Frozen shoulder diagnostikk og behandling. Tore Prestgaard Spes. fysikalsk og rehab.medisin Fys. med. avd., Drammen sykehus

Frozen shoulder diagnostikk og behandling Tore Prestgaard Spes. fysikalsk og rehab.medisin Fys. med. avd., Drammen sykehus

Innhold Generelt om adhesiv kapsulitt Diagnostikk og behandling Rotatorintervallet Kapsulitt-studien ved Kysthospitalet ved Stavern

Flere navn Duplay 1872: Periarthritis Codman 1934: Frozen shoulder ("This entity is difficult to define, difficult to treat, and difficult to explain from the point of view of pathology. ) Naviesar 1945: Adhesive capsulitis (Observasjoner ved kirurgi) ICD-10: M75.0 Adhesjonskapsulitt i skulder I denne presentasjon for enkelthets skyld: kapsulitt

Definisjon/karakteristika Tilstanden er karakterisert ved Smerte Initialt en progredierende smerte, ofte mest uttalt om natten, og ved brå bevegelser i skulderen mot ytterstillinger Stivhet Innskrenket passiv og aktiv humeroskapulær bevegelighet, kapsulært mønster Langvarig forløp, ofte 1-2 år, tre stadier/faser: painful freezing phase 3-8 mnd intermediate phase 4-12 mnd resolution phase 1-3 mnd

Definisjon/karakteristika Opp gjennom årene ulik forståelse og ulike definisjoner, hvilket har gjort det vanskelig å sammenligne tall vedr forekomst, behandling, etc. En stiv og smertefull skulder kan være så mangt. The American Shoulder and Elbow Surgeons : A condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. Derfor viktig å utelukke andre tilstander som kan gi stivhet og smerte.

Neviaser, AS: Adhesive capsulitis: a review of current treatment (Am J Sports Med 2010) Adhesive capsulitis is characterized by a painful, gradual loss of both active and passive glenohumeral motion resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule. Variable nomenclature, inconsistent reporting of disease staging, and a multitude of different treatments have created a confusing and contradictory body of literature about this condition.

Descriptors of adhesive capsulitis (frozen shoulder, periarthritis) (R. Buchbinder) der) No uniformity or standard criteria 4% 4% 4% 4% 34% 34% No definition given 8% 4% 4% 4% 4% pain at night with restriction of active and passive motion 22% 22% 4%

Standard terminology needed to label and define disorders (R. Buchbinder) Adhesive capsulitis: pain and stiffness in predominantly one shoulder and restriction of passive motion > 30 in 2 planes Rule out: Rotator cuff disease pain in predominantly one shoulder and pain on active abduction or external rotation and positive shoulder impingement test not > 50% restriction of passive range in 2 planes True glenohumeral osteoarthritis Other, based upon valid criteria

Patofysiologi Idiopatisk lidelse/ukjent årsak, patofysiologi uavklart. Kan inntre etter traume eller kirurgisk inngrep i eller nær skulderen, etter hjerneslag. Sees ofte i relasjon til diabetes mellitus, thyreoideasykdom, autoimmunsykdommer. Den nedsatte ROM sannsynligvis forårsaket av en prosess i det coracohumerale ligament, i rotatorintervallet, i m. subscapularis (og bursa subacromiale?) Hyperplastisk fibroplasi and eksessiv type III collagen -> stivhet/kontaktur (kapsulær fibrose) Spesifikke genetiske avvik i fibroblastene i kapselen er blitt identifisert i forb. med kirurgi (sent i forløpet) Algonevrodystrofisk prosess?

