The outcome in patients with adhesive capsulitis of the shoulder following hydrodilation distension arthrography

Transcription

1 The outcome in patients with adhesive capsulitis of the shoulder following hydrodilation distension arthrography Poster No.: C-0371 Congress: ECR 2012 Type: Authors: Keywords: DOI: Scientific Paper R. Clement, A. Ray, C. Davidson, F. J. Perks, C. M. Robinson; Edinburgh/UK Musculoskeletal joint, Musculoskeletal soft tissue, Musculoskeletal system, Fluoroscopy, Arthrography /ecr2012/C-0371 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Purpose Distension arthrography of the glenohumeral joint was adopted as a mainstream treatment for adhesive capsulitis before any randomised controlled trials were performed. Interpretation of the effectiveness of this procedure rests on data from cohort studies of which there are few of high quality. Papers reporting on the long-term results have either excluded diabetic patients or failed to report on patient orientated outcome. We present a prospective cohort study of 51 patients with adhesive capsulitis of the shoulder who had a distension arthrogram performed by a single radiologist as a primary intervention. We included diabetic patients. We report on Oxford shoulder score, range of movement, visual analogue pain scores and disturbance of sleep. Methods and Materials Patients with adhesive capsulitis diagnosed by an orthopaedic specialist were eligible for inclusion in the study. INCLUSION AND EXCLUSION CRITERIA Inclusion Criteria Pain and stiffness for over 3 months associated with a restriction of motion in two or more planes of greater than 30 degrees Age over 18 Able to attend local follow up Exclusion Criteria Previous arthrographic distension Systemic inflammatory joint disease Radiological evidence of osteoarthritis or fracture Calcification about the shoulder joint Confirmed or suspected rotator cuff tear Contraindications to arthrogram and or distension including allergy to local anaesthetic or iodinated contrast Pregnancy DISTENSION PROCEDURE Page 2 of 17

3 Performed by one consultant musculoskeletal radiologist (FP) 1. Patient lying supine on the screening table. 2. Affected shoulder cleaned with anti-septic solution. 3. Arm held in external rotation to clear the biceps tendon from the needle path and a suitable skin entry site was then marked using fluoroscopy. 4. Local anaesthetic was injected into the skin and down the anticipated needle pathway (Xylocaine with epinephrine 1:200000). 5. A 19G needle was then inserted and intra-articular needle placement confirmed with iodinated contrast material injection ml 1% lidocaine and 80mg Kenalog (Triamcinolone) were then injected into the joint. 7. The joint capsule was then distended with up to 40ml of warmed saline. Saline was injected until the plunger became difficult to depress or the patient complained of pain. From this point on a few millilitres of saline was injected then the pressure was taken off to allow backflow into the syringe. 8. This process was repeated until all the saline was injected to a total capacity of 52mL or until capsular rupture that was felt as a sudden loss of capsular pressure with relief of discomfort. 9. The patient was referred for a physiotherapy session. OUTCOME MEASURES The following were recorded: 1. Oxford Shoulder Score 2. Visual Analogue Pain Score 3. Range of Movement: Measured bt visual estimation by a trained physiotherapist (CD) 4. Disturbance of sleep: Recorded as difficulty sleeping the night prior to examination as a direct result of shoulder pain only. These were taken at the following time points: 1. Immediately pre-procedure 2. 2 days post procedure 3. 1 month post procedure 4. Finally at a mean of 14 months post procedure (range 8-26 months). Results Page 3 of 17

4 Patient Demographics 51 patients (53 procedures) Age range: (mean age of 52) 22 females and 29 males Left shoulder affected in 31 cases, Right in 22 Dominant limb was affected in 23 patients Onset of adhesive capsulitis was secondary to trauma in 5 patients, following surgery in 2 and insidious in the remainder 12 patients had diabetes (50% type 1) Oxford Shoulder Score Oxford shoulder score improved from pre-procedure mean of 25.7 by 8.8 points at day 2, 14.2 points at 1 month and 16.9 points at final follow up in September 2011 (p <0.001 in each case). Time Number Mean Standard deviation pre-procedure days month final follow up Standard error of the mean Page 4 of 17

5 Fig. 1: Graphical representation of the Oxford shoulder score following distension arthrogram References: R. Clement; Edinburgh Orthopaedic Department, NHS Lothian, Edinburgh, UNITED KINGDOM Visual Analogue Pain Score Visual analogue pain scores improved from a mean pre-procedure score of 7.1 by -1.8 at 2 days, by -4.0 at 1 month and -3.5 by September Page 5 of 17

6 Fig. 2: Graphical representation of the visual analogue pain score following distension arthrogram References: R. Clement; Edinburgh Orthopaedic Department, NHS Lothian, Edinburgh, UNITED KINGDOM Range of Motion The mean improvement in ROM was highly significant (p <0.001) for all movements at both 2 days and 1 month. Flexion improved from a mean of degrees pre-procedure by 20.7 degrees at day 2 and by 39.3 degrees at 1 month. Page 6 of 17

7 Fig. 3: Graphical representation of the mean maximal flexion in patients following distension arthrogram References: R. Clement; Edinburgh Orthopaedic Department, NHS Lothian, Edinburgh, UNITED KINGDOM Abduction improved from a mean of 80.3 degrees by 36.5 degrees at day 2 and 55.2 degrees at 1 month. Page 7 of 17

