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Use of intravenous prednisolone in the treatment of adhesive capsulitis to improve the shoulder range of motionJundis
Jundishapur Journal of Natural Pharmaceutical Products 2009; 4(1): 15-23 Journal
THE RAPID EFFECT OF INTRAVENOUS PREDNISOLONE TO
IMPROVE THE SHOULDER RANGE OF MOTION IN
PATIENTS WITH FROZEN SHOULDER
Saeidian R1*, Hemmati A A2, Haghighi M H3
1Assistant professor in Physical medicine and rehabilitation, Golestan Hospital, Jundishapur University 2Associate professor in Pharmacology, School of Pharmacy, Jundishapur University of Medical 3Lecturer in biostatistics, School of Health sciences, Jundishapur University of Medical Sciences, Received: 30 December 2009
Accepted: 16 May 2010
Adhesive capsulitis is a disabling painful and often prolonged shoulder condition that requires careful
clinical diagnosis and management. Patients recover usually, but they may never regain their full range
of motion. In order to evaluate the beneficial effects of short-course IV Prednisolone in increasing
shoulder range of motion, this comparative study was planned.
Two age-sex matched groups of thirty patients suffered from idiopathic adhesive capsulitis for more
than four months from the onset were collected. The extreme range of shoulder active motions at
external rotation and abduction were measured and the mean values were calculated. Patients’ pain in
external rotation was qualified via visual analog scale before and after the two weeks course of the
treatment. The first group received oral Diclofenac (100mg/day), Omeprazole 20mg oral for two
weeks associated with physiotherapy, but the second group received 500mg IV Prednisolone for three
consecutive days at the beginning of the treatment in addition to the schedule for the first group.
Data obtained from before and after the treatment showed that mean improvement in shoulders
external rotation in the first group was 30.7 degrees, while it was 51.4 degrees for the second group,
this difference was significant at p<0.001. Also, the mean value of shoulder abduction improvement
for the first group was 34.1 degrees while it was 26.1 degrees for the second group. Patients from both
groups reported a significant reduction in pain severity. It can be concluded that adding 500mg IV
prednisolone for three consecutive days to the routine treatment may improve shoulder movements at
shoulder external rotation and abduction which reduces disability caused by adhesive capsulitis.
Shoulder motion, Frozen Shoulder, Prednisolone, Diclofenac.
presenting symptoms in patients who seek difficulty in sleeping on the affected side shoulder condition of insidious onset that labeled "peri-arthritis" by Duplay (3). Saeidian R / JJNPP 2009; 4(1):15-23 In 1945, Neviaser called the term adhesive corticosteroid injection and arthrographic Although still in use, adhesive capsulitis is Manipulations under anesthesia or surgical conservative treatments have failed (5, 6, synovitis and capsular contracture, it is not had little long-term advantage, but steroid injections may improve the pain and range that has a natural history of spontaneous resolution, but it requires a management pathway to prevent any remain limitations On the other hand, frozen shoulder could completely different from other shoulder Corticosteroids not only exert a positive leads to spontaneous resolution, this may not be complete. Reeves in a prospective such as frozen shoulder while NSAIDs are not potent and reliable pain-alleviating without functional disability, and 7% had drugs enough to elevate patients' mood in functional limitation (3). Shaffer et al. the chronic inflammatory musculoskeletal pain medications in their own right (11, and stiffness, an average of seven years 12, 13, 14, 15, 16, 17, 18, 19, 20, 21). There is no good consensus regarding the significant role in the treatment of arthritic amount of range of motion loss to define conditions (6, 11, 12), only recently the usage of IV Prednisolone for the treatment abduction, and internal rotation are the of frozen shoulder was reported in medical literature (22). The present prospective study by comparing the results of the two contracture can be helpful in determining methods of treatment, with and without IV typically associated with an antero-inferior shoulder range of motion in patients with improve the outcome of this condition, a Materials and Methods
Based on the time of referral, patients of either sex were randomly divided into two medications e.g. anti-inflammatory drugs suffered from painful shoulder stiffness adhesive capsulitis may be achieved using The rapid effect of intravenous prednisolone The ranges of shoulders external rotation patients were evaluated to assure that they differential and erythrocyte sedimentation rate in order to exclude the inflammatory positioned in pronation so that arms facing processes. Plain shoulder radiography was their feet. In this method shoulder ranges performed to preclude any tumor or gross of external and internal rotation varies calcifications around the shoulder joint or fracture. Other exclusion criteria in this study were a history of diabetes mellitus, duration of the patients΄ awareness of their and pain was calculated and recorded. All and end of the two weeks treatment plan. patients' ranges of shoulders motion from the beginning to the end of the treatment considered as the final treatment efficacy. measured while patients' arms were placed at their sides with the palms toward the 20mg every twelve hours for two weeks to prevent gastrointestinal tract ulceration ultrasound for 10 minutes, followed by a degrees abduction, and up to 10 degrees or techniques and interferential therapy for shoulders range of motions decreases (Fig. Fig.1: Techniques of shoulder joint goniometric measurements. A- Shoulder abduction; B- Shoulder external rotation Saeidian R / JJNPP 2009; 4(1):15-23 Analog Scale using a 10cm baseline in the years old and the mean age for the first morning of starting and finishing days of monitored for their blood pressure, blood sugar and electrolytes, gastrointestinal on hip and ankle motions to secure about Only 26 patients remembered a history of necrosis of bones during research period significant physical trauma at the onset of The results of the independent sample test statistically matched and similar enough to be compared or not. If so, the researchers the first group was 77.6 ± 1.62 degrees could compare the results in both groups. after the treatment period while the range of external rotation for the second group shoulders range of motions in both groups. 11.86 ± 0.96 degrees after the treatment degrees, while it was 51.4 degrees for the second group. Statistically, the initial patients were informed about the research similar in both groups. And the result of process and the drug side effects, and the absolute improvement is much more in the second group (p ≤ 0.001) (fig 1 & table 1). but they did not know on which treatment the first group was 78.8 ± 1.61 degrees sure that they are under close medical and and for the second group was 66.93 ± 3.02 medical staff during research period. Even they could refer to the researchers because degrees more at the beginning. After the to the research after this period. All the abduction reached to 44.7 ± 2.5 while for evidences of bone pain or limitation of hip 4.56 degrees. On the other hand the mean the research. It was expected that the two for the first group was 34.1 degrees while it was 26.1 degrees for the second group. But the results of independent sample test statistically comparable (fig 1 & table 2). The rapid effect of intravenous prednisolone Patients from both groups were satisfied Fig 2: Representative photographs from patient with frozen shoulder A: before treatment that patient was not able to bring his hand behind his head, B: after treatment.
