The effectiveness of interventions in the management of patients with primary frozen shoulder

Vitamin C as a Potential Prophylactic Measure Against Frozen Shoulder in an In Vivo Shoulder Contracture Animal Model

BACKGROUND

Frozen shoulder is a common, painful, and movement-restricting condition. Although primary frozen shoulder is idiopathic, secondary frozen shoulder can occur after trauma or surgery. Prophylactic and therapeutic options are often unsatisfactory. Vitamin C (ascorbic acid) is a potent physiological antioxidant and likely inhibits the activation of nuclear factor κB, which plays a decisive role in inflammatory reactions.

HYPOTHESIS

Because of its anti-inflammatory effects, vitamin C may be valuable in the prevention of secondary frozen shoulder.

STUDY DESIGN

Controlled laboratory study.

METHODS

An in vivo shoulder contracture model was conducted by fixation of the right proximal limb of Sprague-Dawley rats. A treatment group (n = 8) receiving vitamin C orally was compared with a control group (n = 9) without vitamin C. The primary outcome was capsular thickness at the shoulder joint measured on magnetic resonance imaging (MRI) examination. Further histological examination was performed but was not statistically analyzed because of variability of the cutting plane through the glenoid.

RESULTS

Vitamin C treatment resulted in less thickening of the axillary fold of the operated shoulder at 2 of the 3 locations measured on MRI compared with untreated controls (insertion to the glenoid, P = .074; insertion to the humerus, P = .006; middle of the axillary recess, P = .008). The observed structural changes in histological examination corroborated the significant changes obtained from the MRI measurements.

CONCLUSION

Prophylactic vitamin C seemed to reduce the thickening of the axillary recess in secondary frozen shoulder in this preclinical study.

CLINICAL RELEVANCE

Vitamin C may be helpful as a noninvasive therapeutic measure to prevent secondary frozen shoulder (eg, within the context of surgery in the shoulder region or immobilization) or to treat primary frozen shoulder at an early stage. Further studies are required to evaluate the effect of this treatment in humans and the necessary dosage in humans.

Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: Is There Any Adjunct Effect of Immediate Post-Procedural Manipulation Over Instructed Physical Therapy?

OBJECTIVES

To compare the additive value of immediate post-procedural manipulation versus physiotherapy, following ultrasound (US)-guided hydrodistention of the glenohumeral joint (GHJ) in patients with adhesive capsulitis (AC) and define predictors of outcome.

METHODS

Within a 19-month period, 161 consecutive patients with AC were prospectively enrolled and allocated to two groups according to treatment, based on patients' individual preferences: 1) group-I, US-guided hydrodistension plus immediate post-procedural manipulations and 2) group-II, US-guided hydrodistension plus supervised physiotherapy program. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and a visual analog scale (VAS) were used for clinical assessment at baseline (immediately after treatment), 1, 3, and 6 months. Comparisons were performed with Mann-Whitney U test and Kolmogorov-Smirnov test. Linear regression was used to identify predictors of outcome. P value <.05 defined significance.

RESULTS

GHJ hydrodistension with manipulation or physiotherapy was linked to clinical improvement at all follow-up time-points. DASH scores of group-I remained constantly lower than DASH scores of group-II at all time-points (P < .001). VAS scores were lower in group-I than group-II at 1 and 3 months (P < .001 and P = .0019, respectively). Both groups had improved to a similar degree with respect to pain at 6 months (P = .29). The performance of post-interventional manipulations was predictive of improved shoulder functionality (as assessed with DASH scores) at all time-points, while low-grade disease and milder symptoms at presentation were associated with improved short-term pain.

CONCLUSIONS

Immediate post-procedural manipulations appeared to be superior to physiotherapy following GHJ hydrodistension for AC in terms of shoulder functionality during a 6-month follow-up period. Post-interventional manipulations, the stage of AC and lower DASH and VAS scores at presentations were predictive of improved outcome.

