Research Article

Fluroscopic guided

Orthopaedic Journal of MP Chapter

Publisher: Madhya Pradesh Orthopaedic Association www.mpioa.com
E-ISSN:2582-7243, P-ISSN:2320-6993
2023 Volume 29 Number 1 Jan-Jun

Fluroscopic guided capsular distention with and without suprascapular nerve block in frozen shoulder patients a prospective comparative study

Peepra D1, Lodhi JS2, Gajbhiye S3, Vidyarthi A4, Chauhan H5*

1 D Peepra, Department of Orthopaedics, Netaji Subhash Chandra Bose Medical College, Jabalpur, MP, India.

2 J S Lodhi, Department of Orthopaedics, Netaji Subhash Chandra Bose Medical College, Jabalpur, MP, India.

3 S Gajbhiye, Department of Orthopaedics, Netaji Subhash Chandra Bose Medical College, Jabalpur, MP, India.

4 A Vidyarthi, Department of Orthopaedics, Netaji Subhash Chandra Bose Medical College, Jabalpur, MP, India.

5* Hemendra Chauhan, Pg Resident, Department of Orthopaedics, Netaji Subhash Chandra Bose Medical College, Jabalpur, MP, India.

Background: In general practise, frozen shoulder is a common condition, in which pain and gross restriction of movement around affected shoulder joint occur. Aim of our study is to compare the effectiveness of fluoroscopic guided capsular distension with and without suprascapular nerve block to relieve pain and improve range of movement.

Material and method: An observational study of 60 patients of frozen shoulder to compare capsular distension with steroid, local anaesthetic and normal saline in 30 patients with suprascapular nerve block (group A). Capsular distension with steroid, local anaesthetic and normal saline without suprascapular nerve block in 30 patients (Group B). After capsular distension all patients advised physiotherapy, ranges of movement and pain over shoulder joint were assessed over a 12-week period.

Results: In comparison to fluoroscopic guided capsular distension without suprascapular block (Group B), fluoroscopic guided capsular distension with suprascapular block (group A) has a more decreased SPADI and VAS score

Conclusions: According to this study, suprascapular nerve block is a more safe and effective method of treating frozen shoulder than distension with no nerve block.

Keywords: adhesive capsulitis, frozen shoulder, suprascapular nerve block

Corresponding Author How to Cite this Article To Browse
Hemendra Chauhan, Pg Resident, Department of Orthopaedics, Netaji Subhash Chandra Bose Medical College, Jabalpur, MP, India.
Email: 		Peepra D, Lodhi JS, Gajbhiye S, Vidyarthi A, Chauhan H, Fluroscopic guided capsular distention with and without suprascapular nerve block in frozen shoulder patients a prospective comparative study. ojmpc. 2023;29(1):18-22.
Available From
https://ojmpc.com/index.php/ojmpc/article/view/171
Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-06-03 2023-06-10 2023-06-17 2023-06-24 2023-06-30
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Authors state no conflict of interest. Non Funded. The conducted research is not related to either human or animals use. 12.23 All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

© 2023by Peepra D, Lodhi JS, Gajbhiye S, Vidyarthi A, Chauhan Hand Published by Madhya Pradesh Orthopaedic Association. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by-nc/4.0/ unported [CC BY NC 4.0].

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Chauhan et al: Fluroscopic guided capsular distention suprascapular nerve block

Introduction

Frozen shoulder (also known as adhesive capsulitis) is characterized by a painful, progressive loss of both active and passive glenohumeral motion as a result of persistent fibrosis and eventual contracture of the glenohumeral joint capsule. [1,2] Because of the inconsistent reporting of the disease stage, variable nomenclature, and wide range of treatments, the approach to manage is unclear and contradictory. [1]

There are numerous treatments that have been mentioned in the literature, including rest, non-steroidal anti-inflammatory drugs (NSAIDs), active and passive mobilization, physiotherapy, intra-articular corticosteroids, hydro dilatation, manipulation under anesthesia, arthroscopic capsular release, intra-articular hyaluronate injection, regional nerve block, and others. [3-9]

Pain relief and the restoration of normal shoulder function are the common treatment objectives for frozen shoulder. Therapeutic activities and patient’s co-operation are essential to achieving this goal. The main barrier preventing people from engaging in active exercise is pain. Both chronic and recent pain can be effectively treated with a regional nerve block. [2,10] One of several effective, simple, and helpful nerve block techniques for treating shoulder pain is the suprascapular nerve block. [2,11-13] It is possible to place the needle in a clinic using anatomical cues. [14]

Hence the present study was tried to find out clinical effectiveness and safety of suprascapular block as well as capsular distension in the treatment of frozen shoulder using anatomical landmarks.

