Comparison of intra-articular and subacromial corticosteroid injection in frozen shoulder: A meta-analysis of randomized controlled trials

Is platelet-rich plasma a new solution for shoulder adhesive capsulitis? A systematic scoping review of the literature

Background

Platelet-rich plasma (PRP) has shown promising results for adhesive shoulder capsulitis (AC) in pre-clinical models. The aim of this review is to investigate the clinical outcomes of using PRP in AC.

Materials and Methods

We conducted a systematic scoping review of the literature using bibliographic databases from inception until the 9th of January 2022 [PubMed, Web of Science, Scopus, and CENTRAL]. Randomized studies were included if they investigated the use of PRP in human patients with a diagnosis of AC. Authors performed individual study quality assessments using the RoB 2 tool.

Results

We screened a total of 470 results and 6 were included in the final synthesis. Studies included data of 578 patients with 263 patients receiving PRP (45.5%). All studies used PRP as part of non-operative treatment. PRP was compared to another intervention in all six studies. Four of these studies found PRP to be more effective. No major adverse effects were reported in any study.

Conclusion

PRP is a safe treatment option that can be added to the investigative treatment arsenal of AC. Despite showing some favorable results, several limitations and patient-centered questions remain to be addressed by future studies.

Level of Evidence

IV.

Bone and Joint-on-Chip Platforms: Construction Strategies and Applications

Organ-on-a-chip, also known as "tissue chip," is an advanced platform based on microfluidic systems for constructing miniature organ models in vitro. They can replicate the complex physiological and pathological responses of human organs. In recent years, the development of bone and joint-on-chip platforms aims to simulate the complex physiological and pathological processes occurring in human bones and joints, including cell-cell interactions, the interplay of various biochemical factors, the effects of mechanical stimuli, and the intricate connections between multiple organs. In the future, bone and joint-on-chip platforms will integrate the advantages of multiple disciplines, bringing more possibilities for exploring disease mechanisms, drug screening, and personalized medicine. This review explores the construction and application of Organ-on-a-chip technology in bone and joint disease research, proposes a modular construction concept, and discusses the new opportunities and future challenges in the construction and application of bone and joint-on-chip platforms.

Rotator Interval vs Posterior Approach Ultrasound-guided Corticosteroid Injections in Primary Frozen Shoulder: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS).

DATA SOURCES

A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted.

STUDY SELECTION

Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS.

DATA EXTRACTION

The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD).

DATA SYNTHESIS

A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks.

CONCLUSION

The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.

Corticosteroid Injection Methods for Frozen Shoulder: A Network Meta-analysis

OBJECTIVE

To investigate the efficacy of corticosteroid (CS) injection methods for frozen shoulder.

DATA SOURCES

PubMed, Embase, and Cochrane Library were searched up to May 6, 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) that investigated CS injection methods for frozen shoulder were included.

DATA EXTRACTION

Data were extracted independently by 2 authors. Risk of bias was assessed using the RoB 2 tool.

DATA SYNTHESIS

A random-effects network meta-analysis was performed within a frequentist framework. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. A total of 66 RCTs involving 4491 patients were included. For short-term outcomes, 4-site injection (vs placebo [PLA]: standardized mean difference [SMD]=-2.20, 95% confidence interval [CI], -2.81 to -1.59 in pain; SMD=2.02; 95% CI, 1.39-2.65 in global function) was the most effective (low certainty). Rotator interval injection was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.07, 95% CI, -1.51 to -0.64 in pain; SMD=0.94, 95% CI, 0.49-1.40 in global function). For midterm outcomes, 4-site injection was most effective (vs PLA: SMD=-1.71, 95% CI, -2.41 to -1.01 in pain; SMD=2.22, 95% CI, 1.34-3.09 in global function; low certainty). Distension via rotator interval (D-RI) was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.10, 95% CI, -1.69 to -0.51 in pain; SMD=1.46, 95% CI, 0.73-2.20 in global function). Distension and intra-articular injection via anterior or posterior approaches produced effects equivalent to those of rotator interval injection and D-RI.

CONCLUSIONS

Rotator interval injection, distension, and intra-articular injection had equivalent effects on symptom relief. More RCTs are required to validate the superiority of multisite injections.

Nitrous oxide provided during intensive physiotherapy for shoulder adhesive capsulitis does not improve function: A randomised controlled trial

BACKGROUND

There is no consensus on treatment for adhesive capsulitis of the shoulder. Physiotherapy is often used to increase range of motion but individuals may experience pain during mobilisation.

OBJECTIVES

The objective of this study was to determine whether rehabilitation under N2O for shoulder AC improved pain and function more than rehabilitation alone (with placebo gas).

