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The effectiveness of physiotherapeutic

interventions in treatment of frozen
shoulder/adhesive capsulitis: A systematic
review
ARTICLE in JOURNAL OF BACK AND MUSCULOSKELETAL REHABILITATION NOVEMBER 2013
Impact Factor: 1.04 DOI: 10.3233/BMR-130443 Source: PubMed
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Tarang Kumar Jain
Neena K Sharma
Northern Arizona University
Univesity of Kansas Medical Center, KC, KS,
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Journal of Back and Musculoskeletal Rehabilitation 27 (2014) 247273

DOI 10.3233/BMR-130443
IOS Press
Systematic Review
The effectiveness of physiotherapeutic

interventions in treatment of frozen
shoulder/adhesive capsulitis: A systematic
review
Tarang K. Jain and Neena K. Sharma
Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City,
KS, USA
Abstract.
BACKGROUND AND OBJECTIVE: Frozen shoulder is a common condition, yet its treatment remains challenging. In this
review, the current best evidence for the use of physical therapy interventions (PTI) is evaluated.
METHOD: MEDLINE, CINAHL, Cochrane, PEDro, ProQuest, Science Direct, and Sport Discus were searched for studies
published in English since 2000.
RESULTS: 39 articles describing the PTI were analyzed using Sacketts levels of evidence and were examined for scientific
rigor. The PTI were given grades of recommendation that ranged from A to C.
CONCLUSIONS: Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving range of
motion (ROM) and function in patients with stages 2 and 3 of frozen shoulder. Low-level laser therapy is strongly suggested
for pain relief and moderately suggested for improving function but not recommended for improving ROM. Corticosteroid
injections can be used for stage 1 frozen shoulder. Acupuncture with therapeutic exercises is moderately recommended for pain
relief, improving ROM and function. Electro- therapy can help in providing short-term pain relief. Continuous passive motion
is recommended for short-term pain relief but not for improving ROM or function. Deep heat can be used for pain relief and
improving ROM. Ultrasound for pain relief, improving ROM or function is not recommended.
Keywords: mobilization, therapeutic exercises, pain, range of motion, function
1. Introduction
Frozen shoulder or adhesive capsulitis is a musculoskeletal condition that is commonly encountered
in physical therapy practice. The exact incidence and
Corresponding author: Neena K. Sharma, Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Mailstop 2002, 3901 Rainbow Blvd, Kansas City, KS
66160, USA. Tel.: +1 913 588 4566; Fax: +1 913 588 4568; E-mail:
nsharma@kumc.edu.
prevalence of frozen shoulder is unknown, but is often

quoted to affect approximately 2% to 5% of the general
population [14] and mainly individuals 4065 years
of age, with a female predominance (58:42) [1,3]. It
is characterized by a spontaneous onset of pain with
gradual, progressive loss of glenohumeral joint motion which can lead to gross loss of shoulder function. The conditions usually starts with one shoulder
and commonly affects the contralateral side years after the onset of symptoms in the first shoulder but
it does not affect the same shoulder twice [3,58].
c 2014 IOS Press and the authors. All rights reserved

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248
T.K. Jain and N.K. Sharma / Physiotherapeutic interventions for frozen shoulder
Table 1
Stages of frozen shoulder
Stage 1
The preadhesive stage
Stage 2
The acute adhesive or freezing
stage
Hyper vascular synovitis with Decrease in hyper vascular synnormal underlying capsule.
ovitis with early adhesion formation leading to capsular contraction and thickening.
Stage 3
The fibrotic or frozen stage
Stage 4
The thawing phase
Less synovitis but more mature ad- Severe capsular restriction withhesion in the capsule and axillary out apparent synovitis.
fold.
Patients present with mild or no Patients have a high level of dis- Patients note significant motion
end-range limitation and pain. comfort, limited passive and ac- limitation with minimal pain.
tive motion, and increased pain
near end-range of motion.
Patients in this phase present

with painless restriction of motion, which typically improves by
remodeling.
Treatment Goal decrease pain Treatment Goal restore the norby interrupting the cycle of in- mal glenohumeral biomechanics
in addition to decreasing inflamflammation and pain
mation and pain.
Treatment goal aggressively treat

significant loss of motion and restore normal range of motion and
functionality of the shoulder joint.
Treatment goal maintain the

normal range of motion and
shoulder function while maintaining the normal glenohumeral
biomechanics and avoiding pain
and inflammation.
May last between 03 months.
May last between 1524 months
The risk of being affected appears to be increased

by trauma/surgery [9], hormonal diseases such as diabetes, ACTH deficiency, and thyroid disease [10,
11], cardiac diseases [12], neurologic diseases such as
Parkinsons and stroke [13], neurosurgery [14], malignancies [15], hyperlipidemia [16], certain medications such as metalloproteinase inhibitors, protease inhibitors, antiretrovirals, influenza and pneumococcal
vaccine, and fluoroquinolones, and Dupuytrens contracture [17].
Although the underlying etiology and pathophysiology of frozen shoulder is poorly understood and disagreement remains in the literature whether to define
this pathologic process as an inflammatory or a fibrosing condition [4], several authors have attempted to
identify homogeneous subgroups to simplify treatment
choices and make outcomes more predictable. Lundberg categorized frozen shoulder patients into two subgroups idiopathic/primary frozen shoulder when patients displayed symptoms with no identifiable cause,
and secondary when patients had a similar presentation
and progression but resulted from a known intrinsic,
extrinsic, or systemic cause [3].
Patients with frozen shoulder typically demonstrate
a characteristic history, clinical presentation, and recovery. It is believed to be a self-limiting condition,
lasting 1824 months with no long-term sequelae. Although majority of patients show complete resolution
of the disease, many others report long term pain and
residual motion restriction [8,16,18]. Various authors
have tried to characterize the natural course of the
frozen shoulder but it still remains controversial. For
example, Reeves in 1975 described the natural his-
tory of frozen shoulder as a continuum of 3 phases: 1)

painful (freezing) phase lasting 1036 weeks, 2) stiff
(frozen) phase lasting 412 months, and 3) recovery
(thawing) phase lasting 526 months or more [19]. In
their report, the full duration of the disease lasted anywhere from 1 to 3.5 years, with a mean of 30 months,
but subsequent reports have described a longer and
more protracted course in many patients. Later, Hannafin and Chiaia described 4 stages (Table 1) incorporating the arthroscopic stages described by Nevaiser,
the clinical examination, and the histological findings
in frozen shoulder patients [2].
The diagnosis of frozen shoulder is based upon a
thorough history and physical examination without formal criteria. The most used criteria in previous studies
to diagnose frozen shoulder are insidious or minimal
event resulting in onset, significant shoulder pain that
interferes with successful activities of daily living, significant night pain, significant limitations of active and
passive shoulder motion in more than 1 plane to less
than 100 and 50% or greater than 30 loss of passive
external rotation (at the side), painful end range motion
in all movements, significant pain/weakness of the internal rotators, normal radiological appearance, and no
secondary causes [3,5,7,8,19].
Many treatments have been advocated to treat frozen
shoulder: rest/education, analgesia, joint mobilization,
thermotherapy, massage, therapeutic exercises and
physical therapy, acupuncture, oral and injected corticosteroids, laser therapy, capsular distension, manipulation under anesthesia, nerve blocks, and arthroscopic
capsular release [7,20,21]. Currently there is no consensus as to which treatment is most effective in frozen
Computer database search (n=2917)

MEDLINE (n=1061)
CINAHL (n=54)
Cochrane Review (n=48)
PEDro (n=55)
ProQuest (n=946)
Science Direct (n=630)
Sport Discus (n=123)
Unrelated articles excluded based on title

and abstract (n=1829)
Screening of title and abstract for

inclusion and exclusion (n = 173)
Irrelevant and uncertain articles excluded

(n=46)
249
Duplicate articles excluded (n=915)
Articles excluded (n=62)

