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Radiotherapy for painful shoulder syndrome: a retrospective evaluation

Authors:
  • Krankenhaus MärkischOderland GmbH
  • MVZ Strahlentherapie Duisburg

Abstract

Purpose We evaluated the efficacy of low-dose radiotherapy for painful shoulder syndrome from an orthopedic perspective. Methods Patients with painful shoulder syndrome were recruited for this retrospective clinical quality assessment from January 2011 to December 2017. Patients were treated with a linear accelerator or an orthovoltage device at individual doses of 0.5–1.0 Gy and total doses of 3.0–6.0 Gy. To assess response, we used the von Pannewitz score with five levels: “worsened,” “unaffected,” “improved,” “significantly improved,” and “symptom free.” “Good treatment success” was defined as “significantly improved” and “symptom free.” Within-group and between-group differences were statistically evaluated. Results Of 236 recruited patients (150 women, 86 men; mean age 66.3 [range 31–96] years), 180 patients underwent radiotherapy with a linear accelerator and 56 with an orthovoltage device. Fractionation was 12 × 0.5 Gy in 120 patients, 6 × 0.5 Gy in 74, and 6 × 1 Gy in 42 patients. Treatments were completed in one series for 223 and in two series at least 6 weeks apart for 13 patients. Of the 236 patients, 163 patients (69.1%) agreed to be re-interviewed at a median of 10.5 (range 4–60) months after radiotherapy completion. Directly after radiotherapy, 30.9% (73 patients) had “good treatment success,” which had increased to 55.2% (90 patients) at follow-up. Conclusion Protracted pain improvement with low-dose radiotherapy is possible in painful shoulder syndrome. Patients with refractory pain because of subacromial syndrome or shoulder osteoarthritis should also be evaluated for radiotherapy.
ORIGINAL ARTICLE
https://doi.org/10.1007/s00066-024-02302-x
Strahlentherapie u nd Onkologie
Radiotherapy for painful shoulder syndrome: a retrospective
evaluation
Ronny Leist1·OliverMicke
2· M. Heinrich Seegenschmiedt3·IrenaeusA.Adamietz
4· Kashyar Fakhrian5·
Ralph Muecke4,6
Received: 15 February 2024 / Accepted: 2 July 2024
© The Author(s) 2024
Abstract
Purpose We evaluated the efficacy of low-dose radiotherapy for painful shoulder syndrome from an orthopedic perspective.
Methods Patients with painful shoulder syndrome were recruited for this retrospective clinical quality assessment from
January 2011 to December 2017. Patients were treated with a linear accelerator or an orthovoltage device at individual
doses of 0.5–1.0Gy and total doses of 3.0–6.0Gy. To assess response, we used the von Pannewitz score with five levels:
“worsened, “unaffected, “improved, “significantly improved, and “symptom free. “Good treatment success” was
defined as “significantly improved” and “symptom free. Within-group and between-group differences were statistically
evaluated.
Results Of 236 recruited patients (150 women, 86 men; mean age 66.3 [range 31–96] years), 180 patients underwent
radiotherapy with a linear accelerator and 56 with an orthovoltage device. Fractionation was 12× 0.5Gy in 120 patients,
6× 0.5Gy in 74, and 6× 1Gy in 42 patients. Treatments were completed in one series for 223 and in two series at least
6 weeks apart for 13 patients. Of the 236 patients, 163 patients (69.1%) agreed to be re-interviewed at a median of 10.5
(range 4–60) months after radiotherapy completion. Directly after radiotherapy, 30.9% (73 patients) had “good treatment
success, which had increased to 55.2% (90 patients) at follow-up.
Conclusion Protracted pain improvement with low-dose radiotherapy is possible in painful shoulder syndrome. Patients
with refractory pain because of subacromial syndrome or shoulder osteoarthritis should also be evaluated for radiotherapy.
Keywords Benign diseases · Low-dose radiotherapy · Linear accelerator · Orthovoltage device · Good treatment success
The authors K. Fakhrian and R. Muecke contributed equally to
the manuscript.
