REPORTS

Pain Relieving Effect of Short-Course, Pulse Prednisolonein Managing Frozen Shoulder

Seyed Reza SaeidianAli Asghar Hemmati

Mohammad Hasan Haghighi

ABSTRACT. Adhesive capsulitis or frozen shoulder is a common condition characterized byshoulder pain and stiffness in which conservative methods of treatment such as glucocorti-costeroids, anti-inflammatory drugs, and physiotherapy play a significant part. To evaluate thepain relieving effect of short-course pulse prednisolone, this comparison study was planed. Twoage and sex-matched groups of patients were studied during three years. Each group consisted ofthirty patients suffered from idiopathic Frozen Shoulder. The mean duration from the onset of thedisorder to referral to our clinic was five months. Patients’ pain on external rotation was qualifiedusing a visual analog scale before and after finishing the treatment. The first group received oraldiclofenac (100 mg/day) and physiotherapy. The second group received 500 mg of prednisoloneintravenously (IV) for three consecutive days at the beginning of treatment in addition to the fulltreatment regimen of the first group. The pain relieving effects of the two methods of treatmentwere compared. The mean pain scale for the first group decreased from 7.16 to 4.9 (p < 0.001) andfor the second group from 7.10 to 2.96 (p < 0.001) as indicated by Paired sample test. Based on theresults of this study, inclusion of 500 mg prednisolone for three days appears to improve thepain-relieving effect of routine conservative treatment of frozen shoulder using NSAIDs and phys-iotherapy. doi:10.1300/J354v21n01_06 [Article copies available for a fee from The Haworth Document De-livery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2007 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Pain, frozen shoulder, prednisolone, pulse therapy, visual analog scale

Seyed Reza Saeidian, MD, is Assistant Professor of Physical Medicine and Rehabilitation at the Golestan Hos-pital, Jundishapur University of Medical Sciences; Ali Asghar Hemmati, PhD, is Associate Professor of Pharma-cology, School of Pharmacy, Jundishapur University of Medical Sciences; and Mohammad Hasan Haghighi,MSc, is in the Department of Epidemiology, School of Health, Jundishapur University of Medical Sciences,Ahvaz, Iran.

Address correspondence to: Dr. Seyed Reza Saeidian, Department of Physical Medicine and Rehabilitation,Golestan Hospital, Jundishapur University of Medical Sciences, Ahvaz, Iran (E-mail: seyedrezasaeidian@yahoo.com).

Journal of Pain & Palliative Care Pharmacotherapy, Vol. 21(1) 2007Available online at http://jppcp.haworthpress.com

© 2007 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J354v21n01_06 27

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INTRODUCTION

Although frozen shoulder is a common dis-order of the gleno-humeral joint, it is poorly un-derstood and has remained an enigma. Thissyndrome is characterized by contraction andthickening of the joint capsule which causesgradual loss of joint motion, pain, and disabil-ity.1-4 Other terms such as shoulder peri-arthritis, stiff painful shoulder, and adhesivecapsulitishavebeenused todescribe thiscondi-tion of painful restriction of shoulder motionwith a normal X-ray. Sequelae include osteo-penia of the humeral head from disuse. Thediagnosis is usually made clinically and clini-cians should be concerned about a possible un-derlying rotator cuff tear.2,3,5

Most patients recover within two years afteronset of frozen shoulder whether or not it istreated. To decrease the time to recovery and toimproveoutcomesfor thisconditionacarefullydesigned treatment plan including physiother-apy, pain medication such as NSAIDs andcorticosteroids is required. Oral glucocorti-coids, intra-articular corticosteroid injections,and arthrographic distention of the constrictedcapsule have been reported to be effective ther-apeutic interventions for achieving symptom-atic relief from adhesive capsulitis. Surgical re-ferral may be indicated when conservativetreatment fails. The exact timing of surgeryshould be determined on an individual ba-sis.2,3,6,7 Numerous studies have shown littlelong-term advantage in any one treatment regi-men, but that steroid injections may improvethe patients’ pain and a range of motion in theearly stage of this condition.8,9 Althoughglucocorticoids play a significant role in thetreatment of arthritic conditions, using pre-dnisolone pulses for treating chronic frozenshoulder is not reported in the medical litera-ture.1,2,4 This studyevaluated theeffectof pulseprednisolone therapy of chronic frozen shoul-der by measuring patient’s reported pain usinga visual analog scale and patients’ complaintsof night time sleep difficulties.

MATERIALS AND METHODS

Thisstudywasperformedontwoageandsexmatched groups of thirty patients sufferingfrom painful shoulder stiffness who were re-

ferred to a musculoskeletal pain clinic duringthe period of January 2002 to January 2005. Allof the patients were evaluated to assure thatthey had normal complete blood counts as wellas normal cell differential and erythroblast sed-imentation rates to exclude inflammatory jointdiseases or serious infectious processes. Plainshoulder radiography was done to preclude anytumor or gross anatomic abnormalities such ascalcification about the shoulder joint or frac-ture. Other exclusion criteria in this study werea history of diabetes mellitus, pregnancy, pep-tic ulceration and uncontrolled hypertension.Themeandurationof thepatients’awarenessoftheir shoulder motion limitation and discom-fort was five months with a range of four to 13months.Only 26 patients rememberedahistoryof significant trauma at the onset of the disease.All of the patients complained of pain on shoul-der mobilization and difficulty sleeping whenlying over the involved shoulder. The pain re-ported by the patients was quantified viaself-report Visual Analog Scale using a 10 cmbaseline in the morning on the days when theywhen started and finished treatment. All pa-tients were asked about their functional abilityin performing tasks which require shoulder ele-vation and abduction. They were asked abouttheirnight sleepqualityandquantitybeforeandafter the treatment.

