A randomized controlled trial of ultrasound-guided pulsed radiofrequency for patients with frozen shoulder

Suprascapular Nerve Pulsed Radiofrequency as an Effective Pain Relief Strategy in Supraspinatus Muscle Tendon Tears

INTRODUCTION

The supraspinatus muscle tendon is the most frequently rotator cuff muscle torn. Reliable shoulder pain relief strategies are needed for patients with severe pain, refractory to conservative management, and without surgical indication.

MATERIALS AND METHODS

We conducted a retrospective analysis in a Portuguese reference Rehabilitation Centre during the 1st of January 2020 and the 30th of June 2021, including all patients with partial or complete supraspinatus tendon tear, older than 50 years, who presented with severe pain and who were submitted to suprascapular nerve pulsed radiofrequency.

RESULTS

We included 32 patients in our retrospective analysis, mainly female (53%) with a mean age of 66.50 years old. Most of the patients reported right shoulder pain (21 patients, 66%). The mean baseline pain, reported on the numeric rating scale, was 8.00 ± 0.88. Compared to baseline, mean pain reduced 4.00 ± 3.19 at three months (p<0.001), 3.59 ± 3.13 at six months (p<0.001) and 2.94 ± 2.78 at 12 months (p<0.001). From the 3rd to the 12th month there was an increase of 1.06 ± 2.77 in mean pain (p=0.038). There was no difference (p>0.05) in average pain at 0, 3, 6, or 12 months between patients who were simultaneously submitted to an intra-articular shoulder injection.

DISCUSSION

Our analysis revealed 36% average shoulder pain reduction for, at least, 12 months following suprascapular nerve pulsed radiofrequency, with a peak pain reduction of 50% at three months. Slow fading of pain reduction in the following nine months was seen, however, compared to baseline, pain reduction was always statistically significant. Cortico-anaesthetic intra-articular shoulder injections seem not to add benefit in shoulder pain reduction when performed simultaneously with suprascapular nerve pulsed radiofrequency.

CONCLUSION

Suprascapular nerve pulsed radiofrequency seems to be an effective strategy for shoulder pain reduction, in patients with severe pain, refractory to other management modalities. Nonetheless, larger prospective studies, analyzing shoulder functionality and quality of life lost scores, besides pain reduction, should be pursued.

Current concepts in the diagnosis and treatment of adhesive capsulitis: role of diagnostic imaging and ultrasound-guided interventional procedures

Adhesive capsulitis is a common cause of painful shoulder, characterized by pain and restricted range of motion of the glenohumeral joint. With a well-known clinical presentation, and an increasing understanding of its clinical and radiologic features, early diagnosis of adhesive capsulitis is becoming a reality. Although often treated conservatively, for refractory cases arthroscopic release and open capsulotomy have been the only therapeutic option for a long time. Therefore, in the last years, a particular effort was put into the development of novel minimal-invasive techniques capable of pain relief and functional range improvement of the glenohumeral joint. The purpose of this literature review is to report the main updates on diagnosis and treatment for adhesive capsulitis with a focus on imaging diagnosis techniques and novel minimally invasive ultrasound-guided treatments. Results showed that ultrasound-guided procedures come with a high success rate in terms of pain reduction and improved range of motion, thus making the ultrasound a unique tool capable of giving the operator real-time diagnostic information confirming the clinical suspicion, and subsequently performing an interventional procedure.

Comparison of bedside ultrasonography and bedside chest radiography in neonatal peripherally inserted central catheters: A before and after self-control study

Objective

This study aimed to compare the applications of bedside ultrasonography (US) and bedside chest radiography (CR) in positioning peripherally inserted central venous catheter (PICC) at Neonatal Intensive Care Units (NICUs).

Methods

The study is a prospective before and after self-control clinical trial. A consecutive series of 181 neonate patients were finally enrolled for PICC placement. CR, followed by US, was used to evaluate and readjust the sites of catheter tips. The imaging capability for PICC key structures, fluctuation of the measured data, measurement of tip-to-atrium distance, operation time, infants' body temperature changes, and direct expenses of the two imaging modalities were obtained and compared.