Study design=38
Intervention =15
Full text access not available =9
Full text articles retrieved for further
analysis (n=55)
Irrelevant articles excluded (n=16)
Included in review (n=39)
Fig. 1. Selection of studies.
shoulder patients [20]. Generally the treatment regimens include a trial of conservative therapy, followed
by more invasive procedures for recalcitrant cases.
However, varied inclusion criteria, different diagnostic criteria and treatment protocols, and numerous outcome measures used in studies make study comparisons difficult. Many studies do not provide details
regarding the stage of the disease process, previous
treatment, and etiological considerations. Despite the
amount of research that has been carried out into this
topic, the results still appear to be inconclusive regarding the effectiveness of interventions specifically for
frozen shoulder. Selecting or grouping subjects based
on specific criteria would enhance the validity, reproducibility, and comparability of the results. Physical
therapy alone is an effective treatment but is also a
complement to other therapies [5].
The purpose of this review is to systematically consider the evidence from the recent published literature
on the effectiveness of physical therapy interventions
(PTI) for the management of frozen shoulder.
1.1. Objectives
The main objectives of our review are:
1. To analyze the functional outcomes in patients
who received PTI for the management of frozen
shoulder as compared to those given no treatment, other treatment or a placebo control.
2. To present the best-available evidence of the effectiveness of PTI for the management of frozen
shoulder.
3. To critically assess the quality of the recently
published studies and to identify deficiencies that
might be corrected by further research.
2. Methods
To conduct this systematic review, a literature search
and review was performed using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Physiotherapy Evidence
Database (PEDro), ProQuest, Science Direct, and
Sport Discus databases (Fig. 1). The databases were
used to search the literature on the University of
Kansas library system initially during the month of
MarchApril 2011 and then updated in January 2012.
The search was limited to human subjects and articles
published in English within last 12 years.
To focus the search on the PTI for the treatment
of frozen shoulder, adhesive capsulitis and frozen
shoulder, the two most common terms used to describe the condition, were used as key terms for the
search. The MEDLINE search was conducted in two
ways. First, we conducted search using the MeSH terminology restricted to MeSH major topic with pre-
250
vention and control, rehabilitation, and therapy as subheadings. Second, we used the basic search index using the combinations of these two key terms and the
AND operation with the following terms: physical therapy, physiotherapy, manual therapy, exercise, electrotherapy, mobilization, acupuncture, rehabilitation, treatment, and education.
Using this method, the various search combinations, in
total, generated 2917 articles.
In the first step, the titles and abstracts of these references were examined, and articles that were not related
to the topic of interest or duplicate were removed. Following this screening process, 173 articles were identified in the search on the various databases. From the
list of 173 articles, irrelevant and uncertain articles
were excluded, including articles comparing surgical
techniques. Following this screening process, 55 full
text articles were retrieved for further review of appropriateness and analysis. Articles were included in
the subsequent analysis if: 1) they were experimental
or quasi-experimental reports from peer-reviewed journals, 2) an intervention that included physical therapy, manual therapy, exercise, electrotherapy,
mobilization, acupuncture, rehabilitation, treatment, and education with the intended goal of treating frozen shoulder was implemented, 3) subjects were
diagnosed with the frozen shoulder diagnostic criteria
mentioned above. The excluded articles were those that
investigated other shoulder disorders, surgical techniques, utilized no treatment such as long term outcome studies, and economic evaluation studies. After applying the inclusion/exclusion criteria, 39 articles
were included in the review (Fig. 1).
In the second step, we evaluated each article independently using a modified version of Sacketts critical
appraisal criteria outlined by Mortenson and Eng [22].
Additionally, a level of evidence was assigned for each
article and graded as described by Sackett [23], and
Butler and Campbell [24] (Table 2). One point was
awarded for each factor met, which generated a potential maximum value of eight points. If information regarding criteria was not mentioned in the article, no
points were assigned for that category. The grade of
recommendation for each of the major outcome measures was based on the level of supporting evidence.
Specifically, grade A is given to a measurement if supported by at least one level I study; B if supported by
at least one level II study; and C if supported by level
III, IV, or V evidence.
Table 2
Appraisal and recommendation criteria
Criteria for assessment of methodological quality of studies
Confounding factors
Random assignment
Blinded assessment
Monitored intervention
Report of dropout
Descriptions of reliability
Validity of measurements
Follow-up
Hierarchy of quality of individual studies and strength of evidence
Level I = large randomized controlled trial, low error risk
Level II = small randomized trial, moderate to high error risk
Level III = nonrandomized design
Level IV = case series, no control
Level V = case report
Formulation of recommendations
Grade A at least one level I study
Grade B at least one level II study
Grade C if supported by level III, IV, or V evidence.
3. Results
Thirty-nine studies (n = 4350) from 2917 citation postings met the inclusion criteria of the qualitative review (Fig. 1). All studies assessed the effect of
the PTI in the treatment of frozen shoulder (Table 3).
The number of patients in the reviewed studies ranged
from 1 to 2370. After the exclusion of one retrospective study that studied 2370 subjects [25], total number of subjects averaged 49.5 with 31.4 (63.4%) subjects being females per study. All studies had more female patients except three studies [2628] which had
either equal or more number of male patients. The patients age ranged from 2296 years with the mean
age of 53.77 3.97 years. The duration of symptoms in the reviewed studies ranged from 6 weeks to
10.2 months, placing almost of the subjects in Stages
1, 2 and 3 of frozen shoulder. Most studies included
a separate control group for their experiments, while
five of the cohort studies had no control group [25,29
32], and six studies were either case series [33,34] or
case reports [3538]. Follow-up time post-intervention
ranged from day 1 to 9.2 9.7 years in the reviewed
studies.
3.1. Level of evidence
The level of evidence varied from level V (lowest evidence) to level I (highest evidence) (Table 4). Twenty
four out of thirty nine studies were randomized control
trials with pre- and post-test groups. Eight studies were
cohort design (four prospective and four retrospective),
Design = RCT
MOR Not stated
LOE = Level II
Design = RCT
MOR Table of
random numbers
LOE = Level II
Calis et
al. [43],
2006
Carette et
al. [44],
2003
Design and Level of

Evidence (LOE)
Design = RCT
Arslan and
Celikar [26], MOR Not stated
2001
LOE = Level II
Author/Year
At 6 weeks and 3 months, the to CS inj 40 mg triamcinolone SPADI

tal SPADI scores and total range
SF-36
with fluoroscopic guidance
of motion improved significantly
Active
and
passive
ROM
PT
12x1
hr
sessions
(3
4
Group 1: CS inj+PT (n = 21 (7M + 14F),
more in combined group
in shoulder flexion, abweeks)
age = 54.9 10.5)
duction and ER Hand be- There was no difference between
TENS
Group 2: CS inj alone (n = 23 (8M +
groups 3 and 4 at any of the
hind back
US
15F), age = 55.4 10.0)
follow-up assessments except for
Assessments:
Ice
Group 3: PT alone (n = 26 (14M + 12F),
greater improvement in the range
Active and auto assisted ROM Baseline
age = 54.2 8.3)
of shoulder flexion in group 3 at
ex
Group 4: Placebo (n = 23 (9M + 14F),
6 weeks
3 months
Mobilization
age = 56.5 9.4)
3 months
At 12 months, all groups had im
Isometric
strengthening
ex
6 months
DOS:
proved to a similar degree with
1 year
HEP in both groups
Group 1: 22.1 14.9 weeks
respect to all outcome measures
n=93
Male = 38, Female = 55
DOS: Not stated
Group 1: Sodium hyaluronate Pain using VAS scale

In all groups, significant im30 mg weekly for 2 weeks
provements at both the 15th day
Passive ROM in shoulder
Group
2:
Triamselonone
aseand 3 month in all parameters.
abduction
and
IR
Group 1: Sodium hyaluronate 30 mg (n =
tonide 40 mg
Constant shoulder assess- The passive abduction values and
24 (10M + 14F), age = 59.7 9.81)
constant score in PT group better
ment scale
Group 2: Triamselonone asetonide 40 mg Group 3: Physical therapy
than other groups on the 15th day
Assessments:
Hot pack 20 min
(n = 25 (9M + 16F), age = 56.36
and 3 month
US 1.5W/cm2 for 5 min
11.3)
Baseline
TENS for 20 min
Group 3: Physical therapy (n = 21 (8M
15 days
Stretching ex for 10 days
+ 13F), age = 52.33 10.1)
3 months
Group 4: Stretching and Codman Ex (n = Group 4: Stretching and Codman
20 (6M + 14F), age = 59.25 6.8)
Ex at home
n = 95 shoulders
Interventions
Outcome measures and

Results
assessments
Intervention period: CS inj. once Active and passive ROM ROM improved at both 2 and 12
week time points
in shoulder flexion, aband PT-2 weeks
Mean difference in ER ROM at 2
duction, IR, and ER
Group A: 40 mg methylprednisolone ac- Group A: 40 mg methylpredand 12 weeks in both groups not
nisolone acetate injection with Pain using VAS scale
etate injection with local anesthetic (n =
significant
Assessments:
1 ml of 2% lidocaine
10 (3M + 7F), age = 55.6 12.2)
Mean difference in pain VAS at
Group B: PT measures plus NSAIDs (n = Group B: PT and NSAID
Baseline
2 and 12 weeks in both groups
10 (7M + 3F), age = 56.4 7.1)
2 weeks
Hot pack 20 min
significant
2
12
weeks
US 3.5 W/cm for 5 min
DOS:
Passive GH jt stretching ex
Group A = 4.6 1.6 months
Codman ex and Wall climbing
Group B = 3.5 1.7 months
Both Group A & B same HEP
Patients characteristics and duration of

symptoms (DOS)
n = 20
Table 3
Level of evidence and summary of methods and results
251
Cheing et
al. [45],
2008
Design = RCT
MOR Not stated
LOE = Level II
Design = RCT
n =15, 54.8 yrs. (range 3876 yrs.)
MOR Computer Male = 3, Female = 12
generated
Passive mobilization group:
LOE = Level II
passive mobilization + home care program (n = 7 (2M+5F), age = 50.9; range
4876 yrs.)
Control group: home care program only
(n = 8 (1M+7F), age = 56.7; range 39
59 yrs.)
Group 1: 6.71 6.50 months

DOS:
Group 1: Electroacupuncture + Ex
(n = 24)
Group 2: IFT + Ex (n = 23)
Group 3: Control (n = 23)
n = 70 (range 3390 yrs.)

Passive mobilization group 2.5 months

Control group 2.4 months
DOS:
DOS: Not stated
Group 1: GH ROM exercises (n = 14

(5M + 9F), age = 54.8; range 4265 yrs.)
Group 2: GH ROM + scapulothoracic exercises (n = 15 (2M + 13F), age = 49.6;
range 3862 yrs.)
Chan et
al. [55],
2010
elik [54],
2010

symptoms (DOS)
n = 29, 52.1 yrs. (range 3865 yrs.)
Design and Level of

Evidence (LOE)
Design = RCT
MOR Not stated
LOE = Level II
Author/Year
Forward flexion
External rotation
Horizontal adduction
Internal rotation
Group 1 EA treatment for 10

sessions over 4-week period (23
/week) + HEP
Group 2 IFT treatment for 10
sessions over 4-week period (23
/week) + HEP
HEP standard set of shoulder ex
5 times/day for 6 months
Active and active-assisted

ROM exercises
Capsular stretching exercises
Postural correction, and
Scapular stabilizing exercises
Both groups received 30 mg triamcinolone acetonide (Kenalog)

and 3.25 ml 1% lidocaine.
Passive mobilization group:
Grade A & B mobilization (six
30 minute weekly sessions over
10 weeks) + home care program
Control group: home care program
Intervention period 10 weeks
Both groups had HEP twice

daily with 20 repeats of exercises
lief, when needed
Baseline
2 weeks
4 weeks
7 weeks
10 weeks
Baseline
Post-intervention
1 month
3 months
6 months
Assessments:
Constant Murley Assessment (this should be in the

footnotes) (CMA) score
Pain using VAS scale
Assessments:

SPADI
Active ROM in shoulder
abduction, IR, and ER
Significant change in CMA and

VAS score in EA and IFT group as
compared to control at least until
the 6 month follow up
By week 10, both groups showed

improvement in pain, shoulder
function and shoulder range of
movements, with the control group
showing a trend towards better
improvement than the passive
mobilization group

Results
assessments
All outcome measures improved
Intervention period 6 weeks (30 Pain using VAS scale
in both groups
Modified Constant score
sessions)
Group 1: Glenohumeral ROM Shoulder ROM in flexion, VAS score showed greater improvement in group 2 at 6 weeks
IR, and ER
exercises
Modified Constant score was not
Group 2: Glenohumeral ROM + Assessments:
significantly different between
scapulothoracic exercises
Baseline
the groups
Both groups received TENS,
6 weeks
ROM improved significantly in
cold pack, and NSAIDs
12 weeks
group 2 at 12 weeks
following exercises for pain re-
Interventions
Table 3, continued
252
Design = RCT
MOR Not stated
LOE = Level II
Design = Prospective n = 54, Male = 26, Female = 28

cohort study
Average age of onset 51.8 9.7 yrs. (range
3182 yrs.)
LOE = Level III
DOS: 9.7 6.7 months
Design = RCT
MOR Not stated
LOE = Level II
Dudkiewicz
et al. [29],
2004
Dundar et
al. [47],
2009
Intervention period 2 years
Interventions

assessments
Constant score
HEP
Baseline
Post-intervention
3 months
Intervention period 20 days
Baseline
4 weeks
3 months (12 weeks)
All the outcome measures im Pain using VAS scale

proved from baseline.
Passive ROM in shoulder flexion, abduction, IR, Pain reduction was significant at
follow up compared to baseline.
and ER
Constant functional score CPM application has no superiority over PT on shoulder ROM,
SPADI
functional ability
Assessments:
Active ROM in shoulder Active ROM improved significantly

