Effectiveness of Ultrasonography-guided Pericapsular Nerve Group Block in Patients With Adhesive Capsulitis

Effectiveness of Ultrasonography-guided Pericapsular Nerve Group Block in Patients With Adhesive Capsulitis Resistant to Conservative Treatment

We aimed to observe the effects of Ultrasound-Guided Pericapsular Nerve Group Block administered before joint mobilization therapy on shoulder pain levels, function, and kinesiophobia in patients with resistant Adhesive Capsulitis.

Voluntary patients who applied to the Physical Therapy and Algology Department, did not benefit from physical therapy, and were recommended injection and mobilization therapy will be included in the study. Patients who decline injection but consent to mobilization therapy will be included as the control group. Those who accept the injection will be treated as Group 1 (Block + mobilization therapy), and those who decline the injection will be treated as Group 2 (mobilization therapy only).

Group 1 patients will receive a pericapsular nerve block before mobilization therapy, and a one-hour observation period will follow to assess the effectiveness of the procedure and monitor the patient. Patients will be evaluated for pain and range of motion (ROM) before and after the injection. Subsequently, they will undergo mobilization therapy three times a week for six weeks. Group 2 will follow the same program but will only receive mobilization therapy.

The following demographic data will be collected from the patients included in the study: age, gender, height, weight, education level, occupation, employment status, history of alcohol and smoking, comorbidities, current medications, dominant hand, and exercise status.

Patients' medical histories will be reviewed, and any prior test results (e.g., blood glucose, thyroid dysfunction, lipid levels, vitamin D, and vitamin B12 levels) will be recorded. Findings from previous diagnostic or differential diagnostic imaging for shoulder pain (shoulder X-rays, ultrasound, or MRI) as well as routine biochemistry blood test results will be evaluated and documented. Comprehensive physical examinations, including systemic and neurological assessments, ROM measurements, and muscle strength evaluations, will also be conducted.

• **DASH Score (Disabilities of the Arm, Shoulder, and Hand Questionnaire):** This questionnaire consists of three sections. Among the 30 questions, 21 assess difficulty in daily living activities, 5 address pain, activity-related pain, tingling, stiffness, and weakness, while 4 evaluate social function, work, sleep, and self-confidence. All questions are rated on a 5-point Likert scale, where 5 indicates extreme difficulty. Higher scores reflect greater disability.
• **Modified Constant-Murley Score:** This score evaluates four parameters with a total of 100 points. Pain is allocated 15 points, daily living activities 20 points, muscle strength 25 points, and shoulder ROM (elevation, external rotation, abduction, internal rotation) 40 points. Higher scores indicate better function.
• **VAS (Visual Analog Scale) for Pain:** Pain is scored as rest VAS, movement-related VAS, and night pain VAS on a scale from 0 to 10, where 0 indicates no pain and 10 indicates the highest level of pain.
• **Tampa Scale of Kinesiophobia:** A 17-item scale developed to measure fear of movement and re-injury. It includes parameters such as work-related activities, fear of injury/re-injury, and fear-avoidance behavior.
• **Shoulder Range of Motion (ROM):** Measured in degrees using a goniometer and recorded.

• **Complications and Side Effects:** These will be inquired from the patient and recorded.

  • **Ultrasound-Guided Pericapsular Nerve Group Block:** This procedure will be performed in an outpatient clinic setting and applied only once to Group 1.

During the procedure, with the patient's arm in an externally rotated and 45-degree abducted position, a linear ultrasound probe will be placed longitudinally between the coracoid process and the humeral head. After identifying the humeral head, the subscapularis muscle tendon and the overlying deltoid muscle will be visualized. A 50 mm needle will be advanced using an in-plane technique into the area between the deltoid muscle and subscapularis tendon. A total of 20 cc of a solution containing 0.25% bupivacaine hydrochloride and 6 mg of betamethasone (Celestone Chronodose) will be injected.

Study Overview

• Status: Completed
• Conditions: Kinesiophobia; Adhesive Capsulitis and Frozen Shoulder Syndrome; Pericapsular Nerve Group Block (PENG Block)
• Intervention / Treatment: Procedure: ultrasonography-guided PENG block; Other: Mobilization

• Study Type: Interventional
• Enrollment (Actual): 61
• Phase: Phase 4

Contacts and Locations

Study Locations

• Turkey
  • Samsun, Turkey, 55105
    • Medical Faculty, Ondokuz Mayis University, Samsun, Turkey

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Shoulder pain (Visual Analog Scale, VAS: 50 mm or more) and limitation of movement (at least 50% loss in active and passive ROM on the affected side) for at least 3 months
2. Poor response to previous exercise and drug therapy

