A Comparative Study on Assessment of Pain as an Outcome by Vas Score in Patients of Adhesive Capsulitis Treated by Hydrodilatation with and ...
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4460 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
A Comparative Study on Assessment of Pain as an Outcome
by Vas Score in Patients of Adhesive Capsulitis Treated by
Hydrodilatation with and without Corticosteroids
Kunal.K.Saoji, Vasant Gawande2, Tejas Sadavarte3, Kiran M Saoji4
1
Assistant Professor, Department of Orthopedics, Shalinitai Meghe Hospital and Research Centre. (SMHRC),
Wanadongri, Hingna. (Maharashtra), 2Associate Professor, Department of Orthopedics, Shalinitai Meghe Hospital
and Research Centre. (SMHRC), Wanadongri, Hingna. (Maharashtra),3Assistant Professor, Department Of Radio-
Diagnosis And Interventional Radiology, Shalinitai Meghe Hospital and Research Centre. (SMHRC), Wanadongri,
Hingna. (Maharashtra), 4HOD & Professor, Department Of Orthopedics, DMIMS(DU), JNMC, Sawangi
(Wardha)Maharashtra
Abstract
Background: Adhesive Capsulitis is a painful condition commonly occurring in middle age group population
and injectable corticosteroids have shown significant improvement in the pain as an outcome variable.
Methodology: A prospective study was conducted from June 2010 to June 2012 for a period of 2 year, at a
tertiary care hospital in central India. Results: The marked difference in pain relief was seen on VAS scale
on pre intervention to follow up of 3rd week. The mean on pre intervention of steroid group was (8.10) while
that post intervention 3rd week was (4.90). On the same basis, the pre injection mean was (7.55) in saline
group while post injection 3rd week mean came out to be (5.75). Thus, pain was relieved on injecting both
solutions. But, more improvement was observed in steroid group than saline group. Conclusion: Intra saline
group and steroid group analysis revealed a marked improvement in shoulder range of motion and pain relief
on immediate post intervention and follow up in hydro dilatation of steroid group of patients.
Keywords: Adhesive capsulitis, hydrodilatation, corticosteroids, Frozen shoulder, acromioclavicular joint.
Introduction and disturbing sleep, and difficulty in doing most normal
daily activities. Pain from the acromioclavicular joint is
The condition ‘adhesive capsulitis’ or ‘Frozen
common, because the restricted glenohumeral movement
shoulder’ is a clinical diagnosis; Physical examination
increases the stress on this joint.
is crucial and history also. It is essential to confirm the
characteristic features of the condition on grading, its Hannafin JA3 (2000) Reeves B4 (1975), divided
severity and exclude other contributory systemic or local into three consecutive stages:
causes which may require laboratory investigations,
‘freezing’ (10 – 36 weeks) with acute pain and
radiographs and imaging. The majority of patients with
stiffness,
adhesive capsulitis do not seek medical attention until
weeks to months after the onset of stiffness and pain. ‘frozen’ (4- 12 mths) with established stiffness and
reduced pain and
The pain is characteristically severe, felt diffusely
around the shoulder girdle, with a deep burning quality. ‘thawing’ (5-26 mths) with the return of movement.
Except other intermittent causes of shoulder pain, would
have been around for more than one month. However, clear stages of development are often
difficult to define, or may be absent.
Neviaser RJ 1 (1987) and Nicholson GP2 (2003)
stated that key diagnostic feature is intense night pain The history and physical examination areIndian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2 4461
essential to differentiating between painful shoulder 2. Patients contraindicated for steroid injection-
and stiffness with identifying true adhesive capsulitis. bleeding disorders, known drug allergy.
Patients will often describe an insidious onset of vague,
3. Patients whit history of trauma to shoulder
dull pain at the deltoid insertion, a pain pattern that
needing immobilization.
may be due to innervations of the joint capsule by the
axillary nerve. Night pain is a very common feature, 4. Patients with serious mental illness.
and sleeping is not possible on affected shoulder is one
of the symptom. Pain, restricted elevation and external 5. Patients with age under 18 or over 70.
rotation are common. As the patient progresses from the
6. Patients currently taking oral corticosteroid
freezing to frozen stage, the pain increases more, and the
therapy.
restriction in elevation and rotation increases4-6.
7. Patients with less glenohumeral range of
Methodology motion for reasons other than adhesive capsulitis with
Type of study: It was a hospital based prospective X-ray signs of glenohumeral arthritis, dislocation or
study carried for 2 years (June 2010 to June 2012) in a full-thickness rotator cuff tears with dislocations of the
single centre in a tertiary care hospital in Central India. humeral head.
Patients were randomized in two groups of 20 patients
Technique: The proper consent of the procedure
each
was taken from the patient and Xylocaine sensitivity
1. Group A-Injection of corticosteroid, local test was performed 45 minutes before the procedure.
anaesthetic and saline, The procedure was performed according to the Kaye-
Schneider technique. The patients were placed supine
2. Group B-Injection of normal saline and local on a table with an overhead X-ray tube and a supporting
anaesthetic. pillow under the opposite shoulder. Under image-
Inclusion Criteria: intensified fluoroscopy or ultrasonographically guided
a marker was placed over the glenohumeral joint space
1. Limitation of passive movement of the at about the junction of its middle and lower third or
glenohumeral joint compared with the unaffected side, just lateral to the coracoid process in collaboration with
more than 30 degrees for at least two of three movements: internventional radiology department for guidance.
forward flexion, abduction or external rotation.