Forekomst Livstidsprevalens: 2-5% Betydelig høyere forekomst hos diabetikere (10-20%?) Gj.snittsalder : 52-56 år (40 70 år) Kvinner > menn (1,5 : 1) Ikke-dominant side hyppigst 10-17% får senere tilstanden på motsatt skulder Residiv i samme skulder: svært uvanlig

Blir alle bra? Det naturlige forløp Self limiting condition lasting for an average of 2-3 years B. Reeves, Scand J Rheumatol 1975 Noen studier indikerer at så mange som 40 % har vedvarende, men for det meste milde symptomer etter tre år, og 15 % har long-term disability Binder et al, Ann Rheum Dis 1984. B. Hazleman, Rheumatol Phys Med 1972. Schaffer et al, J Bone Joint Surg Am 1992 Studie med 223 pas, 269 skuldre, gj.snittl. 4,4 år oppfølging: 59% normal eller tilnærmet normal funksjon 6 % betydelige symptomer Unbearable symptoms første 6 mnd predikerte dårligere outcome Hand et al: Long term outcome of frozen shoulder, J Shoulder Elbow Surg 2008

Klinisk undersøkelse: Diagnostikk Stiv skulder eller ikke? - Teste passiv humeroskapulær bevegelighet. Innskrenket utadrotasjon vanligvis mest uttalt. Standard skuldertester vanskelig/umulig å utføre pga stiv og vond skulder.

Klinisk undersøkelse: kapsulært mønster Utadrotasjon Abduksjon Hånd på rygg

Klinisk undersøkelse: Må vi ha 30 grader innskrenket bevegelighet i minst to plan? Personlig erfaring: Mange gråtoner, ikke alle har uttalt passiv bevegelighetsinnskrenking. Viktig å utelukke andre diagnoser. Diagnostisk blokade med Xylocain subacromialt kan i noen tilfelle være nyttig. Følsom test: føre armen opp i max abduksjon, og så utadrotere passivt (med fiksert skulderblad).

Billeddiagnostikk Rtg: utelukke arthrose, andre skjelettforandringer MR: Fortykket leddkapsel, spesielt axillærrecessen Bløtvevsfortykkelse/signalforandringer i rotatorintervallet Fortykket coracohumeral-ligament Ultralyd: Væske langs lange bicepssene Fortykket coracohumeral-ligament

Behandlingsalternativer Benign neglect (analgetica, NSAIDs) Fysioterapi Ikke anbefalt i tidlig fase, men kan benyttes når tilstanden begynner å bedre seg. Nyttig etter at det er injisert kortison (med effekt)? Kortison pr os short-term benefits in pain, range of movement of the shoulder and function in adhesive capsulitis but the effect may not be maintained beyond six weeks (Cochrane). Kortisoninjeksjon Intra-artikulært, med eller uten rtg/ultralydveiledning, Rotatorintervall-injeksjon Tilleggsinjeksjon i bursa subacr. Når injisere, gjentatte injeksjoner, hvilken dose? Intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. (Cochrane)

Kortisoninjeksjon med hydrodilatasjon (distensjon) Five trials with 196 people were included. Authors' conclusions: There is "silver" level evidence that arthrographic distension with saline and steroid provides short-term benefits in pain, range of movement and function in adhesive capsulitis. It is uncertain whether this is better than alternative interventions (Cochrane 2008) Kirurgi (Manipulasjon under narkose) Arthroskopisk kapsulotomi Når?

Rotator(cuff)intervallet Mellom subscapularis og supraspinatus, langs lange bicepssene Lig. coracohumerale Lig. glenohumerale superior Arthroskopi ved kapsulitt: Synovitt med hyperemi Arraktige forandringer Predileksjonsstedet synes å være rotatorintervallet.>>>

SiV, Fys.med. avd., Kysthospitalet ved Stavern, 2009-2015

Based upon the observations of the involvement of the rotator interval, we hypothesised that combining a rotator interval injection with an intra-articular injection may enhance the treatment effectiveness of adhesive capsulitis. The aim of the study was to compare short and long term effects of an ultrasound guided intra-articular corticosteroid injection versus a combined intra-articular/rotator interval injection versus a sham injection. It is debated whether the accuracy of needle placement, frequency, and dose of corticosteroid influences effectiveness. Some trials report that inaccurate injections are less effective at reducing pain and improving function.

