Comparative Efficacy and Patient-Specific Moderating Factors of Nonsurgical Treatment Strategies for Frozen Shoulder: An Updated Systematic Review and Network Meta-analysis

The importance of context (placebo effects) in conservative interventions for musculoskeletal pain: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Contextual effects (e.g. patient expectations) may play a role in treatment effectiveness. This study aimed to estimate the magnitude of contextual effects for conservative, non-pharmacological interventions for musculoskeletal pain conditions. A systematic review and meta-analysis of randomized controlled trials (RCTs) that compared placebo conservative non-pharmacological interventions to no treatment for musculoskeletal pain. The outcomes assessed included pain intensity, physical functioning, health-related quality of life, global rating of change, depression, anxiety and sleep at immediate, short-, medium- and/or long-term follow-up.

DATABASES AND DATA TREATMENT

MEDLINE, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL and SPORTDiscus were searched from inception to September 2021. Trial registry searches, backward and forward citation tracking and searches for prior systematic reviews were completed. The Cochrane risk of bias 2 tool was implemented.

RESULTS

The study included 64 RCTs (N = 4314) out of 8898 records. For pain intensity, a mean difference of (MD: -5.32, 95% confidence interval (CI): -7.20, -3.44, N = 57 studies with 74 outcomes, GRADE: very low) was estimated for placebo interventions. A small effect in favour of the placebo interventions for physical function was estimated (SMD: -0.22, 95% CI: -0.35, -0.09; N = 37 with 48 outcomes, GRADE: very low). Similar results were found for a broad range of patient-reported outcomes. Meta-regression analyses did not explain heterogeneity among analyses.

CONCLUSION

The study found that the contextual effect of non-pharmacological conservative interventions for musculoskeletal conditions is likely to be small. However, given the known effect sizes of recommended evidence-based treatments for musculoskeletal conditions, it may still contribute an important component.

SIGNIFICANCE

Contextual effects of non-pharmacological conservative interventions for musculoskeletal conditions are likely to be small for a broad range of patient-reported outcomes (pain intensity, physical function, quality of life, global rating of change and depression). Contextual effects are unlikely, in isolation, to offer much clinical care. But these factors do have relevance in an overall treatment context as they provide almost 30% of the minimally clinically important difference.

Psychometric properties of the Disability of Arm Shoulder and Hand (DASH) in subjects with frozen shoulder: a reliability and validity study

BACKGROUND

Frozen Shoulder (FS) is a painful condition characterized by severe pain and progressive restriction of shoulder movement, leading to functional impairment and reduced quality of life. While different Patient Reported Outcome Measurements (PROMs) tools exist for assessing shoulder diseases, few specific PROMs are validated for FS patients.

PURPOSE

This study aims to assess the psychometric properties of the Disability of Arm, Shoulder, and Hand (DASH) questionnaire in FS patients.

METHODS

One hundred and twenty-four subjects (mean ± SD age = 55.4 ± 7.9 years; 55.6% female) diagnosed with FS were included and completed the DASH questionnaire, the Numerical Pain Rating Scale (NPRS), the Shoulder Pain and Disability Index (SPADI), and the Short-Form Health Survey 36 (SF-36). Floor or ceiling effects were investigated. Structural validity was analysed through a unidimensional Confirmatory Factor Analysis (CFA), internal consistency through Cronbach's alpha, test-retest reliability through the Intraclass Correlation coefficient (ICC), measurement error through the Standard Error of Measurement (SEM), and the Minimum Detectable Change (MDC), and construct validity through the hypothesis testing with the correlation with the other outcome measures used.

RESULTS

No floor or ceiling effects were observed. CFA confirmed a one-factor structure after addressing local item dependency (Root Mean Square Error of Approximation = 0.055; Standardized Root Mean Square Residual = 0.077; Comparative Fit Index = 0.970; Tucker-Lewis Index = 0.968). Cronbach's alpha was high (= 0.951), and test-retest reliability was excellent (ICC = 0.999; 95% CI: 0.998-1.000). SEM was equal to 0.5 points, and MDC to 1.5 points. Construct validity was considered satisfactory as 80% of the a-priori hypotheses were met.

