JIIMS.cdr ABSTRACT Objective: Study Design: It was a quasi experimental study. Place and Duration of Study: The study was conducted at the department of Orthopedics, Pakistan Railway Hospital, Rawalpindi, from August 2011 to September 2012. Materials and Methods: Results: Conclusion: Key Words: Frozen shoulder, Suprascapular nerve block, Intra-articular injection. The objective of this study was to compare the effect of supra scapular nerve block and intra articular injection to relieve pain and reduce disability in the patients of frozen shoulder. Patients diagnosed as the cases of frozen shoulder in outpatient department of Orthopedics irrespective of their gender were included in the study. Forty patients and 50 shoulders were divided into two groups by randomization, one group received single suprascapular nerve block and second group received single intra-articular steroid injection. Both groups were advised for physiotherapy after injection. Patients' pain levels and ranges of movement were assessed over a period of twelve weeks. The study included 40 patients and 50 shoulders to a single suprascapular nerve block and intra articular steroid injection. The mean age of the patients was 49.4 + 9.97 and the range was 40-60 years. There were 16 females and 24 male patients. Post injection assessment of patients was done at two, six, eight and twelve weeks. There was a significant decrease in pain and marked improvement in range of movement with supra scapular nerve block than with intra articular injection. Patients' pain levels and ranges of movement were assessed over a twelve week period. Suprascapular nerve block produced a faster and more complete resolution of pain and restoration of range of movement than intra articular injection. 76 ORIGINAL ARTICLE s p o n d y l o a r t h r o p a t h i e s a n d c r y s t a l 2 arthropathies. Frozen shoulder or adhesive capsulitis, is a common problem in general practice presenting as pain that may be severe, accompanied by a progressive loss of 3 movements resulting in a loss of function. W h i l e m a n y t re a t m e n t s h a v e b e e n employed, few have been proven in randomized controlled trials such as simple analgesia, NSAIDs, intra-articular steroid injection and surgery, all have their 4 limitations. Physiotherapy is often the first line of management for shoulder pain, it can help in early stages but in established cases, physiotherapy seems to be of little benefit 5 and its efficacy has not been established. The suprascapular nerve supplies sensory fibers to about 70% of the shoulder joint, including the superior and postero-superior Introduction Shoulder pain has a prevalence of 15%30% in the adult population. It is a common complaint especially amongst the elderly and may lead to functional disability and 1 d e c r e a s e i n q u a l i t y o f l i f e . B o t h suprascapular nerve block (SSNB) and intra- articular injection are effective methods for the treatment of frozen shoulder. Shoulder pain is a common cause of morbidity in the community and most common causes of that pain include d e g e n e r a t i v e d i s e a s e a ff e c t i n g t h e glenohumeral and acromioclavicular joints and supporting soft tissue structures in addition to inflammatory diseases such as rheumatoid arthritis (RA), seronegative ------------------------------------------------- Correspondence: Dr. Sohail Iqbal Sheikh HOD Orthopaedics IIMC-T, Pakistan Railway Hospital Rawalpindi Comparison of Suprascapular Nerve Block & Intra-articular Injection in the treatment of Frozen Shoulder Sohail Iqbal Sheikh, Awais Ahmed, Shahid Javaid, Abdul Basit , Imran Sohail Sheikh Saba Sohail Sheikh, Zara S. Sheikh 77 regions of the shoulder joint and capsule, and the acromioclavicular joint. In addition i t s u p p l i e s m o t o r b r a n c h e s t o t h e 6 supraspinatus and infraspinatus muscles. SSNB performed in conjunction with rehabilitation program can provide the window of opportunity to proceed with 7 effective rehabilitation program. Regional nerve block is effective for 8, 9 managing acute or chronic pain. Among v a r i o u s n e r v e b l o c k t e c h n i q u e s , suprascapular nerve block is an effective, simple, and practical method for the 8,10-12 management of shoulder pain. It can be performed in the clinic using anatomical 13 landmarks to determine needle placement. The aim of the study was to compare the effectiveness of SSNB versus intraarticular steroid injection, in management of