Physiotherapy in the Management of Frozen ShoulderA Randomised Controlled Trial of Physiotherapy Modalities
Julia WaltonSpecialist Shoulder Physiotherapist
Acknowledgments•Sarah Russell•Physiotherapy department at
Wrightington•University of Central Lancashire
A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder.Russell S, Jariwala A, Conlon R, Selfe J, Richards J, Walton M.J Shoulder Elbow Surg. 2014 Apr;23(4):500-7.
Physiotherapy
•Most initial presentations will be in primary care to GP or Physiotherapy
•Treat effectively•Refer appropriately
Physiotherapy•CSP Guidelines
Hanchard N, Goodchild L, Thompson J, O’Brien T, Richardson C, Davison D, Watson H, Wragg M, Mtopo S, Scott M. (2011) Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder v.1.6, ‘standard’ physiotherapy .
Hanchard NC, Goodchild L, Thompson J, O'Brien T, Davison D, Richardson C Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder: quick reference summary. Physiotherapy. 2012 Jun;98(2):117-20.
CSP Guidelines
Current Evidence
•Lots of “Probably”•Limited quality
research
Current Evidence•Recent vogue for more
interventional procedures •Hydrodilitation•MUA / Capsular Release•Significant cost
implications
What we need...
•Better evidence for physiotherapy•Randomnised controlled trials•Good quality methodology
Study Design•Randomised Controlled Trial of
Physiotherapy Modalities•Group Exercise Class•Individual Multimodal Physiotherapy•Home Exercise Programme
Study Design
•All primary care referrals to Wrightington physiotherapy department with a diagnosis of Primary Idiopathic Frozen Shoulder
Inclusion Criteria• Age 40 to 70 years old
• Spontaneous onset of a painful stiff shoulder
• Symptoms present for at least three months
• Patient reported local shoulder pain, frequently present over either the anteromedial aspect of the shoulder extending distally into the biceps region, or over the lateral aspect of the shoulder extending into the lateral deltoid region.
• Marked loss of active and passive global shoulder motion, with at least 50% loss of external rotation
• Normal x-rays on anteroposterior and axillary radiographs of the glenohumeral joint
Exclusion Criteria• Radiographic pathological findings or glenohumeral
osteoarthritis on x-ray
• Local corticosteroid injection or any physiotherapy intervention to the affected shoulder within the last three months
• Prior surgery, dislocation or trauma to the affected shoulder
• Inflammatory joint disease affecting the shoulder
• Active medico legal involvement
Exclusion Criteria• Clinical evidence of significant cervical spine disease
• Cerebral vascular accident affecting the shoulder
• Bilateral frozen shoulder due to possible underlying systemic cause
• Thyroid disease
• Any coronary event, post coronary artery by-pass or catheterisation prior to the clinical appearance of frozen shoulder
Study Design•Ethical approval•Clinical trial registration -
05/Q1401/86•Conformed to CONSORT statement
(Altman et al 2001)•Computer-generated permutated
block randomisation (Statistician!)