Material and Method

After approval from Institutional Ethics Committee (IEC) between 2020-2022 all the patient who were fit in our inclusion criteria and ready to give written informed consent were included in the study. 60 patients were enrolled in the study.

They were randomly allocated in two groups i.e., capsular distension with steroid, local anaesthetic and normal saline without suprascapular nerve block in 30 patients (Group A).

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Figure 1:

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Figure 2:

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Figure 3:

In group B suprascapular nerve block followed by capsular distension done with steroid, local anaesthetic and normal saline in 30 patients. After capsular distension all patients advised physiotherapy, range of movement and pain over shoulder joint were assessed over a 12-week period for evaluation of pain VAS scale and SPADI score were calculate

Results

In our study among 60 participant 26 were female and 34 were male while in Group – A and group B the gender composition is same 17 male and 13 female in both the groups, in both the groups most of the cases belong to age group 46-55, in group A- 13 patients and in group B – 15, followed by age group 35-45 years in which number of participants were 9 and 8 in group A and group- B respectively, followed by 56-65 years group in which number of participants were 8 and 7 in group A and group- B, respectively. The mean age of participant in group A and B was 51.1± 5.79 and 50.13± 6.34, respectively.


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Chauhan et al: Fluroscopic guided capsular distention suprascapular nerve block

The mean BMI of participants in group A was 27.27 ± 3.41while in group B was slightly higher 29.62 ± 4.90. In our study in group A right side was mostly affected while in group- B the distribution was equal, in both the groups the most of patient were having symptoms from past 7-9 months.

Table 1: Demographic characteristic and clinical presentation of study participants

ParticularsSub particularsGroup A(Without Block)GroupB(With Block)
Number of PatientsNumber of Patients
Age (in years)35-4598
46-551315
56-6587
Total3030
SexFemale1313
Male1717
BMIMean ± Std Deviation27.27 ± 3.4129.62 ± 4.90
Affected SideLeft1215
Right1815
Duration of illness in monthsMean ± Std Deviation6.47 ± 1.896.40 ± 1.69

Most of the patients were belong to age group of 46-55 years, male are predominant in study subjects in both groupBMI is more than normal in both the groups,,right side affected more in group A while while in group b both are equal.mean duration of illness is same in both group

Table 2: Comparison of VAS and SPADI Score among Group- A and Group –B at Pre-procedure,15 Days, 1 Month and 3Months

VAS (With and Without Block)Pre-procedure15 days1 month3 months
Mean ± Std.DeviationGroup A (Without Block)6.2 ± 0.925.23 ± 0.573.7 ± 0.593.33 ± 0.48
GroupB(With Block)7.03 ± 0.765.5 ± 0.734.6 ± 0.563.5 ± 0.57
t – value-3.47-1.16-5.83-1.3
p – value<.001<.001<.0010.100893

The Means VAS score was statistically significantly difference between preprocedure and follow up at 15 days and 1 month

SPADI (With and Without Block)Pre-procedure15 days1 month3 months
Mean ± Std.DeviationGroup A
(Without Block)		74.37 ± 6.0765.93 ± 5.5551.6 ± 3.653.33 ± 0.48
Group B
(With Block)		77.07 ± 4.7466.57 ± 4.4258.07 ± 4.223.5 ± 0.57
t - value-1.99-0.53-6.19-4.65
p - value<.001<.001<.001<.001

The Means SPADI score was statistically significant difference between preprocedure and follow up at 15 days,1motnh and 3 month