Optimising the use of physiotherapy resources after manipulation under anaesthetic for frozen shoulder

INTRODUCTION

Manipulation under anaesthetic (MUA) is a successful treatment for frozen shoulder (FS), and the recovery period and recurrence rates may be reduced by postoperative physiotherapy. This study evaluates two physiotherapy pathways for patients undergoing MUA for FS.

METHODS

Between 2016 and 2018, 248 age- and sex-matched patients presented to either a NHS secondary care upper limb service or the lead author's independent practice with a diagnosis of FS. The patients had differential access to postprocedure physiotherapy based on which service they presented to. In Group 1, physiotherapy advice only was given to the patient. In Group 2, supervised hydrotherapy and physiotherapy occurred postoperatively. Pre- and postprocedure Oxford Shoulder Scores (OSS) were collected for each group. Analysis of covariance (ANCOVA) was used to measure the effect of physiotherapy on postoperative OSS.

RESULTS

Group 2 showed a significantly greater improvement in postprocedure OSS when compared with Group 1 (18.2 vs 16.7) p<0.001). The estimated maximum effect of physiotherapy on postoperative OSS was an increase of 3.2.

CONCLUSION

Following MUA for FS, a statistically significant increase in OSS was detected in patients receiving postprocedure physiotherapy compared with advice alone. There was no difference in recurrence rates. The increase in OSS (3.2) is below the minimal clinically important difference, raising questions regarding the relative importance of postprocedure physiotherapy in a resource-limited environment.

Platelet-rich plasma as a potential prophylactic measure against frozen shoulder in an in vivo shoulder contracture model

INTRODUCTION

Frozen shoulder (adhesive capsulitis) is a common painful and functionally-limiting disease affecting around 2% of the population. So far, therapeutic options are limited and often unsatisfactory. Platelet-rich plasma (PRP) has been used as a treatment option in other orthopedic diseases since it contains growth factors that stimulate tissue repair. So far, the effect of PRP on frozen shoulder lacks evidence. We hypothesized that PRP may be valuable in the prophylaxis and treatment of secondary frozen shoulder due to capsular remodeling.

MATERIALS AND METHODS

An experimental study of an in vivo frozen shoulder model was conducted. Twenty Sprague-Dawley rats underwent surgery in which the body of the scapula was connected to the humerus with a high-strength suture. Two groups of 8 weeks survival time were allocated; a treatment group with one intraoperative injection of PRP into the glenohumeral joint (n = 10) and a control group without PRP (n = 10). The primary outcome was the structural change in the posterior synovial membrane of the posterior and inferior part of the glenohumeral joint using a semi-quantitative grading from 0 (lowest) to 3 (highest).

RESULTS

The posterior synovial membrane structural changes were significantly lower in the PRP group (median = 1 [interquartile range (IQR) = 0-1]) compared to controls (median = 2 [IQR = 1-3]) (p = 0.028). There were no differences for the remaining synovial membrane changes and fibrous capsule responses between groups.

CONCLUSIONS

In this in vivo shoulder contracture model, PRP injections seem to reduce the histological severity grade of some parts (i.e., posterior synovial membrane changes) of the secondary frozen shoulder without causing any side effects. It may be considered to investigate this effect further in future studies as a potential prophylaxis of secondary frozen shoulder (e.g., in operated or immobilized shoulders) or as a treatment option for patients with frozen shoulder in the early stage.

Hydrodilatation with corticosteroids is the most effective conservative management for frozen shoulder

PURPOSE

The purpose of this overview is to summarise the findings of meta-analyses of randomised controlled trials that compare conservative treatment options for frozen shoulder.

METHODS

The authors conducted an electronic literature search for meta-analyses published using PubMed, Web of Science and the Cochrane Library. Two researchers independently applied selection criteria and assessed quality of meta-analyses using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). Short-, medium- and long-term outcomes were synthesised narratively.

