Cochrane UK’s Sarah Chapman blogs about evidence and experience in treating adhesive capsulitis, or ‘frozen shoulder’, with the help of another Sarah, a physiotherapist.
I have happy memories of races round my grandparents’ garden on the pair of crutches Grandpa used while his knee (the cap blown away on the Western Front) was healing. They were brilliant things, which I suspect he must have made or altered himself; wooden, with curved runners on the bottom, which allowed us to propel ourselves round at some speed! I rediscovered them a few years ago and had to have another go. I’ve always taken a grateful delight in having a body that does what I ask of it. Give me a supermarket trolley and a clear aisle, and I can’t resist scooting along with my feet off the ground, and every now and then I like to check that I can still stand on my head. On leaving the care home I’d been visiting recently, I sprinted across the courtyard, just for the joy of being able to do so.
But I’ve recently turned into a ‘bad arm in first’ kind of person and, horror of horrors, have caught myself uttering “oofs” and “ahs” when exerting myself. I’ve developed a cunning technique for pegging washing on the line, involving a sort of launch-and-slide manoeuvre. I now wash my hair one-handed and act my age in supermarkets. It turns out that the reason for all this is that I have adhesive capsulitis, or ‘frozen shoulder’. So, as an example of making everyday health choices, I thought I’d write about it.
Three important things
Ideally, health choices are made on the basis of three things: the best available evidence from research, the patient’s preferences and values, and clinical expertise.
Unlike this tidy diagram, these elements won’t necessarily make an equal contribution and, as I’m all too aware, there may not be reliable evidence to inform a decision. Let’s see…
Health choices begin when the problem does
My first choice, on developing a sore arm, is to do nothing and hope it resolves. But actually, a decision has to be made even at this point; should I rest it or use it? I don’t think ‘sore arm’ will bear much fruit in Google or the Cochrane Library, so I don’t try the internet. Instead, I do that thing that forms part of our decision-making about health and much else: I ask other people what they think it might be, and listen to tales of other people’s sore arms and what it was and what they did. I drop out of my exercise class, although aware that this is not a good move for my general health and fitness, and otherwise carry on as near normally as possible. After all, it’s not that bad.
Next stop, the GP
Fast forward a few weeks, I see a GP. He thinks it’s a rotator cuff problem and gives me a leaflet showing shoulder exercises for unspecified problems and suggests I take ibuprofen for a week. He mentions that, if it doesn’t improve, physiotherapy might help. I don’t feel very confident about the effectiveness of the exercises, but resolve to do them diligently. I don’t do them diligently… I do them sometimes, when I remember, and decide to give it a couple of weeks before seeing a physiotherapist. I’m reluctant to take the ibuprofen; I don’t want to be taking medication for weeks and I’m not so sore I feel I have to so, after a few doses, I don’t. I’m reminded of that terrible phrase given to patients (I’ve become a patient!) like me – ‘non-compliant’. Ugh!
Better see a physiotherapist
Three weeks on and I am more restricted in what I can do and, if I move my arm suddenly, the pain is enough to stop me in my tracks. I am fortunate in being able to take myself to a physiotherapist, also called Sarah. She is great. I am a bit horrified at just how limited my range of movement is shown to be. She tells me this isn’t a rotator cuff problem but adhesive capsulitis. The good news is that it will resolve by itself. The bad news, this is likely to take one to two years. YEARS! Is there anything I can do while I’m waiting, other than invent gadgets that will help me do stuff, like hang out the washing (where are you, Grandpa?)?
It seems there are a few things that may help increase my range of movement, at least a little, and reduce pain. Injected steroids, manipulation, and exercises. Before I’ve even looked at the evidence for each option, my preferences come into play. I reject the idea of steroids and resolve to embark on the exercises Sarah has shown me. I now need to do two things: get hold of a walking stick with which to perform the exercises and look for evidence about the benefits and harms of each intervention.
What’s the evidence on treating frozen shoulder?
I start with the Cochrane Library, hoping there are some relevant Cochrane Reviews, bringing together the best available primary research on treatments for frozen shoulder.
Evidence on manual therapy and exercise
There is a Cochrane review on manual therapy and exercise for frozen shoulder. Manual therapy includes any movement of the joints and other structures or manipulation done by a clinician (such as a physiotherapist), while exercise in this context includes any purposeful movement of a joint, muscle contraction or prescribed activity. These components combined in a physical therapy intervention are commonly used to treat frozen shoulder.