METHOD

A randomised, 1:1 parallel arm, double-blind study in 4 university hospital outpatient centres. Adults with adhesive capsulitis for at least 3 months with intact cartilage were included. Participants were randomised in blocks of 4 and stratified by centre to receive 20 sessions of intensive physiotherapy over 10 days; the 10 morning sessions were performed with either nitrous oxide (intervention) or sham gas (placebo).

PRIMARY OUTCOME

improvement in shoulder function at day 14 (D14) (Constant-Murley score).

RESULTS

Seventy-five participants were included, and data from 69 were analysed: 37 in the placebo group and 32 in the intervention group. Improvements occurred in both groups after the intervention. No significant difference in the Constant-Murley score was found between groups at D14 (median score increase of 12.0, IQR 5.6; 19.5 points in placebo group vs. 13.7, 5.2; 18.2 in the N20 group, p = 0.78). Pain score during sessions reduced in the intervention group from the first to final session (-11.6, p = 0.053) but not for the placebo group (-4.2, p = 0.414). Seven serious adverse events were recorded, 4 in the intervention group and 3 in the placebo group, with 11 minor adverse events only in the intervention group (mostly shortness of breath).

CONCLUSION

Nitrous oxide gas associated with intensive physiotherapy for shoulder adhesive capsulitis did not improve function, pain or quality of life more than physiotherapy alone. zHowever, pain experienced during physiotherapy sessions appeared lower.

TRIAL REGISTRATION

Clinical Trial registration number NCT01087229.

Similar outcomes between arthroscopic capsular release and manipulation under anaesthesia for frozen shoulder: A meta-analysis

To compared the arthroscopic capsular release (ACR) with manipulation under anaesthesia (MUA) for the surgical treatment of frozen shoulder (FS) based on postoperative outcomes and complications. PubMed, Cochrane Library, Embase, and Web of Science were searched on October 2, 2023 to retrieve eligible studies that compared ACR with MUA in terms of clinical outcomes (pain visual analogue scale, external rotation, forward flexion and adverse events) for patients with FS. Mean differences (MD) were calculated for continuous outcomes and odds ratios (OR) were calculated for dichotomous outcomes. Six papers, including 5 clinical studies (a total of 690 shoulders), were included in the final meta-analysis. The forward flexion was found to be larger in the ACR group at 3 months (MD, 2.73; 95%CI, 0.42-5.04; I2 = 44%; P = 0.02) and 6 months (MD, 2.36; 95%CI, 1.29-3.44; I2 = 0%; P < 0.0001). Except for this, ACR was comparable with MUA in terms of pain visual analogue scale at 3, 6 and 12 months (p = 0.25, p = 0.11, p = 0.28, respectively), external rotation at 3, 6 and 12 months (p = 0.15, p = 0.52, p = 0.23, respectively), and forward flexion at 12 months (p = 0.08). There were no differences in complication rates between the two groups (OR, 0.82; 95%CI, 0.47-1.44; I2 = 0%; P = 0.50). In comparison with MUA, ACR demonstrated better outcomes for forward flexion at 3 and 6 months, while there were no significant differences between ACR and MUA in terms of pain visual analogue scale, external rotation and adverse events.

Combined arthroscopic release with corticosteroid hydrodilatation versus corticosteroid hydrodilatation only in treating freezing-phase primary frozen shoulder: a randomized clinical trial

BACKGROUND

There has been no ideal treatment for freezing-phase frozen shoulder to rapidly relieve pain and improve joint mobility. No any other team directly compared the effectiveness of combination of arthroscopic release and corticosteroid hydrodilatation with corticosteroid hydrodilatation only in treatment of freezing-phase frozen shoulder.

METHODS

Seventy-two patients with freezing-phase frozen shoulder were randomly assigned to combined arthroscopic release with corticosteroid hydrodilatation (group A) or corticosteroid hydrodilatation only (group B). Clinical states were examined at baseline and periodically (Weeks 1, 4, 12, 24 and 1 year) after intervention by passive ROM; visual analog scale (VAS); UCLA and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

RESULTS

The passive ROM, VAS, UCLA and DASH scores always improved along the time points (all p < 0.01). The passive abduction (pAB), passive forward flexion (pFL), passive external rotation (pER), passive internal rotation (pIR) were better in group A than in group B at Week 1, 4, 12, 24 (all p < 0.01). At 1 year post-operation, the pFL and pIR were better in group A than in group B (all p < 0.01). VAS scores of group A were similar with those of group B (all p > 0.01), the differences between group A and group B were all lower than minimal clinically important difference (MCID). At Week 12, the UCLA sores and DASH scores were 26.8 ± 3.8, 14.2 ± 2.0 in group A versus 22.3 ± 3.4, 22.5 ± 3.1 in group B (all p < 0.01). At Week 24 post-operation, there were 32.7 ± 2.0, 9.8 ± 1.5 in group A versus 26.3 ± 3.6, 17.5 ± 3.5 in group B (all p < 0.01). At 1 year post-operation, there were 34.5 ± 0.8, 1.7 ± 1.5 in group A versus 32.1 ± 2.3, 8.8 ± 2.8 in group B (all p < 0.01), the differences of UCLA scores between group A and group B at Week 24 was higher than the MCID. There were no complications such as infection, nerve or vascular injury.