Ralph Muecke
r.muecke@strahlentherapie-rheinmainnahe.de
1Clinic for Orthopedics Wriezen, Wriezen, Germany
2Department of Radiotherapy and Radiation Oncology,
Franziskus Hospital Bielefeld, Bielefeld, Germany
3Radiotherapy Duisburg, Duisburg, Germany
4Department of Radiotherapy and Radiation Oncology,
Marien Hospital Herne, Ruhr, University Bochum, Bochum,
Germany
5Radiotherapy Aschaffenburg, Aschaffenburg, Germany
6Radiotherapy RheinMainNahe, Bad Kreuznach, Mainz,
Rüsselsheim, Germany
Background
Painful shoulder syndrome is common, with a lifetime
prevalence of up to 66.7% [1]. The frequency of chronic
shoulder complaints and the socioeconomic aspects are
reflected in health insurance company reports, such as one
published in 2021 showing that in 2020, 15.7% of em-
ployees subject to social insurance contributions reported
complaints due to shoulder syndrome. The diagnostic sub-
group “shoulder lesions” according to the International
Statistical Classification of Diseases and Health-Related
Health Problems, tenth revision (ICD-10) [2], caused 20.18
days of incapacity for work per 100 insured person years,
placing this diagnosis 13th among three-digit ICD-10 codes
in 2021 and third among all diseases of the musculoskeletal
system and connective tissue [3].
Shoulder pain syndrome is a broad term encompassing
various conditions including subacromial syndrome in its
multiple manifestations, acromioclavicular arthrosis, and
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Strahlentherapie und Onkologie
enthesopathies, each characterized by distinct pathophys-
iological mechanisms and clinical presentations. Standard
radiographs are fundamental to diagnosing shoulder pain
syndrome [4]. They often reveal subchondral sclerosis of
the major tuberosity, subacromial spurs, acromial shape
anomalies, and acromioclavicular joint arthrosis. These ra-
diographs are crucial for the differential diagnosis, identi-
fying calcifying tendinitis, fractures, and neoplasms. Mag-
netic resonance imaging (MRI) is generally considered the
preferred method for assessing the rotator cuff and adjacent
structures [5].
Because of the high burden of related illness, numerous
therapeutic measures and strategies have been developed
and optimized for shoulder pain. Despite these predomi-
nantly operative and conservative treatment options, many
patients live with an unsatisfactory outcome or cannot be
treated surgically [6]. Another option is low-dose radiother-
apy, which has become established for the treatment of os-
teoarthritis and enthesiopathies, including painful shoulder
syndrome [716].
Our objective was to broaden the evidence base concern-
ing the use of radiotherapy for painful shoulder syndrome,
specifically examining the analgesic effects of low-dose ir-
radiation from an orthopedic viewpoint.
Methods
Patients and treatment
Patients with painful shoulder syndrome were recruited for
this retrospective clinical quality assessment.
The data were collected during 2011 to 2013 at Klinikum
Lippe in Lemgo and in 2017 at RheinMainNahe Radiother-
apy using linear accelerators at both sites and the orthovolt-
age device at Klinikum Lippe, with different fractionation
schemes. All patients provided informed consent regard-
ing radiotherapy and participation in this clinical quality
assessment prior to enrollment.
In our study, 197 of 236 patients (83.5%) were referred
by orthopedic surgeons after undergoing a clinical exam-
ination that included X-ray for all patients and MRI for
34 patients (14.4%). Thirty-nine patients (16.5%) were re-
ferred by family physicians and had a prolonged history of
treatments extending over more than 6 months, involving
various interventions suggested and performed by both or-
thopedic surgeons and family physicians. All 39 patients
underwent X-ray imaging, and 28/39 (71.7%) also received
MRI. Overall, the duration of pain before initiating radio-
therapy varied, with 71 patients experiencing pain for more
than 3 months but less than 6 months, and 165 patients
for longer than 6 months. Radiation therapy was the pri-
mary treatment choice in only 20 cases; the remaining 216
patients had received multiple pretreatments, including lo-
cal injections, oral cortisone, nonsteroidal anti-inflamma-
tory drugs (NSAIDs), shockwave therapy, and physiother-
apy.