RESULTS

A total of 319 studies were identified, of which 8 meta-analyses were eligible for inclusion. All included meta-analyses were judged to be low or critically low quality according to AMSTAR-2, however, their data synthesis and interpretation was considered valid. Physiotherapy, intra-articular and subacromial corticosteroid injection (CSI), and arthrographic distension/hydrodilatation with corticosteroid were reported with sufficient evidence. Intra-articular CSI and arthrographic distension/hydrodilatation with corticosteroid provide advantages over placebo in short-term pain relief, range of motion (ROM) and shoulder function, with improvements in ROM continuing into the medium and long term. Arthrographic distension/hydrodilatation with corticosteroid provides medium-term and long-term improvements in ROM over intra-articular CSI and physiotherapy. Proprioceptive neuromuscular facilitation provides advantages over conventional physiotherapy for pain improvement and external rotation in the short term.

CONCLUSIONS

Arthrographic distension/hydrodilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to CSI or physiotherapy.

LEVEL OF EVIDENCE

Level IV.

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

BACKGROUND

Frozen shoulder is a common shoulder disorder characterized by pain and restriction. Various nonsurgical treatments have been reported, but there is no consensus about their comparative efficacy and the effects of moderators.

PURPOSE

To compare the efficacy of different nonsurgical interventions and identify potential patient-specific moderating factors for frozen shoulder.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception to February 18, 2019. The search was supplemented by manual review of relevant reference lists. Randomized controlled trials of participants with frozen shoulder that compared nonsurgical interventions were selected. Measured outcomes included pain, shoulder function in daily activities, and range of motion.

RESULTS

Of 3136 records identified, 92 trials were eligible, evaluating 32 nonsurgical interventions in 5946 patients. Intra-articular injection improved pain (pooled standardized mean difference [95% CI]: steroid injection, 1.68 [1.03-2.34]; capsular distension, 2.68 [1.32-4.05]) and shoulder function (steroid injection, 2.16 [1.52-2.81]; distension, 2.89 [1.71-4.06]) to a greater extent than placebo. Capsular distension and extracorporeal shockwave therapy showed the highest ranking for pain relief and functional improvement, respectively. Laser therapy also showed benefits for pain relief (3.02 [1.84-4.20]) and functional improvement (3.66 [1.65-5.67]). Subgroup analyses by disease stages revealed that steroid injection combined with physical therapy provided more benefits during the freezing phase, whereas joint manipulation provided more benefits in the adhesive phase. Adjunctive therapies, female sex, and diabetes were also identified as moderators of effectiveness.

CONCLUSION

Capsular distension is a highly recommended choice for treatment of frozen shoulder, contributing greatly to pain relief and functional improvement; steroid injection is also a prevailing effective intervention. Among new options, extracorporeal shockwave therapy and laser therapy show potential benefits for multiple outcomes. Individualized optimal intervention should be considered, given that treatment effect is moderated by factors including the disease stage, time of assessment, adjunctive therapies, female sex, and diabetes.

Wearable Motion Sensor Device to Facilitate Rehabilitation in Patients With Shoulder Adhesive Capsulitis: Pilot Study to Assess Feasibility

BACKGROUND

Adhesive capsulitis (AC) of the shoulder is a common disorder that painfully reduces the shoulder range of motion (ROM) among middle-aged individuals. Although physical therapy with home-based exercises is widely advised to restore ROM in the treatment of AC, clinical results vary owing to inconsistent patient compliance.

OBJECTIVE

In this study, we aimed to verify the feasibility of a treatment model that involves applying a wearable motion sensor device to assist patients conduct home-based exercises to improve training compliance and the accuracy of exercises, with the ultimate goal of improving the functional recovery of patients with AC.

METHODS

The motion sensor device was comprised of inertial measurement unit-based sensors and mobile apps for patients and physicians, offering shoulder mobility tracing, home-based exercise support, and progress monitoring. The interrater reliability of shoulder mobility measurement using the motion sensor device on 10 healthy participants and 15 patients with AC was obtained using an intraclass correlation coefficient analysis and compared with the assessments performed by two highly experienced physicians. A pilot prospective control trial was then carried out to allocate the 15 patients with AC to two groups: home-based exercise group and motion sensor-assisted rehabilitation group. Changes in active and passive shoulder ROM, pain and functional scores, and exercise completion rates were compared between the groups during a treatment period of 3 months.

