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The Authors Respond
Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2013;94:2309-10
DEPARTMENTS Letters to the Editor Ultrasound-Guided Capsular Distension in Adhesive Capsulitis: The Hyaluronic Acid or the Local Anesthetic? We read with interest the recently published article by Park et al1 in Archives of Physical Medicine and Rehabilitation. We congratulate the authors on their successful study, which we deem important for 2 reasons. First, it reports on a relatively new injection/treatment alternative for patients with adhesive capsulitis, and second, it nicely illustrates the role of musculoskeletal ultrasound in guiding interventions during routine physiatry practice. On the other hand, we have a few remarks concerning the authors’ methodology. First and foremost, we could not clearly understand why the authors used higher amounts (18mL vs 4mL) of local anesthetic solution for patients in group B (capsular distension group). In other words, would this increased amount of lidocaine not confound the study results with respect to pain and functional measures of the participants (verbal numeric scale, Shoulder Pain and Disability Index)? Likewise, we would be interested in knowing why the authors did not prefer to supplement the volume excess in group B with saline or dextrose, which would actually better support their hypothesis on the efficacy of hyaluronic acid injection via the distension technique. Further, we also have some doubts about the authors’ application of intra-articular corticosteroids (ie, cumulative dosage and repetition frequency). Do the authors think that their intra-articular corticosteroid posology is safe as far as the mean age SD of the subjects (55.234.69y) in group A is concerned? Last but not least, we also wonder whether the authors had difficulties while injecting a solution of 20mL inside a shoulder joint with diagnosed adhesive capsulitis. Bledjan C¸uni, MD Levent O¨zc¸akar, MD Hacettepe University Medical School, Ankara, Turkey Disclosure: No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.
Reference 1. Park KD, Nam H-S, Lee JK, Kim YJ, Park Y. Treatment effects of ultrasound-guided capsular distension with hyaluronic acid in adhesive capsulitis of the shoulder. Arch Phys Med Rehabil 2013;94:264-70. http://dx.doi.org/10.1016/j.apmr.2013.04.025
The Authors Respond ¨ zc¸akar’s interest in our recently We appreciate C¸uni and O published article and their comments on our research.1 ¨ zc¸akar wondered why we used higher First, C ¸ uni and O amounts (18mL vs 4mL) of local anesthetic solution for patients in the capsular distension group, and whether this increased amount of lidocaine would confound the results. Corticosteroid intra-articular (IA) injection with capsular distension can cause complications as a result of corticosteroid leakage into proximal soft tissues after rupture.2 Thus, we performed the corticosteroidonly IA injection as the intervention method in the comparative group. Although a few clinical studies3,4 demonstrate the positive effect of hyaluronic acid in the treatment of shoulder diseases including adhesive capsulitis, Hsieh et al5 reported that hyaluronic acideonly IA injections did not produce additional benefits to conventional methods. As a result, we aimed to investigate the efficacy of an ultrasound (US)-guided IA hyaluronic acid injection with capsular distension compared with corticosteroid injection alone in this study. Despite the treatment efficacy of IA corticosteroid injection observed in our study, its potential complications lead us to consider IA hyaluronic acid use in patients with diabetes mellitus or those who have a history of adverse effects from corticosteroids. We do not consider the difference in lidocaine amounts to be a confounding factor affecting our results, since lidocaine is a short-acting analgesic, and we checked the Shoulder Pain and Disability Index, the verbal numeric pain scale, and the passive range of motion at 2 and 6 weeks after the final injections. Additionally, as capsular distension is a painful technique, 12 patients in the capsular distension plus IA hyaluronic acid group reported temporary pain during the injection in our study. We thought the use of saline or dextrose solutions would not affect the results but only cause more pain during injection; thus, analgesics such as lidocaine were used as major agents in the mixture. ¨ zc¸akar also wondered whether our IA Second, C¸uni and O corticosteroid posology was safe considering that the mean age SD of the subjects in group A was 55.234.69 years. Patients in group A were administered a mixture of 0.5% lidocaine (4mL) plus triamcinolone (40mg/mL; 1mL). All patients received 3 USguided IA injections at 2-week intervals (a total of 120mg triamcinolone). Although a consensus for optimal corticosteroid dose and injection times for shoulder IA injection has not been established, IA corticosteroid injection (20e40mg per injection, at least for 4-week interval between injections) is a part of the treatment paradigm suggested in the American College of Rheumatology practice guidelines for the treatment of knee osteoarthritis.6,7 Since the shoulder joint is not a weight-bearing structure,
0003-9993/13/$36 - see front matter Ó 2013 by the American Congress of Rehabilitation Medicine
2310
K.D. Park, Y. Park
unlike the knee joint, more frequent injections than at 4-week intervals were thought to be relatively safe. However, physicians need to refine and individually tailor their choice of corticosteroid dosing and frequency in the treatment of shoulder joint diseases. ¨ zc¸akar wondered whether we had difficulties Lastly, C¸uni and O while injecting a solution of 20mL inside a shoulder joint. In the case of severe adhesion and glenohumeral joint space narrowing, delivering 20mL of injectate into the joint space may be somewhat difficult. US-guided interventions have been shown to be of value, because the needle can be monitored in real time during the procedure. In our study, the US guidance method was used to improve injection accuracy. As we mentioned in the Study Limitations section of our article, capsular rupture could not be confirmed in the study. A number of cases of capsular rupture could have occured in the group treated with hyaluronic acid IA injection with capsular distension. Ki Deok Park, MD Gachon University of Medicine and Science, Gil Medical Center, Incheon, Republic of Korea Yongbum Park, MD Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea Disclosure: No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.