Patients were treated with either the linear accelerator
or the orthovoltage device. The single doses amounted to
0.5 to 1.0Gy and the total doses to 3.0 to 6.0Gy.
Prior to radiation therapy on the linear accelerator, 120
patients underwent simulator-based and 60 patients three-
dimensional computer tomographic (CT)-based treatment
planning. In the 56 patients who were treated with the or-
thovoltage device, radiation therapy was carried out after
clinical adjustment on the device with the 8 × 8cm and 10 ×
10cm tube. After simulator-based and CT planning, the
field sizes were determined individually depending on the
size of the patients. In each case, the lungs and, in women,
also the breasts were shielded.
To assess the response to treatment directly after ra-
diotherapy and at follow-up, we used the von Pannewitz
score consisting of five categorical levels: “worsened,
“unaffected, “improved, “significantly improved, and
“symptom free.” “Good treatment success” according to
this score was defined as “significantly improved” and
“symptom free.
The assessment of analgesic efficacy was carried out by
a telephone survey. All results were recorded in an Ex-
cel (Microsoft, Redmond, WA, USA) spreadsheet and then
transferred to SPSS (IBM Corp., Armonk, NY, USA) for
evaluation after completion of the survey.
Statistical analysis
All data were stored and analyzed using the SPSS sta-
tistical package v. 23.0. Descriptive statistics were com-
puted for continuous and categorical variables, including
median and interquartile ranges of ordinal variables, mean
and standard deviations of continuous variables, and fre-
quencies and relative frequencies of categorical factors.
The Wilcoxon signed-rank test was used to test for dif-
ferences in continuous and categorical variables within the
groups. To test for between-group differences, we used the
Mann–Whitney U test for continuous variables and Fisher’s
exact test for categorical variables, as appropriate. All -val-
ues were two-sided statistical tests, and P< 0.05 was con-
sidered significant.
Results
Patients
A total of 236 evaluable patients (150 women, 86 men)
with a mean age of 66.3 years (range 31–96 years) were
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Strahlentherapie und Onkologie
Tab le 1 Von Pannewitz score
survey results directly after
therapy and at follow-up in the
overall patient cohort
Timing (n) Symptom
free, n(%)
Significantly im-
proved, n(%)
Improved,
n(%)
Unaffected,
n(%)
Worsened,
n(%)
End of radiother-
apy (n= 236)
8 (3.4) 65 (27.5) 96 (40.7) 57 (24.2) 10 (4.2)
Follow-up (n=
163)
29 (17.8) 61 (37.4) 33 (20.2) 35 (21.5) 5 (3.1)
recruited. Radiotherapy was carried out using a linear accel-
erator in 180 patients and an orthovoltage device in 56 pa-
tients. A total of 120 patients were treated with a fractiona-
tion scheme of 12 × 0.5 Gy, 74 patients with 6 × 0.5 Gy, and
42 patients with 6 × 1 Gy. In 223 patients radiation treat-
ments were completed in one series, and in 13 patients they
were completed in two series at least 6 weeks apart. No side
effects were observed. Of the 236 patients, 163 (69.1%)
agreed to be re-interviewed at a median of 10.5 months
(range 4–60 months) after the end of radiotherapy.
Treatment success: within-group comparisons
Directly after radiotherapy, 30.9% (73/236) experienced
good treatment success, which had increased to 55.2%
(90/163 patients) at the time of follow-up care (P< 0.001;
Table 1).
Table 2shows the von Pannewitz score results by treat-
ment device. Among those receiving therapy with a lin-
ear accelerator, 27.2% (49/180 patients) experienced good
treatment success at the end of radiotherapy, compared with
52.6% (71/135 patients) at follow-up. The increase between
these two timepoints was highly significant (93.4%, P<
0.001). For patients receiving treatment with an orthovolt-
age device, 42.9% (24/56 patients) experienced good treat-
ment success directly after radiotherapy ended, which in-
creased to 67.9% (19/28 patients) at follow-up. The increase
between these timepoints was not significant (58.3%; P=
0.157).
