Treatment of frozen Treatment of frozen shoulder shoulder –– evidence basedevidence based

Postgraduate Teaching Programme Postgraduate Teaching Programme 20102010

Thomas Barwick, SpR T&OThomas Barwick, SpR T&O

Areas to look at……Areas to look at……

�� Pain relieving modalitiesPain relieving modalities�� NSAIDSNSAIDS

�� IntraIntra--articular steroidsarticular steroids

�� Supraclavicular nerve blocksSupraclavicular nerve blocks�� Supraclavicular nerve blocksSupraclavicular nerve blocks

�� Restoring range of motion/ functionRestoring range of motion/ function�� PhysioPhysio

��MUAMUA

�� SurgerySurgery

NSAIDSNSAIDS

�� Must have regular analgesia Must have regular analgesia

�� Theoretical early role only; for synovitic painTheoretical early role only; for synovitic pain

�� N.b.MultiN.b.Multi--factorial causes of pain; abnormal factorial causes of pain; abnormal movement etcmovement etc

�� No studies regarding NSAIDS in literatureNo studies regarding NSAIDS in literature

�� Try if not contraTry if not contra--indicated with regular indicated with regular analgesicsanalgesics

IntraIntra--articular steroidsarticular steroids

�� Van der Windt 1998Van der Windt 1998�� RCT RCT �� n=109, follow up 1 yearn=109, follow up 1 year�� Steroid significantly better vs physio at 6 weeks for Steroid significantly better vs physio at 6 weeks for pain relief and disability (no ROM assessed)pain relief and disability (no ROM assessed)

�� Carette 2003Carette 2003�� RCT with PlaceboRCT with Placebo�� n=93n=93�� Compared injection, physio and combination Compared injection, physio and combination �� Combo is best: physio alone no benefitCombo is best: physio alone no benefit

IntraIntra--articular steroidsarticular steroids

�� Shah and Lewis 2007Shah and Lewis 2007�� Systematic reviewSystematic review

�� 3 high quality RCT showed benefit of 3 3 high quality RCT showed benefit of 3 injections up to 16 weeks after 1injections up to 16 weeks after 1stst injectioninjection

�� Reduction in pain, improved function and Reduction in pain, improved function and ROM ROM

�� IntraIntra--articular steroids give pain relief and articular steroids give pain relief and therefore can improve function (Level 1)therefore can improve function (Level 1)

Oral steroidsOral steroids

�� Buchbinder 2004Buchbinder 2004

�� Double blind RCT (n=50) with 3 weeks pred Double blind RCT (n=50) with 3 weeks pred or placeboor placebo

�� Short effect <6 weeks for pain Short effect <6 weeks for pain �� Short effect <6 weeks for pain Short effect <6 weeks for pain

�� Cochrane review also by Buchbinder 2006Cochrane review also by Buchbinder 2006

�� 5 small RCTs; variable quality5 small RCTs; variable quality

�� Short term benefit for pain only Short term benefit for pain only

(Level 1); no evidence vs injection(Level 1); no evidence vs injection

Supraclavicular nerve blockSupraclavicular nerve block

�� Dahan TH 2000Dahan TH 2000

�� Double blind RCT with placeboDouble blind RCT with placebo

�� n=34; mean 1 year symptomsn=34; mean 1 year symptoms

�� Bupivicaine; series of 3 injectionsBupivicaine; series of 3 injections�� Bupivicaine; series of 3 injectionsBupivicaine; series of 3 injections

�� 64% reduction in pain vs 13% in placebo at 1 64% reduction in pain vs 13% in placebo at 1 monthmonth

�� No effect on ROMNo effect on ROM

Supraclavicular nerve blockSupraclavicular nerve block

�� Jones DS 1999Jones DS 1999�� RCT by GPRCT by GP

�� N=30N=30

�� 3 month f/u3 month f/u

�� Single injection (including steroid) vs intraSingle injection (including steroid) vs intra--articular articular �� Single injection (including steroid) vs intraSingle injection (including steroid) vs intra--articular articular steroidssteroids

�� Faster resolution of pain in block groupFaster resolution of pain in block group

�� Effectively reduces pain (Level 1)Effectively reduces pain (Level 1)

�� ?role in diabetics/ avoid repeated steroids?role in diabetics/ avoid repeated steroids