RESULTS

Shoulder ROM, as measured using the motion sensor device, exhibited good to excellent reliability based on the comparison with the measurements of two physicians (intraclass correlation coefficient range, 0.771 to 0.979). Compared with patients with AC in the home-based exercise group, those in the motion sensor-assisted rehabilitation group exhibited better shoulder mobility and functional recovery and a higher exercise completion rate during and after 3 months of rehabilitation.

CONCLUSIONS

Motion sensor device-assisted home-based rehabilitation for the treatment of AC is a useful treatment model for telerehabilitation that enhances the compliance of patients through training, thus improving functional recovery. This helps overcome important obstacles in physiotherapy at home by providing comprehensible and easily accessible exercise instructions, enhancing compliance, ensuring the correctness of exercise, and monitoring the progress of patients.

The effectiveness of hydrodistension and physiotherapy following previously failed conservative management of frozen shoulder in a UK primary care centre

BACKGROUND

There is a lack of evidence on the clinical effectiveness of hydrodistension for frozen shoulder following failed conservative management.

METHODS

A total of 90 patients opted for hydrodistension following failed initial treatment which included physiotherapy and at least one corticosteroid injection. Shoulder pain and function were assessed at baseline, and 6, 12 and 24 weeks using the Shoulder Pain Disability Index (SPADI), The Upper Extremity Functional Index (UEFI) and a visual analogue scale (VAS) for pain. Active ranges of motion were assessed at baseline, post-24 hr and discharge.

RESULTS

We observed clinically important improvements in pain (VAS -5.5; 90% confidence interval [CI] -6.0 to -5.0; SPADI pain, -20; 90% CI-23 to -17) and function (UEFI 23; 90% CI 19 to 26; SPADI disability, -32; 90% CI -36 to -28) at 6 weeks. These improvements remained clearly substantial at 24 weeks. Active range of motion improved substantially post-24 hr (flexion 20, 90% CI 18 to 23; lateral rotation 14, 90% CI 12 to 16; abduction 22, 90% CI 19 to 25) and at discharge (flexion 37, 90% CI 33 to 41; lateral rotation 24, 90% CI 21 to 27; abduction 44, 90% CI 38 to 50).

DISCUSSION

This single-arm observational study suggests that hydrodistension is an effective treatment of frozen shoulder within a UK primary care setting when standard treatment has failed.

Criteria used for diagnosis of adhesive capsulitis of the shoulder: a scoping review protocol

REVIEW OBJECTIVE

The objective of this scoping review is to locate and summarize the current criteria used in the diagnosis of adhesive capsulitis of the shoulder in recent academic literature. Furthermore, we aim to explore differences, if any, in the criteria used across treating professions, study country of origin and study level of evidence.

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

BACKGROUND

There is no consensus about the optimal treatment strategy for frozen shoulders (FS). Conservative treatment consisting of intra-articular corticosteroid infiltrations and physiotherapy are considered appropriate for most patients. However, with a conservative strategy, patients experience a prolonged rehabilitation period with a considerable amount of pain and disabilities in daily life. Also, at long term, a residual amount of pain and restriction of range of motion is frequently reported. Manipulation under anesthesia is a short and relative simple procedure with the potential to rapidly reduce symptoms and restore the range of motion. The objective of this trial is to evaluate the effectiveness of MUA followed by a PT program compared to a PT program alone, in the treatment of patients with a stage two FS. We hypothesize that the course of the disease can be shortened with MUA with a quicker functional recovery.

