoring the need for future research to standardize methodologies and improve consistency.

Pharmacological interventions for early-stage frozen shoulder: a systematic review and network meta-analysis

OBJECTIVES

To evaluate the efficacy of pharmacological interventions for treating early-stage, pain predominant, adhesive capsulitis, also known as frozen shoulder.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Searches were conducted on MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials on 24 February 2022. Outcomes were shoulder pain, shoulder function and range of movement. Synthesis involved both qualitative analysis for all studies and pairwise meta-analyses followed by a network meta-analysis for randomized controlled trials (RCTs).

RESULTS

A total of 3252 articles were found, of which 31 met inclusion criteria, and 22 of these were RCTs. IA injection of CS (8 RCTs, 340 participants) and IA injection of platelet-rich plasma (PRP) (3 RCTs, 177 participants) showed benefit at 12 weeks compared with physical therapy in terms of shoulder pain and function, while oral NSAIDs (2 RCTs, 44 participants) and IA injection of hyaluronate (2 RCTs, 42 participants) did not show a benefit. Only IA PRP showed benefit over physical therapy for shoulder range of movement.

CONCLUSION

These results shows that IA CS and IA PRP injections are beneficial for early-stage frozen shoulder. These findings should be appraised with care considering the risk of bias, heterogeneity and inconsistency of the included studies. We believe that research focused on early interventions for frozen shoulder could improve patient outcomes and lead to cost-savings derived from avoiding long-term disability. Further well-designed studies comparing with standardized physical therapy or placebo are required to improve evidence to guide management.

Rat shoulder contracture models: Techniques, evaluation, pathophysiology, and applications in developing treatment interventions

Studies on the pathophysiology of shoulder contracture and development of interventions have greatly benefited from the use of animal models. This narrative review comprehensively analyzes research on established rat model of shoulder contracture and new treatment approaches. This review evaluated existing literature on the available techniques for inducing contracture models, assessed these models, conducted pathological analyses, and explored their application in developing new treatment interventions. Our review highlights the usefulness of different rat shoulder contracture models, including external immobilization, internal immobilization, and intra-articular injection models, each with varying levels of success. Pathological analyses have demonstrated similarities to the human condition. The effective models have been instrumental in developing new treatment interventions, including recombinant human relaxin-2, platelet-rich plasma, collagenase clostridium histolyticum, and peroxisome proliferator-activated receptor-γ agonists. Therefore, rat shoulder contracture models serve as valuable tools for researchers to establish an effective animal model foundation for investigating the etiology and potential treatment.

The clinical efficacy and safety of platelet-rich plasma on frozen shoulder: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically review the clinical efficacy (pain, function, quality of life) and safety of platelet-rich plasma (PRP) in the treatment of frozen shoulder through meta-analysis, and provide evidence-based medical evidence for the effectiveness of PRP in the treatment of frozen shoulder.

METHODS

A search was conducted on international databases (Pubmed, Web of science, Embase) and Chinese databases (CNKI, Wanfang, VIP) to search the clinical studies on the efficacy of platelet-rich plasma in treating frozen shoulder (adhesive capsulitis/periarthritis/50 shoulder) and their corresponding references published from inception until January 2024. Thoroughly excluded literature not meeting the predetermined inclusion criteria, extracted relevant data from the literature, and input it into RevMan5.4 for meta-analysis.

RESULTS

This study ultimately included 14 RCTs, with a total of 1024 patients. The results showed that PRP has significant advantages compared with control groups in VAS (mean difference (MD) =-0.38, 95% confidence interval(CI)(-0.73, -0.03), P = 0.03), UCLA (MD = 3.31, 95% CI (1.02,5.60),P = 0.005), DASH (MD = -4.94,95% CI (-9.34, -0.53),P = 0.03), SPADI (SPADI Total: MD =-16.87, 95% CI (-22.84, -10.91), P < 0.00001; SPADI Pain: MD =-5.38, 95% CI (-7.80, -2.97), P < 0.0001; SPADI Disability: MD =-11.00, 95% CI (-13.61,-8.39), P < 0.00001), and the active and passive Range of Motion (active flexion: MD = 12.70, 95% CI (7.44, 17.95), P < 0.00001; passive flexion: MD = 9.47, 95% CI(3.80, 15.14), P = 0.001; active extension: MD = 3.45, 95% CI(2.39, 4.50), P < 0.00001; active abduction: MD = 13.54, 95% CI(8.42, 18.67), P < 0.00001; passive abduction: MD = 14.26, 95% CI (5.97, 22.56), P = 0.0008; active internal rotation: MD = 5.16, 95% CI (1.84, 8.48), P = 0.002; passive internal rotation: MD = 3.65, 95% CI(1.15, 6.15), P = 0.004; active external rotation: MD = 10.50, 95% CI(5.47, 15.53), P < 0.0001; passive external rotation: MD = 6.00, 95% CI (1.82, 10.19), P = 0.005) except passive extension (MD = 2.25, 95% CI (-0.77, 5.28), P = 0.14). In terms of safety, most studies reported no adverse effects, and only one study reported common complications of joint puncture such as swelling and pain after treatment in both PRP and control groups. Previous studies have shown a risk of osteonecrosis caused by corticosteroids. Therefore, the safety of PRP treatment is more reliable.

