Comparison of the Treatment Efficacy of Suprascapular Nerve Block and Intraarticular Shoulder Injection Techniques in Patients Diagnosed With Adhesive Capsulitis
Condition: Adhesive Capsulitis; Shoulder Pain
MeSH terms: Shoulder Pain; Bursitis
Study type: Interventional

Summary: 
      Objective: We aim to compare the efficiency of the ultrasonography-guided suprascapular nerve
      block (SSNB) and ultrasonography-guided intra-articular shoulder injection (IAI) techniques
      in terms of pain and functional status in the treatment of adhesive capsulitis.

      Design: 60 patients with adhesive capsulitis were divided into two groups: SSNB and IAI. Both
      groups received an injection of 1 ml of 40 mg of triamcinolone acetonide and 9 ml of 0.5%
      bupivacaine hydrochloride. The patients' Shoulder Pain and Disability Index (SPADI) scores,
      shoulder active and passive range of motions (ROM), and visual analog scale (VAS) scores were
      evaluated before and after the injection in the 1st week, 4th week, and 12th week.
    

Detailed description: 
      Materials and Methods

      Calculation of the Sample Size

      The sample size of our study was calculated based on assuming the power of the study to be
      80% and a type 1 (α) error of 0.05 using the G-Power 3.1.9.4 program. The sample size was
      calculated as 24 patients for each group. Considering the possibility of being excluded from
      the study, it was planned to recruit 30 patients for each group.

      Patient Selection and Randomization

      Our study was conducted at the Physical Therapy and Rehabilitation outpatient clinic of
      Antalya Education and Research Hospital between March and October 2022. A total of 84
      patients aged between 18 and 75 who were found to be in the adhesive phase of AC after a
      detailed physical examination by the clinician were screened.

      Patients with bilateral symptoms, radicular or inflammatory pain, uncontrolled DM,
      superficial infection at the injection site, bleeding disorder, stroke, history of drug
      allergy, shoulder trauma in the last month, any steroid injection in the last 3 months,
      pregnant or postpartum patients, and patients who had previously received shoulder physical
      therapy were excluded from the study.

      As a result, a total of 60 patients who met the criteria and agreed to participate in the
      trial were included in the study. The patients were randomized into two groups suprascapular
      nerve block (SSNB) and intra-articular injection (IAI) using the closed envelope method.

      Each patient was informed about the course of the disease, possible side effects of
      injections, and complications. Written informed consent was obtained from each patient. This
      study was approved by the Local Ethics Committee and was conducted by the principles of the
      Declaration of Helsinki.

      Interventions

      All injections were performed by a physiatrist with 15 years of experience under the guidance
      of a Clarius portable USG device (L7 HD Linear Ultrasound Scanner). A total of 10 ml of a
      mixture of 1 ml of 40 mg triamcinolone acetonide (Kenakort-A ampoule) and 9 ml of 0.5%
      bupivacaine hydrochloride (Marcaine) was used in each injection.

      SSNB group: The patients were asked to sit comfortably in the chair, and the transducer was
      placed on the spine of the scapula in the coronal plane and moved laterally to observe the
      supraspinatus notch and the suprascapular nerve. The injection mixture was applied in-plane
      with a 22-gauge, 90-mm needle on the suprascapular nerve, under the fascia of the
      supraspinatus muscle.

      IAI group: The patients were asked to sit on the chair with their hands facing the opposite
      shoulder, and the transducer was placed slightly below the spina scapula. The humeral head
      was observed by moving laterally. The injection mixture was applied in-plane with a 22-gauge,
      90-mm needle entering the skin at a 45-degree angle and applied to the joint space.

      In addition, both groups were given a home exercise program consisting of shoulder range of
      motion exercises in all directions, especially posterior capsule stretching, isometric
      strengthening exercises, and Codman exercises.

      Clinical Evaluation

      The primary outcome measure of the study was the Shoulder Pain and Disability Index (SPADI),
      and the secondary outcome measures were the Visual Analog Scale (VAS) and ROM measures. SPADI
      is a self-assessment scale with Turkish validity and reliability, consisting of two parts and
      a total of 13 questions; each question is given a score between 0 and 10. 21,22 Pain,
      disability, and total scores between 0 and 100 are obtained by calculating the percentage of
      the score indicated by the patients. SPADI variables were recorded as pain (SPADI-P),
      disability (SPADI-D), and total (SPADI-T) scores. VAS scores were marked between 0 and 100 mm
      by the patients. 23 ROM measurements, including active and passive shoulder flexion,
      abduction, extension, internal rotation, and external rotation, were measured with a
      goniometer.

      All outcome measures were evaluated by an injection-blind clinician. Outcomes were evaluated
      four times: pre-injection, post-injection week 1, week 4, and week 12. Information such as
      age, gender, duration of symptoms, additional disease, affected side, and dominant extremity
      was recorded before the intervention.

      Statistical Analysis

      Descriptive statistics are presented with frequency, percentage, mean, standard deviation,
      median, minimum, and maximum values. In the analysis of categorical data, Fisher's Exact Test
      (Fisher's Exact Test) was used if the percentage of cells with the expected value less than 5
      was greater than 20%, and the Pearson Chi-Square Test was used if it was small. The
      assumption of normality was checked with the Shapiro-Wilk Test. In the analysis of the
      difference between the numerical data of the two groups, the Independent Samples T-Test was
      used when the data conformed to the normal distribution, and the Mann-Whitney U-Test was used
      when they did not. Repeated measures ANOVA analysis was applied to compare the pre-injection,
      post-injection week 1, week 4, and week 12 measurements of the continuous numbers of
      variables according to the SSNB and IAI groups. Since the VAS score did not provide a normal
      distribution, the SSNB and IAI groups were evaluated within themselves with the Friedman
      test. Analyzes were made with the SPSS 23.0 program. A P value <0.05 was considered
      statistically significant.
    

Intervention name(s): Suprascapular Nerve Block; Intraarticular Shoulder Injection
Intervention type(s): Procedure; Procedure
Intervention description(s): SSNB group: The patients were asked to sit comfortably in the chair, and the transducer was placed on the spine of the scapula in the coronal plane and moved laterally to observe the supraspinatus notch and the suprascapular nerve. The injection mixture was applied in-plane with a 22-gauge, 90-mm needle on the suprascapular nerve, under the fascia of the supraspinatus muscle.; IAI group: The patients were asked to sit on the chair with their hands facing the opposite shoulder, and the transducer was placed slightly below the spina scapula. The humeral head was observed by moving laterally. The injection mixture was applied in-plane with a 22-gauge, 90-mm needle entering the skin at a 45-degree angle and applied to the joint space
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A total of 60 patients who met the criteria and agreed to participate in the trial were included in the study. The patients were randomized into two groups suprascapular nerve block (SSNB) and intra-articular injection (IAI) using the closed envelope method.
Masking: Single (Investigator)
Primary purpose: Treatment
Keywords: adhesive capsulitis; suprascapular nerve blockade; intra-articular shoulder injection