Results

(1) Comparison in viewing PICC key structures: the display rate of catheter tip, SVC-and-right-atrium junction, IVC-and-right-atrium junction and tip-to-atrium distance is 99.47%, 100%, 100% and 99.47% for US and 100%, 98.42%, 97.37% and 95.79% for CR, respectively. (2) Fluctuation of the measured data by US and CR: the tip-to-atrium distance measured by US is 0.631 (0.435-0.820) cm, and that measured by CR is 0.593 (0.210-0.825) cm. US showed a narrower range of datum variance. (3) Consistency between US and CR: for consistency analysis, the Kappa coefficient (κ) was 0.843 (P < 0.05), showing their favorable consistency. (4) Comparison of operation time and infants' body temperature drop: for a CR exam, the time period taken was significantly longer than that of US (59.7 ± 26.33 vs. 79.6 ± 28.06, P < 0.001); and CR operations caused a significant babies' body temperature drop compared to US (0.14 ± 0.11 vs. 0.34 ± 0.19, P < 0.001). (5) Comparison of the direct expenses: the total cost for CR positioning was significantly higher than that for US (¥153.99 vs. ¥143, P = 0.026).

Conclusion

US exhibited superior traits to CR in the positioning of PICC tip. It could be promising for routine use in NICU.

Efficacy of Radiofrequency as Therapy and Diagnostic Support in the Management of Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Radiofrequency (RF) is a minimally invasive procedure used to interrupt or alter nociceptive pathways for treating musculoskeletal pain. It seems a useful tool to relieve chronic pain syndromes, even if, to date, solid evidence is still needed about the effectiveness of this therapy. By this systematic review and meta-analysis, we aimed to evaluate the efficacy of RF in treating musculoskeletal pain. PubMed, Medline, Cochrane, and PEDro databases were searched to identify randomized controlled trials (RCTs) presenting the following: patients with chronic musculoskeletal pain as participants; RF as intervention; placebo, anesthetic injection, corticosteroid injection, prolotherapy, conservative treatment, physiotherapy, and transcutaneous electrical nerve stimulation as comparisons; and pain and functioning as outcomes. Continuous random-effect models with standardized mean difference (SMD) were used to compare the clinical outcomes. Overall, 26 RCTs were eligible and included in the systematic review. All of them analyzed the efficacy of RF in four different regions: cervical and lumbar spine, knee, sacroiliac (SI) joint, shoulder. The outcomes measures were pain, disability, and quality of life. A medium and large effect in favor of the RF treatment group (SMD < 0) was found for the shoulder according to the Visual Analogical Scale and for the SI joint according to the Oswestry Disability Index. A small effect in favor of the RF treatment group (SMD > 0) was found for the spine according to the 36-item Short Form Survey. Non-significant SMD was found for the other outcomes. RF represents a promising therapy for the treatment of chronic musculoskeletal pain, especially when other approaches are ineffective or not practicable. Further studies are warranted to better deepen the effectiveness of RF for pain and joint function for each anatomical region of common application.

Current updates in image-guided musculoskeletal interventions

Image-guided musculoskeletal interventions are frequently done in clinical practice. Even then, the literature regarding their effectiveness is relatively scarce. Image guidance adds value over the conventional landmark-based approach and should be preferred. We hereby try to list the commonly performed procedures along with the current practice guidelines regarding their clinical indications and periprocedural care.

A systematic review and meta-analysis of radiofrequency procedures on innervation to the shoulder joint for relieving chronic pain

BACKGROUND AND OBJECTIVE

Studies have reported relief of chronic shoulder pain with non-ablative pulsed neuromodulatory (pRF) or ablative radiofrequency (aRF) procedures on innervation of the shoulder joint but interpretation of these reports is hampered by inconsistent indications, anatomic targets and follow-up. This systematic review was conducted to synthesize the existing literature on procedures employing pRF or aRF for treating chronic shoulder pain.

DATABASES AND DATA TREATMENT

MEDLINE and other medical literature databases were reviewed up to 31 December 2019 for publications on pRF or aRF procedures on shoulder joint innervation to relieve chronic pain. Data on analgesic and functional outcomes measured at any time point following the interventions were extracted. Existing knowledge on innervation of the shoulder joint with relevance to RF procedures was also synthesized.

RESULTS

In all, 42 publications, 7 randomized controlled trials (RCTs) and 35 observational studies, case series or reports were identified. Thirty-six of these publications were on pRF procedure and 29 of these reported procedures exclusively targeting the suprascapular nerve. A meta-analysis of the seven RCTs evaluating pRF indicated no analgesic benefit or functional improvement with this treatment over conventional medical management. Case series and reports on aRF indicate a potential for analgesic benefit but the quality of this evidence was low.