CONCLUSION

The results showed that PRP was more durable and safer than corticosteroids and other control groups in the treatment of frozen shoulder.

STUDY DESIGN

Systematic review.

TRIAL REGISTRATION

PROSPERO CRD42022359444, date of registration: 22-09-2022.

Outcomes of platelet rich plasma injections in the adhesive capsulitis of the shoulder

Background

Platelet rich plasma (PRP) injections have been utilized in an attempt to provide improved pain and functional outcomes to patients with a variety of orthopaedic ailments. Adhesive capsulitis, also known as frozen shoulder is a common debilitating condition that carries significant morbidity due to the painful and prolonged course. Various studies have investigated intra-articular PRP administration with different methodologies and outcomes.

Hypothesis/purpose

We sought to perform a meta-analysis on outcomes of adhesive capsulitis after PRP injection, determine effectiveness compared to corticosteroid, and compare adverse events.

Study design

Meta analysis.

Methods

EMBASE, EBSCO, Pubmed and Google Scholar were used to extract titles and abstracts using keywords "adhesive capsulitis", "frozen shoulder", "PRP", "platelet rich plasma". 41 articles were found and after duplicates removed and full-text review, 7 studies investigating 385 patients undergoing PRP or corticosteroid injections were found. Age, gender, body mass index (BMI), and ASA scores were obtained. Patient reported outcomes (PROs) were obtained and all reported range of motion (ROM) were recorded and compared after PRP and steroid injections using random effects meta-regression pre-injection and post-injection.

Results

Both intra-articular PRP and steroid injections resulted in improved outcomes for treatment of adhesive capsulitis at 3 months. PRP injections had significantly better range of motion in passive forward flexion (151° vs 144.1°, p = 0.024) and had improved Shoulder Pain and Disability Index (SPADI) scores (14.6° vs 18.6°, p = 0.009) compared to steroid, however these may not reach minimum clinical thresholds. PRP had significantly better active (60° vs 43. 5°, p = 0.038) and passive internal rotation (69.6° vs 52.7°, p = 0.017) compared to steroid which did reach minimum clinical thresholds. There were no differences detected between VAS pain, active forward flexion, extension, abduction, external rotation nor difference in adverse events.

Discussion

Both injections decreased pain and improved range of motion in patients. Intra-articular PRP injections may result in improved internal rotation compared to corticosteroid. Improvement in SPADI and passive forward flexion may be statistically significantly but may not be clinically relevant.

Level of evidence

3, Therapeutic.

The efficacy of platelet-rich plasma injections compared to corticosteroids and physiotherapy in adhesive capsulitis: A systematic review and meta-analysis

Introduction

Adhesive Capsulitis is a common condition of the shoulder with significant morbidity and protracted disease. It is usually characterized by sudden onset with progressive symptoms of pain and loss of function. This systematic review compares platelet rich plasma (PRP) intra-articular injections with corticosteroids (CS) injections and physiotherapy.

Material and methods

A literature search was performed using online databases (Pubmed, Cochrane, EMBASE, Medline and CINAHL) including all the studies performed on humans through April 2023. Prospective comparative studies were included in this review of patients with adhesive capsulitis assessing the use of PRP injections versus corticosteroid injections or physiotherapy. The standardized mean difference (SMD) with 95 % confidence interval in VAS/DASH/SPADI and ROM scores was calculated using a random effects model, comparing PRP to corticosteroids injections and physiotherapy across studies.

Results

A total of 11 studies and 971 patients, with a mean age of 52.1, were included in this analysis with 7 being randomised trials and four cohort studies. The control group was corticosteroid injections in 8 studies and physiotherapy in the other three studies. Overall PRP lead to a statistically significant improved outcome at 3 and 6 months follow up for all outcome parameters. The outcome measures at three months includes VAS 0.73 (0.31, 1.16) SMD, DASH 0.66 (0.36, 0.96) SMD, SPADI 1.50 (0.43, 2.57) SMD, ER 1.47 (0.27, 2.66) SMD and Abduction 1.10 (0.21, 1.98) SMD. Six months assessment similarly favoured PRP with VAS 3.17 (1.26, 5.08) SMD and DASH 2.10 (1.66, 2.55) SMD scores. Furthermore, a subgroup analysis demonstrated that PRP was favourable to corticosteroids as control with significant improvement in pain (VAS) at 3 months 0.65 (0.29, 1.00) and 6 months 3.17 (1.26, 5.08) SMD.

Conclusion

This review demonstrated that intra-articular PRP injections for adhesive capsulitis produces favourable outcomes when compared to corticosteroid injections and physiotherapy. PRP produces improved pain and functional scores as well as range of motion, which is statistically significant from 3 to 6 months post intervention. PRP seems to be a safe and effective alternative non-invasive treatment modality for patients with adhesive capsulitis.

