Manipulation under anesthesia versus physiotherapy treatment in stage two of a frozen shoulder: a study protocol for a randomized controlled trial

Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial

Background

Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS.

Methods

A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work.

Results

In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial.

Conclusion

MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.

A multi-center, single-blinded, randomized, parallel-group, superiority study to compare the efficacy of manipulation under anesthesia versus intra-articular steroid injection in the treatment of patients with frozen shoulder and a diagnosis of rotator cuff injury or tear by MRI: study protocol for a randomized controlled trial

BACKGROUND

Frozen shoulder (FS) is a common condition that can cause severe pain and limited range of motion in the shoulder joint. While intra-articular steroid injection has been shown to be an effective treatment for FS, manipulation under anesthesia (MUA) is an alternative treatment that has gained popularity in recent years. However, there is a lack of evidence regarding the effectiveness of MUA on FS patients with concomitant rotator cuff injury or tear. Though a few studies have shown that MUA is not associated with rotator cuff tears, and will not exacerbate the injury, more high-quality studies with bigger sample sizes are needed. Therefore, the aim of this multi-center, single-blinded, randomized, parallel-group, superiority study is to compare the efficacy of MUA versus intra-articular steroid injection in the treatment of FS patients with a diagnosis of rotator cuff injury or tear by MRI.

METHODS

A parallel, single-blinded, multi-center randomized controlled trial of 320 patients will be conducted at three hospitals of China. Eligible patients with frozen shoulder and rotator cuff injury or tear diagnosed by MRI will be randomly assigned to, in equal proportions, the manipulation under anesthesia group and the intra-articular steroid injection group via a central randomization system, undergoing a corresponding operation on day one and a sequent physical exercise for 14 days. The primary outcome is the comprehensive efficacy evaluation (total effective rate) and the change of Constant-Murley Score. Outcome assessors and data analysts will be blinded, and participants will be asked not to reveal their allocation to assessors.

DISCUSSION

This study aims to explore the superiority of manipulation under anesthesia in reducing pain and improving shoulder function in frozen shoulder patients accompanied with rotator cuff injury. To provide a scientific basis for the dissemination and application of manipulation under anesthesia, and a better knowledge for the role of MUA in the treatment of frozen shoulder accompanied with rotator cuff injury.

TRIAL REGISTRATION

Chictr.org.cn ChiCTR2200067122 . Registered on 27 December 2022. ChiCTR is a primary registry of the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) network and includes all items from the WHO Trial Registration data set in Trial registration.

Effect of Transfer Energy Capacitive and Resistive Therapy on Shoulder Pain, Disability, and Range of Motion in Patients With Adhesive Capsulitis: A Study Protocol for a Randomized Controlled Trial

Objective

We describe a protocol to evaluate the effectiveness of transfer energy capacitive and resistive (TECAR) therapy on shoulder passive range of motion, shoulder pain, and disability index in patients with adhesive capsulitis.

Methods

This study will be a double-blinded randomized clinical trial with a 1-month follow-up. For the purpose of this research, 30 patients with a 3-month history of shoulder pain and disability diagnosed as adhesive capsulitis will be selected and then randomized into 2 groups, including conventional physiotherapy consisting of electrophysical modalities and therapeutic exercises, which will be given to the control group. In the intervention group, after conventional physiotherapy, 10 minutes of TECAR therapy in resistive mode will be applied on both the anterior and inferior aspects of the shoulder joint. Outcome measures will be related to shoulder passive range of abduction, flexion, and external rotation that will be measured using a digital inclinometer, as well as shoulder pain and disability index that will be assessed by the validated questionnaire. Assessment will be done at baseline, 1 day after the intervention, and by passing 1 month.

Results

The statistical analysis will describe within-group and between-group comparisons; the findings will be illustrated in tables and charts.

Conclusion

Given the reason that the effectiveness of TECAR therapy has not been widely evaluated in adhesive capsulitis, the findings of this pilot study would provide baseline information on the effectiveness and complications of this treatment method and possibly propose a more appropriate protocol for patients with adhesive capsulitis.

Efficacy of high-intensity home mechanical stretch therapy for treatment of shoulder stiffness: a retrospective review

Background

Shoulder stiffness resulting in motion loss can be caused by numerous conditions, the most common of which is adhesive capsulitis. Surgical intervention is often necessary when conservative methods fail. High-intensity stretch (HIS) treatment may be able to provide increased motion gains while avoiding the cost and complications of surgery.

Objectives

The purpose of this study was to review data from patients who were prescribed a HIS device to recover their shoulder motion to determine the efficacy of the device. The hypotheses were that patients would achieve significant range of motion (ROM) gains and that ROM would increase to a level at which patients would be able to avoid a motion loss surgery and perform activities of daily living.

