{"id":76440,"date":"2024-04-15T09:54:18","date_gmt":"2024-04-15T07:54:18","guid":{"rendered":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/?p=76440"},"modified":"2024-04-17T08:27:04","modified_gmt":"2024-04-17T06:27:04","slug":"effectiveness-of-prolotherapy-vs-local-anesthetic-infiltration-guided-by-ultrasound-in-the-treatment-of-shoulder-pain-syndrome","status":"publish","type":"post","link":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/effectiveness-of-prolotherapy-vs-local-anesthetic-infiltration-guided-by-ultrasound-in-the-treatment-of-shoulder-pain-syndrome\/","title":{"rendered":"Effectiveness of prolotherapy vs local anesthetic infiltration guided by ultrasound in the treatment of shoulder pain syndrome"},"content":{"rendered":"<p style=\"text-align: justify;\"><strong>Effectiveness of prolotherapy vs local anesthetic infiltration guided by ultrasound in the treatment of shoulder pain syndrome<\/strong><\/p>\n<p style=\"text-align: justify;\">Autor principal: Juan Alberto Lira-Lucio<\/p>\n<p style=\"text-align: justify;\">Vol. XIX; n\u00ba 7; 207<!--more--><\/p>\n<p style=\"text-align: justify;\"><strong>Prolotherapy vs local anesthetic infiltration in shoulder pain syndrome<\/strong><\/p>\n<p style=\"text-align: justify;\">Fecha de recepci\u00f3n: 18\/03\/2024<\/p>\n<p style=\"text-align: justify;\">Fecha de aceptaci\u00f3n: 10\/04\/2024<\/p>\n<p style=\"text-align: justify;\">Incluido en Revista Electr\u00f3nica de PortalesMedicos.com Volumen XIX. N\u00famero 7 Primera quincena de Abril de 2024 \u2013 P\u00e1gina inicial: Vol. XIX; n\u00ba 7; 207<\/p>\n<p style=\"text-align: justify;\"><strong>Autores:<\/strong><\/p>\n<p style=\"text-align: justify;\">Lira-Lucio, Juan Alberto<sup>1<\/sup>; Padilla-Rivera, Christian I. <sup>1,2<\/sup>; Ochoa-Gait\u00e1n, Guillermo<sup>1,2<\/sup>; Hern\u00e1ndez Porras, Berenice C. <sup>3<\/sup>; Ju\u00e1rez-Lemuz, \u00c1ngel M.<sup>3<\/sup>; Varela-Flores, Gloria<sup>1<\/sup> ; Rold\u00e1n-Rodr\u00edguez, Enrique<sup>1,2,3<\/sup>*.<\/p>\n<p style=\"text-align: justify;\"><sup>1<\/sup>Anestesia Integral de la Mujer, Gynecology and obstetrics, Centro Medico ABC, M\u00e9xico City, M\u00e9xico; <sup>2<\/sup> Gynecology and obstetrics, Institution, Centro Medico ABC, M\u00e9xico City, M\u00e9xico; <sup>3<\/sup> Alergology Department, Instituto Nacional de Cancerolog\u00eda, M\u00e9xico City, M\u00e9xico; <sup>4<\/sup> Anesthesiology, Hospital Real San Jos\u00e9, Guadalajara, M\u00e9xico. <sup>6<\/sup> Anesthesiology, Centro Medico ABC, M\u00e9xico City, M\u00e9xico.<\/p>\n<p style=\"text-align: justify;\">BACKGROUND\u00a0 Chronic Shoulder Pain (CSP) is a health problem that affects almost 67% of the general population. Almost a third of patients with acute shoulder pain syndrome don\u00b4t respond to initial therapy with analgesics and need interventional therapy. Corticosteroid injection is the standard therapy. Prolotherapy has been demonstrated to be effective in other chronic pain syndromes, but not in CSP. The aim of this study was to determine the effectiveness of prolotherapy compared to local anesthetic injection in the treatment of chronic shoulder pain.<\/p>\n<p style=\"text-align: justify;\">METHODS: Retrospective and comparative study of 77 patients from the National Institute of Oncology in Mexico City who received treatment for Chronic Shoulder Pain guided by ultrasound between 2017-2019. 57 patients were kept in the study for further analysis. 39 received infiltration with corticosteroids and 17 prolotherapy. Effectiveness \u00a0therapies was determined based on the decrease in VAS score in next follow-up session. Statistical analysis were performed with SPSS and RStudio Software. 37<\/p>\n<p style=\"text-align: justify;\">RESULTS: 51% of patients with Chronic Shoulder Pain were unemployed. 84% of the patients needed 3 different types of analgesics before they received ultrasound guided local treatment. Prolotherapy was as efficient as local anesthetic injection, no matter basal pain severity or underlying shoulder diagnosis, despite prolotherapy being more used as treatment for Rotator Cuff Tendinopathy.