Jurnal Frozen PDF

Galley Proof 21/11/2013; 9:53 File: bmr443.tex; BOKCTP/wyn p.
Journal of Back and Musculoskeletal Rehabilitation 00 (2013) 1–27 1

DOI 10.3233/BMR-130443
IOS Press
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 Sackett’s 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 1. Introduction of age, with a female predominance (58:42) [1,3]. It 8
is characterized by a spontaneous onset of pain with 9
2 Frozen shoulder or adhesive capsulitis is a mus- gradual, progressive loss of glenohumeral joint mo- 10
3 culoskeletal condition that is commonly encountered tion which can lead to gross loss of shoulder func- 11
4 in physical therapy practice. The exact incidence and tion. The conditions usually starts with one shoulder 12
5 prevalence of frozen shoulder is unknown, but is often and commonly affects the contralateral side years af- 13
6 quoted to affect approximately 2% to 5% of the general ter the onset of symptoms in the first shoulder but 14
7 population [1–4] and mainly individuals 40–65 years it does not affect the same shoulder twice [3,5–8]. 15
The risk of being affected appears to be increased 16
by trauma/surgery [9], hormonal diseases such as di- 17

∗ Corresponding author: Neena K. Sharma, Department of Physi- abetes, ACTH deficiency, and thyroid disease [10, 18
cal Therapy and Rehabilitation Science, University of Kansas Med-
ical Center, Mailstop 2002, 3901 Robinson Building, Kansas City,
11], cardiac diseases [12], neurologic diseases such as 19
KS 66160, USA. Tel.: +1 913 588 4566; Fax: +1 913 588 4568; E- Parkinson’s and stroke [13], neurosurgery [14], ma- 20
mail: nsharma@kumc.edu. lignancies [15], hyperlipidemia [16], certain medica- 21
ISSN 1053-8127/13/$27.50
c 2013 – IOS Press and the authors. All rights reserved
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2 T.K. Jain and N.K. Sharma / The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis
Table 1
Stages of frozen shoulder
Stage 1 Stage 2 Stage 3 Stage 4
The preadhesive stage The acute adhesive or “freezing” The fibrotic or “frozen” stage The “thawing” phase
stage
Hyper vascular synovitis with Decrease in hyper vascular syn- Less synovitis but more mature ad- Severe capsular restriction with-
normal underlying capsule. ovitis with early adhesion forma- hesion in the capsule and axillary out apparent synovitis.
tion leading to capsular contrac- fold.
tion and thickening.
Patients present with mild or no Patients have a high level of dis- Patients note significant motion Patients in this phase present
end-range limitation and pain. comfort, limited passive and ac- limitation with minimal pain. with painless restriction of mo-
tive motion, and increased pain tion, which typically improves by
near end-range of motion. remodeling.
Treatment Goal – decrease pain Treatment Goal – restore the nor- Treatment goal – aggressively treat Treatment goal – maintain the
by interrupting the cycle of in- mal glenohumeral biomechanics significant loss of motion and re- normal range of motion and
flammation and pain in addition to decreasing inflam- store normal range of motion and shoulder function while main-
mation and pain. functionality of the shoulder joint. taining the normal glenohumeral
biomechanics and avoiding pain
and inflammation.
May last between 0–3 months. May last between 3–9 months. May last between 9–15 months. May last between 15–24 months
22 tions such as metalloproteinase inhibitors, protease in- but subsequent reports have described a longer and 55
23 hibitors, antiretrovirals, influenza and pneumococcal more protracted course in many patients. Later, Han- 56
24 vaccine, and fluoroquinolones, and Dupuytren’s con- nafin and Chiaia described 4 stages (Table 1) incorpo- 57
25 tracture [17]. rating the arthroscopic stages described by Nevaiser, 58
26 Although, the underlying etiology and pathophysi- the clinical examination, and the histological findings 59
27 ology of frozen shoulder is poorly understood and dis- in frozen shoulder patients [2]. 60
28 agreement remains in the literature whether to define The diagnosis of frozen shoulder is based upon a 61
29 this pathologic process as an inflammatory or a fibros- thorough history and physical examination without for- 62
30 ing condition [4], several authors have attempted to mal criteria. The most used criteria in previous studies 63
31 identify homogeneous subgroups to simplifying treat- to diagnose frozen shoulder are – insidious or minimal 64
32 ment choices and make outcomes more predictable. event resulting in onset, significant shoulder pain that 65
33 Lundberg categorized frozen shoulder patients into interferes with successful activities of daily living, sig- 66
34 two subgroups – idiopathic/primary frozen shoulder nificant night pain, significant limitations of active and 67
35 when patients displayed symptoms with no identifiable passive shoulder motion in more than 1 plane to less 68
36 cause, and secondary when patients had a similar pre- than 100◦ and 50% or greater than 30◦ loss of passive 69
37 sentation and progression but resulted from a known external rotation (at the side), painful end range motion 70
38 intrinsic, extrinsic, or systemic cause [3]. in all movements, significant pain/weakness of the in- 71
39 Patients with frozen shoulder typically demonstrate ternal rotators, normal radiological appearance, and no 72
40 a characteristic history, clinical presentation, and re- secondary causes [3,5,7,8,19]. 73
41 covery. It is believed to be a self-limiting condition, Many treatments have been advocated to treat frozen 74
42 lasting 18–24 months with no long-term sequelae. Al- shoulder: rest/education, analgesia, joint mobilization, 75
43 though majority of patients show complete resolution thermotherapy, massage, therapeutic exercises and 76
44 of the disease, many others report long term pain and physical therapy, acupuncture, oral and injected corti- 77
45 residual motion restriction [8,16,18]. Various authors costeroids, laser therapy, capsular distension, manipu- 78
46 have tried to characterize the natural course of the lation under anesthesia, nerve blocks, and arthroscopic 79
47 frozen shoulder but it still remains controversial. For capsular release [7,20,21]. Currently there is no con- 80
48 example, Reeves in 1975 described the natural his- sensus as to which treatment is most effective in frozen 81
49 tory of frozen shoulder as a continuum of 3 phases: 1) shoulder patients [20]. Generally the treatment regi- 82
50 painful (freezing) phase lasting 10–36 weeks, 2) stiff mens include a trial of conservative therapy, followed 83
51 (frozen) phase lasting 4–12 months, and 3) recovery by more invasive procedures for recalcitrant cases. 84
52 (thawing) phase lasting 5–26 months or more [19]. In However, varied inclusion criteria, different diagnos- 85
53 their report, the full duration of the disease lasted any- tic criteria and treatment protocols, and numerous out- 86
54 where from 1 to 3.5 years, with a mean of 30 months, come measures used in studies make study compar- 87
T.K. Jain and N.K. Sharma / The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis 3
Computer database search (n=2917)

MEDLINE (n=1061)
CINAHL (n=54)
Cochrane Review (n=48) Unrelated articles excluded based on title
PEDro (n=55) and abstract (n=1829)
ProQuest (n=946)
Science Direct (n=630)
Sport Discus (n=123) Duplicate articles excluded (n=915)
Screening of title and abstract for Irrelevant and uncertain articles excluded
inclusion and exclusion (n = 173) (n=46)
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.
88 isons difficult. Many studies do not provide details 2. Methods 115
89 regarding the stage of the disease process, previous

90 treatment, and etiological considerations. Despite the To conduct this systematic review, a literature search 116
91 amount of research that has been carried out into this
and review was performed using MEDLINE, Cumu- 117
92 topic, the results still appear to be inconclusive regard-
lative Index to Nursing and Allied Health Litera- 118
93 ing the effectiveness of interventions specifically for
94 frozen shoulder. Selecting or grouping subjects based ture (CINAHL), Cochrane, Physiotherapy Evidence 119
95 on specific criteria would enhance the validity, repro- Database (PEDro), ProQuest, Science Direct, and 120
96 ducibility, and comparability of the results. Physical Sport Discus databases (Fig. 1). The databases were 121
97 therapy alone is an effective treatment but is also a used to search the literature on the University of 122
98 complement to other therapies [5]. Kansas library system initially during the month of 123
99 The purpose of this review is to systematically con- March–April 2011 and then updated in January 2012. 124
100 sider the evidence from the recent published literature The search was limited to human subjects and articles 125
101 on the effectiveness of physical therapy interventions published in English within last 12 years. 126
102 (PTI) for the management of frozen shoulder. To focus the search on the PTI for the treatment 127
of frozen shoulder, “adhesive capsulitis” and “frozen 128

103 1.1. Objectives
shoulder”, the two most common terms used to de- 129
104 The main objectives of our review are: scribe the condition, were used as key terms for the 130
105 1. To analyze the functional outcomes in patients search. The MEDLINE search was conducted in two 131
106 who received PTI for the management of frozen ways. First, we conducted search using the MeSH ter- 132
107 shoulder as compared to those given no treat- minology restricted to MeSH major topic with pre- 133
108 ment, other treatment or a placebo control. vention and control, rehabilitation, and therapy as sub- 134
109 2. To present the best-available evidence of the ef- headings. Second, we used the basic search index us- 135
110 fectiveness of PTI for the management of frozen ing the combinations of these two key terms and the 136
111 shoulder. “AND” operation with the following terms: “physi- 137
112 3. To critically assess the quality of the recently cal therapy”, “physiotherapy”, “manual therapy”, “ex- 138
113 published studies and to identify deficiencies that ercise”, “electrotherapy”, “mobilization”, “acupunc- 139
114 might be corrected by further research. ture”, “rehabilitation”, “treatment”, and “education”. 140
Table 2
Appraisal and recommendation criteria
awarded for each factor met, which generated a poten- 173
tial maximum value of eight points. If information re- 174

Criteria for assessment of methodological quality of studies
garding criteria was not mentioned in the article, no 175
Confounding factors
Random assignment points were assigned for that category. The grade of 176
Blinded assessment recommendation for each of the major outcome mea- 177
Monitored intervention sures was based on the level of supporting evidence. 178
Report of dropout Specifically, grade A is given to a measurement if sup- 179
Descriptions of reliability
Validity of measurements ported by at least one level I study; B if supported by 180
Follow-up at least one level II study; and C if supported by level 181
Hierarchy of quality of individual studies and strength of evidence III, IV, or V evidence. 182
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
3. Results 183
Level V = case report

Formulation of recommendations Thirty-nine studies (n = 4350) from 2917 cita- 184
Grade A – at least one level I study tion postings met the inclusion criteria of the qualita- 185
Grade B – at least one level II study tive review (Fig. 1). All studies assessed the effect of 186
Grade C – if supported by level III, IV, or V evidence.
the PTI in the treatment of frozen shoulder (Table 3). 187
The number of patients in the reviewed studies ranged 188

141 Using this method, the various search combinations, in from 1 to 2370. After the exclusion of one retrospec- 189
142 total, generated 2917 articles. tive study that studied 2370 subjects [25], total num- 190
143 In the first step, the titles and abstracts of these refer- ber of subjects averaged 49.5 with 31.4 (63.4%) sub- 191
144 ences were examined, and articles that were not related jects being females per study. All studies had more fe- 192
145 to the topic of interest or duplicate were removed. Fol- male patients except three studies [26–28] which had 193
146 lowing this screening process, 173 articles were iden- either equal or more number of male patients. The pa- 194
147 tified in the search on the various databases. From the tients’ age ranged from 22–96 years with the mean 195
148 list of 173 articles, irrelevant and uncertain articles age of 53.77 ± 3.97 years. The duration of symp- 196
149 were excluded, including articles comparing surgical toms in the reviewed studies ranged from 6 weeks to 197
150 techniques. Following this screening process, 55 full 10.2 months, placing almost of the subjects in Stages 198
151 text articles were retrieved for further review of ap- 1, 2 and 3 of frozen shoulder. Most studies included 199
152 propriateness and analysis. Articles were included in a separate control group for their experiments, while 200
153 the subsequent analysis if: 1) they were experimental five of the cohort studies had no control group [25,29– 201
154 or quasi-experimental reports from peer-reviewed jour- 32], and six studies were either case series [33,34] or 202
155 nals, 2) an intervention that included “physical ther- case reports [35–38]. Follow-up time post-intervention 203
156 apy”, “manual therapy”, “exercise”, “electrotherapy”, ranged from day 1 to 9.2 ± 9.7 years in the reviewed 204
157 mobilization”, “acupuncture”, “rehabilitation”, “treat- studies. 205
158 ment”, and “education” with the intended goal of treat-

