The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy. 2010;96:95-107. [PMID: 20420956 DOI: 10.1016/j.physio.2009.09.003]

Provider opinions on effectiveness of physical therapy as treatment for glenohumeral arthritis

BACKGROUND

Physical therapy (PT) is a described first-line treatment option for glenohumeral arthritis, but its efficacy for treating this spectrum of disease is not well understood. The purpose of this study is to evaluate the opinions of expert providers-orthopedic surgeons and physical therapists-regarding the utility of PT in treating glenohumeral arthritis in different stages of radiographic severity. Our goal is to identify areas of interprofessional majority agreement as well as areas without agreement that warrant further investigation.

METHODS

A 35-question survey was created and distributed via email to members of the American Shoulder and Elbow Surgeons and the American Society of Shoulder and Elbow Therapists, collecting information on demographics, professional experience, and the perceived benefit of PT for patients with different stages of glenohumeral arthritis based on radiographic severity. Survey responses were analyzed for inter-professional differences in distribution of answer choices as well as for majority agreement statements. Items with >50% agreement from a professional group were considered statements of majority agreement.

RESULTS

One hundred and ninety surgeons and 39 physical therapists completed the survey. Surgeons and therapists demonstrated different distribution of answer choices in 25 of the 29 nondemographic related questions (86%). Surgeons and therapists reached the same majority statement in 8 items (28%) and reached disagreeing majority statements in 4 items (14%). They agreed on the benefits of PT for mild arthritis, the benefits of corticosteroid injections, the frequency of strengthening exercises, and that PT failure should not be required for surgical approval in patients with severe arthritis. They disagreed on the whether PT exacerbates symptoms in patients with moderate arthritis, and whether preoperative PT influences postoperative outcomes.

CONCLUSION

Both surgeons and therapists agreed that PT may be less beneficial for patients with more advanced radiographic arthritis and that PT failure should not be required for insurance approval for surgical intervention in patients with severe glenohumeral arthritis. Further research is needed to determine the efficacy of PT for patients with moderate arthritis as well as the utility of preoperative PT for improving postoperative outcomes.

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.

Efficacy of Platelet-Rich Plasma Injection on Range of Motion, Pain, and Disability in Patients With Adhesive Capsulitis: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the therapeutic effects of platelet-rich plasma (PRP) injection on range of motion, pain, and disability in patients with adhesive capsulitis (AC).

DATA SOURCES

The authors performed the literature search in the PubMed, Embase, and Cochrane Library databases in February 2023.

STUDY SELECTION

Prospective studies comparing the outcomes of PRP with other intervention in patients with AC.

DATA EXTRACTION

The quality of included randomized trials was assessed using the revised Cochrane Risk of Bias (RoB 2.0) tool. The Risk of Bias in Non-Randomized Studies of Interventions tool was applied to assess the quality of nonrandomized trials. The mean difference (MD) or standardized mean difference (SMD) was determined as the effect size for continuous outcomes, and outcome accuracy was determined using 95% confidence intervals (CIs).

DATA SYNTHESIS

Fourteen studies involving 1139 patients were included. Our meta-analysis revealed that PRP injection can significantly improve passive abduction (MD=3.91; 95% CI, 0.84-6.98), passive flexion (MD=3.90; 95% CI, 0.15-7.84), and disability (SMD=-0.50; 95% CI, -1.29 to -0.74) within 1 month after intervention. Moreover, PRP injection can significantly improve passive abduction (MD=17.19; 95% CI, 12.38-22.01), passive flexion (MD=17.74; 95% CI, 9.89-25.59), passive external rotation (MD=12.95; 95% CI, 10.04-15.87), pain (MD=-8.40; 95% CI, -16.73 to -0.06), and disability (SMD=-1.02; 95% CI, -1.29 to -0.74) 3 months after intervention. PRP injection can also significantly improve pain (MD=-18.98; 95% CI, -24.71 to -13.26), and disability (SMD=-2.01; 95% CI, -3.02 to -1.00) 6 months after intervention. In addition, no adverse effects of PRP injection were reported.

CONCLUSIONS

PRP injection may serve as an effective and safe treatment for patients with AC.

Allogenic Platelet-Rich Plasma for the Treatment of Adhesive Capsulitis

Adhesive capsulitis (AC) is a common shoulder disorder leading to pain and restricted range of motion (ROM) and affects the patient's activities of daily living (ADL) and overall quality of life (QoL). Conservative therapies are prioritized, resorting to surgical intervention only when necessary. Unfortunately, these modalities have limitations and do not address the underlying pathological cause of AC. The use of autologous biologics, such as platelet-rich plasma (PRP), has evolved and shown promise for managing musculoskeletal (MSK) injuries, including AC. However, subpar functional outcomes have led clinicians to question the long-term efficacy of autologous PRP. To circumvent this, the possibility of utilizing a standardized and well-characterized allogenic PRP for AC has been explored. In this manuscript, we qualitatively present in vitro, pre-clinical, clinical, and ongoing studies investigating the varied applications of allogenic PRP for the management of AC. The results demonstrated that allogenic PRP acts in a pleiotropic manner and decreases pro-inflammatory cytokines only in the inflammatory condition. In addition, the administration of allogenic PRP is safe and potentially efficacious, in terms of reducing pain and improving range of motion, shoulder strength, and function, in non-surgical management of AC. Nonetheless, more pre-clinical studies and adequately powered, multicenter, prospective, non-randomized, and randomized controlled trials with longer follow-up are warranted to further establish the safety and efficacy of allogenic PRP and justify its routine clinical use.

What are small, medium and large effect sizes for exercise treatments of tendinopathy? A systematic review and meta-analysis

Objective

To quantify and describe effect size distributions from exercise therapies across a range of tendinopathies and outcome domains to inform future research and clinical practice through conducting a systematic review with meta-analysis.

Design

Systematic review with meta-analysis exploring moderating effects and context-specific small, medium and large thresholds.

Eligibility criteria

Randomised and quasi-randomised controlled trials involving any persons with a diagnosis of rotator cuff, lateral elbow, patellar, Achilles or gluteal tendinopathy of any severity or duration.

Methods

Common databases, six trial registries and six grey literature databases were searched on 18 January 2021 (PROSPERO: CRD42020168187). Standardised mean difference (SMD_pre) effect sizes were used with Bayesian hierarchical meta-analysis models to calculate the 0.25 (small), 0.5 (medium) and 0.75 quantiles (large) and compare pooled means across potential moderators. Risk of bias was assessed with Cochrane's Risk of Bias tool.

Results

Data were obtained from 114 studies comprising 171 treatment arms 4104 participants. SMD_pre effect sizes were similar across tendinopathies but varied across outcome domains. Greater threshold values were obtained for self-reported measures of pain (small=0.5, medium=0.9 and large=1.4), disability (small=0.6, medium=1.0 and large=1.5) and function (small=0.6, medium=1.1 and large=1.8) and lower threshold values obtained for quality of life (small=-0.2, medium=0.3 and large=0.7) and objective measures of physical function (small=0.2, medium=0.4 and large=0.7). Potential moderating effects of assessment duration, exercise supervision and symptom duration were also identified, with greater pooled mean effect sizes estimated for longer assessment durations, supervised therapies and studies comprising patients with shorter symptom durations.

Conclusion

The effect size of exercise on tendinopathy is dependent on the type of outcome measure assessed. Threshold values presented here can be used to guide interpretation and assist with further research better establishing minimal important change.

Platelet-Rich Plasma Injections Are at Least Equivalent to Corticosteroid Injections for Adhesive Capsulitis: A Systematic Review of Prospective Cohort Studies

PURPOSE

To evaluate the role of platelet-rich plasma (PRP) for adhesive capsulitis (AC) as compared with other injectables.

METHODS

A literature search of the PubMed and Embase online databases was performed to identify articles evaluating injection therapy for the treatment of AC. The inclusion criteria included prospective studies comparing PRP against alternative injectables with a minimum of 15 patients in each treatment arm and a minimum 12-week follow-up period. Pain scores, range of motion, and function scores were the primary outcomes assessed.

