Learning Objectives: After participating in this continuing professional development activity, the provider should be better able to:
1. Compare the use of intra-articular corticosteroid with other approaches in addressing pain and function in frozen shoulder.
In a recent systematic review and meta-analysis, Dimitris Challoumas, MD, of the Institute of Infection, Immunity, and Inflammation at the College of Medicine at the University of Glasgow in Scotland, and colleagues assessed and compared the effectiveness of available treatments for adhesive capsulitis, or frozen shoulder.1
They found that only the administration of intra-articular (IA) corticosteroid was associated with short-term statistical and clinical superiority in pain and function in affected patients.
What Methods Did Researchers Employ?
Challoumas et al1 defined patients, intervention, comparison, and outcomes as follows: patients as those with frozen shoulder of any etiology, duration, and severity; intervention as any treatment modality for frozen shoulder; comparison as any other treatment modality, placebo, or no treatment; and outcome as pain, and function (primary outcomes) and external rotation range of movement (ER ROM) (secondary outcome) in the short-term, mid-term, or long-term.
They included studies of any randomized design, with at least one of the preset outcome measures included, and those assessing the effectiveness of the same modality applied in different anatomical sites.
Participants had to be older than 18 years with a clinical diagnosis of adhesive capsulitis. Although no formal diagnostic criteria were used to define frozen shoulder, the researchers accounted for the use of inappropriate or inadequate diagnostic criteria in risk-of-bias assessments. Duration of the condition was not a criterion, nor were previous treatments and follow-up.
Studies including patients with the general diagnosis of shoulder pain were excluded, even if a proportion of them had frozen shoulder, as were studies assessing the effectiveness of different types of physiotherapy-led interventions, exercise, or stretching regimens. Studies that compared different types, regimens, dosages, or durations of the same intervention were also excluded.
What Do Researchers Report?
Of the 65 eligible studies, 34 studies were included in pairwise meta-analyses (2402 participants). Duration of symptoms ranged from 1 month to 7 years and length of follow-up from 1 week to 2 years, with most follow-up occurring at 6 weeks, 12 weeks, and 6 months.
In the analyses, Challoumas et al1 compared the effectiveness of each intervention with other interventions (or placebo/no treatment) in the short-term (early: 2-6 weeks; late: 8-12 weeks) and mid-term (4-6 months). Data for long-term follow-up (>12 months) were inadequate for analyses.
They presented their results as mean differences (MD) for pain and ER ROM and standardized mean differences (SMD) for function.
IA Corticosteroid vs. No Treatment or Placebo
IA corticosteroid appeared to be associated with superior outcomes compared with control for early short-term pain (moderate certainty; MD, -1.4 visual analog scale [VAS] points; 95% confidence interval [CI], -1.8 to -0.9 VAS points; P < 0.001), ER ROM (high certainty; MD, 4.7 degrees; 95% CI, 2.7 to 6.6 degrees; P < 0.001), and function (high certainty; SMD, 0.6; 95% CI, 0.3 to 0.9 degrees; P < 0.001), and late short-term pain (moderate certainty; MD, -1.0 VAS points; -1.5 to -0.5 VAS points; P < 0.001), ER ROM (high certainty; MD, 6.8 degrees; 95% CI, 3.4 to 10.2 degrees; P < 0.001), and function (moderate certainty; SMD, 0.6; 95% CI, 0.3 to 0.8; P < 0.001).
In the mid-term, IA corticosteroid was associated with better outcomes than control only for function (moderate certainty; SMD, 0.3; 95% CI, 0.1 to 0.5; P = 0.01). However, effects for pain and ER ROM were similar (moderate certainty for both).
Physiotherapy Versus No Treatment or Placebo
Physiotherapy was associated with improved outcomes compared with control in the early short-term for ER ROM (moderate certainty; MD, 11.3 degrees; 95% CI, 8.6 to 14.0 degrees; P < 0.001). Data for other follow-up periods were insufficient for quantitative analysis.
IA Corticosteroid Plus Physiotherapy Versus No Treatment or Placebo
Combined treatment with IA corticosteroid plus physiotherapy was associated with superior outcomes versus control for early short-term ER ROM (high certainty; MD, 17.9 degrees; 95% CI, 12.1 to 23.7 degrees; P < 0.001). Data for other follow-up periods were insufficient for quantitative analysis.
IA Corticosteroid Versus Physiotherapy
IA corticosteroid was associated with significant benefits compared with physiotherapy for early short-term function (moderate certainty; MD, 0.5; 95% CI, 0.2 to 0.7; P < 0.001) and late short-term pain (high certainty; MD, -1.1 VAS points; 95% CI, -1.7 to -0.5 VAS points; P < 0.001) only. Differences for early short-term pain (moderate certainty), late short-term function (moderate certainty), and early and late short-term ER ROM (moderate and high certainty, respectively) were insignificant.
