Effect of Hypertonic Saline in Intra-Articular Hydraulic Distension for Adhesive Capsulitis

A Comparative Study Between Hydrodilatation and Intra-Articular Corticosteroid Injection in Patients with Shoulder Adhesive Capsulitis: A Single-Blinded Randomized Clinical Trial

This study compares the efficacy of hydrodilatation (HD) alone with intra-articular corticosteroid injection (ICI) in treating frozen shoulder (FS). A total of 48 patients with FS were randomly assigned to two groups: 24 patients received HD treatment, while the other 24 patients received ICI treatment. HD involved 20 mL 0.9% normal saline solution with 3 mL 2% lidocaine, and ICI included 1 mL of 40 mg/mL methylprednisolone acetate with 1 mL 2% lidocaine and 3 mL normal saline. Outcome measures included Visual Analog Scale (VAS), Shoulder Pain and Disability Index (SPADI), and passive range of motion (ROM) at baseline, two-, four-, and eight-week follow-ups. Both treatments demonstrated significant improvement in the VAS, SPADI, and passive ROM, when between-times comparison was conducted in each group at all follow-up points over the eight-week study period (p < 0.001). However, no significant differences were found in between groups comparison at study end (p > 0.05), with no significant interaction between groups and times (p > 0.05). Absolute changes from baseline to eight-week follow-up were not significantly different between HD and ICI (p > 0.05). In the short term, HD alone demonstrates strong efficacy in managing FS, matching the effectiveness of ICI.

Comparative-effectiveness study evaluating outcomes for transforaminal epidural steroid injections performed with 3% hypertonic saline or normal saline in lumbosacral radicular pain

BACKGROUND

Transforaminal epidural steroid injections (TFESI) are commonly employed to treat lumbosacral radiculopathy. Despite anti-inflammatory properties, the addition of 3% hypertonic saline has not been studied.

OBJECTIVE

Compare the effectiveness of adding 0.9% NaCl (N-group) vs. 3% NaCl (H-group) in TFESI performed for lumbosacral radiculopathy.

METHODS

This retrospective study compared TFESI performed with lidocaine, triamcinolone and 0.9% NaCl vs. lidocaine, triamcinolone and 3% NaCl. The primary outcome was the proportion of patients who experienced a ≥ 30% reduction in pain on a verbal rating scale (VRS; 0-100) at 3 months. Secondary outcome measures included the proportion of patients who improved by at least 30% for pain at 1 and 6 months, and who experienced ≥15% from baseline on the Oswestry disability index (ODI) at follow-up.

RESULTS

The H-group experienced more successful pain outcomes than the N-group at 3 months (59.09% vs. 41.51%; P = .002) but not at 1 month (67.53% vs. 64.78%; P = .61) or 6 months (27.13% vs 21.55%: P = .31). For functional outcome, there was a higher proportion of responders in the H-group than the N-group at 3 months (70.31% vs. 53.46%; P = .002). Female, age ≤ 60 years, and duration of pain ≤ 6 months were associated with superior outcomes at the 3-month endpoint. Although those with a herniated disc experienced better outcomes in general with TFESI, the only difference favoring the H-group was for spondylolisthesis patients.

CONCLUSIONS

3% hypertonic saline is a viable alternative to normal saline as an adjunct for TFESI, with randomized studies needed to compare its effectiveness to steroids as a possible alternative.

REGISTRATION

Thai Clinical Trials Registry ID TCTR 20231110006.

Efficacy of hydrodilatation in frozen shoulder: a systematic review and meta-analysis

INTRODUCTION

It is unclear whether hydrodilatation is beneficial in the management of frozen shoulder compared with other common conservative management modalities. This systematic review evaluates the efficacy of hydrodilatation for the management of frozen shoulder.

SOURCES OF DATA

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An extensive search of PubMed, Embase, Scopus, Cochrane Central, Web of Science and CINAHL databases using multiple keyword combinations of 'shoulder', 'rotator', 'adhesive capsulitis', 'hydrodilatat*', 'distension' since inception of the databases to June 2023 was implemented.

AREAS OF AGREEMENT

Hydrodilatation leads to at least transient more marked improvements in shoulder disability and passive external rotation compared with intra-articular corticosteroid injections.

AREAS OF CONTROVERSY

Hydrodilatation improves passive external rotation in the longer term. Moreover, hydrodilatation may be a preferable option over manipulation under anaesthesia, given its lower cost and better patient convenience.

