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