|Year : 2016 | Volume
| Issue : 1 | Page : 49-54
Comparison of clinical effects of ultrasound guided suprascapular nerve block and oral pregabalin versus suprascapular nerve block alone for pain relief in frozen shoulder
Pratik Kumar Mitra, Dipasri Bhattacharya
Department of Anesthesiology and Critical care and Pain, R.G. Kar Medical College, Kolkata, West Bengal, India
|Date of Web Publication||7-Jan-2016|
Dr. Dipasri Bhattacharya
B-26/10, Abhyudoy Housing, EKTP, Kolkata - 700 107, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Frozen shoulder is a painful and disabling condition in patients in 40-70 years age group , affecting 2-5% of general population. Aim of the study was to assess pain relief and functional improvement after supracapular nerve block with or without pregabalin, in patients with diagnosed case of frozen shoulder who failed to respond to medical treatment for 3 months. Material and methods: 100 patients with unilateral frozen shoulder was divided into two equal groups (n = 50) in a randomized double blind protocol. Group A (n = 50) received three doses of suprascapular nerve block and oral pregabalin 75 mg at bed time daily while Group B (n = 50) received suprascapular nerve block and oral placebo tablets in a similar way. Suprascapular nerve block was given with Inj depot methyl prednisolone acetate 1 ml (40 mg) + 9 ml 0.25% inj bupivacine for three successive weeks with ultrasound. Patients were followed up at 4 th , 6 th and 12 th week after injection. Visual Analogue Scale (VAS) was used to assess intensity of pain and range of movement estimated using goniometer in terms of abduction, external rotation and internal rotation in sitting position. Results: Results showed Group-A patients had almost complete pain relief and significant improvement in the range of movement at the end of 12 th week compared to Group B (P < 0.05). Conclusion: Combination therapy of suprascapular nerve block and oral pregabalin 75 mg is better for patients with frozen shoulder compare to suprascapular nerve block only.
Keywords: Frozen shoulder, oral pregabalin, range of movement, suprascapular nerve block, Visual Analogue Scale, ultrasound
|How to cite this article:|
Mitra PK, Bhattacharya D. Comparison of clinical effects of ultrasound guided suprascapular nerve block and oral pregabalin versus suprascapular nerve block alone for pain relief in frozen shoulder. Indian J Pain 2016;30:49-54
|How to cite this URL:|
Mitra PK, Bhattacharya D. Comparison of clinical effects of ultrasound guided suprascapular nerve block and oral pregabalin versus suprascapular nerve block alone for pain relief in frozen shoulder. Indian J Pain [serial online] 2016 [cited 2020 May 30];30:49-54. Available from: http://www.indianjpain.org/text.asp?2016/30/1/49/173473
| Introduction|| |
Frozen shoulder is a very common extremely painful condition of the shoulder mostly affecting middle and old age group.  It is rare in children and people under 40 but peaks between 40 and 70 years of age. It is often considered to be self-limiting, but the available evidence does not support this.  Women are more often affected than men, and it is common in persons with diabetes. It is a diffuse inflammatory process involving all the soft tissue components of the scapula humeral joint including the biceps tendon (bicipital tenosynovitis), insertion of deltoid and rotator cuff. Though complete remission often occur within 2 years, most of the patients suffer from severe pain at night initially followed by pain or stiffness or both for a long period. 
Despite the increased understanding of the underlying pathology,  there is still confusion regarding which is the most effective treatment. Physiotherapy can help in the early stages, but in established shoulder pain of synovial origin it has been demonstrated to be of little benefit. ,, Various different modalities of treatment have been recommended like nonsteroidal anti-inflammatory drugs, nerve blockade, opioids, intra-articular injection of corticosteroid, physiotherapy, manipulation under anesthesia and combination of these. ,,,,,
It has been suggested that a suprascapular nerve block may be a more effective alternative treatment. This technique, which was first described in 1941,  aims to block the nerves to the glenohumeral joint as they branch from the suprascapular nerve near the scapular notch, and has been used to reduce shoulder pain caused by a range of pathologies. In the classical technique, the needle is aimed, perpendicular to the skin, into the region of the scapular notch. Reported complications, including pneumothorax and damage to the suprascapular nerve and vessels, have limited its use. The modified technique described by Dangoisse et al.  is safer but not without complications. So we have used ultrasound real image technique to detect suprascapular nerve in suprascapular groove and then inject the drug.
Pregabalin is second-generation antiepileptic drug. Pregabalin is described chemically as (S)-3-(aminomethyl)-5-methylhexanoic acid. It is used for treating pain caused by neuropathic pain. The mechanism of action of pregabalin in preventing neuropathic pain is not definitely known. Its binding to the alpha2-delta subunit in central nervous system may be involved in antinociceptive and anti-seizure effects in animal models. In vivo Pregabalin binds to calcium channels on nerves and may modify the release of neurotransmitters act as an analgesic and prolongs duration of local anesthetics. It decreases release of neurotransmitter by binding to voltage-dependent calcium channel.