Platelet-Rich Plasma for Adhesive Capsulitis: A Systematic Review

Adhesive capsulitis (AC) is a common cause of shoulder pain seen in 3%-5% of the population. Platelet-rich plasma (PRP) is platelet-rich blood with pro-inflammatory and anti-inflammatory properties that has been proposed as a treatment option for patients with AC. The purpose of this study was to analyze outcomes of range of motion (ROM) and subjective outcomes, including the visual analog scale (VAS), disability of arm, shoulder, and hand (DASH), and shoulder pain and disability index (SPADI) scores. PubMed, Embase, and Cochrane databases were searched, and manuscripts were screened using defined preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria. Two reviewers independently screened articles for inclusion/exclusion using PICOS criteria and extracted data regarding ROM and subjective outcome scores. Nineteen total articles were included. Eleven of the 19 studies recorded ROM as a dependent variable. All articles reported improved ROM with PRP injection when compared to baseline. When recording degrees of shoulder ROM in different planes at the latest follow-up, there were a total of 67 comparative data points for PRP vs. control. Of the 67 comparisons, 62 (93%) had a larger final ROM in the PRP group. VAS scores were reported in 16 of the 19 studies, DASH scores were reported in eight of the 19 articles, and SPADI scores were reported in seven of the 19 articles. VAS, DASH, and SPADI scores were all superior in the PRP group compared to the control. Two studies reported the same final VAS score, but the PRP groups had a larger overall improvement. Of the studies that reported objective ROM outcomes, the PRP group had greater ROM at the longest follow-up compared to control in the vast majority of comparisons. For the studies that reported subjective outcomes, all patients that received PRP had a decrease in VAS pain scores and an improvement in DASH and SPADI questionnaires.

A Comparison of the Treatment Outcomes With and Without the Use of Intra-articular Corticosteroids for Frozen Shoulder Manipulation

Background Manipulation under anesthesia is known to be an effective treatment method for a frozen shoulder. However, this process is painful and causes difficulty in early physiotherapy. Intra-articular corticosteroids may relieve pain after manipulation. This study compared patients who underwent manipulation under anesthesia with those who only underwent physiotherapy and those who received intra-articular corticosteroid administration and physiotherapy. Methodology A total of 33 patients presenting with frozen shoulders were included in this study. Those who underwent manipulation after anesthesia were determined as group 1 (16 patients) and those who received intra-articular corticosteroids in addition to manipulation under anesthesia were determined as group 2 (17 patients). Pain was evaluated using the Visual Analog Scale (VAS) scores. Functional outcomes were assessed using the University of California-Los Angeles (UCLA) scores and shoulder range of motion (ROM). Results VAS and UCLA scores of both groups were similar at 12 weeks and six months. ROM improved significantly after manipulation in both group 1 and group 2 (p < 0.05). There was no significant difference between the ROM in the two groups after manipulation and physiotherapy. Only the external rotation ROM value was better in group 2 (p = 0.032) Conclusions Physiotherapy after manipulation is a successful treatment method for frozen shoulder patients. It reduces pain in the early period compared to patients who are not administered intra-articular corticosteroids. However, it has no functional superiority.

The use of platelet-rich plasma in management of musculoskeletal pain: a narrative review

Musculoskeletal pain is the most common pain reported by patients. Platelet-rich plasma (PRP) is widely used to treat musculoskeletal pain. However, the efficacy of PRP to treat this pain remains controversial. This review highlights the application of PRP in the treatment of musculoskeletal pain. PRP treatment appears to reduce pain and improve function in patients with musculoskeletal pain. However, there are limitations to the currently published studies. These limitations include the PRP preparation methods, type of activators, types of pathology to be treated, methods and times of administration, and association of PRP with other treatments.

Safety and Efficacy of Embolization with Microspheres in Chronic Refractory Inflammatory Shoulder Pain: A Pilot Monocentric Study on 15 Patients

Purpose: Musculoskeletal (MSK) embolization is emerging in tendinopathy treatment. The objective of this study was to assess the efficacy and safety of MSK embolization with microspheres in the treatment of chronic shoulder pain. Patients and methods: This retrospective monocentric study included patients with chronic shoulder pain resistant to 6 months or more of conventional therapies who were treated with MSK embolization between 2017 and 2021. Embolization was performed using calibrated 100–250 µm microspheres. Clinical success was defined as pain reduction, i.e., a decrease in the visual analogue scale (VAS) pain score of ≥50% at 3 months after MSK embolization as compared to baseline. Adverse events were collected. Results: Fifteen patients (11 women, 4 men) were included, with a median age of 50.3 years (IQR: 46.7–54.5). The median duration of symptoms was 26.6 months (20.6–39.8). The median VAS pain scores were 7.0 (7.0–8.0) at baseline, 6.0 (3.5–7.0) at 1 month, 5.0 (4.5–6.5) and 5.0 (3.0–7.4) at 3 months and 6 months (p = 0.002). Three patients (20%) reported clinical success at 3 months. Three patients experienced minor complications after embolization (paresthesia, n = 2; transient osteo-medullary edema, n = 1) and two patients had moderate complications (transient skin ischemia). Conclusion: MSK embolization with microspheres for treatment of refractory chronic shoulder pain showed moderate results in terms of clinical success and safety.