159 ing frozen shoulder was implemented, 3) subjects were 3.1. Level of evidence 206
160 diagnosed with the frozen shoulder diagnostic criteria

161 mentioned above. The excluded articles were those that The level of evidence varied from level V (lowest ev- 207
162 investigated other shoulder disorders, surgical tech- idence) to level I (highest evidence) (Table 4). Twenty 208
163 niques, utilized no treatment such as long term out- four out of thirty nine studies were randomized control 209
164 come studies, and economic evaluation studies. Af- trials with pre- and post-test groups. Eight studies were 210
165 ter applying the inclusion/exclusion criteria, 39 articles cohort design (four prospective and four retrospective), 211
166 were included in the review (Fig. 1). three studies were case series, and four studies were 212
167 In the second step, we evaluated each article inde- case reports. Five studies [39–52] were assigned level 213
168 pendently using a modified version of Sackett’s critical I because of the randomized design and large number 214
169 appraisal criteria outlined by Mortenson and Eng [22]. of subjects included. Twenty four studies [26,28,43– 215
170 Additionally, a level of evidence was assigned for each 48,50,51,53–60] which were randomized trials with 216
171 article and graded as described by Sackett [23], and small sample sizes (less than or equal to 30 per group) 217
172 Butler and Campbell [24] (Table 2). One point was were classified at level II. Eight studies [25,29–32, 218
Table 3
Level of evidence and summary of methods and results
Author/Year Design and Level of Patients characteristics and duration of Interventions Outcome measures and Results
Evidence (LOE) symptoms (DOS) assessments
Galley Proof
Arslan and – Design = RCT n = 20 Intervention period: CS inj. once – Active and passive ROM – ROM improved at both 2 and 12
Celikar [26], – MOR – Not stated Male = 10, Female = 10 and PT-2 weeks in shoulder flexion, ab- week time points.
2001 – LOE = Level II – Group A: 40 mg methylprednisolone ac- – Group A: 40 mg methylpred- duction, IR, and ER – Mean difference in ER ROM at 2
etate injection with local anesthetic (n = nisolone acetate injection with – Pain using VAS scale and 12 weeks in both groups– not
10(3M + 7F), age = 55.6 ± 12.2) 1 ml of 2% lidocaine Assessments: significant
– Group B: PT measures plus NSAIDs (n = – Group B: PT and NSAID – Mean difference in pain VAS at
– Baseline 2 and 12 weeks in both groups –
10(7M + 3F), age = 56.4 ± 7.1) ∗ Hot pack – 20 min – 2 weeks
2
significant
DOS: ∗ US 3.5 W/cm for 5 min – 12 weeks
– Group A = 4.6 ± 1.6 months ∗ Passive GH jt stretching ex
– Group B = 3.5 ± 1.7 months ∗ Codman ex and Wall climbing
Both Group A & B – same HEP
Calis et – Design = RCT n = 95 shoulders – Group 1: Sodium hyaluronate – Pain using VAS scale – In all groups, significant im-
al. [43], – MOR – Not stated Male = 33, Female = 57 30 mg weekly for 2 weeks – Passive ROM in shoulder provements at both the 15th day
2006 – LOE = Level II – Group 1: Sodium hyaluronate 30 mg (n = – Group 2: Triamselonone ase- abduction and IR and 3 month in all parameters.
24 (10M + 14F), age = 59.7 ± 9.81) tonide 40 mg – Constant shoulder assess- – The passive abduction values and
ment scale constant score in PT group better
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– Group 2: Triamselonone asetonide 40 mg – Group 3: Physical therapy

(n = 25 (9M + 16F), age = 56.36 ± ∗ Hot pack – 20 min Assessments: than other groups on the 15th day
11.3) ∗ US 1.5W/cm2 for 5 min and 3 month
– Baseline
– Group 3: Physical therapy (n = 21 (8M + ∗ TENS for 20 min – 15 days
13F), age = 52.33 ± 10.1) ∗ Stretching ex for 10 days – 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
DOS: Not stated
Carette et Design = RCT n=93 – CS inj – 40 mg triamcinolone – SPADI – At 6 weeks and 3 months, the to-
al. [44], MOR – Table of Male = 38, Female = 55 with fluoroscopic guidance – SF-36 tal SPADI scores and total range
2003 random numbers – Group 1: CS inj+PT (n = 21 (7M + 14F), – PT – 12x1 hr sessions (3 × 4 – Active and passive ROM of motion improved significantly
LOE = Level II age = 54.9 ± 10.5) weeks) in shoulder flexion, ab- more in combined group.
– Group 2: CS inj alone (n = 23(8M + ∗ TENS duction and ER Hand be- – There was no difference between
15F), age = 55.4 ± 10.0) ∗ US hind back groups 3 and 4 at any of the
– Group 3: PT alone (n = 26 (14M + 12F), ∗ Ice Assessments: follow-up assessments except for
age = 54.2 ± 8.3) ∗ Active and auto assisted ROM – Baseline greater improvement in the range
– Group 4: Placebo (n = 23(9M + 14F), age ex of shoulder flexion in group 3 at
– 6 weeks 3 months.
= 56.5 ± 9.4) ∗ Mobilization – 3 months
∗ Isometric strengthening ex – At 12 months, all groups had im-
DOS: – 6 months proved to a similar degree with
– Group 1: 22.1 ± 14.9 weeks HEP in both groups – 1 year respect to all outcome measures.
– Group 2: 21.2 ± 11.0 weeks
– Group 3: 20.8 ± 11.2 weeks
T.K. Jain and N.K. Sharma / The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis
– Group 4: 20.3 ± 7.3 weeks

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6
Table 3, continued
Çelik [54], – Design = RCT n = 29, 52.1 yrs. (aged 38–65 yrs.) Intervention period – 6 weeks (30 – Pain using VAS scale – All outcome measures improved
2010 – MOR – Not stated sessions) – Modified Constant score in both groups.
Galley Proof
Male = 7, Female = 22
– LOE = Level II – Group 1: GH ROM exercises (n = 14 (5M – Group 1: Glenohumeral ROM – Shoulder ROM in flexion, – VAS score showed greater im-
+ 9F), age = 54.8; range 42–65 yrs.) exercises IR, and ER provement in group 2 at 6 weeks.
– Group 2: GH ROM + scapulothoracic ex- – Group 2: Glenohumeral ROM + Assessments: – Modified Constant score was not
ercises (n = 15 (2M + 13F), age = 49.6; scapulothoracic exercises significantly different between
– Baseline the groups.
range 38–62 yrs.) – Both groups received TENS, – 6 weeks
cold pack, and NSAIDs – ROM improved significantly in
DOS: Not stated – 12 weeks group 2 at 12 weeks.
following exercises for pain re-
lief, when needed.
∗ Both groups had HEP twice
daily with 20 repeats of exer-
cises.
Chan et – Design = RCT n =15, 54.8 yrs. (aged 38-76 yrs.) Intervention period – 10 weeks – Pain using VAS scale By week 10, both groups showed
al. [55], – MOR – Computer Male = 3, Female = 12 – Both groups received 30 mg tri- – SPADI improvement in pain, shoulder
2010 generated – Passive mobilization group: amcinolone acetonide (Kenalog) – Active ROM in shoulder function and shoulder range of
– LOE = Level II passive mobilization + home care pro- and 3.25 ml 1% lidocaine. abduction, IR, and ER movements, with the control group
21/11/2013; 9:53
gram (n = 7 (2M+5F), age = 50.9; range – Passive mobilization group: Assessments: showing a trend towards better
48–76 yrs.) Grade A & B mobilization (six improvement than the passive
– Baseline mobilization group.
– Control group: home care program only 30 minute weekly sessions over – 2 weeks
(n = 8 (1M+7F), age = 56.7; range 39– 10 weeks) + home care program – 4 weeks
59 yrs.) – Control group: home care pro- – 7 weeks
DOS: gram – – 10 weeks
– Passive mobilization group – 2.5 months ∗ Active and active-assisted
– Control group – 2.4 months ROM exercises
∗ Capsular stretching exercises
∗ Postural correction, and
∗ Scapular stabilizing exercises
Cheing et – Design = RCT n = 70 (aged 33–90 years) – Group 1 – EA treatment for 10 – Constant Murley Assess- Significant change in CMA and
al. [45], – MOR – Not stated Male = 22, Female =48 sessions over 4-week period (2–3 ment (this should be in the VAS score in EA and IFT group as
2008 – LOE = Level II – Group 1: Electroacupuncture + Ex /week) + HEP footnotes) (CMA) score compared to control at least until
(n = 24) – Group 2 – IFT treatment for 10 – Pain using VAS scale the 6 month follow up.
– Group 2: IFT + Ex (n= 23) sessions over 4-week period (2–3 Assessments:
– Group 3: Control (n= 23) /week) + HEP
– HEP– standard set of shoulder ex – Baseline
DOS: 5 times/day for 6 months – Post-intervention
– Group 1: 6.71 ± 6.50 months – 1 month
∗ Forward flexion – 3 months
– Group 2: 6.70 ± 6.05 months ∗ External rotation
– Group 3: 8.26 ± 7.94 months – 6 months
∗ Horizontal adduction
∗ Internal rotation
Table 3, continued
Diercks et – Design = Con- n = 77 Intervention period – 2 years – Constant score At both 12 and 24 months’ time pe-
al. [62], trolled, cohort riod, patients in the group treated
Galley Proof
Male = 30, Female = 47 – Supervised neglect group: educa- Assessments:

2004 study – Supervised neglect group: supportive ther- tion, pendulum and active exer- – Baseline with supervised neglect achieved
– MOR – Computer apy and exercises within the pain limits (n cises within the painless range quicker and greater improvement in
generated – 3-month intervals up to constant score than patients in the
= 45 (19M + 26F), age = 50 ± 6.0) – Physical therapy group: 24 months
– LOE = Level III – Physical therapy group: passive stretching physical therapy group.
∗ Active exercises up to and be-
and manual mobilization (n = 32 (11M + yond the pain threshold
21F), age = 51 ± 7.0) ∗ Passive stretching and manip-
DOS: ulation of the GH joint
– Supervised neglect group – 5 months ∗ Home exercises for stretching
(Range 3–12 months) and maximal reaching.
– Physical Therapy group – 5 months
(Range 3–10 months)
Dogru et – Design = RCT n = 49, 55.4 ± 7.6 yrs. (aged 41–72 yrs.) Intervention – 10 sessions – Shoulder ROM in flexion, – No significant difference in
al [46], – MOR – Not stated Male = 21, Female = 28 (2 weeks) abduction, IR, and ER pain, SPADI and SF-36 between
2008 – LOE = Level II – Group 1: US (n = 25 (11M+14F), age = – US group – US + superficial heat – SPADI groups.
Pain using VAS scale – ROM increased b/w pre and post
21/11/2013; 9:53
53.9 ± 7.8)) + exercise program + HEP