Table 3: Comparison Of abduction, flexion and external rotation degree among Group- A and Group –B at Pre-procedure, 15 Days, 1 Month and 3 Months

Abduction (With and Without Block)Pre-procedure15 days1 month3 months
Mean ± Std.DeviationGroup A
(Without Block)		66.83 ± 10.13108.17 ±16.68141.5 ± 14.81170.67 ± 8.28
Group B
(With Block)		70.33 ± 13.5899.67 ± 10.98125.33 ± 12.52158 ± 11.26
t - value-1.092.734.375.92
p - value<.001<.001<.001<.001

The Mean abduction degree Among Group- A And Group –B At Prepocedure,15 Days 1 Month And 3Month was statistically different

Flexion (With and Without Block)Pre-procedure15 days1 month3 months
Mean ± Std.DeviationGroup A
(Without Block)		44.5 ± 21.59112.5 ± 20.92142.83 ± 17.15168.67 ± 9.37
Group B
(With Block)		55.5 ± 16.8399.67 ± 13.77128.33 ± 13.67160.33 ± 8.89
t - value-1.962.573.393.78
p - value<.001<.001<.001<.001
Mean flexion degree Among Group- A And Group –B At Prepocedure,15 Days 1 Month And 3Month was statistically different
ER (With and Without Block)Pre-procedure15 days1 month3 months
Mean ±
Std.Deviation		Group A
(Without Block)		43.5 ± 6.8458.33 ± 8.0275.5 ± 6.0784.5 ± 4.61
Group B
(With Block)		39.5 ± 6.7456.17 ± 5.8367.17 ± 6.7877.33 ± 6.79
t - value2.111.275.764.68
p - value<.001<.001<.001<.001

Mean degree of External Rotation Among Group- A And Group –B At Prepocedure,15 Days 1 Month And 3Month was statistically different

Discussion

The main clinical manifestations of frozen shoulder are shoulder pain and restricted glenohumeral movements. Recovery occurs at a varying and frequently incomplete rate. [2,19] In long-term follow-up studies, 7% to 15% of patients had functional disability, and 33% to 61% of patients still had some residual motion restriction. [19] Pain management and therapeutic exercises for early mobilization are the most crucial elements of treatment for better outcome. [2]

Suprascapular nerve block (SSNB) is a quick and efficient method for treating shoulder pain. Haque R et al. [21] stated that suprascapular nerve block helped in effective mobilization and increased the tolerability of pain in the patients. Additionally, it was easy to perform as an outpatient procedure, with minimal complications. Shanahan EM et al. [22] concluded that SSNB improved pain and reduced the duration of frozen shoulder by 6 months.

Hydrodilation is used to dilate contracted capsule and to increase range of motion. ElKardosy et al (2021) [23], in their study, performed hydrodilation of the glenohumeral capsule, and observed improvement in VAS, ROM and SPADI score. Debeer P et al [24] concluded that hydrodilation resulted in continuous improvement of pain and range of movements. It also significantly improved depression and anxiety in these patients.

Injection of steroids directly into the joint capsule causes anti-inflammatory effect and reduces pain. Goyal T et al [25] observed that corticosteroid injections administered in the sub-acromial and gleno-humeral joint provided relief in pain, as well as, improved function in patients with a frozen shoulder. The improvement was statistically significant at 3,6,12 weeks and 6 months.


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Chauhan et al: Fluroscopic guided capsular distention suprascapular nerve block

Our study comprised of performing all three procedures i.e. hydrodilation (which consisted of injecting 5 ml of 2% lignocaine, 5 ml of injection triamcinolone 40mg and 20 ml Normal Saline) after giving supraclavicular nerve block, thus increasing patient compliance for painless procedure. Also, here block effect wears off after 5-6 hours. Thus, patient gets time to perform active painless shoulder ROM. It was also observed that by combining these three procedures, the duration of pain relief was greater than by the use of isolated procedures. The reduction in pain and disability was statistically and clinically significant. This benefit was extended in duration, and it persisted through the fourth week. Our findings are comparable with Gencer Atalay Ket al [26], who studied SSNB and intra-articular corticosteroid injection and concluded that it led to immediate relief in pain and functional improvement. Dai Z et al[27] observed that a combined approach of arthroscopic release and corticosteroid hydrodilatation yielded better results in terms of ROM and function as compared to corticosteroid hydrodilatation alone.