CONCLUSION

The DASH questionnaire demonstrated good psychometric properties in FS patients, supporting its use as a valuable tool for assessing the impact of FS in clinical and research settings.

Rotator Interval vs Posterior Approach Ultrasound-guided Corticosteroid Injections in Primary Frozen Shoulder: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS).

DATA SOURCES

A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted.

STUDY SELECTION

Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS.

DATA EXTRACTION

The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD).

DATA SYNTHESIS

A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks.

CONCLUSION

The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.

A new perspective of frozen shoulder pathology; the interplay between the brain and the immune system

Frozen shoulder (FS), also known as adhesive capsulitis of the shoulder (FS), is a fibrotic inflammatory process of unknown etiology whose main symptoms are pain, stiffness and the loss of joint mobility. These symptoms may be associated with pathologies such as diabetes, Dupuytren's syndrome and the prevalence of today's sedentary lifestyle. This literature review provides an overview of the epidemiology and pathogenesis of this pathology, as well as the mechanisms of lowgrade chronic inflammation and infection, insulin resistance, and omics-science associated with it. We also propose a new hypothesis related to the possibility that the GABAergic system could play a decisive role in the development of frozen shoulder and that therefore diabetes type 1, endocrinological autoimmune disorders and frozen shoulder are connected by the same pathophysiological mechanisms. If that is true, the combined presence of psycho-emotional stress factors and pathogenic immune challenges could be the main causes of frozen shoulder syndrome. Finally, we propose a series of possible intervention strategies based on a multifactorial etiological and mechanistic concept.

Predictive Factors of Intra-articular Corticosteroid Injections With Ultrasound-Guided Posterior Capsule Approach for Patients With Primary Adhesive Capsulitis

BACKGROUND

Adhesive capsulitis affects the shoulder joint, causing pain and limiting motion. In clinical practice, the effectiveness of injections varies, and the factors influencing their success remain unclear. This study investigates the predictors of effective corticosteroid injections in patients with primary adhesive capsulitis.

DESIGN

This retrospective study enrolled adhesive capsulitis patients older than 35 yrs who received intra-articular corticosteroid injections. The response was determined based on patients' pain and range of motion 3 mos after the injection. Demographic data, medical comorbidities, and radiographic parameters (critical shoulder angle and acromial index) were compared between the effective and noneffective groups. Receiver operating characteristic curves and logistic regression were used to identify the predictors of injection effectiveness.

RESULTS

This study included 325 patients with primary adhesive capsulitis, who were divided into responder (189 patients, 58.2%) and nonresponder (136 patients, 41.8%) groups. The receiver operating characteristic curve revealed that the acromial index score indicated favorable discrimination for predicting a poor response to injections, whereas the critical shoulder angle score did not. Logistic regression revealed that the pain period, diabetes mellitus, and acromial index are predictors of nonresponders to injections.

CONCLUSIONS

Long pain duration, the presence of diabetes mellitus, and an acromial index score greater than 0.711 were predictors of nonresponse to corticosteroid injections for primary adhesive capsulitis patients.

Efficacy of combined ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy in patients with adhesive capsulitis: A randomised controlled trial

OBJECTIVE

To evaluate the therapeutic effect of combining ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy compared with physical therapy alone in patients with adhesive capsulitis.

DESIGN

A prospective, single-blinded, randomised controlled trial.

SETTING

Single medical centre.

PARTICIPANTS

Patients with adhesive capsulitis (N = 62) were divided into group A: ultrasound-guided hydrodilatation with hyaluronic acid + physical therapy (N = 31) and group B: physical therapy alone (N = 31).

INTERVENTIONS

Group A received three doses of ultrasound-guided hydrodilatation with hyaluronic acid-based injectates (20 mL in total). Both groups underwent structured physical therapy.

OUTCOME MEASURES

The primary outcome measure was Constant score, while secondary outcomes included Shoulder Pain and Disability Index score, numerical rating scale (at rest, night, and during motion), 36-item Short Form Health Survey, and range of motion of the shoulder. All measurements were collected at baseline, 6 weeks, and 12 weeks post-injection.