CONCLUSIONS

Combined arthroscopic release with corticosteroid hydrodilatation would yield better results in passive ROM and function than corticosteroid hydrodilatation only.

TRIAL REGISTRATION

ChiCTR1900024235, July 2, 2019 (Retrospectively registered).

Ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of frozen shoulder

BACKGROUND

Frozen shoulder (FS), also known as shoulder adhesive capsulitis, is a musculoskeletal disorder associated with pain and functional disability. There is a lack of evidence on the optimal treatment strategy for FS.

OBJECTIVE

The present study aimed to evaluate the effectiveness and safety of ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of FS.

METHODS

In this prospective randomized, double-blind, controlled study, 63 FS patients were recruited, and equally allocated to treatment group and control group. The treatment group was treated with ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy, while the control group was only treated with ultrasound-guided hydrodilatation of glenohumeral joint. The pain and mobility of shoulder, overall efficacy and adverse reactions were evaluated 3 months after treatment.

RESULTS

At baseline, no significant difference in all characteristic value was found between the treatment group (n= 33) and control group (n= 30). Three months after operation, the joint's Active Range of Motion (AROM) and Constant-Murley Scale (CMS) scores in the experimental group were higher than those in the control group, and the coracohumeral ligament (CHL) thickness and the rate of hypoechoic thickening in rotator cuff space in the experimental group were lower than those in the control group (all P< 0.05). The amount of injection volume at the third hydrodilatation was significantly higher in the experimental group than that in the control group (15.8 ± 4.7 vs 12.2 ± 5.2, P= 0.03). After 2 times of treatment, the volume increment of glenohumeral joint Δ2 in the experimental group was greater than that in the control group (3.5 ± 1.8 vs 1.2 ± 1.6, P< 0.001). There were significant differences in the effective rate between the two groups (93.94% vs. 76.67%, P= 0.04).

CONCLUSION

The ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy may benefit FS patients.

Single-Site Corticosteroid Injection Is as Effective as Multisite Corticosteroid Injection in the Nonsurgical Treatment of Frozen Shoulder: A Systematic Review With Meta-Analysis of Randomized Controlled Trials

Purpose

To determine whether multisite corticosteroid injection is more effective than a single injection in the nonsurgical treatment of frozen shoulder (FS) via a meta-analysis of randomized controlled trials

Methods

We identified studies that evaluated the efficacy of multisite corticosteroid injections compared with single-site injection for FS. The Embase, PubMed, and Cochrane Library databases were systematically searched from inception to June 5, 2022. Methodologic quality and risk of bias were assessed using the Modified Coleman Methodology Score and the Cochrane Collaboration risk of bias tool, respectively. Visual analog scale scores, abduction, flexion, internal rotation, external rotation, American Shoulder and Elbow Surgeons Assessment Form scores, Constant–Murley Shoulder scores, and complications were extracted. The meta-analysis was conducted with random effects, and 4 time intervals were analyzed: 3 to 4 weeks, 6 to 8 weeks, 12 to 16 weeks, and 24 to 26 weeks

Results

The initial search identified 260 studies, and 5 randomized controlled trials that met the inclusion criteria were included. There were no significant differences in visual analog scale scores at 3 to 4 weeks, 6 to 8 weeks, 12 to 16 weeks, or 24 to 26 weeks. There were no significant differences in flexion or external rotation at 3 to 4 weeks, 6 to 8 weeks, 12 to 16 weeks, or 24 to 26 weeks. Multisite injection performed better in terms of abduction (mean difference –15.66 [–30.03, –1.28], P = .03) and American Shoulder and Elbow Surgeons Assessment Form score (mean difference –10.13 [–19.54, –0.72] P = .03) than single-site injection at 3 to 4 weeks. There were significant differences in internal rotation in favor of the multisite treatment at 3 to 4 weeks, 6 to 8 weeks, 12 to 16 weeks, and 24 to 26 weeks. In addition, there were no significant differences in complications.

Conclusions

Single-site steroid injection is as effective as multisite corticosteroid injection for the nonoperative treatment of FS.

Level of Evidence

Level II, meta-analysis of Level I and II studies.