RESULTS

Five articles comparing PRP with corticosteroid or saline solution injections met the inclusion criteria. A total of 157 patients were treated with PRP, with a follow-up duration ranging from 3 to 6 months. All 5 studies showed statistically significant improvements in pain scores, motion, and function scores in patients receiving PRP, corticosteroid, and saline solution injections. However, PRP was consistently superior on intergroup analyses in all but 1 study. In 4 studies, pain and function scores favored PRP over control at final follow-up (range in mean difference, -2.2 to 0.69 for visual analog scale pain score [n = 5] and -50.5 to -4.0 for Shoulder Pain and Disability Index score [n = 3]), whereas 3 studies found greater improvement in shoulder motion after PRP (range in mean difference, 0.7° to 34.3° for forward flexion and -2.3° to 20.4° for external rotation [n = 4]). One study found no significant difference between PRP and corticosteroid injections but noted that the results were comparable.

CONCLUSIONS

According to a limited number of prospective studies, PRP injections for AC are at least equivalent to corticosteroid or saline solution injections and often lead to improved pain, motion, and functional outcomes at 3- to 6-month follow-up. Given the small number of studies, with design heterogeneity, there is insufficient evidence to routinely recommend PRP for AC. However, the results are promising and do support considering PRP as an adjunct treatment option for AC, especially for patients refractory and/or averse to corticosteroids or alternative treatment modalities.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Adhesive Capsulitis of the Hip: A Case Presentation and Review

There remains a paucity of literature addressing adhesive capsulitis of the hip (ACH), making the diagnosis and treatment a continued challenge for healthcare providers. ACH encompasses restricted hip range-of-motion and pain that progresses through analogous Stages (1-4) to adhesive capsulitis of the shoulder. We report a case presentation of a middle-aged man that illustrates the significance of certain patient factors and provide a review of current literature to aid in the diagnostic evaluation and treatment for addressing ACH. Initial conservative treatment of ACH includes the appropriate management of associated comorbidities, oral and/or injectable pharmacologics, and physical therapy. While frequently resolving with time, refractory cases of ACH may require more aggressive approaches including pressure dilation, manipulation under anesthesia, synovectomy, capsular release and, for select patients, total hip arthroplasty. Given the limited available literature addressing ACH, healthcare providers may be forced to rely on a small number of published case reports and outdated review articles to guide their diagnostic evaluation and treatment approaches. Thus, this case presentation and review provides an updated approach to better diagnose and manage patients with ACH.

Comparison of the Efficacy of Platelet-Rich Plasma (PRP) and Local Corticosteroid Injection in Periarthritis Shoulder: A Prospective, Randomized, Open, Blinded End-Point (PROBE) Study

Background

Periarthritis or frozen shoulder, also called adhesive capsulitis, is characterized by stiffness and pain along with gradual loss of active and passive movement in the glenohumeral joint. More than 2-5% of the population suffers from periarthritis with a higher incidence in the age group of 40-60 years. The various treatment modalities used for its management include simple physiotherapy, short-wave therapy, ultrasonic therapy, transcutaneous electrical nerve stimulation, hydrotherapy, analgesics, intra-articular injections, manipulation under general anesthesia (MUA), and surgical management. The application of intra-articular steroid injection has been a common and efficacious option in rapidly diminishing shoulder pain and disability. Some recent studies reported a better outcome using platelet-rich plasma (PRP) injections in frozen shoulder cases. Hence, this randomized controlled trial was conducted to compare the efficacy of intra-articular injections of PRP and triamcinolone in patients of shoulder periarthritis in a population from the eastern region of India

Methodology

A total of 60 patients with periarthritis shoulder were allocated into two groups after randomization. Group A received 2 mL autologous PRP, and Group B received 2 mL of triamcinolone (40 mg/mL) intra-articular injection. Patients were followed up on the 4th week, 12th week, and 24th week. The assessment of pain and function using the visual analog scale (VAS) score and the Disabilities of Arm, Shoulder, and Hand (DASH) score, respectively, was done at each follow-up. The primary analyses of both primary and secondary outcomes were conducted in the intention-to-treat (ITT) population. SPSS version 24 (IBM Corp., Armonk, NY, USA) was used for data analysis.

Results

The mean VAS score in the PRP and triamcinolone groups was 14.33 ± 3.79 and 31.63 ± 7.62, respectively (p = 0.0001) after 24 weeks. The mean DASH score in the PRP and triamcinolone groups was 18.08 ± 8.08 and 31.76 ± 3.63, respectively (p = 0.0001), which shows significant improvement in both pain and disability scores in the PRP group after 24 weeks.

Conclusions

The triamcinolone group showed better short-term outcomes whereas PRP showed better long-term outcomes in reducing pain and disability scores in terms of VAS and DASH scores.

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.

Non-Surgical and Rehabilitative Interventions in Patients with Frozen Shoulder: Umbrella Review of Systematic Reviews

Background

Frozen shoulder (FS) is a painful condition characterized by progressive loss of shoulder function with passive and active range of motion reduction. To date, there is still no consensus regarding its rehabilitative treatment for pain management.

Purpose

The aim of this umbrella review of systematic reviews was to analyze the literature, investigating the effects of non-surgical and rehabilitative interventions in patients suffering from FS.

Patients and Methods

A review of the scientific literature was carried out from 2010 until April 2020 using the following search databases: PubMed, Medline, PEDro, Scopus and Cochrane Library of Systematic Reviews. A combination of terms was used for the search: frozen shoulder OR adhesive capsulitis AND systematic review OR meta-analysis AND rehabilitation NOT surgery NOT surgical intervention. We included systematic reviews that specifically dealt with adults with FS, treated with non-surgical approaches. All the systematic reviews and meta-analyses included in the study that met the inclusion criteria were assessed using the Assessment of Multiple Systematic Reviews as a quality assessment tool.

Results

Out of 49 studies, only 14 systematic reviews respected the eligibility criteria and were included in this study. Their results showed an important heterogeneity of the studies and all of them agree on the lack of high-quality scientific work to prove unequivocally which rehabilitative treatment is better than the other. Due to this lack of gold standard criteria, there may be also a heterogeneity in the diagnosis of the reviews analyzed.

Conclusion

Non-surgical and rehabilitative interventions are undoubtedly effective in treating FS, but there is no evidence that one approach is more effective than the other regarding the methods reported. Future high-quality RCTs are needed to standardize the treatment modalities of each physiotherapy intervention to provide strong recommendations in favor.

The benefit of platelet-rich plasma injection over institution-based physical therapy program in adhesive capsulitis patients with diabetes mellitus: prospective observational cohort study

Background

The objective of this study was to compare the efficacy of platelet-rich plasma (PRP) injection with an institution-based physical therapy (PT) program for adhesive capsulitis (AC) of the shoulder in patients with diabetes mellitus (DM).

Methods

A total of seventy diabetic patients with AC of the shoulder for <6 months were assigned to two groups: PRP group and PT group. In the PRP group, 35 patients were administered a single shot of PRP (4 mL) into the glenohumeral joint. In the PT group, 35 patients were given institution-based PT that included 10 30-minute sessions of planned PT over a 2-week period. After the interventions, all patients were prospectively followed for 12 weeks. Intensity of shoulder pain, function, and range of motion were assessed at baseline and then at 3, 6, and 12 weeks.

Results

Thirty-three patients in the PRP group and 32 in the PT group completed the 12-week study. At 12 weeks, patients who received PRP injections showed greater improvement in shoulder pain (p<0.001) than those recruited to the PT group. In the range of motion and shoulder function activities, patients in the PRP group showed significant improvement compared with the institution-based PT group (p<0.001). No significant complications were reported from any groups.

Conclusions

In a diabetic population, PRP injections significantly improved shoulder pain and function compared with an institution-based PT program for shoulder AC. Additionally, it is a safe and well-tolerated method for AC management for diabetic patients.

Comparative analysis of intra-articular injection of steroid and/or sodium hyaluronate in adhesive capsulitis: prospective, double-blind, randomized, placebo-controlled study

Background

Few studies have reported the effects of simultaneous injections of corticosteroid (CS) and hyaluronic acid (HA) on adhesive capsulitis (AC) of the shoulder. This study investigated the synergistic effects of simultaneous intra-articular injections of CS and compared them to those of CS or HA alone.