The Cochrane review brings together the evidence from 32 trials with 1836 people. None of the trials compared the treatments with placebo (a dummy, or inactive, treatment) or with doing nothing. The review shows that a combination of manual therapy and exercise, compared with glucocorticoid injection, probably results in less improvement at seven weeks and a similar number of adverse events. Of the 56 people who had manual therapy and exercise, 26 (46%) reported treatment success, compared with 40 people (77%) of the 52 who had the injection. There were no differences between the groups after 12 months in terms of pain and function. Greater uncertainty remains about other treatment combinations and comparisons.
…and for rotator cuff disease?
I also had a sneaky look at the Cochrane review on manual therapy and exercise for rotator cuff disease, which includes 60 trials but only one which ‘compared a combination of manual therapy and exercise reflective of common current practice to placebo’. The evidence is high quality (and so reliable) and shows no clinically important difference between groups in any outcome.
Evidence on electrotherapy
Electrotherapy, such as therapeutic ultrasound or low-level laser therapy (LLLT), may also be offered as part of a physical therapy intervention. A Cochrane review looking at the benefits and harms of these for frozen shoulder found 19 studies with 1249 people. It leaves us with more questions than answers with no or only limited evidence on the benefits and harms of a range of electrotherapy treatments. There is evidence of benefit for only one type of electrotherapy, LLLT, which, when added to exercise, is probably better than placebo in improving pain and function at four weeks and four months. On its own, LLLT may be more effective than placebo at the end of six days of treatment.
Back to Sarah, my physiotherapist
When I return for a second appointment, Sarah and I have both done some homework on the evidence and I have even done the exercises, with maybe a slight improvement. Maybe… Very slight…
So, over to Sarah:
“In my career as a musculoskeletal physio, I have seen and treated many true frozen shoulders, not to be confused with stiff shoulders caused by osteoarthritis. Some practitioners like to x-ray to rule out osteoarthritis, fractures, and rare but serious problems such as secondary metastases (cancers) in the humeral head. Treatments have come and gone as evidence is collected on the effectiveness of each. Some physios have very strong personal preferences on how to treat their patients and some favour certain techniques.
Frozen shoulder is one of the conditions that proves problematic for many physios, if I am honest. Most standard physiotherapy treatment such as massage, joint mobilsation, manipulation, passive stretching, acupuncture, electrotherapy can vary widely regarding the evidence and effectiveness. But, and this is the bit that does vary from physio to physio, some physiotherapy treatments are poorly evidence-based at un-stiffening a frozen shoulder but very beneficial for pain relief, such as massage or acupuncture. That may be a good clinical decision to get the pain down to allow the patient to start their exercise. I have tried all of the above with huge variances in success, and I have seen the results of more invasive treatments, including steroid injections and manipulation under anaesthetic. Again, the outcomes for the patient vary on a big scale, much like the UK weather.
However, there seems to be gathering evidence in the physio world on the use of eccentric muscle strengthening exercises. These are specific exercises to load a muscle in a lengthened position (think about a biceps curl; well when you straighten the arm out again, that’s loading the biceps in a lengthened position). It seems that a stiff and very painful shoulder does respond to this method. We don’t know how this strategy works yet on the shoulder (we do in the lower limb), but it may be something to do with relieving pain resulting from muscle guarding around the shoulder. Guarding muscles become painful just adding to the misery of an already sore and tight capsule. For me, I have got good results in both reduction in pain and increase in range of movement. The two things that patients want to change! So I tend not to bother with the other treatments now and just concentrate on this exercise based therapy.”
So what now?
After the session learning eccentric muscle strengthening exercises with Sarah, I was pretty sore, so I left it for a day. Then I was away from home and busy (feeble excuses I know…) so I left it a bit longer. That slid into a week or so and then I noticed my shoulder felt a little better, and I had a bit more movement. But I don’t know if this is the result of one intensive exercise session, rest, or just natural recovery, which leaves me not knowing what to do next! The realities of managing a condition and making choices about it!
In the interests of my general health and fitness, I’ve gone back to my Jazzercise classes. I have discovered something too: the walking stick, no longer required for my exercises, is the very thing I need for pulling down the washing line and pushing things onto it. And I’m not forgetting to be thankful that I don’t (yet) need to use it to help me walk.
References may be found here.
Sarah Chapman has nothing to disclose.