Inclusion criteria pain and stiffness in one shoulder for 1-6 months restriction of passive motion >30 in two or more planes of movement measured with a goniometer age 25-70 years Exclusion criteria systemic inflammatory joint disease polymyalgia rheumatica treatment with corticosteroids the previous three months poorly controlled diabetes pregnancy allergy to local anaesthetic contraindications to corticosteroid injections severe infections osteoarthritis of the glenohumeral joint fractures of the shoulder or humerus rotator cuff disease fibromyalgia insufficient Norwegian language skills

All the participants had a diagnostic ultrasonography a subacromial diagnostic test with a local anaesthetic plain x-ray of the shoulder to rule out pathology that would exclude them from participation Only one injection (at inclusion) Follow-up: 3, 6, 12, 26 weeks by blinded physiotherapists

Methods Consenting patients who met the inclusion criteria were stratified by gender and randomised by computer generated simple randomisation in permuted blocks of nine to receive an intra-articular injection Corticosteroid intra-articular, Lidocain into the interval a combined interval/intra-articular injection Corticosteroid intra-articular + interval (+ lidocain) a sham injection Lidocain

Methods Intra-articular group 1 ml triamcinolone hexacetonide 20 mg/ml + 2.5 ml lidocaine intra-articularly 3.5 ml lidocaine into the rotator interval Combined intra-articular/interval group 0.5 ml triamcinolone + 3 ml lidocaine into the rotator interval and anterior capsule, 0.5 ml triamcinolone + 3 ml lidocaine was injected intra-articularly. Sham injection group 3.5 ml lidocaine into the rotator interval 3.5 ml lidocaine intra-articularly. Patients were blinded

Outcomes The main outcome measure was shoulder pain (in general) at week 6. The participants rated pain intensity on a numerical rating scale from no pain (0) to worst imaginable pain (10). Secondary outcome measures were Shoulder pain at the other follow-up visits SPADI active range of motion shoulder pain at night health related quality of life (EQ-5D) the use of pain medication at all the follow-up visits The percentage of patients with no or minor symptoms (pain score 2) was calculated at baseline and at the follow-up visits.

Måling av aktiv abduksjon, fleksjon, utadrotasjon

SPADI (shoulder pain and disability index) Hvor sterke SMERTER har du hatt den siste uken? På det verste? Når du lå på den vonde siden? Når du strakte deg etter noe på en høy hylle? Når du tok deg på nakken? Når du skjøv med den vonde armen? Hvor store VANSKER har du hatt den siste uken når du utførte aktivitetene som er listet opp nedenfor? Når du vasket håret? Når du vasket deg på ryggen? Når du tok på deg undertrøye eller genser? Når du tok på deg en skjorte med knepping foran? Når du tok på deg buksene? Når du plasserte en gjenstand på en høy hylle? Når du bar en tung gjenstand på 5 kg eller mer? Når du tok opp noe fra baklomma? Score 0-100

Figure 1. Flow-chart of participants: Enrolment, allocation, follow-up and analysis.

Table 1 Baseline characteristics of participants with adhesive capsulitis according to treatment group Intra-articular injection Combined injection Sham injection (n= 42) (n= 40) (n= 40) Age, years; mean (SD) 53.2 (6.9) 55.0 (7.2) 55.4 (6.5) Gender, women; % 64 63 65 Dominant arm affected; % 41 38 33 Diabetes; n 0 3 7 First episode; % 83 82 90 Duration of symptoms weeks; mean (SD) 15.1 (4.6) 15.0 (5.9) 15.0 (5.6) Analgesics, at least weekly usage; % 65 65 40

Primary outcome: Adjusted mean values (95% CI) for shoulder pain at baseline and 6 weeks according to treatment group. Results are adjusted for baseline scores, time to follow-up, diabetes, age and gender. Intra-articular injection Combined injection Sham injection Mean (95% CI) Mean (95% CI) Mean (95% CI) Shoulder pain Baseline 6.1 (5.8 to 6.4) 6.4 (6.1 to 6.7) 6.4 (6.1 to 6.7) Week 6 3.2 (2.5 to 3.9) 2.8 (2.0 to 3.5) 4.9 (4.1 to 5.6)

