Journal of Rehabilitation Medicine 51-8 | Page 17

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