Method

Sixty patients with AC were enrolled in this randomized, placebo-controlled trial. The participants were divided into 4 groups: saline, CS, HA, and CS with HA groups. The primary outcome measure was changes in the Shoulder Pain and Disability Index (SPADI) scores at one month. The secondary outcome measures included changes in pain, range of motion, muscle strength, and additional shoulder functional scores at 1 day, 1 week, and 1, 3, and 6 months after injection.

Results

After 1 month, changes of the SPADI scores were significantly higher in the CS with HA group (−58.4%) than those in the saline (−7.7%) and HA (−14.4%) groups. The score changed more in the CS with HA group than that in the CS group (−43.7%), but there was no significant difference. In the changes in pain, the CS with HA group showed significantly better and faster effects than the saline and HA groups. In the changes of range of motion, functional scores, the CS with HA group showed better results than the saline and HA groups.

Conclusion

In the treatment of AC, the simultaneous injection of CS and HA was more effective in improving SPADI scores at one month after injection than a single injection of CS or HA.

Effectiveness of interventions for the management of primary frozen shoulder : a systematic review of randomized trials

AIMS

This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI.

METHODS

MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder.

RESULTS

Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero.

CONCLUSION

The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773-784.

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.

Allogenic Pure Platelet-Rich Plasma Therapy for Adhesive Capsulitis: A Bed-to-Bench Study With Propensity Score Matching Using a Corticosteroid Control Group

BACKGROUND

While platelet-rich plasma (PRP) has been widely studied for musculoskeletal disorders, few studies to date have reported its use for adhesive capsulitis (AC). Fully characterized and standardized allogenic PRP may provide clues to solve the underlying mechanism of PRP with respect to synovial inflammation and thus may clarify its clinical indications.

PURPOSE

To clinically evaluate the safety and efficacy of a fully characterized pure PRP injection in patients with AC and to assess the effects of pure PRP on synoviocytes with or without inflammation in vitro.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 3.

METHODS

For the clinical analysis, a total of 15 patients with AC received an ultrasonography-guided intra-articular PRP injection and were observed for 6 months. Pain, range of motion (ROM), muscle strength, shoulder function, and overall satisfaction in the patients were evaluated using questionnaires at 1 week as well as at 1, 3, and 6 months after the PRP injection and results were compared with the results of a propensity score-matched control group that received a corticosteroid injection (40 mg triamcinolone acetonide). For the in vitro analysis, synoviocytes were cultured with or without interleukin-1β (IL-1β) and PRP. The gene expression of proinflammatory and anti-inflammatory cytokines as well as matrix enzymes and their inhibitors was evaluated.

RESULTS

At 6-month follow-up, pure PRP significantly decreased pain and improved ROM, muscle strength, and shoulder function to levels comparable with those after a corticosteroid injection. All pain values, strength measurements, and functional scores significantly improved up to 6 months in the PRP group, but these measures improved up to 3 months and then were decreased at 6 months in the corticosteroid group. ROM was significantly improved in the 2 groups at 6 months compared with baseline. Allogenic PRP did not cause adverse events. For the in vitro findings, PRP induced inflammation but significantly improved the IL 1β-induced synovial inflammatory condition by decreasing proinflammatory cytokines such as IL-1β, tumor necrosis factor-α, IL-6, cyclooxygenase-2, and microsomal prostaglandin E synthase-1 and decreased matrix enzymes (matrix metalloproteinase-1, -3, and -13 as well as a disintegrin and metalloproteinase with thrombospondin motifs-4 and -5) and further increasing anti-inflammatory cytokines such as vasoactive intestinal peptide.

CONCLUSION

This study showed that PRP decreased pain and improved shoulder ROM and function to an extent comparable with that of a corticosteroid in patients with AC. Allogenic pure PRP acted in a pleiotropic manner and decreased proinflammatory cytokines only in the inflammatory condition.

CLINICAL RELEVANCE

Allogenic PRP could be a treatment option for the inflammatory stage of AC.

Comparative Efficacy and Patient-Specific Moderating Factors of Nonsurgical Treatment Strategies for Frozen Shoulder: An Updated Systematic Review and Network Meta-analysis

BACKGROUND

Frozen shoulder is a common shoulder disorder characterized by pain and restriction. Various nonsurgical treatments have been reported, but there is no consensus about their comparative efficacy and the effects of moderators.

PURPOSE

To compare the efficacy of different nonsurgical interventions and identify potential patient-specific moderating factors for frozen shoulder.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception to February 18, 2019. The search was supplemented by manual review of relevant reference lists. Randomized controlled trials of participants with frozen shoulder that compared nonsurgical interventions were selected. Measured outcomes included pain, shoulder function in daily activities, and range of motion.

RESULTS

Of 3136 records identified, 92 trials were eligible, evaluating 32 nonsurgical interventions in 5946 patients. Intra-articular injection improved pain (pooled standardized mean difference [95% CI]: steroid injection, 1.68 [1.03-2.34]; capsular distension, 2.68 [1.32-4.05]) and shoulder function (steroid injection, 2.16 [1.52-2.81]; distension, 2.89 [1.71-4.06]) to a greater extent than placebo. Capsular distension and extracorporeal shockwave therapy showed the highest ranking for pain relief and functional improvement, respectively. Laser therapy also showed benefits for pain relief (3.02 [1.84-4.20]) and functional improvement (3.66 [1.65-5.67]). Subgroup analyses by disease stages revealed that steroid injection combined with physical therapy provided more benefits during the freezing phase, whereas joint manipulation provided more benefits in the adhesive phase. Adjunctive therapies, female sex, and diabetes were also identified as moderators of effectiveness.

CONCLUSION

Capsular distension is a highly recommended choice for treatment of frozen shoulder, contributing greatly to pain relief and functional improvement; steroid injection is also a prevailing effective intervention. Among new options, extracorporeal shockwave therapy and laser therapy show potential benefits for multiple outcomes. Individualized optimal intervention should be considered, given that treatment effect is moderated by factors including the disease stage, time of assessment, adjunctive therapies, female sex, and diabetes.

Effectiveness of interactive augmented reality-based telerehabilitation in patients with adhesive capsulitis: protocol for a multi-center randomized controlled trial

Background

As the primary treatment for adhesive capsulitis, intensive and accurate home exercise is as important as physical therapy in hospitals. Augmented reality (AR)-based telerehabilitation has been implemented recently in various musculoskeletal conditions to increase patient compliance and enable patients to exercise with the correct posture. The objective of this study is to present a protocol for investigating the additive effect of interactive AR-based telerehabilitation in comparison with the usual care for patients with adhesive capsulitis.

Methods

This study presents the protocol of a prospective, multi-center, single-blinded, two-armed randomized controlled trial (RCT). One hundred patients with stage I or II adhesive capsulitis will be recruited at the physical medicine and rehabilitation clinic. Patients will be randomly divided into two groups with 1:1 allocation. The intervention group will receive 3 months of hospital-based physical therapy in conjunction with home-based telerehabilitation. The control group will receive 3 months of hospital-based physical therapy in conjunction with a home-based exercise described in a brochure provided by the hospital. The primary outcome will be the change in passive range of motion (ROM) of the affected shoulder joint from baseline to 12 weeks after baseline assessment. The secondary outcomes will be active ROM, pain measured with the numeric rating scale, shoulder pain and disability index, 36-Item Short Form Survey, EuroQoL-5D-5L, and Canadian Occupational Performance Measure.

Discussion

This will be the first RCT study protocol to investigate the effect of telerehabilitation in patients with adhesive capsulitis. The result of this RCT will determine whether AR-based telerehabilitation is more effective than a brochure-based home exercise program and will provide evidence of the usefulness of “telerehabilitation” using hardware (IoT) and software (monitoring platform) technologies to develop “digital therapeutics” for the future.

Trial registration

This trial was retrospectively registered at the Clinicaltrials.gov website on 20 March 2020, with the identifier NCT04316130.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04261-1.

