Published online Sep 18, 2018. doi: 10.5312/wjo.v9.i9.165
Peer-review started: April 7, 2018
First decision: June 14, 2018
Revised: July 1, 2018
Accepted: August 2, 2018
Article in press: August 3, 2018
Published online: September 18, 2018
Frozen shoulder (FS) is a common cause of shoulder pain and disability. A contracted capsule with a decreased capsular volume leads to a typical loss of passive external rotation seen in FS. Physiotherapy and corticosteroid injections are the most widely used treatment modalities in FS, in both primary and secondary healthcare settings.
Corticosteroid injections demonstrated a positive effect on shoulder pain and range of motion (ROM), at least in the short term. However, the role of physiotherapy in the treatment of FS is more uncertain. For example, supervised neglect, consisting of supportive therapy and exercises within pain limits, has also been advocated as an appropriate treatment for FS.
The objective of this randomized controlled trial was therefore to investigate the additional value of physiotherapy treatment (PT) after an intra-articular corticosteroid injection in the management of early stage idiopathic FSs. It is hypothesized that additional physiotherapy is superior to corticosteroid injection alone with respect to ROM and shoulder function.
A two center prospective randomized controlled trial was undertaken. Patients with painful early-stage idiopathic FS were eligible for inclusion. After written consent, patients were randomly allocated into two groups. All patients received an ultrasound-guided intra-articular corticosteroid injection. One group underwent additional PT and the other group did not (non-PT). The primary outcome measure was the SPADI. Secondary outcomes were pain (NPRS), ROM, quality of life (RAND-36 score), and patient satisfaction. Follow-up was scheduled after 6, 12 and 26 wk.
Twenty-one patients were included, 11 patients in the non-PT and ten in the PT group. Both treatment groups showed a significant improvement at 26 wk for SPADI score. At the 6 wk follow-up, median SPADI score was significantly decreased in the PT group (14 IQR: 6-38) vs the non-PT group (63 IQR: 45-76) (P = 0.01). Significant differences in all three ROM directions were observed after 6 wk in favor of the PT group (P ≤ 0.02 for all directions). At 26 wk, both groups did not differ significantly with respect to any of the outcome parameters. No complications were reported in both groups.
Intra-articular corticosteroid infiltration is effective in the treatment of FS. Additional PT can improve shoulder function and shorten the duration of functional limitations during the recovery of early-stage FS patients up to the first three months. The physiotherapy intensity should be guided on tissue irritability. Future research should focus on the different populations other than idiopathic FSs, like post-operative or post-traumatic FSs. Furthermore, a small subset of patients is not satisfactorily treated with conservative treatment as an injection and physiotherapy. It would be very interesting to investigate if these patients with a prolonged and refractory course of disease could be identified at an early time point.
It would be very interesting to investigate if these patients with a prolonged and refractory course of disease could be identified at an early time point.