<\/p>\n<p style=\"text-align: justify;\">CONCLUSIONS\u00a0 Prolotherapy and corticosteroid injection guided by ultrasound have the same efficacy in pain relief for chronic shoulder pain in oncologic patients. 47<\/p>\n<p style=\"text-align: justify;\">Keywords: <em>Local anesthetic infiltration, Prolotherapy, Shoulder Pain Treatment,Capsulitis.<\/em><\/p>\n<p><strong>Introduction<\/strong><\/p>\n<p style=\"text-align: justify;\"><em>Chronic Shoulder Pain (CSP) is a health problem that affects almost 67% of the general population with high economic and lifestyle burden <sup>1<\/sup>. Patients with an oncologic disease have an increased risk of developing shoulder pain after surgical interventions, radiotherapy, and the pathologic features of their underlying disease<sup>23<\/sup>. Even with pharmacologic treatment, almost a third part \u00a0of patients with acute shoulder pain syndrome don\u2019t respond to initial therapy with acetaminophen, non-steroidal antiinflammatory drugs (NSAIDs) or muscle relaxants and will develop chronic shoulder pain.<sup>4<\/sup> If initial therapy, such as NSAIDs, rest, and physical rehabilitation, fail to relieve pain and improve function, the second line of treatment may non-invasive treatment a local anesthetic injection or prolotherapy <sup>5<\/sup>.<\/em><\/p>\n<p style=\"text-align: justify;\"><em>Local corticosteroid (CS) infiltration is the second most common non-surgical therapy used to treat CSP, after the use of multiple analgesics. Almost 11% of patients with shoulder pain receive CS local infiltration in primary care <sup>6<\/sup>. There is uncertainty about CS injection efficacy as therapy of shoulder pain after recent evidence that demonstrate a small and transient pain relief without additional benefit to other therapies. Anesthetic infiltration and physical therapy show equal long-term results for function, range of motion and patient-perceived improvement <sup>78<\/sup>. Additionally, CS injections display multiple adverse effects, such as rotator cuff tendon degeneration, exacerbation of neuropathic pain and delay in tissue repair and tendon necrosis, possibly secondary to an increase of oxidative stress by an increase of glutamate receptor NMDAR1 that promote apoptosis after injection of CS<sup>9<\/sup>.<\/em><\/p>\n<p style=\"text-align: justify;\"><em>Prolotherapy (PT) is a non-surgical technique for the treatment of chronic painful musculoskeletal conditions. It\u2019s based in the infiltration of local tissues with irritating agents to promote fibrous repair in tissues like tendons, joints, or damaged ligaments <sup>10<\/sup>.<\/em><\/p>\n<p style=\"text-align: justify;\"><em>The most common irritating agents used are hyaluronic acid, hypertonic dextrose, zinc, growth hormone, and autologous cells such as platelet-rich plasma<sup>11<\/sup>. PT has won field in recent years as treatment elected by patients, physicians, and researchers. In figure 1. Most common words used in PubMed publication about PT are represented. PT has demonstrated beneficial effects in function, pain relief, and quality of life in patients with osteoarthritis, plantar fasciitis, and adhesive capsulitis; with high treatment adherence and patient satisfaction <sup>12<\/sup> <sup>13<\/sup>. Bertrand et al. demonstrated prolotherapy efficacy vs placebo in Painful Rotator Cuff Tendinopathy treatment with pai improvement and a higher patient satisfaction.