RESULTS

At week 12, the Constant scores were 68.29 ± 14.55 and 62.77 ± 14.44 for groups A and B, respectively. There was a greater reduction in the Constant score, Shoulder Pain and Disability Index, and numerical rating scale between the baseline and 6 weeks and between the baseline and 12 weeks in group A (Constant score: p < 0.05, Shoulder Pain and Disability Index: p < 0.01, and numerical rating scale: p < 0.05).

CONCLUSION

The combination of ultrasound-guided hydrodilatation with hyaluronic acid in conjunction with physical therapy provides additional benefits compared to physical therapy alone for the treatment of adhesive capsulitis at up to 12 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02708706.

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus

PURPOSE

Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS.

METHODS

The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience.

RESULTS

Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS.

CONCLUSIONS

A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale.

LEVEL OF EVIDENCE

Level I.

Efficacy of Platelet-Rich Plasma Injection on Range of Motion, Pain, and Disability in Patients With Adhesive Capsulitis: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the therapeutic effects of platelet-rich plasma (PRP) injection on range of motion, pain, and disability in patients with adhesive capsulitis (AC).

DATA SOURCES

The authors performed the literature search in the PubMed, Embase, and Cochrane Library databases in February 2023.

STUDY SELECTION

Prospective studies comparing the outcomes of PRP with other intervention in patients with AC.

DATA EXTRACTION

The quality of included randomized trials was assessed using the revised Cochrane Risk of Bias (RoB 2.0) tool. The Risk of Bias in Non-Randomized Studies of Interventions tool was applied to assess the quality of nonrandomized trials. The mean difference (MD) or standardized mean difference (SMD) was determined as the effect size for continuous outcomes, and outcome accuracy was determined using 95% confidence intervals (CIs).

DATA SYNTHESIS

Fourteen studies involving 1139 patients were included. Our meta-analysis revealed that PRP injection can significantly improve passive abduction (MD=3.91; 95% CI, 0.84-6.98), passive flexion (MD=3.90; 95% CI, 0.15-7.84), and disability (SMD=-0.50; 95% CI, -1.29 to -0.74) within 1 month after intervention. Moreover, PRP injection can significantly improve passive abduction (MD=17.19; 95% CI, 12.38-22.01), passive flexion (MD=17.74; 95% CI, 9.89-25.59), passive external rotation (MD=12.95; 95% CI, 10.04-15.87), pain (MD=-8.40; 95% CI, -16.73 to -0.06), and disability (SMD=-1.02; 95% CI, -1.29 to -0.74) 3 months after intervention. PRP injection can also significantly improve pain (MD=-18.98; 95% CI, -24.71 to -13.26), and disability (SMD=-2.01; 95% CI, -3.02 to -1.00) 6 months after intervention. In addition, no adverse effects of PRP injection were reported.

CONCLUSIONS

PRP injection may serve as an effective and safe treatment for patients with AC.

Effectiveness of electrophysical agents in subjects with frozen shoulder: a systematic review and meta-analysis

PURPOSE

This systematic review with meta-analysis aimed to assess the effectiveness of electrophysical agents in improving pain, function, disability, range of motion, quality of life, perceived stiffness, and time to recovery in subjects with frozen shoulder (FS).

METHODS

A thorough search of MEDLINE, Cochrane Library, PEDro, and EMBASE yielded 1143 articles, of which 23 randomized controlled trials were included. Risk of bias (RoB) was assessed through Cochrane Risk of Bias 2 tool. The certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

The analysis included a total of 1073 subjects. None of the studies were judged as low RoB. Potentially clinically significant differences were observed in pain at 6 weeks and 5 months after extracorporeal shockwave therapy (ESWT), and in disability up to 3 months with laser therapy, albeit with uncertain results due to the high RoB and to the study heterogeneity. Ultrasound (US) therapy did not yield significant differences in any outcomes. The certainty of evidence was very low.

CONCLUSIONS

Based on the high heterogeneity and low quality and certainty of evidence, ESWT, laser, and US cannot be recommended for FS treatment. Caution should be exercised in interpreting the findings.