CONCLUSIONS

RF treatments targeting the sensory innervation of the shoulder joint affected by degenerative conditions have the potential to reduce pain but the current evidence does not suggest analgesic or functional benefit (GRADE certainty of evidence-low). Studies of high methodological quality are required to further investigate the role of these interventions.

SIGNIFICANCE

This is a comprehensive review of literature on pulsed (non-ablative) and ablative radiofrequency (RF) procedures for chronic shoulder pain. The systematic review and meta-analysis of 7 trials found that pulsed RF for chronic shoulder pain provided similar analgesia and functional improvement as conservative medical management at three months after the procedures. The case series and reports on ablative RF for shoulder pain indicate possible analgesic benefit but their quality was low. This review highlights the need for studies of a high quality on ablative RF treatments for chronic shoulder pain.

Current concepts of natural course and in management of frozen shoulder: A clinical overview

Frozen Shoulder (FS) by many specialists is still considered a benign, self-limiting condition, which usually resolves without intervention. This concept originated in the 70’, stating that FS will proceed from “the freezing” phase, with the predominance of inflammation and pain to “the frozen” phase with marked stiffness in the joint and “the thawing” phase, with a progressive return to the normal Range Of Motion (ROM) and function. Nevertheless, numerous authors have recently challenged this concept, arguing that most patients with FS will never fully recover, and suffer from residual pain and loss of function. Lack of early intervention, when a patient does not improve with conservative treatment, might lead to disability. We have discussed the recent concepts in the natural course of the disease and discussed both noninvasive and surgical methods in the treatment of FS.

Suprascapular Nerve Pulsed Radiofrequency for Chronic Shoulder Pain in a Pediatric Patient

Pulsed radiofrequency of the suprascapular nerve has shown efficacy in adults with chronic shoulder pain, but its use in pediatrics is relatively new. We present a case of a successful use of pulsed radiofrequency to treat refractory chronic shoulder pain in an adolescent patient. Case Report. We present a 53 kg, 14-year-old female, with a medical history of septic arthritis of the left shoulder within the first month of life leading to persisting pain during childhood. She presented with a complaint of progressive pain starting at age 12, refractory to analgesics including opioids and intra-articular injection of local anesthetic and steroids. After pulsed radiofrequency of the suprascapular nerve, significant pain relief and improvement of the range of motion was obtained. These results were maintained at the 1-, 3-, and 6-month follow-up visits with the pain being reported as mild and manageable with nonsteroidal anti-inflammatory drugs. Conclusion. There is limited data today of the use of pulsed radiofrequency for pediatric chronic pain. We successfully used this intervention in a 14-year-old patient with chronic shoulder pain extrapolating from adult experience and as a last resort after all other treatments had failed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

STUDY REGISTRATION NUMBER

INPLASY202040070.

The Effectiveness of Pulsed Radiofrequency on Joint Pain: A Narrative Review

BACKGROUND

Pulsed radiofrequency (PRF) stimulation has been safely and effectively applied for controlling various types of pain.

PURPOSE

We reviewed the literature on the efficacy of PRF for controlling pain in joint disorders.

METHODS

We searched PubMed for papers published prior to September 7, 2019, that used PRF to treat pain due to joint disorders. The key search phrases for identifying potentially relevant articles were (PRF AND joint) OR (PRF AND arthritis) OR (PRF AND arthropathy). The following inclusion criteria were applied for the selection of articles: (1) patients' pain was caused by joint disorders; (2) PRF stimulation was applied to manage joint-origin pain; and (3) after PRF stimulation, follow-up evaluation was performed to assess the reduction in pain intensity. Moreover, joints with more than 3 reported PRF studies were included in our review.

RESULTS

The primary literature search yielded 141 relevant papers. After reading their titles and abstracts and assessing their eligibility based on the full-text articles, we finally included 34 publications in this review. Based on the positive therapeutic outcomes of previous studies, PRF stimulation seems to be an effective treatment for cervical and lumbar facet, sacroiliac, knee, and glenohumeral joint pain. PRF appears to be beneficial. For confirmation of the effectiveness of PRF on joint pain, more high-quality studies are needed.

CONCLUSIONS

Our review provides insights on the degree of evidence according to pain in each joint, which will help clinicians make informed decisions for using PRF stimulation in various joint pain conditions.

Clinical indications for image guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part III, nerves of the upper limb

BACKGROUND

Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence.

METHODS

An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed.

RESULTS

Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).

CONCLUSIONS

This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus.

KEY POINTS

• An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb • Two statements reached the highest level of evidence • Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).