<sup>14<\/sup><\/em><\/p>\n<p style=\"text-align: justify;\"><em>An ultrasonography (US) approach has recently been added to the management of<\/em> <em>interventional shoulder pain. Therapy guided by ultrasonography (US) is an economic<\/em> <em>and fast tool to improve previously needle blinded procedures. It has the advantage of being less traumatic to tissues, because it allows puncture to the exact site of infiltration, making this therapy more accurate <sup>1512<\/sup> . PT has not been studied previously in should pain syndrome. Both techniques have been widely used in pain control with local anesthetic infiltration, but the superiority for pain relief in these patients has not been compared. The aim of this study is to compare the efficacy of prolotherapy versus local anesthetic infiltration for pain relief guided by ultrasonography in patients with chronic shoulder pain.<\/em><\/p>\n<p><strong> Materials and methods<\/strong><\/p>\n<ul style=\"text-align: justify;\">\n<li><strong><em>Study Design<\/em><\/strong><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><em>Retrospective and comparative study of 77 patients recorded from the National Institute of Oncology in M\u00e9xico City with diagnosis of CSP who received US guided interventional pai management between Januar 2017 and December 2019. Demographic data were collected from medical records and captured in a database.<\/em><\/p>\n<ul style=\"text-align: justify;\">\n<li><strong><em>Studied Population<\/em><\/strong><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><em>Inclusion criteria were &gt;18 years and CSP secondary to capsulitis, rotator cuff syndrome, or impingement syndrome. Exclusion criteria were incomplete medical records, patients with a primary tumor in the shoulder, combined technique, or history of previously infiltration. Other pathologies were excluded because low frequency (n=&lt;2) with low statistical representation. The studied population was divided into patients who received nervous infiltration with local anesthetic, and those who were treated with prolotherapy. Mild efficacy of treatment was considered as relief of less than 30% of basal AVS score previous the intervention, moderate efficacy a reduction of 30-50% and, strong efficacy a decrease of &gt;50% from basal AVS score. The present study has been carried out under the Helsinki principles with number of approbation INCAN 2019\/0140 by the local bioethics committee.<\/em><\/p>\n<ul style=\"text-align: justify;\">\n<li><strong><em>Statistical analysis<\/em><\/strong><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><em>Statistical analysis was performed under IBM<sup>\u00ae<\/sup>, SPSS<sup>\u00ae<\/sup> software Version 25 , WordMap was created in RStudio V 2.3.1 for MacOs Catalina Version 10.15.5 with Bibliometrix package <sup>16<\/sup> <sup>17<\/sup> <sup>18<\/sup>. Data distribution was calculated with Shapiro-Wilk test. Data is represented with median and standard deviations (SD). Median differences were determined by T student test; for categorical data X2 test and Fisher Exact Test were used <\/em>as required. Statistical significance was considered with a p-value &lt;0.05.<\/p>\n<p><strong> Results<\/strong><\/p>\n<p style=\"text-align: justify;\"><strong><em>Demographic patient characteristics.<\/em><\/strong><\/p>\n<p style=\"text-align: justify;\"><em>Patients received pain treatment guided by US between January 2017 and December 2019. 57 patients were selected according to inclusion and exclusion criteria.39 were assigned to the local anesthetic with corticosteroids group (CS) and 17 patients to the prolotherapy group (PT). Demographic features are represented in table 1. There were no differences in age, PT group was 60 (\u00b112.4) vs 60 (\u00b114.06) in LA (p&gt;0.05), 78% of PT patients were women vs 82% in LA but there was not statistical significance. 51% of the patients in both groups were unemployed when the first session of treatment was received. Prolotherapy treatment was more used when the left shoulder was affected. CS therapy was also used more when rotator cuff was affected (90% vs 83%, p&lt;0.0.001). Tumors in the stomach and kidneys were more frequent when prolotherapy was used. 84% of patients in both groups needed treatment with three different families of analgesics before US-guided pain treatment without differences between groups. There was no difference in basal severity of pain between the groups.