As the etiology of frozen shoulder is multifactorial with probably a neuropathic component may be one of the causes, we have used pregabalin with suprascapular nerve block in one group and compared the result with the group where suprascapular nerve block alone was used.
| Materials and Methods|| |
This randomized prospective, double blind analytical study was conducted at pain clinic of R.G. Kar Medical College, Kolkata, between 14 June 2012 and 14 June 2014. 100 patients during that period were selected randomly using random number table and divided into two groups (Group A and Group B), each with 50 patients after obtaining informed written consent and ethical committee approval. Inclusion criteria were: Age between 40 and 60 years, weight 40-70 kg, ASA I, II and III, unilateral frozen shoulder not responding to medicine and physiotherapy for 3 months, no history of trauma, contralateral normal shoulder, blood glucose, erythrocyte sedimentation rate, and rheumatoid arthritis factor within normal limit, normal X-ray of affected shoulder and loss of movement (external rotation <50°, internal rotation <70°, passive combined abduction <100° with constant or radiating pain beyond the elbow or disturbed sleep.
Exclusion criteria included ASA IV patients, bilateral involvement of the shoulder joint, hypersensitivity to pregabalin and diabetes mellitus.
Baseline Visual Analogue Scale (VAS) score, range of movements (external rotation, abduction, internal rotation) were checked. Range of motion estimated using goniometer, VAS score was evaluated using scale constructed of 10cm line anchored at one end by "0" means no pain and at the other end "10" which means severe unbearable pain. All the patients were examined prior to treatment and on 4 th week, 6 th week, 12 th week after injection, degree of pain relief and range motion examined.
All injections were administered by the same doctor in the pain clinic with proper aseptic technique as required for minor surgical procedure.
A mixture of 1 ml (40 mg) depot methyl prednisolone acetate + 9 ml of 0.25% bupivacaine was injected using ultrasound to detect suprascapular notch and the nerve. All patients seated with elbow flexed to 90° and a line drawn along the length of the spine of scapula. This was bisected with a vertical line drawn from the angle of scapula, dividing the scapula into two quadrants. After skin preparation, 2 ml 2% lignocaine was injected for local anesthesia at the proposed site of injection. Ultrasound probe was used after proper lubrication, 2.5 cm along the line of the spine in the upper outer quadrant. After identifying the nerve in the suprascapular groove, the needle was directed over the spine in the plain of scapula until the tip was visualized in the floor of suprascapular fossa. 9 ml of 0.25% bupivacaine and 1 ml (40 mg) of depomethyle prednisolone was used for suprascapular nerve block. 50 patients in Group A received tablet pregabalin 75 mg and the same patient in Group B received placebo at bedtime started from day 1 of nerve block.
Following each treatment, all patients were given verbal and written instruction regarding a home exercise program of self-mobilization, joint stretching and static rotator cuff strengthening. Patients of Group A were also informed about side effects of pregabalin like dizziness, drowsiness, dry mouth, edema, blurred vision, weight gain, muscle pain and advised to report us if any of the symptoms appeared.
| Results|| |
For the purpose of data analysis, multiple table and table diagram have been used. Simple percentage, mean and standard deviation have been calculated. Different tests are significant for this study like Chi-square test, paired t-test, independent t-test and relative risk with 95% confidence interval have been calculated. For this study purpose SPSS version 19 was utilized.
[Table 1] showed patients of both the group were comparable with respect to age, weight, duration of symptoms (P > 0.05).
|Table 1: Distribution of the participants as per their baseline demographic and clinical attributes (n = 50)|
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[Table 2] showed patients of both groups were comparable with respect to gender and shoulder involved (P > 0.05).
|Table 2: Distribution of the participants as per their baseline demographic and clinical attributes (n = 50)|
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[Table 3] showed analysis of within-group variation of VAS score, internal rotation, abduction and external rotation after the intervention in Group A (suprascapular nerve block and oral Pregabalin) and Group B (suprascapular nerve block alone). There was improvement in VAS score and range of movements in both the groups after treatment (P < 0.05).
|Table 3: Distribution of within-group variation of different clinical attributes after the intervention (n = 50)|
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[Table 4] showed the distribution of the study subjects as per VAS before and after the intervention.
|Table 4: Distribution of the study subjects as per VAS, extent of abduction, external rotation, internal rotation before and after the intervention (n = 50)|
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[Figure 1] showed there was a significant decrease in pain sensation in Group A compared to Group B at 4 th week, 6 th week and 12 th week after intervention, and it was statistically significant (P < 0.05).
|Figure 1: Visual analogue scale score - showed visual analogue scale score in both the groups and the difference were statistically significant (P < 0.05)|
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[Figure 2] showed improvement in active and passive shoulder abduction at 4 th week, and some improvement at 6 th week and 12 th week compare to 4 th week. Improvement in Group A was more compared to Group B, and it was statistically significant (P < 0.05).