Methods

Clinical notes were reviewed for patients whose progress plateaued after 4 weeks of therapy and were subsequently prescribed the HIS device after failing to meet their treatment goals. ROM data were recorded for external rotation, abduction, forward flexion, and internal rotation. Pre- and post-treatment ROM data were compared using t-tests.

Results

Significant ROM gains were seen in all planes of motion (p < 0.001). Patients gained an average of 29.9° in external rotation with a last recorded rotation of 59.2°. In abduction, patients gained 40.5° with a last recorded abduction of 123.3°. In forward flexion, patients gained 30.3° with a last recorded flexion of 138.7°. In internal rotation, patients gained 15.2° with a last recorded rotation of 57.6°. These last recorded ranges of motion were sufficient to perform nearly all activities of daily living.

Conclusions

The HIS device was effective in treating patients with shoulder motion loss as demonstrated by the significant ROM gains in all planes of motion. The ability for a patient to recover lost motion quickly without surgery is of great value to quality of life and in healthcare cost savings. We believe this high-intensity stretch device should be considered for use by patients who are at risk for a motion loss surgery.

Post-surgical physiotherapy in frozen shoulder: A review

Despite its prevalence, the optimal management of frozen shoulder is unclear. A range of conservative measures are often undertaken with varying degrees of success. In cases of severe and persistent symptoms, release procedures which could include any combination of manipulation under anaesthetic, arthroscopic capsular release or hydrodilatation are frequently offered, none of which has been shown to offer superior outcome over the others. When surgical release is performed a period of rehabilitation is normally recommended but no best practice guidelines exist resulting in considerable variations in practice which may or may not directly affect patient outcome. During this narrative review, we hypothesise that these differing responses to treatment (both conservative and surgical options) are potentially the result of different causal mechanisms for frozen shoulder and may also suggest that post-release rehabilitation may need to take this into account.

Role of suprascapular nerve block in idiopathic frozen shoulder treatment: a clinical trial survey

Background

Several therapeutic methods have been proposed for frozen shoulder syndrome. These include suprascapular nerve block, a simple and cost-effective technique that eliminates the need for nonsteroidal anti-inflammatory drug therapy.

Methods

This was a clinical trial that included patients with unilateral shoulder joint stiffness. Patients were divided into three groups: those treated with isolated physiotherapy for 12 weeks (PT group), those treated with a single dose intra-articular injection of corticosteroid together with physiotherapy (IACI group), and those treated with a suprascapular nerve block performed with a single indirect injection of 8-mL lidocaine HCL 1% and 2 mL (80 mg) methylprednisolone acetate together with physiotherapy (SSNB group). The variables assessed were age, sex, side of involvement, dominant limb, presence of diabetes, physical examination findings including erythema, swelling, and muscle wasting; palpation and movement findings; shoulder pain and disability index (SPADI) score; and the visual analog scale (VAS) score pre-intervention and at 2-, 4-, 6-, and 12-week post-intervention.

Results

Ninety-seven patients were included in this survey (34 cases in the PT group, 32 cases in the IACI group, and 31 cases in the SSNB group). Mean age was 48.55±11.06 years. Fifty-seven cases were female (58.8%) and 40 were male (41.2%). Sixty-eight patients had a history of diabetes (70.1%). VAS and SPADI scores and range of mototion degrees dramatically improved in all cases (p<0.001). Results were best in the SSNB group (p<0.001), and the IACI group showed better results than the PT group (p<0.001).

Conclusions

Suprascapular nerve block is an effective therapy with long-term pain relief and increased mobility of the shoulder joint in patients with adhesive capsulitis.

Acute Femoropopliteal Bypass Graft Occlusion After Knee Manipulation Under Anesthesia: A Case Report and Review of Current Literature

Bilateral tibiofemoral knee dislocations are a relatively rare injury, and there is a scarcity of literature on its appropriate evaluation and treatment. Even less knee dislocations with concomitant popliteal artery injury have been described. Postoperative graft occlusion accounts for approximately half of the overall complication rate, occurring in up to 18% of the patients undergoing femoropopliteal bypass grafting. Furthermore, anticoagulation and antiplatelet therapy after graft placement is a point of contention. Here, we describe a case of a knee dislocation with associated popliteal artery transection treated initially with successful knee-spanning external fixation and arterial grafting, respectively. At 6 weeks after injury, the patient underwent external fixation removal and closed manipulation of the knee for arthrofibrosis. After manipulation, yet still under anesthesia, distal pulses were acutely diminished and subsequent CTA demonstrated femoropopliteal graft thrombosis. This case demonstrates successful recognition, thrombectomy, and restoration of arterial blood flow, which has since been maintained. Written consent by the patient involved in this case report was obtained.