References 1. Park KD, Nam H-S, Lee JK, Kim YJ, Park Y. Treatment effects of ultrasound-guided capsular distension with hyaluronic acid in adhesive capsulitis of the shoulder. Arch Phys Med Rehabil 2013;94: 264-70. 2. Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Me´dicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85. 3. Itokazu M, Matsunaga T. Clinical evaluation of high molecular-weight sodium hyaluronate for the treatment of patients with periarthritis of the shoulder. Clin Ther 1995;17:946-54. 4. Leardini G, Perbellini A, Franceschini M, Mattara L. Intra-articular injections of hyaluronic acid in the treatment of painful shoulder. Clin Ther 1988;10:521-6. 5. Hsieh LF, Hsu WC, Lin YJ, Chang HL, Chen CC, Huang V. Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: a randomized controlled trial. Arch Phys Med Rehabil 2012; 93:957-64. 6. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum 2000;43: 1905-15. 7. Douglas RJ. Corticosteroid injection into the osteoarthritic knee: drug selection, dose, and injection frequency. Int J Clin Pract 2012; 66:699-704. http://dx.doi.org/10.1016/j.apmr.2013.07.025
www.archives-pmr.org
DEPARTMENTS Letters to the Editor Ultrasound-Guided Capsular Distension in Adhesive Capsulitis: The Hyaluronic Acid or the Local Anesthetic? We read with interest the recently published article by Park et al1 in Archives of Physical Medicine and Rehabilitation. We congratulate the authors on their successful study, which we deem important for 2 reasons. First, it reports on a relatively new injection/treatment alternative for patients with adhesive capsulitis, and second, it nicely illustrates the role of musculoskeletal ultrasound in guiding interventions during routine physiatry practice. On the other hand, we have a few remarks concerning the authors’ methodology. First and foremost, we could not clearly understand why the authors used higher amounts (18mL vs 4mL) of local anesthetic solution for patients in group B (capsular distension group). In other words, would this increased amount of lidocaine not confound the study results with respect to pain and functional measures of the participants (verbal numeric scale, Shoulder Pain and Disability Index)? Likewise, we would be interested in knowing why the authors did not prefer to supplement the volume excess in group B with saline or dextrose, which would actually better support their hypothesis on the efficacy of hyaluronic acid injection via the distension technique. Further, we also have some doubts about the authors’ application of intra-articular corticosteroids (ie, cumulative dosage and repetition frequency). Do the authors think that their intra-articular corticosteroid posology is safe as far as the mean age SD of the subjects (55.234.69y) in group A is concerned? Last but not least, we also wonder whether the authors had difficulties while injecting a solution of 20mL inside a shoulder joint with diagnosed adhesive capsulitis. Bledjan C¸uni, MD Levent O¨zc¸akar, MD Hacettepe University Medical School, Ankara, Turkey Disclosure: No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.