Table 3shows von Pannewitz score results by fraction-
ation scheme. With the 12× 0.5 Gy fractionation scheme,
31.7% (38/120 patients) had good treatment success at the
end of radiotherapy, compared with 57.2% (40/70 patients)
Tab le 2 Von Pannewitz score survey results directly after therapy and at follow-up, by device
Device and timepoint (n) Symptom free, n
(%)
Significantly improved,
n(%)
Improved, n
(%)
Unaffected, n
(%)
Worsened, n
(%)
Linear accelerator, end of radiother-
apy (n= 180)
5 (2.8) 44 (24.4) 75 (41.7) 48 (26.7) 8 (4.4)
Linear accelerator, follow-up (n=
135)
21 (15.6) 50 (37.0) 31 (23.0) 28 (20.7) 5 (3.7)
Orthovoltage device, end of radio-
therapy (n= 56)
3 (5.4) 21 (37.5) 21 (37.5) 9 (16.1) 2 (3.5)
Orthovoltage device, follow-up (n=
28)
8 (28.6) 11 (39.3) 2 (7.1) 7 (25.0) 0 (0.0)
at follow-up (80.1% increase; P< 0.001). Among patients
receiving 6 × 1.0Gy, 35.8% (15/42 patients) had good treat-
ment success directly after the therapy, compared with
73.7% (14/19 patients) at the follow-up, for an increase of
106.4% (P= 0.102). For those receiving 6 × 0.5 Gy, 27.1%
(20/74 patients) had good treatment success just after ther-
apy and 48.7% (36/74 patients) did so at follow-up. This
increase also was highly significant (80.0%; P< 0.001).
Treatment success: between-group comparisons
Among patients receiving therapy with the orthovoltage de-
vice, 42.9% experienced treatment success directly after
therapy, compared with 27.7% undergoing treatment with
the linear accelerator (P= 0.033). The two groups did not
differ at follow-up, with 67.9% experiencing treatment suc-
cess with the orthovoltage device compared to 52.6% for
the linear accelerator (P= 0.141).
For the different fractionation regimens, the percent-
ages of patients experiencing treatment success directly
after therapy did not vary among the groups (32.5% for
12 × 0.5Gy, 35.7% for 6 × 1.0Gy, 26.8% for 6 × 0.5 Gy; P=
0.353). The groups also did not differ significantly at fol-
low-up (57.1% for 12 × 0.5Gy, 73.7% for 6 × 1.0Gy, 48.6%
for 6 × 0.5Gy; P= 0.136).
Sex-based differences
Women and men did not differ in treatment success rates
either directly after therapy (women 29.7% vs. men 34.1%;
P= 0.488) or at follow-up (women 54.4% vs. men 56.7%;
P= 0.777).
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Strahlentherapie und Onkologie
Tab le 3 Von Pannewitz score survey results directly after therapy and at follow-up for each fractionation scheme
Scheme and timepoint (n) Symptom free, n
(%)
Significantly improved,
n(%)
Improved, n
(%)
Unaffected, n
(%)
Worsened, n
(%)
12 × 0.5Gy, end of radiotherapy
(n= 120)
5 (4.2) 33 (27.5) 45 (37.5) 33 (27.5) 4 (3.3)
12 × 0.5Gy, follow-up (n= 70) 21 (30.0) 19 (27.2) 12 (17.1) 18 (25.7) 0 (0.0)
6 × 1Gy, end of radiotherapy (n=
42)
2 (4.8) 13 (31.0) 19 (45.1) 7 (16.7) 1 (2.4)
6×1Gy, follow-up(n=19) 5 (26.3) 9 (47.4) 2 (10.5) 3 (15.8) 0 (0.0)
6 × 0.5Gy, end of radiotherapy (n=
74)
1 (1.4) 19 (25.7) 32 (43.2) 17 (23.0) 5 (6.7)
6×0.5Gy, follow-up (n=74) 3 (4.1) 33 (44.6) 19 (25.7) 14 (18.8) 5 (6.8)
Discussion
The results of our retrospective clinical quality assessment
confirm findings from recently published retrospective and
prospective randomized studies showing a good analgesic
effect of low-dose radiotherapy in patients with painful
shoulder syndrome.