METHODS

This is a prospective, single center, randomized controlled trial. Eligible patients will be allocated to either the manipulation (MUA) group or the physiotherapy alone (PT) group. In the MUA group manipulation will be performed under interscalene block, directly followed by an intensive physiotherapy treatment protocol, with the goal to maintain the obtained range of motion. Patients allocated to the PT group are given advice and education and receive a written protocol to hand out to their physical therapist based on the recent guideline of the Dutch Shoulder Network for the treatment of frozen shoulders. Descriptive statistics will be used to describe the sample size, patients demographics, presence of diabetes mellitus, range of motion, duration of symptoms till randomization and will be presented for each treatment group. The SPADI is used as primary functional outcome parameter. Secondary outcome parameters are; OSS, NPRS, EQ-5D 3-L, passive range of motion, WORQ-UP, duration of symptoms, usage of analgesics and adverse events. A sample size of 41 subjects in each group was calculated. Follow up is planned after 1,3 and 12 months. The length of physiotherapy treatment in both groups is variable, depending on individual progression. Differences between groups in outcome parameters will be analysed using the linear mixed modelling and the restricted maximum likelihood ratio technique for estimating the model parameters.

DISCUSSION

Successful completion of this trial will provide evidence on the best treatment strategy for patients with a stage two frozen shoulder. The results of this study can lead to a better understanding for the role of manipulation in the treatment of frozen shoulders.

TRIAL REGISTRATION

This trial is registered in the Dutch Trial Register under the number NTR6182 on the 20th of February 2017.

The effectiveness of ultrasound guided hydrodistension and physiotherapy in the treatment of frozen shoulder/adhesive capsulitis in primary care: a single centre service evaluation

BACKGROUND

Evidence for optimal non-operative treatment of frozen shoulder is lacking. The present study aimed to evaluate a treatment strategy for stage II to III frozen shoulder provided by the current primary care musculoskeletal service.

METHODS

General practioner referrals of shoulder pain to the musculoskeletal service diagnosed with stage II to III frozen shoulder and who opted for a treatment strategy of hydrodistension and guided physiotherapy exercise programme over a 12-month period were evaluated for 6 months. Thirty-three patients were diagnosed with stage II to III frozen shoulder by specialist physiotherapists and opted for the treatment strategy. Outcome measures included Shoulder Pain Disability Index (SPADI) and Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH), pain score and range of movement. Data were collected at baseline, as well as at 6 weeks, 12 weeks and 6 months.

RESULTS

All patients significantly improved in shoulder symptoms on the SPADI and QuickDASH scores (p < 0.001). Pain scores and range of shoulder movement flexion, abduction, external rotation showed significant improvement at all time points (p < 0.001).

CONCLUSIONS

This service evaluation demonstrates that management of frozen shoulder stage II to III, as conducted by physiotherapists in a primary care setting utilizing hydrodistension and a guided exercise programme, represents an effective non-operative treatment strategy.

Mobile Phone-Supported Physiotherapy for Frozen Shoulder: Feasibility Assessment Based on a Usability Study

BACKGROUND

Patients with frozen shoulder show limited shoulder mobility often accompanied by pain. Common treatment methods include physiotherapy, pain medication, administration of corticosteroids, and surgical capsulotomy. Frozen shoulder often lasts from months to years and mostly affects persons in the age group of 40 to 70 years. It severely reduces the quality of life and the ability to work.

OBJECTIVE

The objective of this study was to evaluate the feasibility of a mobile health (mHealth) intervention that supports patients affected by "stage two" frozen shoulder. Patients were supported with app-based exercise instructions and tools to monitor their training compliance and progress. These training compliance and progress data supplement the patients' oral reports to the physiotherapists and physicians and can assist them in therapy adjustment.

METHODS

In order to assess the feasibility of the mHealth intervention, a pilot study of a newly developed app for frozen shoulder patients was conducted with 5 patients for 3 weeks. The main function of the app was the instruction for exercising at home. Standardized questionnaires on usability such as System Usability Scale (SUS) and USE (Usefulness, Satisfaction, and Ease of use), and Technology Acceptance Model-2 (TAM-2) were completed by the study participants at the end of the study. Additionally, a nonstandardized questionnaire was completed by all patients. The correctness of the exercises as conducted by the patients was assessed by a physiotherapist at the end of the study. The mobility of the shoulder and pain in shoulder movement was assessed by a physiotherapist at the start and the end of the study.