– Group 2: Sham (n = 24 (10M+14F), age – Group 2 – Imitative US + super- – SF-36 treatment in both groups but
= 56.8 ± 7.3)) ficial heat + exercise program + Assessments: more in US group
DOS: HEP – Baseline
– US group: 6.3 ± 3.5 months HEP – 3 months – Post-intervention
– Sham group: 5.2 ± 2.9 months – Codman ex – 3 months
– Active ROM and stretching ex
Dudkiewicz Design = Prospective n = 54, Male = 26, Female = 28 Intervention period – Not stated – Active ROM in shoulder Active ROM improved significantly
et al. [29], cohort study Average age of onset – 51.8 ± 9.7 yrs. (aged All patients were treated with long- elevation, IR, and ER in all the measured movement di-
2004 – LOE = Level III 31–82 yrs.) term course of physical therapy + Assessments: rections.
DOS: 9.7 ± 6.7 months NSAIDs
– Baseline
– Mean follow up period –
9.2 ± 9.7 yrs.
Dundar et – Design = RCT n = 57 Intervention period – 20 days – Pain using VAS scale – All the outcome measures im-
al. [47], – MOR – Not stated Male = 18, Female = 39 – CPM group: CPM for 1 h once – Passive ROM in shoul- proved from baseline.
2009 – LOE = Level II – Group 1: CPM (n = 29 (9M + 20F), age a day for 20 days × 4 weeks + der flexion, abduction, IR, – Pain reduction was significant at
= 56.3 ± 7.8)) HEP and ER follow up compared to baseline.
– Group 2: PT (n = 24(9M+19F), age = – PT group: daily PT including ac- – Constant functional score – CPM application has no superi-
57.1 ± 8.3)) tive stretching and pendulum ex- – SPADI ority over PT on shoulder ROM,
ercises for 1 h once a day for 20 Assessments: functional ability.
DOS:
days × 4 weeks. + HEP – Baseline
– CPM group: 6.3 ± 4.2 months
– PT group: 5.9 ± 4.0 months HEP: passive range of motion and – 4 weeks
pendulum exercises – 3 months (12 weeks)
7
8
Table 3, continued
Earley and – Design = Case re- 53 years old Caucasian female Occupation as means intervention – Pain using VAS Scale Pain and ROM improved continu-
Shannon [37] port University professor – Active ROM in shoulder ously at follow up periods.
Galley Proof
– US
2006 – LOE = Level V DOS: 4 weeks post onset – ADL’s flexion, extension, abduc-
– Games tion, adduction, horizon-
– HEP tal abduction, horizontal
adduction, IR, and ER.
Assessments:
– Baseline
– 6 weeks
– 6 Months
– 9 months
Gaspar and Design = Controlled, n = 62, Intervention – 90 days (PT-more – Active ROM in shoulder – Significant difference was found
Willis [61], cohort study Male = 26, Female = 28 than 2/week, SDS worn more than ER for all treatment groups
2009 – LOE = Level III Average age of onset – 55.6 ± 7.9 yrs. (aged 2/day) Assessments: – The greatest change in active
36–75 yrs.) PT – ER was found for the combined
– Baseline treatment group (mean change of
– Group I (Control (n = 15)); – Moist heat – After 90 days
– Group II (PT exclusively with standard- – Patient education 29◦ ).
21/11/2013; 9:53
ized protocols) (n = 16); – Joint mobilization

– Group III; (Shoulder Dynasplint system – PROM, AROM
exclusively (n = 16)); – PNF
– Group IV (Combined treatment with – Therapeutic ex
Shoulder Dynasplint and standardized PT)
(n = 16)
DOS: Not stated
Griggs et – Design = Case se- n = 75, 53 yrs. (aged 35–76 yrs.) Rehabilitation exercise protocol – 2 – Pain using subjective pain – Significant improvements in pain
al. [6], ries Male = 17, Female = 58 sessions per week questionnaire scores, ROM were observed.
2000 – LOE = Level IV DOS: 9.2 months (range – 1.3–47 months) – Pendulum circumduction – Active and passive ROM – DASH scores were observed to
– Passive stretching exercises in in shoulder in elevation, be lower than the known popula-
forward elevation, ER, horizontal IR, and ER tion norms.
adduction, and IR. – DASH – SF-36 were comparable to age
– SF-36 and gender-matched control pop-
HEP – 5 times per day to the toler- ulations.
able limit Assessments:
– Baseline
– Mid-term evaluation (6–
12 weeks)
– Final (12–41 months)
Guler-Uysal – Design = RCT n = 40, 56.0 ± 8.6 yrs. (aged 40–85 yrs.) Intervention period – 2 weeks – Recovery rate – 19 patients in the CYR group
and Kozano- – MOR – Not stated Male = 12, Female = 28 – CYR group: 1 hour Cyriax mob – Passive ROM in shoul- (95%) and 13 patients in the PT
glu [48], – LOE = Level II der flexion, abduction, IR, group (65%) reached sufficient
– CYR Group: Cyriax (n = 20 (5M + 15F), three times a week (deep friction
2004 age = 53.6 ± 6.9)) Stages I/II – 6/14 massage and manipulation) + and ER ROM at the end of the second
Active stretching and week.
Table 3, continued
– PT Group: PT (n = 20 (7M + 13F), pendulum exercises – Pain during activity ques- – The improvement in shoulder
tionnaire flexion, inner and outer rotation
Galley Proof
age = 58.4 ± 9.7)) Stages I/II – 8/12 – PT group: 1-hour physical ther-
DOS: apy session + active stretching Assessments: values and the decrease in pain
and pendulum exercises with motion were significantly
– CYR Group: 7.6 ± 3.9 months – Baseline better in the CYR group after the
– PT Group: 5.6 ± 3.9 months Hot packs for 20 minutes followed – 1 week first week of treatment.
by SWD applied for 20 minutes – 2 weeks
– HEP: passive range of motion
and pendulum exercises
Hsieh et – Design = RCT n = 70, Intervention period – 12 weeks – Active and passive ROM – Both groups improved in terms
al. [40], – MOR – Computer Male = 20, Female = 50 – Group 1: 20 mg hyaluronate in- in shoulder flexion, ab- of pain, disability, and quality of
2012 generated – Group 1 (HAPT group): Hyaluronate jection once per week for 3 con- duction, IR, and ER life after the treatments.
– LOE = Level I intra-articular injections with PT (n = 32 secutive weeks + PT program – SPADI – The active and passive ROM im-
(12M + 20F), age = 52.6 ± 6.3) for 3 months. – SDQ proved linearly with increasing
– Group 2 (PT group): PT alone (n = 31 – Group 2: PT program only (3 ses- SF-36 treatment duration.
(8M + 23F), age = 56.4 ± 9.0) sions per week for 12 weeks) Assessments: – No significant group effect was
found for any of the outcome
DOS: ∗ Heat therapy – Baseline measurements.
21/11/2013; 9:53
– Group 1 = 5.2 ± 2.6 months ∗ Electric therapy – 1.5 months

– Group 2 = 3.8 ± 2.6 months ∗ Exercise – 3 months
Janjua and – Design = Case re- – 39 years old male Intervention period – 3 weeks (3 – Passive ROM in shoulder At the end of the third week’s treat-
Ali [36], port DOS: 3 months sessions per week) abduction, flexion, and ment, the patient had pain free full
2011 – LOE = Level V – Phonophoresis ER range of motion.
– Moist hot pack Assessments:
– Maitland’s Grade I, II and III dis- – Baseline
traction mobilization – 2 weeks
– Pendular home exercises for – 3 weeks
shoulder
– Soft tissue mobilization
– Isotonic strength exercises using
free weights
Jewell et – Design = n = 2370, 55.3 ± 12.4 yrs. 21 interventions (listed at http:// – Physical Component – None of the patients achieved a
al. [25], Retrospective Male = 820, Female = 1550 ptjournal.apta.org/content/suppl/ Summary-12 (PCS-12) – 50% or greater improvement in
2009 Cohort Study DOS: 41% patients (n ≈ 972) > 90 days 2009/04/24/89.5.419.DC1/zad605 physical function (PF) PCS-12 scores.
– LOE = Level III 09000001.pdf) and bodily pain (BP) – The presence of 2 intervention
– Hybrid function (HF) categories – “joint mobilization
scores and mobility” and “exercise” in-
Assessments: N/A creased the odds of a successful
outcome in the BP and HF mod-
els, respectively.
– Use of iontophoresis, phonopho-

resis, ultrasound, or massage re-
9
Table 3, continued
10
duced the likelihood of improve-
ment in PF, BP, and HF scores by
Galley Proof
19% to 32%.
Johnson et – Design = RCT n = 20, aged 37–66 years Intervention period – 6 sessions – Pain using VAS scale – Pain significantly decreased in
al. [59], – MOR – Random- Male = 4, Female = 16 – Capsule preheated with US – Self-assessment both groups.
2007 numbers table – AM group: Anterior mob (n = 10 (2M + – Joint mob (AM or PM) functional questionnaire – A significant difference between
– LOE = Level II 8F), age = 54.7 ± 8.0)) – Upper body ergometer ex – Active ROM in shoulder groups was present by the third
– PM group: Posterior mob (n = 8 (2M + ER treatment.
No HEP – AM group patients had a mean
6F), age = 50.4 ± 6.9)) Assessments:
improvement in external rotation
DOS: – 1st session ROM of 3.0◦ whereas the PM
– AM group: 8.4 ± 2.12 months – 2nd session group patients had a mean im-
– PM group: 10.9 ± 4.6 months – 3rd session provement of 31.3◦
th
– 4 session
– 5th session
– 6th session
Jürgel et – Design = Prospec- n = 20 Intervention period – 4 weeks – Active ROM in shoulder – In patients with FS, shoulder
al. [63], tive cohort study Male = 6, Female = 14 – Individualized exercise therapy flexion, extension, abduc- flexion, extension, abduction,
21/11/2013; 9:53
2005 – LOE = Level III – Frozen shoulder patient group: n = 10 sessions (30 min/day) tion, adduction, IR, and and adduction and active ROM,
(3M + 7F), age = 50.2 ± 4.6 – massage procedures (20 min/ ER MF in all measured force direc-
– Control group: asymptomatic shoulders as day) – Isometric maximal force tions and net impulse during
control (n = 10 (3M+7F), age = 49.8 ± – electrical therapy procedures of the muscles (MF) for shoulder muscle isometric en-
4.6) (5–10 min/day) shoulder flexors, abduc- durance test for involved extrem-
tion, adduction, IR, and ity increased after rehab.
DOS: 2 weeks – 3 months ER – No significant changes in shoul-
– Shoulder muscle isomet- der IR and ER active ROM for in-
ric endurance volved extremity in patients with
– Pain using VAS scale FS were observed with rehab.
Assessments:
– Baseline
– 4 weeks
Kumar et – Design = RCT n = 40 Intervention period – 4 weeks – Pain using VAS scale – A significant improvement was
al [28], – MOR – Chit pick Male = 26, Female = 14 – Maitland technique: 5 sets of gle- – SPADI recorded in all outcome measures
2012 box method – Group A: Maitland mobilization + exer- nohumeral caudal and postero- – Shoulder ROM in abduc- in both the groups.
– LOE = Level II cises (n= 20, age = 47.9) anterior glides at the rate of 2–3 tion and ER – Group A showed higher
– Group B: Exercises alone (n = 20, age = glides per second for 30 seconds Assessments: improvement than group B.
47.1) (3 days/week for 4 weeks) – Baseline
DOS: Not stated – Supervised exercise program: – 4 weeks
5 days per week for 4 weeks
∗ Codman exercise
∗ Shoulder wheel exercises