|Figure 2: Range of abduction - showed range of abduction in both the groups and the difference were statistically significant (P < 0.05)|
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[Figure 3] showed both groups had improvement in active and passive external rotation of the shoulder at 4 th week. Improvement in Group A was more compared to Group B, and it was statistically significant (P < 0.05). Improvement at 6 th week and 12 th week compare to 4 th week was not significant in both the groups.
|Figure 3: External rotation - showed range of external rotation in both the groups and the difference were statistically significant (P < 0.05)|
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[Figure 4] showed improvement in active and passive internal rotation of the shoulder at 4 th week. Improvement in Group A was more compared to Group B, and it was statistically significant (P < 0.05). Improvement at 6 th week was not significant compared to 4 th week in both the groups.
|Figure 4: Internal rotation - showed range of internal rotation in both the groups and the difference were statistically significant (P < 0.05)|
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| Discussion|| |
In this study, the degree of pain relief and the range of movement were significantly improved after treatment in both the group but Group A had more improvement compared to Group B, and the result was statistically significant.
Three doses of suprascapular nerve block were given at 1 week interval using ultrasound technique in both the groups along with oral pregabalin 75 mg daily in Group A and placebo in Group B. Suprascapular nerve block was given with 40 mg depot methyl prednisolone acetate + 9 ml of 0.25% bupivacaine. We have used ultrasound technique for perfect real time image of the nerve block.
Suprascapular nerve originates from the C5 and C6 nerve roots of the superior trunk of the brachial plexus; contribution from the C4 is usually present as well.  It descends posteriorly, passing through the scapular notch, innervating the supraspinatus and the infraspinatus muscle. ,
It supplies sensory fibers to about 70% of the shoulder joint including the superior and posterior-superior regions of the shoulder joint and capsule  and the acromial clavicular joint.  In addition, it supplies motor branches to the supraspinatus and infraspinatus muscle.
There are multiple etiologies of frozen shoulder. In 1872, Duplay described a painful stiffening condition of the shoulder and termed it periarthrite scapulohumeral. , The initial stage of frozen shoulder is the freezing or painful stage, which last for 6-9 months, the next stage is slow improvement of pain but stiffness last for 4-9 months. In the last stage is the thawing or recovery stage (5-26 months).  Bicipital tenosynovitis is responsible for the pain factor.  The main anatomical changes are the thickening of coracohumeral ligament and superior glenohumeral ligament (component of rotator interval capsule).  In 1934 Codman gave the name "frozen shoulder" stating that it was characterized by insidious onset of pain near insertion of deltoid, inability to sleep on affected side, painful and restricted abduction, external rotation but normal radiological appearance.  The pain is neither typical of inflammatory pain nor of definite neurogenic type which is more severe during the night, complex regional pain syndrome  may be the cause.
We blocked the nerve with two drugs bupivacaine and methyl prednisolone acetate. Bupivacaine worked for 24-72 h after that steroid worked. Steroid blocks transmission of nociceptive C fiber by decrease in the central sensitization of dorsal horn nociceptive neurons (wind down theory).  Its ability to inhibit the synthesis, release of pro-inflammatory substances, to inhibit neuronal peptide synthesis or action, to suppress the ongoing neuronal discharge (by alternation of function of potassium channel on the excitable tissue). ,
Pregabalin is a second-generation antiepileptic medication. It binds to calcium channels on nerves and may modify the release of neurotransmitters act as an analgesic and prolongs duration of local anesthetics.  It decreases release of neurotransmitter by binding to voltage-dependent calcium channel. ,,
Biswas et al. in 2012 showed 3 doses of suprascapular nerve block better than single dose or two doses  which conforms to our study.
In many patients, three doses of nerve block pain were persisted. This may be due to the fact that supraspinatus tendinitis may be associated with involvement of rotator cuff tears, osteoarthritis and bone fractures. As all the patients have normal X-ray of the affected shoulder (as per inclusion criteria), osteoarthritis and bone fractures were excluded.
Symptoms of a rotator cuff tear include pain when lifting or lowering the arm, weakness when moving the arm, atrophy of the muscles around the shoulder and a crackling sensation while moving the shoulder in certain positions. In these patients, only suprascapular nerve block will not give complete pain relief. So we used combination therapy of three doses of suprascapular nerve block with pregabalin, and our study showed better pain relief in this group compared to nerve block alone. Fewer patients had persisting pain more than 3 months after initiation of combination therapy. They were excluded from study and dose of pregabalin increased and sent for surgical opinion. So, more and more studies are required to evaluate the optimal dose of oral pregabalin.
The side effects like dizziness, sweating for short duration following nerve block were noted but the long term side effect of steroid like fluid retention, sodium retention, hypertension, congestive heart failure, peptic ulcer were not noted probably due to small dose of depot methyl prednisolone used in our study and small sample size. Side effect of steroid usually does not appear with a safe dose.  One patient got vasovagal attack while the procedure managed conservatively and excluded from the study.
So to conclude ultrasound guided suprascapular nerve block with oral pregabalin is a better technique of pain relief improving range of movement in patients suffering from frozen shoulder not responding to conservative treatment.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]