In the mid-term, IA corticosteroid was associated with better outcomes than physiotherapy for ER ROM (moderate certainty; MD, 4.6 degrees; 95% CI, 0.7 to 8.6 degrees; P = 0.02). However, the researchers observed no significant differences in pain (low certainty) or function (moderate certainty)
IA Corticosteroid Plus Physiotherapy Versus IA Corticosteroid Only
Compared with IA corticosteroid alone, combined treatment with IA corticosteroid plus physiotherapy was only associated with superior outcomes for early short-term ER ROM (moderate certainty; MD, 11.6 degrees; 95% CI, 3.7 to 19.4 degrees; P = 0.004). The researchers report that pain and function in the early short-term (moderate and low certainty, respectively) and late short-term function (high certainty) were similar between groups.
In the mid-term, no significant differences were found between the groups in pain (high certainty), function (moderate certainty), or ER ROM (high certainty).
IA Corticosteroid Plus Physiotherapy Versus Physiotherapy Only
Combined therapy was associated with significant benefits compared with physiotherapy alone only for early short-term function (low certainty; SMD, 0.7; 95% CI, 0.3 to 1.0; P < 0.001). Differences for early short-term pain and ER ROM and late short-term function were not significant (moderate certainty for all).
No significant differences were found mid-term between the groups for pain, function, or ER ROM. These comparisons had moderate, low, and high certainty, respectively.
IA Corticosteroid Versus Subacromial Corticosteroid
Compared with subacromial administration, IA administration was only associated with superior outcomes for early short-term pain (moderate certainty; MD, -0.6 VAS points; 95% CI, -1.1 to -0.1 VAS points; P = 0.02) and late short-term function (moderate certainty; SMD, 0.3; 95% CI, 0 to 0.6; P = 0.03). Improvements in late short-term pain (moderate certainty) and ER ROM (high certainty) and early short-term function (high certainty) were similar with the 2 interventions.
No significant differences were found mid-term between the groups for pain or ER ROM. These comparisons had moderate and high certainty, respectively.
Arthrographic Distension Plus IA Corticosteroid Versus IA Corticosteroid Only
Adding arthrographic distension to IA corticosteroid appeared to be associated with greater improvements in early and late short-term pain (early: high certainty; MD, -0.9 VAS points; -1.3 to -0.4 VAS points; P < 0.001; late: high certainty; MD, -0.8 VAS points; 95% CI, -1.1 to -0.5 VAS points; P < 0.001). Early and late short-term function (moderate and high certainty, respectively) and early and late short-term ER ROM (high certainty for both) were similar.
Acupuncture Plus Physiotherapy Versus Physiotherapy Only
The researchers found no differences with the addition of acupuncture to physiotherapy for early short-term pain and ER ROM. These comparisons had low and high certainty, respectively.
In a network meta-analysis, Challoumas et al1 found that, in the late short-term, arthrographic distension plus IA corticosteroid had the highest probability (96%) of being the most effective treatment. In the mid-term, combined treatment with IA corticosteroid plus physiotherapy had the highest probability (43%) of being the best treatment with physiotherapy.
The potential benefit of home exercise was assessed by comparing the mean improvement in pain in patients who received IA corticosteroid plus a home exercise program versus IA corticosteroid without home exercise, and no treatment or placebo plus home exercise versus no treatment/placebo without home exercise.
For the first comparison, a statistically significant (but clinically small) mean benefit of home exercise on pain improvement was identified at 8 to 12 weeks (MD, -0.5 VAS points; 95% CI, -0.9 to -0.1 VAS points; P = 0.01). The benefit of home exercise was much more substantial (clinically and statistically) in those receiving no treatment or placebo (MD, -1.4 VAS points; 95% CI, -1.8 to -1.1 VAS points; P < 0.001). Both results were based on 10 studies with low overall risk of bias.
Similarly, the researchers assessed for an effect of IA placebo by comparing samples who received IA placebo and no treatment from the IA corticosteroid versus no treatment or placebo comparison. Both subgroups received a home exercise program. Based on 9 studies with high overall risk of bias, IA placebo was associated with statistically and clinically significant effects on pain compared with no treatment (MD, -1.6 VAS points; 95% CI, -2.1 to -1.1 VAS points; P < 0.001).
What Limitations Do Researchers Note?
Challoumas et al1 recognize limitations to their findings. As frozen shoulder of all chronicity was analyzed together, they could not draw conclusions about specific stages and their most effective management. Most studies included a home exercise program, but its frequency, intensity, and duration were not accounted for in comparisons nor were separate analyses made adjusting for it. Finally, physiotherapy interventions, regardless of nature and duration, were grouped and analyzed together to minimize imprecision; in reality, some might be more effective than others.
Disclosures in the original study: None declared.
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