Ultrasonographic evaluation of chronic shoulder pain after breast cancer surgery: single center, cross-sectional study

Chronic shoulder pain is a common complication in breast cancer patients after surgery. Chronic shoulder pain after breast cancer surgery was formerly considered as neuropathic pain, however the pathophysiology including structural damages has not been assessed comprehensively. We hypothesized that the structural change could be one of the cause of shoulder pain after breast cancer surgery and evaluated various ultrasonography findings of the shoulder in breast cancer patients with chronic shoulder pain. Patients who were suffering from chronic shoulder pain on unilateral side for at least 3 months after breast cancer surgery were enrolled from a single tertiary hospital. Demographic and clinical data were collected at the baseline. Articular and adjacent structures of both shoulders (painful and contralateral side) were evaluated by ultrasonography. The ultrasonography findings were compared between painful and contralateral sides. Logistic regression analysis was performed to determine the factors associated with abnormal ultrasonography findings. Fifty-two female patients (average age of 55) were enrolled. Significantly more abnormal ultrasonography findings were observed in the painful side than in the contralateral side [39 (75.0%) vs 11 (21.2%), P < 0.001]. The coracohumeral ligament was significantly thicker in the painful side than in the contralateral side (2.48 ± 0.69 vs 1.54 ± 1.25 mm, P < 0.001); adhesive capsulitis was also more frequent in the painful side [14 (26.9%) vs 0, P < 0.001]. Furthermore, patients with a history of breast cancer surgery on the ipsilateral side were associated with abnormal ultrasonography findings and adhesive capsulitis. This study is the first to evaluate ultrasonography in patients with chronic shoulder pain after breast cancer surgery. The results showed that ultrasonography could reveal several structural problems in these patients.

Clostridium histolyticum (AA4500) for the Treatment of Adhesive Capsulitis of the Shoulder: A Randomised Double-Blind, Placebo-Controlled Study for the Safety and Efficacy of Collagenase - Single Site Report

Background/Hypothesis

Adhesive capsulitis of the shoulder results in pain and restricted movement of the glenohumeral joint. Hypothesis: There would be a difference in active range of movement in the affected shoulder of patients with adhesive capsulitis after receiving a series of injections of collagenase Clostridium histolyticum (CCH) compared to placebo.

Methods

This study reports the results from a single site that was part of a 321-participant, multicenter, double-blind, prospective parallel-group, randomized controlled clinical trial. Inclusion criteria: over 18 years of age, unilateral idiopathic adhesive capsulitis for >3 months, but <12 months. Exclusion criteria: recent physical therapy, injections, subacromial impingement, calcific tendonitis or glenohumeral joint arthritis in the affected shoulder. Subjects were randomized 3:1 to receive CCH 0.58 mg or placebo under ultrasound guidance. Injections were on days 1, 22, and 43. The primary outcome measure was a functional assessment of active range of movement.

Results

Overall, 37 patients were screened, 26 subjects were excluded, and 11 subjects were randomly assigned to the treatment group (n=9) or the control group (n=2). Both control and treatment groups showed improvement in ROM between baseline and day 95. In the treatment group, AROM improved from the baseline of 272.89° (SD 86.25) to 462.11° (SD 96.89) and the control group from 246.00° (SD 5.66) to 451.50° (SD 50.20) at day 95 with no statistical difference between groups p=0.78. Site data were in line with the whole study findings. Treatment-related adverse events at the injection site, including haematoma (bruising) and localised pain and swelling, were common.

Conclusion

Although the participants showed improvement in function, statistical significance was neither reached in the site nor the overall study cohort. Given the adverse events and the potential risks of the procedure, we would not recommend this drug for the treatment of adhesive capsulitis of the shoulder.

Level of Evidence

2, cohort from one site of RCT.

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

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.

A central nervous system-focused treatment approach for people with frozen shoulder: protocol for a randomized clinical trial

Background

Frozen shoulder (FS) is a musculoskeletal condition of poorly understood etiology that results in shoulder pain and large mobility deficits. Despite some physical therapy interventions, such as joint mobilization and exercise, having shown therapeutic benefit, a definitive treatment does not currently exist. The aim of this study will be to compare the effectiveness of a central nervous system (CNS)-directed treatment program versus a standard medical and physical therapy care program on outcomes in participants with FS.

Methods/design

The study is a two-group, randomized clinical trial with blinding of participants and assessors. Participants will be recruited via referrals from orthopedic surgeons and physical therapists, community-based advertisements, private care practices and hospitals. Participants will be randomized to receive either a CNS-focused treatment program or standard medical and physical therapy care. The Shoulder Pain And Disability Index (SPADI) will be the primary outcome, while the Numeric Pain Rating Scale (NPRS), shoulder range of movement (ROM), The Patient Specific Functional Scale, two-point discrimination threshold and laterality judgement accuracy will be the secondary outcomes. Assessment will occur at baseline, at the end of the treatment program (week 10), and at 3 and 6 months’ follow-up.

Discussion

Preliminary data suggest that treatments that target CNS function are a promising approach to the treatment of people with shoulder pain including patients with FS. In the context of modest effects from most available physical therapy treatments for FS, this CNS-focused approach may lead to improved clinical outcomes. The trial should determine if the CNS-directed program is more effective than traditional interventions at reducing pain intensity and improving function in a FS cohort and will follow up participants for 6 months, providing important information on the persistence of any treatment effects.

Trial registration

NCT03320200. Registered on October 25, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3585-z) contains supplementary material, which is available to authorized users.

Does Combining a Suprascapular Nerve Block With an Intra-articular Corticosteroid Injection Have an Additive Effect in the Treatment of Adhesive Capsulitis? A Comparison of Functional Outcomes After Short-term and Minimum 1-Year Follow-up

BACKGROUND

No therapeutic intervention is universally accepted as the most effective treatment for adhesive capsulitis. An intra-articular corticosteroid injection (IAI) with a suprascapular nerve block (SSNB), a common treatment for this disease, is a safe and effective method for the resolution of pain and restoration of shoulder range of motion (ROM).

PURPOSE

To compare the efficacy of combined SSNB and IAI with that of IAI alone in the treatment of adhesive capsulitis.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of 102 patients with adhesive capsulitis who were treated at an outpatient clinic from July 2016 to January 2017. A combined SSNB with IAI was performed in 48 patients (SSNB + IAI group), and an IAI alone was performed in 54 patients (IAI group). Patients were assessed before the intervention and at 2 weeks and 2 months after the intervention. ROM and pain and function visual analog scales (PVAS and FVAS, respectively), the American Shoulder and Elbow Surgeons (ASES) score, the Korean Shoulder Scoring System (KSS), the Constant score, the Simple Shoulder Test (SST), and the Shoulder Pain and Disability Index (SPADI) were used for clinical assessments. PVAS, FVAS, and ASES scores at a minimum of 1 year after the intervention were assessed for 82 patients.

RESULTS

At the 2-month assessment, all parameters significantly improved in both the SSNB + IAI and IAI groups (P < .05), however, improvements in forward flexion (FF) and abduction (ABD) between the 2-week and 2-month assessments were better in the SSNB + IAI group. At the 2-month assessment, improvements in the FVAS, ASES, SST, and SPADI scores and FF and ABD values were statistically significantly greater in the SSNB + IAI group compared with the IAI group. Improvements in FVAS and ASES scores were significantly greater in the SSNB + IAI group at a minimum of 1 year.

CONCLUSION

Both a combined SSNB and IAI and an IAI alone significantly improved pain and functional outcomes in patients with adhesive capsulitis. The use of an SSNB with an IAI further increased treatment efficacy, as per the FVAS, ASES, SST, and SPADI scores and FF and ABD values. Patients who underwent SSNB combined with an IAI showed better improvements in the FVAS and ASES scores compared with IAI alone at a minimum of 1 year after the intervention. Therefore, an SSNB combined with an IAI may be a good treatment choice for adhesive capsulitis.

Effectiveness of Nonsurgical Interventions for Managing Adhesive Capsulitis in Patients With Diabetes: A Systematic Review

OBJECTIVE

This systematic review evaluated the effectiveness of nonsurgical interventions for managing adhesive capsulitis (AC) in patients with diabetes on pain, function, and range of motion.

DATA SOURCES

MEDLINE and other databases were searched for studies published in the last 20 years.

STUDY SELECTION

Randomized controlled trials (RCTs) that assessed AC in people with diabetes and implemented 1 or a combination of physiotherapeutic interventions, corticosteroids, and manipulation under anesthesia (MUA) were eligible for inclusion.

DATA EXTRACTION

The Cochrane Risk of Bias was used by 2 independent raters who met to achieve consensus. The quality of trials was assessed using Grading of Recommendations, Assessment, Development and Evaluations. Data extracted from the eligible studies included study design, participant characteristics and duration of symptoms, type of intervention, outcome measures, follow-up intervals, and research findings.