The impact of introducing hydrodistension as a treatment for frozen shoulder in a primary care musculoskeletal service: A retrospective audit

INTRODUCTION

Hydrodistension, where a relatively high volume of local anaesthetic, corticosteroid, and sterile saline are injected into the shoulder joint, is a treatment of interest for frozen shoulder. In the UK National Health Service this is typically provided in the hospital setting. In 2017 we introduced hydrodistension into our physiotherapy led musculoskeletal service. This report describes the findings from our audit of onward referral for orthopaedic assessment following the introduction of hydrodistension to our frozen shoulder treatment pathway.

METHODS

A retrospective audit of data from 102 patients who followed our hydrodistension treatment pathway for frozen shoulder since 2017 was conducted. All 102 patients received at least one hydrodistension procedure performed by a physiotherapist. This involved injecting the glenohumeral joint with a combination of local anaesthetic, corticosteroid, and saline under ultrasound guidance with a total volume of 25-35 mls. This data was compared to the outcomes of 102 patients who presented with frozen shoulder prior to 2017 who did not receive hydrodistension.

RESULTS

Of 102 patients who received hydrodistension within the musculoskeletal service, six patients required onward referral to orthopaedics. Of the 102 patients who did not receive hydrodistension prior to 2017, 58 required onward referral to orthopaedics.

CONCLUSION

We report a reduction in onward referral to orthopaedics following the introduction of hydrodistension to our physiotherapist-led treatment pathway for patients with frozen shoulder. This preliminary data identifies the need to further evaluate the clinical and cost-effectiveness of hydrodistension performed by physiotherapists for patients with frozen shoulder.

Combined arthroscopic release with corticosteroid hydrodilatation versus corticosteroid hydrodilatation only in treating freezing-phase primary frozen shoulder: a randomized clinical trial

BACKGROUND

There has been no ideal treatment for freezing-phase frozen shoulder to rapidly relieve pain and improve joint mobility. No any other team directly compared the effectiveness of combination of arthroscopic release and corticosteroid hydrodilatation with corticosteroid hydrodilatation only in treatment of freezing-phase frozen shoulder.

METHODS

Seventy-two patients with freezing-phase frozen shoulder were randomly assigned to combined arthroscopic release with corticosteroid hydrodilatation (group A) or corticosteroid hydrodilatation only (group B). Clinical states were examined at baseline and periodically (Weeks 1, 4, 12, 24 and 1 year) after intervention by passive ROM; visual analog scale (VAS); UCLA and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

RESULTS

The passive ROM, VAS, UCLA and DASH scores always improved along the time points (all p < 0.01). The passive abduction (pAB), passive forward flexion (pFL), passive external rotation (pER), passive internal rotation (pIR) were better in group A than in group B at Week 1, 4, 12, 24 (all p < 0.01). At 1 year post-operation, the pFL and pIR were better in group A than in group B (all p < 0.01). VAS scores of group A were similar with those of group B (all p > 0.01), the differences between group A and group B were all lower than minimal clinically important difference (MCID). At Week 12, the UCLA sores and DASH scores were 26.8 ± 3.8, 14.2 ± 2.0 in group A versus 22.3 ± 3.4, 22.5 ± 3.1 in group B (all p < 0.01). At Week 24 post-operation, there were 32.7 ± 2.0, 9.8 ± 1.5 in group A versus 26.3 ± 3.6, 17.5 ± 3.5 in group B (all p < 0.01). At 1 year post-operation, there were 34.5 ± 0.8, 1.7 ± 1.5 in group A versus 32.1 ± 2.3, 8.8 ± 2.8 in group B (all p < 0.01), the differences of UCLA scores between group A and group B at Week 24 was higher than the MCID. There were no complications such as infection, nerve or vascular injury.

CONCLUSIONS

Combined arthroscopic release with corticosteroid hydrodilatation would yield better results in passive ROM and function than corticosteroid hydrodilatation only.

TRIAL REGISTRATION

ChiCTR1900024235, July 2, 2019 (Retrospectively registered).

