Ultrasound Guided Shoulder Intra-Articular Ozone Injection Versus Pulsed Radiofrequency Application for Shoulder Adhesive Capsulitis

The aim of this study is to evaluate the efficacy of the ultrasound guided shoulder intra-articular Ozone injection versus pulsed radiofrequency application in patients with shoulder adhesive capsulitis.

* Primary Outcome :

  - Pain score using visual analogue scale during rest (VASr) and movement (VASm).
* Secondary Outcome :

  * Quality of life using Shoulder Pain and Disability Index (SPADI). It assesses the overall functionality of the shoulder joint.
  * Levels of serum ICAM -1, and serum high sensitive C-reactive protein (hs-CRP) are compared before and after treatment intervention.

After approval of the local ethical committee of Medical Research Institute - Alexandria University (IORG0008812), an informed written consent will be taken from all patients participating in the study. The study will be carried out on 45 adult patients (15 per group) of either gender, aged from 30 to 65 years. Eligible patients are those who were diagnosed with primary shoulder adhesive capsulitis according to the previously mentioned diagnostic criteria, with history of inadequate response to a trial of conservative therapy (NSAIDs and physiotherapy) for at least four weeks.

Patients will be assigned into three equal groups using computerized random blocks method:

1. Steroid Group (S): \[15 patients\] Control group treated with intra-articular injection of 5 ml of Bupivacaine 0.125% added to triamcinolone 40 mg under the ultrasound guidance.
2. Ozone Group (O3): \[15 patients\] Patients will be treated with intra-articular injection of 5 ml of Bupivacaine 0.125% followed by injection of 10 ml of Oxygen-Ozone mixture (15 μg/ml) under the ultrasound guidance.
3. Pulsed radiofrequency Group (PRF): \[15 patients\] Patients will be treated with shoulder intra-articular injection of 5 ml of Bupivacaine 0.125% followed by pulsed radiofrequency application under the ultrasound guidance.

Patients' Evaluation and Preparation:

Patients' preparation starts with pre-intervention evaluation visit. Proper history taking and clinical examination will be carried out. Documentation of the range of motion and VAS score will be done after proper explanation. Patients will be asked to fill a SPADI score form.

Laboratory investigations will include complete blood count (CBC), prothrombin time (PT), and international normalized ratio (INR).

Baseline serum ICAM-1 level and hs-CRP level will be measured using 5 ml of patient's venous blood.

Patients will be asked to sign a consent form to participate in the study. Participants will be admitted to pain management ward. Random assignment will be carried out using computerized random blocks with variable block size.

All interventions will be carried out in the operating theatre (OR) for proper monitoring and sterilization procedures. A 20 G intravenous (IV) cannula will be inserted for all patients in the OR. Basic monitoring will be applied; continuous electrocardiogram (ECG) monitoring, arterial Oxygen saturation (SPO2) monitoring, and non-invasive blood pressure (NIBP) monitoring.

Intervention Methodology:

1. Group S:

   Patients will be put in lateral semi-prone position with the affected shoulder facing up. Shoulder space will be opened by arm internal rotation and adduction across the chest. Under sterile conditions and proper draping of the affected shoulder, scanning will start using Sonosite® M- turbo™ ultrasound machine. A high frequency linear probe (7-14 MHz) will be put parallel and just inferior to spine of the scapula. Identification of humeral head, joint capsule, labrum, glenoid, and infraspinatus and deltoid muscles should be available in one image to avoid wrong needle positioning. The in-plane posterior approach for intra-articular injection will be used (Furman et al., 2017). Needle insertion (22 Gauge, 5 cm length) approach from inferomedial to superolateral direction towards the humeral head. The targeted needle path should avoid labrum puncture. The end point for injection is subcapsular and adjacent to the labrum.

   After confirmation of proper needle position, 5 ml of Bupivacaine 0.125% will be injected added to triamcinolone 40 mg (Babaei-Ghazani et al., 2019).
2. Group O3:

   Under the previously described position and scanning technique, intra-articular injection of 5 ml of Bupivacaine 0.125% followed by 10 ml of Oxygen-Ozone mixture (15 μg/ml) will be done (Noori-Zadeh et al., 2019).
3. Group PRF:

Under the previously described position and scanning technique, 5 ml of Bupivacaine 0.125% will be directly injected. Following, Intra-articular PRF will be applied with a 10 cm neurotherm needle with 10 mm active tip for 4 minutes to the glenohumeral joint (Ozyuvaci et al., 2011).

Post-Procedure Assessment:

All participants will be treated as day-case patients and will be observed in the recovery ward for 2 h after therapy. VAS, shoulder joint ROM, and any complication (e.g., hematoma formation, vasovagal attack, etc.) will be recorded before discharge.

Follow-up visits will be planned for all participants at week 1, 2, 4, 8 post-intervention. During these visits, reassessment will be done for VASr, VASm, SPADI score, and ROM.

* Pain score Using visual analogue scale during rest (VASr) and movement (VASm), pain will be categorized as mild (0-3), moderate (4-6), or severe (7-10). Improved pain score is considered significant when there is a categorical improvement in pain level.
* Quality of life Using Shoulder Pain and Disability Index (SPADI), improvement in quality of life is considered significant when there is 10% reduction in the final index.

During the last follow-up visit, samples for serum ICAM-1 and highly sensitive CRP levels will be obtained.

Statistical Analysis:

Data will be analyzed using descriptive statistical methods as well as comparison of the qualitative and quantitative data. Presentation will be carried out in the form of proper tables and graphical presentation.

Eligibility Criteria:
Inclusion Criteria:

* Aged from 30 to 65 years
* Either gender
* Diagnosed with Adhesive Capsulitis
* Inadequate response for conservative therapy (NSAIDs and physiotherapy) for four weeks

Exclusion Criteria:

* Patients diagnosed with central post-stroke neuropathic pain
* Patients with documented rheumatoid arthritis
* Patients with current shoulder fracture or trauma
* Known causes for secondary adhesive capsulitis (e.g., diabetes)
* Patients with local tumor at shoulder region
* Patients with local skin infection over shoulder region
* Patients with reported coagulopathy
* Patients with allergy to LA