1ORIGINAL RESEARCH

2Rifki Albana et al

3Comparison of the effects of a hydrodilatation

4procedure with suprascapular nerve block augmentation

5and without augmentation for frozen shoulder therapy

6Rifki Albana, Hermawan Nagar Rasyid, Yoyos Dias Ismiarto [Please list all authors here and do

7not include abbreviated qualifications]1

8Author name2

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13Correspondence: [Full name of corresponding author.]

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19Abstract:

20Purpose: Frozen shoulder, also known as adhesive capsulitis, is a shoulder movement disorder
21that affects 2-5 percent of adults and is more common in the elderly. The goal of frozen shoulder
22treatment is to alleviate pain and improve the functional capacity of the shoulder of a patient who
23is having trouble moving. The goal of this study is to see how comparison of the effects of
24hydrodilatation procedures with suprascapular nerve block augmentation and without
25augmentation for the treatment of frozen shoulder.
26

27Patients and methods: A prospective cohort study were performed, including patients (40-60
28years) diagnosed and treated frozen shoulder in Hasan Sadikin Hospital according to Zuckerman
29criteria. An open-arm single blind with block randomization sampling method was used. Exclusion
30criteria in this study were previous history of procedures on the breast or other orthopedic
31procedures on the upper limbs, history of systemic disease, and received other therapy prior to
32the study. The participants were divided into two groups: group A (hydrodilatation with saline and
33corticosteroids) and group B (hydrodilatation with saline and corticosteroids plus augmentation of
34suprascapular nerve block). Before the intervention, during the intervention, and after the
35intervention, shoulder function and pain scores were assessed (at the 1st and 6th month).
36

37Results: The total number of patients in the study was 31, with 16 in group A and 15 in group B.
38Preoperative functional scores and demographic variables were not significantly different
39between the two groups (p > 0.05). In each group, functional improvement was significant in the
40post-intervention VAS, ASES, and DASH (p0.05). In group A, there was no significant difference
41in intra-intervention VAS (p>0.05), whereas group B had a significant difference (p<0.05). The
42difference in functional score delta values between groups was significant at intra-intervention
43and post-month 1 (p0.05), but not at month 6 (p>0.05).
44

45Conclusion: Suprascapular nerve block augmentation has a positive effect on the short-term
46evaluation of shoulder pain and function in hydrodilation procedures in the treatment of frozen
47shoulder.
48

49Keywords: frozen shoulder, hydrodilation, corticosteroid, suprascapular nerve block

50Introduction

51Frozen shoulder or adhesive capsulitis is found in 2 – 5% of adult population. 1,2 The peak

52incidence of the cases were found in individuals aged 40 – 60 years. 1–3 The exact etiology of

53frozen shoulder remains unknown. It is hypothesized that chronic inflammation and fibrosis may

54play a part in the pathogenesis of frozen shoulder and their subsequent mobility issues of the

55affected shoulder, with previous study had noted increase in inflammatory mediators, such as

56interleukin (IL)-1a and 1b and tumor necrosis factor (TNF)-alpha in the tissue sample from

57patients affected with frozen shoulder.4

58Patients affected from frozen shoulder may suffer discomfort or even disability on the affected

59side of the shoulder, with the resolution of the illness may take months to heal. 5 Due to the

60relatively benign nature of the condition, treatments had been focused on addressing symptoms

61related to the limited mobility of the affected shoulder. Several treatment modalities had been

62attempted to alleviate the reduction of range of motion, such as rest, analgesia, active/passive

63mobilization, acupuncture, physiotherapy, oral/injected corticosteroid, capsule distention, and

64surgical capsule release.6

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65Hydrodilatation of shoulder joint capsule was noted to be a novel treatment to alleviate the pain of

66the affected shoulder. The procedure may be given with or without adjuvant corticosteroid.

67Hydrodilatation using saline and corticosteroid were noted to be superior in short-term pain

68reduction and range of motion improvement compared to management only using physiotherapy

69and corticosteroid injection in patients treated for frozen shoulder. 7 The proposed hypothesis

70regarding the mechanism of action in hydrodilatation and pain reduction in patients with frozen

71shoulder were associated with reduction of synovitis and fibrosis. 8,9 Previous studies had also

72noted higher efficacy in pain reduction in patients receiving hydrodilatation with adjuvant

73corticosteroid compared with only corticosteroid injection. 10,11Several other adjuvants were studied

74in frozen shoulder treatment using hydrodilatation, one of such procedure were usage of

75suprascapular nerve block. One of the rationale of usage of nerve block in frozen shoulder

76treatment was to give immediate, short-term pain relief from the pain of the affected shoulder

77during movement.12–14 The literature comparing the efficacy of suprascapular nerve block used as

78an adjunct in hydrodilatation of frozen shoulder remains sparse, specifically in Indonesia.