Based on the timeof referral, patientsof bothsexes with an age range of 44 to 67 years, wererandomly divided into two groups (n = 30). Thefirst group received oral diclofenac (25 mgQID) for ten days associated with physiother-apy including pulsed-ultrasound for 10 min-utes, interferential therapy for another 10 min-utes, and active assistive range of shouldermotion exercises for the whole 10 day treat-ment period. For the second group treatmentstarted with 500 mg of intravenous predniso-lone for three consecutive days added to thetreatments provided to the first group. Finallythemeanreportedpainscalesby the two groupsbefore and two weeks after the treatment, werecalculated and compared as the indicators oftreatments efficacy.

Ethical Considerations

All of the patients were informed about theresearch process, but not the exact drug effects.

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They were under close medical observation bythe medical staff during research period. Be-cause it was expected that the two treatmentregimens would improve the patients’ condi-tions, all of them voluntarily agreed to partici-pate in the research program.

Data were analyzed and compared using a“paired sample test.” Significant differenceswere defined at p < 001.

RESULTS

Theinitial;meanpainscalefor thefirstgroupwas 7.17 ± 1.08 and for the second group was7.1 ± 1.26 that showed both groups were suffi-ciently similar to compare the results.

The Mean Pain Scale for the first group sig-nificantly decreased to 4.9 ± 1.24 following thetreatment course (p < 0.001). The Mean PainScale for the second group significantly de-creased to 2.96 ± 0.88 after the treatmentperiodat p < 0.001.

Sixteen patients in the first group reportednight time sleep improvement while 25 sub-jects in the second group claimed their nighttime sleeping had become normal.

DISCUSSION

More than90%ofshoulderpainepisodesaredue to non-articular causes, the two most com-mondisordersbeingrotatorcuff lesionsandad-hesive capsulitis.5 Adhesive capsulitis charac-terized by spontaneous onset of shoulder painand global stiffness of the gleno-humeral jointaccompanied by significant disability. Numer-ous studieshavesuggested that this is a self lim-iting condition lasting an average of two tothreeyears,butmanypatientssuffer fromresid-ual clinically detectable restriction of move-ment beyond three years and smaller numbershave residual disability.2-4

Corticosteroids inhibit production of cyto-kines and pro-inflammatory enzymes via pro-moting the production of certain cell proteins.Therefore, they can reduce pain and inflamma-tion in many diseases. Oral steroids were firstemployedin the1950s to improvefrozenshoul-der recovery and reduce the need for manipula-

tion under anesthesia.2-4,10,11 A recent studysuggests that 30 mg of prednisolone daily hassignificant benefit in adhesive capsulitis. Al-though controversial, intra-articular cortico-steroid injections are used to decrease pain andinflammation. These injections dramaticallyameliorate thesymptomsof inflammatory jointdiseases such as rheumatic diseases.2-4,12

Oral corticosteroids have been used infrozen shoulder for many years.7,13,14 Althoughthe beneficial effects intravenous corticoster-oid infusionshasbeenshownincertainmedicalconditions such as ulcerative colitis,15 asthma,16

and primary Sjogren’s syndrome,17 we couldfindnoreport regarding the intravenousadmin-istration of corticosteroids in recent publica-tions. Clinical trials may be needed to comparepulse parenteral corticosteroid administrationwith oral regimens. It is important to considerthe potential benefits and risks of high dosepulse steroid treatment, especially in self-lim-ited disorders such as adhesive capsulitis. Be-causeof theriskofadverseeffects, it isessentialtousesystemiccorticosteroidscautiouslyin theelderly, in the smallestpossible dose and for thebriefest possible period. On the other hand,corticosteroids fail to control the generation ofplatelet derived thromboxane (possibly be-cause platelets do not possess a nucleus andcannot form lipocortin) and it may be the causeof concomitant and widespread use of plateletsuppressing NSAIDs.2-4,18

Some studies concluded that increasing thejoint space may improve joint motion, isomet-ric shoulder strength and decrease pain. Thismay be achieved by a four week rehabilitationprogram, arthrographic shoulder distention, ormanipulation under anesthesia.4,6,19,20 Thesefindings support the significant role of theshoulder capsule in the pathogenesis of frozenshoulder. Physiotherapy directed to increaseshoulder range of motion have a positive im-pact on improving the patients’ pain and condi-tion.21

Frozen shoulder could lead to be a chronicpain. Due to neuronal plasticity in which thenumbers of noxious stimuli are increased, be-havioral changes may also occur.22,23 Corti-costeroids not only exert a positive effect on themood but also have a significant pain-control-ling effect involved in the inflammatory pro-cessesof frozenshoulderwhileNSAIDsarenot

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potent enough and reliable pain-reliever andmood-elevator in a chronic inflammatory mus-culoskeletal pain conditions. NSAIDs are ef-fective pain medications in their own right.11,23-26

Theresultsof this studysupport the inclusionofpulse prednisolone therapy in patients with ad-hesive capsulitis.

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RECEIVED: 06/06/06REVISED: 08/08/06

ACCEPTED: 08/18/06

doi:10.1300/J354v21n01_06

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