PhysiotherapyPhysiotherapy

�� Bulgen 1984Bulgen 1984

�� Prospective, n=42, 8 month f/uProspective, n=42, 8 month f/u

�� 4 groups: Intra4 groups: Intra--articular steroid injection/ articular steroid injection/ physio/ ice/ pendular exercises for allphysio/ ice/ pendular exercises for allphysio/ ice/ pendular exercises for allphysio/ ice/ pendular exercises for all

�� No difference in outcomes LONG TERMNo difference in outcomes LONG TERM

�� Early pain relief for injection groupEarly pain relief for injection group

PhysiotherapyPhysiotherapy

�� Diercks 2004Diercks 2004

�� supervised neglect vs intensive physiosupervised neglect vs intensive physio

�� n=77, prospective (nonn=77, prospective (non--randomised)randomised)

�� 2 year f/u2 year f/u

�� Exercise within the limits of pain had better resultsExercise within the limits of pain had better results

�� 89% vs 63% ‘normal’ painless ROM at 24 months 89% vs 63% ‘normal’ painless ROM at 24 months (Constant score >80) (Constant score >80)

�� No good evidence exists for use of No good evidence exists for use of physiotherapy alone (Level 2)physiotherapy alone (Level 2)

MUAMUA

�� Dodenhoff 2000Dodenhoff 2000�� N=37, prospectiveN=37, prospective�� MUA as EARLY treatmentMUA as EARLY treatment�� 94% satisfaction (C. score 69 at 3 months)94% satisfaction (C. score 69 at 3 months)�� At 3 months 60% no/mild disabilityAt 3 months 60% no/mild disability�� At 3 months 60% no/mild disabilityAt 3 months 60% no/mild disability

�� Hamdan 2003Hamdan 2003�� n=98 (22 DM). Follow up 8 monthsn=98 (22 DM). Follow up 8 months�� Prospective; 3 groups: RESISTANT casesProspective; 3 groups: RESISTANT cases�� MUA vs MUA + SALINE 100ML vs MUA + steroidMUA vs MUA + SALINE 100ML vs MUA + steroid�� Improved function/ ROM at 3 months for all (saline Improved function/ ROM at 3 months for all (saline best). High failure rate in DMbest). High failure rate in DM

MUAMUA

�� Kivimaki et al 2008Kivimaki et al 2008�� Single blind RCT; 1 year follow upSingle blind RCT; 1 year follow up

�� N=125, mean 7 months frozen shoulderN=125, mean 7 months frozen shoulder

�� 10% diabetic; 10% diabetic; no previous treatmentsno previous treatments

�� MUA VS home exercise programmeMUA VS home exercise programme�� MUA VS home exercise programmeMUA VS home exercise programme

�� No difference at 3 months (better flexion MUA)No difference at 3 months (better flexion MUA)

�� MUA alone has limited role in the MUA alone has limited role in the management of freezing shoulder management of freezing shoulder (Level 1)(Level 1)

�� MUA may have a role in resistant cases MUA may have a role in resistant cases (Level 2)(Level 2)

Joint distensionJoint distension

�� Arthrographic saline and/ or steroid Arthrographic saline and/ or steroid distension (under LA)distension (under LA)

�� Cochrane review 2008Cochrane review 2008�� Buchbinder et alBuchbinder et al�� Buchbinder et alBuchbinder et al

�� No metaNo meta--analysis possible; poor quality analysis possible; poor quality

�� Short term benefit for pain and ROMShort term benefit for pain and ROM

�� No evidence of benefit vs other No evidence of benefit vs other treatmentstreatments

Operative treatmentOperative treatment

�� ControversialControversial

�� No RCT; no comparisons to ‘supervised neglect’No RCT; no comparisons to ‘supervised neglect’

�� Ozaki 1989 (n=365)Ozaki 1989 (n=365)�� Ozaki 1989 (n=365)Ozaki 1989 (n=365)

�� 5% open release after 10.5 months 5% open release after 10.5 months

�� Bunker 1995 (n=50)Bunker 1995 (n=50)

�� 82% MUA, 12% open release 82% MUA, 12% open release

�� Warner 1996 (n=81)Warner 1996 (n=81)