Intervention period Not stated
elevation, IR, and ER
All patients were treated with longin all the measured movement diterm course of physical therapy + Assessments:
rections
NSAIDs
Baseline
Mean follow up period
9.2 9.7 yrs.
Codman ex
Active ROM and stretching ex
HEP 3 months
CPM group: CPM for 1 h once

a day for 20 days 4 weeks +
Group 1: CPM (n = 29 (9M + 20F), age
HEP
= 56.3 7.8)
Group 2: PT (n = 24 (9M+19F), age = PT group: daily PT including active stretching and pendulum ex57.1 8.3)
ercises for 1 h once a day for 20
DOS:
days 4 weeks. + HEP
CPM group: 6.3 4.2 months
HEP:
passive range of motion and
PT group: 5.9 4.0 months
pendulum exercises
n = 57
US group: 6.3 3.5 months

Sham group: 5.2 2.9 months
DOS:
Intervention 10 sessions
(2 weeks)
ulation of the GH joint

Home exercises for stretching
and maximal reaching
At both 12 and 24 months time period, patients in the group treated

with supervised neglect achieved
quicker and greater improvement in
constant score than patients in the
physical therapy group
Results
Shoulder ROM in flexion, No significant difference in

pain, SPADI and SF-36 between
groups.
Group 1: US (n = 25 (11M+14F), age = US group US + superficial heat SPADI
ROM increased b/w pre and post

Pain
using
VAS
scale
+ exercise program + HEP
53.9 7.8)
treatment in both groups but
Group 2: Sham (n = 24 (10M+14F), age Group 2 Imitative US + super- SF-36
more in US group
ficial heat + exercise program + Assessments:
= 56.8 7.3)
n = 49, 55.4 7.6 yrs. (aged 4172 yrs.)

Supervised neglect group 5 months

(Range 312 months)
Physical Therapy group 5 months
(Range 310 months)
DOS:
Supervised neglect group: educa- Assessments:

tion, pendulum and active exer- Baseline
Supervised neglect group: supportive thercises within the painless range
apy and exercises within the pain limits
3-month intervals up to
(n = 45 (19M + 26F), age = 50 6.0) Physical therapy group:
24 months
Physical therapy group: passive stretching
Active exercises up to and beand manual mobilization (n = 32 (11M
yond the pain threshold
+ 21F), age = 51 7.0)
Passive stretching and manip-
Dogru et
al [46],
2008
Diercks et
al. [62],
2004

symptoms (DOS)
n = 77
Design and Level of

Evidence (LOE)
Design = Controlled, cohort
study
MOR Computer
generated
LOE = Level III
Author/Year
Table 3, continued
253
US
ADLs
Games
HEP
Baseline
6 weeks
6 Months
9 months
Assessments:
Rehabilitation exercise protocol 2 Pain using subjective pain Significant improvements in pain
scores, ROM were observed
questionnaire
sessions per week
Active and passive ROM DASH scores were observed to
Pendulum circumduction
be lower than the known populain shoulder in elevation,
Passive stretching exercises in
tion norms
IR, and ER
forward elevation, ER, horizontal
SF-36 were comparable to age
DASH
adduction, and IR.
and gender-matched control pop SF-36
HEP 5 times per day to the tolerulations
Assessments:
able limit
Baseline
Mid-term evaluation (6
12 weeks)
Final (1241 months)
Significant difference was found

for all treatment groups
The greatest change in active
ER was found for the combined
treatment group (mean change of
29 )

Results
assessments
Pain using VAS Scale
Pain and ROM improved continu Active ROM in shoulder ously at follow up periods
flexion, extension, abduction, adduction, horizontal abduction, horizontal
adduction, IR, and ER
Recovery rate
19 patients in the CYR group
(95%) and 13 patients in the PT
CYR group: 1 hour Cyriax mob Passive ROM in shoulder flexion, abduction, IR,
group (65%) reached sufficient
three times a week (deep friction
CYR Group: Cyriax (n = 20 (5M + 15F),
and ER
ROM at the end of the second
massage and manipulation) +
age = 53.6 6.9) Stages I/II 6/14
week
Active stretching and
Design = RCT
MOR Not stated
LOE = Level II
Guler-Uysal
and Kozanoglu [48],
2004
n = 40, 56.0 8.6 yrs. (range 4085 yrs.)

Design = Case se- n = 75, 53 yrs. (range 3576 yrs.)

ries
LOE = Level IV
DOS: 9.2 months (range 1.347 months)
DOS: Not stated
Occupation as means intervention
Interventions
Intervention 90 days (PT-more Active ROM in shoulder

ER
than 2/week, SDS worn more than
2/day)
Assessments:
PT
Baseline
Moist heat
Group I Control (n = 15);
After 90 days
Group II PT exclusively with standardized Patient education
Joint mobilization
protocols (n = 16);
Group III Shoulder Dynasplint system ex- PROM, AROM
PNF
clusively (n = 16);
Group IV Combined treatment with Therapeutic ex
Shoulder Dynasplint and standardized PT
(n = 16)
Design = Controlled, n = 62,

cohort study
Average age of onset 55.6 7.9 yrs. (range
LOE = Level III
3675 yrs.)

symptoms (DOS)
53 years old Caucasian female
University professor
DOS: 4 weeks post onset
Griggs et
al. [6],
2000
Gaspar and
Willis [61],
2009
Design and Level of

Evidence (LOE)
Design = Case reEarley and
port
Shannon [37]
LOE = Level V
2006
Author/Year
Table 3, continued
254
Design = RCT
n = 70
Group 1: 20 mg hyaluronate ingenerated
Group 1 (HAPT group): Hyaluronate
jection once per week for 3 con LOE = Level I
intra-articular injections with PT (n = 32
secutive weeks + PT program
(12M + 20F), age = 52.6 6.3)
for 3 months
Group 2 (PT group): PT alone (n = 31 Group 2: PT program only (3 ses(8M + 23F), age = 56.4 9.0)
sions per week for 12 weeks)
Design =
Retrospective
Cohort Study
LOE = Level III
Jewell et
al. [25],
2009
n = 2370, 55.3 12.4 yrs.

DOS: 41% patients (n 972) > 90 days
Design = Case re- 39 years old male

port
DOS: 3 months
LOE = Level V
Janjua and
Ali [36],
2011
Group 1 = 5.2 2.6 months

Group 2 = 3.8 2.6 months
DOS:
Active and passive ROM Both groups improved in terms

of pain, disability, and quality of
in shoulder flexion, ablife after the treatments
duction, IR, and ER
The active and passive ROM im SPADI
proved linearly with increasing
SDQ
treatment duration
SF-36
No significant group effect was
Assessments:
found for any of the outcome
Baseline
measurements
1.5 months
3 months
21 interventions (listed at http://

ptjournal.apta.org/content/suppl/
2009/04/24/89.5.419.DC1/zad605
09000001.pdf)
Moist hot pack

Maitlands Grade I, II and III distraction mobilization
Pendular home exercises for
shoulder
Soft tissue mobilization
Isotonic strength exercises using
free weights
None of the patients achieved a

Physical Component
50% or greater improvement in
Summary-12 (PCS-12)
PCS-12 scores
physical function (PF)
The presence of 2 intervention
and bodily pain (BP)
categories joint mobilization
Hybrid function (HF)
and mobility and exercise inscores
creased the odds of a successful
Assessments: N/A
outcome in the BP and HF models, respectively
Use of iontophoresis, phonophoresis, ultrasound, or massage re-
Baseline
2 weeks
3 weeks
Assessments:
Intervention period 3 weeks (3 Passive ROM in shoulder At the end of the third weeks treatabduction, flexion, and ment, the patient had pain free full
sessions per week)
ER
range of motion
Phonophoresis
Heat therapy
Electric therapy
Exercise
HEP: passive range of motion

and pendulum exercises

Results
assessments
Pain during activity ques- The improvement in shoulder
pendulum exercises
flexion, inner and outer rotation
tionnaire
PT group: 1-hour physical thervalues and the decrease in pain
apy session + active stretching Assessments:
with motion were significantly
and pendulum exercises
Baseline
better in the CYR group after the
Hot packs for 20 minutes followed 1 week
first week of treatment
2 weeks
by SWD applied for 20 minutes
Interventions
Hsieh et
al. [40],
2012
CYR Group: 7.6 3.9 months

PT Group: 5.6 3.9 months
DOS:

symptoms (DOS)
PT Group: PT (n = 20 (7M + 13F),
age = 58.4 9.7) Stages I/II 8/12
Design and Level of

Evidence (LOE)
Author/Year
Table 3, continued
255
Kumar et
al [28],
2012
Jrgel et
al. [63],
2005
duced the likelihood of improvement in PF, BP, and HF scores by

19% to 32%
Results

Pain significantly decreased in
Self-assessment
both groups
functional questionnaire A significant difference between
groups was present by the third
ER
treatment
AM group patients had a mean
Assessments:
improvement in external rotation
1st session
ROM of 3.0 whereas the PM
2nd session
group
patients had a mean im 3rd session
provement of 31.3
th
4 session
5th session
6th session

assessments
Assessments:
Baseline
4 weeks
Active ROM in shoulder In patients with FS, shoulder

flexion, extension, abduction,
flexion, extension, abduc Individualized exercise therapy
and adduction and active ROM,
tion, adduction, IR, and
sessions (30 min/day)
MF in all measured force direcER
massage procedures (20 min/
tions and net impulse during
Isometric maximal force
day)
shoulder muscle isometric enof the muscles (MF) for
electrical therapy procedures
durance test for involved extremshoulder flexors, abduc(510 min/day)
ity increased after rehab
tion, adduction, IR, and
No significant changes in shoulER
der IR and ER active ROM for in Shoulder muscle isometvolved extremity in patients with
ric endurance
FS were observed with rehab
No HEP
Capsule preheated with US