∗ Self-stretching exercises
∗ Wall-ladder exercises
Table 3, continued
Leung and – Design = RCT n = 30, age = 59.87 ± 12.45 yrs. (aged 37–Intervention period – 12 treatment – Pain using VAS scale – A significant improvement was
Cheing [58], – MOR – Online ran- 79 years) sessions (20 minute session – 3 – ASES seen in all groups in all out-
Galley Proof
2008 domization Male = 9, Female = 21 days/4 weeks) – Shoulder score index come measures except for that of
– LOE = Level II – Group 1 – SWD + stretching (n = 10, age HEP: pendulum exercises and – Active ROM in shoulder shoulder flexion range.
= 53 ± 8.4) stretching techniques forward elevation, ER, – The improvement in the shoul-
– Group 2 – Hot pack +stretching (n = 10, hand behind back, and der score index and in the range
age = 53 ± 8.6) cross body adduction. of motion was significantly better
– Group 3 – Stretching alone (n = 10) Assessments: in the deep heating group than in
the superficial heating group.
DOS: Not stated – Baseline
– Session 6
– Session 12
– 4 week follow up
Levine et – Design = n = 98 with 105 shoulders, 55 yrs. Intervention period (mean – Active ROM in forward In the non-operative group, forward
al. [32], Retrospective (aged 20–96 yrs.) duration) – elevation, ER and IR elevation and ER improved signif-
2007 cohort study Male = 30, Female = 68 – Physical therapy only – Assessments: icantly from pre-treatment to post-
– LOE = Level III – Non-operative group (94 shoulders) 3.3 months treatment with no significant differ-
– Baseline ence between physical therapy only
–
21/11/2013; 9:53
∗ Physical therapy only – 55 shoulders Physical therapy + Injection – – Post-intervention

4.5 months and physical therapy + injection
∗ Physical therapy + Injection – 39 – 15–121 months group.
shoulders – Operative group – 12.4 months
before surgery
– Operative group (11 shoulders) – Physical therapy group: stan-
DOS: Not stated dardized program + NSAID’s
– Physical therapy + injection
group: standardized program +
corticosteroid inj . + NSAID’s
Ma et – Design = RCT n = 75, 54.8yrs Intervention period – 4 weeks – Active and passive ROM – All patients showed improve-
al. [49], – MOR – Not stated Male = 36, Female = 39 – Acupuncture group: 15 minute in shoulder flexion, exten- ment in quality of life (SF-36).
2006 – LOE = Level II – Control group – PT only (n = 15, age = session – 2 days/4 weeks sion, abduction, IR, and – Pain was controlled better by
54.1) – PT group: 30–40 minute session ER acupuncture while ROM
– Group 1 – Acupuncture only (n = 30 , age – 5 days/4 weeks – Pain using VAS scale improved following physical
= 56.4) – SF-36 therapy. However, patients
∗ SWD – 15 min treated by both methods had the
– Group 2-PT + acupuncture (n = 15, age ∗ Joint mob – 5–10 min Assessments:
= 52.8) best outcome.
∗ Active shoulder ex – 5–10 min – Baseline
DOS: 25.8 weeks – 2 weeks
– 4 weeks
11
Table 3, continued
12
Maricar et Design = Single case A 54-year-old male with a 5-month history Intervention – 2 times a week for – SPADI – Greater improvement observed
al. [35], design (ABCBC) ABCBC where 15 weeks with each phase lasting 3 – Shoulder ROM in flexion, for all shoulder ROM during the
Galley Proof
2009 – LOE = Level V – A – no treatment baseline phase, weeks abduction, IR and ER C phases, the SPADI scores did
– B phases (B1 and B2) – exercise only 20 min of mob with each tech for 10 Assessments: not behave similarly nor to the
treatment phases, and min same extent.
– 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
bilization phases. grade IV mobs th
phase A but improved in phases
15 week B1, C1, and B2.
DOS: 5 months post onset of symptoms – Exercise – stretching, active as-
sisted ex
NO HEP
Maryam et – Design = RCT n = 87 – CS inj – 60 mg triamcinolone – SPADI – At 6 weeks, the total SPADI
al. [60], – MOR – Not stated Male = 9, Female = 78 acetonide and 2cc lidocaine in – Active and passive ROM scores improved significantly
2012 – LOE = Level II – Group 1: PT alone (n = 27 (1M + 26F), shoulder joint + 20 mg triamci- in flexion, abduction, ER more in combined group.
age = 53.73 ± 7.49) nolone acetonide and 1.5cc lido- and active combined mo- – ER ROM showed greater im-
– Group 2: CS inj + PT (n = 29 (4M + caine in subacromial bursa tion of the shoulder provement in injection group but
25F), age = 53.71 ± 6.69) – PT – 10 sessions Assessments: it was not significant.
– Group 3: CS inj alone (n = 31 (2M + ∗ TENS – Baseline
21/11/2013; 9:53
27F), age = 53.33 ± 7.49) ∗ Ice – 6 weeks

DOS: ∗ Active ROM ex
– Group 1: 4.48 ± 3.37 months
– Group 2: 6.21 ± 3.95 months
– Group 3: 6.83 ± 3.75 months
Pajareya et – Design = RCT n = 122 Intervention period – 3 weeks – SPADI – At 3 weeks, 21 of 60 patients in
al. [39], – MOR – Computer Male = 38, Female = 81 – Control group: ibuprofen 400 mg – Global rating of pain and the study group had successful
2004 generated – Control group: Ibuprofen only (n = 59 three times a day for 3 weeks + disability treatment as compared with 11 of
– LOE = Level I (14M + 45F), age = 57.7 ± 10.00) education – Active ROM in shoulder 59 in the control group.
– Study group: Ibuprofen and physical ther- – Study group – ibuprofen + edu- abduction, IR, and ER – There was no significant differ-
apy (n = 60 (24M + 36F), age = 56.3 ± cation + 3 times a week physical Assessments: ence in the success rate between
10.6) therapy the two groups at the 12th week
– Baseline follow up.
DOS: ∗ SWD (20 minutes) – 6 weeks
– Control group: ∗ Mobilization and passive – 12 weeks
– < 6 weeks – n = 6 stretching – 24 weeks
– 6–12 weeks – n = 20 ∗ HEP – pulley exercises, active
– > 12 weeks – n = 33 non-assisted exercises, and hot
– Study group: pack
– < 6 weeks – n = 13
– 6–12 weeks – n = 20
– > 12 weeks – n = 27
Table 3, continued
Rill et – Design = n = 85 with 88 shoulders, 52 yrs. (aged 34– Intervention period – average of 9 – Simple shoulder test and – In the non-operative group, for-
al. [30], Retrospective 72 yrs.) weeks ASES ward elevation, ER and IR to the
Galley Proof
2011 cohort study Male = 29, Female = 52 (59 shoulders) Non-operative group: – Active ROM in forward back improved significantly from
– LOE = Level III – Non-operative group: n = 61 (23M + – Supervised physiotherapy + elevation, ER, and IR to pre-treatment to post-treatment.
38F), age = 53.4 yrs. NSAID’s and home exercise: the back – Self-assessed shoulder function
– Surgery group: n = 24 (6M + 18F), age ∗ 4-quadrant stretching in for- Assessments: also improved for the entire
= 47.3 yrs. ward elevation, ER, IR, and group.
DOS: cross-body adduction – Baseline
– 3.4 months (Range – 1 to
– Non-operative group: 8 months (Range – ∗ HEP – 3 times daily
1 to 48 months) ∗ Physical therapy + injection: 22 months).
– Surgery group: 7.9 months (Range – 1 to all activities in the above
60 months) group + corticosteroid inj
Ruiz [38], – Design = Case 51 years old female employed as a coder Intervention period – 8 supervised – DASH – DASH and SPADI scores im-
2009 report DOS: 6 weeks in-office therapy sessions and 17 – SPADI proved following 1 month after
– LOE = Level V episodes of self-stretching home – Active/Passive ROM in the onset of physical therapy.
program over a 4-week period. shoulder flexion, abduc- – Passive ER ROM showed greater
– 8-minute active warm-up on tion, combined extension/ improvement than other move-
body ergometer adduction ER, IR, and ments.
21/11/2013; 9:53
– Positional coracohumeral liga- reaching back to the spine

ment (CHL) stretching repetition with the thumb
along with cold pack (5–15 min- Assessments:
utes)
– Volitional rotator cuff exercises – Baseline
(10 repetitions) – 4 weeks
HEP – positional CHL stretching
with cold pack for 20 minutes
(twice per day)
Ryans et – Design = RCT n = 78 Intervention period – 4 weeks – SDQ – 6/52: significant improvement in
al. [50], – MOR – Sealed en- Male = 30, Female = 48 – CS inj – 20 mg triamcinolone and – Passive ROM in shoulder SDQ and global VAS for steroid
2005 velopes – Group A (Inj + PT group)– CS (saline) inj 2 ml saline. Combined approach ER injection only.
– LOE = Level II + PT (n = 20 (9M + 11F), age = 56.3 ± 1.5 ml anterior approach, 1.5 ml – Pain using VAS scale – Significant improvement in pas-
6.4) lateral approach – VAS global disability sive external rotation for PT.
– Group B (inj group) – CS (saline) inj + no – PT – 8 sessions in 4 weeks – SF-36 – 16/52: No significant improve-
PT (n = 19 (6M + 13F), age = 52.3 ± ∗ PNF Assessments: ment across all interventions for
9.3) ∗ Maitland mob. all outcomes.
– Group C (PT group) – saline inj + PT (n – Baseline
∗ IFT – 6 weeks
= 20 (6M + 14F), age = 52.6 ± 7.7) Active ex therapy
– Group D (control group) – saline inj + PT – 16 weeks
(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
13
– Placebo group – 14.9 ± 3.7 weeks

Table 3, continued
14
Samnani [53], – Design = RCT n = 20 (aged 35–60 yrs.) Intervention period – 6 weeks – Functional hand-to-back Functional hand-to-back improved
2004 – MOR – Not stated more in patients who performed
Galley Proof
Male = 9, Female = 11 – Therapeutic activity program and Assessments:

– LOE = Level II – Experimental group: Therapeutic activity/ active exercises – Codman pen- – Baseline passive exercises along with thera-
active + passive exercises (n = 10 (3M + dulum exercises, pulley exerci- peutic activities than patients who
– 6 weeks were treated with therapeutic activ-
7F), age = 42.9 ± 6.5) ses, shoulder wheel, finger step-
– Control group: Therapeutic activity and ping and corner search, and ities alone.
active exercises alone (n = 10 (6M + 4F), reaching out tasks (45 minutes
age = 42.7 ± 9.0) /6 times a week).
DOS: < 3 months – Passive ROM exercises – passive
ROM in flexion, adduction, ab-
duction, IR, ER, circumduction,
and supraspinatus stretching
(15 minutes/6 times a week).
Stergiou- – Design = RCT n = 63 Intervention period – 8 weeks (12 – Pain using VAS scale Relative to placebo group, active
las [27], – MOR – Sealed en- Male = 40, Female = 23 sessions) – SPADI laser group showed
2008 velopes – Active laser group: low level laser therapy – Active laser group: 810-nm Ga- – Croft shoulder disability – Significant decrease in pain
– LOE = Level I (LLLT) (n = 31 (19M + 12F), age = 55.1 Al-As laser with continuous out- questionnaire scores at 4, 8 and 16 weeks
21/11/2013; 9:53
± 5.84) put of 60 mW applied to 8 points – DASH – Significant decrease in SPADI