DATA SYNTHESIS

Because of the lack of similar interventions, a narrative synthesis was conducted, and meta-analyses were not performed. The effect sizes or between-group differences of the interventions were reported. A total of 8 RCTs met the inclusion criteria: 4 addressed physiotherapeutic interventions, 3 corticosteroid injections, and 1 MUA. The effect sizes for physiotherapeutic interventions were 0.8-2.0, 0.9-2.0, and 1.0 for ROM, function, and pain, respectively, with the largest effect size (2.0) being reported for joint mobilization plus exercises. The effect sizes for corticosteroids were 0.2-0.5 and 0.1 for ROM and pain. The between-group improvement for MUA was 5.6 points on Constant Shoulder Score.

CONCLUSION

Low-quality evidence suggests large effects of joint mobilization plus exercises on AC in people with diabetes, although confidence in this conclusion is limited due to the high risk of bias. Even weaker support was available for corticosteroid and MUA. Future high-quality RCTs are needed to determine the best intervention for managing AC in patients with diabetes.

Corticosteroid injection alone vs additional physiotherapy treatment in early stage frozen shoulders

AIM

To investigate the additional value of physiotherapy after a corticosteroid injection in stage one or two idiopathic frozen shoulders (FSs).

METHODS

A two center, randomized controlled trial was done. Patients with a painful early stage idiopathic FS were eligible for inclusion. After written consent, patients were randomly allocated into two groups. All patients received an ultrasound-guided intra-articular corticosteroid injection. One group underwent additional physiotherapy treatment (PT) and the other group did not (non-PT). The primary outcome measure was the Shoulder Pain and Disability Index (SPADI). Secondary outcomes were pain (numeric pain rating scale), range of motion (ROM), quality of life (RAND-36 score), and patient satisfaction. Follow-up was scheduled after 6, 12 and 26 wk.

RESULTS

Twenty-one patients were included, 11 patients in the non-PT and ten in the PT group, with a mean age of 52 years. Both treatment groups showed a significant improvement at 26 wk for SPADI score (non-PT: P = 0.05, PT: P = 0.03). At the 6 wk follow-up, median SPADI score was significant decreased in the PT group (14 IQR: 6-38) vs the non-PT group (63 IQR: 45-76) (P = 0.01). Pain decreased significantly in both groups but no differences were observed between both treatment groups at any time point, except for night pain at 6 wk in favor of the PT group (P = 0.02). Significant differences in all three ROM directions were observed after 6 wk in favor of the PT group (P ≤ 0.02 for all directions). A significantly greater improvement in abduction (P = 0.03) and external rotation (P = 0.04) was also present in favor of the PT group after 12 wk. RAND-36 scores showed no significant differences in health-related quality of life at all follow-up moments. At 26 wk, both groups did not differ significantly with respect to any of the outcome parameters. No complications were reported in both groups.

CONCLUSION

Additional physiotherapy after corticosteroid injection improves ROM and functional limitations in early-stage FSs up to the first three months.

Effectiveness of translational manipulation under interscalene block for the treatment of adhesive capsulitis of the shoulder: A nonrandomized clinical trial

Study Design: Nonrandomized controlled trial. Objective: To determine whether translational manipulation under anesthesia/local block (TMUA) adds to the benefit of mobilization and range of motion exercise for improving pain and functional status among patients with adhesive capsulitis of the shoulder (AC). Background: TMUA has been shown to improve pain and dysfunction in patients with AC. This intervention has not been directly compared to physical therapy treatment without TMUA in a prospective trial. Methods: Sixteen consecutive patients with a primary diagnosis of AC were divided into two groups. Patients in the first (TMUA) group received a session of translational manipulation under interscalene block, followed by six sessions of manipulation and exercise. Patients in the comparison group received seven sessions of manipulation and exercise. Outcome measures taken at baseline and 3, 6, 12 months and 4 years included Shoulder Pain and Disability Index (SPADI) scores. Four-year outcomes included percent of normal ratings, medication use, and activity limitations. Results: Both groups showed improved SPADI scores across all follow-up times compared to baseline. The TMUA group showed a greater improvement in SPADI scores than the comparison group at 3 weeks, with no significant differences in SPADI scores at other time points. However, at 4 years, significantly more subjects in the comparison group (5 of 8) had activity limitations versus subjects in the TMUA group (1 of 8). No subject experienced a complication from either intervention protocol. Conclusion: Physical therapy consisting of manual therapy and exercise provides benefit for patients with AC. Translational manipulation under local block may be a useful adjunct to manual therapy and exercise for patients with AC.

Hydrodilatation With Corticosteroid for the Treatment of Adhesive Capsulitis: A Systematic Review

BACKGROUND

Current evidence suggests that corticosteroid injection alone expedites the recovery of pain-free range of motion (ROM) in patients with adhesive capsulitis compared to physiotherapy or placebo. However, it remains unclear whether the addition of hydrodilatation with corticosteroid provides improvement in pain-free ROM as well as pain relief.

OBJECTIVE

A review of the literature was conducted to determine whether the combined intervention of hydrodilatation and corticosteroid injection expedites restoration of pain-free ROM compared to a control treatment of corticosteroid injection in patients with adhesive capsulitis.

METHODS

EMBASE, MEDLINE, and CINAHL were searched from database inception to January 2017. Relevant studies were determined as randomized controlled trials written in English, comparing the outcomes of hydrodilatation and corticosteroid injection to a control group treated with corticosteroid injection alone in patients with adhesive capsulitis. Two independent reviewers assessed manuscripts for study inclusion and extracted data.

RESULTS

A total of 2276 studies were identified through the search, of which 6 randomized controlled studies (involving 410 shoulders) met criteria for inclusion in this review. Mean age ranged from 51-61 years, with mean symptom duration of 4-9 months. Studies varied significantly regarding the volume of injectate, anatomical injection approach, symptom duration, and the method of glenohumeral capsule distension (capsular rupture versus preservation). Two studies demonstrated clinically and statistically significant improvement in the combination group at 3-month follow-up, and one study demonstrated clinically significant improvement only in ROM and/or pain/functional scales, compared to 3 studies demonstrating no benefit when compared to corticosteroid injection alone.

CONCLUSION

Combining hydrodilatation with corticosteroid injection potentially expedites recovery of pain-free ROM. The greatest benefit is experienced within the first 3 months of intervention. Differences in hydrodilatation techniques, inclusion of capsular preservation, anatomical approach, and length of symptoms may explain the variability in efficacy demonstrated. Further trials using larger sample sizes, better anatomical approaches, image guidance, and hydrodilatation techniques are required to determine the true nature of benefits of hydrodilatation with corticosteroid injection.

LEVEL OF EVIDENCE

II.

The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction

OBJECTIVE

To evaluate extracorporeal shockwave therapy (ESWT) in treating Achilles tendinopathy (AT), greater trochanteric pain syndrome (GTPS), medial tibial stress syndrome (MTSS), patellar tendinopathy (PT) and proximal hamstring tendinopathy (PHT).

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Randomised and non-randomised studies assessing ESWT in patients with AT, GTPS, MTSS, PT and PHT were included. Risk of bias and quality of studies were evaluated.

RESULTS

Moderate-level evidence suggests (1) no difference between focused ESWT and placebo ESWT at short and mid-term in PT and (2) radial ESWT is superior to conservative treatment at short, mid and long term in PHT. Low-level evidence suggests that ESWT (1) is comparable to eccentric training, but superior to wait-and-see policy at 4 months in mid-portion AT; (2) is superior to eccentric training at 4 months in insertional AT; (3) less effective than corticosteroid injection at short term, but ESWT produced superior results at mid and long term in GTPS; (4) produced comparable results to control treatment at long term in GTPS; and (5) is superior to control conservative treatment at long term in PT. Regarding the rest of the results, there was only very low or no level of evidence. 13 studies showed high risk of bias largely due to methodology, blinding and reporting.

CONCLUSION

Low level of evidence suggests that ESWT may be effective for some lower limb conditions in all phases of the rehabilitation.