Joint mob (AM or PM)
Upper body ergometer ex
Intervention period 6 sessions
Interventions
Design = RCT
A significant improvement was
n = 40
MOR Chit pick Male = 26, Female = 14
recorded in all outcome measures
SPADI
Maitland technique: 5 sets of glebox method
in both the groups
Group A: Maitland mobilization + exernohumeral caudal and postero- Shoulder ROM in abduc LOE = Level II
Group A showed higher
tion and ER
anterior glides at the rate of 23
cises (n= 20, age = 47.9)
improvement than group B
glides per second for 30 seconds Assessments:
Group B: Exercises alone (n = 20, age =
(3 days/week for 4 weeks)
47.1)
Baseline
Supervised exercise program:
4 weeks
DOS: Not stated
5 days per week for 4 weeks
Codman exercise
Shoulder wheel exercises
Self-stretching exercises
Wall-ladder exercises
DOS: 2 weeks 3 months
Design = Prospec- n = 20
tive cohort study
LOE = Level III
Frozen shoulder patient group: n = 10
(3M + 7F), age = 50.2 4.6
Control group: asymptomatic shoulders as
control (n = 10 (3M+7F), age = 49.8
4.6)
AM group: 8.4 2.12 months

PM group: 10.9 4.6 months
DOS:
Design = RCT
n = 20, range 3766 years
MOR Random- Male = 4, Female = 16
numbers table
AM group: Anterior mob (n = 10 (2M +
LOE = Level II
8F), age = 54.7 8.0)
PM group: Posterior mob (n = 8 (2M +
6F), age = 50.4 6.9)
Johnson et
al. [59],
2007

symptoms (DOS)
Design and Level of

Evidence (LOE)
Author/Year
Table 3, continued
256
Design =
Retrospective
cohort study
LOE = Level III
Design = RCT
MOR Not stated
LOE = Level II
Ma et
al. [49],
2006
Design and Level of

Evidence (LOE)
Design = RCT
MOR Online randomization
LOE = Level II
Levine et
al. [32],
2007
Leung and
Cheing [58],
2008
Author/Year
Group 3 Stretching alone (n = 10)
Baseline
Session 6
Session 12
4 week follow up
Active and passive ROM All patients showed improvement in quality of life (SF-36)
in shoulder flexion, exten Acupuncture group: 15 minute
Pain was controlled better by

sion,
abduction,
IR,
and
Control group PT only (n = 15, age =
session 2 days/4 weeks
acupuncture while ROM
ER
54.1)
PT group: 3040 minute session
improved following physical
Group 1 Acupuncture only (n = 30, age
5 days/4 weeks
therapy. However, patients
SF-36
= 56.4)
SWD 15 min
treated by both methods had the
Assessments:
Group 2 PT + acupuncture (n = 15, age
Joint mob 510 min
best outcome
= 52.8)
Active shoulder ex 510 min Baseline
2 weeks
DOS: 25.8 weeks
4 weeks
n = 75, 54.8yrs
Operative group (11 shoulders)

DOS: Not stated
Assessments:
A significant improvement was

seen in all groups in all outcome measures except for that of
shoulder flexion range
The improvement in the shoulder score index and in the range
of motion was significantly better
in the deep heating group than in
the superficial heating group
Results
Active ROM in forward In the non-operative group, forward

elevation, ER and IR
elevation and ER improved significantly from pre-treatment to postAssessments:
Physical therapy only
treatment with no significant differ3.3 months
Baseline
ence between physical therapy only
Physical therapy + Injection Post-intervention
and physical therapy + injection
4.5 months
15121 months
group
Operative group 12.4 months
before surgery
Physical therapy group: standardized program + NSAIDs
Physical therapy + injection
group: standardized program +
corticosteroid inj . + NSAIDs
Intervention period (mean

duration)
Physical therapy only 55 shoulders

Physical therapy + Injection 39
shoulders
Non-operative group (94 shoulders)
n = 98 with 105 shoulders, 55 yrs.

(range 2096 yrs.)
DOS: Not stated
Interventions

assessments
Intervention period 12 treatment Pain using VAS scale
sessions (20 minute session 3 ASES
Shoulder score index
days/4 weeks)
Group 1 SWD + stretching (n = 10, HEP: pendulum exercises and Active ROM in shoulder
forward elevation, ER,
stretching techniques
age = 53 8.4)
hand behind back, and
Group 2 Hot pack +stretching (n = 10,
cross body adduction
age = 53 8.6)

symptoms (DOS)
n = 30, age = 59.87 12.45 yrs. (range
3779 years)
Table 3, continued
257
Control group:
< 6 weeks n = 6
612 weeks n = 20
> 12 weeks n = 33
Study group:
< 6 weeks n = 13
612 weeks n = 20
> 12 weeks n = 27
DOS:
SWD (20 minutes)

Mobilization and passive
stretching
HEP pulley exercises, active
non-assisted exercises, and hot
pack
Design = RCT
n = 122
Control group: ibuprofen 400 mg
generated
three times a day for 3 weeks +
Control group: Ibuprofen only (n = 59
LOE = Level I
education
(14M + 45F), age = 57.7 10.00)
Study group: Ibuprofen and physical ther- Study group ibuprofen + education + 3 times a week physical
apy (n = 60 (24M + 36F), age = 56.3
therapy
10.6)
Pajareya et
al. [39],
2004

At 3 weeks, 21 of 60 patients in
SPADI
the study group had successful
Global rating of pain and
treatment as compared with 11 of
disability
59 in the control group
There was no significant differabduction, IR, and ER
ence in the success rate between
Assessments:
the two groups at the 12th week
Baseline
follow up
6 weeks
12 weeks
24 weeks
At 6 weeks, the total SPADI

CS inj 60 mg triamcinolone SPADI
acetonide and 2cc lidocaine in Active and passive ROM
scores improved significantly
in flexion, abduction, ER
shoulder joint + 20 mg triamcimore in combined group
Group 1: PT alone (n = 27 (1M + 26F),
and active combined mo- ER ROM showed greater imnolone acetonide and 1.5cc lidoage = 53.73 7.49)
tion of the shoulder
caine in subacromial bursa
provement in injection group but
Group 2: CS inj + PT (n = 29 (4M +
PT
10
sessions
it was not significant
Assessments:
25F), age = 53.71 6.69)
TENS
Group 3: CS inj alone (n = 31 (2M +
Baseline
Ice
27F), age = 53.33 7.49)
6 weeks
Active ROM ex
DOS:
n = 87
NO HEP
Interventions

Results
assessments
Greater improvement observed
Intervention 2 times a week for SPADI
for all shoulder ROM during the
15 weeks with each phase lasting 3 Shoulder ROM in flexion,
abduction, IR and ER
C phases, the SPADI scores did
weeks
A no treatment baseline phase,
not behave similarly nor to the
B phases (B1 and B2) exercise only 20 min of mob with each tech for 10 Assessments:
same extent
min
treatment phases, and
Baseline
The SPADI scores deteriorated in

C phases (C1 and C2) exercise plus mo- Joint mob 2 types of Maitland Twice every week till the
phase A but improved in phases
grade IV mobs
bilization phases.
th
15 week
B1, C1, and B2
Exercise
stretching,
active
asDOS: 5 months post onset of symptoms
sisted ex

symptoms (DOS)
A 54-year-old male with a 5-month history
ABCBC where
Design = RCT
MOR Not stated
LOE = Level II
LOE = Level V
Design and Level of

Evidence (LOE)
Design = Single case
design (ABCBC)
Maryam et
al. [60],
2012
Maricar et
al. [35],
2009
Author/Year
Table 3, continued
258
Design = RCT
n = 78
MOR Sealed en- Male = 30, Female = 48
CS inj 20 mg triamcinolone and
velopes
Group A (Inj + PT group) CS (saline)
2 ml saline. Combined approach
LOE = Level II
inj + PT (n = 20 (9M + 11F), age = 56.3
1.5 ml anterior approach, 1.5 ml
6.4)
lateral approach
Group B (inj group) CS (saline) inj + no PT 8 sessions in 4 weeks
PT (n = 19 (6M + 13F), age = 52.3
PNF
9.3)
Maitland mob.
Group C (PT group) saline inj + PT
IFT
(n = 20 (6M + 14F), age = 52.6 7.7)
Active ex therapy
Group D (control group) saline inj + PT
(n = 19 (9M + 10F), age = 55.2 9.4)
DOS:
CS inj + PT group 14.2 4.4 weeks
CS inj group 12.2 5.3 weeks
PT group 14.4 4.4 weeks
Placebo group 14.9 3.7 weeks
Ryans et
al. [50],
2005
Intervention period 8 supervised

in-office therapy sessions and 17
episodes of self-stretching home
program over a 4-week period.
8-minute active warm-up on
body ergometer
Positional coracohumeral ligament (CHL) stretching repetition
along with cold pack (515 minutes)
Volitional rotator cuff exercises
(10 repetitions)
HEP positional CHL stretching
with cold pack for 20 minutes
(twice per day)
51 years old female employed as a coder

DOS: 6 weeks
Design = Case
report
LOE = Level V
Ruiz [38],
2009
Rill et
al. [30],
2011
6/52: significant improvement in

SDQ
SDQ and global VAS for steroid
Passive ROM in shoulder
injection only
ER
Significant improvement in pas Pain using VAS scale
sive external rotation for PT
VAS global disability
16/52: No significant improve SF-36
ment across all interventions for
Assessments:
all outcomes
Baseline
6 weeks
16 weeks
Baseline
4 weeks
Assessments:
DASH and SPADI scores im DASH

proved following 1 month after
SPADI
the onset of physical therapy
Active/Passive ROM in
shoulder flexion, abduc- Passive ER ROM showed greater
improvement than other movetion, combined extension/
ments
adduction ER, IR, and
reaching back to the spine
with the thumb

Results
assessments
Intervention period average of 9 Simple shoulder test and In the non-operative group, forward elevation, ER and IR to the
ASES
weeks
back improved significantly from
Active ROM in forward
Non-operative group:
pre-treatment to post-treatment
elevation, ER, and IR to
Supervised physiotherapy +
Self-assessed shoulder function
the back
NSAIDs and home exercise:
also improved for the entire
4-quadrant stretching in for- Assessments:
group
ward elevation, ER, IR, and
Baseline
cross-body adduction
3.4 months (Range 1 to
HEP 3 times daily
22 months)
Physical therapy + injection:
all activities in the above
group + corticosteroid inj
Interventions

symptoms (DOS)
n = 85 with 88 shoulders, 52 yrs. (range 34
72 yrs.)
Male = 29, Female = 52 (59 shoulders)
Non-operative group: n = 61 (23M +
38F), age = 53.4 yrs.
Surgery group: n = 24 (6M + 18F), age
= 47.3 yrs.
DOS:
Non-operative group: 8 months (range 1
to 48 months)
Surgery group: 7.9 months (range 1 to
60 months)
Design and Level of