79Therefore, the aim of the study was to compare the efficacy in pain reduction in frozen shoulder

80therapy between hydrodilatation with and without suprascapular nerve block.

81Material and methods

82Study Design

83A prospective cohort study was conducted on the patients diagnosed and treated for frozen

84shoulder in Hasan Sadikin General Hospital. The patients with frozen shoulders were confirmed

85using Zuckerman’s criteria.

86Inclusion and Exclusion Criteria

87Inclusion criteria of the patients in the study consist of patients with frozen shoulder aged 40 – 60

88years old and fulfilling Zuckerman’s criteria, consisting of:

89 1. Sudden onset,

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 90 2. Range of motion (ROM) in active and passive elevation of the shoulders <100 o,

91 3. ROM limitation in external rotation <50% on the contralateral side;

92 4. Shoulder pain during night;

93 5. Normal radiographical findings

94Exclusion criteria of the patients in the study were patients with previous significant medical

95history (ipsilateral breast or upper extremity procedures, systemic diseases, previous shoulder

96surgery), had received treatment prior to the study, and secondary diagnosis on extracapsular

97joint pathologies.

98Sample Collection

99Open-arm single blind sampling method were used. The population of the study was patients

100diagnosed and treated for frozen shoulder in Hasan Sadikin General Hospital. There were two

101groups in the study, group A (receiving hydrodilatation with saline and corticosteroid injection

102without suprascapular nerve block) and group B (receiving hydrodilatation, corticosteroid

103injection, and suprascapular nerve block).

104Treatment

105Patients in both groups will receive hydrodilatation and corticosteroid injection under

106ultrasonography (USG) guidance. Triamcinolone 40 mg were given on the affected shoulder after

107local anesthesia using lidocaine 2%. Hydrodilatation were performed using saline. On group A,

108additional suprascapular nerve block was performed using bupivacaine 0.5%.

109Outcomes

110The study included three assessment scores for shoulder function, consisting of visual analog

111scale (VAS), American Shoulder and Elbow Surgeons (ASES) scoring, and Disabilities of the

112Arm, Shoulder, and Hand (DASH) score. The procedures and evaluation of all three scores were

113performed by the same physician in charge of the patient. Early manual exercise was prescribed

114after the hydrodilatation with or without suprascapular nerve block.

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115In this study, assessment was performed on different time periods. The outcomes were assessed

116before and after the procedure; on 1st month of follow-up; and 6th month of follow-up.

117Data Analysis

118Data analyses were performed using Statistic Program Social Service (SPSS) 25. Univariate

119tests were performed using t-test and Mann-Whitney test on inter-group comparisons. Paired t-

120test and Wilcoxon tests were performed on each variable according to the prior normality test. P

121value of <0.05 was deemed significant. Normality tests were performed for the study prior to the

122further analysis using Shapiro-Wilk test.

123Results

124There were 30 patients included in the study, each group consisted of 15 patients. Baseline

125variables for age, gender, affected side, and all three scores were collected for all the patients; no

126significant differences between both groups were noted (p > 0.05). Between both groups, before

127and after functional scores were taken. In group A, intraoperative VAS score was not significantly

128different compared to the prior baseline score.

129Pain scores were measured using VAS. Immediately after the surgery, no significant difference in

130pain were noted in both groups (p = 0.210 in group A and p = 0.052 in group B). Mean pre-

131intervention scores in pain scores (measured using VAS) were not significantly different between

132both groups. Lower pain scores were noted in group B compared to group A in both immediately

133after intervention (p = 0.000) and on the 1st month of follow-up (p = 0.000). However, the

134difference was not significant on the longer term follow-up (p = 0.052).

135Patient characteristics were underlined on Table 1. No significant differences were noted

136between the therapy and control group prior to the study. Significant differences between VAS,

137ASES, and DASH scores were noted within the groups with pre- and post-scores significantly

138different in all follow-up period (p = 0.001). Differences between group A and B were outlined on

139Table 3. Significant differences were noted on delta between pre and specified time period

140between groups in several variables. Functional scores were significantly higher on the 1 st month

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141in all three scores used for assessment (p < 0.05); however, no significant differences were noted

142on the 6th month of assessments on all three scores (p > 0.05).