According to Ott et al., who reviewed 25 relevant
studies published from 1943 to 2012 and covering 2928
(range 21–546) patients, the overall response rate was 82%
(59%–96%): 40% (6%–79%) experienced complete symp-
tom remission and 42% (15%–83%) had a partial remission
[11,13]. The wide ranges in these results reflect in part the
different periods of data collection and in part the different
treatment regimens and measurement instruments used for
the evaluation.
The response rates among our patients of 71.6% directly
after radiotherapy and 75.5% at the time of follow-up care
are in line with earlier results (Table 1). The 3.4% experi-
encing complete remission directly after radiotherapy, how-
ever, is proportionally lower than some other findings, but
the 17.8% having remission at follow-up appears to be more
in line with the results of other studies (Table 1). The range
of complete remissions is quite wide, indicating the neces-
sarily subjective basis of each patient’s assessment of the
response to therapy and the resulting classification.
In this study, we found no significant difference among
the three low-dose fractionation regimens. These results are
consistent with and confirm those of the Erlangen dose op-
timization study and the recommendations of the German
Society for Radiation Oncology (DEGRO) [1113].
There is a lack of consensus data regarding the advan-
tages of different treatment devices in producing improved
short- and long-term outcomes [16,17]. Given the restricted
patient sample size in our analysis, it is not feasible to con-
clusively favor one therapeutic device over another. Our
study found that there was a higher number of individuals
who experienced successful treatment with the orthovolt-
age device compared to linear accelerators immediately af-
ter radiation therapy. However, it is important to interpret
these data with caution. The observed outcomes could po-
tentially be attributed to use of the orthovoltage device at
only a single location and involving a limited number of pa-
tients, in contrast to the deployment of linear accelerators at
several sites. Large-scale comparative studies are necessary
to definitively assess the influence of treatment equipment
selection on the effectiveness of radiation therapy.
In contemporary orthopedic practice, a comprehensive
understanding of various treatment modalities is crucial,
particularly as the population ages and the incidence of de-
generative shoulder conditions rises. Reviews in orthope-
dics suggest that treatment strategies for shoulder pain syn-
drome typically include NSAIDs, exercise therapies, steroid
injections, and surgery for severe or refractory cases. How-
ever, many patients are not suitable candidates for surgical
intervention due to a range of medical and personal factors.
Notably, low-dose radiation therapy, as a conservative treat-
ment option prior to considering surgery, is infrequently or
not at all discussed in these reviews [18,19]. Our research
shows a positive response to low-dose radiation therapy in
55.2% of patients, highlighting its potential to significantly
improve quality of life for patients in whom surgery is not
feasible. Therefore, it is critical for orthopedic surgeons to
consider low-dose radiation therapy as a viable treatment
alternative. This approach not only broadens the scope of
patient care but also promotes a multidisciplinary treatment
strategy.
Concerns regarding the carcinogenic potential of radia-
tion therapy for benign diseases occasionally deter its use.
It is important to recognize that the bulk of data indicat-
ing a risk of cancer following radiation therapy for benign
conditions are derived from outdated studies focusing on
pediatric and young adult populations, who are no longer
candidates for such treatments [20]. Current evidence sug-
gests that the risk of cancer development after radiation
therapy for benign diseases in middle-aged and older adults
is exceedingly low. McKeown et al., in their seminal work
investigating the carcinogenicity associated with radiation
therapy for benign diseases, note in their conclusion that
assessing the risk of radiation therapy for benign condi-
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Strahlentherapie und Onkologie
tions presents numerous challenges, as the evidence base is
limited and often derived from a disparate array of sources
that are not directly comparable. They emphasize that the
risk of radiation-induced cancer in older adults treated with
radiation therapy for benign conditions, particularly those
affecting peripheral tissues, is very small and diminishes
further with age.