Evidence (LOE)
Design =
Retrospective
cohort study
LOE = Level III
Author/Year
Table 3, continued
259
Sun et
al. [51],
2001
Stergioulas [27],
2008
DOS: < 3 months
Experimental group: Therapeutic activity/

active + passive exercises (n = 10 (3M
+ 7F), age = 42.9 6.5)
Control group: Therapeutic activity and
active exercises alone (n = 10 (6M + 4F),
age = 42.7 9.0)

symptoms (DOS)
n = 20 (range 3560 yrs.)
Exercise only group 7.1 3.9 months

Exercise + acupuncture group 5.5 1.6
months
DOS:
Design = RCT
n = 35, range 4169 years
MOR Random ta- Male = 11, Female = 24
Acupuncture Zhongping point
ble method
Group A Exercise only (n = 22 (7M + PT gentle stretching , ROM and
LOE = Level I
15F), age = 57.1 8.6)
HEP (Chart)
Group B Exercise +acupuncture (n =
13 (4M + 9F), age = 55.0 7.6)
Active laser group: 26.5 12.8 weeks

Placebo group: 27.1 13.6 weeks

assessments
Functional hand-to-back
Baseline
4 weeks
8 weeks
16 weeks
Baseline
6 weeks
20 weeks
Assessments:
Constant Shoulder
Assessment (CSA)
Assessments:

SPADI
Croft shoulder disability
questionnaire
DASH
HAQ
Active ROM in shoulder flexion and abduction,
and ER
Therapeutic activity program and Assessments:

active exercises Codman pen- Baseline
dulum exercises, pulley exerci 6 weeks
ses, shoulder wheel, finger stepping and corner search, and
reaching out tasks (45 minutes
/6 times a week)
Passive ROM exercises passive
ROM in flexion, adduction, abduction, IR, ER, circumduction,
and supraspinatus stretching
(15 minutes/6 times a week)
Interventions
Design = RCT
n = 63
Intervention period 8 weeks (12
MOR Sealed en- Male = 40, Female = 23
sessions)
velopes
Active laser group: low level laser therapy Active laser group: 810-nm Ga LOE = Level I
(LLLT) (n = 31 (19M + 12F), age =
Al-As laser with continuous output of 60 mW applied to 8 points
55.1 5.84)
on the shoulder for 30 seconds
Placebo group: placebo laser treatment
each, for a total dose of 1.8 J per
(n = 32 (21M + 11F), age = 56.83
point and 14.4 J per session
6.82)
Placebo group: sham laser
DOS:
Design and Level of

Evidence (LOE)
Samnani [53], Design = RCT
MOR Not stated
2004
LOE = Level II
Author/Year
Table 3, continued
Compared with the exercise

group the exercise + acupuncture group was significantly
improved
Improvements in scores by
39.8% and 76.4% were seen for
the exercise and the exercise +
acupuncture groups, respectively
at 6 weeks and were sustained at
the 20-week re-assessment
Significant decrease in pain

scores at 4, 8 and 16 weeks
Significant decrease in SPADI
and Croft shoulder disability
questionnaire scores at 4, 8, and
16 weeks
Significant decrease in DASH
scores at 8 and 12 weeks
Significant decrease in HAQ
scores at 4 and 8 weeks
ROM improved but didnt reach
the significance level
Relative to placebo group, active

laser group showed
Functional hand-to-back improved

more in patients who performed
passive exercises along with therapeutic activities than patients who
were treated with therapeutic activities alone
Results
260
Vermeulen et Design = Case se- n =7, 50.2 6.0 yrs. (aged 4165 yrs.)
ries
al. [33],
LOE = Level IV
DOS: 8.4 3.3 months (range 3 to
2000
12 months)
High grade mob group 8 months

Low grade mob group 9 months
DOS:
End range mobilization

Massage
US, SWD, and electrotherapy
Active exercises
Intervention period 3 months

(twice per week)
n = 100 (presented 92), 51 yrs. (range 45 Intervention 2/week for 30 min

57 yrs.)
12 weeks
High grade group Grade III/IV
High grade mob group (n = 44 (15M + Low grade group Grade I/ II
29F))
Low grade mob group (n = 48 (15M +
33F))
Design = RCT
MOR Computer
generated
LOE = Level I
Van den
Hout et
al. [41],
2005
Ulusoy et
al. [31],
2011
Active and passive ROM All subjects showed improvement in shoulder abduction, flexin shoulder flexion, abion, and ER active and passive
duction, and ER
ROM
Arthrographic assessment The mean capacity of the GH
joint. capsule increased
of joint capacity
Measurement of GH joint. 4 subjects rated their shoulder
function as excellent, 2 rated as
Abduction ROM using
good, and 1 rated it as moderate
plain radiograph
All patients maintained their gain
Assessments:
in joint mobility at 9 month
Baseline
follow-up
3 months
9 months
Costs
HG mob group received 2.9 ses Utility and quality adsions less than LG mob group
justed life years (QALY) PT also less in HG group but not
significant
Assessment:
Hospitalization more in HG
12 weeks
group

Results
assessments
Average length of supervised phys- Passive ROM in shoulder Following physiotherapy, shoulder flexion, abduction, and ER
flexion, abduction, ER,
iotherapy 3.5 0.5 weeks
ROMs improved significantly
and total ROM
All patients received physiother Shoulder pain also decreased sigapy program (35 times/week) + Pain using VAS scale
nificantly following physiotherAssessments:
NSAIDs
apy
Baseline
Hot pack (20 minutes)
The resolved patients
US (510 minutes)
were re-evaluated 1
TENS/IFT
4 years after supervised
Passive stretching exercises
physiotherapy
Codman and wall climbing exercises
Interventions

symptoms (DOS)
n = 29, 55.4 9.2 yrs.
DOS: 15.7 8.3 weeks (range 6 to 36
weeks)
Design and Level of

Evidence (LOE)
Design =
Retrospective
cohort study
LOE = Level III
Author/Year
Table 3, continued
261
n = 30 (presented 28) 5 more lost to follow Intervention 2/week for 30 min FLEX-SF
+ simple ex (pendulum + scapu- Shoulder kinematics
up
lar setting ex) 3 weeks each in- Assessments:
ABAC group (n = 14 (1M + 13F), age tervention = 12 weeks
Baseline
Mid-range mob
= 53.3 6.5)
3 weeks
ACAB group (n = 14 (3M + 11F), age End-range mob
6 weeks
= 58.0 10.1) where A = MRM, B = Mob with movement
9 weeks
ERM and C = MWM)
12 weeks
DOS:
Design = RCT
MOR Computer
generated
LOE = Level II
Yang et
al. [56],
2007
ABAC group 18 8 weeks

ACAB group 22 10 weeks
Assessments:
niques (30 minutes)
HEP stretching and isometric Baseline
strengthening, progressing to re- Every week till 12th
sisted exercises as tolerated
week
Additionally, MWM corrected

scapulohumeral rhythm significantly better than ERM did
Overall, subjects in both groups

improved over the 12 weeks
Statistically significant improvements were found in ERM and
MWM
Intervention period average of 10 Active ROM in shoulder All patients improved significantly
abduction, flexion, and in active ROM of shoulder abducvisits over a mean of 14 weeks
ER
tion, flexion, and ER
Soft tissue mobilization tech-
n=8
DOS: > 3 months
Design = Case
series
LOE = Level IV
HGMT group 8 months (range 514.5

months)
LGMT group 8 months (range 614
months)
DOS:
High grade mob group (n = 49 (17M +

32F), age = 51.6 7.6)
Low grade mob group (n = 51 (17M +
34F), age = 51.7 8.6)

Results
assessments
Intervention 2/week for 30 min Active and passive ROM Both groups improved over
12 months
in shoulder flexion, ab12 weeks
HGMT group showed sig.
duction, and ER
High grade group Grade III/IV
greater changed scores for pas Shoulder disability (SRQ
Low grade group Grade I/II
sive abduction (at the time points
and SDQ)
3 and 12 months), and for active
and passive external rotation (at
SF-36
12 months)
Assessments:
At 12 months, HGMT group
Baseline
showed greater changes in pas 3 months
sive external rotation, SRQ, and
6 months
SDQ than the LGMT group
12 months
Interventions
Wies [34],
2005
Vermeulen
et al. [42],
2006

symptoms (DOS)
n = 100 (presented 96), range 4557 yrs.
Design and Level of

Evidence (LOE)
Design = RCT
MOR Computer
generated
LOE = Level I
Author/Year
Table 3, continued
262
Design and Level of

Evidence (LOE)
Design = RCT
MOR Computer
generated
LOE = Level II
(twice per week)
Interventions
19.6 12.8 weeks

Criteria Control group:
22.4 9.2 weeks
Control group:
15.8 10.7 weeks
Criteria Intervention group: end-range Criteria intervention group:

end-range mobilization and
mobilization and scapular mobilization
scapular mobilization
treatment approach (EMSMTA) (n = 10
(EMSMTA)
(3M + 7F), age = 56.8 7.2)
Criteria Control group: standardized Criteria Control and control
group:
treatment approach (n = 12 (2M + 10F),
age = 54.9 10.3)
Passive mid-range mobiliza Control group: standardized treatment aption
proach (n = 10 (5M + 5F), age = 54.3
Flexion and abduction stretch7.6)
ing techniques
US, SWD, electrotherapy
DOS:
Active exercises
Criteria intervention group:

symptoms (DOS)
n = 32
Baseline
4 weeks
8 weeks
Assessments:

