|Year : 2022 | Volume
| Issue : 2 | Page : 90-94
Ultrasonography-guided hydrodissection using platelet-rich plasma or corticosteroid in adhesive capsulitis of the shoulder: A comparative study
Iqra Mehak, Aftab Hussain, Hammad Usmani, Syed Hussain Amir
Department of Anaesthesiology and Critical Care, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Submission||13-Jan-2022|
|Date of Decision||24-Apr-2022|
|Date of Acceptance||25-Apr-2022|
|Date of Web Publication||25-Aug-2022|
Dr. Aftab Hussain
Assistant Professor, Pain Clinic, Department of Anaesthesiology, A.M.U, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Adhesive capsulitis is a condition that presents with pain and progressive limitation of both active and passive shoulder movements. It can be primary or secondary, the latter includes causes such as rotator cuff tear, cardiovascular disease, and diabetes mellitus. The American Shoulder and Elbow Surgeons defines that adhesive capsulitis is a condition of uncertain ethology characterized by a significant restriction of both active and passive shoulder motions that occur in the absence of known intrinsic shoulder disorder. Commonly described as: Stage 1 – Freezing stage, with pain and stiffness lasting around 9 months. Stage 2 – Frozen stage, with persistent stiffness lasting 4–12 months. Stage 3 – Thawing stage, with spontaneous recovery lasting 12–42 months. Ultrasonography (USG)-guided hydrodissection is used for adhesive capsulitis of the shoulder due to its cost-effectiveness and acceptance among patients. As adhesive capsulitis is postulated as an i nflammatory and fibrotic disease, easy treatment with intra-articular corticosteroids (CSs) injection may reduce synovitis, limit the development of capsular fibrosis, and alter the natural history of disease. CS injections are effective for shorter duration, but newer agents such as platelet-rich plasma (PRP) are more effective with no serious side effects. Materials and Methods: In this study, 40 patients were taken of adhesive capsulitis of the shoulder and were divided randomly into two groups. One group received injection PRP and the other group received injection CS. The outcome was recorded. Results: There was a statistically significant reduction in numeric rating scale pain scores in both the groups over a time period of 6 weeks, but the PRP injection was observed to be better in reducing the pain scores when compared to the CS injection after the 6th week (P = 0.037). Initially, the CS injection performed better in the 1st week due to anti-inflammatory action. By the 3rd week, both the injections showed a similar effect. However, at the end of the study period (6 weeks), there was a better reduction in the Shoulder Pain and Disability Index (SPADI) pain scores (P = 0.0057) and SPADI disability scores (P = 0.029) of the group PRP. Conclusion: We concluded that USG-guided hydrodissection with PRP is more effective therapy than CS in terms of reduction of pain and improvement in shoulder function in the treatment of adhesive capsulitis of shoulder.
Keywords: Adhesive capsulitis, platelet-rich plasma, ultrasonography
|How to cite this article:|
Mehak I, Hussain A, Usmani H, Amir SH. Ultrasonography-guided hydrodissection using platelet-rich plasma or corticosteroid in adhesive capsulitis of the shoulder: A comparative study. Indian J Pain 2022;36:90-4
|How to cite this URL:|
Mehak I, Hussain A, Usmani H, Amir SH. Ultrasonography-guided hydrodissection using platelet-rich plasma or corticosteroid in adhesive capsulitis of the shoulder: A comparative study. Indian J Pain [serial online] 2022 [cited 2022 Sep 30];36:90-4. Available from: https://www.indianjpain.org/text.asp?2022/36/2/90/354721
| Introduction|| |
Adhesive capsulitis, as defined by the American Shoulder and Elbow Surgeons, is “a condition of uncertain ethology characterized by a significant restriction of both active and passive shoulder motions that occur in the absence of a known intrinsic shoulder disorder.” This condition is characterized by shoulder pain and limitation of movement in the upper extremity. Both active and passive shoulder movements are affected, mainly involving the glenohumeral joint. It commonly affects patients suffering from diabetes mellitus (20% of the incidence), affecting 2%–5% of the general population. The ethology can be idiopathic or secondary to shoulder injury such as rotator cuff tear, cardiovascular diseases, and diabetes mellitus.,
There are three stages of adhesive capsulitis: Stage 1 is freezing stage (2–9 months) characterized by pain and stiffness; Stage 2 is frozen stage (4–12 months) characterized by persistent stiffness; and Stage 3 is thawing stage (12–42 months) that comprises spontaneous recovery. The symptoms are generally self-limiting over 1 to 3 years, more commonly affecting females over males in the 5th and 6th decades. The treatments for this condition aim to relieve pain, restore movement, and eventually regain shoulder function. The treatment options can be conservative or invasive. Conservative methods include nonsteroidal anti-inflammatory drugs (NSAIDS) and physical therapy, less invasive methods are corticosteroid (CS) injections, injection of saline with local anesthetic, pure invasive include capsular distension, myofascial release, manipulation under anesthesia, and arthroscopic capsular release.,