GROWING POINTS

Intensive mobilization after hydrodilatation is a promising adjuvant treatment option for patients suffering from a frozen shoulder.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although current evidence suggests that hydrodilatation provides a transient improvement in disability in patients with frozen shoulder, its clinical relevance remains unclear. Further research is necessary to establish its role in the management of the condition.

Comparative Effectiveness of Corticosteroid Dosages for Ultrasound-Guided Glenohumeral Joint Hydrodilatation in Adhesive Capsulitis: A Randomized Controlled Trial

OBJECTIVE

To investigate the efficacy of hydrodilatation with 40 mg triamcinolone acetonide (TA) compared with the same procedure with 10 mg TA in patients with adhesive capsulitis (AC) of the shoulders.

DESIGN

Prospective, double-blind, randomized controlled trial with 12 weeks of follow-up.

SETTING

Tertiary care rehabilitation center.

PARTICIPANTS

Eighty-four patients diagnosed with AC (N=84).

INTERVENTIONS

Ultrasound guidance using (A) hydrodilatation with 4 mL of TA (40 mg)+4 mL 2% lidocaine hydrochloride+12 mL normal saline or (B) hydrodilatation with 1 mL of TA (10 mg)+4 mL 2% lidocaine hydrochloride+15 mL normal saline through the posterior glenohumeral recess.

MAIN OUTCOME MEASURES

Shoulder Pain and Disability Index (SPADI), visual analog scale (VAS) for pain, and range of motion (ROM) at baseline and at 6 and 12 weeks after injection.

RESULTS

Both groups experienced improvements in the SPADI score, VAS scores for pain, and ROM throughout the study period. However, group-by-time interactions were not significant for any outcome measurement at any follow-up time point. No adverse events were reported in either group.

CONCLUSION

Ultrasound-guided hydrodilatation with 40 and 10 mg TA yielded similar improvements in SPADI, VAS score, and ROM at the 12-week follow-up. Considering the potential detrimental effects of corticosteroids on the adjacent cartilage and tendons, a low dose of TA would be preferable for ultrasound-guided hydrodilatation for AC.

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials.

METHODS

A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model.

RESULTS

Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy.

CONCLUSIONS

No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone.

LEVEL OF EVIDENCE

II, systematic review and network meta-analysis of level I and II studies.

Hydraulic distension as a treatment for patellofemoral pain syndrome (PFPS) non-responsive to standard rehabilitation

BACKGROUND

The occurrence of Patellofemoral Pain Syndrome (PFPS) is often found in daily medical care. Rehabilitation is usually applied with good results. However, patients often do not respond to standard rehabilitation, suggesting there may be some undetected factors that standard treatments cannot address. It is known that post-traumatic adhesive capsulitis in the knee often shows symptoms similar to those of PFPS, but idiopathic adhesive capsulitis (IAC) has seldom been mentioned as a possible cause of PFPS. Adhesive capsulitis in the shoulder joint causes frozen shoulder (FS), and hydraulic distension (HD) is often applied to FS effectively.

PURPOSE

The purpose of this study was to investigate and report on the clinical application of HD to treat PFPS non-responsive to rehabilitation treatment.

PATIENTS AND METHODS

HD was applied to 72 knees that had resisted regular conservative treatments for PFPS. Follow-up data (e.g. visual analogue scale) was collected immediately after HD, and at periods of 1, 3 and 6 months later.

RESULTS

Of the 72 patients, 64 patients obtained pain relief after HD. Pain was relieved for at least 6 months for 33 of the 64 patients. No benefit was received for 8 patients.

CONCLUSIONS

HD could be an additional conservative option for some PFPS that resisted rehabilitation. Assuming that the mechanisms of action for HD in the knee are the same as those in FS, there is evidence to suggest that IAC might play a role in the development of PFPS for some patients.

Effect of Hypertonic Saline during Flexible Nasopharyngeal Laryngoscopy: A Double-Blinded, Randomized, Controlled Trial

OBJECTIVES

Flexible nasopharyngeal laryngoscopy (NPL) is a cost-effective, simple procedure that provides visualization of the nasal airways. However, it involves a number of challenges for both the clinician and the patient. Hypertonic saline nasal wash is used to prevent nasal secretion in acute/chronic sinusitis and after nasal surgery. We aimed to determine the efficacy of hypertonic saline by comparing the clinician's and patients' experiences during NPL.

METHODS

This prospective, double-blinded, randomized, controlled study was performed at a tertiary referral university hospital. Two hundred patients were randomly divided into hypertonic saline, lidocaine, xylometazoline, and isotonic saline groups. During NPL, the clinician's experiences in terms of the quality of the field of view and the patients' experiences in terms of pain and discomfort resulting from the 4 premedication drugs were compared.