assessments
Passive ROM for shoulder
Hand behind back distance
FLEX-SF
Shoulder kinematics
Subjects in the EMSMTA group
experienced greater improvement
in outcomes compared with the
criteria-control group and control
group at 4 and 8 weeks
Results
AC adhesive capsulitis; ADL activities of daily living; AM - anterior mobilization; AROM - active range of motion; ASES American Shoulder and Elbow surgeons assessment form;
CPM - continuous passive motion; CMA Constant Murley assessment; CSA Constant shoulder assessment; CS inj. corticosteroid injection; DASH Disabilities of the Arm Shoulder
and Hand ; DOS duration of symptoms; EA electro-acupuncture; EMSMTA End-range mobilization and scapular mobilization treatment approach; ER external rotation; ERM end
range mobilization; FLEX-SF flexion scale of shoulder function; FS frozen shoulder; GH jt. glenohumeral joint; HAQ Health-assessment questionnaire; HEP home exercise program;
HG mob high grade mobilization; HGMT high grade mobilization therapy; IA improved angle; IFT interferential therapy; LG mob low grade mobilization; LGMT low grade
mobilization therapy; LOE level of evidence; MOR method of randomization; MRM mid range mobilization; MWM mobilization with movement; n = number of subjects; N/A Not
Applicable; NSAIDs non steroidal anti-inflammatory drugs; PCS-12 Physical component summary 12; PM posterior mobilization; PNF proprioceptive neuromuscular facilitation;
PROM passive range of motion; PT physical therapy; RCT randomized, controlled trial; ROM range of motion; SDQ shoulder disability questionnaire; SDS - shoulder dynasplint
system; SF-36 Short Form-36 health survey; SPADI Shoulder Pain and Disability Index Score; SRQ shoulder rating questionnaire; SWD short wave diathermy; TENS transcutaneous
electrical nerve stimulation; US ultrasound; VAS visual analogue Scale. Data given as mean SD, unless stated otherwise.
Yang et
al. [57],
2012
Author/Year
Table 3, continued
263
Noa Not formally discussed by authors.
Avoided contamination Random assignment Blinded Monitored Accounted for Reported reliability Reported validity Follow- Total number
and co-intervention
to conditions
assessment intervention all subjects
of measures used of measures used
up
of criteria met
Arslan and Celikar [26], 2001
No
Yes
No
Yes
Yes
No
No
Yes
4
Calis et al. [43], 2006
No
Yes
No
Yes
Yes
No
No
Yes
4
Carette et al. [44], 2003
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
7
elik. [54], 2010
No
Yes
No
Yes
Yes
Noa
No
Yes
4
Chan et al. [55], 2010
No
Yes
Yes
Yes
Yes
Yes
Yes
No
6
Cheing et al. [45], 2008
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
7
Diercks et al. [62], 2004
No
No
No
Yes
Yes
No
Yes
Yes
4
Dogru et al. [46], 2008
No
Yes
No
Yes
Yes
No
No
Yes
4
Dudkiewicz et al. [29], 2004
No
No
No
Noa
Noa
No
No
Yes
1
Dundar et al. [47], 2009
No
Yes
No
Yes
Yes
No
No
Yes
4
Earley and Shannon [37], 2006
Noa
No
No
Yes
Yes
No
No
Yes
3
Gaspar and Willis [61], 2009
Yes
No
No
Yes
Yes
No
No
No
3
Griggs et al. [6], 2000
No
No
No
Yes
Yes
No
No
Yes
3
Guler-Uysal and Kozanoglu [48], 2004
Yes
Yes
Yes
Yes
Yes
No
No
No
5
Hsieh et al. [40], 2012
Noa
Yes
Yes
Yes
Yes
Yes
Noa
No
5
Janjua and Ali [36], 2011
No
No
No
Yes
Yes
No
No
No
2
Jewell et al. [25], 2009
No
No
No
Yes
Yes
Noa
Noa
Yes
3
Johnson et al. [59], 2007
Yes
Yes
No
Yes
Yes
Noa
Yes
No
5
Jrgel et al. [63], 2005
Noa
No
No
Yes
Noa
No
No
No
1
Kumar et al. [28], 2012
Yes
Yes
No
Yes
Yes
No
No
No
4
Leung and Cheing [58], 2008
Noa
Yes
Yes
Yes
Yes
Yes
Yes
Yes
7
Levine et al. [32], 2007
No
No
No
Yes
Yes
No
No
No
2
Ma et al. [49], 2006
No
Yes
No
Yes
Yes
Yes
Yes
No
5
Maricar et al. [35], 2009
Yes
No
No
Yes
Yes
Yes
Yes
No
5
Maryam et al. [60], 2012
No
Yes
Yes
Yes
Yes
Noa
Noa
No
4
Pajareya et al. [39], 2004
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
7
Rill et al. [30], 2011
No
No
No
Yes
Yes
No
No
Yes
3
Ruiz [38], 2009
Yes
No
No
Yes
Yes
Yes
Yes
No
5
Ryans et al.[50], 2005
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
7
Samnani [53], 2004
No
Yes
No
Yes
Noa
No
No
No
2
Stergioulas [27], 2008
No
Yes
Yes
Yes
Noa
Yes
Yes
Yes
6
Sun et al. [51], 2001
Yes
Yes
Yes
Yes
Yes
Noa
Noa
Yes
6
Ulusoy et al. [31], 2011
No
No
No
Yes
Yes
No
No
Yes
3
Van den Hout et al. [41], 2005
No
Yes
Yes
Yes
Yes
No
No
No
4
Vermeulen et al. [33], 2000
No
No
Yes
Yes
Yes
Yes
Yes
Yes
6
Vermeulen et al. [42], 2006
No
Yes
No
Yes
Yes
Yes
Yes
Yes
6
Wies [34], 2005
No
No
No
Yes
Yes
No
No
No
2
Yang et al. [56], 2007
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
7
Yang et al. [57], 2012
No
Yes
Yes
Yes
Yes
Yes
Yes
No
6
Author/Year
Table 4
Quality review: Criteria demonstrating rigor of study
264
three studies were case series, and four studies were

case reports. Five studies [3952] were assigned level
I because of the randomized design and large number
of subjects included. Twenty four studies [26,28,43
48,50,51,5360] which were randomized trials with
small sample sizes (less than or equal to 30 per group)
were classified at level II. Eight studies [25,2932,
6163] were assigned level III because of their nonrandomized design (cohort design). Three studies [6,
33,34,37] were assigned level IV and four studies [35
38] were assigned level V based on their case series
and case report designs, respectively. Except four studies [25,3032,41], all the studies included in this review were prospective studies.
3.2. Quality review
The results of the qualitative review are summarized in Table 4. Overall, the results of the quality review were good. Of the 39 studies included
based on the 8 criteria, six studies each met 7 [39,
44,45,50,56,58], 6 [27,33,42,51,55,57], and 5 [35,38,
40,48,49,59] of Sacketts critical appraisal criteria, respectively. Nine studies [26,28,29,41,43,46,54,60,62]
met 4, six studies [6,18,25,30,31,37,61] met 3, four
studies [32,34,36,53] met 2, and two studies [47,63]
met 1 of Sacketts critical appraisal criteria, respectively (Fig. 2). Twenty four studies assigned their
subjects randomly to either the experimental or control group [2629,3946,4851,5360]. Of the twenty
four randomized studies, eleven studies failed to disclose their method of randomization [26,43,4549,52
54,60]. Generally, interventions were monitored by a
physical therapist or took place in a clinic (38 out
of 39 studies). Only eleven studies managed to avoid
cross-contamination of results [28,35,38,39,44,48,50,
51,56,59,61]. The studies that did avoid confounding
results specifically requested their subjects not seek
out or participate in additional treatments. Except four
studies [27,47,53,63], all studies included in the review accounted for subjects in their study. Fifteen
out of thirty nine studies [27,33,3941,44,45,48,50,
51,5558,60] utilized blinded assessment of the subjects pre- and post-treatment. Only fourteen studies
included minimal discussion of reliability (pain 3
studies [27,33,55], range of motion 5 studies [33,35,
39,40,55], and function 11 studies [27,35,38,42,44,
45,49,5558]) and validity (pain 2 studies [27,59],
range of motion 2 studies [33,35], and function 11
studies [27,35,38,42,45,49,50,5558,62]) of outcome
measures utilized in their studies. Twenty one studies
265
included follow-up of the subjects [6,2527,2931,33,

37,39,4247,50,51,54,58,62]. We used a cut-off point
(6 points) for considering a study as high quality. On
the basis of this, twelve studies were considered high
quality studies [27,33,39,42,44,45,50,51,5558].
3.3. Interventions
Interventions included therapeutic exercises [6,29,
31,3739,53,54,62,63], joint mobilizations of the shoulder girdle [7,28,35,36,41,42,5557,59], Mobilization-with-Movement [56], Cyriaxs manipulation [48],
acupuncture [49,51], electro-acupuncture and interferential therapy [45], ultrasound [46], continuous passive
motion [47], heat [58], splinting [61], laser [27], occupational based treatment (exercises to mimic patients
occupation) [37] and physical therapy compared with
corticosteroid injections [26,40,43,44,50,60].
A variety of active exercise interventions were used
as conservative treatment for frozen shoulder, and
many utilized the combination of range of motion exercises with mobilization, stretching, massage, or electrotherapy. Celik et al. [54] compared the effects of
scapulothoracic exercises versus scapulothoracic exercises and glenohumeral exercises combined. Three
studies studied the effect of physical therapy program alone, NSAID alone or physical therapy and
NSAIDs [29,31,39]. Five studies developed rehabilitation protocols and studied their effectiveness [6,34,
38,53,63] while Diercks et al. [62] tried to compare
physical therapy with supervised neglect (supportive
therapy and exercises within pain limit). Earley and
Shannon [37] used occupation based treatment along
with home exercise program. Gaspar and Willis [61]
used shoulder dynasplint in isolation or in combination
with physical therapy to assess the effect of splinting
in frozen shoulder.
Among the studies that used mobilization of the
shoulder girdle, three studies [28,36,55] studied the effect of Maitland mobilization on patients with frozen
shoulder while Johnson et al. [59] compared the effects of anterior vs. posterior mobilization, Van den
Hout et al. [41] and Vermeulen et al. [42] compared
the effects of high vs. low grade mobilization. Maricar
et al. [35] in their case study, tried to evaluate the effects of exercise only vs. mobilization and exercise
combined. Vermeulen et al. [33] utilized end-range
mobilization and studied its effect on frozen shoulder
patients while Yang et al. [56] compared mid-range
mobilization, end-range mobilization and mobilization
with movement to evaluate the effect of specific mo-
266
Fig. 2. The results of the qualitative review. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BMR-130443)
bilization techniques on patients with frozen shoulder.