Intra-articular CS injection is one of the most commonly used procedures for treating adhesive capsulitis due to it being economical and easily acceptable among patients. The CS injection provides symptomatic relief and prevents the formation of capsular fibrosis, but it is associated with increased blood sugar levels, increased risk of tendon rupture, harmful effects on articular cartilage, local depigmentation of the skin, and atrophy of subcutaneous tissue. Recently, new evidence has emerged on the effectiveness of the orthobiologic agent, platelet-rich plasma (PRP), as an adjuvant in treating musculoskeletal injuries. In PRP therapy, autologous platelets obtained after centrifugation of whole blood are concentrated and then injected back into the affected shoulder joint. Alpha granules, present in the platelets, are rich in several growth factors such as platelet-derived growth factor, vascular endothelial growth factor, and epidermal growth factor. These play an important role in repair and stimulate healing process of tissues with chronic injuries and relieve pain and stiffness of joints., PRP is safe, and it has antinociceptive, anti-inflammatory, and regenerative properties.
The objective of this study was to compare the effects of single intra-articular PRP injection with single intra-articular CS injection. We hypothesized that although CS injections are good in providing symptomatic relief to the patients in early stages of adhesive capsulitis, PRP will ultimately provide better improvement in pain and shoulder function.
| Materials and Methods|| |
Forty patients suffering from adhesive capsulitis were chosen for this study after proper clinical and radiological assessments. All the studies were performed at the pain clinic, Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College, AMU. The procedure was explained, and informed consent was taken. The patients were divided randomly into two subgroups: Subgroup A received injection PRP and Subgroup B received CS injection. All the patients were more than 18 years of age, with persistent shoulder pain diagnosed clinically and radiologically, more than 1/3rd restriction of shoulder flexion, abduction, and external rotation. Other selection criteria included willingness to participate in the study and forgo any other concomitant treatment modality. The exclusion criteria were intrinsic glenohumeral pathology, history of injection in the involved shoulder during preceding 6 months, history of shoulder trauma or surgery, patients receiving anticoagulants, aspirin, aspirin-containing NSAIDS, patients on antiplatelet or anticoagulant therapy or with hematological disorders, patients having hypersensitivity to local anesthetics, uncontrolled psychiatric disorder or major depression, patients with autoimmune disease, malignancy, uncontrolled diabetes mellitus, local infection or ongoing septicemia , hyperlipidemia, pregnant and breastfeeding females, and patients with body mass index >30.
The PRP injection was made by withdrawing 20 ml of the patient's venous blood, and with addition of Citrate Phosphate Dextrose solution with Adenine (CPDA), double centrifugation was done to get high concentration of PRP. It was filled in a syringe and 4 ml was injected in the affected shoulder joint of Subgroup A. The CS (triamcinolone acetonide), 4 ml was injected in affected shoulder joint of 18 patients in Subgroup B. Both the procedures were carried out under ultrasound guidance [Figure 1]a, [Figure 1]b and [Figure 2]. All patients were advised not to take any analgesics such as NSAIDS during the study period. All the patients were assessed 1 week before the procedure and standard protocol for treatment, i.e., a combination of oral tramadol 37.5 mg and paracetamol 325 mg was advised to them. Patients were followed up at 1 week postinjection, then after the 3rd week, and then at the end of the 6th week.
|Figure 1: (a and b) CPDA vials before and after used for preparation of PRP. CPDA: Citrate Phosphate Dextrose solution with Adenine, PRP: Platelet-rich plasma|
Click here to view
|Figure 2: PRP Ultra Machine – To prepare PRP using PRP vial containing patient's venous blood|
Click here to view
| Results|| |
All the subjects finished the entire 6-week study period. Most of the patients were in the age group of 40–60 years in both the groups. To assess the degree of pain and shoulder function, the numeric rating scale (NRS) and the Shoulder Pain and Disability Index (SPADI) scores were calculated for each patient at the start of the study and later at each follow-up visit. The mean and standard deviation of these values are presented in [Table 1] (PRP) and [Table 2] (CS). The average changes with respect to the baseline scores are also recorded. The repeated measures analysis of variance test was used to test for significant differences in scores at each time interval. Then, the NRS and SPADI scores for the two groups were compared at each period of time, and the significance in differences was evaluated using a paired t-test.