RESULTS

The pilot study was successfully conducted, and the app was evaluated by the patients after 3 weeks. The results of the standardized questionnaires showed high acceptance (TAM-2) and high usability (SUS) of the developed app. The overall usability of the system as assessed by the SUS questionnaire was very good (an average score of 88 out of 100). The average score of the TAM-2 questionnaire on the intention to further use the app was 4.2 out of 5, which indicated that most patients would use the app if further available. The results of the USE questionnaires highlighted that the patients learned how to use the app easily (an average score of 4.2 out of 5) and were satisfied with the app (an average score of 4.7 out of 5). The frequency of app usage and training was very high based on patient reports and verified by analysis of the usage data. The patients conducted the exercises almost flawlessly.

CONCLUSIONS

Our results indicate the feasibility of the mHealth intervention, as the app was easy to use and frequently used by the patients. The app supported the patients' physiotherapy by providing clear exercising instructions.

The Urgent Need for Evidence in Arthroscopic Meniscal Surgery

BACKGROUND

Arthroscopic surgery of the knee is one of the most frequently performed orthopaedic procedures. One-third of these procedures are performed for meniscal injuries. It is essential that this commonly performed surgery be supported by robust evidence.

PURPOSE

To compare the effectiveness of arthroscopic surgery for meniscal injuries in all populations.

STUDY DESIGN

Systematic review.

METHODS

An online search was conducted for randomized controlled trials (RCTs) and systematic reviews (SRs) that compared treatment options for meniscal injury. The following databases (inception to April 2015) were included in the search: CENTRAL; MEDLINE; EMBASE; NHS Evidence; National Guideline Clearing House, Database of Abstracts of Reviews of Effects, Health Technology Assessment; ISRCTN; Clinicaltrials.gov ; WHO trials platform. Only studies whose participants were selected on the basis of meniscal injury were included; no restrictions were placed on patient demographics. Two independent reviewers applied AMSTAR (A Measurement Tool to Assess Systematic Reviews) criteria for SRs and the Cochrane Collaboration risk-of-bias tool for RCTs.

RESULTS

Nine RCTs and 8 SRs were included in the review. No difference was found between arthroscopic meniscal debridement compared with nonoperative management as a first-line treatment strategy for patients with knee pain and a degenerative meniscal tear (mean difference: Knee injury and Osteoarthritis Outcome Score, 1.6 [95% CI, -2.2 to 5.2], pain visual analog scale, -0.06 [95% CI, -0.28 to 0.15]). Some evidence was found to indicate that patients with resistant mechanical symptoms who initially fail nonoperative management may benefit from meniscal debridement No studies compared meniscal repair with meniscectomy or nonoperative management. Initial evidence suggested that meniscal transplant might be favorable in certain patient groups.

CONCLUSION

Further evidence is required to determine which patient groups have good outcomes from each intervention. Given the current widespread use of arthroscopic meniscal surgeries, more research is urgently needed to support evidence-based practice in meniscal surgery in order to reduce the numbers of ineffective interventions and support potentially beneficial surgery.

Adhesive Capsulitis of the Shoulder. Is there Consensus Regarding the Treatment? A Comprehensive Review

Background:

Adhesive capsulitis of the shoulder (ACS) is a common self-limiting condition characterized by disabling pain and restricted movements. Its pathophysiology is poorly understood, clinically it is characterized by stages of pain and stiffness, and finally often patients never recover fully. However, there is no consensus about available methods of treatment for ACS. The aims of this paper are to discuss and develop issues regarding approaches to management in ACS in the stages of it.

Methods:

A review of the literature was performed and guidelines for the treatment of that clinical entity for doctors and health care professionals are provided.

Results:

Anti-inflammatory medications, steroid and/or hyaluronate injections and physiotherapy is the mainstay of conservative management either alone in the first stages or in combination with other treatment modalities in the later stages. Next line of treatment, involving minor to moderate intervention, includes suprascapular nerve block, distension arthrography and manipulation under anaesthesia. In order to avoid complications of “blind intervention”, arthroscopic capsular release is gradually more commonly applied, and in recalcitrant severe cases open release is a useful option.