Table 1: Means and Standard Errors of the range of active assistive shoulder external rotation (degrees)
*Indicates significant difference with group I (p<0.001). Table 2: Means and Standard Errors of the range of active assistive shoulder abduction (degrees) Saeidian R / JJNPP 2009; 4(1):15-23 Discussion
been the major patients' complains which drive them to the medical centers. ''Frozen shoulder '' was first described by Codman osteoporoses and other complications (2, Because of their potent analgesia steroids movement in the presence of normal plain are used in the treatment of radiculopthies, Complex Regional Pain Syndrome type ΙΙ and other neuropathic pain conditions (19, capsule seen during open surgeries of the 20). Because of strong anti-inflammatory adhesive capsulitis ' . Its natural clinical corticosteroids have been shown in certain course includes an insidious initial painful associated with the gradual loss of joint (21, 22, 23). Also they have been used for the treatment of frozen shoulder (5, 8, 24, 25). Recent studies suggest by including treatment schedule of adhesive capsulitis percent of patients have persisting severe one can get significant short term benefit improving shoulder range of motion(5, 6, 12, 16). Some researchers suggested that corticosteroid injections (5, 6, 7, 15). steroids or injections into the subacromial still remain the main problems of patients shoulder by analgesics-oral steroids and During the initial painful freezing stages, shortening of disease natural history (2, 8, treatment should be directed to relieve the 26, 27). Another study which was done by pain. Because the pain keep them to limit all activities require their shoulder motion activity, it has been a tradition to give patients the NSAIDs, if they tolerate them. Because of the potential corticosteroids other analgesics. However, there are not side effects, it is important to evaluate the enough randomized controlled trials that patient's general conditions, the severity of benefits that a patient may gain. Also it is The use of adreno-corticiods has provided a great relief for patients with rheumatoid necessary in the smallest possible dose for reducing the production of cytokines and induce anti-inflammatory effects. But they effect of exercise within the limits of pain The rapid effect of intravenous prednisolone with intensive physiotherapy in patients References:
1. Dias R, Cutts S, Massoud S. Frozen
results with exercise performed within the intra-articular gleno-humeral joint which may reduce the synovitis(24). De Jong et steroid injection is dose-dependent. Those limited benefit, but that a single steroid 5. Harrast M, Rao A. The stiff shoulder. In a randomized placebo controlled trial, Carette et al. compared the effectiveness treatment of frozen shoulder such as: 1) articular steroid injection given under X- combination and 4) a fourth placebo group physiotherapy has a limited benefit when Conclusion
The results of this study indicates that consecutive days to its routine treatment 10. Kivi J, Pohjolainent T. Manipulation adhesive capsulitis. Although the thawing of shoulder motion limitation could be due corticosteroids, their analgesic effect may effective range of motion exercises. Thus another question may rise, whether pain or shoulder in different conditions? Because of this, another research to compare these (frozen shoulder or stiff painful shoulder): a randomized, double blind, Saeidian R / JJNPP 2009; 4(1):15-23 lupus)patients. Lupus.2005;
17. Nicholas JJ. Rehabilitation of Patients Tokyo: Saunders; 1996:1003-1026.
The rapid effect of intravenous prednisolone course, pulse prednisolone in managing frozen shoulder2007;21(1): 27-30. Dieppe PA, Frank CA, Brooks PM, Canoso JJ, Carettes et al., Rheumatology, 2end edition. London, Mosby, 1998; Vol: 1 Chap 3: 5.1 5.6. Thawing of the of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg 2004; 13: 499-502. Bessete L, Morin F, Froment P,et al.Intra-articular corticosteroids, supervised physiotherapy or a combination of two in the treatment of adhesive capsulitis of the shoulder: a placebo controlled trial. Arthritis Rheum 2003; 48: 329-838.
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