<\/em><\/p>\n<ul style=\"text-align: justify;\">\n<li><strong><em>Effectiveness in pain control<\/em><\/strong><\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><em>Pain control was categorized as mild, moderate, or strong. First, we wanted to know if patient choice of the therapy was associated to basal pain severity, but we did not find any difference. We then evaluated if pain control was dependent on the initial pain, <strong>table<\/strong>. PT demonstrated to be equal effective as CS to control pain, no matter the basal pain severity. Both groups had good results decreasing chronic pain in patients; 0% in both groups reported mild or no control of pain, 30% in CS had mild control vs 47% in PT group, and respectively 27% vs 56% reported strong control, without statistical difference between the groups (p=0.16).<\/em><\/p>\n<p style=\"text-align: justify;\"><em>CS infiltration was more used in the treatment of rotator cuff syndrome (RCS) than prolotherapy. We evaluated if there is a difference in pain decrease based on the primary<\/em> <em>diagnosis of CSP. 35 patients in the CS group have RCS vs 15 in the PT group. PT group<\/em> <em>was equally effective as CS in pain control, with respectively 34% of patients with<\/em> <em>moderate control vs 45%, and 66% vs 55% with strong relief of pain (p&lt;0.21). This<\/em> <em>control was not dependent of the number of different analgesics required after infiltration<\/em> <em>procedures, none of the groups needed 3 families of analgesics. 83% of CS group needed<\/em> <em>2 classes of analgesics, vs 57% PL. In the population with strong control, 56% and 50%<\/em> <em>required 2 classes of analgesics, respectively. None of the participants in this study<\/em> <em>presented adverse events. <\/em><\/p>\n<p><strong> Discussion<\/strong><\/p>\n<p style=\"text-align: justify;\"><em>To our knowledge, this is the first study to evaluate the efficacy of CS vs PT for shoulder pain management. PT has demonstrated to be safe and effective in chronic pain therapy in many musculoskeletal pathologies, but just a few studies have investigated PT in CSP, even though it is the third most common musculoskeletal disorder in general practice<sup>6<\/sup>. As in other studies reported previously, in this age group the main cause of CSP was Rotator Cuff Syndrome, with a frequency of 88% in the population of this study. This indicates that even though oncologic patients have an increased risk of CSP, the main cause is still Rotator Cuff Syndrome.<sup>15<\/sup> <sup>6<\/sup>There is no clear indication of prolotherapy for pain treatment in shoulder pathologies, but in this study, we have demonstrated that it is equally effective as CS injections for treatment of Capsulitis, Rotator Cuff Syndrome and adhesive capsulitis. Further studies are needed to evaluate each of the procedures separately in CSP. Interestingly, almost 50% of patients in both groups were unemployed when they received local therapy. This agrees with other studies about the potential functional restriction that CSP leads to in patients, and the importance of a therapy that improves these functional restrictions. <sup>19<\/sup>Ultrasound guided pain management has been studied widely. This is a useful equipment for shoulder pain management <sup>15<\/sup>. Raeissadat et al. demonstrated in a prospective study that CS and PT in patients with plantar fasciitis has the same efficacy in pain relief after a 24-weeks follow up. <sup>12<\/sup> In this study, we have also demonstrated that the use of PT has the same efficacy as LA infiltration for chronic shoulder pain. We also found that pain relief does not depend on basal pain severity. The mechanism of PT effectiveness is based on the induction of anti-inflammatory reactions by irritant agents that enhance tissue healing. <sup>11<\/sup><\/em><\/p>\n<p style=\"text-align: justify;\"><em>We are aware of the limitations of this study, as a retrospective study