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Three Part Question

In [adults with frozen shoulder], is [a higher dose corticosteroid injection (CS) 40mg better than a lower dose corticosteroid injection 20mg ] in [reducing pain]?

P: Adults with frozen shoulder I: Corticosteroid injection C: High versus low dose O: Pain

Clinical Scenario

A 63 year old male, presents with a 4 month history of a painful adhesive capsulitis or frozen shoulder. He is non-diabetic. He has restriction in motion in the capsular pattern of the shoulder. He experiences, a deep throbbing ache/ pain in his mid-upper arm, which is worse at night, affecting his sleep hygiene. A referral to physiotherapy for management of his range and pain made by his GP. If offered an injection, is there a significance of the dosage of CS (triamcinolone acetonide) on his pain reduction?

Search Strategy

Assisted search performed using following resources: NICE Evidence; TRIP Database; Cochrane Library; AMED (Ovid); CINAHL(EBSCO); EMBASE(Ovid); MEDLINE(EBSCO); Google Scholar; Google Search.

Search terms: “frozen shoulder*” OR “adhesive capsulitis”; “painful shoulder*”OR “stiff shoulder*” OR “shoulder pain” OR “shoulder stiffness”; steroid* OR corticosteroid*; triamcinolone OR methylprednisolone; high OR low OR optimal; dose* OR dosage*; pain* OR discomfort*.

Search Outcome

Ten articles were found. No systematic reviews found for the specific dosage comparison topic. Three of the articles had no mention of the dosage amounts in the abstract. One compared doses of 10mg and 40mg triamcinolone acetonide.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Yoon et al. (2013) South Korea	53 participants (27 male) with primary adhesive capsulitis in the freezing stage. Intervention: intra-articular triamcinolone acetonide (TA) injection. High dose group: 40mg TA plus 1% lidocaine (n=20), low dose group: 20mg TA plus 1% lidocaine (n=20) and placebo group: 1% lidocaine alone (n=10).	Randomised, triple blind, placebo controlled trial. Level of evidence: 1	SPADI VAS PROM	Improvement for both dose groups compared to placebo for all outcome measures. No significant difference between the dose groups for all outcome measures.	Participants’ initial VAS scored low compared to other studies, because of selecting less severely affected patients. Exercise compliance not reviewed. Placebo group (n=11) compared to (n=20) for the other two groups, due to dropout.
Kim et al. 2018 South Korea	32 patients recruited, randomly divided in low dose - 20mg triamcinolone acetonide mixed with 4ml of 1% lidocaine,( n=16) and high dose groups - 40mg triamcinolone acetonide mixed with 4ml of 1% lidocaine, (n=16).	Prospective, randomised, double blind, dose comparative study.	NRS SPADI PROM	No statistical difference after 3 weeks (P=0.63). Significant improvement at 3 weeks in both groups. (P= 0.02 in 20mg dose group, and P<0.01 in 40mg dose group). No difference observed overall. No significant difference between the two groups at 3 weeks.	Small sample size. Statistical data obtained from results three after injections. No results past this time scale for further comparative data to be collected.

Comment(s)

e are fair randomised blind clinical trials, albeit with limitations and weaknesses. Larger sample sizes for future studies would reinforce results. Additionally, review of pain levels at 6 weeks to 12 weeks appears to be more clinically meaningful to pain levels from the effects of CS. Dropout rates reduced number of participants in groups at the end of the trials.

Clinical Bottom Line

The research suggests there is no statistically significant difference between CS injection doses of 20mg and 40mg of triamcinolone acetonide for pain relief at 3 weeks and 12 weeks.

References

1. Yoon, S-H., Lee, H.Y., Lee, H.J. and Kwack, K.-S. Optimal Dose of Intra-articular Corticosteroids for Adhesive Capsulitis. A Randomized, Triple Blind, Placebo-controlled Trial The American Journal of Sports Medicine 2013; 1133-1139
2. Kim, K.H., Park, J.W., & Kim, S.J. High- vs Low-Dose Corticosteroid Injection in the Treatment of Adhesive Capsulitis with Severe Pain: A Randomized Controlled Double-Blind Study Pain Medicine 2018; 735-741