Predictive Factors for Failure of Intraarticular Injection in Management of Adhesive Capsulitis of the Shoulder

Intraarticular (IA) corticosteroid injections have been demonstrated to be an effective management for adhesive capsulitis in both the short- and mid-term. Yet, certain patients fail to improve both subjectively and clinically. This study aims to identify predictive factors for treatment failure of IA injections in management of adhesive capsulitis. A retrospective review found 533 patients undergoing IA corticosteroid or IA NSAID injection for adhesive capsulitis between June 2015 and May 2020 at a single healthcare institution. Patient demographics characteristics, comorbidities, pain scores, and range of motion were compared. Treatment failure was defined as need for subsequent IA injection within 6 months or progression to surgical management within 12 months. 152 patients (28.52%) experienced treatment failure of IA corticosteroid injection. Pre-injection pain scores were greater for those who experienced treatment failure (5.40 vs. 4.21, p < 0.05). Post-injection pain scores were greater for those who experienced treatment failure (3.77 vs. 2.17, p < 0.01). Reduced post-injection external rotation in abduction also predicted treatment failure (56.88° vs. 70.22°, p < 0.01). IA corticosteroid injections are associated with increased rates of failure and progression to surgical management when patients present with increased pain levels as well as with less improvement in pain levels and ROM following injection.

A retrospective study of ultrasound-guided intervention for frozen shoulder in the frozen stage

Background

To investigate the clinical value of ultrasound (US)-guided intervention for frozen shoulder (FS) in the frozen stage.

Methods

This study included 40 patients who had primary FS in the frozen stage and were evaluated by US. These 40 patients have all received conservative treatment elsewhere, and no satisfactory results have been achieved, with no improvement in active and passive movement angles, and no improvement in scores within 3 months. Therefore, their previous treatment was set as comparison. All patients underwent US-guided shoulder joint capsule distension by injection of sterilized water. Of these participants, 22 patients with scapulohumeral periarthritis received a compound betamethasone injection, and 14 patients with thickened coracohumeral ligaments (CHLs) underwent acupotomy lysis, and the remaining 4 patients had no extra treatments. The Constant-Murley score (CMS) was evaluated before and after the operation and analysed for each patient.

Results

Before treatment, the indices for the thickening of the subaxillary joint capsule, subacromial bursa (with or without effusion), long head of the biceps brachii tendon (LHBBT) and CHL were 40, 22, 16 and 14, respectively. After treatment, all the indices were significantly decreased (all P < 0.010) except for that of the LHBBT (P = 0.123). The patients' CMSs improved, with the median total CMS increasing from 59 points (interquartile range: 53–64 points) to 86 points (interquartile range: 78–90 points) (P < 0.010). While the internal rotation (Ir) of the shoulder joint did not improve (FDRs < 0.50), abduction, forward flexion (Ff) and external rotation (Er) improved significantly (all FDRs = 1.00).

Conclusion

Compared with conservative treatment, US-guided intervention for FS in the frozen stage is highly effective and of great clinical value.

Trends in Practice Among Shoulder Specialists in the Management of Frozen Shoulder: A Consensus Survey

Background:

The management of frozen shoulder (FS) differs depending on experience level and variation between scientific guidelines and actual practice.

Purpose:

To determine the current trends and practices in the management of FS among shoulder specialists and compare them with senior shoulder specialists.

Study Design:

Consensus statement.

Methods:

A team of 15 senior shoulder specialists (faculty group) prepared a questionnaire comprising 26 questions regarding the definition, terminology, clinical signs, investigations, management, and prognosis of FS. The questionnaire was mailed to all the registered shoulder specialists of Shoulder and Elbow Society, India (SESI) (specialist group; n = 230), as well as to the faculty group (n = 15). The responses of the 2 groups were compared, and levels of consensus were determined: strong (>75%), broad (60%-74.9%), inconclusive (40%-59.9%), or disagreement (<40%).

