Non-surgical interventions for primary frozen shoulder: systematic review
was 31.2 (out of 100) and at 6 weeks was 14.9. In the
injection-only group the score was 28.1; in the placebo
injection and physiotherapy group, 28.2; and in the
placebo injection-only group, 38.7.
Maund et al. (21) concluded that: “There may be
short-term benefit from adding a single intra-articular
steroid injection to home exercise for patients with
primary FS of < 6 months’ duration. In the same po-
pulation there may also be benefit from adding phy-
siotherapy (including mobilization in 8–10 sessions
over 4 weeks) to a single steroid injection” (p. xv).”
The current review identified one new trial deemed
to be at low risk of bias investigating injection therapy
for primary FS (32). Concerns included; short-term
follow up, 3 groups, and small sample size. No dif-
ference between high- and low-dose corticosteroid
groups was identified and both performed better than
lidocaine only. Based on their findings, Yoon et al.
recommended using low-dose corticosteroid (2 ml
of 10 mg/ml triamcinolone acetonide and 3 ml of 1%
lidocaine) and the home programme.
As such, the findings of the current review support
and extend on those published by Maund et al. (21),
and recommend the use of corticosteroid and a home
exercise programme for people with a duration of FS
symptoms less than 6 months.
Shortwave diathermy, passive mobilization and
home exercise
Maund et al. (21) concluded: “Based on a single study
(3-arm RCT (86) (quality score 7/13) comparing SWD
and stretching, heat pack and stretching, and, a home
exercise programme), and for some outcomes only,
there may be benefit from adding SWD to passive
mobilisation and home exercise” (p. xv).
The current review did not identify any new studies
that investigated the effectiveness of SWD and, as
such, we are not able to add additional information
to that provided in the earlier review. In addition, the
current review did not find any new research deemed
to be at low risk of bias to further inform the use of
electrotherapy modalities, acupuncture, taping or dry
needling in the management of primary FS.
Time to return to work and recreation, and, adverse
events
None of the 4 studies (28, 30–32) deemed to be at
low risk of bias reported return to work and/or return
to recreation times. Three studies (28, 30, 31) did not
report data on the occurrence of any adverse or serious
events. Yoon et al. (32) reported no serious complica-
tions, such as infections, but they did report 4 cases of
facial flushing (3 in the high-dose CS group and one
in the low-dose group). Two participants experienced
553
dizziness due to vasovagal reactions (one in the low-
dose CS group and one in the lidocaine-only group).
Limitations
Whilst the search strategy was comprehensive, and was
developed and performed by the team together with a
healthcare librarian, it remains a possibility that other
studies exist and have been missed from the review.
As the flow diagram shows, the searches returned 7
studies that were not published in English, which could
not be fully screened, and so were excluded from the
review. Whilst there is conflicting evidence regarding
the extent and effects that language bias may have
upon review findings (38) it is possible that these stu-
dies might have met the review inclusion criteria and
provided additional data pertinent to the review, and
this is acknowledged.
Discussions between reviewers (CML, JL) follo-
wing independent risk of bias assessments achieved
consensus, and the third reviewer was not required
to discuss studies. It was clear that, due to the variety
of participants included/excluded in trials, the low
number of studies evaluated as being at low risk of
bias and the different methods, interventions and out-
comes used across the studies meant that it was not
appropriate to conduct meta-analyses in this review.
Only 4 trials were evaluated as being at low risk of
bias and could be included in the data synthesis stage
of the review. Limitations were identified in each of
these trials, including; small sample size (n = 30) (28),
short-term follow-up (30, 32), and potential methodo-
logical bias (31).
The aim of this study (21) was to update a previous
review and provide guidance to clinicians and patients
on any new information deemed to be at a low risk of
bias on the non-surgical management of idiopathic
FS, which may inform clinical practice and shared
decision-making. Unfortunately, the majority of studies
were evaluated as being at high risk of potential bias,
implying that, despite 30 trials meeting the eligibility
criteria and being included in the review, there is limi-
ted new evidence to inform the non-surgical manage-
ment and treatment of people with FS. Given that so
many trials were evaluated as being at high risk of bias
we believe our decision to exclude these trials from
data syntheses to be the correct choice for this review;
their overwhelming predominance in syntheses might
have led to confusing, inappropriate or misleading
findings if they had been included (25, 26). None of
the included studies had a no-treatment group, and
return to work and recreation data were lacking in all.
We recommend that, in addition to reporting adverse
events, all future research report these aspects.
In conclusion, there is limited additional guidance
available to support clinicians and those seeking care
J Rehabil Med 51, 2019