Real-world experience of treating frozen shoulder using active manipulation under local anesthetic: A retrospective study

Currently, there is limited evidence to guide treatment and no standard management guidelines exist for treating frozen shoulder (FS). A general management approach consists of initial evaluation, range of motion (ROM) exercises, intra-articular injection of glucocorticoid, home exercise program (HEP), and/or physical therapies. However, the general approach lacks detail and has limited evidence of its effectiveness. This retrospective cohort study evaluates the short-term recovery of near-full to full-ROM technique followed by an instructed HEP for strengthening and coordinating shoulder girdle muscle group for FS management. This study details our experiences following a general approach to managing FS and aims to fill this knowledge void, providing additional context of the efficacy of FS management in the real-world. Seven-two adult patients with FS (46 females, 26 males; mean age of 66; standard deviation of 15.1; range 23-87) from an orthopedic and physical medicine and sport medicine office between 2014 and 2018 were included in this study. Following general management of FS, patients received a glucocorticoid-lidocaine mixture injection administered to the respective shoulder at the glenohumeral joint space and/or subacromial separately. Immediately, patients underwent active manipulation of the affected shoulder in 3 directions: forward flexion, abduction, and extension in the sagittal plane. Lastly, patients were instructed to perform movements similar to the active manipulation protocol as a HEP. The abduction and forward flexion ROM showed significant improvements with the described protocol. Following treatment, there was a 90.20° and 77.33° increase in average shoulder abduction and forward flexion ROM, respectively (P < .05). The immediate goal of this protocol was to gain maximum ROM in different directions of shoulder mobility. Following the general management of FS, active manipulation under local anesthetic was a highly effective treatment modality for adhesive capsulitis that was time-saving and cost-effective.

Effects of comorbidities on the outcomes of manipulation under anesthesia for primary stiff shoulder

BACKGROUND

Studies on the effects of manipulation under anesthesia (MUA) for primary stiff shoulder when different comorbidities are present are lacking. Our aim was to assess how comorbidities influence the recovery speed and clinical outcomes after MUA.

METHODS

Between April 2013 and September 2018, 281 consecutive primary stiff shoulders in the frozen phase treated with MUA were included in this study. We investigated the comorbidities of patients and divided them into the control (n = 203), diabetes mellitus (DM) (n = 32), hyperlipidemia (n = 26), and thyroid disorder (n = 20) groups. The range of motion (ROM) and clinical scores for each group before MUA and 1 week, 6 weeks, and 3 months after MUA were comparatively analyzed. We identified the ROM recovery time after MUA and the responsiveness to MUA. Then, subjects were subdivided into early and late recovery groups based on their recovery time and into successful and nonsuccessful MUA groups based on their responsiveness to MUA.

RESULTS

Significant improvements in ROM and clinical scores at 3 months after MUA were observed in all groups. Significant differences in ROM among the 4 groups were also observed during follow-up (P < .05). The DM group had significantly lower ROM values, even at 3 months after MUA, compared with the control group. The ROM recovery speed after MUA was slowest in the DM group, followed by the thyroid disorder, hyperlipidemia, and control groups. Most (90.6%) of the DM group experienced late recovery. The proportion of nonsuccessful MUA was higher in the DM and thyroid disorder groups than that in the control and hyperlipidemia groups (P = .004). During follow-up, there were no differences among groups regarding the visual analog scale, University of California at Los Angeles shoulder, and Constant scores.

CONCLUSION

The ROM recovery speed and responsiveness to MUA for primary stiff shoulder were poorer for the DM and thyroid disorder groups than for the control group. In particular, compared with any other disease, outcomes were poorer when the comorbidity was DM. If patients have comorbidities, then they should be informed before MUA that the comorbidity could affect the outcomes of treatment.

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials.

METHODS

A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model.

RESULTS

Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy.

CONCLUSIONS

No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone.

LEVEL OF EVIDENCE

II, systematic review and network meta-analysis of level I and II studies.

What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey

OBJECTIVE

Despite usually being considered necessary, the rehabilitation regime that optimises outcomes for patients following release procedures for frozen shoulder has not been established and no accepted best practice guidelines currently exist. The purpose of this study was to gain insight into what physiotherapists considered best practice and factors they considered likely to affect patient outcome.

METHODS

A cross-sectional, self-administered online questionnaire was developed and distributed to UK based Physiotherapists, undergraduate students and support workers via email, social media and professional networks.