RESULTS

The groups differed significantly in terms of the clinician's field of view, and patients' pain scores and levels of discomfort (P < 0.025). The field of view results were the highest in the hypertonic saline group, and the lowest in the lidocaine group. The pain scores were the lowest in the lidocaine group, whereas they were the highest in the hypertonic saline group. The discomfort scores were the lowest in the xylometazoline group, but the highest in the lidocaine and isotonic saline groups.

CONCLUSION

The use of hypertonic saline facilitated the NPL procedure by improving the clinician's field of view. Moreover, intranasal hypertonic saline reduced the patient's discomfort. Intranasal hypertonic saline can be a good alternative to premedication before NPL.

Efficacy of Pharmacological Therapies for Adhesive Capsulitis of the Shoulder: A Systematic Review and Network Meta-analysis

BACKGROUND

Several pharmacological interventions are used for the management of adhesive capsulitis of the shoulder, although the optimal treatment has yet to be defined.

PURPOSE

To conduct a network meta-analysis to compare the effects of different pharmacological interventions for adhesive capsulitis, administered either alone or after distension of the shoulder capsule.

STUDY DESIGN

Network meta-analysis.

METHODS

The authors searched Scopus, PubMed, and the Cochrane Central Register of Controlled Trials up to April 22, 2018, for completed studies. They enrolled trials that assessed the results of different pharmacological treatments for the primary management of adhesive capsulitis. The primary outcome was pain relief as measured by self-administered questionnaires. The secondary outcome included the assessment of composite instruments that evaluated, at a minimum, pain and function. The authors clinically interpreted the results after back-transforming the standardized mean differences into mean differences in simple instruments and assessed the quality of the source studies using the Cochrane "risk of bias" tool.

RESULTS

The authors considered 30 trials with a total of 2010 participants in this systematic review. For pain relief, there was a significant difference in favor of intra-articular corticosteroids and distension of the shoulder capsule with steroids as compared with control in the short term (mean difference in visual analog scale (VAS): -1.4 [95% CI, -2.5 to -0.4] and -1.7 [95% CI, -3.2 to -0.1], respectively). Furthermore, rotator-interval injections were found to be superior to placebo (mean difference in VAS: -7.2; 95% CI, -10.1 to -4.4), although the intervention was considered in only 1 trial. Finally, there was a statistically significant difference in favor of multiple-site corticosteroid injections compared to placebo in both the short- (mean difference in Shoulder Pain and Disability Index [SPADI]: -86.7; 95% CI, -133.6 to -40) and intermediate-term assessment (mean difference in SPADI: -102.9; 95% CI, -163.9 to -41.8).

CONCLUSION

Intra-articular corticosteroid intervention, administered either alone or after distension of the shoulder capsule, provided clinically meaningful improvements in the short term. Likewise, rotator-interval corticosteroid injections yielded promising results in terms of pain relief. However, these short-term benefits of steroids dissipated over time. Multiple-site corticosteroid injections showed clinical advantage over placebo for short- and intermediate-term composite outcome assessments.

Adhesive capsulitis: review of imaging findings, pathophysiology, clinical presentation, and treatment options

Adhesive capsulitis, commonly referred to as "frozen shoulder," is a debilitating condition characterized by progressive pain and limited range of motion about the glenohumeral joint. It is a condition that typically affects middle-aged women, with some evidence for an association with endocrinological, rheumatological, and autoimmune disease states. Management tends to be conservative, as most cases resolve spontaneously, although a subset of patients progress to permanent disability. Conventional arthrographic findings include decreased capsular distension and volume of the axillary recess when compared with the normal glenohumeral joint, in spite of the fact that fluoroscopic visualization alone is rarely carried out today in favor of magnetic resonance imaging (MRI). MRI and MR arthrography (MRA) have, in recent years, allowed for the visualization of several characteristic signs seen with this condition, including thickening of the coracohumeral ligament, axillary pouch and rotator interval joint capsule, in addition to the obliteration of the subcoracoid fat triangle. Additional findings include T2 signal hyperintensity and post-contrast enhancement of the joint capsule. Similar changes are observable on ultrasound. However, the use of ultrasound is most clearly established for image-guided injection therapy. More aggressive therapies, including arthroscopic release and open capsulotomy, may be indicated for refractory disease, with arthroscopic procedures favored because of their less invasive nature and relatively high success rate.