– Placebo group: placebo laser treatment (n on the shoulder for 30 seconds – HAQ and Croft shoulder disability
= 32 (21M + 11F), age = 56.83 ± 6.82) each, for a total dose of 1.8 J per – Active ROM in shoul- questionnaire scores at 4, 8, and
point and 14.4 J per session. der flexion and abduction, 16 weeks.
DOS: and ER
– Placebo group: sham laser – Significant decrease in DASH
– Active laser group: 26.5 ± 12.8 weeks Assessments: scores at 8 and 12 weeks.
– Placebo group: 27.1 ± 13.6 weeks – Significant decrease in HAQ
– Baseline
– 4 weeks scores at 4 and 8 weeks.
– 8 weeks – ROM improved but didn’t reach
– 16 weeks the significance level.
Sun et – Design = RCT n = 35, aged – 41-69 years Intervention period – 6 weeks – Constant Shoulder – Compared with the exercise
al. [51], – MOR – Random ta- Male = 11, Female = 24 – Acupuncture – Zhongping point Assessment (CSA) group the exercise + acupunc-
2001 ble method – Group A – Exercise only (n = 22 (7M + – PT – gentle stretching , ROM and Assessments: ture group was significantly
– LOE = Level I 15F), age = 57.1 ± 8.6) HEP (Chart) improved.
– Baseline – Improvements in scores by
– Group B – Exercise +acupuncture (n = 13 – 6 weeks
(4M + 9F), age = 55.0 ± 7.6) 39.8% and 76.4% were seen for
– 20 weeks the exercise and the exercise +
DOS: acupuncture groups, respectively
– Exercise only group – 7.1 ± 3.9 months at 6 weeks and were sustained at
– Exercise + acupuncture group – 5.5 ± 1.6 the 20-week re-assessment.
months
Table 3, continued
Ulusoy et – Design = n = 29, 55.4 ± 9.2 yrs. Average length of supervised phys- – Passive ROM in shoulder – Following physiotherapy, shoul-
al. [31], Retrospective flexion, abduction, ER, der flexion, abduction, and ER
Galley Proof
Male = 14, Female = 15 iotherapy – 3.5 ± 0.5 weeks

2011 cohort study DOS: 15.7 ± 8.3 weeks (range – 6 to 36 – All patients received physiother- and total ROM ROMs improved significantly.
– LOE = Level III weeks) apy program (3–5 times/week) + – Pain using VAS scale – Shoulder pain also decreased sig-
NSAIDs Assessments: nificantly following physiother-
apy.
∗ Hot pack (20 minutes) – Baseline
∗ US (5–10 minutes) – The resolved patients
∗ TENS/IFT were re-evaluated 1–
∗ Passive stretching exercises 4 years after supervised
∗ Codman and wall climbing ex- physiotherapy
ercises
Van den – Design = RCT n = 100 (presented 92), 51 yrs. (aged 45–57 Intervention – 2/week for 30 min × – Costs – HG mob group received 2.9 ses-
Hout et – MOR – Computer yrs.) 12 weeks – Utility and quality ad- sions less than LG mob group.
al. [41], generated Male = 30, Female = 62 – High grade group – Grade III/IV justed life years (QALY) – PT also less in HG group but not
2005 – LOE = Level I – High grade mob group (n = 44 (15M + – Low grade group – Grade I/ II Assessment: significant.
29F)) – Hospitalization more in HG
– 12 weeks group
– Low grade mob group (n = 48 (15M +
21/11/2013; 9:53
33F))
DOS:
– High grade mob group – 8 months
– Low grade mob group – 9 months
Vermeulen et – Design = Case se- n =7, 50.2 ± 6.0 yrs. (aged 41–65 yrs.) Intervention period – 3 months – Active and passive ROM – All subjects showed improve-
al. [33], ries Male = 4, Female = 3 (twice per week) in shoulder flexion, ab- ment in shoulder abduction, flex-
2000 – LOE = Level IV DOS: 8.4 ± 3.3 months (Range – 3 to – End range mobilization duction, and ER ion, and ER active and passive
12 months) – Massage – Pain using VAS scale ROM
– US, SWD, and electrotherapy – Arthrographic assessment – The mean capacity of the GH
– Active exercises of joint capacity joint. capsule increased.
– Measurement of GH joint. – 4 subjects rated their shoulder
Abduction ROM using function as excellent, 2 rated as
plain radiograph good, and 1 rated it as moderate.
Assessments: – All patients maintained their gain
in joint mobility at 9 month
– Baseline follow-up.
– 3 months
– 9 months
15
Table 3, continued
16
Vermeulen – Design = RCT n = 100 (presented 96), age – 45–57 yrs. Intervention – 2/week for 30 min × – Active and passive ROM – Both groups improved over 12
et al. [42], – MOR – Computer 12 weeks in shoulder flexion, ab- months.
Galley Proof

2006 generated – High grade mob group (n = 49 (17M + – High grade group – Grade III/IV duction, and ER – HGMT group showed sig.
– LOE = Level I 32F), age = 51.6 ± 7.6) – Low grade group – Grade I/II – Shoulder disability (SRQ greater changed scores for pas-
– Low grade mob group (n = 51 (17M + and SDQ) sive abduction (at the time points
34F), age = 51.7 ± 8.6) – Pain using VAS scale 3 and 12 months), and for active
– SF-36 and passive external rotation (at
DOS: 12 months).
Assessments:
– HGMT group – 8 months (range – 5–14.5 – At 12 months, HGMT group
months) – Baseline showed greater changes in pas-
– LGMT group – 8 months (range – 6–14 – 3 months sive external rotation, SRQ, and
months) – 6 months SDQ than the LGMT group.
– 12 months
Wies [34], – Design = Case n=8 Intervention period – average of 10 – Active ROM in shoulder All patients improved significantly
2005 series Male = 2, Female = 6 visits over a mean of 14 weeks abduction, flexion, and in active ROM of shoulder abduc-
– LOE = Level IV DOS: > 3 months – Soft tissue mobilization tech- ER tion, flexion, and ER
niques (30 minutes) Assessments:
21/11/2013; 9:53
– HEP – stretching and isometric – Baseline

strengthening, progressing to re- – Every week till 12th
sisted exercises as tolerated week
Yang et – Design = RCT n = 30 (presented 28) 5 more lost to follow Intervention – 2/week for 30 min – FLEX-SF – Overall, subjects in both groups
al. [56], – MOR – Computer up + simple ex (pendulum + scapu- – Shoulder kinematics improved over the 12 weeks.
2007 generated Male = 6, Female = 24 lar setting ex) × 3 weeks each in- Assessments: – Statistically significant improve-
– LOE = Level II – ABAC group – (n = 14 (1M + 13F), age tervention = 12 weeks ments were found in ERM and
– Baseline MWM.
= 53.3 ± 6.5) – Mid-range mob – 3 weeks
– ACAB group – (n = 14 (3M + 11F), age – End-range mob – 6 weeks Additionally, MWM corrected
= 58.0 ± 10.1) where A = MRM, B = – Mob with movement – 9 weeks scapulohumeral rhythm significan-
ERM and C = MWM) – 12 weeks tly better than ERM did.
DOS:
– ABAC group – 18 ± 8 weeks
– ACAB group – 22 ± 10 weeks
Table 3, continued
Yang et – Design = RCT n = 32 Intervention period – 8 weeks – Passive ROM for shoulder Subjects in the EMSMTA group
al. [57], – MOR – Computer (twice per week) abduction, IR, and ER experienced greater improvement
Galley Proof

2012 generated – Criteria – intervention group: end-range – Criteria – intervention group: – Hand behind back dis- in outcomes compared with the
– LOE = Level II mobilization and scapular mobilization end-range mobilization and tance criteria-control group and control
treatment approach (EMSMTA) (n = 10 scapular mobilization – FLEX-SF group at 4 and 8 weeks.
(3M + 7F), age = 56.8 ± 7.2) (EMSMTA) – Shoulder kinematics
– Criteria – Control group: standardized – Criteria – Control and control Assessments:
treatment approach (n = 12 (2M + 10F), group: – Baseline
age = 54.9 ± 10.3) ∗ Passive mid-range mobiliza- – 4 weeks
– Control group: standardized treatment ap- tion – 8 weeks
proach (n = 10 (5M + 5F), age = 54.3 ± ∗ Flexion and abduction stretch-
7.6) ing techniques
DOS: ∗ US, SWD, electrotherapy
– Criteria – intervention group: ∗ Active exercises
19.6 ± 12.8 weeks
– Criteria – Control group:
22.4 ± 9.2 weeks
– Control group:
21/11/2013; 9:53
15.8 ± 10.7 weeks
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.
17
Table 4
18
Quality review: Criteria demonstrating rigor of study
Author/Year 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
Galley Proof
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
Çelik. [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
21/11/2013; 9:53
Jürgel 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
Noa – Not formally discussed by authors.
219 61–63] were assigned level III because of their non- 3.3. Interventions 266
220 randomized design (cohort design). Three studies [6,

221 33,34,37] were assigned level IV and four studies [35– Interventions included therapeutic exercises [6,29, 267
222 38] were assigned level V based on their case series 31,37–39,53,54,62,63], joint mobilizations of the sho- 268
223 and case report designs, respectively. Except four stud- ulder girdle [7,28,35,36,41,42,55–57,59], Mobiliza- 269
224 ies [25,30–32,41], all the studies included in this re- tion-with-Movement [56], Cyriax’s manipulation [48], 270
225 view were prospective studies. acupuncture [49,51], electro-acupuncture and interfer- 271
ential therapy [45], ultrasound [46], continuous passive 272
motion [47], heat [58], splinting [61], laser [27], occu- 273
226 3.2. Quality review pational based treatment (exercises to mimic patients 274
occupation) [37] and physical therapy compared with 275
227 The results of the qualitative review are summa- corticosteroid injections [26,40,43,44,50,60]. 276
228 rized in Table 4. Overall, the results of the qual- A variety of active exercise interventions were used 277
229 ity review were good. Of the 39 studies included as conservative treatment for frozen shoulder, and 278
230 based on the 8 criteria, six studies each met 7 [39, many utilized the combination of range of motion ex- 279
231 44,45,50,56,58], 6 [27,33,42,51,55,57], and 5 [35,38, ercises with mobilization, stretching, massage, or elec- 280
232 40,48,49,59] of Sackett’s critical appraisal criteria, re- trotherapy. Celik et al. [54] compared the effects of 281
233 spectively. Nine studies [26,28,29,41,43,46,54,60,62] scapulothoracic exercises versus scapulothoracic ex- 282
234 met 4, six studies [6,18,25,30,31,37,61] met 3, four ercises and glenohumeral exercises combined. Three 283
235 studies [32,34,36,53] met 2, and two studies [47,63] studies studied the effect of physical therapy pro- 284
236 met 1 of Sackett’s critical appraisal criteria, respec- gram alone, NSAID alone or physical therapy and 285
237 tively (Fig. 2). Twenty four studies assigned their NSAIDs [29,31,39]. Five studies developed rehabilita- 286
238 subjects randomly to either the experimental or con- tion protocols and studied their effectiveness [6,34,38, 287
239 trol group [26–29,39–46,48–51,53–60]. Of the twenty 53,63] while Diercks et al. [62] tried to compare phys- 288
240 four randomized studies, eleven studies failed to dis- ical therapy with supervised neglect (supportive ther- 289
apy and exercises within pain limit). Earley and Shan- 290
241 close their method of randomization [26,43,45–49,52–
non [37] also used occupation based treatment along 291
242 54,60]. Generally, interventions were monitored by a
with home exercise program. Gaspar and Willis [61] 292
243 physical therapist or took place in a clinic (38 out
used shoulder dynasplint in isolation or in combination 293
244 of 39 studies). Only eleven studies managed to avoid
with physical therapy to assess the effect of splinting 294
245 cross-contamination of results [28,35,38,39,44,48,50,
in frozen shoulder. 295
246 51,56,59,61]. The studies that did avoid confounding
Among the studies that used mobilization of the 296
247 results specifically requested their subjects not seek
shoulder girdle, three studies [28,36,55] studied the ef- 297
248 out or participate in additional treatments. Except four fect of Maitland mobilization on patients with frozen 298
249 studies [27,47,53,63], all studies included in the re- shoulder while Johnson et al. [59] compared the ef- 299
250 view accounted for subjects in their study. Fifteen fects of anterior vs. posterior mobilization, Van den 300
251 out of thirty nine studies [27,33,39–41,44,45,48,50, Hout et al. [41] and Vermeulen et al. [42] compared 301
252 51,55–58,60] utilized blinded assessment of the sub- the effects of high vs. low grade mobilization. Maricar 302
253 jects’ pre- and post-treatment. Only fourteen studies et al. [35] in their case study, tried to evaluate the ef- 303
254 included minimal discussion of reliability (pain – 3 fects of exercise only vs. mobilization and exercise 304
255 studies [27,33,55], range of motion – 5 studies [33,35, combined. Vermeulen et al. [33] utilized end-range 305
256 39,40,55], and function – 11 studies [27,35,38,42,44, mobilization and studied its effect on frozen shoulder 306
257 45,49,55–58]) and validity (pain – 2 studies [27,59], patients while Yang et al. [56] compared mid-range 307
258 range of motion – 2 studies [33,35], and function – 11 mobilization, end-range mobilization and mobilization 308
259 studies [27,35,38,42,45,49,50,55–58,62]) of outcome with movement to evaluate the effect of specific mo- 309
260 measures utilized in their studies. Twenty one studies bilization techniques on patients with frozen shoulder. 310
261 included follow-up of the subjects [6,25–27,29–31,33, Yang et al. [57] took this intervention a step further and 311
262 37,39,42–47,50,51,54,58,62]. We used a cut-off point studied the effects of combined end-range mobiliza- 312
263 (6 points) for considering a study as ‘high quality’. On tion along with scapular mobilization treatment. Guler- 313
264 the basis of this, twelve studies were considered high Uysal et al. [48] compared Cyriax’s manipulation with 314
265 quality studies [27,33,39,42,44,45,50,51,55–58]. physical therapy. 315

