Arthritis/ Frozen Shoulder/ Inflammation

ARTHRITIS/ FROZEN SHOULDER/ INFLAMMATORY SHOULDER CONDITIONS (BURSITIS)

Degenerative as well as inflammatory joint diseases can affect the shoulder joint causing irregular motion, pain and inflammation during the shoulder motion. Osteoarthritis causes damage to the cartilage layers making them thin and increases the friction between bone on bone contact resulting in pain, stiffness and inflammation. It is usually the other way round in cases of inflammatory arthritis. As the condition progress, patient loses range of motion of the shoulder and arms.

Frozen shoulder is characterized by shoulder joint stiffness and pain that worsens over time. The shoulder upper arm bone sits in a socket that has a strong connective tissue known as the shoulder capsule. Due to various reasons, the shoulder capsule thickens and develops thick bands of adhesions. This condition is termed as a frozen shoulder and the shoulder joint becomes stiff with severe pain and unable to move the upper arm.

The most common symptoms associated with shoulder arthritis and frozen shoulder is pain during movement, stiffness and inflammation that increase the severity when trying to reach over the head and eventually loss of motion.

Conventional treatment methods include over-the-counter pain relievers, anti-inflammatory drugs, and steroid injections in to the shoulder joint, joint distension and shoulder manipulation to reduce the stiffness and pain and improve mobility of the shoulder joint and shoulder surgery.

ALTERNATIVE TREATMENT METHODS AT BETH YEHUDAH ARTHRITIS CENTER , PULLAD AND DAYSTAR CLINIC, ALAPPUZHA -

1) Platelet Rich Plasma in Osteoarthritis of Shoulder : Plasma rich platelet prolotherapy is the recent trend in treating various joint conditions and is designed to stimulate repair of chronically inflamed synovium, partially torn ligaments in the affected joint and to reduce swelling and pain caused by the condition. PRP prolotherapy is a combination treatment where PRP is usually injected into the joint and/or bursa (cushions around the joint) and dextrose prolotherapy is given to the ligaments of the joint. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and stimulates the local immune response to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

 PRP injection delivers a high concentration of autologous (patient’s own) platelets to the joints and soft tissues, where Osteoarthritis is present. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.  
      
Patient Benefits of PRP Prolotherapy:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay Joint Replacement Surgery
• Significantly reduces the symptoms associated with osteoarthritis
• Reduced risk of adverse events
• Repairs and tightens ligaments improving joint stability and ease of walking
• Safe and effective treatment method
• Faster healing and recovery
• PRP Prolotherapy results in safe, significant, effective, progressive improvement of hip pain, function and reduction of stiffness.
• The throbbing pain is stopped by stimulating the healing mechanism at the source of the ligament.

2) Prolotherapy for Shoulder: Prolotherapy is a natural and cost effective alternative method to surgery. Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint. Prolotherapy  works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells through the cell membrane to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. Prolotherapy is an effective non surgical treatment method used successfully in osteoarthritis/ degenerative joint disease condition. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in the joint. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles due to osteoarthritis joint condition.

Patient Benefits of Prolotherapy:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Avoid if not delay Shoulder Surgery
• May significantly reduce the symptoms associated with Osteoarthritis, Rotator cuff abnormalities & frozen shoulder.
• Reduced risk of adverse events
• Repairs and tightens ligaments improving joint stability and ease of walking
• Safe and effective treatment method
• Faster healing and recovery
• Prolotherapy results in safe, significant,effective, progressive improvement of knee pain, function and reduction of stiffness.
• The throbbing pain is reduced by stimulating healing mechanism at the source of the joint.

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Avoid if not delay Joint Replacement Surgery in Inflammatory Arthritis/ Bursitis/ Tendonitis.
• Significantly reduces the symptoms associated with Inflammation in cases of Arthritis/ Bursitis/Tendonitis.
• Reduced risk of adverse events compared to oral steroid tablets which are usually taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces joint stiffness.
• More effective treatment method in inflammatory joint diseases.
• Faster recovery.
• NESTIT treatment results in significant, effective, progressive improvement of knee pain, function and reduction of stiffness if given in series.

At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha, we have a team of experts to help you treat and recover from all medical conditions affecting the shoulders. To know more about shoulder arthritis, inflammation and frozen shoulder and treatment cost, book an appointment now.