�� 41% MUA, 28% arthroscopic release41% MUA, 28% arthroscopic release

Arthroscopic releaseArthroscopic release

�� Pollock 1994Pollock 1994�� n=30, retrospective n=30, retrospective �� Resistant cases (mixed primary and secondary)Resistant cases (mixed primary and secondary)�� 25 (83%) satisfactory results; DM 64% satisfactory25 (83%) satisfactory results; DM 64% satisfactory�� PrePre--scope MUAscope MUA�� PrePre--scope MUAscope MUA

�� OgilvieOgilvie--Harris 1995Harris 1995�� Prospective cohortProspective cohort�� n= 40; 1 year symptoms; 2n= 40; 1 year symptoms; 2--5 year follow up5 year follow up�� MUA vs arth. release (extensive)MUA vs arth. release (extensive)�� ROM equal; release had better pain and function ROM equal; release had better pain and function scores (significant): diabetics no differentscores (significant): diabetics no different

Arthroscopic releaseArthroscopic release

�� Berghs 2004Berghs 2004

�� Arthroscopic capsular release (N=25)Arthroscopic capsular release (N=25)

�� 80% improved at 2 weeks: Pain (esp at night) 80% improved at 2 weeks: Pain (esp at night) and stiffnessand stiffnessand stiffnessand stiffness

�� C. score 25 pre vs 76 post op at mean 1 yr C. score 25 pre vs 76 post op at mean 1 yr

�� Role in pain relief and restoring ROM Role in pain relief and restoring ROM faster (Level 2/3)faster (Level 2/3)

Open releaseOpen release

�� Osaki 1989Osaki 1989

�� n=17 n=17

�� retrospectiveretrospective

�� Good results for pain relief and ROMGood results for pain relief and ROM�� Good results for pain relief and ROMGood results for pain relief and ROM

�� Omari 2001Omari 2001

�� n=25 failed MUA proceeded to releasen=25 failed MUA proceeded to release

�� 80% good/excellent results for pain, function 80% good/excellent results for pain, function and ROMand ROM

ConclusionsConclusions

�� Lots of unanswered questions/controversyLots of unanswered questions/controversy

�� Poor quality studiesPoor quality studies

�� Variable outcome measures usedVariable outcome measures used

Constant scores of nonConstant scores of non--op vs op no op vs op no �� Constant scores of nonConstant scores of non--op vs op no op vs op no appear no different long termappear no different long term

�� No surgical treatment has clear advantage No surgical treatment has clear advantage

ConclusionsConclusions

�� Need for good quality RCTsNeed for good quality RCTs

�� to compare treatments in freezing vs frozen to compare treatments in freezing vs frozen stages vs ‘supervised neglect’stages vs ‘supervised neglect’

�� Refractory cases/ DiabeticsRefractory cases/ Diabetics�� Refractory cases/ DiabeticsRefractory cases/ Diabetics

�� ?effect of/on natural history?effect of/on natural history

How to manage the patientHow to manage the patient

�� Confirm frozen and rule out ‘stiff’ onesConfirm frozen and rule out ‘stiff’ ones

�� Freezing or frozen stage?Freezing or frozen stage?

�� Education reduces frustrationEducation reduces frustration

Incomplete but improved ROM by 2Incomplete but improved ROM by 2--3 years3 years�� Incomplete but improved ROM by 2Incomplete but improved ROM by 2--3 years3 years

�� Surgery may not affect long term outcomeSurgery may not affect long term outcome

How to manage the patientHow to manage the patient

�� Freezing stageFreezing stage�� steroid injections and home exercise programmesteroid injections and home exercise programme

�� Frozen stageFrozen stage�� no good evidence but role for MUA or release to no good evidence but role for MUA or release to shorten natural historyshorten natural historyshorten natural historyshorten natural history

�� Bottom line:Bottom line:�� ARE THEY WILLING TO PUT UP WITH IT?ARE THEY WILLING TO PUT UP WITH IT?