An overview of effective and potential new conservative interventions in patients with frozen shoulder

Frozen shoulder (FS) is a pathology that is difficult to understand and difficult to manage. Over the last ten years, contradictory and new evidence is provided regarding the recovery and its natural course. This narrative review provides new information about the diagnosis and conservative treatment of patients with FS and ongoing research hypotheses that might provide new insights in the pathology and treatment options. FS has a characteristic course. People with Diabetes Mellitus and thyroid disorders have a higher risk of developing a FS. The diagnosis FS is based on pattern recognition and physical examination. Additionally, 'rule-in' and 'rule-out' criteria can be used to increase the likelihood of the frozen shoulder diagnosis. Recommended and most common physical therapy interventions are mobilization techniques and exercises, in which tissue irritability can guide its intensity. In addition, physical therapy is often complementary with patient education and pharmacotherapy. The latest evidence-based practice related to FS is proprioceptive neuromuscular facilitation and mirror therapy. In addition, interventions like pain neuroscience education, high-intensity interval training and lifestyle changes are still hypothetical. Finally, better insight in the involvement of biochemical processes, function of myofibroblasts and matrix metalloproteinases can provide better understanding in the pathophysiology and will be addressed in current review.

Hydrodilatation with corticosteroids is the most effective conservative management for frozen shoulder

PURPOSE

The purpose of this overview is to summarise the findings of meta-analyses of randomised controlled trials that compare conservative treatment options for frozen shoulder.

METHODS

The authors conducted an electronic literature search for meta-analyses published using PubMed, Web of Science and the Cochrane Library. Two researchers independently applied selection criteria and assessed quality of meta-analyses using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). Short-, medium- and long-term outcomes were synthesised narratively.

RESULTS

A total of 319 studies were identified, of which 8 meta-analyses were eligible for inclusion. All included meta-analyses were judged to be low or critically low quality according to AMSTAR-2, however, their data synthesis and interpretation was considered valid. Physiotherapy, intra-articular and subacromial corticosteroid injection (CSI), and arthrographic distension/hydrodilatation with corticosteroid were reported with sufficient evidence. Intra-articular CSI and arthrographic distension/hydrodilatation with corticosteroid provide advantages over placebo in short-term pain relief, range of motion (ROM) and shoulder function, with improvements in ROM continuing into the medium and long term. Arthrographic distension/hydrodilatation with corticosteroid provides medium-term and long-term improvements in ROM over intra-articular CSI and physiotherapy. Proprioceptive neuromuscular facilitation provides advantages over conventional physiotherapy for pain improvement and external rotation in the short term.

CONCLUSIONS

Arthrographic distension/hydrodilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to CSI or physiotherapy.

LEVEL OF EVIDENCE

Level IV.

Treatment effect and mechanism of Fu's subcutaneous needling among patients with shoulder pain: A retrospective pilot study

Fu's subcutaneous needling (FSN) is a new acupuncture therapy developed from acupuncture and Traditional Chinese Medicine models. The aim of this study was to investigate the effect of FSN on shoulder pain. In this retrospective comparative study, patient case files with shoulder pain (Group A) treated with FSN were analyzed and compared with the same number of patients with shoulder pain (Group B) treated with conventional acupuncture and physical therapy. Motion-related pain (MRP), pain under pressure (PUP), and Range of motion (ROM) were collected before and after intervention. In the 68 patients, there were 39 males and 29 females, aged 21-53 years old (mean ± SD = 36.4 ± 8.15) with onset time ranging from 1 day to 7 days (mean ± SD = 3.15 ± 1.73). MRP, PUP, and ROM scores were improved after FSN intervention (p < .05). There were significant differences between group A and group B in MRP, PUP, and ROM scores after FSN intervention and 1 week follow-up (p < .05). No adverse events, such as fainting and sharp pain, occurred during the treatment process. FSN can be an effective rehabilitation intervention for improving shoulder pain and shoulder range of motion.

Effect and safety of Huangqi-Guizhi-Wuwu Decoction and Erxian Decoction in the treatment of frozen shoulder: A protocol for systematic review and meta-analysis

BACKGROUND

The purpose of this study is to evaluate the effect and safety of Huangqi-Guizhi-Wuwu Decoction (HGWD) and Erxian Decoction (EXD) in the treatment of frozen shoulder (FS).

METHODS

We will compressively search potential randomized controlled trials from electronic databases of MEDLINE, EMBASE, Cochrane Library, CINAHL, PsycINFO, Web of Science, Allied and Complementary Medicine Database, Google Scholar, and China National Knowledge Infrastructure. We will search all of them from inception of each electronic database up to the present without language limitations. Two researchers will conduct selection of study, data extraction, and study quality evaluation independently. Study quality will be identified using Cochrane risk of bias tool. Statistical analysis will be performed using RevMan 5.3 software.

RESULTS

This study will summarize high quality evidence of randomized controlled trials on exploring the effect and safety of HGWD and EXD in the treatment of FS.

CONCLUSIONS

The results of this study will provide helpful evidence of the effect and safety of HGWD and EXD in the treatment of FS to facilitate the clinical practice and guideline development.

STUDY REGISTRATION NUMBER

INPLASY202040070.