1. 指導老師 : 李惠敏 老師 報告學生 : 劉家宏 103.09.04 1

2. Background  There is little evidence for the optimal form of non-operative treatment in the management of frozen shoulder. 2

3. 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 3

4. 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. 4

5. 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 5

6. Frozen shoulder 6  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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8. 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. 8

9. 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. 9

10. 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 10

11. Methods  Exclusion criteria  Inappropriate of idiopathic frozen shoulder  Pathologic findings on radiographic evaluation  Trauma  Local corticosteroid injection  Inflammatory  Bilateral frozen shoulder  Surgery  Fractures  Dislocation 11

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13. 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. 13

14. 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 14

15. 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 15

16. 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 16

17. Intervention groups  Randomly allocated to 1 of the 3 treatment groups  Group 1: exercise class plus home exercises  Group 2: individual multimodal physiotherapy plus home exercises  Group 3: home exercises alone 17

18. Intervention groups  Group 1: exercise class plus home exercises (4min/station,12stations/time, 2times/week)  Home exercise program 18

19. DATE: 1 Pulleys Forwards 2’ Backwards 2’ 2 Flexion / Horizontal Add Over Head 2” Across Body 2” 3 Ball Rolling (time) Forwards 2’ Sideways 2’ 4 Medial Rot/ Extension Towel + Rope Stick behind back 5 Lateral Rotation Lying with stick 130 o 260 o 390 o 6 Abduction Stretch 4Stick 2Doorway 7 Scapula Setting 10o0o 260 o 8Trunk rotation 1Chair 2Ball 9 Trunk side flx rot Ball Rolling side to side 10 Proprioception/Bal Circular ball rolling 19

20. 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 20

21. 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. 21

22. 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 22

23. Results 850 p’t75 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 23

24. Results MeanRange Age51.1 years40-65 years Female to male ratio1:1.14 Duration of symptom5.78 months4-10 months Constant score39.816-64 Oxford score34.420-48 Forward elevation 95 ∘ 85 ∘ -120 ∘ External rotation 16 ∘ 10 ∘ -25 ∘ 24

25. Results  In both Constant and Oxford scores for all groups between the different time intervals (P <.001). 25

26. Results  Exercise class greater than with individual physiotherapy or home exercises alone (P <.001) 26

27. Results  Both physiotherapy groups over home exercises (P <.001) baseline6 weeks6 months 1 years 27

28. 28 IndividualHome exercise Exercise class P <.001 IndividualP =.002 P<.001

29. 29 IndividualHome exercise Exercise class P =.037P <.001 IndividualP <.001

30. Results  HADS scores : compared with any of the post- treatment time periods (P <.001)  Exercise class and individual multimodal without significant difference 30

31. Results  HADS anxiety score over the home exercise group  Exercise class: P <.001  Individual multimodal physiotherapy : P =.024 31

32. Results  SF-36 ( self-administered)  Bodily pain (P =.011)  Mental health (P =.009)  Social function (P <.001) 32

33. Results 850 p’t75 p’t Exercise class(n=25) 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 participate 705 p’t didn’t fit inclusion criteria 33

34. 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. 34

35. 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% 35

36. 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. 36

37. 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. 37

38. 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 38

39. 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. 39

40. 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 40

41. 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 41

42. 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. 42

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