Effectiveness of Glenohumeral Joint Dilatation for Treatment of Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The objective was to explore the effectiveness of glenohumeral joint distension for the treatment of frozen shoulder. We searched electronic data sources including PubMed, Scopus, and Embase from the earliest records available to February 2017. Eleven randomized controlled trials including at least one pair of comparisons between capsular distension and a reference treatment were included, comprising 747 participants. Patients’ characteristics, details of reference treatments, aspects of capsular distension therapy, and outcome measurement were evaluated at three points in time: baseline, early following intervention, and at the trial’s end. The primary and secondary outcomes were the between-group standardized mean differences of changes in shoulder function and range of motion, respectively. Regarding the long-term primary outcome, the superiority of capsular distension to reference treatments was not identified. One secondary outcome (external rotation limitation) showed a probable early positive response to capsular distension when compared to intra-articular corticosteroid injection. Aspects of approaches, imaging guiding techniques and doses of distension were not found to modify treatment effectiveness. In conclusion, distension of the glenohumeral joint provides a similar long-term efficacy to all reference treatments. A single dose of a corticosteroid-contained regimen introduced through the ultrasound-guided posterior approach is a preferable practice of capsular distension for the management of frozen shoulder.

Analysis of the Clinical Outcome of Arthrographic Steroid Injection for the Treatment of Adhesive Capsulitis

BACKGROUND

Idiopathic adhesive capsulitis is a condition of uncertain etiology characterized by pain and decreased shoulder range of motion (ROM) that occurs without a known intrinsic disorder. Many treatments have been advocated, yet the best option remains unclear. The purpose of this study was to determine if arthrographic injection of the shoulder joint with steroid and local anesthetic results in decreased pain and increased shoulder function in a cohort of patients with idiopathic adhesive capsulitis.

METHODS

This is a retrospective case series of patients who were treated with an arthrographic steroid and local anesthetic injection for adhesive capsulitis. The injections were all given by the same musculoskeletal radiologist using image guidance, and the patients were all from the same surgeon's practice. Patients were evaluated with the Shoulder Pain and Disability Questionnaire (SPADI) and Constant Shoulder Score and their shoulder ROM was tested. Descriptive statistics in the form of counts, percentages, means and standard deviations were used, as well as parametric and non-parametric tests.

RESULTS

Thirty-three shoulders in 25 patients were examined. The average length of follow-up was 17 months. Sixty-nine percent of the cohort continued to complain of some shoulder pain in the post-injection follow-up clinic, however, their pain had improved from 8.8/10 pre-injection to 2.2/10 post-injection (p=0.01). The average score of the SPADI Pain, SPADI Disability and Constant Score were 36, 31 and 64, respectively.

CONCLUSION

All patients who received an arthrographic injection using steroid and local anesthetic reported improved pain and mobility. In addition, those who had tried other treatment modalities felt that the injection had been the most beneficial.

Effectiveness of Occupational Therapy Interventions for Musculoskeletal Shoulder Conditions: A Systematic Review

People with musculoskeletal disorders of the shoulder commonly experience pain, decreased strength, and restricted range of motion (ROM) that limit participation in meaningful occupational activities. The purpose of this systematic review was to evaluate the current evidence for interventions within the occupational therapy scope of practice that address pain reduction and increase participation in functional activities. Seventy-six studies were reviewed for this study-67 of Level I evidence, 7 of Level II evidence, and 2 of Level III evidence. Strong evidence was found that ROM, strengthening exercises, and joint mobilizations can improve function and decrease pain. The evidence to support physical modalities is moderate to mixed, depending on the shoulder disorder. Occupational therapy practitioners can use this evidence to guide daily clinical decision making.

Subclinical hypothyroidism and diabetes as risk factors for postoperative stiff shoulder

PURPOSE

Postoperative stiffness can be a disabling condition after arthroscopic shoulder surgery. The purpose of this study was to analyse the potential contribution of subclinical forms of hypothyroidism and diabetes in the development of postoperative shoulder stiffness.

METHODS

A prospective study was conducted on 65 consecutive patients scheduled for arthroscopic subacromial decompression or rotator cuff tear repair. Patients with preoperative stiffness were excluded. Preoperative measurements of free thyroxine, free triiodothyronine, thyroid-stimulating hormone and fasting glycaemia were taken in all patients to detect subclinical forms of diabetes and hypothyroidism. A follow-up was planned at 30, 60, 90 and 180 days after surgery. According to range of motion measurements, postoperative stiffness was classified as severe or moderate at follow-up. Univariate and logistic regression analyses were performed for the assessment of risk factors for stiffness.

RESULTS

The overall incidence of postoperative stiffness was 29 % (19/65) in our cohort. Considering only the arthroscopic rotator cuff repairs, this incidence was 23 % (7/31). A new diagnosis of subclinical forms of diabetes or hypothyroidism was made in five cases. All five of these cases developed postoperative stiffness. The logistic regression analysis demonstrated that hypothyroidism was a risk factor for severe stiffness (RR = 25; p = 0.001) and that diabetes was a risk factor for moderate stiffness (RR = 5.7; p = 0.03).

CONCLUSION

The postoperative stiffness in the majority of patients can be predicted by a careful analysis of past medical history and by detecting subclinical forms of hypothyroidism and diabetes.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis

BACKGROUND

Intra-articular steroid injection is a common intervention for frozen shoulder (FS).

PURPOSE

This review aimed to illustrate the effects of intra-articular steroid injection for FS.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) comparing intra-articular steroid injection with no injection or sham injections for FS. Visual analog scale (VAS) pain scores were the primary outcome measure. Secondary outcome measures included passive external rotation, abduction, flexion, internal rotation, and functional scores. Complication rates were the safety outcome measure. Comparisons were performed with mean differences (MDs) and 95% confidence intervals (95% CIs). Three time intervals were analyzed: 4 to 6 weeks, 12 to 16 weeks, and 24 to 26 weeks postintervention. Trial sequential analysis was used to verify the pooled results. Line charts were drawn to view the recovery trend in both the intervention and control groups.

RESULTS

Eight RCTs with 416 patients were included. Compared with controls, patients who received intra-articular steroid injection had significantly reduced VAS pain scores at 4 to 6 weeks (MD, 1.28 cm [95% CI, 0.75 to 1.82]), 12 to 16 weeks (MD, 1.00 cm [95% CI, 0.47 to 1.52]), and 24 to 26 weeks (MD, 0.65 cm [95% CI, 0.19 to 1.10]) postinjection. Trial sequential analysis confirmed the pooled results at 4 to 6 weeks and 12 to 16 weeks but not at 24 to 26 weeks. Patients who received intra-articular steroid injection had improved passive external rotation, abduction, and flexion and Shoulder Pain and Disability Index (SPADI) scores at all 3 time intervals, as well as improved American Shoulder and Elbow Surgeons (ASES) scores at 12 to 16 weeks (MD, 12.20 [95% CI, 2.55 to 21.85]). No difference was noticed in Constant scores (MD, 5.70 [95% CI, -0.59 to 11.99]) or internal rotation except at 12 to 16 weeks (MD, 0.81° [95% CI, 0.18° to 1.44°]) and 24 to 26 weeks (MD, 3.88° [95% CI, 0.51° to 7.25°]) between steroid injection and placebo. Complication rates were 1.78% for facial flushing, 0.71% for dizziness owing to vasovagal reactions during injection, 1.07% for chest or shoulder pain, and 0.36% for nausea. Line charts improved in both groups.

CONCLUSION

Intra-articular steroid injection is effective and safe for FS and relieves pain, improves functional performance, and increases range of motion. The effects are significant at 4 to 6 and 12 to 16 weeks postintervention and may last as long as 24 to 26 weeks.

Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence

BACKGROUND & AIMS

Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.

METHODS

A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.

RESULTS

Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.

CONCLUSION

This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.

Comparative Efficacy of Platelet Rich Plasma Injection, Corticosteroid Injection and Ultrasonic Therapy in the Treatment of Periarthritis Shoulder

INTRODUCTION

Periarthritis (PA) shoulder characterised by pain and restricted range of motion has a plethora of treatment options with inconclusive evidence. Platelet Rich Plasma (PRP) is an emerging treatment option and its efficacy needs to be examined and compared with other routine interventions.

AIM

To assess the efficacy of PRP injection and compare it with corticosteroid injection and ultrasonic therapy in the treatment of PA shoulder.