8 Fig. 4: Graphical representation of the mean maximal abduction in patients following distension arthrogram References: R. Clement; Edinburgh Orthopaedic Department, NHS Lothian, Edinburgh, UNITED KINGDOM External rotation improved from degrees by 11.1 degrees at day 2 and 19.5 degrees at 1 month. Page 8 of 17

9 Fig. 5: Graphical representation of the mean maximal external rotation in patients following distension arthrogram References: R. Clement; Edinburgh Orthopaedic Department, NHS Lothian, Edinburgh, UNITED KINGDOM Disturbed Sleep 39 were troubled pre-distension, 19 at 2 days and only 6 at 1 month. This corresponds to an 84.6% reduction in the number of patients reporting sleep disturbance by 1 month after distension. Page 9 of 17

10 Fig. 6: Graph to show the number of patients with disturbed sleep secondary to shoulder pain before and after a distension arthrogram References: R. Clement; Edinburgh Orthopaedic Department, NHS Lothian, Edinburgh, UNITED KINGDOM Diabetic Patients There was no significant difference in any of the outcome measures when diabetic patients were compared to non-diabetic patients Images for this section: Page 10 of 17

11 Fig. 1: Graphical representation of the Oxford shoulder score following distension arthrogram Page 11 of 17

12 Fig. 2: Graphical representation of the visual analogue pain score following distension arthrogram Fig. 3: Graphical representation of the mean maximal flexion in patients following distension arthrogram Page 12 of 17

13 Fig. 4: Graphical representation of the mean maximal abduction in patients following distension arthrogram Page 13 of 17

14 Fig. 5: Graphical representation of the mean maximal external rotation in patients following distension arthrogram Fig. 6: Graph to show the number of patients with disturbed sleep secondary to shoulder pain before and after a distension arthrogram Page 14 of 17

15 Conclusion Distension Arthrograms are an effective treatment for adhesive capsulitis of the glenohumeral joint Patients report reduced pain, increased ROM, improved functional outcomes and reduced sleep disurbance following distention Diabetic patients do well following this procedure References 1. Loveday DT, Johnston P, Arthur A, Tytherleigh-Strong GM. Frozen shoulder: a clinical review. Br J Hosp Med (Lond) May;70(5): Duplay ES. Dr la peri-arthrite scapulo humerale et des raideurs de l'epaule qui en son la consequence. Arch Gen Med. 1872;20(51): Codman EA. The Shoulder. Boston: Thomas Todd; Neviaser J. Adhesive capsulitis of the shoulder: a study of pathologic findings in periarthritis of the shoulder. Journal of Bone and Surgery. 1945;27(2): Neviaser JS. Arthrography of the shoulder joint: study of the findings in adhesive capsulitis of the shoulder. Study of the findings in adhesive capsulitis of the shoulder. J Bone Joint Surg Am Oct;44-A: Anton HA. Frozen shoulder. Can Fam Physician Aug;39: Tighe CB, Oakley WS, Jr. The prevalence of a diabetic condition and adhesive capsulitis of the shoulder. South Med J Jun;101(6): Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br Jul;89(7): Rizk TE, Gavant ML, Pinals RS. Treatment of adhesive capsulitis (frozen shoulder) with arthrographic capsular distension and rupture. Arch Phys Med Rehabil Jul;75(7): Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4(4): Hazleman B. Why is a frozen shoulder frozen? Br J Rheumatol Apr;29(2):130. Page 15 of 17

16 12. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am Jun;74(5): Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ Dec 17;331(7530): Andren L, Lundberg BJ. Treatment of Rigid Shoulders by Joint Distension during Arthrography. Acta Orthop Scand. 1965;36: Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2008(1):CD Buchbinder R, Green S, Forbes A, Hall S, Lawler G. Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial. Ann Rheum Dis Mar;63(3): Corbeil V, Dussault RG, Leduc BE, Fleury J. [Adhesive capsulitis of the shoulder: a comparative study of arthrography with intra-articular corticotherapy and with or without capsular distension]. Can Assoc Radiol J Apr;43(2): Gam AN, Schydlowsky P, Rossel I, Remvig L, Jensen EM. Treatment of "frozen shoulder" with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial. Scand J Rheumatol. 1998;27(6): Jacobs LG, Barton MA, Wallace WA, Ferrousis J, Dunn NA, Bossingham DH. Intraarticular distension and steroids in the management of capsulitis of the shoulder. BMJ Jun 22;302(6791): Khan AA, Mowla A, Shakoor MA, Rahman MR. Arthrographic distension of the shoulder joint in the management of frozen shoulder. Mymensingh Med J Jan;14(1): Watson L, Bialocerkowski A, Dalziel R, Balster S, Burke F, Finch C. Hydrodilatation (distension arthrography): a long-term clinical outcome series. Br J Sports Med Mar;41(3): Bell S, Coghlan J, Richardson M. Hydrodilatation in the management of shoulder capsulitis. Australas Radiol Sep;47(3): Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perceptions of patients about shoulder surgery. J Bone Joint Surg Br Jul;78(4): Hayes K, Walton JR, Szomor ZR, Murrell GA. Reliability of five methods for assessing shoulder range of motion. Aust J Physiother. 2001;47(4): Page 16 of 17

17 25. Thomas WJ, Jenkins EF, Owen JM, Sangster MJ, Kirubanandan R, Beyon C, et al. Treatment of frozen shoulder by manipulation under anaesthetic and injection: does the timing of treatment affect the outcome? J Bone Joint Surg Br. Oct;93(10): Personal Information Page 17 of 17