Functional improvement was defined as the ability to accomplish a specific task that had been impossible prior to the procedure. Example functions included combing hair, putting an arm around a spouse, freestyle swimming, and reaching into a back pocket.
Pain relief was immediate in 11 of 21 shoulders. Temporary injection pain occurred in some procedures but injection pain resolved spontaneously. Significant pain relief was reported approximately 1 week following the procedure in 15 of 21 treatments.
Sustained benefits were confirmed by a telephone survey for the 14 patients whom we were able to contact. Ten of nineteen procedures (53%) produced enduring benefit of comfort, motion, and function for up to 55 months. One patient was lost to follow-up and one patient died prior to the telephone survey. The deceased patient suffered from gallbladder cancer and died in Mexico after a cancer-related operation 7 months after the hydroplasty procedure. Results are summarized in the Table.
TABLE 1
ROTATION CHANGES FOLLOWING HYDROPLASTY PROCEDURE
| Procedure Number | Patient (Shoulder Treated) | Duration of Symptoms, in Months | Change in ROM | Immediate Function Benefit | Immediate Effect on Pain* | Pain at 1 to 6 Weeks* | Prolonged Benefit † (Months) |
|---|---|---|---|---|---|---|---|
| 1 | A (L) | 4 | NM | Y | ↓ | ↓ | Y (55) |
| 2 | B (L) | 3 | +50 | Y | ↓ | ↓ | Y (41) |
| 3 | B (R) | 3 | +35 | Y | → | ↓ | Y (40) |
| 4 | C (R) | 8 | +30 | Y | ↓ | ↓ | Y (36) |
| 5 | D (R) | 60 | +25 | Y | ↓ | ↓ | N |
| 6 | E (L) | 6 | NM | Y | ↓ | Lost | Lost |
| 7 | F (R) | 12 | NM | Y | ↓ | ↓ | Y (30) |
| 8 | G (L) | 8 | +30 | Y | ↓ | ↓ | Y (4) |
| 9 | H (R) | 19 | +20 | Y | → | ↓ | N |
| 10 | I (L) | 84 | -35 | N | ↑ | ↑ | N |
| 11 | G (L) | 8 | +50 | Y | ↓ | ↓ | Y (25) |
| 12 | J (R) | 7 | +25 | Y | ↓ | ↓ | Y (1) |
| 13 | J (R) | 8 | +5 | N | ↑ | ↑ | D |
| 14 | A (R) | 3 | +45 | Y | ↓ | ↓ | Y (16) |
| 15 | K (L) | 3 | +25 | N | ↑ | ↑ | N |
| 16 | L (R) | 4 | +30 | Y | → | ↓ | N |
| 17 | M (L) | 4 | +20 | Y | → | → | N |
| 18 | L (R) | 7 | +30 | N | ↑ | ↑ | N |
| 19 | N (R) | 1 | +20 | N | → | → | N |
| 20 | O (L) | 4 | +20 | Y | → | ↓ | Y (7) |
| 21 | P (L) | 6 | +10 | Y | ↓ | ↓ | N |
| Summary Results | 16 patients; 21 treatments | Average = 12.5 months | 17/18 (94%) increased ROM | 16/21 (76%) improved function | 11/21 (52%) immediate relief | 15/20 (75%) relief at 1-6 weeks | 10/19 (53%) prolonged benefit |
| NM denotes not measured; Lost, lost to follow-up. | |||||||
| *Pain abbreviations: ↓=Pain decreased; →=Pain was unchanged; ↑Pain increased. | |||||||
| † Y denotes yes; N, no; D, deceased. | |||||||
Discussion
In our case series of hydroplasty for an unrestricted population of patients with capsular syndrome in the primary care office, 52% percent of patients experienced immediate pain relief and functional improvement. Benefits were sustained in 53% of patients for up to 55 months. Individuals who experienced improvement considered the benefits dramatic.
Study limitations include few patients, failure to record patients who refused the procedure, potential selection bias, and pathophysiologic diagnostic uncertainty. Although a few patients declined the procedure by authors’ recollection, these were not tallied. Patients were encountered by presenting to an author or by word-of-mouth publicity. Patients who were pleased by the results of their procedure referred other patients. This may not be typical of a primary care practice.
Because this was not a randomized controlled trial, we cannot be certain that the benefit was a result of injected medications or saline distension. We attempted to exclude the anesthetic effect by reassessing pain and function approximately 1 week after the procedure. Corticosteroid injection was unlikely to explain the immediate benefits observed.
The question of diagnostic uncertainty is important. Adhesive capsulitis could logically respond to capsular distension. A clinical examination may be insufficient to differentiate this process from other inflammatory processes that cause pain and tethering loss of motion. Hydroplasty would likely fail if a capsular contraction process were not in progress.
Reports of some other published trials suggest results superior to our series.9,10,11 There are several possible explanations. Visualization during arthrography might improve diagnostic certainty and consequently improve patient selection. More restrictive clinical patient selection parameters might improve the likelihood of treating patients who actually have adhesive capsulitis. Success might also depend on technical details, such as the volume and pressure applied during the distention injections. Randomized controlled trials comparing this treatment to other treatments were methodologically flawed.13,14 A systematic review concludes there is little evidence to support or refute efficacy of common interventions.6
Conclusions
Shoulder hydroplasty is an office procedure that may provide immediate and dramatic benefit to patients suffering from adhesive capsulitis. There is a need for a comprehensive study of this syndrome and its treatment by primary care clinicians. Explicit definitions and prospective evaluation of treatments might clarify options for the patient and the front-line clinician. Use of expanded symptom scoring systems such as the Simple Shoulder Test and the Medical Outcomes Study Short-Form Health Survey could provide valid, reliable outcome measures.2 While hydroplasty is an option for treatment of stiff and painful shoulders, it should ideally be compared with other treatment modalities in a randomized controlled trial.
Acknowledgments
The authors are grateful to Martee Robinson, Sheri Price, Vickie Greenwood, and the Cox Family Practice Residency writing group for immeasurable support and assistance.