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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 62-65

Management of adhesive capsulitis of shoulder joint by single platelet rich plasma injection


Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Web Publication19-Aug-2019

Correspondence Address:
Prof. Alok Chandra Agrawal
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_28_19

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  Abstract 


Introduction: Adhesive capsulitis of shoulder is a condition characterized by painful and global restriction of active and passive glenohumeral range of motion in at least two directions, most notably shoulder abduction and external rotation. Platelet-rich plasma (PRP) is an emerging treatment option and its efficacy needs to be examined. Aim: The aim of the study is to assess the efficacy of PRP injection in the treatment of adhesive capsulitis of the shoulder joint. Materials and Methods: Patients with adhesive capsulitis received a single injection of PRP (4 ml) (n = 20). All participants were also advised to perform a home-based 10 min exercise therapy after injection. The outcome was measured using Constant and Murley shoulder score. Participants were evaluated at 0, 3rd day, and 1 month. Unpaired t-test tests were used to determine significant differences. Results: PRP treatment showed increase in pain for few participants at the 3rd day, causing decreased active range of motion. However, at 1 month, PRP treatment resulted in statistically significant improvements in constant score. No major adverse effect was seen in PRP injection. Conclusion: This study demonstrates that single injection of PRP improves both in pain and all range of motion of shoulder joint.

Keywords: Adhesive capsulitis, constant score, platelet-rich plasma


How to cite this article:
Agrawal AC, Nayak B, Sakale H. Management of adhesive capsulitis of shoulder joint by single platelet rich plasma injection. J Orthop Traumatol Rehabil 2019;11:62-5

How to cite this URL:
Agrawal AC, Nayak B, Sakale H. Management of adhesive capsulitis of shoulder joint by single platelet rich plasma injection. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2019 Nov 22];11:62-5. Available from: http://www.jotr.in/text.asp?2019/11/1/62/264724




  Introduction Top


Adhesive capsulitis of shoulder is a condition characterized by painful and global restriction of active and passive glenohumeral range of motion in at least two directions, most notably shoulder abduction and external rotation.[1] Adhesive capsulitis has an incidence of 3%–5% in the general population and up to 20% in those with diabetes.[2] It has a prevalence rate of 2%–5%.[3] It is more common in females, peak in 40–60 years age group, and 10 times more in a diabetic patient.

Inflammation is an important event that leads to stiffness, pain, and capsular fibrosis.[4] Inflammatory cytokines such as tumor necrosis factor-alpha, interleukin-1 (IL-1) alpha, IL-1 beta, and IL-6 are known to appear both in the glenohumeral and subacromial bursa.[5] Fibroblast/myofibroblast along with abundant type-3 collagen deposition are seen on coracohumeral ligament and rotator interval capsule. The absence of multiplication is seen at the superficial synovial layers.

Therapeutic options for the management of adhesive capsulitis are nonsteroidal anti-inflammatory drugs, intra-articular steroid injections, suprascapular nerve block, platelet-rich plasma (PRP) injection, manipulation under general anesthesia, or arthroscopic capsular release.[6],[7],[8],[9],[10] PRP is an emerging treatment option, and its efficacy needs to be examined.

Several fundamental protein growth factors that are actively secreted by platelets initiate the wound healing process. Blood activation causes the granules present in platelets to fuse to its cell membrane and release their growth factors (degranulation). The secretory proteins (e.g., platelet-derived growth factor and transforming growth factor beta)[11] are then transformed into their bioactive state by the addition of histones and carbohydrate side chains.[12] The active proteins then bind to the transmembrane receptors of target cells, which include mesenchymal stem cells, osteoblasts, fibroblasts, endothelial cells, and epidermal cells.

PRP is a fraction of the whole blood containing concentrated growth factors and proteins and has a higher concentration of platelets as compared to whole blood. Connective tissue healing takes place in three phases: inflammation, proliferation, and remodeling. The unique combination and concentration of bioactive molecules that exist within PRP have profound effects on the inflammatory, proliferative, and remodeling phases of wound healing.[13]


  Materials and Methods Top


Those patients attended the outpatient department (OPD), Department of Orthopedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India, with pain and restricted shoulder joint mobility in any plane of <25% specially abduction and external rotation for more than a month duration and a normal X-ray were included in the study.

Inclusion criteria were pain and stiffness in one or both the shoulders for at least 4 weeks, restricted the active and passive range of motion at the glenohumeral joint, age of ≥40 and ≤60 years, and who gave voluntary consent for participation in the study. The exclusion criteria were patients with chronic shoulder pain due to other causes such as nerve damage or neurologic disorders, patient had any skin problems including trauma and infection over the affected shoulder, history of fracture around the shoulder joint, patient following shoulder surgery, and uncontrolled diabetes.

A volume of 35 ml of blood will be drawn from the peripheral vein of the patient undergoing this procedure. This product was prepared at blood bank by two consecutive techniques: centrifugation followed by buffy coat-based PRP harvesting. The final PRP product contains approximately 4 ml of blood product.

