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exercises, external and internal rotations using a bar
and posterior shoulder stretching. The exercise pro-
gramme was to be performed for 10-min, 3-times a
day. No other treatments or medications were permit-
ted. Follow-up assessments were performed at 1, 3, 6
and 12 weeks. All groups improved over time. There
were significant improvements in favour of the high
and low dose corticosteroid groups in comparison to
the placebo group but no difference between the high
and low dose corticosteroid groups, suggesting that in
the short term (12 weeks) corticosteroid has a better
effect on pain, range of movement (flexion, abduction,
extension, internal and external rotation) and functio-
nal outcome (SPADI) than lidocaine alone (Table I).
Other than facial flushing (3 in the high-dose group and
one in the low-dose group) and dizziness (one in the
low-dose and one in the lidocaine group), no serious
complications (such as infections) were reported. The
authors acknowledged that compliance with the home
exercises were not checked and people with higher pain
scores than reported in the study may have responded
differently to the different doses. The findings suggest
that in the short term a single ultrasound guided intra-
articular injection of low-dose corticosteroid and a
home exercise programme is preferable to high-dose
corticosteroid or lidocaine in isolation.
DISCUSSION
This review has updated the existing 2012 review (21),
evaluating the clinical effectiveness of non-surgical
management interventions of primary FS in terms of
pain, range of shoulder joint movement, self-reported
function and disability, quality of life, recovery time,
return to work and recreation, and adverse events.
Manual therapy
Maund et al. (21) concluded: “Based on a single study
(33) (2-arm RCT, quality score 8/13, comparing twice
weekly, 30-min sessions of high-grade (Maitland grades
III and IV) in the stiff zone, to low-grade (Maitland
grades I and II) in the pain-free zone, for a maximum
of 12 weeks): “and for some outcomes only, high-grade
mobilisation may be more effective than low-grade mo-
bilisation in a population of patients who have already
had physiotherapy and/or steroid injection” (21, xv).
The findings of the current review identified 3 new
trials, deemed to be of low risk of bias that investigated
the use of manual therapy as an intervention. Celik
& Kaya Mutlu (28) compared joint mobilization and
stretching or stretching alone. The reported improve-
ments in symptoms and range of movement need to be
interpreted with caution as they may not have achieved
clinically important differences (34, 35).
www.medicaljournals.se/jrm
The uncertainty surrounding clinically meaningful
findings also exists for the findings of Gutiérrez Espi-
noza et al. (30). Whether the improvements reported
for the passive ranges of shoulder flexion, abduction
and external rotation are clinically important remain
unclear. Whilst the improvements in pain and Con-
stant score are encouraging; these findings need to be
considered cautiously due to the lack of medium- and
long-term follow-up data.
That the addition of a daily static stretching pro-
gramme plus multi-modal treatment improved range of
movement, DASH scores and pain when compared with
the multi-modal treatment programme alone, requires
further investigation and longer term follow-up. For
many healthcare systems, including the National Health
Service (NHS) in the UK, the number of treatment ses-
sions and resources included in the intervention may
prevent the treatment from becoming widely available.
Maund et al. (21) identified one study that compared
high- with low-grade mobilization and reported that,
for people who had received a previous corticosteroid
injection, the addition of high-grade mobilization may
be of benefit. No new study investigating the same
parameters was identified in the current review. The
3 new studies deemed to be of low risk of bias in the
current review tentatively support the use of manual
therapy and stretching in the more stiff than painful
stage of the condition (15, 28, 31). However, small
sample sizes, uncertainty over clinically important dif-
ferences, no differences for certain outcome measures,
and potential cost vs benefit of the interventions chal-
lenges the certainty of any recommendations regarding
manual therapy in the management of FS.
Injection therapy
Two of 6 studies that investigated the use of corticoste-
roid injections were considered of satisfactory quality
in the earlier review (21). In these 2 studies identified
concerns were; uncertainty regarding adequate allo-
cation concealment in one study, adequate power in
one study, and loss to follow-up, in both studies. In a
4-arm trial, Carette et al. (36) (quality score 9/13) re-
ported best outcomes for a multi-modal treatment that
included corticosteroid injections and physiotherapy.
In this group, using the SF-36 Physical Component
Summary (PCS), the mean score at baseline was 35.2
and the mean change from baseline at 6 weeks was
6.4, at 3 months 8.6, at 6 months 8.8 and at 12 months,
11.5. Also, in this group, the baseline score for the SF-
36 Mental Component Score was 43.1, and the mean
change at 6 weeks 5.7, at 3 months 6.6, at 6 months 9.2
and at 12 months 9.3. Ryans et al. (31) (quality score
8/13) reported that the mean daytime resting pain score
in the group receiving corticosteroid and physiotherapy