�� If not: Offer Release/ MUAIf not: Offer Release/ MUA

The EndThe End

ReferencesReferences

1.1. Diercks RL et al. Gentle thawing of the frozen shoulder. J Shoulder Elbow Surg 13: 499Diercks RL et al. Gentle thawing of the frozen shoulder. J Shoulder Elbow Surg 13: 499--502,2004502,2004

2.2. Shah N, Lewis M. Shoulder adhesive capsulitis: systematic review of randomised trials using multiple steroid injections. Br JShah N, Lewis M. Shoulder adhesive capsulitis: systematic review of randomised trials using multiple steroid injections. Br J GeGen n Pract 2007; 57: 662Pract 2007; 57: 662--77

3.3. Berghs BM, SoleBerghs BM, Sole--Molins X, Bunker TD. Arthroscopic release of adhesive capsulitis. JEES 2004; 13(2): 180Molins X, Bunker TD. Arthroscopic release of adhesive capsulitis. JEES 2004; 13(2): 180--55

4.4. Bulgen DY et al. Frozen shoulder: prospective clinical study with an evaluation of three treament regimens. Ann Rheum Dis 198Bulgen DY et al. Frozen shoulder: prospective clinical study with an evaluation of three treament regimens. Ann Rheum Dis 1984; 4; 43(3): 3343(3): 33--6060

5.5. Carette S et al. IntraCarette S et al. Intra--articular steroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive articular steroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebocapsulitis of the shoulder: a placebo--controlled trial. Arthritis Rheum 2003; 48(3): 829controlled trial. Arthritis Rheum 2003; 48(3): 829--3838

6.6. Van der Windt et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder Van der Windt et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in in primary primary care: randomised trial. BMJ 1998; 317(7168):1292care: randomised trial. BMJ 1998; 317(7168):1292--66

7.7. OgilvieOgilvie--Harris, Biggs DJ. The resistant frozen shoulder. Manipulation versus arthroscopic release. COOR 1995:319:238Harris, Biggs DJ. The resistant frozen shoulder. Manipulation versus arthroscopic release. COOR 1995:319:238--48487.7. OgilvieOgilvie--Harris, Biggs DJ. The resistant frozen shoulder. Manipulation versus arthroscopic release. COOR 1995:319:238Harris, Biggs DJ. The resistant frozen shoulder. Manipulation versus arthroscopic release. COOR 1995:319:238--4848

8.8. Omari A, Bunker TD. Open surgical release of frozen shoulder:surgical findings and results of the release. JEES 2001; 10(4): Omari A, Bunker TD. Open surgical release of frozen shoulder:surgical findings and results of the release. JEES 2001; 10(4): 353353--77

9.9. Ozaki J et al. Recalcitrant chronic adhesive capsulitis of the shoulder. JBJS 1989;71A:1511Ozaki J et al. Recalcitrant chronic adhesive capsulitis of the shoulder. JBJS 1989;71A:1511--1515

10.10. Pollock RG, et al. The use of arthroscopy in the treatment of resistant frozen shoulder. COOR 1994; 304: 30Pollock RG, et al. The use of arthroscopy in the treatment of resistant frozen shoulder. COOR 1994; 304: 30--66

11.11. Hamdan TA, AlHamdan TA, Al--Essa KA. Manipulation under anaesthesia for the treatment of frozen shoulder. Int Orthop 2003;27(2):107Essa KA. Manipulation under anaesthesia for the treatment of frozen shoulder. Int Orthop 2003;27(2):107--99

12.12. Buchbinder R et al. Short course prednisolone for adhesive capsulitis:a randomised double blind, placebo controlled trial. AnBuchbinder R et al. Short course prednisolone for adhesive capsulitis:a randomised double blind, placebo controlled trial. Ann n Rheum Dis 2004; 63(11):1460Rheum Dis 2004; 63(11):1460--99

13.13. Buchbinder R et al. Oral steroidsfor adhesive capsulitis. Cochrane Database Syst Rev 2006; 4: CD006189Buchbinder R et al. Oral steroidsfor adhesive capsulitis. Cochrane Database Syst Rev 2006; 4: CD006189

14.14. Dahan TH. Double blind randomised clinical trial examining the efficacy of bupivacaine suprascapularnerve blocks in frozen Dahan TH. Double blind randomised clinical trial examining the efficacy of bupivacaine suprascapularnerve blocks in frozen shoulder. J Rheumatol 2000; 27:1329shoulder. J Rheumatol 2000; 27:1329--3131

15.15. Jones DS. Supracapular nerve block for the treatment of frozen shoulderin primary care: a randomised trial. Br J Gen Pract 19Jones DS. Supracapular nerve block for the treatment of frozen shoulderin primary care: a randomised trial. Br J Gen Pract 1999;99;49: 3949: 39--4141