Study Design•Baseline evaluation•Constant Shoulder Score•Oxford Shoulder Score•SF-36
•Repeated 6 weeks, 6 months, and 1 year•All assessments made by independent
blind physiotherapist
Group Exercise Class
•Twice per week for 6 weeks•50min exercise circuit - 12x4 min
stations•Senior physio (>10yrs experience shoulder
therapy)
•Home Exercise Sheet and Information Booklet
Individual Physiotherapy•2 Sessions of individual mulitimodal
physiotherapy per week for 6 weeks•Senior Physio (>10yrs experience of shoulder
therapy)
•Maitland mobilisations, soft tissue massage, myofacial trigger point release, heat, stretches
•Home Exercise Sheet and Information Booklet
Home Exercise•Home Exercise Sheet and
Information Booklet•pathology•pain management•posture
Statistical Analysis
•Tested for Normal Distribution•Repeated measures one-way
analysis of variance (RM-ANOVA)•Pairwise comparison using Least
Squares Difference
Power Calculation•80% Power & 5% Significance•Minimal Clinically Important
Difference for Constant Score of 15•No accepted MCID•General local consensus
•117 Patients, 39 per Group
Results•850 patients referred over 12
months•705 (83%) did not meet inclusion
criteria for Primary Idiopathic Frozen Shoulder
•70 declined to participate
Results
•75 Patients•Group Exercise Class - 25•Individual Physiotherapy - 24•Home Exercises - 26
Demographics•Mean Age 51.1 (40-65)•Male:Female 1:1.14•Dominant Arm 53% (73% Right-
Handed)•Mean duration of Symptoms 5.79
months (4-10)
Results•1 pt from EC died•1 patient from IP referred for
injection at 6 months•2 patients from HE referred for
injection at 6 months•Intention to treat principal
Results•No difference between groups at
baseline•Significant improvement in
Constant Score at 6 weeks in all groups (p<0.001)
•Continued improvement in all groups at 1 year
Results - Constant•Baseline 39.8 (18-64)
•Group Exercise Class•6 Weeks 71.4 (60-89)•1 year 88.1 (71-96)
Results - Constant•Baseline 39.8 (18-64)
•Group Exercise Class•6 Weeks 71.4 (60-89)•1 year 88.1 (71-96)
Results - Oxford
ResultsPairwise
ComparisonMean
DifferenceStandard
Error p ValueExercise Class
vs Physiotherapy
10.7 2.871 <0.001
Exercise Class vs Home Exercises
20.304 2.936 <0.001
Physiotherapy vs Home Exercises
9.606 2.970 0.002
Results• Improvement in Constant Score was
significantly greater in Group Exercise Class than individual physiotherapy (p<0.001) or home exercises (p<0.001)
• Individual Multimodal Physiotherapy Significant better then HE (p=0.002)
•Significance demonstrated for all domains of Constant Score and also Oxford Score
Results• Improvement in Constant Score was
significantly greater in Group Exercise Class than individual physiotherapy (p<0.001) or home exercises (p<0.001)
• Individual physiotherapy significantly better then home exercises (p=0.002)
•Significance demonstrated for all domains of Constant Score and Oxford Score
Results•Significant improvement over time•Baseline and 6 weeks (p<0.001)•6 week and 6 months (p<0.001)•6 months and 1 year (p<0.001)
•Both Constant and Oxford Scores
Results•Short Form - 36
•Significant improvements in bodily pain (p=0.011) mental health (p=0.009) and social function (p<0.001)
•No other significant differences between groups or over time
Results•SF-36 does not appear to
accurately reflect shoulder symptoms and change
•We would not recommend SF-36 as a PROM for shoulder pathology (Beaton 1996, Griggs 2000 Carette, 2003, Buckbinder 2004)
Discussion•91% of patients in the group
exercise class had a clinically important improvement in constant score within 6 weeks
•68% with individual physiotherapy•41% with home exercise
programme
Discussion•Group exercise class gives
significant improvement in symptoms of frozen shoulder
•Improvement is greater than with individual physiotherapy
•Both better than a home exercise programme
Discussion
XX
Hopefully removed some “Probablies....”
Discussion•Group Therapy•Psychological Impact •Discuss condition with
similar patients•Reassurance•Competition
•HADS analysis - improvement significantly improved with group and physio intervention over home exercise group
Discussion•Primary care diagnosis of
Frozen Shoulder•ONLY 17% of referrals
had accurate diagnosis•Significant implications
for primary care management / triage services / care in the community
Discussion•Prevalence: 2-3% with
female predisposition•? Based on inaccurate
primary care diagnosis•True prevalence much
lower •Equal gender
distribution (Bunker et al)
Limitations•Principal limitation is not meeting
Power •Based upon “inaccurate” prevalence
and referral data•Unable to collect enough patients in
timescale•Still significant despite smaller
numbers
Limitations•Ethically unable to offer “no treatment” arm
•Home exercises provides a control against physiotherapy intervention
•Home exercises probably close to natural history
Conclusions•Group exercise class - Cost effective
and Time effective treatment option for frozen shoulder
• Individual physiotherapy more effective than a home exercise programme
•Highlights non-responders after 6 week course
•Appropriate referrals to Surgeons
Thank you