Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: A placebo‐controlled trial

Abstract

Objective. To compare the efficacy of a single intraarticular corticosteroid injection, a supervised physiotherapy program, a combination of the two, and placebo in the treatment of adhesive capsulitis of the shoulder.Methods. Ninety-three subjects with adhesive capsulitis of <1 year's duration were randomized to 1 of 4 treatment groups: group 1, corticosteroid injection (triamcinolone hexacetonide 40 mg) performed under fluoroscopic guidance followed by 12 sessions of supervised physiotherapy; group 2, corticosteroid injection alone; group 3, saline injection followed by supervised physiotherapy; or group 4, saline injection alone (placebo group). All subjects were taught a simple home exercise program. Subjects were reassessed after 6 weeks, 3 months, 6 months, and 1 year. The primary outcome measure was improvement in the Shoulder Pain and Disability Index (SPADI) score.Results. At 6 weeks, the total SPADI scores had improved significantly more in groups 1 and 2 compared with groups 3 and 4 (P ‫؍‬ 0.0004). The total range of active and passive motion increased in all groups, with group 1 having significantly greater improvement than the other 3 groups. At 3 months, groups 1 and 2 still showed significantly greater improvement in SPADI scores than group 4. There was no difference between groups 3 and 4 at any of the followup assessments except for greater improvement in the range of shoulder flexion in group 3 at 3 months. At 12 months, all groups had improved to a similar degree with respect to all outcome measures.Conclusion. A single intraarticular injection of corticosteroid administered under fluoroscopy combined with a simple home exercise program is effective in improving shoulder pain and disability in patients with adhesive capsulitis. Adding supervised physiotherapy provides faster improvement in shoulder range of motion. When used alone, supervised physiotherapy is of limited efficacy in the management of adhesive capsulitis.Adhesive capsulitis is a common cause of shoulder pain and disability. It is characterized by spontaneous onset of shoulder pain accompanied by progressive limitation of both active and passive glenohumeral movement (1). The pathophysiology of idiopathic adheSupported by a grant from the Arthritis Society of Canada.

Frozen Shoulder: Evidence and a Proposed Model Guiding Rehabilitation

“…Clinically, the idea that frozen shoulder occurs in the absence of inflammation is difficult to accept, especially because corticosteroid injections have been shown to have such a significant positive short-term effect. 3,15,20,58,104,108,117 There is little disagreement regarding significant capsuloligamentous complex (CLC) fibrosis and contracture, which are consistently found in open or arthroscopic shoulder surgery and histologic examinations in patients with frozen shoulder. 80,115 Contracture of the rotator cuff interval (RCI) is prevalent in patients with frozen shoulder.…”

“…3,15,20,46,117 Additionally, the optimal use of common physical therapy interventions (modalities, exercise, joint mobilization), frequency and timing of visits, and discharge criteria have not been established. The proposed physiologic effect and supporting literature for using modalities, exercises, and manual techniques in physical therapy will be discussed in the following sections.…”

“…Instruction in performing a consistent home exercise program (HEP) is important, because daily exercise is effective in relieving symptoms. 15,20,55 Little data exist to supporting the use of frequently employed modalities such as heat, ice, ultrasound, or electric stimulation. Modalities are suggested to influence pain and muscle relaxation; therefore, they might enhance the effect of exercises and manual techniques.…”

“…These exercises primarily influence different regions of the synovial/CLC and have been used in supervised physical therapy programs and an HEP in patients with frozen shoulder. 20,28,39,55,104 Aggressive stretching beyond the pain threshold resulted in inferior outcomes in patients with frozen shoulder, particularly if performed in the early phase of the condition. 28 As the synovitis/angiogenesis and pain reduce, the fibrotic connective tissue wall is reached (stage 3).…”

Letter to the Editor: Effectiveness of Sustained Stretching of the Inferior Capsule in the Management of a Frozen Shoulder

“…VAS and ROM did not reach statistical significant difference between the intervention and control group. The amount of ROM gained in both groups is one of the best reported results compared to other studies [2,8]. This raises the important question of whether the underlying condition of all patients truly was a frozen shoulder.…”