This document summarizes the debate around adhesive capsulitis and hydrodistension treatment. It provides background on the classification, epidemiology, and natural history of adhesive capsulitis. It then discusses the development of arthrodistension/hydrodistension treatment, including early studies from the 1960s. The 2006 Cochrane Review on this topic is summarized, which identified 4 randomized controlled trials comparing arthrodistension to other treatments. The review found arthrodistension provided short-term improvements in pain and range of motion compared to placebo or other interventions.

1.
Adhesive
Capsuli.s
Debate:
Hydrodistension
Abbas
Rashid
FRCS
(Tr&Orth)
Wrigh;ngton
Upper
Limb
Unit

2. Background
History
‘painful
s*ffening
of
the
shoulder‘
Classifica;on
&
Epidemiology
• 2-­‐
5%
of
general
popula.on
• Up
to
40%
contralateral
shoulder
affected
• Up
to
20%
of
diabe.cs
(Anton
1993;
Lundberg
1969)
• Peak
incidence
between
40-­‐60
years
• women
>
men
• ae.ology
and
pathophysiology
poorly
understood
‘presence
of
shoulder
pain
with
restric*on
of
ac*ve
and
passive
glenohumeral
joint
movements
in
at
least
two
planes’
1872
Duplay
Periarthrite
scapulohumerale
1934
Codman
Frozen
Shoulder
1945
Nevaiser
Adhesive
capsuli;s
1949
Withers
Involvement
of
subacromial
bursa
1949
Simmonds
Inelas.c
fibrous
.ssue
1952
DePalma
muscular
inac.vity
1952
Meulengracht
Associa.on
with
Dupuytren’s
1962
Nevaiser
Reduced
joint
volume
1970
Lundberg
change
in
GAGs
in
affected
shoulder
1972
Bridgeman
Diabe;c
associa;on
1985
Bunker
Myofibroblasts,
T3
collagen,
few
inflammatory
cells
1989
Ozaki
Thickened
MGHL
&
RI

3. Natural
History
1. painful
phase:
(2-­‐9
months),
insidious
onset,
diffuse
severe
pain,
worse
at
night,
inability
to
lie
on
affected
side
2. s;ff
phase:
(4-­‐12
months),
s.ffness
and
severe
loss
of
ROM,
pain
less
pronounced
but
s.ll
present
par.cularly
at
end
of
ROM
3. recovery
phase:
(5-­‐24
months)
gradual
return
of
ROM
• ?self
limi.ng
• 1934:
Codman
‘even
the
most
protracted
cases
recover
without
treatment
in
2
years’
• improved
Constant
score
with
“supervised
neglect”
(Reeves
1975,
Diercks
&
Stevens
2004)
• 2004:
Dudikiewiczs
-­‐
40%
:
normal
ROM
+
are
pain
free
-­‐
45%:
func.onal
ROM
but
show
residual
symptoms
-­‐
15%:
persis.ng
s.ffness
with
marked
handicap
• Recurrence
rare

4. Arthrodisten;on
• Andren
and
Lundberg
in
1965
-­‐
injec.on
of
20
ml
contrast
medium
in
theatre
-­‐
allowed
to
flow
back
into
syringe
-­‐
Repeated
un.l
capsular
rupture
• Blind,
XR,
US
• saline,
LA,
steroid,
contrast
and
air
(Ekelund
1992;
Fareed
1989;
Gavant
1994)
• disrupts
adhesions
→
improved
ROM
(Gavant
1994)
• transient
pain
during
and
aier
the
procedure
• pa.ent
goes
home
• safe

5. Cochrane
Review
2006
• update
of
1998
review
• Previously
no
arthrodistension
studies
par%cipants
• adults
with
FS
• mixed
popula.ons
studies
included
if
FS
par.cipants
were
presented
separately
or
>
90%
of
par.cipants
in
the
study
interven%ons
• Arthrodistension
vs.
placebo
or
other
interven.ons
outcome
measures
• 1o
outcomes:
pain
and
func.on/disability
assessment
• 2o
measures:
ROM;
severity;
analgesic
use;
adverse
events;
.me
to
recovery
or
recurrence.
• November
1999
to
November
2006
• Combined
search
terms:
‘adhesive
capsuli.s’
and
‘arthrodistension’
1.
The
Cochrane
Musculoskeletal
Review
Group
Specialised
Register
2.
Cochrane
Central
Register
of
Controlled
Trials
(CENTRAL)
3.
MEDLINE
(OVID)
4.
EMBASE
(embase.com)
5.
CINAHL
(OVID)
6.
Reference
lists
in
review
ar.cles
and
trials
retrieved
7.
Personal
communica.on
with
experts
in
the
field