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)
316 Two studies by Ma et al. [49] and Sun et al. [51] 28,31,33,37,39,42,43,45–50,54,55,58,59,63] (22 out 342
317 compared acupuncture to acupuncture and physical of 39 studies), goniometric range of motion [6,26– 343
318 therapy combined and a control group but Ma et 40,42–44,46–50,53–55,57–61,63] (33 out of 39 stud- 344
319 al. [49] incorporated no home exercise program where- ies), and various functional outcome measures such 345
320 as Sun et al. [51] incorporated a home exercise pro- as American Shoulder and Elbow Surgeons Assess- 346
321 gram in their intervention protocol. The effects of ment Form (ASES) [30,58], Constant Murley As- 347
322 electro-acupuncture and interferential therapy [45], sessment (CMA) [43,45,47,51,54,62], Croft shoul- 348
323 deep and superficial heat [58], continuous passive moder assessment scale [27], Disabilities of the Arm 349
324 tion [47] and ultrasound [46] were assessed in com- Shoulder and Hand Questionnaire (DASH) [6,27,38], 350
325 bination with stretching/ home exercises vs. either Flexion Scale of Shoulder Function (FLEX-SF) [56, 351
326 stretching alone or exercise alone with home exercise 57], Health Assessment Questionnaire (HAQ) [27], 352
327 program. Stergioulas [27] compared low level laser Physical Component Summary – 12 (PCS-12) [25], 353
328 treatment with sham laser therapy. We also included Self-assessment disability questionnaire [59], Shoul- 354
329 the studies that compared the effects of local corti- der Disability Questionnaire (SDQ) [40,42,50], Shoul- 355
330 costeroid injections with physical therapy [26,43,44, der Pain and Disability Index Score (SPADI) [27,28, 356
331 50,60]. These studies either compared corticosteroid 35,38–40,44,46,47,55,60], Shoulder Rating Question- 357
332 injections alone to physical therapy [26,43] or corti- naire (SRQ) [42], and VAS global disability [39,50]. 358
Nine studies [6,32,40–42,44,46,49,50] measured gen- 359

333 costeroid injections combined with physical therapy
eral health status of their patients via short form-36. 360
334 to corticosteroid injection alone or physical therapy
Yang et al. [56,57] also measured shoulder kinemat- 361
335 alone [44,50,60].
ics as an outcome measure of their interventions. All 362
groups in the reviewed studies were comparable at 363

336 3.4. Outcome measures baseline. 364
337 A variety of outcome measures were utilized in

338 the thirty nine studies and almost all studies used 4. Discussion 365
339 more than one outcome measure (Table 1). The most
340 common outcome measures in the reviewed studies A great number of therapeutic regimens have been 366
341 were pain (with visual analogue scale (VAS)) [6,25– recommended for frozen shoulder, but none of them 367
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

• Corticosteroid inj + PT Grade B
• Deep Heat Grade B
• Dynasplint + PT Grade C
• Low level laser therapy Not recommended
• Continuous passive motion Not recommended
Grade of recommendations for improvement in shoulder function

• Low level laser therapy Grade B
• Electro-acupuncture and IFT Grade B
• Deep heat Grade B
• Ultrasound Not recommended
• Continuous passive motion Not recommended
368 have been proved for efficacy consistently. Therefore, vance for evaluating the effects of PTI in the manage- 392
369 this review was attempted to aid physical therapists ment of frozen shoulder. When the thirty nine reviewed 393
370 in making the best choice among PTI by determining studies were grouped by area of measured outcome 394
371 the comparability of the results in the recently pub- measures, three major categories emerged: pain, range 395
372 lished studies relating to the PTI for the management of motion, and function. After compiling information 396
373 of different stages of frozen shoulder. Although frozen from the quality and level of evidence reviewed, we 397
374 shoulder is one of the most prevalent shoulder con- believe that the comments can be made regarding the 398
375 dition affecting the general population, only 39 stud- quality issues and effect of PTI in these categories. 399
376 ies were found relating to the PTI for the management Grades of recommendation can be given based on the 400
377 of frozen shoulder in the past 12 years while meet- level of evidence demonstrated by the studies and clin- 401
378 ing the criteria for this systematic review. Most of the ical guidelines can be created for what is ‘best practice’ 402
379 studies included in the review had good quality crite- for the management of frozen shoulder. 403
380 ria. In general, patients in stage 2/stage 3 were found

381 to better respond to physical therapy, stretching, and 4.1. Pain 404
382 other rehabilitation programs as compared to patients

383 in stage 1. The exact biological mechanisms by which The reduction in pain is often cited as the primary 405
384 the PTIs improve tissue healing are not yet understood goal of PTI in frozen shoulder; however, only 22 of 406
385 but they are believed to facilitate collagen production the 39 studies measured pain. Of the twenty two stud- 407
386 and tendon healing. Corticosteroid injections seem to ies, six [6,31,37,39,54,63] utilized therapeutic exer- 408
387 be the treatment of choice in patients with stage 1 cises, six [25,28,33,42,48,55,59] utilized mobilization 409
388 frozen shoulder due to their ability to reduce inflam- therapy, three [26,43,50] compared corticosteroid in- 410
389 mation and pain associated with stage 1. jections and physical therapy, and six studies (1 study 411
390 The studies in the review showed a variety of out- each) utilized acupuncture [49], electro-acupuncture 412
391 come measures of different quality and clinical rele- and interferential therapy [45], continuous passive mo- 413
414 tion [47], heat [58], ultrasound [46], and low level laser short term follow-up; and Leung and Cheing [58] sug- 465
415 therapy [27] to study their effects on pain. One study gested better pain relief with deep heating and stretch- 466
416 looked at the effects of different physical therapy inter- ing exercises to superficial heat and stretching exer- 467
417 ventions [25] on reducing pain in patients with frozen cises at short term and long term follow-up. In contrast 468
418 shoulder. to these findings with various physical therapy modal- 469
419 Six studies that utilized therapeutic exercises had pa- ities, Dogru et al. [46] did not find any benefit of using 470
420 tients in various stages of frozen shoulder. two stud- ultrasound for pain relief in frozen shoulder patients. 471
421 ies [37,63] reported to study subjects in stage I, one Stergioulas [27] also found low level laser therapy to 472
422 study [31] used patients in stage II, 1 study [6] used help in significant pain relief in short term and long 473
423 patients in stage III, 1 study [39] used mixed stages, term follow-up. 474
424 and one study [54] failed to report the mean duration of On the basis of available level of evidence, mobiliza- 475
425 the frozen shoulder. All the six studies suggested that tion, therapeutic exercises and low level laser therapy 476
426 the exercises they used in their studies were effective can be given grade A recommendation for short term 477
427 in reducing pain in patients with frozen shoulder. pain relief in patients with frozen shoulder. Studies that 478
428 In the studies that evaluated the effects of mobiliza- utilized corticosteroid injections, acupuncture, electro- 479
429 tion therapy in patients with frozen shoulder, five au- acupuncture and interferential therapy, continuous pas- 480
430 thors [25,28,33,42,48,55,59] found mobilizations to be sive motion, and deep heat were graded as level II and 481
431 effective along with home exercise program whereas therefore, grade B recommendation can be supported 482
432 one study [55] didn’t find mobilization to be effec- by this review for the use of these interventions for 483
433 tive over home exercise program in controlling pain. short term pain relief for patients with frozen shoul- 484
434 The difference in results could be attributed to limited der. The use of ultrasound for pain relief is not recom- 485
435 sample size and enrollment of stage 1 frozen shoul- mended. 486
436 der patients in Chan et al. study [55] as compared to

437 other studies. The five studies mentioned above, pri- 4.2. Range of Motion (ROM) 487
438 marily had patients in stage II frozen shoulder enrolled

439 in them. The ROM was the most studied outcome measure 488
440 Mixed results were found among the three studies in the reviewed articles for PTI in patients with frozen 489
441 that compared corticosteroid injections and physical shoulder (33 of the 39 studies). In all the 33 studies, 490
442 therapy [26,43,50]. The findings of this review indicate ROM was measured using a goniometer. Of the thirty 491
443 that in general, corticosteroid injections are more ef- three studies, ten [1,6,29,31,34,37–39,53,54,63] inves- 492
444 fective than PTI in short term pain relief, and to a lesser tigated the effect of therapeutic exercises, nine [28,33, 493
445 extent in the long term pain relief. Both Arslan and Ce- 35,36,42,48,55,57,59] utilized mobilization, six [26, 494
446 likar [26] and Ryans et al. [50] suggested that corti- 40,43,44,50,60] compared the effect of corticosteroid 495
447 costeroid injections helped in better managing pain as injections and physical therapy, and six studies (1 study 496
448 compared to PTI and exercises in short term follow-up, each) evaluated the effect of acupuncture [49], continu- 497
449 however, the effect disappeared in long term follow- ous passive motion [47], heat [58], ultrasound [46], low 498
450 up. On the contrary, Calis et al. [43] found pain relief lever laser [27], and dynasplint [61] on range of mo- 499
451 with physical therapy applications more pronounced tion. Two studies [30,32] evaluated subjects who were 500
452 than corticosteroid injections. treated with either non-operative means or operative 501
453 Ma et al. [49] compared the effects of physical ther- means. 502
454 apy to acupuncture and found pain to be better con- Therapeutic exercises were generally found to be 503
455 trolled by acupuncture as compared to physical ther- effective in improving ROM at either short term or 504
456 apy. They suggested integration of acupuncture and long term follow up. All studies reported the beneficial 505
457 physical therapy for short term pain relief. Several effects of exercises on ROM in patients with frozen 506
458 studies also evaluated the effects of various physi- shoulder. The subjects represented in these studies var- 507
459 cal therapy modalities for pain relief in patients with ied from Stage I to Stage III when enrolled in the study. 508
460 frozen shoulder. For example, Cheing et al. [45] found In the studies that evaluated the effects of mobiliza- 509
461 both electro-acupuncture and interferential therapy to tion therapy in patients with frozen shoulder, five stud- 510
462 be effective in short term and long term pain relief; ies [28,36,48,57,59] found mobilization along with ex- 511
463 Dundar et al. [47] found continuous passive motion ercises to be effective in improving ROM at short term 512
464 to reduce pain more than active stretching exercises at follow-up. At the long term follow-up, these findings 513
514 are consistent with the studies of Maricar et al. [35], given grade C recommendation for improving short 565
515 Vermeulen et al. [33] and Vermeulen et al. [42]. How- term ROM in frozen shoulder patients. Continuous 566
516 ever, Chan et al. [55] didn’t find any significant differ- passive motion and low level laser for improving ROM 567
517 ence in ROM following mobilization, possibly due to is not recommended. 568
518 limited sample size in their study.