Reference 1. Park KD, Nam H-S, Lee JK, Kim YJ, Park Y. Treatment effects of ultrasound-guided capsular distension with hyaluronic acid in adhesive capsulitis of the shoulder. Arch Phys Med Rehabil 2013;94:264-70. http://dx.doi.org/10.1016/j.apmr.2013.04.025
The Authors Respond ¨ zc¸akar’s interest in our recently We appreciate C¸uni and O published article and their comments on our research.1 ¨ zc¸akar wondered why we used higher First, C ¸ uni and O amounts (18mL vs 4mL) of local anesthetic solution for patients in the capsular distension group, and whether this increased amount of lidocaine would confound the results. Corticosteroid intra-articular (IA) injection with capsular distension can cause complications as a result of corticosteroid leakage into proximal soft tissues after rupture.2 Thus, we performed the corticosteroidonly IA injection as the intervention method in the comparative group. Although a few clinical studies3,4 demonstrate the positive effect of hyaluronic acid in the treatment of shoulder diseases including adhesive capsulitis, Hsieh et al5 reported that hyaluronic acideonly IA injections did not produce additional benefits to conventional methods. As a result, we aimed to investigate the efficacy of an ultrasound (US)-guided IA hyaluronic acid injection with capsular distension compared with corticosteroid injection alone in this study. Despite the treatment efficacy of IA corticosteroid injection observed in our study, its potential complications lead us to consider IA hyaluronic acid use in patients with diabetes mellitus or those who have a history of adverse effects from corticosteroids. We do not consider the difference in lidocaine amounts to be a confounding factor affecting our results, since lidocaine is a short-acting analgesic, and we checked the Shoulder Pain and Disability Index, the verbal numeric pain scale, and the passive range of motion at 2 and 6 weeks after the final injections. Additionally, as capsular distension is a painful technique, 12 patients in the capsular distension plus IA hyaluronic acid group reported temporary pain during the injection in our study. We thought the use of saline or dextrose solutions would not affect the results but only cause more pain during injection; thus, analgesics such as lidocaine were used as major agents in the mixture. ¨ zc¸akar also wondered whether our IA Second, C¸uni and O corticosteroid posology was safe considering that the mean age SD of the subjects in group A was 55.234.69 years. Patients in group A were administered a mixture of 0.5% lidocaine (4mL) plus triamcinolone (40mg/mL; 1mL). All patients received 3 USguided IA injections at 2-week intervals (a total of 120mg triamcinolone). Although a consensus for optimal corticosteroid dose and injection times for shoulder IA injection has not been established, IA corticosteroid injection (20e40mg per injection, at least for 4-week interval between injections) is a part of the treatment paradigm suggested in the American College of Rheumatology practice guidelines for the treatment of knee osteoarthritis.6,7 Since the shoulder joint is not a weight-bearing structure,
0003-9993/13/$36 - see front matter Ó 2013 by the American Congress of Rehabilitation Medicine
2310
K.D. Park, Y. Park
unlike the knee joint, more frequent injections than at 4-week intervals were thought to be relatively safe. However, physicians need to refine and individually tailor their choice of corticosteroid dosing and frequency in the treatment of shoulder joint diseases. ¨ zc¸akar wondered whether we had difficulties Lastly, C¸uni and O while injecting a solution of 20mL inside a shoulder joint. In the case of severe adhesion and glenohumeral joint space narrowing, delivering 20mL of injectate into the joint space may be somewhat difficult. US-guided interventions have been shown to be of value, because the needle can be monitored in real time during the procedure. In our study, the US guidance method was used to improve injection accuracy. As we mentioned in the Study Limitations section of our article, capsular rupture could not be confirmed in the study. A number of cases of capsular rupture could have occured in the group treated with hyaluronic acid IA injection with capsular distension. Ki Deok Park, MD Gachon University of Medicine and Science, Gil Medical Center, Incheon, Republic of Korea Yongbum Park, MD Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea Disclosure: No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.
References 1. Park KD, Nam H-S, Lee JK, Kim YJ, Park Y. Treatment effects of ultrasound-guided capsular distension with hyaluronic acid in adhesive capsulitis of the shoulder. Arch Phys Med Rehabil 2013;94: 264-70. 2. Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Me´dicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85. 3. Itokazu M, Matsunaga T. Clinical evaluation of high molecular-weight sodium hyaluronate for the treatment of patients with periarthritis of the shoulder. Clin Ther 1995;17:946-54. 4. Leardini G, Perbellini A, Franceschini M, Mattara L. Intra-articular injections of hyaluronic acid in the treatment of painful shoulder. Clin Ther 1988;10:521-6. 5. Hsieh LF, Hsu WC, Lin YJ, Chang HL, Chen CC, Huang V. Addition of intra-articular hyaluronate injection to physical therapy program produces no extra benefits in patients with adhesive capsulitis of the shoulder: a randomized controlled trial. Arch Phys Med Rehabil 2012; 93:957-64. 6. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum 2000;43: 1905-15. 7. Douglas RJ. Corticosteroid injection into the osteoarthritic knee: drug selection, dose, and injection frequency. Int J Clin Pract 2012; 66:699-704. http://dx.doi.org/10.1016/j.apmr.2013.07.025
www.archives-pmr.org