Physiotherapy for primary frozen shoulder in secondary care: Developing and implementing stand-alone and post operative protocols for UK FROST and inferences for wider practice

Abstract

Objectives The United Kingdom Frozen Shoulder Trial (UK FROST) compares stand-alone physiotherapy and two operative procedures, both with post operative rehabilitation, for primary frozen shoulder in secondary care. We developed physiotherapy protocols for UK FROST, incorporating best evidence but recognizing uncertainty and allowing flexibility. Methods We screened a UK Department of Health systematic review and UK evidence-based guidelines (Hanchard et al., 2012; Maund et al., 2012) for recommendations, and previous surveys of UK physiotherapists (Hanchard et al., 2011, 2013) for strong consensus. We conducted a two-stage, questionnaire-based, modified Delphi survey of shoulder specialist physiotherapists in the UK National Health Service. This required positive, negative or neutral ratings of possible interventions in four clinical contexts (stand-alone physiotherapy for, respectively, predominantly painful and predominantly stiff frozen shoulder; and post operative physiotherapy for, respectively, predominantly painful and predominantly stiff frozen shoulder). We proposed respectively mandating or recommending interventions with 100% and 90% positive consensus, and respectively disallowing or discouraging interventions with 90% and 80% negative consensus. Other interventions would be optional. Results The systematic review and guideline recommended including steroid injection and manual mobilizations in non-operative care, and we mandated these for stand-alone physiotherapy. Consensus in the pre-existing surveys strongly favoured advice, education and home exercises, which we mandated across contexts. The Delphi survey led to recommendation of some supervised exercise modalities, plus the disallowing or discouragement-in various contexts-of immobilization and some 'higher-tech' electrotherapies and alternative therapies. Conclusions We developed physiotherapy protocols despite incomplete empirical evidence. Their clear structure enabled implementation in data-sheets designed to facilitate recording, monitoring of fidelity and reporting of interventions. Other trials involving physiotherapy may benefit from this approach.

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

“…The physiotherapy programmes developed are available online. 35 It is important to emphasise that, although physiotherapy is a common treatment in NHS practice, the ESP intervention was a specifically designed, standardised, new physiotherapy pathway to test the optimal delivery of physiotherapy in the NHS based on the best available evidence and expert consensus.…”

Muscle stiffness, gait instability, and liver cirrhosis in Wilson's disease

“…All participants were provided with written advice detailing the home exercises that they needed to do. 20 The main limitation of the study was that participants who had capsular release or manipulation had to wait longer to receive their treatment. However, our additional analysis incorporating different waiting times confirmed that this factor did not influence the main trial results.…”

“…The early structured physiotherapy and postprocedural physiotherapy programmes were standardised using evidence from a systematic review, 13 UK guidelines, and previous surveys of UK physiotherapists and Delphi consensus methodology. 20 The full standard course of early structured physiotherapy and postprocedural physiotherapy was 12 sessions during up to 12 weeks. If the physiotherapist and participant were satisfied with their progress, not all 12 sessions were necessary; otherwise, participants were encouraged to attend the full standard course.…”

“…21 Full details about the physiotherapy programmes are given elsewhere, 12,16 and included information on pain management, mobilisation techniques (increasingly stretching into the stiff part of the range of movement), and a graduated home exercise programme that progressed from gentle pendular exercises to firm stretching exercises according to the stage of frozen shoulder, as is accepted good practice. 11,20 Manipulation under anaesthesia and arthroscopic capsular release were done as day case surgical procedures within 18 weeks of randomisation. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder in a controlled way to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by an intra-articular steroid injection during surgery.…”

“…We called this early structured physiotherapy because it is more quickly accessible within secondary care than are the surgical interventions. 12 It is not known whether early structured physiotherapy or either of the surgical interventions followed by physiotherapy is more effective. 13 Systematic reviews have identified large gaps in evidence and a need for high quality primary research.…”