Journal of Rehabilitation Medicine 51-8 | Page 16

552 C. Minns Lowe et al. 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