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指導老師 : 李惠敏 老師報告學生 : 劉家宏103.09.04

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Background

There is little evidence for the optimal form of non-operative treatment in the management of frozen shoulder.

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Background

The Chartered Society of Physiotherapy has completed a project on the management of frozen shoulder conclusions drawn from these evidence-based clinical guidelines

Detail to remove ambiguity, consider multicenter trials, and focus on specific stages of frozen shoulder

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Frozen shoulder

Uncertain etiology characterized by the spontaneous onset of pain with significant restriction of both active and passive range of movement of the shoulder.

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Frozen shoulder

A primary of ‘‘true’’ frozen shoulder occurs when there is no exogenous cause , preexisting condition, no systemic diagnosis or radiographic explanation can be found

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Frozen shoulder

Arthroscopic and histologic studies have shown that the condition is one of glenohumeral capsular contraction, particularly of the coracohumeral ligament within the rotator interval.

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Frozen shoulder

Phases of Frozen shoulder Freezing Frozen Thawing

The importance of recognizing that the disease process is a continuum rather than having well-defined stages.

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Methods

The study used a randomized controlled trial of 3 common physiotherapy interventions.

Eligible patients were all new referrals to the physiotherapy department with a diagnosis of frozen shoulder.

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Methods

Inclusion criteria: 40-70 years Insidious onset pain Stiffness with loss of ROM, ER >50% With out underlying radiologic abnormality Symptoms over 3 months

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Methods

Exclusion criteria Inappropriate of idiopathic frozen shoulder Pathologic findings on radiographic evaluation Trauma Local corticosteroid injection Inflammatory Bilateral frozen shoulder Surgery Fractures Dislocation

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Methods

Range of motion was measured in a standardized manner with a universal goniometer

Most patients were unable to reach 90 of abduction; therefore, external rotation was measured at the maximum pain-free angle of abduction.

A single independent physiotherapist, made all assessments.

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Outcome measures

The primary outcome measure was the Constant-Murley score Activities of daily living Range of motion Pain Strength

The score combines subjective and objective measures to produce a 100-point score

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Outcome measures

The secondary outcome measures were the Oxford Shoulder Score, the Short Form 36 (SF-36) questionnaire, and the Hospital Anxiety and Disability Scale (HADS)

Oxford Shoulder Score: subjective questionnaire that contains 12 questions Pain Function

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Outcome measures

Short Form 36: self-administered Physical functioning (10 items) Role limitations due to physical health problems (4 items), Bodily pain(2 items) Social functioning (2 items) Mental health (5 items) Role limitations due to emotional problems (3 items), General health perceptions (5 items)

Hospital Anxiety and Disability Scale 7 depressive items and 7 anxiety-related items

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Intervention groups

Randomly allocated to 1 of the 3 treatment groupsGroup 1: exercise class plus home exercisesGroup 2: individual multimodal

physiotherapy plus home exercisesGroup 3: home exercises alone

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Intervention groups

Group 1: exercise class plus home exercises (4min/station,12stations/time, 2times/week) Home exercise program

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DATE:

1Pulleys

 Forwards 2’

Backwards 2’

2Flexion / Horizontal Add

 

Over Head 2”

Across Body 2”

3Ball Rolling

(time)Forwards 2’Sideways 2’

4Medial Rot/Extension

Towel + RopeStick behind back

 5 Lateral Rotation

Lying with stick

1 30o

2 60o

3 90o

6Abduction

Stretch 

4 Stick

2 Doorway

7ScapulaSetting

 

1 0o

2 60o

8 Trunk rotation1 Chair2 Ball

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 Trunk side flx rot 

 Ball Rolling side to side

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 Proprioception/Bal 

 Circular ball rolling

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Intervention groups

Group 2:individual multimodal physiotherapy plus home exercises (2 times/weak)

The treatment program was based on local practice and expert opinion: Maitland mobilizations Soft tissue massage Myofascial trigger point release Heat Stretches

Home exercise program

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Intervention groups

Group 3: home exercises alone The information booklet included the home

exercises; a description of frozen shoulder; and advice on sleep, posture, and pain relief.