|Table 1: Changes of outcome measurements after platelet-rich plasma injection (n=20)|
Click here to view
|Table 2: Changes of outcome measurements after corticosteroid injection (n=20)|
Click here to view
There was a statistically significant reduction in NRS pain scores in both the groups over a time period of 6 weeks, but the PRP injection was observed to be better in reducing the pain scores when compared to the CS injection after the 6th week. Initially, the CS injection performed better in the 1st week due to anti-inflammatory action. By the 3rd week, both the injections showed a similar effect. However, at the end of the study period (6 weeks), a marked difference was observed between the resulting scores of PRP and CS groups. There was a significant reduction in SPADI scores of both the groups, but PRP gave better results in the long run compared to the other group [Table 3].
|Table 3: Comparison of changes from baseline between platelet-rich plasma and corticosteroid groups|
Click here to view
| Discussion|| |
The primary aim of this study was to evaluate the effectiveness of injection PRP and injection CS in the treatment of patients suffering from adhesive capsulitis of the shoulder. Adhesive shoulder capsulitis, or arthrofibrosis, describes a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to stiffness, pain, and dysfunction. Painful stiffness of the shoulder can adversely affect day-to-day activities and consequently impair quality of life.
PRP is an autogenous concentration of human platelets in a small volume of plasma. PRP can produce collagen and growth factors and might increase stem cells, which consequently enhances the healing process by delivering high concentrations of alpha granules containing biologically active moieties (such as vascular endothelial growth factor and transforming growth factor-β) to the areas of soft-tissue damage. PRP therapy is a volume of the plasma fraction of autologous blood that has platelet concentration above the baseline. It is theorized that PRP may help stimulate the development of normal-appearing histologic tissue characteristics at the repair site and improve clinical outcomes.
Niazi et al. carried out ultrasound-guided injection of PRP in rotator cuff tendinopathy and found that PRP injection is a safe, cheap, and easily prepared outpatient procedure, which showed competitive, promising, and well-proved results when compared to other modality outcomes such as conventional surgeries, arthroscopic procedures, and physiotherapy.
All the injections were performed under ultra sonographic guidance [Figure 3]. The radiological images while performing the injection on the shoulder joint have been shown in [Figure 4].
|Figure 3: (a and b) USG images of intra-articular shoulder injections. USG: Ultrasonography|
Click here to view
|Figure 4: (a and b) USG-guided intra-articular injections by anterior approach. USG: Ultrasonography|
Click here to view
In an interventional case series, Talay Çalış injected PRP into the glenohumeral joint under sonography guidance, at baseline and in week 2. Significant improvements were detected in visual analog scale (VAS), shoulder pain, and disability scores on weeks 2, 6, and 12 when compared with baseline (P < 0.05). There was a significant improvement in active and passive range of motions (ROMs) on weeks 2, 6, and 12 when compared with baseline (P < 0.05). Treatment of adhesive capsulitis with PRP may be an alternative treatment method. Kothari et al. assessed the efficacy of PRP injection and compared it with CS injection and ultrasonic therapy in the treatment of periarthritis shoulder. PRP treatment resulted in statistically significant improvements over CS and ultrasonic therapy in active as well as passive ROM of the shoulder, VAS, and QuickDASH at 12 weeks. At 6 weeks, PRP treatment resulted in statistically significant improvements over ultrasonic therapy in VAS and QuickDASH. No major adverse effects were observed. This study demonstrates that single injection of PRP is effective and better than CS injection or ultrasonic therapy in the treatment of periarthritis shoulder. In 2018, Schneider et al. reviewed the current literature regarding the indications and outcomes of PRP for the surgical and nonsurgical management of common shoulder pathologies, including rotator cuff tears. They found that the evidence in favor of PRP use for operative and nonoperative management of shoulder conditions is inconsistent and cannot be absolutely supported or refuted. However, the potential benefits of PRP, perhaps not yet elucidated, could outweigh the risks, which are minimal. Lin evaluated the efficiency of PRP in the treatment of frozen shoulder compared to procaine. PRP was more effective and had a more prolonged efficiency than the procaine control.