This point was then marked on the skin with a pen.
2. Patients with previous adhesive capsulitis in the The skin area was cleaned with an antiseptic. The joint
opposite shoulder were accepted even if the differences was punctured by a needle (18 or 22 Gauge intramuscular
between sides were smaller than 30 degrees. spinal needle) and its position was checked frequently
by fluoroscopy during the procedure. The needle was
3. Patients with history of diabetes on medication
connected to a 20 ml syringe. Upto 16 ml of sterile
(controlled blood sugar levels) and limited range of
normal saline , 2 ml of local anesthetic (Bupivacaine
motion.
hydrochloride, 5 mg/ml), and an injection of 2 ml
All included patients were clinically assessed Depomedrol (80 mg Methyl Prednisolone) as total of 20
for restriction of active and passive range of motion. ml solution was injected slowly in group “A” patients.
Plain radiographs of shoulder joint to rule out other
Similar procedure was carried out for hydrodilatation
pathologies were done and ultrasonography of shoulder
in group “B” patients with 18ml of sterile normal saline
joint for confirming the diagnosis of adhesive capsulitis
and 2 ml of local anesthetic (Bupivacaine hydrochloride,
was carried out.
5 mg/ml),
Exclusion Criteria:
In both the groups, following hydrodilatation,
1. Patients not willing to give consent for study. manipulation of affected shoulder joint was done.4462 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
Results: A total of 40 patients were selected based The comparison between saline and steroid groups
on the inclusion and exclusion criteria for the study, using student’s unpaired t test with respect to VAS on
which were then divided into 2 groups of 20 patients 3rd week follow up resulted in a significant p value.
each. The mean value pre intervention was 8.05 and 7.55 in
steroid and saline groups respectively. There was no
The present study is to compare the pain on VAS
significant difference on comparing the two groups on
pre intervention and post injection (Hydrodilatation)
pre intervention analysis.
after 3 weeks. The intra group analysis of steroid group,
pre intervention to that on post injection resulted in a The post injection 3rd week follow up had a mean of
significant p value on student’s paired t test. The mean 4.8 and 5.7 in steroid and saline groups respectively. The
pre intervention value was 8.10 and post injection on the resultant p value was 0.033 giving a significant result.
3rd week follow up was 4.90. This shows pain reduces
The inference derived was that an improvement was
post injection on 3rd week follow up in steroid group.
observed using both steroid and saline groups. But the
Similarly the intra saline group analysis pre intervention
use of steroid was more effective in pain relief on 3rd
to that on 3rd week post injection gave a mean value of
week post intervention.
7.55 and 5.75 respectively, Hence the pain was reduced
post injection 3rd week comparatively.
Table 1 showing Comparison of pain on VAS at pre intervention and post injection 3 weeks in both the
groups.
Group Mean N Std. Deviation Std. Error Mean
Pre Intervention 8.10 20 1.05 0.23
Steroid
Post Injection 3 wks 4.90 20 1.07 0.23
Pre Intervention 7.55 20 1.14 0.25
Saline
Post Injection 3 wks 5.75 20 1.44 0.32
Table 2: Student’s paired t test
Paired Differences
95% Confidence Interval of
Group t df p-value
Std. the Difference
Mean Std. Deviation Error
Mean
Lower Upper
0.000
Steroid 3.15 1.26 0.28 2.55 3.74 11.11 19
pIndian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2 4463
Table 3 showing Comparison of VAS in both groups at pre intervention, And post injection 3 weeks in both
the groups
Group N Mean Std. Deviation Std. Error Mean
Steroid 20 8.10 1.05 0.23
Pre Intervention
Saline 20 7.55 1.14 0.25
Steroid 20 4.90 1.07 0.23
3 wks
Saline 20 5.75 1.44 0.32
Table 4: Student’s unpaired t test
95% Confidence
Interval of the
Mean Std. Error Difference
t df p-value
Difference Difference
Lower Upper
0.158
Pre Intervention 1.43 38 0.50 0.34 -0.20 1.20
NS,p>0.05
0.041
3 wks 2.11 38 0.85 0.40 0.07 1.66
S,p4464 Indian Journal of Forensic Medicine & Toxicology, April-June 2021, Vol. 15, No. 2
Ryans I16 (2005) found that patients having intra saline group.
articular corticosteroid therapy had better outcome in
Limitations: The limitations were Small study
disability scores but not in pain and range of motion in
sample, Single dosage of hydrodilatation. and Multiple
the 6th week.
operators, Lack of timely follow up and Lack of patient
Van der Windt DA17 (1983) in his trial of compliance for Physiotherapy.
fluoroscopically guided injection with and without
Conflict of Interest: Nil
physiotherapy found corticosteroid-injected patients had
less disability and good range of motion outcome at six Source of Funding: Nil
weeks compared with physiotherapy alone or placebo
injection. Ethical Clearance: taken from institutional ethics
committee
In our study both the groups received single shot
hydrodilatation. References
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