Frozen shoulder: The effectiveness of conservative and surgical interventions - Systematic review
Authors:
Favejee M, Huisstede BMA & Koes BW
Author's Affiliations:
Department of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Physiotherapy, Erasmus University Medical Center, Rotterdam, The Netherlands.
Publication Information:
British Journal of Sports Medicine 2011: 45: 49-56.
Background Information:
Adhesive capsulitis, also commonly referred to as ‘frozen shoulder’has an estimated incidence of 2-5%. Although the etiology and pathogenesis of primary frozen shoulder are unknown, patients with diabetes and hemiplegia are predisposed. To quickly review, there are three phases of frozen shoulder:
Freezing Phase (~3-9 months): pain and restricted motion of the glenohumeral (GH) joint in all planes
Frozen Phase (~9-15 months): consisting of stiffness (which reaches a maximum); and
Thawing Phase (~15-24 months): when range of motion (ROM) returns to normal
While considered to be self-limiting, functional improvement without symptoms does not always occur in frozen shoulder patients. In fact, one study suggests that only 59% of patients have full functional use of the shoulder after 4 years (1). Those in practice who have dealt with this condition realize that is can be difficult to manage. Persistent symptoms are often mild but no therapeutic intervention is currently universally accepted as the most effective treatment approach for re-establishing full range of motion and symptom reduction. The authors of this study therefore, aimed to review the literature and provide an evidence-informed intervention outline for primary frozen shoulder.
Pertinent Results:
The authors’ literature search identified 5 Cochrane reviews and 18 RCTs that met the inclusion criteria (see study methods below). Of the Cochrane reviews, three examined a mixed population with shoulder pain and two concentrated on frozen shoulder exclusively.
Analysis of these studies produced the following recommendations:
Oral steroids: Three high quality trials comparing oral steroids to placebo or no treatment revealed no significant differences in short or long term pain reduction or shoulder ROM. In a separate study, results at 3 weeks revealed significant differences in favor of oral steroids for pain and ROM. That study did show poor functional outcome with no significant differences at 7, 13, 26 and 52 weeks, however. Another study concluded that oral steroids administered prior to manipulation under anesthesia were superior to manipulation alone with regard to ROM at 6 weeks. Although no specific data was provided and it was not reported which treatment was superior, a study focusing on comparison of oral steroids with intra-articular steroids was conducted. At 1 week a significant difference was found both for pain and cure rate (defined as 90% of normal abduction and external rotation).
Corticosteroid injections: Intra-articular corticosteroid injections are frequently utilized in the treatment of general shoulder pain, including patients with adhesive capsulitis. Corticosteroids may be injected into the subacromial space, tendon sheaths or locally into trigger or tender points (2). Three high quality recent RCTs compared steroid injections to placebo in patients with adhesive capsulitis. All studies found significant differences in favor of intra-articular steroids for pain (short and mid-term). However, no significant differences were found for ROM.
Different dosages, anatomical sites or approaches of steroid injections: One of the Cochrane reviews discussed 6 other RCTs (3 that were considered high quality studies) that reported on the effectiveness of corticosteroid injections in the treatment of shoulder pain. No significant differences on pain or ROM were found with the application of different dosages, anatomical sites or approaches.
Steroid injections versus physiotherapy: One high quality RCT revealed a significant benefit of intra-articular injections over physiotherapy with pain and ROM at 3 and 7 weeks follow-up. After 26 weeks only the external rotation ROM change remained significant. The findings from 3 recent high quality RCTs compared steroid injections with several physiotherapy modalities (ranging from interferential electrical stimulation to therapeutic exercises). The results from 6 weeks to 4 months follow-up from all trials showed significant benefit of intra-articular injections over physiotherapy alone or placebo on pain. For ROM, the combination of steroid injection with physiotherapy was found to be more effective than physiotherapy or steroid injection alone (3). In contrast two studies reported significant differences in favor of physiotherapy on external rotation at 3 to 4 months versus corticosteroid injections. (p=0.02 and p<0.05, respectively)
Steroid injection versus other treatments: Two studies focused on the comparison of steroid injections with arthrographic distension. The results concluded that there were significant differences in favor of distension on ROM primarily with external rotation, flexion and extension. Another high quality RCT reported no significant differences between steroid injection and steroid injection in combination with hydrodilatation affecting ROM.