Primary outcome: Estimates of the adjusted mean difference (95% CI) between intervention groups on shoulder pain 6 weeks. Results are adjusted for baseline scores, time to follow-up, diabetes, age and gender. Intra-articular injection versus sham injection Combined injection versus sham injection Intra-articular injection versus combined injection Mean a (95% CI) p-value Mean a (95% CI) p-value Mean b (95% CI) p-value Shoulder pain Week 6-1.7 (-2.7 to -0.6) 0.002-2.1 (-3.2 to -1.1) 0.001 0.4 (-0.6 to 1.5) 0.42

Secondary outcomes Intra-articular injection Combined injection Sham injection Mean (95% CI) Mean (95% CI) Mean (95% CI) Shoulder pain Baseline 6.1 (5.8 to 6.4) 6.4 (6.1 to 6.7) 6.4 (6.1 to 6.7) Week 3 4.3 (3.7 to 4.9) 3.7 (3.1 to 4.3) 5.1 (4.5 to 5.8) Week 6 3.2 (2.5 to 3.9) 2.8 (2.0 to 3.5) 4.9 (4.1 to 5.6) Week 12 2.2 (1.5 to 2.9) 2.6 (1.9 to 3.3) 3.7 (3.0 to 4.4) Week 26 1.8 (1.2 to 2.5) 2.2 (1.5 to 2.8) 2.5 (1.8 to 3.2) SPADI Baseline 68.9 (63.7 to 74.1) 67.1 (62.3 to 71.9) 68.8 (63.1 to 74.5) Week 3 47.9 (42.0 to 53.8) 47.8 (41.8 to 53.8) 56.8 (50.5 to 63.0) Week 6 33.7 (26.6 to 40.8) 35.0 (27.8 to 42.2) 48.5 (41.1 to 56.0) Week 12 22.7 (15.9 to 29.6) 30.3 (23.4 to 37.2) 41.1 (34.0 to 48.3) Week 26 17.0 (9.9 to 24.1) 24.5 (17.3 to 31.7) 25.6 (18.1 to 33.0)

Table 3 Estimates of the adjusted mean difference (95% CI) between intervention groups on shoulder pain, shoulder pain at night, active shoulder range of motion, SPADI and EQ-5D at 3, 6, 12 and 26 weeks. Results are adjusted for baseline scores, time to follow-up, diabetes, age and gender. Intra-articular injection versus sham injection Combined injection versus sham injection Intra-articular injection versus combined injection Mean a p-value Mean a p-value Mean b p-value Shoulder pain Week 3-0.8 (-1.7 to 0.1) 0.08-1.4 (-2.3 to -0.5) 0.002 0.6 (-0.3 to 1.5) 0.17 Week 6-1.7 (-2.7 to -0.6) 0.002-2.1 (-3.2 to -1.1) 0.001 0.4 (-0.6 to 1.5) 0.42 Week 12-1.5 (-2.5 to -0.6) 0.002-1.2 (-2.1 to -0.2) 0.02-0.4 (-1.3 to 0.6) 0.44 Week 26-0.7 (-1.6 to 0.3) 0.16-0.3 (-1.3 to 0.6) 0.48-0.3 (-1.2 to 0.6) 0.47 SPADI Week 3-11.9 (-22.6 to -1.3) 0.03-12.2 (-23.0 to -1.4) 0.03 0.3 (-10.2 to 10.7) 0.96 Week 6-19.5 (-32.2 to -6.9) 0.003-19.1 (-31.9 to -6.3) 0.004-0.4 (-12.9 to 12.0) 0.94 Week 12-23.9 (-36.5 to -11.4) 0.001-14.0 (-26.7 to -1.4) 0.03-9.9 (-22.2 to 2.5) 0.12 Week 26-11.0 (-24.1 to 2.0) 0.10-1.7 (-14.8 to 11.4) 0.79-9.3 (-22.1 to 0.3) 0.15 EQ-5D Week 3-0.09 (-0.20 to 0.01) 0.07-0.03 (-0.13 to 0.08) 0.63-0.07 (-0.17 to 0.03) 0.18 Week 6-0.15 (-0.27 to -0.03) 0.02-0.10 (-0.22 to 0.03) 0.13-0.06 (-0.18 to 0.07) 0.36 Week 12-0.09 (-0.17 to -0.00) 0.04-0.11 (-0.20 to -0.03) 0.01 0.02 (-0.06 to 0.11) 0.59 Week 26-0.03 (-0.11 to 0.05) 0.50-0.04 (-0.13 to 0.04) 0.28 0.02 (-0.06 to 0.10) 0.68 a Negative difference in adjusted mean scores indicates that the active treatment group improved more than the sham injection group; b Negative difference in adjusted mean scores indicates that the intra-articular injection group improved more than the combined injection group.