Comparative Efficacy of Intra-Articular Steroid Injection and Distension in Patients With Frozen Shoulder: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare the efficacy of intra-articular (IA) steroid injection and distension in patients with frozen shoulder.

DATA SOURCES

Databases, including MEDLINE (via PubMed), Embase, Scopus, and Cochrane Library, were searched for studies published up to November 2016.

STUDY SELECTION

We included all published randomized controlled trials (RCTs), quasi-experimental studies, and observational studies investigating the effectiveness of IA steroid injection, distension, and physiotherapy in patients with frozen shoulder. Sixteen RCTs and 1 observational study were enrolled in meta-analysis.

DATA EXTRACTION

Full texts were independently reviewed, and quality of RCTs was assessed with The Cochrane Collaboration's tool. The primary outcome was functional improvement; the secondary outcomes included pain reduction and external rotation (ER) improvement.

DATA SYNTHESIS

In pairwise meta-analysis, pooled standardized mean difference (SMD) of functional improvement and pain reduction revealed equal efficacy at 3 follow-up time points. With respect to ER improvement, distension has a superior effect compared with IA steroid injection in the short term [(2-4wk; SMD, -.36; 95% confidence interval [CI], -.68 to -.04) and medium term (6-16wk; SMD, -0.80; 95% CI, -1.32 to -0.29). The network meta-analysis indicated a better efficacy for distension than for IA steroid injection in ER improvement only in the medium term (6-16wk; SMD, -0.70; 95% CI, -1.19 to -0.21).

CONCLUSIONS

IA steroid injection was as effective as distension in shoulder function improvement, pain reduction, and increasing ER of the shoulder. Distension yielded better ER improvement in the medium term but to a minor extent in the long term. For patients with predominant ER limitation, early distension could be considered the primary choice of treatment.

Effectiveness of Glenohumeral Joint Dilatation for Treatment of Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The objective was to explore the effectiveness of glenohumeral joint distension for the treatment of frozen shoulder. We searched electronic data sources including PubMed, Scopus, and Embase from the earliest records available to February 2017. Eleven randomized controlled trials including at least one pair of comparisons between capsular distension and a reference treatment were included, comprising 747 participants. Patients’ characteristics, details of reference treatments, aspects of capsular distension therapy, and outcome measurement were evaluated at three points in time: baseline, early following intervention, and at the trial’s end. The primary and secondary outcomes were the between-group standardized mean differences of changes in shoulder function and range of motion, respectively. Regarding the long-term primary outcome, the superiority of capsular distension to reference treatments was not identified. One secondary outcome (external rotation limitation) showed a probable early positive response to capsular distension when compared to intra-articular corticosteroid injection. Aspects of approaches, imaging guiding techniques and doses of distension were not found to modify treatment effectiveness. In conclusion, distension of the glenohumeral joint provides a similar long-term efficacy to all reference treatments. A single dose of a corticosteroid-contained regimen introduced through the ultrasound-guided posterior approach is a preferable practice of capsular distension for the management of frozen shoulder.

Hypertonic saline in critical illness - A systematic review

INTRODUCTION

The optimal approach to fluid management in critically ill patients is highly debated. Fluid resuscitation using hypertonic saline was used in the past for more than thirty years, but has recently disappeared from clinical practice. Here we provide an overview on the currently available literature on effects of hypertonic saline infusion for fluid resuscitation in the critically ill.

METHODS

Systematic analysis of reports of clinical trials comparing effects of hypertonic saline as resuscitation fluid to other available crystalloid solutions. A literature search of MEDLINE and the Cochrane Controlled Clinical trials register (CENTRAL) was conducted to identify suitable studies.

RESULTS

The applied search strategy produced 2284 potential publications. After eliminating doubles, 855 titles and abstracts were screened and 40 references retrieved for full text analysis. At total of 25 scientific studies meet the prespecified inclusion criteria for this study.

CONCLUSION

Fluid resuscitation using hypertonic saline results in volume expansion and less total infusion volume. This may be of interest in oedematous patients with intravascular volume depletion. When such strategies are employed, renal effects may differ markedly according to prior intravascular volume status. Hypertonic saline induced changes in serum osmolality and electrolytes return to baseline within a limited period in time. Sparse evidence indicates that resuscitation with hypertonic saline results in less perioperative complications, ICU days and mortality in selected patients. In conclusion, the use of hypertonic saline may have beneficial features in selected critically ill patients when carefully chosen. Further clinical studies assessing relevant clinical outcomes are warranted.