Physiotherapy/Modalities: Two high quality studies reported on laser therapy being more beneficial than placebo on improvement defined as an excellent or good result (after 15 treatments). Another high quality RCT also supported laser therapy over placebo regarding pain and disability at 16 weeks. The use of exercise combined with mobilization compared to exercise alone on ROM (internal rotation and abduction) provided short-term significant benefits versus exercise alone in a high quality RCT (n = 20). In a high quality RCT the combination of deep friction massage (Cyriax method) with exercise was more therapeutic in ROM than hot packs and short-wave diathermy (p<0.05). A RCT involving 100 patients compared high-grade mobilization with low-grade mobilization techniques. Both group’s subjects improved significantly between baseline and 1-year follow-up. The high-grade mobilizations proved slightly more effective than low-grade mobilization techniques in improving glenohumeral joint mobility and reducing disability (4). In a study of 18 patients receiving either anterior or posterior joint mobilization on external rotation a significant difference was found to favor posterior joint mobilization (after 3 treatment sessions). Three mobilization techniques were applied to 28 patients in a study involving end-range mobilization, mobilization with movement and mid-range mobilization comparisons in the management of frozen shoulder. The results concluded that that significant benefit of end-range mobilization and mobilization with movement were significantly beneficial versus mid-range mobilization techniques after 12 weeks. One final, high quality RCT (n = 125) concluded that home exercises in combination with manipulation under anesthesia produced better outcome results than exercises alone regarding ROM at 3 months.
Acupuncture: A Cochrane review looked at the effectiveness of acupuncture for shoulder pain (9 studies were included: 3 RCTs reported on frozen shoulder). One high quality study revealed a significant difference in favor of acupuncture and exercises compared with exercises alone on shoulder function at 20 weeks. Another study (low quality) supported suprascapular nerve blocks versus acupuncture on pain and ROM after 30 minutes of treatment.
Arthrographic distension: This procedure is aimed at disrupting adhesions that might be restricting the shoulder ROM. A high quality study supported the use of distension versus placebo demonstrating significant differences in ROM (abduction and internal rotation) at 3 weeks. Out of 3 studies conducted on distension and corticosteroid injections, one favored (with significant differences) distension for improved ROM. When combining distension and physiotherapy versus physiotherapy only the combination proved more effective with respect to pain and ROM at 8 weeks. Another recent high quality RCT on the effectiveness of active physiotherapy (manual therapy and directed exercise) after distension (n = 144) versus passive physiotherapy (sham ultrasound) with distension revealed significant results in favor of active physiotherapy at 12 weeks.
Suprascapular nerve block: In a high quality trial that focused on the effectiveness of (bupivacaine) SSNB versus placebo a reduction of pain in the treatment group compared with the placebo group was noted at 1-month follow-up (62% vs 13%). In a high quality study focusing on SSNB techniques; needle tip guided by superficial bony landmarks was compared to near-nerve electromyographically guided technique. The later proved more effective in providing and maintaining pain relief for up to 60 minutes (although it was not significant). A study on the effectiveness of SSNB compared with a series of intra-articular injections was studied and significance was found to be evident in the SSNB at 12 weeks for pain and ROM.
Polarity Exchangeable Permanent Magnet: One final, high quality RCT reported on the effect of polarity exchangeable permanent magnet (PEPM) on frozen shoulder pain. The findings supported a significantly greater pain relief found with north-south PEPM compared with non-PEPM on pain at 24h (39.2% vs. 22.4%, respectively).