Limitations
For some subgroups, the sample size was small; for ex-
ample, only 28 patients could be recruited for follow-up
treatment with the orthovoltage device and only 19 patients
for follow-up treatment with 6× 1.0 Gy. These small num-
bers may have affected the significance of increases in good
treatment success.
One caveat of this study is that the exact diagnosis was
not documented. Painful shoulder syndrome comprises sev-
eral entities that differ in terms of pathogenesis and course,
and the distribution of these diagnoses may not be the same
between our patient population and the overall population
with painful shoulder syndrome. In addition, radiotherapy
may have variable effects depending on the specific shoul-
der condition. How these conditions differed in proportion
between treatment devices and among fractionation regi-
mens is not clear and could have been a factor in the sig-
nificant advantage of the orthovoltage device.
Regarding the timing of treatment and previous and con-
comitant therapies in the overall course of the disease, this
analysis can offer no precise conclusions. It is possible that
some data were missing or incomplete from pretreatment
physicians or that patient information was inaccurate, thus
affecting the results and the comparability with other stud-
ies.
Furthermore, the response to radiotherapy in this study
is based solely on pain perception and subjective report.
Objective function scores, such as improvement in shoulder
mobility, were not investigated. Finally, a placebo group
with a similar composition was not included to exclude the
effects of spontaneous changes or concomitant therapies
[2123].
Conclusion
In line with previous literature, the present study shows that
pain improvement in patients with painful shoulder syn-
drome is possible with low-dose radiotherapy, as is a pro-
tracted effect. Patients with refractory shoulder pain re-
sulting from subacromial syndrome or osteoarthritis in the
shoulder area should also be evaluated for radiotherapy.
Author Contribution R. Leist was the principal investigator of the ret-
rospective clinical evaluation. R. Leist, I.A. Adamietz, K. Fakhrian,
and R. Muecke participated in the design of the retrospective clinical
quality assessment and its coordination and performed a part of the
statistical analysis. R. Leist participated in patient accrual and the fol-
low-up examinations. R. Leist, O. Micke, K. Fakhrian, M.H. Seegen-
schmiedt, and R. Muecke drafted the manuscript. All authors read and
approved the final manuscript.
Availability of data and materials Please contact the corresponding au-
thor for data requests.
Conflict of interest R. Leist, O. Micke, M. H. Seegenschmiedt,
I.A. Adamietz, K. Fakhrian, and R. Muecke declare that they have
no competing interests.
Open Access This article is licensed under a Creative Commons At-
tribution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, pro-
vide a link to the Creative Commons licence, and indicate if changes
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0/.
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Article
Objectives Low-dose radiation therapy (LDRT) for benign disorders such as knee osteoarthritis (OA) is widely used in some parts of the world, despite absence of controlled studies. We evaluated the effect of LDRT on symptoms and inflammation in patients with knee OA. Methods In this randomised, double-blinded, sham-controlled clinical trial (RCT), we recruited patients with knee OA (clinical ACR criteria) in the Netherlands, aged ≥50 years, pain score ≥5/10 and non-responding to analgesics and exercise therapy. Patients were randomised 1:1 to receive LDRT (1 Gray per fraction) or sham intervention six times in 2 weeks, stratified by pain (<8 versus ≥8/10). Primary outcome was the proportion of OMERACT-OARSI responders, 3 months postintervention. Secondary outcomes included pain, function and inflammatory signs assessed by ultrasound, MRI and serum inflammatory markers. Results We randomly assigned 55 patients: 27 (49%) to LDRT and 28 (51%) to sham. At 3 months postintervention, 12/27 patients (44%; 95% CI 26% to 63%) in the LDRT vs 12/28 patients (43%; 95% CI 25% to 61%) in the sham group responded; difference 2% (95% CI 25% to 28%), OR adjusted for the stratifying variable was 1.1 (95% CI 0.4 to 3.2). Also, for clinical and any of the inflammatory signs, no differences were observed. Conclusions We found no substantial beneficial effect on symptoms and inflammatory signs of LDRT in patients knee OA, compared with sham treatment. Therefore, based on this RCT and the absence of other high-quality evidence, we advise against the use of LDRT as treatment for knee OA. Trial registration number NTR4574.