519 The findings of this review indicate that in general, 4.3. Function 569
520 PTI are more effective than corticosteroid injections

521 in short term ROM improvement. Calis et al. [43] and Various functional outcome measures were used to 570
522 Ryans et al. [50] suggested that PTI helped in better measure function in the reviewed articles for PTI in 571
523 improving passive ROM as compared to corticosteroid patients with frozen shoulder (26 of the 39 studies). 572
524 injections in short term follow-up, however, the effect All the functional outcome measures used in the re- 573
525 disappeared in long term follow-up. Carette et al. [44] viewed articles have been reported to be valid and re- 574
526 found the combination of corticosteroid injection and liable. Of the twenty six studies, five [6,38,39,54,62] 575
527 PTI to be more effective in improving active and pas- assessed the effects of therapeutic exercises, nine [25, 576
528 sive ROM than either corticosteroid injections only or 28,35,41,42,55–57,59] studied the effect of mobiliza- 577
529 PTI only. In contrast, Maryam et al. [60] found active tion therapy, five [40,43,44,50,60] compared the ef- 578
530 and passive ROM to be improved more in corticos- fect of corticosteroid injections and physical ther- 579
531 teroid injection group. Arslan and Celikar [26] found apy, six studies (1 study each) evaluated the effect 580
532 no difference in the effect of PTI and corticosteroid in- of acupuncture [51], continuous passive motion [47], 581
533 jections in improving active/passive ROM in short term ultrasound [46], heat [58], low level laser [27] and 582
534 follow-up. electro-acupuncture and interferential therapy [45] on 583
535 Ma et al. [49] compared the effects of physical ther- improvement of function. One study [30] tried to as- 584
536 apy to acupuncture and found ROM to be better im- sess the patients response when through non-operative 585
537 proved by physical therapy as compared to acupunc- means as compared to operative means. 586
538 ture. They further reported that combined acupunc- Of the five studies that assessed the effects of thera- 587
539 ture and physical therapy gives better improvement peutic exercises, four studies reported exercises to im- 588
540 in ROM than either acupuncture alone or physical prove function [6,38,39,54] whereas one study [62] 589
541 therapy alone. The authors suggested integration of found supervised neglect to be better than physical 590
542 acupuncture and physical therapy for short term im- therapy in improving function in patients with frozen 591
543 provement in ROM. Several studies also evaluated the shoulder. 592
544 effects of various physical therapy modalities for im- In the studies that evaluated the effects of mobiliza- 593
545 provement in ROM. Dundar et al. [47] found con- tion therapy, mixed results were reported in the re- 594
546 tinuous passive motion to be no different in improv- viewed studies. Two studies [35,55] did not find sig- 595
547 ing ROM than active stretching exercises at short term nificant change in the function following mobilization 596
548 follow-up. Leung and Cheing [58] suggested more therapy whereas other studies reported mobilization 597
549 improvement in ROM with deep heat and stretching to be effective in improving function in patients with 598
550 exercises to superficial heat and stretching exercises frozen shoulder. Specifically, high grade mobilization, 599
551 at short term and long term follow-up. Gaspar and end range mobilization and mobilization with move- 600
552 Willis [61] in their cohort study found dynasplint com- ment, and end range mobilization and scapular mobi- 601
553 bined with physical therapy to be more effective in im- lization techniques were reported to be more effective 602
554 proving ROM than physical therapy alone or splint- in improving function in patients with frozen shoulder. 603
555 ing alone in patients with frozen shoulder at initial and Mixed findings were reported in the reviewed stud- 604
556 long term follow-up. Stergioulas [27] did not find low ies about the effect of PTI and corticosteroid injec- 605
557 level laser to help in significant ROM improvement in tions in functional improvement. Carette et al. [44] and 606
558 short term and long term follow-up. Maryam et al. [60] found the combination of corticos- 607
559 On the basis of available level of evidence, thera- teroid injection and PTI to be more effective in im- 608
560 peutic exercises and mobilization can be given grade A proving function than either corticosteroid injections 609
561 recommendation for short term improvement in ROM only or PTI only. Ryans et al. [50] found corticos- 610
562 in patients with frozen shoulder. Corticosteroid injec- teroid injections only to be more effective in improv- 611
563 tions, acupuncture, and deep heat can be given grade ing function than either the combination of corticos- 612
564 B recommendation, and the use of dynasplint can be teroid injection and PTI or PTI only. In contrast, Calis 613
614 et al. [43] found PTI to be better in improving function 5. Methodological limitations 665
615 than either sodium hyaluronate injection only or corti-

616 costeroid injection only. Calis et al. [43] also found PTI The interpretation of the results of many studies de- 666
617 to be effective in long term follow up as well whereas scribing therapeutic regimens is hampered by method- 667
618 Maryam et al. [60] and Ryans et al. [50] found the con- ological flaws, such as small number of subjects, lack 668
619 trary. of indication for duration of symptoms before treat- 669
620 Sun et al. [51] compared the effects of physical ment, high dropout rates, the use of co-interventions, 670
621 therapy to acupuncture and reported that combined and a short follow-up. Moreover, many studies do not 671
622 acupuncture and physical exercises gives better im- even provide details regarding the stage of the disease 672
623 provement in function than physical exercises alone. process, previous treatments, and etiological consider- 673
624 The authors suggested integration of acupuncture and ations. 674
625 physical therapy for short term improvement in func- Since only 12 studies were considered high quality, 675
626 tion. Several studies also evaluated the effects of var- the results must be viewed in perspective of the good 676
627 ious physical therapy modalities for improvement in methodological quality of the individual studies. How- 677
628 function. Leung and Cheing [58] suggested more im- ever, the nature of the interventions does not allow a 678
629 provement in function with deep heat and stretching design that meets all methodological criteria. For ex- 679
630 exercises to superficial heat and stretching exercises at ample: double blinding is usually impossible in stud- 680
631 short term and long term follow-up. Stergioulas [27] ies with PTI. Therefore, we used a low cut-off point (6 681
632 recommended that low level laser therapy can also be points) for considering a study as “high quality”. 682
633 used to improve function at both short term and long The best-evidence synthesis using a rating system 683
634 term follow-up. Electro-acupuncture and interferential based on the quality of the individual studies has its 684
635 therapy were also reported to be effective in improv- limitations. Rating is to some extent subjective, and a 685
636 ing function by Cheing et al. [45]. In contrast to these high quality level can be difficult to score. However, by 686
637 results, Dundar et al. [47] found that continuous pas- ranking the evidence of the conclusions, some insight 687
638 sive motion is no different in improving function than can be gained in the strength of the conclusions. 688
639 active stretching exercises. Dogru et al. [46] also did There is limited literature on the effectiveness of 689
640 not find any benefit of using ultrasound for improving specific exercise regimen for the treatment of frozen 690
641 function in patients with frozen shoulder. shoulder. While there were few studies addressing the 691
642 On the basis of available level of evidence, thera- effects of therapeutic exercises for frozen shoulder, no 692
643 peutic exercises and mobilization can be given grade A identical exercise regimen was followed in any of the 693
644 recommendation for short term improvement in func- studies and the measured outcomes were not always 694
645 tion. Of the two studies comparing corticosteroid in- superior to the compared interventions. Additionally, 695
646 jections and physical therapy, both studies were level the intensity, frequency, duration of exercises and the 696
647 I studies. No specific recommendation can be given to use of physical therapy modalities varied across stud- 697
648 either the combination of corticosteroid injection and ies. 698
649 PTI and corticosteroid injections only or PTI only for The duration of symptoms in the reviewed studies 699
650 improving short term function in patients with frozen ranged from 6 weeks to 10.2 months, placing the sub- 700
651 shoulder. Grade B recommendation can be supported jects in all three stages 1, 2 and 3 of frozen shoulder. 701
652 by this review for the use of acupuncture, low level The majority of the studies evaluated patients in stage 702
653 laser, and electro-acupuncture and interferential ther- 2 and 3 and therefore, the recommendations provided 703
654 apy along with physical exercises, for short term func- in this review article apply only to patients with stage 704
655 tional improvement in treatment of frozen shoulder. 2 and stage 3 frozen shoulder. 705
656 Continuous passive motion and the use of ultrasound

657 for improving function are not recommended. The pas-
658 sive modalities may decrease inflammation associated 6. Clinical relevance and future research 706
659 with frozen shoulder and allow patients to use their

660 shoulder with less pain. The negative effects of ultra- When different stages of frozen shoulder and the 707
661 sound may be attributed to ineffective parameter selec- associated pathophysiology are taken into account, it 708
662 tion. Continuous passive motion may have limited im- would seem reasonable that certain treatments would 709
663 pact on function unless the patients are encouraged to be more effective at different times. Many studies in 710
664 functionally use their shoulder. the past have not taken this into consideration which 711
712 may seriously influence their results. Clinically, in- the treatment of choice in patients with stage 1 frozen 760
713 stead of time wise classification, classification based shoulder, followed by the use of corticosteroid injec- 761
714 on stage of pathology, which is related to patient’s ir- tions along with PTI in patients with stage 2 frozen 762
715 ritability level (low, moderate, and high) [7] should shoulder. Acupuncture along with physical therapy ex- 763
716 be used when deciding on rehabilitation interventions. ercises is also moderately recommended for pain relief, 764
717 Kelley et al. [7] suggested irritability to be determined improving ROM and function in patients with frozen 765
718 upon pain, range of motion, and disability status of shoulder. Electro-acupuncture and interferential ther- 766
719 the patient. Patients in early stage frozen shoulder will apy can also help in providing short term pain relief. 767
720 demonstrate high level of irritability and patients in While the continuous passive motion is recommended 768
721 later stages will have low irritability. for short term pain relief, it is not recommended for im- 769
722 Future research into the effectiveness of specific ex- proving ROM or function in patients with frozen shoul- 770
723 ercises for pain relief, ROM improvement and im- der. Evidence also suggests the use of deep heat for 771
724 proved functional status is needed. Additionally, fur- pain relief and improving ROM. There is also mild ev- 772
725 ther research is needed in determining the optimal idence for the use of dynasplint in restoring ROM. The 773
726 dose of different exercises such as the intensity, fre- use of ultrasound for pain relief, improving ROM or 774
727 quency, and duration of exercises for patients with improving function for treatment of frozen shoulder is 775
728 frozen shoulder. not recommended. 776
729 This review targets physical therapy clinicians and The results of this review must be viewed in perspec- 777
730 health researchers. The information will be most use- tive to limited database search and heterogeneity of the 778
731 ful for decision-makers wanting to know which inter- studies. Both the lack of use of standardized/identical 779
732 ventions are the ‘best buys’ when making decision on exercises and varied physical therapy modalities in dif- 780
733 the available interventions. A study of interest may be ferent studies limit the ability to generalize these find- 781
734 identified as appropriate for a particular setting and, ings in order to treat patients with frozen shoulder in 782
735 following some re-analysis to reflect individual pa- the clinic. In order to apply these findings to the clinical 783
736 tient requirements, the intervention may be considered settings, future studies should examine whether partic- 784
737 by clinicians for translation into practice. The review ular PTI protocols specifically improve pain, ROM and 785
738 may also act as a reference guide for various inter- functionality, and then apply follow-up data to prove 786
739 ventions utilized in clinics and the relative differences effectiveness of the intervention. 787
740 between the interventions as compared using reliable

741 and validated outcome measures. In addition, the re-
742 view has highlighted the gaps in treatment methods, Acknowledgements 788
743 and steers researchers and clinicians towards improv-