Clinical Application & Conclusions:
The study provided an overview of the effectiveness of some conservative and surgical interventions in the treatment of primary frozen shoulder. While relieving pain and restoring shoulder function are common aims in treating frozen shoulder it is important to note the phase being treated due to the differences in symptoms in each phase. Therefore, it is suggested that both the treatment modality and the evaluation of treatment effects should be individualized based on the stage of the frozen shoulder.
When disuse of the arm occurs due to the insidious onset of pain, the result is loss of shoulder mobility. Pain and muscular inhibition result in compensatory movements of the scapula to minimize the pain. This continued use of these compensatory movements can result in pain and dysfunction elsewhere. Once pain has ceased and the ROM returns to normal (thawing phase) restoring the normal scapular movement should be an important goal in treating frozen shoulder. Further research needs to focus on assessment of the effectiveness of interventions used to normalize the scapulothoracic movement. Another factor is that most of these studies concentrated on short-term results. High quality RCTs are also needed to study the effectiveness of interventions in the longer term.
As aggressively as possible (within patient tolerance) – address any fibrotic changes in the musculo-fascial structures about the shoulder – particularly the posterior joint capsule, subscapularis, serratus anterior and pectoralis minor/major
If you use acupuncture, try needling any particularly painful trigger points that you find, particularly in the infraspinatus and pec minor
Mobilize/manipulate the upper thoracic spine and ipsiliateral costovertebral joints in combination with home exercise geared toward mobility in this area – cat/camels, foam rolling etc.
Mobilize he scapula-thoracic interface – this can help free up the shoulder as well
Try to engage then patient to stay as active as possible and work on ROM/posterior capsule mobility relentlessly (‘Sleeper stretch’ etc.)
Employ the Kimura mobilization as demonstrated by Dr. Spina in the video below
Study Methods:
A search of systematic reviews on primary frozen shoulder was performed utilizing the Cochrane Library. Reviews and RCTs in PubMed, Embase, Cinahl and Pedro were also searched for interventions that would fit the inclusion criteria. The inclusion criteria consisted of:
the study included patients with frozen shoulder;
the disorder was not caused by an acute trauma or systemic disease;
an intervention for treating frozen shoulder was evaluated;
results on pain, function or recovery were reported;
the article was written in English, French, German or Dutch.
A best-evidence synthesis was then used to summarize the results.
Study Strengths/Weaknesses:
Due to the lack of an unambiguous definition for frozen shoulder there were differences in selection criteria (e.g. differences in loss of ROM and duration of injuries). This created a weakness in the study causing a wide-ranging search strategy even with the broadly accepted clinical definition of “restriction of ROM in all directions”. Another factor to be considered in the review of studies is that every trial presented results of less than 3 months, whereas symptoms of frozen shoulder may last up to 4 years. Another weakness was that there were differences in study designs. Pooling of studies on the same interventions was not possible due to the heterogeneity of the interventions. This also created a difference in the outcome measures used which made it difficult to compare results. Studies that presented results on pain and restricted ROM were measured using different outcome scales.
An area of concern is that most common medical interventions in treating frozen shoulder are non-steroidal anti-inflammatory drugs (NSAIDs). RCTs reporting on the effectiveness of NSAIDs in treating frozen shoulder are lacking, as are RCTs studying the arthroscopic release of the glenohumeral capsular. This latter intervention is, however, the main operative treatment for frozen shoulder at present.
Overall this review was effective in incorporating a clinical perspective by categorizing the effectiveness of interventions into the different stages of the disease process of frozen shoulder. Prior to this review a systematic, evidence-based overview of the literature was lacking.
Additional References:
Hand C et al. Long-term outcome of frozen shoulder. J. Shoulder Elbow Surg 2008; 17: 231-236.
Buchbinder R et al. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003; 1 CD004016.
Carette S et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum 2003; 48: 829-838.
Vermeulen H. et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther 2006; 86: 355-368.
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