Yang et al. [57] took this intervention a step further and
studied the effects of combined end-range mobilization along with scapular mobilization treatment. GulerUysal et al. [48] compared Cyriaxs manipulation with
physical therapy.
Two studies by Ma et al. [49] and Sun et al. [51]
compared acupuncture to acupuncture and physical
therapy combined and a control group but Ma et
al. [49] incorporated no home exercise program whereas Sun et al. [51] incorporated a home exercise program in their intervention protocol. The effects of
electro-acupuncture and interferential therapy [45],
deep and superficial heat [58], continuous passive motion [47] and ultrasound [46] were assessed in combination with stretching/ home exercises vs. either
stretching alone or exercise alone with home exercise
program. Stergioulas [27] compared low level laser
treatment with sham laser therapy. We also included
the studies that compared the effects of local corticosteroid injections with physical therapy [26,43,44,
50,60]. These studies either compared corticosteroid
injections alone to physical therapy [26,43] or corticosteroid injections combined with physical therapy
to corticosteroid injection alone or physical therapy
alone [44,50,60].
3.4. Outcome measures

A variety of outcome measures were utilized in
the thirty nine studies and almost all studies used
more than one outcome measure (Table 1). The most
common outcome measures in the reviewed studies
were pain (with visual analogue scale (VAS)) [6,25
28,31,33,37,39,42,43,4550,54,55,58,59,63] (22 out
of 39 studies), goniometric range of motion [6,26
40,4244,4650,5355,5761,63] (33 out of 39 studies), and various functional outcome measures such
as American Shoulder and Elbow Surgeons Assessment Form (ASES) [30,58], Constant Murley Assessment (CMA) [43,45,47,51,54,62], Croft shoulder assessment scale [27], Disabilities of the Arm
Shoulder and Hand Questionnaire (DASH) [6,27,38],
Flexion Scale of Shoulder Function (FLEX-SF) [56,
57], Health Assessment Questionnaire (HAQ) [27],
Physical Component Summary 12 (PCS-12) [25],
Self-assessment disability questionnaire [59], Shoulder Disability Questionnaire (SDQ) [40,42,50], Shoulder Pain and Disability Index Score (SPADI) [27,28,
35,3840,44,46,47,55,60], Shoulder Rating Questionnaire (SRQ) [42], and VAS global disability [39,50].
Nine studies [6,32,4042,44,46,49,50] measured general health status of their patients via short form-36.
Yang et al. [56,57] also measured shoulder kinematics as an outcome measure of their interventions. All
267
Table 5
Grades of recommendations
Grade of recommendations for shoulder pain relief
Mobilization (High grade)
Grade A
Therapeutic exercises
Grade A
Low level laser therapy
Grade A
Corticosteroid injection
Grade B
Acupuncture + exercises
Grade B
Electro-acupuncture and IFT Grade B
Continuous passive motion
Grade B
Deep heat
Grade B
Ultrasound
Not recommended
Grade of recommendations for improvement in shoulder range of motion
Grade A
Grade A
Corticosteroid inj + PT
Grade B
Grade B
Deep Heat
Grade B
Dynasplint + PT
Grade C
Not recommended
Not recommended
Grade of recommendations for improvement in shoulder function
Grade A
Grade A
Grade B
Grade B
Electro-acupuncture and IFT Grade B
Deep heat
Grade B
Ultrasound
Not recommended
Not recommended
groups in the reviewed studies were comparable at

baseline.
4. Discussion
A great number of therapeutic regimens have been
recommended for frozen shoulder, but none of them
have been consistently proved for efficacy. Therefore,
this review was attempted to aid physical therapists
in making the best choice among PTI by determining
the comparability of the results in the recently published studies relating to the PTI for the management
of different stages of frozen shoulder. Although frozen
shoulder is one of the most prevalent shoulder condition affecting the general population, only 39 studies were found relating to the PTI for the management
of frozen shoulder in the past 12 years while meeting the criteria for this systematic review. Most of the
studies included in the review had good quality criteria. In general, patients in stage 2/stage 3 were found
to better respond to physical therapy, stretching, and
other rehabilitation programs as compared to patients
in stage 1. The exact biological mechanisms by which
the PTIs improve tissue healing are not yet understood

but they are believed to facilitate collagen production
and tendon healing. Corticosteroid injections seem to
be the treatment of choice in patients with stage 1
frozen shoulder due to their ability to reduce inflammation and pain associated with stage 1.
The studies in the review showed a variety of outcome measures of different quality and clinical relevance for evaluating the effects of PTI in the management of frozen shoulder. When the thirty nine reviewed
studies were grouped by area of measured outcome
measures, three major categories emerged: pain, range
of motion, and function. After compiling information
from the quality and level of evidence reviewed, we
believe that the comments can be made regarding the
quality issues and effect of PTI in these categories.
Grades of recommendation can be given based on the
level of evidence demonstrated by the studies and clinical guidelines can be created for what is best practice
for the management of frozen shoulder.
4.1. Pain
The reduction in pain is often cited as the primary
goal of PTI in frozen shoulder; however, only 22 of
268
the 39 studies measured pain. Of the twenty two studies, six [6,31,37,39,54,63] utilized therapeutic exercises, seven [25,28,33,42,48,55,59] utilized mobilization therapy, three [26,43,50] compared corticosteroid
injections and physical therapy, and six studies (1 study
each) utilized acupuncture [49], electro-acupuncture
and interferential therapy [45], continuous passive motion [47], heat [58], ultrasound [46], and low level laser
therapy [27] to study their effects on pain. One study
looked at the effects of different physical therapy interventions [25] on reducing pain in patients with frozen
shoulder.
Six studies that utilized therapeutic exercises had patients in various stages of frozen shoulder. two studies [37,63] reported to study subjects in stage I, one
study [31] used patients in stage II, 1 study [6] used
patients in stage III, 1 study [39] used mixed stages,
and one study [54] failed to report the mean duration of
the frozen shoulder. All the six studies suggested that
the exercises they used in their studies were effective
in reducing pain in patients with frozen shoulder.
In the studies that evaluated the effects of mobilization therapy in patients with frozen shoulder, six authors [25,28,33,42,48,59] found mobilizations to be effective along with home exercise program whereas one
study [55] didnt find mobilization to be effective over
home exercise program in controlling pain. The difference in results could be attributed to limited sample
size and enrollment of stage 1 frozen shoulder patients
in Chan et al. study [55] as compared to other studies. The five studies mentioned above, primarily had
patients in stage II frozen shoulder enrolled in them.
Mixed results were found among the three studies
that compared corticosteroid injections and physical
therapy [26,43,50]. The findings of this review indicate
that in general, corticosteroid injections are more effective than PTI in short term pain relief, and to a lesser
extent in the long term pain relief. Both Arslan and Celikar [26] and Ryans et al. [50] suggested that corticosteroid injections helped in better managing pain as
compared to PTI and exercises in short term follow-up,
however, the effect disappeared in long term followup. On the contrary, Calis et al. [43] found pain relief
with physical therapy applications more pronounced
than corticosteroid injections.
Ma et al. [49] compared the effects of physical therapy to acupuncture and found pain to be better controlled by acupuncture as compared to physical therapy. They suggested integration of acupuncture and
physical therapy for short term pain relief. Several
studies also evaluated the effects of various physi-
cal therapy modalities for pain relief in patients with

frozen shoulder. For example, Cheing et al. [45] found
both electro-acupuncture and interferential therapy to
be effective in short term and long term pain relief;
Dundar et al. [47] found continuous passive motion
to reduce pain more than active stretching exercises at
short term follow-up; and Leung and Cheing [58] suggested better pain relief with deep heating and stretching exercises to superficial heat and stretching exercises at short term and long term follow-up. In contrast
to these findings with various physical therapy modalities, Dogru et al. [46] did not find any benefit of using
ultrasound for pain relief in frozen shoulder patients.
Stergioulas [27] also found low level laser therapy to
help in significant pain relief in short term and long
term follow-up.
On the basis of available level of evidence, mobilization, therapeutic exercises and low level laser therapy
can be given grade A recommendation for short term
pain relief in patients with frozen shoulder. Studies that
utilized corticosteroid injections, acupuncture, electroacupuncture and interferential therapy, continuous passive motion, and deep heat were graded as level II and
therefore, grade B recommendation can be supported
by this review for the use of these interventions for
short term pain relief for patients with frozen shoulder. The use of ultrasound for pain relief is not recommended.
4.2. Range of motion (ROM)
The ROM was the most studied outcome measure
in the reviewed articles for PTI in patients with frozen
shoulder (33 of the 39 studies). In all the 33 studies, ROM was measured using a goniometer. Of the
thirty three studies, eleven [1,6,29,31,34,3739,53,54,
63] investigated the effect of therapeutic exercises,
nine [28,33,35,36,42,48,55,57,59] utilized mobilization, six [26,40,43,44,50,60] compared the effect of
corticosteroid injections and physical therapy, and six
studies (1 study each) evaluated the effect of acupuncture [49], continuous passive motion [47], heat [58], ultrasound [46], low lever laser [27], and dynasplint [61]
on range of motion. Two studies [30,32] evaluated subjects who were treated with either non-operative means
or operative means.
Therapeutic exercises were generally found to be
effective in improving ROM at either short term or
long term follow up. All studies reported the beneficial
effects of exercises on ROM in patients with frozen
shoulder. The subjects represented in these studies varied from Stage I to Stage III when enrolled in the study.
In the studies that evaluated the effects of mobilization therapy in patients with frozen shoulder, five studies [28,36,48,57,59] found mobilization along with exercises to be effective in improving ROM at short term
follow-up. At the long term follow-up, these findings
are consistent with the studies of Maricar et al. [35],
Vermeulen et al. [33] and Vermeulen et al. [42]. However, Chan et al. [55] did not find any significant difference in ROM following mobilization, possibly due
to limited sample size in their study.
The findings of this review indicate that in general,
PTI are more effective than corticosteroid injections
in short term ROM improvement. Calis et al. [43] and
Ryans et al. [50] suggested that PTI helped in better
improving passive ROM as compared to corticosteroid
injections in short term follow-up, however, the effect
disappeared in long term follow-up. Carette et al. [44]
found the combination of corticosteroid injection and
PTI to be more effective in improving active and passive ROM than either corticosteroid injections only or
PTI only. In contrast, Maryam et al. [60] found active
and passive ROM to be improved more in corticosteroid injection group. Arslan and Celikar [26] found
no difference in the effect of PTI and corticosteroid injections in improving active/passive ROM in short term
follow-up.
Ma et al. [49] compared the effects of physical therapy to acupuncture and found ROM to be better improved by physical therapy as compared to acupuncture. They further reported that combined acupuncture and physical therapy gives better improvement
in ROM than either acupuncture alone or physical
therapy alone. The authors suggested integration of
acupuncture and physical therapy for short term improvement in ROM. Several studies also evaluated the
effects of various physical therapy modalities for improvement in ROM. Dundar et al. [47] found continuous passive motion to be no different in improving ROM than active stretching exercises at short term
follow-up. Leung and Cheing [58] suggested more
improvement in ROM with deep heat and stretching
exercises to superficial heat and stretching exercises
at short term and long term follow-up. Gaspar and
Willis [61] in their cohort study found dynasplint combined with physical therapy to be more effective in improving ROM than physical therapy alone or splinting alone in patients with frozen shoulder at initial and
long term follow-up. Stergioulas [27] did not find low
level laser to help in significant ROM improvement in
short term and long term follow-up.
On the basis of available level of evidence, therapeutic exercises and mobilization can be given grade A
269
recommendation for short term improvement in ROM