chronic shoulder pain and to assess the effectiveness of these methods, improve range of m o v e m e n t o f t h e s h o u l d e r a n d t o demonstrate the most suitable method for treatment of such patients. Materials and Methods This quasi experimental study was conducted over duration of 1 year and 2 months from August 2011 to September 2012 in the orthopedic unit of Pakistan Railway Hospital Rawalpindi. As such, they had a loss of movement (most loss of external rotation, then abduction, and least loss of internal rotation). With pain that was constant, radiated beyond the elbow, or disturbed sleep. All resisted movements produced no pain. Serious pathology was excluded by measurement of ESR, random blood glucose, and rheumatoid factor. Suprascapular nerve block: A mixture of 40 mg Triamcinolone acetonide and 9.5 ml 0.5% Bupivacaine Hydrochloride (Marcain) was injected using the technique described by 7 Dangoisse et. al. (Figure1). A 21G × 1.5'' needle was introduced through the skin 2 cm cephaloid to the midpoint of the spine of the scapula (Figure 1). The needle was advanced parallel to the blade of the scapula until boney contact was made in the floor of the suprascapular fossa. This technique has previously been demonstrated to be safe and to effectively block the articular branches of the suprascapular nerve. The injection was not repeated. The need to include a steroid in the injection has been 9 debated; we chose to include it to minimize the differences between the treatment groups. Following each treatment, all patients were given verbal and written instructions regarding a home exercise programme of self-mobilization, joint-stretching, and static rotator cuff strengthening. Patients were asked to take only paracetamol for pain relief. Intraarticular injection: The solution injected contained 1cc of 2% lidocaine HCL and 2cc (80 mg) methylprednisolone acetate .All patients were injected once. The posterior approach was used to inject glenohumeral joint. The site of entry was same as used for traditional posterior portal for arthroscopy of shoulder. This portal is located 2 to 3 cm inferior and 1 cm medial to the posterolateral tip of the acromion. At this site the attempt was made to pass through the posterior soft spot between the infraspinatus and teres minor muscles. An 18 gauge spinal needle was inserted in this site with tip pointing towards coracoids process anteriorly. The index and middle finger was placed on the coracoid process to direct the tip of needle anteromedially towards the coracoid. When in right direction, the needle faces little resistance on entering the joint. 78 Assessment Pain levels and range of movement were recorded at initial attendance and after two weeks, six weeks, eight weeks, and twelve weeks. To avoid bias, patients graded their pain using the scale in Table I. The sum of the three columns was recorded as the total pain score. Range of movement was measured using a goniometer in three planes: abduction and external rotation. No attempt was made to isolate gleno-humeral movement, as total shoulder movement gave more reproducible results and is a better gauge of function. Data was entered into performa and was analysed using SPSS 12. Results The study included 40 frozen shoulder patients. The mean age of the patients was 49.4 + 9.97 years and the range was between 40-60 years. There were 16 (40%) females and 24 (60%) males. All patients diagnosed as cases of frozen shoulder were divided into two groups randomly. Patients were placed alternately into the two groups. The group I patients received SSNB while group II received intraarticular injection. After the injections all patients were advised home exercises. Patients were serially followed for three months after 2, 6, 8 and 12 weeks time. Group I had 13 males and 7 females, their ages were 49.4 + 9.97 with disease duration ranged between 3-12 months. While the ages of group II was also the same, disease duration ranged between 3.5-12months and it included 12 males and 8 females. Both Groups did not differ significantly at baseline for personal characteristics as age, sex, disease duration. All the patients recovered in the mean time of six weeks. (Range 3 weeks to 12 weeks). Three patients did not meet the recovery criteria within three months after injection. These patients did not strictly follow the home exercise routine advised after SSNB and intra- artriculer injection. At base time, no significant difference was found between