MATERIALS AND METHODS

Patients with PA shoulder (n=195) were randomised to receive single injection of PRP (2 ml) or corticosteroid (80 mg of methylprednisolone) or ultrasonic therapy (seven sittings in two weeks; 1.5 W/cm², 1 MHz, continuous mode). All participants were also advised to perform a home based 10 minute exercise therapy. The primary outcome measure was active range of motion of the shoulder. Secondary outcome measures used were Visual Analogue Scale (VAS) for pain and a shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) for function. Participants were evaluated at 0, 3, 6 and 12 weeks. Chi-square test, one way and repeated measures of ANOVA tests were used to determine significant differences.

RESULTS

PRP treatment resulted in statistically significant improvements over corticosteroid and ultrasonic therapy in active as well as passive range of motion of shoulder, VAS and QuickDASH at 12 weeks. At six weeks, PRP treatment resulted in statistically significant improvements over ultrasonic therapy in VAS and QuickDASH. No major adverse effects were observed.

CONCLUSION

This study demonstrates that single injection of PRP is effective and better than corticosteroid injection or ultrasonic therapy in treatment of PA shoulder.

Is there a short-term benefit from an intra-articular steroid injection in female patients with adhesive capsulitis of the shoulder treated with physiotherapy?

INTRODUCTION

The purpose of this retrospective study was to investigate the possible short-term benefit of a single intra-articular corticosteroid injection in those patients treated with physiotherapy when compared to a group of patients undergoing physiotherapy only (PT only).

METHODS

A retrospective chart review was conducted to identify eligible patients treated over a 4-year period. All female patients between 40 years and 60 years with a confirmed clinical diagnosis of idiopathic adhesive capsulitis who completed a prescribed physiotherapy program were considered eligible. Sixty-three patients fulfilled the inclusion criteria, but 22 were excluded because of missing data in the medical record. The remaining 41 patients comprise the study cohort; an experienced musculoskeletal physiotherapist assessed these patients both at initial presentation and at 12 weeks. Twenty patients with a mean age of 55.1 years underwent PT only and 21 patients with a mean age of 52.4 years received a single intra-articular dose of 40 mg methylprednisolone followed by physiotherapy. Outcome measures included the visual analogue scale (VAS) and measurement of range of motion.

RESULTS

At final assessment (12 weeks), significant between-group differences were identified for the 'PT only' group for flexion ( p = 0.01) and abduction ( p = 0.008). When comparing the mean change from the initial assessment, a significant between-group difference was observed for abduction ( p = 0.03).

CONCLUSIONS

The results of this study suggest that the intra-articular injection of a single dose of cortisone has no significant short-term benefit in female patients with idiopathic adhesive capsulitis managed with physiotherapy.

CORR® ORS Richard A. Brand Award: Clinical Trials of a New Treatment Method for Adhesive Capsulitis

BACKGROUND

Conservative and even surgical management of adhesive capsulitis often is prolonged and painful. Management of adhesive capsulitis is lacking evidence-based controlled clinical trials.

QUESTIONS/PURPOSES

We asked: (1) Does a collagenase clostridium histolyticum (CCH) injection lyse shoulder capsule collagen in adhesive capsulitis and at what dose? (2) Can a shoulder capsule injection be administered extraarticularly? (3) Do CCH injections result in better scores for pain and function than can be achieved with physical therapy among patients with adhesive capsulitis?

METHODS

First, 60 patients with adhesive capsulitis were evaluated by clinical examination. To make the diagnosis of adhesive capsulitis, a patient had to have restricted active ROM of at least 60° in total active ROM in the affected shoulder compared with the unaffected contralateral shoulder; with the scapula stabilized, external rotation with the elbow at the side was a very important determinant. Patients were randomized to receive a single injection of 0.5 mL placebo or 0.145, 0.29, or 0.58 mg CCH. All 60 patients were followed up at 30 days. After that, if patients did not attain treatment thresholds they were eligible for up to five open-label 0.58-mg collagenase injections. For the longer-term followup in the open-label phase, 53 patients (83%) were followed to 12 months, 46 (77%) for 24 months, 36 (60%) for 36 months, 37 (62%) for 48 months, and 25 (42%) for 60 months. The extraarticular injection was directed at the anterior shoulder capsule with the patient in the supine position. To prove that these injections could be delivered reliably to the anterior shoulder capsule extraarticularly, the next study involved volunteers without adhesive capsulitis, in which 10 volunteers received a 10-mL injection of normal saline under ultrasound guidance. Finally, to determine the efficacy and dosing of CCH, four cohorts of 10 patients received up to three ultrasound-guided injections separated by 21 days. These injections were administered at one of four dose-volume levels. A fifth cohort of 10 patients was used as a control group and performed standardized home shoulder exercises only. All patients performed standardized home shoulder exercises three times daily. For Study 3, followup was at 22, 43, 64, and 92 days. No patients were lost to followup.

RESULTS

In the first study, a single CCH injection did not provide clinically important improvements from baseline in active ROM, passive ROM, and function and pain scores compared with patients who received placebo. Ultrasound guidance confirmed extraarticular injection of the shoulder capsule in Study 2. The CCH injection was more effective than exercise therapy alone at 0.58 mg/1 mL and 0.58 mg/2 mL compared with exercise only in the primary measure of efficacy (active forward flexion) as shown in Study 3. For active forward flexion the mean in degrees in the 0.58 mg/2 mL group was 38° compared with 12° in the exercise-only group (p = 0.03). For active forward flexion the mean in the 0.58 mg/1mL group was 43° compared with 12° in the exercise-only group (p = 0.01).

CONCLUSIONS

Extraarticular injections of CCH for treatment of adhesive capsulitis were well tolerated and seem effective compared with exercise therapy. Future FDA-regulated clinical trials must verify CCH injection therapy for adhesive capsulitis.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials

Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.

Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder

BACKGROUND

Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice.

MATERIALS AND METHODS

A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis.

RESULTS

Fifty-six patients with a mean age of 52.5 ± 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 ± 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% ± 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 ± 9.6; Shoulder Pain and Disability Index score, 7.4 ± 11.4; and Single Assessment Numeric Evaluation score, 92.7% ± 10.1%. The Shoulder Activity Score was 8.3 ± 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient.

CONCLUSIONS

This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care

BACKGROUND

Optimal management for adhesive shoulder capsulitis (frozen shoulder) is currently unclear. We intended to explore whether treatment by intra-articular injections with corticosteroid and distension is more effective than treating with corticosteroids alone or treatment-as-usual in a primary care setting in Norway.

METHODS

In this prospective randomised intention to treat parallel study, 106 patients were block randomised to three groups; 36 (analysed 35) receiving steroid injection and Lidocaine (IS), 34 receiving steroid and additional saline as distension (ISD) and 36 had treatment-as-usual (TAU). Intervention groups received four injections within 8 weeks, assessed on 1st visit, at the 4th and 8th week. Outcomes were Shoulder Pain and Disability Index (SPADI), Numerical pain rating scale (NPRS) and passive range of motion (PROM). Postal assessment was repeated after 1 year for SPADI. Patients in the IS and ISD groups were "blinded" for intervention received and the assessor was "blinded" to group allocation.

RESULTS

At baseline there were no differences between groups in outcome measures. There were no statistical significant differences between the intervention groups in SPADI, NPRS and PROM at baseline, at short-term (4-and 8 weeks) or long-term (12 months). There were statistically significant differences (p < 0.01) in change scores at short-term for SPADI when comparing the IS and TAU groups (-20.8; CI-28.9 to -12.7), and the ISD and TAU groups (-21.7; CI-29.4 to -14.0), respectively for NPRS (-2.0; CI-2.8 to -1.1 and -2.2; CI-3.0 to -1.4), and for PROM, but not at long-term for SPADI (p > 0.05). Effect size (ES) at 8 weeks was large between both injection groups and TAU (ES 1.2). At 12 months ES was reduced to 0.3 and 0.4 respectively. Transitory side effects as flushing and after-pain were reported by 14 % in intervention groups.

CONCLUSION

This intention to treat RCT in primary care indicates that four injections with corticosteroid with or without distension, given with increasing intervals during 8 weeks, were better than treatment-as-usual in treatment of adhesive shoulder capsulitis. However, in the long run no difference was found between any of the groups, indicating that natural healing takes place independent of treatment or not.

TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov/ identifier: NCT01570985.

Axillary Ultrasound and Laser Combined With Postisometric Facilitation in Treatment of Shoulder Adhesive Capsulitis: A Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to compare axillary ultrasound, laser, and postisometric facilitation technique with standard care in the management of shoulder adhesive capsulitis.

METHODS

This is a randomized clinical trial study. Fifty-nine participants with shoulder adhesive capsulitis were selected and randomly assigned for eligibility. Forty-five participants were assigned into 3 equal groups of 15, and 14 participants were excluded from the study. The participants were blinded to their group allocation. Standard care group (A) received traditional physical therapy treatment in the form of pulsed ultrasound, scanning laser, supervised exercise program, and home exercise program; group B received the same physical therapy program as group A, except that the ultrasound and scanning laser were applied to the axillary region of the painful shoulder; and group C received the same modified physical therapy program as group B plus postisometric facilitation technique to the painful shoulder. All dependent variables were measured by the second author, who was blinded to the participant's intervention group. The first author administered treatment to all 3 groups. All participants received 12 sessions (3 times/wk for 4 weeks). Pain level and shoulder range of motion (ROM; flexion, abduction, and external rotation) were recorded 3 times (pretreatment, immediately posttreatment, and 4 weeks of treatment).

RESULTS

Mixed-design multivariate analysis of variance indicated significant pain reduction with significant ROM increase in all groups posttreatment and after 4 weeks. Post hoc analysis for within groups revealed that shoulder ROM and pain levels improved significantly posttreatment compared with pretreatment ROM in all groups, with the greatest improvement in group C. Between-group analysis revealed that pain-free shoulder flexion, abduction, external rotation, and pain level improved significantly in group C compared with groups A and B immediately after treatment and after 4 weeks of follow-up (P < .05). Improvements reported in group B is more than in group A, and C is more than in groups A and B.

CONCLUSIONS

Combining axillary ultrasound and laser with postisometric facilitation had a greater effect in reducing pain and improving shoulder ROM in patients with shoulder adhesive capsulitis compared with axillary ultrasound and laser with traditional exercise.

Steroid Injection Versus Physiotherapy for Patients With Adhesive Capsulitis of the Shoulder: A PRIMSA Systematic Review and Meta-Analysis of Randomized Controlled Trials

To compare the effect of steroid injection and physiotherapy for patients with adhesive capsulitis of the shoulder (ACS).An electronic search was performed on Pubmed, Embase, and Cochrane library, and reference lists were also reviewed for randomized controlled trials (RCTs) comparing steroid injection and physiotherapy for patients with ACS. The quality of included studies were assessed using PEDro scale. Standardized mean differences (SMDs) and 95% confidence interval (CI) were used for comparisons. The primary outcome was functional improvement.Nine RCTs including 453 patients were identified. From 6-7 weeks to 24-26 weeks postintervention, no superiority was noted in favor of either steroid injection or physiotherapy for functional improvement (SMD 0.28; 95% CI -0.01-0.58; P = 0.06) or pain relief (SMD -0.10; 95% CI -0.70-0.50; P = 0.75). Steroid injection provided more improvement in passive external rotation at 24 to 26 weeks (3 studies, SMD 0.42; 95% CI 0.11-0.72; P = 0.007) but not at 6 to 7 weeks (4 studies, SMD 0.63; 95% CI 0.36-0.89; P = 0.32) or 12 to 16 weeks (3 studies, SMD -0.07; 95% CI -0.79-0.65; P = 0.85). Steroid injection was as safe as physiotherapy for patients with ACS (risk ratio 0.94; 95% CI 0.67-1.31).Both steroid injection and physiotherapy are equally effective for patients with ACS. One steroid injection might be the 1st choice for ACS. Results should be interpreted with caution due to the heterogeneity among the studies.

Steroid Injection and Nonsteroidal Anti-inflammatory Agents for Shoulder Pain: A PRISMA Systematic Review and Meta-Analysis of Randomized Controlled Trials

Advantages and possible risks associated with steroid injection compared with nonsteroidal anti-inflammatory drugs (NSAIDs) for shoulder pain are not fully understood. To compare the efficiency and safety of steroid injection versus NSAIDs for patients with shoulder pain. PubMed, Embase, and the Cochrane Library were searched through July 2015. Study eligibility criteria, participants, and interventions: randomized controlled trials (RCTs) that assessed steroid injection versus NSAIDs for patients with shoulder pain. Study appraisal and synthesis methods: predefined primary efficacy outcome was functional improvement; and secondary efficacy outcomes included pain relief and complications. Relative risks (RRs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using a random-effects model accounting for clinical heterogeneity. Eight RCTs involving 465 participants were included in the meta-analysis. Five trials compared steroid injection with oral NSAIDs, and 3 compared steroids injection with NSAIDs injection. Compared with steroid injection, oral NSAIDs were less effective in 4 or 6 weeks for functional improvement (SMD 0.61; 95% CI, 0.08-1.14; P = 0.01), while there was no significant difference in pain relief (SMD 0.45; 95% CI, -0.50-1.40; P < 0.00001) or complication rate (RR 1.10; 95% CI, 0.26-4.58; P = 0.29). Meta-analysis was not performed for NSAIDs injection due to considerable heterogeneity. Conflicting results were observed in favor of either steroid or NSAIDs injection. Not all diseases that can lead to shoulder pain were included, detailed intervention protocols were inconsistent across studies, and some estimated data were input into comparison while some data were lost, which could exert an influence on pooled results. Steroid injection, compared with oral NSAIDs, provides slightly more improvement in shoulder function without superiority in pain relief or risk of complications at 4 to 6 weeks. Treatment decision should be made based on diseases. NSAIDs injection might be a treatment method for shoulder pain.

Arthroscopic capsular release and manipulation under anaesthesia for frozen shoulders: A hot topic

A frozen shoulder is a common cause of shoulder pain and stiffness. The etiology and pathology of frozen shoulders is not fully understood yet. Frozen shoulder is characterized by a decrease in intra-articular volume and capsular compliance. This can lead to significant limitations in daily life. The majority of the patients can be treated conservatively, with functional recovery to be expected in two to three years. However, if conservative treatment fails, manipulation under anaesthesia and arthroscopic capsular release can both be considered as appropriate treatments. Manipulation is a traditionally well-established technique but in recent years it seems that arthroscopic capsular release has gained popularity. Manipulation is a relative time efficient and technically low-demanding procedure in which the glenohumeral joint is forced into different directions under general anaesthesia to release the capsular contracture, thereby increasing the range of motion of the joint. In arthroscopic capsular release the glenohumeral capsule can be released in a more controlled manner under direct vision. There are no prospective comparative trials available to display superiority of one procedure over the other. In addition, the optimal timing of both these interventions still has to be determined. An overview of the literature concerning this topic and a description of both procedures with its own advantages and disadvantages is provided.

Effectiveness of hyaluronic acid administration in treating adhesive capsulitis of the shoulder: a systematic review of randomized controlled trials

Introduction. Adhesive capsulitis (AC) of the shoulder presents with an insidious onset of pain and progressive limitation of shoulder movement. Objectives. To investigate whether intra-articular hyaluronic acid (HA) administration alone is superior to conventional therapies and whether the addition of intra-articular HA administration to conventional therapies improves clinical outcomes in patients with AC. Methods. The PubMed, EMBASE, CINAHL, and Cochrane Library electronic databases were searched without language restrictions in July 2014 with a priori defined inclusion and exclusion criteria. Results. Four randomized controlled trials (273 participants, 278 shoulders) were included in this review. Two trials compared intra-articular HA administration with conventional therapies and 2 trials evaluated intra-articular HA administration as an addition to conventional therapies. Pain and shoulder function/disability outcomes in the HA injection group were not superior to those achieved in the conventional therapy groups. No significant differences in pain or shoulder function/disability outcomes were noted between the groups with and without adjunctive HA administration. Conclusions. Intra-articular HA administration alone is not superior to conventional AC treatments, and the addition of intra-articular HA administration to conventional therapies does not provide significant added benefits. HA administration in AC patients who are receiving conventional therapies should be evaluated to avoid unnecessary medical expenditure.