Result:

Overall, 142 of the 230 participants in the specialist group and all 15 participants in the faculty group responded to the survey. Both groups strongly agreed that plain radiographs are required to rule out a secondary cause of FS, routine magnetic resonance imaging is not indicated to confirm FS, nonsteroidal anti-inflammatory drugs should be administered at bedtime, steroid injection (triamcinolone or methylprednisolone) is the next best option if analgesics fail to provide pain relief, passive physical therapy should be avoided in the freezing phase, <10% of patients would require any surgical intervention, and patients with diabetes and thyroid dysfunction tend to fare poorly. There was broad agreement that routine thyroid dysfunction screening is unnecessary for women, a single 40-mg steroid injection via intra-articular route is preferred, and arthroscopic capsular release (ACR) results in a better outcome than manipulation under anesthesia (MUA). Agreement was inconclusive regarding the use of combined random blood sugar (RBS) and glycosylated hemoglobin versus lone RBS to screen for diabetes in patients with FS, preference of ACR versus MUA to treat resistant FS, and the timing of surgical intervention. There was disagreement over the most appropriate term for FS, the preferred physical therapy modality for pain relief, the most important movement restriction for early diagnosis of FS, and complications seen after MUA.

Conclusion:

This survey summarized the trend in prevalent practices regarding FS among the shoulder specialists and senior shoulder surgeons of SESI.

A Review on Current Notion in Frozen Shoulder: A Mystery Shoulder

Frozen shoulder (FS) is a common condition affecting the population between the ages of 30 and 60; the causative agent is idiopathic, sedentary lifestyle, post-traumatic, or secondary to any pathological conditions. The pathology of FS is characterized by cytokine-mediated synovial inflammation with fibroblastic proliferation. The clinical features of FS vary depending on the phase in which the individual is present. The common clinical features are pain, and reduction in the range of motion in the capsular pattern. The available treatment options are medical therapy such as corticosteroid injection, physical therapy, joint mobilization, joint mobilization under anesthesia, and mirror therapy. When all the conservative methods fail then surgical procedures are used which include the surgical release of the restriction formed in the capsule. In conclusion, steroid injection along with physical therapy shows significant improvement in the range of motion and reduction in pain in the shoulder.

Ultrasound Guıded Multisıte Injectıon Technıque in the Treatment of Frozen Shoulder

Frozen shoulder (FS) is an elusive condition that affects patients' mental and emotional quality of their lives. Corticosteroid injection technique is one of the first-line treatment methods in the treatment of FS. Ultrasound (USG) guidance allows visualization of the shoulder anatomy and improves the accuracy of the injection site. This study describes an USG-guided injection technique for FS treatment. The aim of this technique was to affect glenohumeral joint and capsule, subacromial space, the long head of biceps tendon sheath, and the coracohumeral ligament. For this purpose, four different sites were injected by USG guidance. Patients with FS can be effectively treated through this technique that is detailed in this article.

Expert clinical consensus in the delivery of hydrodilatation for the management of patients with a primary frozen shoulder

Aims

To achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation.

Methods

We conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional.

Results

Between 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating).

Conclusion

In the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation.

Cite this article: Bone Jt Open 2022;3(9):701–709.

Non-Surgical and Rehabilitative Interventions in Patients with Frozen Shoulder: Umbrella Review of Systematic Reviews

Background

Frozen shoulder (FS) is a painful condition characterized by progressive loss of shoulder function with passive and active range of motion reduction. To date, there is still no consensus regarding its rehabilitative treatment for pain management.

Purpose

The aim of this umbrella review of systematic reviews was to analyze the literature, investigating the effects of non-surgical and rehabilitative interventions in patients suffering from FS.

Patients and Methods

A review of the scientific literature was carried out from 2010 until April 2020 using the following search databases: PubMed, Medline, PEDro, Scopus and Cochrane Library of Systematic Reviews. A combination of terms was used for the search: frozen shoulder OR adhesive capsulitis AND systematic review OR meta-analysis AND rehabilitation NOT surgery NOT surgical intervention. We included systematic reviews that specifically dealt with adults with FS, treated with non-surgical approaches. All the systematic reviews and meta-analyses included in the study that met the inclusion criteria were assessed using the Assessment of Multiple Systematic Reviews as a quality assessment tool.

Results

Out of 49 studies, only 14 systematic reviews respected the eligibility criteria and were included in this study. Their results showed an important heterogeneity of the studies and all of them agree on the lack of high-quality scientific work to prove unequivocally which rehabilitative treatment is better than the other. Due to this lack of gold standard criteria, there may be also a heterogeneity in the diagnosis of the reviews analyzed.