143Discussion

144Hydrodilation of shoulder capsule with saline and corticosteroids were the mainstay, symptomatic

145treatment for patients suffering from frozen shoulders. Prior studies had found significant

146improvement in functional scores and reduction of pain scores on the affected shoulder with

147additional suprascapular nerve block.15–17 Studies comparing the treatment with or without

148addition nerve block in treatment of frozen shoulder were relatively scarce.

149Significant difference on pain and functional scores were noted on both groups; therefore, the

150treatment with or without suprascapular nerve block remained effective. The assessment scores

151used in the study consist of pain score (VAS) and functional scores (ASES and DASH).

152Suprascapular nerve block performed in the study was aimed to block the noxious stimuli to the

153glenohumeral joint from the suprascapular nerve. Approximately 70% of the shoulder was

154innervated by suprascapular nerve.18,19 The study had found that lower pain scores on

155intervention on shorter-term follow-up may facilitate early manual exercise. Earlier mobilizations

156had been noted by previous studies to be correlated with better outcomes on patients with frozen

157shoulder.20,21

158On functional scores, better functional scores were noted on the therapy group during the 1 st

159month of the follow-up. The difference in functional score on the 6 th month between both groups

160were not significantly different. Previous studies using similar scores had noted that treatment

161had only improved short-term outcomes in terms of pain reduction and improvement in functional

162scores of the affected shoulder.22 Being a self-limiting condition, the treatment of frozen shoulder

163are meant to be symptomatic.23

164The strength of the study was the prospective study design that follows the development of

165patients’ pain and functional scores. The study was limited by the sample size and possible

166biases that may exist in selecting the patients due to the single-center nature of the study. The

167self-limiting condition of the frozen shoulder meant that treatment should be focused on restoring

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168the mobility and reducing pain of the affected shoulder in order to mitigate possible impact to

169quality of life.

170Conclusion

171Suprascapular nerve block as an adjunctive treatment to hydro dilatation of shoulder capsule for

172cases for frozen shoulder were effective in reducing pain and improving functional scores quicker.

173Faster restoration of shoulder function mitigates the delay to apply rehabilitative efforts and may

174be associated with better outcome on the longer term

175Acknowledgments

176The author would like to express their gratitude for the institution that had provided with the

177necessary tools and access to the data in order to conduct this study.

178Disclosure

179The author reports no conflicts of interest in this work.

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266Table 1. Baseline characteristics

Group A Group B
Variables P value
(n = 16) (n = 15
Age (mean±SD) 55.93 ± 13.18 52.81 ± 10.84 356
Sex .354
Male 3 (18.75%) 4 (26.67%)
Female 13 (81.25%) 11 (73.3%
Affected side .853
Right 8 (50.0%) 7 (46.7%)
Left 8 (50.0%) 8 (53.3%)
267

268Table 2. Functional Assessment for group A and B before and after intervention

Before After
Variables P-value
Mean±SD Mean±SD

Group A
VAS intra 8.06±1.28 7.38±1.58 0.215*
VAS 1 month 8.06±1.28 4.63±1.14 0.000
VAS 6 month 8.06±1.28 2.19±0.83 0.000
ASES 1 month 24.34±12.49 43.63±12.52 0.000
ASES 6 month 24.34±12.49 56.31±17.88 0.000
DASH 1 month 59.01±21.96 41.13±18.34 0.000
DASH 6 month 59.01±21.96 22.38±14.052 0.000
Group B
VAS intra 7.87±1.35 2.13±0.35 0.001
VAS 1 month 7.87±1.35 1.47±1.12 0.001
VAS 6 month 7.87±1.35 0.67±0.90 0.001
ASES 1 month 27.75±9.877 61.00±14.74 0.000
ASES 6 month 27.75±9.877 58.07±16.48 0.000
DASH 1 month 49.56±14.73 11.41±11.25 0.001
DASH 6 month 49.56±14.73 10.64±9.01 0.001
269

270Abbreviations: VAS, visual analogue scale; ASES, American Shoulder; DASH, Disabilities of the

271Arm, Shoulder, and Hand

272Table 3. Comparison of score changes between time periods

Group A Group B
Variables P-value
(n=16) (n = 15)
VAS intra 0.69±2.18 5.73±1.33 0.000
VAS 1 month 3.44±1.93 6.40±2.09 0.000
VAS 6 month 5.88±1.62 7.20±2.00 0.052*
ASES 1 month 19.29±13.19 34.40±18.51 0.013
ASES 6 month 31.97±18.78 30.31±20.97 0.818*
DASH 1 month 17.88±12.87 38.15±15.27 0.000
DASH 6 month 36.63±18.13 38.92±15.11 0.707*
273

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