In our study, we injected injection PRP and injection CS into two groups of patients having adhesive capsulitis of the shoulder. The patients in both the groups showed a statistically significant difference in pain and shoulder function. However, injection PRP showed a significantly better improvement in pain and shoulder function at 6th week as compared to injection CS. A similar study was carried out by Agrawal et al., but there was an increase in pain for few participants at the 3rd day, causing decreased active ROM. No such effect was seen in our study. However, at the end of the 1st month, PRP resulted in statistically significant improvements. No major adverse effects were seen in PRP injection. Another similar study was carried out by Barman et al., where one dose of intra-articular PRP and CS injections was given in patients with adhesive capsulitis of the shoulder. At 12-week follow-up, a single dose of IA-PRP injection was found to be more effective than IA-CS injection, in terms of improving pain, disability, and range of movement of the shoulder.
Systemic effects of intra-articular CSs were studied by Habib. Serum cortisol levels were blunted, reduction in inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate metabolic, hematologic, vascular, allergic, visual, psychologic, and other effects were also reported. Due to concerns about steroid use around healthy/intact tendons, PRP injection has been reported in high-level athletes with subacromial inflammation. Hence, repeated injections of CS come with risks as compared to no significant side effects with PRP injection. Hence, PRP is a good alternative to those refusing repeated steroid injections.
| Conclusion|| |
We can conclude that both PRP and CS are effective in treating adhesive capsulitis of the shoulder. However, at the follow-up after the 6th week, the PRP injection was found to be more effective than the CS injection in terms of improving pain and disability in patients. This study provides evidence that PRP can be used with significantly better results in patients of adhesive capsulitis where CS is contraindicated or refused by the patient.
Financial support and sponsorship
Conflicts of interest
Dr. Aftab Hussain, Dr. Hammad Usmani, and Dr. S. Hussain Amir were editorial board member of IJPN at the time of article submission.
| References|| |
Koh KH. Corticosteroid injection for adhesive capsulitis in primary care: A systematic review of randomised clinical trials. Singapore Med J 2016;57:646-57.
Barman A, Mukherjee S, Sahoo J, Maiti R, Rao PB, Sinha MK, et al.
Single intra-articular platelet-rich plasma versus corticosteroid injections in the treatment of adhesive capsulitis of the shoulder: A cohort study. Am J Phys Med Rehabil 2019;98:549-57.
Jain MP, Agrawal D, Yadav D. Significance of platelet rich plasma (PRP) and Corticosteroid injection in management of adhesive capsulitis of shoulder. Int J Orthop Sci 2021;7:495-8.
Le HV, Lee SJ, Nazarian A, Rodriguez EK. Adhesive capsulitis of the shoulder: Review of pathophysiology and current clinical treatments. Shoulder Elbow 2017;9:75-84.
Aslani H, Nourbakhsh ST, Zafarani Z, Ahmadi-Bani M, Ananloo ME, Beigy M, et al.
Platelet-rich plasma for frozen shoulder: A case report. Arch Bone Jt Surg 2016;4:90-3.
El Gharbawy NH, Labib HS. Role of platelet rich plasma (PRP) injection in treatment of rotator cuff tear. Egypt Rheumatol Rehabil 2020;47:30.
Niazi GE, Hassan MS, Elfawy DM. Ultrasound-guided injection of platelet-rich plasma (PRP) in rotator cuff tendinopathy: Effect on patients' symptoms and supraspinatus tendon thickness. Egypt J Radiol Nucl Med 2020;51:111.
Talay Çalış H. Effects of platelet rich plasma injection on adhesive capsulitis: An interventional case series. Erciyes Med J 2019;41: doi: 10.14744/etd. 2019.16362.
Kothari SY, Srikumar V, Singh N. Comparative efficacy of platelet rich plasma injection, corticosteroid injection and ultrasonic therapy in the treatment of periarthritis shoulder. J Clin Diagn Res 2017;11:C15-8.
Schneider A, Burr R, Garbis N, Salazar D. Platelet-rich plasma and the shoulder: Clinical indications and outcomes. Curr Rev Musculoskelet Med 2018;11:593-7.
Agrawal AC, Nayak B, Sakale H. Management of adhesive capsulitis of shoulder joint by single platelet rich plasma injection. J Orthop Traumatol Rehabil 2019;11:62. [Full text]
Habib GS. Systemic effects of intra-articular corticosteroids. Clin Rheumatol 2009;28:749-56.
Garbis N, et al.
Clinical indications and techniques for the use of platelet-rich plasma in the shoulder. Oper Tech Sports Med 2011;19:165-9. doi: 10.1053/j.otsm.2011.03.002.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]