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Journal Club

March 2010

Nonoperative Management of Adhesive Capsulitis of the Shoulder: Oral Cortisone Application versus Intra-articular Cortisone Injections

Lorbach O, Anagnostakos K, Scherf C, Seil R, Kohn D, Pape D.

Department of Orthopedic and Trauma Surgery, Klinikum Osnabrück, Handsurgery, Osnabrück, Germany

J Shoulder Elbow Surg. 2010 Mar;19(2):172-9.

Abstract Link

Introduction

• Hypothesis
  • "Both oral and intra-articular application of corticosteroid would lead to significant improvement and comparable results"

Methodology

• Study Design
  • Prospective RCT
  • 40 pts
  • Stage II adhesive capsulitis
• Exclusion criteria
  • Surgery, OA, IDDM
• Intra-articular cortisone injections Vs Oral cortisone
  • All
    • Physical therapy
      • 4 weeks after cortisone commenced
      • bd independent, twice weekly supervised for 8 weeks
    • Measurements at 0, 4, 8, 12, 24, 52 weeks
  • Oral cortisone
    • Prednisolone
      • Tapering daily dose 40/30/20/10/5mg
      • 5days each
      • Pantoprazole 40mg mane
    • Patients
      • 10 male 10 female 52 ± 10 years
      • 70% dominant arm
      • Mean duration of symptoms 11 months
• Intra-articular injection
  • 3 radiologically guided injections
    • Bupivicaine (5ml, 0.5%)
    • Mepivicaine (5ml, 0.5%)
    • Triamcinolone (40mg)
    • 0, 4, 8 weeks
  • Patients
    • 13 female, 7 male 50 ± 8 years
    • 50% dominant arm
    • Mean duration of symptoms 11 months
• Outcome Measures
• Constant & Murley Score
  • 100 point score, higher score = better function
  • Pain, function, ROM (strength)
• Simple Shoulder Test
  • 12 yes/no
  • Function based questionnaire
• Visual analog scale
  • pain / function / satisfaction
• Passive ROM
  • goniometry
• Statistical analysis
  • α ≥ 0.5
  • Power calculation
    • Post hoc
    • Power of 0.84 with 20 in each group
    • For external rotation only
  • Analysis for difference between groups
    • Paired and independent t tests
    • ?No analysis of difference at T = 0

Results

• Oral cortisone & Injection
  • Significant improvement in all measures
  • Significant improvement at all time points

"Corticosteroids, as intra-articular injections or... oral administration... lead to significant improvement in pain and range of motion"

• Comparison
  • Improvement in both groups out to one year
  • Consider natural history of the condition
  • Treatment aim: Earlier symptomatic relief and return to function

"The intra-articular series seems to provide faster improvement in pain reduction and patient satisfaction compared with the oral corticosteroid"

Pros of Study

• Study question
  • Clinically relevant: efficacy & resource allocation
• Conclusions
  • Appropriate from evidence
  • Clinically useful

Cons of Study

• Study design & analysis:
  • significantly flawed
  • 25/7 p.o. tapered vs 3 injections over 8/52
  • Treatment arms: justified but ? comparable
  • No control group, small sample
  • No blinding: patient or examiner
  • No comparison of groups at commencement