Conclusion:

Various modalities of conservative management and gradually more surgical release are applied. However, often clinicians choose on personal experience and training rather than on published evidence.

Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder

BACKGROUND

Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice.

MATERIALS AND METHODS

A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis.

RESULTS

Fifty-six patients with a mean age of 52.5 ± 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 ± 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% ± 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 ± 9.6; Shoulder Pain and Disability Index score, 7.4 ± 11.4; and Single Assessment Numeric Evaluation score, 92.7% ± 10.1%. The Shoulder Activity Score was 8.3 ± 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient.

CONCLUSIONS

This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Multi-modal imaging of adhesive capsulitis of the shoulder

Adhesive capsulitis of the shoulder is a clinical condition characterized by progressive limitation of active and passive mobility of the glenohumeral joint, generally associated with high levels of pain. Although the diagnosis of adhesive capsulitis is based mainly on clinical examination, different imaging modalities including arthrography, ultrasound, magnetic resonance, and magnetic resonance arthrography may help to confirm the diagnosis, detecting a number of findings such as capsular and coracohumeral ligament thickening, poor capsular distension, extracapsular contrast leakage, and synovial hypertrophy and scar tissue formation at the rotator interval. Ultrasound can also be used to guide intra- and periarticular procedures for treating patients with adhesive capsulitis.

KEY POINTS

• Diagnosis of adhesive capsulitis is mainly based on clinical findings. • Imaging may be used to exclude articular or rotator cuff pathology. • Thickening of coracohumeral and inferior glenohumeral ligaments are common findings. • Rotator interval fat pad obliteration has 100 % specificity for adhesive capsulitis. • Ultrasound can be used to guide intra- and periarticular treatments.

Limitations of A Measurement Tool to Assess Systematic Reviews (AMSTAR) and suggestions for improvement

A Measurement Tool to Assess Systematic Reviews (AMSTAR) is a commonly used tool to assess the quality of systematic reviews; however, modifications are needed to improve its usability, reliability, and validity. In this commentary, we summarize our experience and the experiences of others who have used AMSTAR and provide suggestions for its improvement. We propose that AMSTAR should modify a number of individual items and their instructions and responses to make them more congruent with an assessment of the methodologic quality of systematic reviews. We recommend adding new items and modifying existing items to assess the quality of the body of evidence and to address subgroup and sensitivity analyses. More detailed instructions are needed for scoring individual items across multiple reviewers, and we recommend that a total score should not be calculated. These suggestions need to be empirically tested prior to implementation.

Arthroscopic capsular release and manipulation under anaesthesia for frozen shoulders: A hot topic

A frozen shoulder is a common cause of shoulder pain and stiffness. The etiology and pathology of frozen shoulders is not fully understood yet. Frozen shoulder is characterized by a decrease in intra-articular volume and capsular compliance. This can lead to significant limitations in daily life. The majority of the patients can be treated conservatively, with functional recovery to be expected in two to three years. However, if conservative treatment fails, manipulation under anaesthesia and arthroscopic capsular release can both be considered as appropriate treatments. Manipulation is a traditionally well-established technique but in recent years it seems that arthroscopic capsular release has gained popularity. Manipulation is a relative time efficient and technically low-demanding procedure in which the glenohumeral joint is forced into different directions under general anaesthesia to release the capsular contracture, thereby increasing the range of motion of the joint. In arthroscopic capsular release the glenohumeral capsule can be released in a more controlled manner under direct vision. There are no prospective comparative trials available to display superiority of one procedure over the other. In addition, the optimal timing of both these interventions still has to be determined. An overview of the literature concerning this topic and a description of both procedures with its own advantages and disadvantages is provided.

Nonoperative treatment of frozen shoulder: oral glucocorticoids

PURPOSE

The aim of this study was to report our results of glucocorticoid therapy combined with pregabalin and a home exercise program in patients with frozen shoulder.