Number of participants with no or mild pain ( 2) and number of participants with no or infrequent use of pain medication (less than weekly), at baseline, 3, 6, 12 and 26 weeks, according to treatment group. Intra-articular injection Combined injection Sham count/n (%) count/n (%) injection count/n (%) No or mild pain Baseline 1/40 3 0/38 0 0/39 0 Week 3 9/39 23 10/38 32 6/36 17 Week 6 19/37 51 18/35 51 8/35 23 Week 12 26/36 72 22/36 61 13/35 37 Week 26 29/36 81 21/36 58 22/34 65 No or infrequent pain medication Baseline 15/41 37 16/40 40 20/39 51 Week 3 22/39 56 22/38 58 22/36 61 Week 6 29/37 78 27/37 78 21/35 60 Week 12 29/36 81 27/36 75 25/35 71 Week 26 28/36 78 31/36 86 25/34 74

Conclusion / discussion No significant differences were found between the intraarticular and combined interval/intra-articular injections. A single ultrasound guided corticosteroid injection was better than a sham injection in improving shoulder pain at 6 weeks and the effect was maintained for 12 weeks. To our knowledge, this is longer than in previous placebo controlled studies.

The effectiveness was consistent for secondary outcomes including: combined disability and pain score (SPADI) range of motion (active flexion, external rotation, abduction) the use of pain medication health related quality of life. Although the clinical significance of pain reduction reported in this study may be discussed, the improvement in health-related quality of life at 3, 6, and 12 weeks was considered to be valuable by the patients, and this supports the effectiveness of the corticosteroid injections.

Styrker og svakheter ved studien + Dobbeltblindet, placebokontrollert, randomisert design, strenge inklusjonskriterier, god compliance, høy prosentandel follow-up, justerte analyser. Baseline demographics lik tidligere studier. Pasienter rekruttert fra allmennpraksis. - Inklusjonskriterier basert på klinikk. Psykologiske faktorer og sykefravær ikke rapportert. Ikke gjort intertester reliability hos fysioterapeutene som foretok kontrollene. Max 6 mnd sykehistorie. 18% av pasienter som kunne blitt inkludert ønsket ikke være med (gjenværende pasienter derfor ikke helt representative?). Lengrevarende effekt av Lidocain påvirket placebogruppen positivt?

UL-veiledet vs blind injeksjon? Ikke belyst i vår studie Varierende resultater fra studier med subacr. Injeksjoner Studier har vist lav treffsikkerhet ved intraartikulære injeksjoner uten veiledning

Erfaringer fra egen praksis I stadium 1: intra-artikulær injeksjon med Triamcinolon hexacetonid (Lederspan/Lederlon) Gjenta injeksjon etter noen uker hvis effekt avtar De fleste greier seg med 1-2 injeksjoner, noen få trenger 3 Etter et år: kapsulotomi hvis fortsatt stiv?

Til slutt TAKK! til alle medarbeidere: Marjon Wormgoor, Simen Haugen, Herlof Harstad, Petter Mowinckel (statistikk), og spesielt til Jens Ivar Brox, som var en uvurderlig hjelp for oss, og til alle pasientene som deltok. En spesiell takk til min gode venn og kollega Herlof Harstad, vår UL- gründer på Kysthospitalet ved Stavern. Det var han som startet det hele...