two groups as regard to pain, disability and total pain scores. Pain improved significantly in all times of follow up with best improvement in group I. Range of active movements showed no significant differences at base time between the two groups. Over the 4 time periods, abduction & flexion and external rotation showed significant differences in all groups with gradual improvement from week 2 to week 6 to week 8 to week 12. No complication occurred in SSNB group. Table I. Scale used to grade severity of pain. TableII: Comparison of the two treatment groups at initial assessment Table III: Pain scores and range of movement in suprascapular nerve block (SNB) and intra- articular groups (IA). 79 While four patients in intra-articular injection complained of shoulder pain anteriorly. Three patients claimed that the pain relieved in 2 to 3 days time. But only one patient remained in distress at first assessment. At final assessment no patient claimed of any side effects of the intervention. Statistical analysis revealed a significant difference in the recovery of the patients of two groups of frozen shoulder. Both the methods used are significant as per statistical value but SSNB give early and long term pain relief and range of motion than intra-articular nerve block. intra-articular oss tabulation suprascapular oss tabulation intra-articular oss tabulation Table VII: Site of injection suprascapular * range of motion Cross tabulation Figure 1: Dangoisse technique. Posterior shoulder view; the needle is inserted 1 cm above the middle of the spine of scapula to the floor of the supraspinatus fossa. AC: acromion; CL: clavicle; SS: spine of scapula. Discussion The results of our study show a clear benefit from the use of suprascapular nerve block using bupivacaine and methylprednisolone over intra- articular steroid injection in patients w i t h f r o z e n s h o u l d e r. T h e r e w e r e statistically and clinically significant reduction in pain and disability. This benefit was prolonged, with benefit still present at th 12 week. The improvement in these 80 parameters are better or at least comparable with published studies examining NSAIDs 14-16or intra-articular steroid injection. Not much literature is present on the comparison study of SSNB and intra-articular steroid injection for the treatment of frozen shoulder There were no significant side effects from the injection, which was well tolerated by most of the patients. The SSNB is an effective and safe pain treatment in chronic diseases that affects the shoulder, and has been widely used by professionals in clinical practice such as rheumatologists, orthopedists, neurologists, and pain specialists. The pain in this joint is a frequent complaint and leads to significant functional disability and reduced quality of life of the affected patients. When properly indicated, SSNB should be considered. S h o u l d e r p a i n a n d r e s t r i c t i o n o f glenohumeral movements are the main clinical findings in frozen shoulder. Three sequential phases are described in its clinical 8 course. After the painful and stiff phases, the last phase, the resolution phase, is a self- l i m i t e d m e m b r a n e o f t h e j o i n t a re innervated via axillary, suprascapular, subscapular, and musculocutaneous nerves. The suprascapular nerve, which provides sensory fibers to approximately 70% of the shoulder joint has afferent, efferent, and 12 sympathetic fibers. The efferent fibers i n n e r v a t e t h e s u p r a s p i n a t u s a n d infraspinatus muscles. The afferent fibers distribute to the articular capsule and ligaments of the glenohumeral and acromioclavicular (AC) joints and to the periosteum and tendons of the scapula. Significant pain relief can be produced if the nerve block can be performed before it gives 8, 12 off to its articular branches. The most appropriate site is around the suprascapular notch, in which the nerve can also be located easily. Prominent pain relief is a natural consequence of the regional block of the suprascapular nerve that innervates a wide 8 portion of the shoulder joint. Va r i o u s s u p r a s c a p u l a r n e r v e b l o c k techniques have been described by several 11, 12, 14investigators. Dangoisse et al described indirect suprascapular nerve blocks, using 14anatomical landmark. We have demonstrated that suprascapular nerve block is efficacious over intra-articular steroid injection without the need to image the area, by ultrasound or