METHODS

Thirty-three patients (seven males, 26 females; mean age 52, range 43-71) diagnosed with primary idiopathic frozen shoulder were included in the study. Secondary causes and systemic diseases related to frozen shoulder were excluded. Administration of 0.5 mg/kg/day methylprednisolone was halved each week and ceased at the end of first month. Pregabalin, paracetamol and proton pump inhibitor was also included in the treatment. Physical therapy as a home program was initiated as the pain subsided. Patients were evaluated using the Constant, DASH and ASES scores in the sixth week and first year. Pain was evaluated with VAS and range of motion at each visit.

RESULTS

Patients were followed up for an average period of 21 months (range 12-37). No adverse effect related to glucocorticoid therapy was observed during the treatment. The DASH, ASES and Constant scores improved significantly in the sixth week and first year (p > 0.05). Average range of motion and pain improved significantly every week until full recovery (p > 0.05).

CONCLUSION

Glucocorticoid therapy combined with pregabalin and a home exercise program is an effective treatment in the first stage of frozen shoulder.

A qualitative study of patients' perceptions and priorities when living with primary frozen shoulder

OBJECTIVES

To elucidate the experiences and perceptions of people living with primary frozen shoulder and their priorities for treatment.

DESIGN

Qualitative study design using semistructured interviews.

SETTING

General practitioner (GP) and musculoskeletal clinics in primary and secondary care in one National Health Service Trust in England.

PARTICIPANTS

12 patients diagnosed with primary frozen shoulder were purposively recruited from a GP's surgery, community clinics and hospital clinics. Recruitment targeted the phases of frozen shoulder: pain predominant (n=5), stiffness predominant (n=4) and residual stiffness predominant following hospital treatment (n=2). One participant dropped out.

INCLUSION CRITERIA

adult, male and female patients of any age, attending the clinics, who had been diagnosed with primary frozen shoulder.

RESULTS

The most important experiential themes identified by participants were: pain which was severe as well as inexplicable; inconvenience/disability arising from increasing restriction of movement (due to pain initially, gradually giving way to stiffness); confusion/anxiety associated with delay in diagnosis and uncertainty about the implications for the future; and treatment-related aspects. Participants not directly referred to a specialist (whether physiotherapist, physician or surgeon) wanted a faster, better-defined care pathway. Specialist consultation brought more definitive diagnosis, relief from anxiety and usually self-rated improvement. The main treatment priority was improved function, though there was recognition that this might be facilitated by relief of pain or stiffness. There was a general lack of information from clinicians about the condition with over-reliance on verbal communication and very little written information.

CONCLUSIONS

Awareness of frozen shoulder should be increased among non-specialists and the best available information made accessible for patients. Our results also highlight the importance of patient participation in frozen shoulder research.

Management of limited joint mobility in diabetic patients

Several rheumatologic manifestations are more pronounced in subjects with diabetes, ie, frozen shoulder, rotator cuff tears, Dupuytren's contracture, trigger finger, cheiroarthropathy in the upper limb, and Achilles tendinopathy and plantar fasciitis in the lower limb. These conditions can limit the range of motion of the affected joint, thereby impairing function and ability to perform activities of daily living. This review provides a short description of diabetes-related joint diseases, the specific pathogenetic mechanisms involved, and the role of inflammation, overuse, and genetics, each of which activates a complex sequence of biochemical alterations. Diabetes is a causative factor in tendon diseases and amplifies the damage induced by other agents as well. According to an accepted hypothesis, damaged joint tissue in diabetes is caused by an excess of advanced glycation end products, which forms covalent cross-links within collagen fibers and alters their structure and function. Moreover, they interact with a variety of cell surface receptors, activating a number of effects, including pro-oxidant and proinflammatory events. Adiposity and advanced age, commonly associated with type 2 diabetes mellitus, are further pathogenetic factors. Prevention and strict control of this metabolic disorder is essential, because it has been demonstrated that limited joint motion is related to duration of the disease and hyperglycemia. Several treatments are used in clinical practice, but their mechanisms of action are not completely understood, and their efficacy is also debated.

Frozen shoulder

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.