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Statistical analyses

Repeated-measures one-way analysis of variance (ANOVA) on the outcome data was conducted

A power calculation was performed estimating the MCID of 15 points for the Constant score to achieve 80% power and 5% significance.

Statistical analysis was performed by the SPSS 18.0

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Results

850 p’t

75 p’t

Exercise class

(n=25)

Individual multimodal

physiotherapy (n=24)

Home exercise (n=26)

70 p’t declined to participate

705 p’t

didn’t fit inclusion criteria

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Results

Mean Range

Age 51.1 years 40-65 years

Female to male ratio 1:1.14

Duration of symptom 5.78 months 4-10 months

Constant score 39.8 16-64

Oxford score 34.4 20-48

Forward elevation 95∘ 85 -120∘ ∘

External rotation 16∘ 10 -25∘ ∘

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Results

In both Constant and Oxford scores for all groups between the different time intervals (P < .001).

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Results

Exercise class greater than with individual physiotherapy or home exercises alone (P <.001)

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Results

Both physiotherapy groups over home exercises (P <.001)

baseline 6 weeks 6 months 1 years

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Individual Home exercise

Exercise class

P < .001 P < .001

Individual P =.002

P<.001 P<.001

P<.001

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Individual Home exercise

Exercise class

P = .037 P < .001

Individual P < .001

P<.001

P<.001

P<.001

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Results

HADS scores : compared with any of the post-treatment time periods (P < .001)

Exercise class and individual multimodal without significant difference

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Results

HADS anxiety score over the home exercise group Exercise class: P < .001 Individual multimodal physiotherapy : P =.024

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Results

SF-36 ( self-administered) Bodily pain (P = .011) Mental health (P = .009) Social function (P < .001)

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Results

850 p’t

75 p’t

Exercise class(n=2

5)1 p’t died (n=24)

Individual multimodal physiotherapy (n=24)

1p’t local injection (n=23)

Home exercise (n=26)

2 p’t with withdrew at 6 months(n=24)

70 p’t declined to participate705 p’t

didn’t fit inclusion criteria

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Discussion

The findings of this study support and provide substantial evidence for use of physiotherapy

An effective treatment intervention should result in a significant change in results during the first 6 weeks.

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Discussion

With an MCID for the Constant score of 15 as a reference, at first 6 weeks

Constant score 15 Exercise class :91% Individual multimodal physiotherapy: 68% Home exercise: 41%

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Discussion

Exercise class group: 72 After arthroscopic capsular release: 75.5 This could standardize treatment outcomes and

have an impact on the need for surgical or more invasive interventions.

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Discussion

This is the first study to our knowledge demonstrating that physiotherapy interventions may be particularly beneficial in improving this anxiety aspect of shoulder pain.

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Discussion

Only 17% of initial referrals (145 of 850) met the inclusion criteria for primary idiopathic frozen shoulder

A large number of patients with rotator cuff or ‘‘impingement’’ symptoms without stiffness

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Discussion

A further limitation of the study is the absence of a natural history control group

Home exercises group without direct physiotherapy management and may well represent a close approximation to the natural history.

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Discussion

Both the Constant score and Oxford score have been validated for the assessment of shoulder conditions.

The SF-36 is lack of sensitivity in the assessment of shoulder disease

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Discussion

An exercise class, aimed at a rapid recovery rate with a minimum number of interventions, in relieving the signs and symptoms of frozen shoulder

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Conclusions

A group exercise class provides superior outcomes in relieving the signs and symptoms of frozen shoulder.

However, standard multimodal physiotherapy remains a good alternative and has been demonstrated to be significantly better than unsupervised exercise at home.

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The end

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