where we lack control of some variables of interest. However, to our knowledge this is the first study to evaluate the efficacy of PT vs CS for CSP. CS therapy requires multiples sessions, in this study PT and LA infiltration demonstrated to be safe when guided by US. CS and PT therapies have limitations in shoulder pain treatment. In randomizedcontrolled trial, Kesikburun et al demonstrate that PT is not a therapy that should be used alone, its effectiveness is dependent of physical rehabilitation <sup>20<\/sup> . In this study, we have evaluated the use of PT and LA nervous infiltration separately. This study allows us to place PT as a safe technique when it is guided by US and enables future blinded studies in shoulder pain. PT is a promising technique, and it has demonstrated that its benefits are not <\/em>limited to pain control, but also improvement of functionality and mobility.<\/p>\n<p style=\"text-align: justify;\"><strong>Conclusions<\/strong><\/p>\n<p style=\"text-align: justify;\"><em>Most patients with CSP needs to receive pharmacologic treatment before receiving an interventional management. LA and PT have demonstrated to relieve pain in short term in these patients, regardless of the severity of basal pain. Prolotherapy is a safe and minimally invasive technique with high adhesion to treatment for pain control in CSP patients. It has the same effectiveness in pain relive as CS nervous injection in oncologic patients, no matter the basal severity of pain. Further prospective, blinded and randomized studies with covariates as functional improvement are needed to prove PT <\/em>long term benefits, but this study demonstrate that it is a promising treatment.<\/p>\n<p style=\"text-align: justify;\"><a href=\"https:\/\/www.revista-portalesmedicos.com\/imagenes\/publicaciones\/2024\/Proloterapia.pdf\"><strong><span class=\"HwtZe\" lang=\"en\"><span class=\"jCAhz ChMk0b\"><span class=\"ryNqvb\">See Annex<\/span><\/span><\/span><\/strong><\/a><\/p>\n<p style=\"text-align: justify;\"><strong>References:<\/strong><\/p>\n<ol style=\"text-align: justify;\">\n<li>Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol.<\/li>\n<li>2004;33(2):73-81. doi:10.1080\/03009740310004667<\/li>\n<li>Gane EM, Michaleff ZA, Cottrell MA, et al. Prevalence, incidence, and risk factors for shoulder and neck dysfunction after neck dissection: A systematic review. Eur J Surg Oncol. 2017;43(7):1199-1218. doi:10.1016\/j.ejso.2016.10.026<\/li>\n<li>Yang S, Park DH, Ahn SH, et al. Prevalence and risk factors of adhesive capsulitis of the shoulder after breast cancer treatment. Support Care Cancer.<\/li>\n<li>2017;25(4):1317-1322. doi:10.1007\/s00520-016-3532-4<\/li>\n<li>Boudreault J, Desmeules F, Roy JS, Dionne C, Fr\u00e9mont P, MacDermid JC. The efficacy of oral non-steroidal anti-inflammatory drugs for rotator cuff tendinopathy: A systematic review and meta-analysis. J Rehabil Med. 2014;46(4):294-306. doi:10.2340\/16501977-1800<\/li>\n<li>Mehta S, Gimbel JA, Soslowsky LJ. Etiologic and pathogenetic factors for rotator cuff tendinopathy. Clin Sports Med. 2003;22(4):791-812. doi:10.1016\/S0278- 5919(03)00012-7<\/li>\n<li>Linsell L, Dawson J, Zondervan K, et al. Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral. Rheumatology. 2006;45(2):215-221. doi:10.1093\/rheumatology\/kei139 Cook T, Lowe CM, Maybury M, Lewis JS. Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff- related shoulder pain? A systematic review. Br J Sports Med. 2018;52(8):497-504. doi:10.1136\/bjsports-2016-097444<\/li>\n<li>Mohamadi A, Chan JJ, Claessen FMAP, Ring D, Chen NC. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017;475(1):232-243. doi:10.1007\/s11999- 016-5002-1<\/li>\n<li>Dean BJF, Franklin SL, Murphy RJ, Javaid MK, Carr AJ. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: A mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy? Br J Sports Med. 2014;48(22):1620-1626. doi:10.1136\/bjsports-2013-093178<\/li>\n<li>Rahimzadeh P, Imani F, Faiz SHR, Entezary SR, Zamanabadi MN, Alebouyeh MR.The effects of injecting intra-articular platelet-rich plasma or prolotherapy on pain score and function in knee osteoarthritis. Clin Interv Aging. 