6. Results
Buchbinder
2004
• Arthrodistension
vs.
sham
• saline,
LA,
steroid
• mean
volume
43.3
ml
(21
to
80
ml)
• anterior
approach
with
fluoroscopy
• n=46
par.cipants
• 3
weeks
+
improvement
:
pain,
PET,
abduc.on,
IR
-­‐
No
difference
in:
FF,
ER
• 6
weeks
+
improvement:
PET
• 12
weeks
+
improvement:
PET
Khan
2006
• Arthrodistension
&
physio
vs.
physio
• Saline,
steroid
• 20
ml
• posterior
approach
under
fluoroscopy
• N=36
par.cipant
• 8
weeks
+
improvement:
abduc.on,
ER,
IR
-­‐
no
difference
:
pain
Gam
1998
• Arthrodistension
vs.
steroid
injec%on
• LA
+
cor.costeroid
• 20mls
• posterior
approach
under
ultrasound
guidance
• N=22
• General
+
improvement:
ROM,
analgesic
requirement
-­‐
no
difference:
pain
or
func.on

7. Results
Corbeil
1992
• Arthrodistension
vs.
steroid
injec%on
• LA
and
cor.costeroid
• 20ml
• repeated
weekly
up
to
6
weeks
or
un.l
no
symptoms
• posterior
approach
under
fluoroscopy
• N=45
par.cipants
• 3
months
-­‐
no
difference
in
:
pain,
passive
abduc.on,
ER
Jacobs
1991
• 3
arm
trial
• 10mls:
steroid,
air
• 9mls:
air
• three
.mes
at
6weekly
intervals
• posterior
landmarks
• N=47
• Arthrodistension
(steroid
&
air)
vs.
steroid
injec%on
• 16
weeks
-­‐
no
difference:
ROM,
pain
• Arthrodistension
(steroid
&
air)
vs.
arthrodistension
(air)
• 16
weeks
+
improvement:
FF
•
-­‐
no
difference
:
Abduc.on
• Arthrodistension
(air)
vs.
steroid
injec%on
• 16
weeks
-­‐
FF
&
Abduc.on
in
injec.on
group
-­‐
no
difference:
ER

8. Discussion
Methodological
Problems
• few
trials
• small
pa.ent
numbers
• criteria
to
define
frozen
shoulder
• different
regimens
• different
outcome
measures
• varying
repor.ng
of
results
→
data
extrac.on
and
pooling
of
results
Adverse
Effects
• Pain
during
procedure
(Buchbinder
2004,)
• Pain
aier
procedure
(Buchbinder
2004,
Gam
1998)
• Claustrophobia
(Buchbinder
2004)
• Fluid
noises
(Buchbinder
2004)
• Facial
flushing
(Jacobs
1991)
• CVA
(Jacobs1991)
• Nb
-­‐
no
difference
in
total
number
of
adverse
events
between
groups

9. Recent
Evidence
Clement
2013
• efficacy
of
arthrodistension
in
diabe.cs
• prospec.ve
cohort
study
• N=51
pa.ents
(12
diabe.cs:39
non-­‐diabe.cs)
with
53
frozen
shoulders
• OSS,
VAS,
ROM:
2
days,
1
month
• OSS,
VAS:
mean
of
14
months
(range
8-­‐26
months).
• 1
month
+
ROM
improved
(p
<
0.001)
• Final
f/u
+
OSS
improved
(p
<
0.001)
+
VAS
improved
(p
<
0.001)
• outcome
in
diabe.c
pa.ents
the
same
! effec.ve
in
diabe.c
pa.ents
! gives
long-­‐term
improvement
! low
number
of
pa.ents
requiring
secondary
procedure
Bae
et
al.
2014
• US-­‐guided
ant
approach
vs.
XR-­‐guided
post
approach
• RCT
• N=54
• XR:
5ml
LA,
5ml
contrast,
1ml
steroid,
9ml
saline
• US:
5ml
LA,
1ml
steroid,
14ml
saline
• Physiotherapy
• f/u:
1
week,
5
weeks,
9
weeks
• No
difference:
SPADI,
VNS,
PROM,
and
hand
power
! Less
radia.on
! ?cost
analysis
! Both
approaches
efficate

10. Recent
Evidence
Koh
2012
• capsule-­‐preserving
arthrodistension
• case
series
• N=18
• 3
distensions
(saline,
steroid)
at
1-­‐month
intervals
• monitored
using
real-­‐.me
pressure-­‐volume
curves
• S.ffness
decreased
• Max
joint
volume
increased
at
each
distension.
• Pressure
at
max
volume
capacity
o
decreased
(P
=
.662)
• clinical
parameters
at
1
month
(P
<
.05
for
all)
! Chages
biomechanical
proper.es
of
joint
capsule
! improved
Rom
and
pain
Elleuch
2008
• long-­‐term
efficacy
• RCT
• N=60
• arthrodistension
vs.
rehabilita.on)
• 1
week
Improvement
in:
pain,
FF,
Abduc.on,
ER,
CS
• 1
year
-­‐
gain
persisted
in
a
sta.s.cally
significant
manner
for
all
func.onal
parameters
and
all
SF-­‐36
dimensions
! Benefit
maintained
at
a
year

11. Conclusion
! minimal
harm
! may
shorten
dura.on
of
symptoms
! may
be
of
value
in
pa.ent
groups
with
high
incidence
of
adhesive
capsuli.s
! ?benefits
due
to
steroid,
capsular
distension
or
both
! Cannot
draw
firm
conclusions
! Further
well-­‐designed
trials
needed

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