RESULTS

260 eligible and fully completed surveys were received. Clear preference for early (within 72 h), frequent (2-3 times per week or weekly) and prolonged (greater than 6 weeks) treatment delivered in a 1:1 setting was expressed. 99% were highly likely/likely to advocate education and advice, range of movement exercises (99.6%), stretching (73.5%) and strengthening (61.9%). More passive modalities (manual therapy, massage, electrotherapy, acupuncture) were highly unlikely/unlikely to be used and lack of manual therapy and insufficient contact with a physiotherapist were the reasons deemed least likely to affect outcome. Most clinicians (89.2%) were likely to prescribe exercises that patients reported as painful but persistent pain and poor adherence by patients to exercises were the top reasons given for poor outcome along with psychological and psychosocial patient characteristics.

CONCLUSION

Physiotherapists consistently advocate early, frequent, prolonged, 1:1 treatment following release procedures for frozen shoulder. Most patients are discharged whilst still experiencing symptoms, particularly pain. Further work is needed to establish high value pathways for this patient group.

Can manipulation under anesthesia alone provide clinical outcomes similar to arthroscopic circumferential capsular release in primary frozen shoulder (FS)?: the necessity of arthroscopic capsular release in primary FS

Background

We evaluated the need for arthroscopic capsular release (ACR) in refractory primary frozen shoulder (FS) by comparing clinical outcomes of patients treated with ACR and manipulation under anesthesia (MUA).

Methods

We assessed patients with refractory primary FS, 57 patients (group A) who were treated with MUA and 22 patients (group B) who were treated with ACR. In group A, manipulation including a backside arm-curl maneuver was performed under interscalene brachial block. In group B, manipulation was performed only to release the inferior capsule before arthroscopic circumferential capsular release, which was carried out for the unreleased capsule after manipulation. Pain, range of shoulder motion, and American Shoulder and Elbow Surgeons score were recorded at 1 week, 3 months, 6 months, and 1 year after surgery. We compared outcome variables between treatment groups and between diabetics and non-diabetics and also evaluated the numbers of patients receiving additional intra-articular steroid injection.

Results

Outcome variables at 3 months after surgery and improvements in outcome variables did not differ between groups. Group A showed significantly better results than group B in the evaluation of pain and range of motion at 1 week. Diabetics showed comparable outcomes to non-diabetics for most variables. Eleven patients required additional steroid injections between 8 to 16 weeks after surgery: 12.2% in group A, 18.2% in group B. Additional injections were given three times more often in diabetics compared to non-diabetics.

Conclusions

MUA alone can yield similar clinical outcomes to ACR in refractory FS.

Treatment of a rotator cuff tear combined with iatrogenic glenoid fracture and shoulder instability: A rare case report

BACKGROUND

The brisement manipulation is an effective treatment for refractory shoulder stiffness. Rotator cuff tears can sometimes exist in combination with adhesive capsulitis. Arthroscopic capsular release combined with rotator cuff repair has achieved good outcomes in published reports.

CASE SUMMARY

We report the case of a patient with right shoulder pain for more than 1 year that was suspected to have adhesive capsulitis and a rotator cuff tear that was treated with brisement manipulation and arthroscopic management. An iatrogenic glenoid fracture with shoulder instability occurred during the manipulation. Arthroscopic treatment for fracture fixation, capsular release, and rotator cuff repair was performed, and the functional results are reported.

CONCLUSION

Arthroscopic fixation for iatrogenic glenoid fracture and repairing coexisting rotator cuff tear can provide the stability needed for early rehabilitation.

A randomized controlled trial of ultrasound-guided pulsed radiofrequency for patients with frozen shoulder

BACKGROUND

This study assessed the effectiveness and safety of ultrasound-guided pulsed radiofrequency (UGPRF) for patients with frozen shoulder (FS).

METHODS

This study was designed as a randomized, double-blind, sham control trial. A total of 136 patients with FS were recruited and then were equally randomly allocated into a treatment group (n = 68) and a sham group (n = 68). The patients in the treatment group received UGPRF, while the subjects in the sham group underwent sham UGPRF. Patients in both groups were treated for a total of 12 weeks. The primary outcome was the pain intensity, measured by the visual analog scale (VAS). The secondary outcomes consisted of shoulder disorder, measured by the score of shoulder pain and disability index (SPADI); quality of life, assessed by the Short Form-36 questionnaire (SF-36); and any adverse events (AEs) during the treatment period. All outcomes were measured at baseline, at the end of 6-week, and 12-week treatment.

RESULTS

At the end of 6 weeks, and 12 weeks, UGPRF showed more promising outcome results in pain relief, as measured by VAS (P <.01), improvement of shoulder disorder, as assessed by SPADI score (pain, P <.01; disability, P <.01; total, P <.01), and enhancement of quality of life, as measured by the SF-36 scale (PCS, P <.01; MCS, P <.01), compared with sham UGPRF in this study.

CONCLUSION

The findings of this study showed that UGPRF may benefit for patients with FS after 12 weeks treatment.