With patient in sitting position, painting and draping were done. A 16G needle inserted 2–3 cm inferior and 1 cm medial to the posterolateral corner of the acromion process and directed anteriorly in the direction of the coracoid process. Then, the position of the needle was confirmed by the image intensifier television. Aspiration was done to ensure that the needle has not been placed in the blood vessel. The PRP will be injected slowly [Figure 1] and [Figure 2].
Figure 1: Technique of injection

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Figure 2: Injection under fluroscopy

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Constant and Murley shoulder assessment score was recorded (using standard orthopedics goniometer ad spring balance) – immediately before the procedure, on day 3, after 1 month.

Statistical analysis

The data were managed using Microsoft Excel and analyzed using t-test for comparing parameters. Results were considered significant at 5% level of significance, i.e., P < 0.05.


  Results Top


A total of 20 patients with complaints of shoulder pain associated with restriction of motion were assessed for eligibility. PRP was injected for all the patients.

Scores were recorded in Constant and Murley score. PRP treatment resulted in significant improvement in the mean active range of shoulder abduction, flexion, external rotation, and internal rotation in 1-month follow-up [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11].
Figure 3: Day-0 abduction

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Figure 4: Day-0 flexion

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Figure 5: Day-0 internal rotation

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Figure 6: Day-0 external rotation

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Figure 7: 1 month- abduction

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Figure 8: 1 month- flexion

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Figure 9: 1 month- internal rotation

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Figure 10: 1 month- external rotation

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Figure 11: Unpaired t-test

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  Discussion Top


In the first follow-up (3rd day), it was found that there was mean increased in pain. However, in 1-month follow-up, there was a significant increase in pain, activity level, arm position, strength of abduction, flexion, abduction, external rotation, and internal rotation which were measured by orthopedic goniometer and spring balance.

No major adverse effects were observed. The PRP was prepared using simple technique and intervention could be done in OPD basis with simple instruments. In uncontrolled diabetic patients, adequate blood sugar control done, followed by PRP injection was given.

Aslani et al. have reported 60% improvement in pain, 70% improvement in functional outcome, where flexion improved from 70° to 150°, abduction improved from 75° to 135°, and external rotation improved from 25° to 50°. He also reported a 70% satisfaction score after treatment with PRP injection in patients suffering with adhesive capsulitis.[14]

In our study, the pain improvement was 73.3%, activity improvement 75%, arm position improved by 55%, strength of abduction by 68%, and range of motion improved by an average of 75%.

Above assessment yielded results that were comparable to the study by Aslani et al.


  Conclusion Top


This case series shows the effectiveness of PRP in the management of adhesive capsulitis which is done by simple technique, without major adverse effects. There were limitation of this study such as small number of patients enrolled in our series and relatively short-term follow-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005;331:1453-6.  Back to cited text no. 1
    
2.
van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: Incidence, patient characteristics, and management. Ann Rheum Dis 1995;54:959-64.  Back to cited text no. 2
    
3.
Morén-Hybbinette I, Moritz U, Scherstén B. The clinical picture of the painful diabetic shoulder – Natural history, social consequences and analysis of concomitant hand syndrome. Acta Med Scand 1987;221:73-82.  Back to cited text no. 3
    
4.
Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl 1969;119:1-59.  Back to cited text no. 4
    
5.
Rodeo SA, Hannafin JA, Tom J, Warren RF, Wickiewicz TL. Immunolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder. J Orthop Res 1997;15:427-36.  Back to cited text no. 5
    
6.
Brue S, Valentin A, Forssblad M, Werner S, Mikkelsen C, Cerulli G. Idiopathic adhesive capsulitis of the shoulder: A review. Knee Surg Sports Traumatol Arthrosc 2007;15:1048-54.  Back to cited text no. 6
    
7.
Holloway GB, Schenk T, Williams GR, Ramsey ML, Iannotti JP. Arthroscopic capsular release for the treatment of refractory postoperative or post-fracture shoulder stiffness. J Bone Joint Surg Am 2001;83-A:1682-7.  Back to cited text no. 7
    
8.
Kivimäki J, Pohjolainen T. Manipulation under anesthesia for frozen shoulder with and without steroid injection. Arch Phys Med Rehabil 2001;82:1188-90.  Back to cited text no. 8
    
9.
Nicholson GP. Arthroscopic capsular release for stiff shoulders: Effect of etiology on outcomes. Arthroscopy 2003;19:40-9.  Back to cited text no. 9
    
10.
Pajareya K, Chadchavalpanichaya N, Painmanakit S, Kaidwan C, Puttaruksa P, Wongsaranuchit Y. Effectiveness of physical therapy for patients with adhesive capsulitis: A randomized controlled trial. J Med Assoc Thai 2004;87:473-80.  Back to cited text no. 10
    
11.
Kevy SV, Jacobson MS. Comparison of methods for point of care preparation of autologous platelet gel. J Extra Corpor Technol 2004;36:28-35.  Back to cited text no. 11
    
12.
Schilephake H. Bone growth factors in maxillofacial skeletal reconstruction. Int J Oral Maxillofac Surg 2002;31:469-84.  Back to cited text no. 12
    
13.
Mishra A, Woodall J Jr., Vieira A. Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med 2009;28:113-25.  Back to cited text no. 13
    
14.
Aslani H, Nourbakhsh ST, Zafarani Z, Ahmadi-Bani M, Ananloo ME, Beigy M, et al. Platelet-rich plasma for frozen shoulder: A case report. Arch Bone Jt Surg 2016;4:90-3.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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