2018;13:73-79. doi:10.2147\/CIA.S147757<\/li>\n<li>Ryu K, Ko D, Lim G, Kim E, Lee SH. Ultrasound-Guided Prolotherapy with Polydeoxyribonucleotide for Painful Rotator Cuff Tendinopathy. Pain Res Manag. 2018;2018. doi:10.1155\/2018\/8286190<\/li>\n<li>Raeissadat SA, Nouri F, Darvish M, Esmaily H, Ghazihosseini P. Ultrasound-guided injection of high molecular weight hyaluronic acid versus corticosteroid in management of plantar fasciitis: A 24-week randomized clinical trial. J Pain Res. 2020; 13:109-121. doi:10.2147\/JPR.S217419<\/li>\n<li>Sit RWS, Wu RWK, Rabago D, et al. Efficacy of intra-articular hypertonic dextrose (Prolotherapy) for knee osteoarthritis: A randomized controlled trial. Ann Fam Med. 2020;18(3):235-242. doi:10.1370\/afm.2520<\/li>\n<li>Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy. Arch Phys Med Rehabil. 2016;97(1):17-25. doi:10.1016\/j.apmr.2015.08.412<\/li>\n<li>Karel YHJM, Miranda A, Thoomes-de Graaf M, et al. Does the outcome of diagnostic ultrasound influence the treatment modalities and recovery in patients with shoulder pain in physiotherapy practice? Results from a prospective cohort study. Musculoskelet Sci Pract. 2019;41(March 2018):28-35. doi:10.1016\/j.msksp.2019.03.003<\/li>\n<li>RStudio Team. RStudio: Integrated Development Environment for R. Published online 2015. Miscellaneous TH, Yes L. Package \u2018 Hmisc .\u2019 Published online 2020.<\/li>\n<li>Villanueva RAM, Chen ZJ, Wickham H. Ggplot2: Elegant Graphics for Data Analysis Using the Grammar of Graphics. Springer-Verlag New York; 2016. doi:10.1080\/15366367.2019.1565254<\/li>\n<li>Silvestri J. Effects of chronic shoulder pain on quality of life and occupational engagement in the population with chronic spinal cord injury: preparing for the best outcomes with occupational therapy. Disabil Rehabil. 2017;39(1):82-90. doi:10.3109\/09638288.2016.1140829 Kesikburun S, Tan AK, Yilmaz B, Ya\u015far E, Yazicio lu K. Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: A randomized controlled trial with 1-year follow-up. Am J Sports Med. 2013;41(11):2609-2615. doi:10.1177\/0363546513496542<\/li>\n<\/ol>\n<p style=\"text-align: justify;\"><em>Conflicts of interest<\/em><\/p>\n<p style=\"text-align: justify;\">The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.<\/p>\n<p style=\"text-align: justify;\"><em>Funding.<\/em><\/p>\n<p style=\"text-align: justify;\">The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work.<\/p>\n<p style=\"text-align: justify;\"><em>Authors\u2019 contributions<\/em>.<\/p>\n<p style=\"text-align: justify;\"><strong>Author Contributions: <\/strong>ER-R, Data collection and curation; JAL-L and GO-G, Formal analysis; JAL- and LH-A, Investigation; ER-R and AJ-L Methodology; JAL-L, COG-G, ER-R , Project administration; JAL-L, Software; GO-G and ER-R, Supervision; JAL-L, GO-G, LH-A, AJ-L ER-R, Validation; JAL-L and LH-A, Visualization; JAL-L and ER-R, Writing\u2014original draft preparation; GO-G, LH-A \u2013 review &amp; editing<strong>. <\/strong>All authors have read and agreed to the published version of the manuscript.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Effectiveness of prolotherapy vs local anesthetic infiltration guided by ultrasound in the treatment of shoulder pain syndrome Autor principal: Juan Alberto Lira-Lucio Vol. XIX; n\u00ba 7; 207<\/p>\n","protected":false},"author":1250,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[34],"tags":[18645,18642,18643,18644],"class_list":["post-76440","post","type-post","status-publish","format-standard","hentry","category-anestesiologia-reanimacion","tag-capsulitis","tag-local-anesthetic-infiltration","tag-prolotherapy","tag-shoulder-pain-treatment","no-featured-image-padding"],"acf":[],"yoast_head":"<!-- This site is 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