in patients with frozen shoulder. Corticosteroid injections, acupuncture, and deep heat can be given grade
B recommendation, and the use of dynasplint can be
given grade C recommendation for improving short
term ROM in frozen shoulder patients. Continuous
passive motion and low level laser for improving ROM
is not recommended.
4.3. Function
Various functional outcome measures were used to
measure function in the reviewed articles for PTI in
patients with frozen shoulder (26 of the 39 studies).
All the functional outcome measures used in the reviewed articles have been reported to be valid and reliable. Of the twenty six studies, five [6,38,39,54,62]
assessed the effects of therapeutic exercises, nine [25,
28,35,41,42,5557,59] studied the effect of mobilization therapy, five [40,43,44,50,60] compared the effect of corticosteroid injections and physical therapy, six studies (1 study each) evaluated the effect
of acupuncture [51], continuous passive motion [47],
ultrasound [46], heat [58], low level laser [27] and
electro-acupuncture and interferential therapy [45] on
improvement of function. One study [30] tried to assess the patients response when through non-operative
means as compared to operative means.
Of the five studies that assessed the effects of therapeutic exercises, four studies reported exercises to improve function [6,38,39,54] whereas one study [62]
found supervised neglect to be better than physical
therapy in improving function in patients with frozen
shoulder.
In the studies that evaluated the effects of mobilization therapy, mixed results were reported in the reviewed studies. Two studies [35,55] did not find significant change in the function following mobilization
therapy whereas other studies reported mobilization
to be effective in improving function in patients with
frozen shoulder. Specifically, high grade mobilization,
end range mobilization and mobilization with movement, and end range mobilization and scapular mobilization techniques were reported to be more effective
in improving function in patients with frozen shoulder.
Mixed findings were reported in the reviewed studies about the effect of PTI and corticosteroid injections in functional improvement. Carette et al. [44] and
Maryam et al. [60] found the combination of corticosteroid injection and PTI to be more effective in improving function than either corticosteroid injections
270
only or PTI only. Ryans et al. [50] found corticosteroid injections only to be more effective in improving function than either the combination of corticosteroid injection and PTI or PTI only. In contrast, Calis
et al. [43] found PTI to be better in improving function
than either sodium hyaluronate injection only or corticosteroid injection only. Calis et al. [43] also found PTI
to be effective in long term follow up as well whereas
Maryam et al. [60] and Ryans et al. [50] found the contrary.
Sun et al. [51] compared the effects of physical
therapy to acupuncture and reported that combined
acupuncture and physical exercises gives better improvement in function than physical exercises alone.
The authors suggested integration of acupuncture and
physical therapy for short term improvement in function. Several studies also evaluated the effects of various physical therapy modalities for improvement in
function. Leung and Cheing [58] suggested more improvement in function with deep heat and stretching
exercises to superficial heat and stretching exercises at
short term and long term follow-up. Stergioulas [27]
recommended that low level laser therapy can also be
used to improve function at both short term and long
term follow-up. Electro-acupuncture and interferential
therapy were also reported to be effective in improving
function by Cheing et al. [45]. In contrast to these studies, Dundar et al. [47] found that continuous passive
motion is no different in improving function than active stretching exercises. Dogru et al. [46] did not find
any benefit of using ultrasound for improving function
in patients with frozen shoulder.
On the basis of available level of evidence, therapeutic exercises and mobilization can be given grade A
recommendation for short term improvement in function. Of the two studies comparing corticosteroid injections and physical therapy, both studies were level
I studies. No specific recommendation can be given to
either the combination of corticosteroid injection and
PTI and corticosteroid injections only or PTI only for
improving short term function in patients with frozen
shoulder. Grade B recommendation can be supported
by this review for the use of acupuncture, low level
laser, and electro-acupuncture and interferential therapy along with physical exercises, for short term functional improvement in treatment of frozen shoulder.
Continuous passive motion and the use of ultrasound
for improving function are not recommended. The passive modalities may decrease inflammation associated
with frozen shoulder and allow patients to use their
shoulder with less pain. The negative effects of ultra-
sound may be attributed to ineffective parameter selection. Continuous passive motion may have limited impact on function unless the patients are encouraged to
functionally use their shoulder.
5. Methodological limitations
The interpretation of the results of many studies describing therapeutic regimens is hampered by methodological flaws, such as small number of subjects, lack
of indication for duration of symptoms before treatment, high dropout rates, the use of co-interventions,
and a short follow-up. Moreover, many studies do not
even provide details regarding the stage of the disease
process, previous treatments, and etiological considerations.
Since only 12 studies were considered high quality,
the results must be viewed in perspective of the good
methodological quality of the individual studies. However, the nature of the interventions does not allow a
design that meets all methodological criteria. For example: double blinding is usually impossible in studies with PTI. Therefore, we used a low cut-off point (6
points) for considering a study as high quality.
The best-evidence synthesis using a rating system
based on the quality of the individual studies has its
limitations. Rating is to some extent subjective, and a
high quality level can be difficult to score. However, by
ranking the evidence of the conclusions, some insight
can be gained in the strength of the conclusions.
There is limited literature on the effectiveness of
specific exercise regimen for the treatment of frozen
shoulder. While there were few studies addressing the
effects of therapeutic exercises for frozen shoulder, no
identical exercise regimen was followed in any of the
studies and the measured outcomes were not always
superior to the compared interventions. Additionally,
the intensity, frequency, duration of exercises and the
use of physical therapy modalities varied across studies.
The duration of symptoms in the reviewed studies
ranged from 6 weeks to 10.2 months, placing the subjects in all three stages 1, 2 and 3 of frozen shoulder.
The majority of the studies evaluated patients in stage
2 and 3 and therefore, the recommendations provided
in this review article apply only to patients with stage
2 and stage 3 frozen shoulder.
6. Clinical relevance and future research

When different stages of frozen shoulder and the
associated pathophysiology are taken into account, it
would seem reasonable that certain treatments would
be more effective at different times. Many studies in
the past have not taken this into consideration which
may seriously influence their results. Clinically, instead of time wise classification, classification based
on stage of pathology, which is related to patients irritability level (low, moderate, and high) [7] should
be used when deciding on rehabilitation interventions.
Kelley et al. [7] suggested irritability to be determined
upon pain, range of motion, and disability status of
the patient. Patients in early stage frozen shoulder will
demonstrate high level of irritability and patients in
later stages will have low irritability.
Future research into the effectiveness of specific exercises for pain relief, ROM improvement and improved functional status is needed. Additionally, further research is needed in determining the optimal
dose of different exercises such as the intensity, frequency, and duration of exercises for patients with
frozen shoulder.
This review targets physical therapy clinicians and
health researchers. The information will be most useful for decision-makers wanting to know which interventions are the best buys when making decision on
the available interventions. A study of interest may be
identified as appropriate for a particular setting and,
following some re-analysis to reflect individual patient requirements, the intervention may be considered
by clinicians for translation into practice. The review
may also act as a reference guide for various interventions utilized in clinics and the relative differences
between the interventions as compared using reliable
and validated outcome measures. In addition, the review has highlighted the gaps in treatment methods,
and steers researchers and clinicians towards improving their practice and reporting high-quality clinical
findings, while building on existing knowledge.
271
abduction ROM, high grade mobilization and mobilization with movement along with self exercises are
recommended for improving function. Low level laser
therapy is strongly suggested for pain relief and moderately suggested for improving function but not recommended for improving ROM. This review also supports
the evidence of using local corticosteroid injections as
the treatment of choice in patients with stage 1 frozen
shoulder, followed by the use of corticosteroid injections along with PTI in patients with stage 2 frozen
shoulder. Acupuncture along with physical therapy exercises is also moderately recommended for pain relief,
improving ROM and function in patients with frozen
shoulder. Electro-acupuncture and interferential therapy can also help in providing short term pain relief.
While the continuous passive motion is recommended
for short term pain relief, it is not recommended for improving ROM or function in patients with frozen shoulder. Evidence also suggests the use of deep heat for
pain relief and improving ROM. There is also mild evidence for the use of dynasplint in restoring ROM. The
use of ultrasound for pain relief, improving ROM or
improving function for treatment of frozen shoulder is
not recommended.
The results of this review must be viewed in perspective to limited database search and heterogeneity of the
studies. Both the lack of use of standardized/identical
exercises and varied physical therapy modalities in different studies limit the ability to generalize these findings in order to treat patients with frozen shoulder in
the clinic. In order to apply these findings to the clinical
settings, future studies should examine whether particular PTI protocols specifically improve pain, ROM and
functionality, and then apply follow-up data to prove
effectiveness of the intervention.
Acknowledgements
The authors have not received any financial payments or other benefits from any commercial entity related to the contents of the work being presented.
7. Conclusions
From this review, therapeutic exercises and mobilization therapy are strongly recommended for reducing pain, improving ROM and function in patients with
stages 2 and 3 frozen shoulder. While high grade posterior mobilization along with self exercises is recommended for improving passive external rotation and
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The effectiveness of physiotherapeutic

Northern Arizona University

Univesity of Kansas Medical Center, KC, KS,

Available from: Tarang Kumar Jain

Journal of Back and Musculoskeletal Rehabilitation 27 (2014) 247273

The effectiveness of physiotherapeutic

prevalence of frozen shoulder is unknown, but is often

c 2014 IOS Press and the authors. All rights reserved

Patients in this phase present

Treatment goal aggressively treat

Treatment goal maintain the

May last between 03 months.

May last between 915 months.

May last between 1524 months

May last between 39 months.

The risk of being affected appears to be increased

tory of frozen shoulder as a continuum of 3 phases: 1)

Computer database search (n=2917)

Unrelated articles excluded based on title

Screening of title and abstract for

Irrelevant and uncertain articles excluded

Duplicate articles excluded (n=915)

Articles excluded (n=62)

Included in review (n=39)

Fig. 1. Selection of studies.

Design and Level of

At 6 weeks and 3 months, the to CS inj 40 mg triamcinolone SPADI

DOS: Not stated

Group 1: Sodium hyaluronate Pain using VAS scale

Outcome measures and

Patients characteristics and duration of

Group 1: 6.71 6.50 months

n = 70 (range 3390 yrs.)

Passive mobilization group 2.5 months

DOS: Not stated

Group 1: GH ROM exercises (n = 14

Patients characteristics and duration of

Design and Level of

Group 1 EA treatment for 10

Active and active-assisted

Both groups received 30 mg triamcinolone acetonide (Kenalog)

Intervention period 10 weeks

Both groups had HEP twice

lief, when needed

Constant Murley Assessment (this should be in the

Pain using VAS scale

Significant change in CMA and

By week 10, both groups showed

Outcome measures and

Design = Prospective n = 54, Male = 26, Female = 28

Intervention period 2 years

Outcome measures and

Intervention period 20 days

All the outcome measures im Pain using VAS scale

Active ROM in shoulder Active ROM improved significantly

CPM group: CPM for 1 h once

US group: 6.3 3.5 months

ulation of the GH joint

At both 12 and 24 months time period, patients in the group treated

Shoulder ROM in flexion, No significant difference in

ROM increased b/w pre and post

n = 49, 55.4 7.6 yrs. (aged 4172 yrs.)