Getting Faster Results with Injection for Frozen ShoulderAdhesive capsulitis, otherwise known as frozen shoulder can be very painful and disabling, no matter what your culture or activities. In this study from South Korea, researchers compared the results of shoulder injection using two different methods. Change n pain, arm motion, and function such as eating with chopsticks, combing the hair, or using a computer were outcomes used to measure the results.
The treatment was an injection of a numbing agent (lidocaine) and triamcinolone (steroid) directly into the joint. Then each of the patients received five more (once a week) injections of sodium hyaluronate, a tissue lubricant to help the joint slide and glide more easily. There were two groups of patients all diagnosed with adhesive capsulitis matched by age, sex, affected side, and how long they had the symptoms of pain and loss of motion. After the first injection, the patients were all given instruction in some shoulder exercises to improve motion and mobility. The exercises were to be done at home every day.
The difference in treatment was in the way the injection was delivered. In one group, a doctor with seven years experience gave the injections by palpation (vision and touch to find the right spot). In the second group, ultrasound imaging was used to guide the needle into the joint. The physician using the ultrasound technique had two years of experience with this treatment approach. Ultrasound is replacing fluoroscopy (real-time 3-D imaging), which has been the preferred guidance system. But fluoroscopy is an X-ray technique that exposes the patient to radiation. So, the new and improved ultrasound machines now available may make it possible to replace fluoroscopy in this treatment.
The authors provided a detailed description of the technique used for both the blind (palpation-guided) and the ultrasonography-guided procedures. Patient position, arm position, type of equipment used, and type of needle and placement of needle are discussed. Photos of both techniques are provided. Before and after measurements were taken of pain levels, joint range-of-motion, and function. A special 10-function test previously published by K. H. Cho was used to assess function. Pain was rated for each of the 10 specific activities in the Cho test. The patients also completed the visual analog scale. (VAS), which is a measure of global (overall) pain.
If you thought the ultrasound-guided injections gave better results, you guessed right. But only for the first two weeks. Patients in the ultrasound group did report significant improvement in all areas. By the third week, the results evened out for the two groups and no further advantage was seen for the ultrasound-guided treatment group.
Patients in both groups continued to report decreased pain levels as the weeks went by. The ultrasound-guided group got the most relief early on with improved motion as well, but the final results were equal between the two groups. The same pattern was seen for shoulder/arm function -- early improvements in the ultrasound group that were matched several weeks later in the blind-guided group.
How should these results be interpreted? The authors suggest that accuracy of injection makes the difference. In fact, previous studies comparing blind to ultrasound-guided injections showed a 33 to 46 per cent accuracy rate with blind injections but a 93 per cent accuracy rate with ultrasound-guided injections. It's hard to argue with those kind of statistics.
And this study confirms that along with improved accuracy comes rapid improvement of symptoms. Patients with serious limitations in shoulder movement and function appreciate those kind of rapid results when it comes to quality of life issues such as getting dressed, getting back to work, and even being able to wipe the bottom after toileting.
The authors conclude that they will continue to follow a protocol of ultrasound-guided articular injections for patients with chronic adhesive capsulitis who have not responded well to conservative care. In their country, where national health insurance provides care for patients, cost is not a factor as it might be in the United States.
Hong-Jae Lee, MD, et al. Randomized Controlled Trial for Efficacy of Intra-Articular Injection for Adhesive Capsulitis: Ultrasonography-Guided Versus Blind Technique. In Archives of Physical Medicine and Rehabilitation. December 2009. Vol. 90. No. 12. Pp. 1997-2002.
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