fluoroscopy during the procedure. This study shows that this treatment not only reduces pain but also decreases disability and gives clinicians a proven efficacious treatment for patients with frozen shoulder. Whether the efficacy would be further improved with guidance of the needle under direct imaging is unknown. Longer period of pain relief and combination of nerve block with other approaches to pain relief would also be a potentially worthwhile area to study. It is not clear how the nerve block acts to produce a resolution of the symptoms. As the direct action of Bupivacaine cannot extend beyond a few hours or days there must be an effect on the underlying pathology, which owes in part to the patient's ability to perform an adequate exercise programme. The Triamcinolone included in the injection may have a systemic anti-inflammatory effect, but this should be the same in both groups. A more definitive study could also have a third group of patients treated by nerve block without steroid. Since the nerve block produces a faster resolution, its widespread use could produce a saving of time and 81 further economic benefits if patients are able to return to work sooner. Conclusion References Combination of physical treatments with suprascapular nerve block significantly improve outcome in chronic shoulder pain, and can be more effective than conventional treatments, offering clear advantages (ease of application, low cost, rare side effects) considering that the top priority of a pain control program is restoring the function of the affected area. Further, it may prove to be a useful treatment for patients who are unfit or unwilling to consider manipulation under anesthesia. 1. Taskaynatan MA, Yilmaz B, Ozgul A, Yazicioglu K, Kalyon TA. Suprascapular nerve block versus steroid injection for non-specifi c shoulder pain. Tohoku J Exp Med 2005; 205:1925. 2. Edward L, Bell L and Theodore A. Inflammation and shoulder pain. A perspective on rotator cuff disease, adhesive capsulitis and osteoarthritis. Business briefing: US orthopedic review2006; 55:233-42. 3. Dahan T, Fortin L, Pelletir M. Double blind randomized clinical trial examining the efficacy of bupivacaine suprascapular nerve block in frozen shoulder. Ann Rheum Dis 2002; 27:1464- 9. 4. Arroll B and Smith FG. Corticosteroid injections for painful shoulder: a meta-analysis. Br J Gen Pract 2005; 55:224-8. 5. G r e e n S , B u c h b i n d e r R , H e t r i c k S : Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev2003; 2:CD004258. 6. Shanahan EM, Ahern M, Smith M, Wetherall M, Bresnihan B and FitzGerald O : Suprascapular n e r v e b l o c k ( u s i n g b u p i v a c a i n e a n d methylprednisolone acetate) in chronic shoulder pain. Ann Rheum Dis 2003 ; 62: 400-6. 7. Dilorenzo L, Pappagallo M, Gimigliano R. Pain relief in early rehabilitation of rotator cuff tendinitis; any role for indirect suprascapular nerve block? Eura Medicopits2006 ; 42:195-204. 8. Karata GK, Meray J. Suprascapular nerve block for pain relief in adhesive capsulitis: Comparison of 2 different techniques. Arch Phys Med Rehib 2002; 83:593-7. 9. B o y l e s R E , F l y n n T W, W h i t m a n J M . Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: a case series. Man Ther 2005; 10: 80-7. 10. Dahan TH, FortinL, Pelletier M, Petit M, Vadeboncoeur R, Suissa S. Double blind randomized clinical trial examining the efficacy of bupivacaine suprascapular nerve blocks in frozen shoulder. J Rheumatol 2000; 27:1464-9. 11. Wassef MR. Suprascapular nerve block: a new approach for the management of frozen shoulder. Anaesthesia 1992; 47: 120-4. 12. Shanahan EM, Smith MD, Wetherall M, Lott CW, Slavotinek J, FitzGerald O et. al. Suprascapular nerve block in chronic shoulder pain: are the radiologists better? Ann Rheum Dis 2004; 63:1035-40. 13. Yasar E, Vural D, Safaz I, Balaban B, Ahmet Y, Goktepe AS et. al. Which treatment approach is better for hemiplegic shoulder pain in stroke patients: intra-articular steroid or suprascapular nerve block? A randomized controlled trial. Clin Rehabil 2011; 25: 60-8. 14. Dangoisse MJ, Wilson DJ, Glynn CJ. MRI and clinical study of an easy safe technique of suprascapular nerve blockade. Acta Anaesth Belg1994; 45:49-54. 15. Bal A, Eksioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clin Rehabil 2008; 22: 503- 12. 16. Ryans I, Montgomery A, Galway R. A randomized controlled trial of intra-articular triamcinolone and/or physiotherapy in shoulder capsulitis. Rheumatology 2005; 44:529- 35.