Conclusion

Non-surgical and rehabilitative interventions are undoubtedly effective in treating FS, but there is no evidence that one approach is more effective than the other regarding the methods reported. Future high-quality RCTs are needed to standardize the treatment modalities of each physiotherapy intervention to provide strong recommendations in favor.

Assessment of isolated glenohumeral range of motion in patients with adhesive capsulitis can help predict failure of conservative treatment: a pilot study

PURPOSE

To prospectively evaluate a cohort of patients with adhesive capsulitis and identify predictors of failure of conservative treatment in the first 2 months of therapy.

METHODS

This was a single-cohort, prospective observational study that included 20 participants (13 females/7 males; median age of 51.8 years [interquartile range: 8.65]) with primary adhesive capsulitis managed conservatively and evaluated clinically every month for at least 2 years of follow-up (29 [5] months). The evaluation included stage of the disease, treatment applied, radiological findings, pain levels and range of motion (active and passive ROM in the four planes and isolated glenohumeral passive ROM in abduction [GH-ABD], external rotation [GH-ER] and internal rotation). The main outcome assessed was failure of conservative treatment defined as the need for surgery and persistent pain or CMS below 70 points at the 1-year follow-up.

RESULTS

Seven patients (7/20, 35%) were considered to have failed conservative treatment because they required arthroscopic capsular release 5.2 (2.1) months after the initial diagnosis. Of all the clinical and epidemiological variables, absence of improvement during the first 2 months in isolated glenohumeral ROM abduction and external rotation predicted failure of conservative treatment: improvement in GH-ABD (10° or more) occurred in 10/13 patients in the conservative treatment group and in 1/7 patients in the surgery group (p = 0.017). Improvement in GH-ER (10° or more) occurred in 9/13 patients in the conservative treatment group and in 0/7 patients in the surgery group (p = 0.005).

CONCLUSIONS

Precise assessment of isolated glenohumeral ROM in patients with adhesive capsulitis can help identify patients in which conservative treatment might fail. In this study, patients who did not experience early improvements in isolated glenohumeral ROM often required surgery.

LEVEL OF EVIDENCE

III (Prospective cohort study).

Effect of proprioceptive neuromuscular facilitation technique on the treatment of frozen shoulder: a pilot randomized controlled trial

Background and objectives

Frozen shoulder is a common painful disease of the shoulder joint characterized by structural changes in the shoulder joint, restricting both active and passive shoulder joint activities. Proprioceptive neuromuscular facilitation (PNF) effectively improved and maintained the range of motion; however, it is not clear whether it can improve the shoulder joint structure in patients with frozen shoulder. This pilot study used magnetic resonance imaging (MRI) observation to assess the improvement of the local structure of the shoulder joint upon PNF treatment to elucidate a target based on structure for the treatment of frozen shoulder.

Materials and methods

Forty-eight patients with frozen shoulder were randomly divided into the traditional manual therapy group and the PNF technique group. Changes in the thicknesses of the coracohumeral ligament (CHL) and capsule in axillary recess (CAR) of the shoulder joint were observed via MRI upon admission and at 4 weeks after treatment. A visual analog scale (VAS) and passive shoulder range of motion (ROM) at abduction, anteflexion and external rotation position were used to evaluate the improvement of shoulder joint pain and function in the initial, mid-term, and discharge of the two groups of patients.

Results

The primary outcome results shown that the PNF joint mobilization significantly reduced the thickness of the CHL (p = 0.0217) and CAR (p = 0.0133). Compared with simple joint mobilization, The mid-term and discharge rehabilitation assessment results showed that PNF has a better effect on shoulder pain. At the mid-term evaluation, the ROM of the PNF group was significantly better than that of the Control group in the three directions (p < 0.05).

Conclusion

As an adjunctive therapy, PNF can improve the shoulder joint structure of patients with frozen shoulder and is an effective treatment strategy for frozen shoulder.