There are also various limitations to the study. Although the study was adequately supported, only a small number of patients were included in the analysis. The follow-up duration of the patients was also less, so long term effects could not be analysed.

Conclusion

This study provides evidence that Capsular distension with Suprascapular nerve block is better than capsular distension without suprascapular nerve block. Both procedure are safe, effective, and well tolerated treatment for patients with frozen shoulder.

References

1. Neviaser AS, Hannafin JA. Adhesive capsulitis: a review of current treatment. Am J Sports Med 2010;38:2346-56. . [Crossref][PubMed][Google Scholar]

2. Karata GK, Meray J. Suprascapular nerve block for pain relief in adhesive capsulitis: Comparison of 2 different techniques. Arch Phys Med Rehib 2002; 83:593-7. . [Crossref][PubMed][Google Scholar]

3. Dias R, Cutts S, Massoud S. Frozen shoulder: clinical review. Br Med J 2005;331:1453-6. . [Crossref][PubMed][Google Scholar]

4. Saqlain HA, Zubari A, Taufiq I. Functional outcome of frozen shoulder after manipulation under anesthesia. J Pak Med Assoc 2007;57:181-5. . [Crossref][PubMed][Google Scholar]

5. Lorbach O, Anagnostakos K, Scherf C, Seil R, Kohn D, Pape D. Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone application versus intra-articular cortisone injections. J Shoulder Elbow Surg 2010;19:172-9. . [Crossref][PubMed][Google Scholar]

6. Loebenberg MI, Rosen JE, Ishk C, Jazrawi LM, Zuckerman JD. A survey of decision making process in treatment of common shoulder ailments among primary care physicians. Bull Hosp Joint Dis 2006;63:137-44. . [Crossref][PubMed][Google Scholar]

7. Lee HJ, Lim KB, Kim D Y, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009;90:1997-2002. . [Crossref][PubMed][Google Scholar]

8. Harris JD, Griesser MJ, Copelan A, Jones GL. Treatment of adhesive capsulitis with intra-articular hyaluronate: A systematic review. Int J Shoulder Surg 2011;5:31-7. . [Crossref][PubMed][Google Scholar]

9. Taskaynatan MA, Yilmaz B, Ozgul A, Yazicioglu K, Kalyon TA. Suprascapular nerve block versus steroid injection for non specific shoulder pain. Tohoku J Exp Med 2005;205:19-25. . [Crossref][PubMed][Google Scholar]

10. Boyles RE, Flynn TW, Whitman JM. Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: a case series. Man Ther 2005;10:80-7. . [Crossref][PubMed][Google Scholar]

11. Dahan TH, FortinL, Pelletier M, Petit M, Vadeboncoeur R, Suissa S. Double blind randomized clinical trial examining the efficacy of bupivacaine suprascapular nerve blocks in frozen shoulder. J Rheumatol 2000;27:1464-9. . [Crossref][PubMed][Google Scholar]

12. Wassef MR. Suprascapular nerve block: a new approach for the management of frozen shoulder. Anaesthesia 1992;47:120-4. . [Crossref][PubMed][Google Scholar]

13. Shanahan EM, Smith MD, Wetherall M, Lott CW, Slavotinek J, FitzGerald O, et alSuprascapular nerve block in chronic shoulder pain: are the radiologists better? Ann Rheum Dis 2004;63:1035-40. . . . [Crossref][PubMed][Google Scholar] [Crossref][PubMed][Google Scholar]

14. Yasar E, Vural D, Safaz I, Balaban B,Bilge, Ahmet Y, Goktepe AS, Alaca R. Which treatment approach is better for hemiplegic. . . [Crossref][PubMed][Google Scholar] [Crossref][PubMed][Google Scholar] [Crossref][PubMed][Google Scholar]