Exclusion Criteria:

1. Severe systemic illnesses such as neurological diseases (e.g., Parkinson's disease, previous cerebrovascular disease, dementia), psychiatric disorders (e.g., major depression), diabetes mellitus, malignancy, infection, rheumatologic diseases (e.g., systemic lupus erythematosus), neuromuscular diseases (e.g., motor neuron diseases)
2. History of major orthopedic surgery, such as total shoulder replacement
3. History of steroid injection into the shoulder within the last 3 months
4. Previous mobilization therapy on the affected shoulder
5. Advanced-stage heart, liver, or kidney failure
6. High risk of bleeding

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Group1 Injection+Mobilization; Group 1 patients underwent ultrasound-guided PENG block (20 cc of a solution containing 0.25% bupivacaine hydrochloride and 6 mg betamethasone) by an experienced algologist (BU) before starting mobilization treatment	Procedure: ultrasonography-guided PENG block; This study aimed to evaluate the effect of ultrasonography-guided PENG block prior to joint mobilization therapy on shoulder pain, function, and kinesiophobia in patients with AC resistant to conservative treatment, in comparison with a control group
Active Comparator: Group 2 Mobilization; only mobilization therapy on shoulder pain, function, and kinesiophobia in patients with AC resistant to conservative treatment,	Other: Mobilization; The mobilization methods encompassed the scapula and clavicular joints, in addition to the glenohumeral (GH) joint, taking into consideration their biomechanical interactions. These exercises were supervised and administered by the physiotherapist during each session. Additionally, the patients were provided with a home exercise program that included exercises for posture, thera band, and finger ladder, with instructions to perform 10-15 repetitions twice a day independently [

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain	Resting pain, pain during activity, and night pain were assessed using VAS, where 0 indicated no pain and 10 represented the highest pain level	for 6 weeks
Shoulder Joint Range of Motion (ROM)	Active and passive shoulder flexion, abduction, internal rotation, and external rotation were measured with the patient lying supine, using a goniometer	for 6 weeks
Function	Disabilities of Arm, Shoulder and Hand (DASH) This questionnaire consists of 3 parts. Twenty-one of the 30 questions are about difficulty in activities of daily living, 5 questions are about pain, activity-related pain, tingling, stiffness and weakness, and 4 questions are about social function, work, sleep and self-confidence. All questions are rated on a Likert scale of 5, where 5 indicate too much difficulty. A high score indicates limitation. Turkish validity and reliability were examined	for 6 weeks
Function	Modified Constant-Murley Score (MCMS) The four parameters are evaluated with a total of 100 points. Pain is calculated as 15 points, activities of daily living 20 points, muscle strength 25 points, and shoulder ROM (elevation, ER, Abd, IR) 40 points and high scores indicate good function. Turkish validity and reliability were investigated	for 6 weeks
Muscle strength	Muscle strength was measured using a portable hand dynamometer	for 6 weeks
Kinesiophobia	The Tampa Scale of Kinesiophobia (TSK): The 17 item TSK total scores range from 17 to 68 where the lowest 17 means no or negligible kinesiophobia, and the higher scores indicate an increasing degree of kinesiophobia. The Turkish version was validated and is reliable	for 6 weeks

Collaborators and Investigators

• Sponsor: Ondokuz Mayıs University

Publications and helpful links

General Publications

• Kupeli I, Yazici Kara M. Anesthesia or analgesia? New block for shoulder surgery: pericapsular nerve group block. Braz J Anesthesiol. 2022 Sep-Oct;72(5):669-672. doi: 10.1016/j.bjane.2021.05.009. Epub 2021 Jun 9.

Study record dates

Study Major Dates

• Study Start (Actual): June 1, 2024
• Primary Completion (Actual): August 30, 2024
• Study Completion (Actual): September 29, 2024

Study Registration Dates

• First Submitted: November 17, 2024
• First Submitted That Met QC Criteria: November 19, 2024
• First Posted (Estimated): November 21, 2024

Study Record Updates

• Last Update Posted (Estimated): November 21, 2024
• Last Update Submitted That Met QC Criteria: November 19, 2024
• Last Verified: November 1, 2024

More Information

Terms related to this study

• Keywords: pain; function; kinesiophobia; Adhesive capsulitis; Pericapsular Nerve Group Block
• Additional Relevant MeSH Terms: Musculoskeletal Diseases; Mental Disorders; Joint Diseases; Phobic Disorders; Anxiety Disorders; Kinesiophobia; Bursitis
• Other Study ID Numbers: (No:223/2024)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No