Extracorporeal Shockwave Therapy as an Adjunctive Therapy for Frozen Shoulder: A Systematic Review and Meta-analysis

Background:

The best nonsurgical treatment for frozen shoulder is still unclear. Extracorporeal shockwave therapy (ESWT) is an innovative adjunctive treatment for frozen shoulder, but its effect is still unclear.

Purpose:

To evaluate the published literature regarding the potential of ESWT as an adjunctive therapy for frozen shoulder.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

Searches were conducted in the PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), and VIP Information databases for relevant studies between inception and November 2020. Included were randomized controlled trials (RCTs) for frozen shoulder that compared ESWT with routine treatments to controls. There were no restrictions on the treatment period, type of ESWT, or severity of symptoms. At least 1 of the following outcome indices was assessed: visual analog scale (VAS) for pain, Constant-Murley score (CMS) for shoulder function assessment, or external rotation range of movement (ER ROM). RevMan 5.3 software was used to evaluate the bias and quality of the included studies. For continuous variables, the mean difference (MD) or standardized MD (SMD) with the 95% CI was extracted. For dichotomous data, event ratios and sample sizes were extracted.

Results:

Overall, 20 studies were included. The ESWT used as an adjunct to other interventions had better outcomes compared with control groups regarding immediate and short-term analgesic effects (immediate: MD, –1.10 [95% CI, –1.27 to –0.92], P < .00001; short-term: MD, –0.72 [95% CI, –0.94 to –0.50], P < .00001) as well as immediate function (SMD, 1.54 [95% CI, 1.19 to 1.89], P < .00001], I² = 0%). There was significant heterogeneity between studies for long-term analgesia (MD, –0.90 [95% CI, –1.40 to –0.41], P < .00001, I² = 89%) and ER ROM (MD, 10.31 [95% CI, 3.46 to 17.17], P < .003, I² = 93%).

Conclusion:

ESWT seems to be beneficial to patients with frozen shoulder by alleviating pain and improving function. ESWT could be used as an adjunct therapy to routine treatments, although the quality of the included RCTs was hampered by significant heterogeneity regarding long-term analgesia and joint ROM.

Effectiveness of interventions for the management of primary frozen shoulder : a systematic review of randomized trials

AIMS

This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI.

METHODS

MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder.

RESULTS

Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero.

CONCLUSION

The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773-784.

Exercise Therapy is Effective for Improvement in Range of Motion, Function, and Pain in Patients With Frozen Shoulder: A Systematic Review and Meta-analysis

OBJECTIVE(S)

To determine (1) the effect of exercise therapy alone or in combination with other interventions compared with solely exercises and programs with or without exercises and (2) what kind of exercise therapy or combination with other interventions is most effective.

DATA SOURCES

PubMed, Web of Science and Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Studies were screened in a 2-phase approach by 2 independent reviewers (M.M. and L.M.). Reference lists of included studies and interesting systematic reviews were hand searched.

DATA EXTRACTION

Two independent reviewers (M.M. and L.M.) extracted information about origin, characteristics of study participants, eligibility criteria, characteristics of interventions, outcome measures and main results in a pre-defined template.

DATA SYNTHESIS

Thirty-three studies were included in the qualitative and 19 in the meta-analysis. Preliminary evidence was found for supervised exercises to be more beneficial than home exercises for ROM and function. Multimodal programs comprising exercises may result in little to no difference in ROM compared to solely exercises. Programs comprising muscle energy techniques show little to no difference in ROM when compared with programs with other exercises. Adding stretches to a multimodal program with exercises may increase ROM. There is uncertain evidence that there is a difference between those programs regarding function and pain. Preliminary evidence was found for several treatment programs including exercises to be beneficial for improvement in both passive and active ROM, function, pain, and muscle strength. No studies used patient satisfaction as an outcome measure.

CONCLUSIONS

ROM, function, and pain improve with both solely exercises and programs with exercises, but for ROM and pain there was little to no difference between programs and for function the evidence was uncertain. Adding exercises improve active ROM compared with a program without exercises, whereas adding physical modalities has no beneficial effect. Muscle energy techniques are a beneficial type of exercise therapy for improving function compared with other types of exercise. Unfortunately, no conclusion can be drawn about the results in the long-term and most effective dose of exercise therapy.