15. Shanahan EM, Ahern M, Smith M, Wetherall M,BresnihanB,FitzGeraldO. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain. Ann Rheum Dis 2003;62:400-406. . [Crossref][PubMed][Google Scholar]

16. Dangoisse MJ, Wilson DJ, Glynn CJ. MRIand clinical study of an easy safe technique of suprascapular nerve blockade. Acta Anaesth Belg1994;45:49-54. . [Crossref][PubMed][Google Scholar]

17. BalA, Eksioglu E, Gulec B,Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clin Rehabil 2008;22:503-12. . [Crossref][PubMed][Google Scholar]


ojmpc 2023;29(1)21
Chauhan et al: Fluroscopic guided capsular distention suprascapular nerve block

18. Ryans I, Montgomery A, Galway R. A randomized controlled trial of intra-articular triamcinolone and/or physiotherapy in shoulder capsulitis. Rheumatology 2005; 44:529-35. . [Crossref][PubMed][Google Scholar]

19. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long term follow-up. J Bone Joint Surg Am 1992;74:738–46. . [Crossref][PubMed][Google Scholar]

20. MooreDC. Blockofsuprascapularnerve. In: Thomas CC, ed. Regional nerve Block. 4thed.Springfield,1979;9:300-303 [Crossref][PubMed][Google Scholar]

21. Haque R, Baruah RK, Bari A, Sawah A. Is Suprascapular Nerve Block Better Than Intra-articular Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder? A Randomized Controlled Study. Ortop Traumatol Rehabil. 2021 Jun 30;23(3):157-165. doi: 10.5604/01.3001.0014.9152. PMID: 34187937 [Crossref][PubMed][Google Scholar]

22. Shanahan EM, Gill TK, Briggs E, Hill CL, Bain G, Morris T. Suprascapular nerve block for the treatment of adhesive capsulitis: a randomised double-blind placebo-controlled trial. RMD Open. 2022 Nov;8(2):e002648. doi: 10.1136/rmdopen-2022-002648. PMID: 36418088; PMCID: PMC9685228 [Crossref][PubMed][Google Scholar]

23. ElKardosy M, Mahmoud A, Zidan A, Elsawy G. Role of interventional radiology in Management of Chronic shoulder pain. Al-Azhar International Medical Journal. 2021;. [Crossref][PubMed][Google Scholar]

24. Debeer P, Commeyne O, De Cupere I, Tijskens D, Verhaegen F, Dankaerts W, Claes L, Kiekens G. The outcome of hydrodilation in frozen shoulder patients and the relationship with kinesiophobia, depression, and anxiety. J Exp Orthop. 2021 Sep 30;8(1):85. doi: 10.1186/s40634-021-00394-3. PMID: 34591188; PMCID: PMC8484410 [Crossref][PubMed][Google Scholar]

25. Goyal T, Singh A, Negi P, Kharkwal B. Comparative functional outcomes of patients with adhesive capsulitis receiving intra-articular versus sub-acromial steroid injections: case-control study. Musculoskelet Surg. 2019 Apr;103(1):31-35. doi: 10.1007/s12306-018-0538-8. Epub 2018 May 23. PMID: 29796762 [Crossref][PubMed][Google Scholar]

26. Gencer Atalay K, Kurt S, Kaplan E, Yağcı İ. Clinical effects of suprascapular nerve block in addition to intra-articular corticosteroid injection in the early stages of adhesive capsulitis: A singleblind, randomized controlled trial. Acta Orthop Traumatol Turc. 2021 Dec;55(6):459-465. doi: 10.5152/j.aott.2021.21071. PMID: 34967732 [Crossref][PubMed][Google Scholar]

27. Dai Z, Liu Q, Liu B, Long K, Liao Y, Wu B, Huang W, Liu C. Combined arthroscopic release with corticosteroid hydrodilatation versus corticosteroid hydrodilatation only in treating freezing-phase primary frozen shoulder: a randomized clinical trial. BMC Musculoskelet Disord. 2022 Dec 17;23(1):1102. doi: 10.1186/s12891-022-06065-3. PMID: 36528565; PMCID: PMC9758809 [Crossref][PubMed][Google Scholar]

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