The authors have not received any financial pay- 789
744 ing their practice and reporting high-quality clinical
ments or other benefits from any commercial entity re- 790
745 findings, while building on existing knowledge.
lated to the contents of the work being presented. 791
746 7. Conclusions
References 792
747 From this review, therapeutic exercises and mobi- [1] Aydeniz A, Gursoy S, Guney E. Which musculoskeletal com- 793
748 lization therapy are strongly recommended for reduc- plications are most frequently seen in type 2 diabetes melli- 794
749 ing pain, improving ROM and function in patients with tus? J Int Med Res. 2008; 36(3): 505-11. 795
[2] Hannafin JA, Chiaia TA. Adhesive capsulitis. A treatment ap- 796
750 stages 2 and 3 frozen shoulder. While high grade pos- proach. Clin Orthop Relat Res. 2000(372): 95-109. 797
751 terior mobilization along with self exercises is recom- [3] Lundberg J. The frozen shoulder. Clinical and radiographical 798
752 mended for improving passive external rotation and observations. The effect of manipulation under general anes- 799
753 abduction ROM, high grade mobilization and mobi- thesia. Structure and glycosaminoglycan content of the joint 800
capsule. Local bone metabolism. Acta Orthop Scand. 1969: 801
754 lization with movement along with self exercises are Suppl 119: 1-59. 802
755 recommended for improving function. Low level laser [4] Sheridan MA, Hannafin JA. Upper extremity: emphasis on 803
756 therapy is strongly suggested for pain relief and moder- frozen shoulder. Orthop Clin North Am. 2006; 37(4): 531-9. 804
[5] Brue S, Valentin A, Forssblad M, Werner S, Mikkelsen C, 805
757 ately suggested for improving function but not recom-
Cerulli G. Idiopathic adhesive capsulitis of the shoulder: A 806
758 mended for improving ROM. This review also supports review. Knee Surg Sports Traumatol Arthrosc. 2007; 15(8): 807
759 the evidence of using local corticosteroid injections as 1048-54. 808
809 [6] Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. retrospective cohort study. Phys Ther. 2009; 89(5): 419-29. 872
810 A prospective functional outcome study of nonoperative treat- Epub 2009/03/10. 873
811 ment. J Bone Joint Surg Am. 2000; 82-A(10): 1398-407. [26] Arslan S, Celiker R. Comparison of the efficacy of local cor- 874
812 [7] Kelley MJ, McClure PW, Leggin BG. Frozen shoulder: evi- ticosteroid injection and physical therapy for the treatment of 875
813 dence and a proposed model guiding rehabilitation. J Orthop adhesive capsulitis. Rheumatol Int. 2001; 21(1): 20-3. 876
814 Sports Phys Ther. 2009; 39(2): 135-48. [27] Stergioulas A. Low-power laser treatment in patients with 877
815 [8] Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long- frozen shoulder: preliminary results. Photomedicine and laser 878
816 term follow-up. J Bone Joint Surg Am. 1992; 74(5): 738-46. surgery. 2008; 26(2): 99-105. Epub 2008/03/18. 879
817 [9] Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathol- [28] Kumar A, Kumar S, Aggarwal A, Kumar R, Das PG. Effec- 880
818 ogy of frozen shoulder. J Bone Joint Surg Br. 2007; 89(7): tiveness of Maitland Techniques in Idiopathic Shoulder Ad- 881
819 928-32. Epub 2007/08/04. hesive Capsulitis. ISRN Rehabilitation. 2012; 2012: 8. 882
820 [10] Bowman CA, Jeffcoate WJ, Pattrick M, Doherty M. Bilateral [29] Dudkiewicz I, Oran A, Salai M, Palti R, Pritsch M. Idiopathic 883
821 adhesive capsulitis, oligoarthritis and proximal myopathy as adhesive capsulitis: long-term results of conservative treat- 884
822 presentation of hypothyroidism. Br J Rheumatol. 1988; 27(1): ment. Isr Med Assoc J. 2004; 6(9): 524-6. Epub 2004/09/18. 885
823 62-4. [30] Rill BK, Fleckenstein CM, Levy MS, Nagesh V, Hasan SS. 886
824 [11] Choy EH, Corkill MM, Gibson T, Hicks BH. Isolated ACTH Predictors of outcome after nonoperative and operative treat- 887
825 deficiency presenting with bilateral frozen shoulder. Br J ment of adhesive capsulitis. Am J Sports Med. 2011; 39(3): 888
826 Rheumatol. 1991; 30(3): 226-7. 567-74. Epub 2010/12/17. 889
827 [12] Tuten HR, Young DC, Douoguih WA, Lenhardt KM, Wilk- [31] Ulusoy H, Sarica N, Arslan S, Olcay C, Erkorkmaz U. The 890
828 erson JP, Adelaar RS. Adhesive capsulitis of the shoulder in efficacy of supervised physiotherapy for the treatment of ad- 891
829 male cardiac surgery patients. Orthopedics. 2000; 23(7): 693- hesive capsulitis. Bratislavske Lekarske Listy. 2011; 112(4): 892
830 6. 204-7. Epub 2011/05/19. 893
831 [13] Lo SF, Chen SY, Lin HC, Jim YF, Meng NH, Kao MJ. [32] Levine WN, Kashyap CP, Bak SF, Ahmad CS, Blaine TA, 894
832 Arthrographic and clinical findings in patients with hemi- Bigliani LU. Nonoperative management of idiopathic adhe- 895
833 plegic shoulder pain. Arch Phys Med Rehabil. 2003; 84(12): sive capsulitis. J Shoulder Elbow Surg. 2007; 16(5): 569-73. 896
834 1786-91. Epub 2007/05/29. 897
835 [14] Bruckner FE, Nye CJ. A prospective study of adhesive cap- [33] Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Roz- 898
836 sulitis of the shoulder (‘frozen shoulder’) in a high risk popu- ing PM, van Den Ende CH. End-range mobilization tech- 899
837 lation. Q J Med. 1981; 50(198): 191-204. niques in adhesive capsulitis of the shoulder joint: A multiple- 900
838 [15] Gheita TA, Ezzat Y, Sayed S, El-Mardenly G, Hammam W. subject case report. Phys Ther. 2000; 80(12): 1204-13. Epub 901
839 Musculoskeletal manifestations in patients with malignant 2000/11/22. 902
840 disease. Clin Rheumatol. 2010; 29(2): 181-8. [34] Wies J. Treatment of eight patients with frozen shoulder: A 903
841 [16] Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome case study series. Journal of Bodywork and Movement Ther- 904
842 of frozen shoulder. J Shoulder Elbow Surg. 2008; 17(2): 231- apies. 2005; 9(1): 58-64. 905
843 6. Epub 2007/11/13. [35] Maricar N, Shacklady C, McLoughlin L. Effect of Maitland 906
844 [17] Degreef I, Steeno P, De Smet L. A survey of clinical manifes- mobilization and exercises for the treatment of shoulder adhe- 907
845 tations and risk factors in women with Dupuytren’s disease. sive capsulitis: A single-case design. Physiother Theory Pract. 908
846 Acta Orthop Belg. 2008; 74(4): 456-60. 2009; 25(3): 203-17. 909
847 [18] Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen [36] Janjua UI, Ali S. Physical Therapy and Maitland’s manual 910
848 shoulder: A long-term prospective study. Ann Rheum Dis. joint mobilization techniques (grade II and III) are effective to 911
849 1984; 43(3): 361-4. manage the Stage I adhesive capsulitis. Interdisciplinary Jour- 912
850 [19] Reeves B. The natural history of the frozen shoulder syn- nal of Contemporary Research in Business. 2011; 3(8): 243-8. 913
851 drome. Scand J Rheumatol. 1975; 4(4): 193-6. [37] Earley D, Shannon M. The use of occupation-based treatment 914
852 [20] Shah N, Lewis M. Shoulder adhesive capsulitis: systematic with a person who has shoulder adhesive capsulitis: a case 915
853 review of randomised trials using multiple corticosteroid in- report. Am J Occup Ther. 2006; 60(4): 397-403. 916
854 jections. Br J Gen Pract. 2007; 57(541): 662-7. [38] Ruiz JO. Positional stretching of the coracohumeral ligament 917
855 [21] Green S, Buchbinder R, Hetrick S. Physiotherapy interven- on a patient with adhesive capsulitis: A case report. The Jour- 918
856 tions for shoulder pain. Cochrane Database Syst Rev. 2003(2): nal of Manual and Manipulative Therapy. 2009; 17(1): 58-63. 919
857 CD004258. Epub 2003/06/14. Epub 2010/01/05. 920
858 [22] Mortenson PA, Eng JJ. The use of casts in the management of [39] Pajareya K, Chadchavalpanichaya N, Painmanakit S, Kaid- 921
859 joint mobility and hypertonia following brain injury in adults: wan C, Puttaruksa P, Wongsaranuchit Y. Effectiveness of 922
860 A systematic review. Phys Ther. 2003; 83(7): 648-58. Epub physical therapy for patients with adhesive capsulitis: A ran- 923
861 2003/07/03. domized controlled trial. Journal of the Medical Association 924
862 [23] Sackett DL. Rules of evidence and clinical recommendations of Thailand = Chotmaihet Thangphaet. 2004; 87(5): 473-80. 925
863 on the use of antithrombotic agents. Chest. 1989; 95(2 Suppl): Epub 2004/06/30. 926
864 2S-4S. Epub 1989/02/01. [40] Hsieh LF, Hsu WC, Lin YJ, Chang HL, Chen CC, Huang 927
865 [24] Butler C, Campbell S. Evidence of the effects of intrathecal V. Addition of intra-articular hyaluronate injection to phys- 928
866 baclofen for spastic and dystonic cerebral palsy. AACPDM ical therapy program produces no extra benefits in patients 929
867 Treatment Outcomes Committee Review Panel. Dev Med with adhesive capsulitis of the shoulder: A randomized con- 930
868 Child Neurol. 2000; 42(9): 634-45. Epub 2000/10/18. trolled trial. Arch Phys Med Rehabil. 2012; 93(6): 957-64. 931
869 [25] Jewell DV, Riddle DL, Thacker LR. Interventions associated Epub 2012/04/17. 932
870 with an increased or decreased likelihood of pain reduction [41] van den Hout WB, Vermeulen HM, Rozing PM, Vliet 933
871 and improved function in patients with adhesive capsulitis: A Vlieland TP. Impact of adhesive capsulitis and economic eval- 934
935 uation of high-grade and low-grade mobilisation techniques. shoulder. The Indian Journal of Occupational Therapy. 2004; 981
936 Aust J Physiother. 2005; 51(3): 141-9. XXXVI(2): 37-40. 982
937 [42] Vermeulen HM, Rozing PM, Obermann WR, le Cessie S, [54] Celik D. Comparison of the outcomes of two different exer- 983
938 Vliet Vlieland TP. Comparison of high-grade and low-grade cise programs on frozen shoulder. Acta Orthopaedica et Trau- 984
939 mobilization techniques in the management of adhesive cap- matologica Turcica. 2010; 44(4): 285-92. Epub 2011/01/22. 985
940 sulitis of the shoulder: randomized controlled trial. Phys Ther. [55] Chan S, Hill R, Kerr J. Passive joint mobilisation: does it 986
941 2006; 86(3): 355-68. enhance outcome of adhesive capsulitis of the shoulder fol- 987
942 [43] Calis M, Demir H, Ulker S, Kirnap M, Duygulu F, Calis HT. lowing corticosteroid injection? International Musculoskele- 988
943 Is intraarticular sodium hyaluronate injection an alternative tal Medicine. 2010; 32(2): 58-67. 989
944 treatment in patients with adhesive capsulitis? Rheumatol Int. [56] Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ. Mobiliza- 990
945 2006; 26(6): 536-40. tion techniques in subjects with frozen shoulder syndrome: 991
946 [44] Carette S, Moffet H, Tardif J, Bessette L, Morin F, Frémont randomized multiple-treatment trial. Phys Ther. 2007; 87(10): 992
947 P, et al. Intraarticular corticosteroids, supervised physiother- 1307-15. 993
948 apy, or a combination of the two in the treatment of adhesive [57] Yang JL, Jan MH, Chang CW, Lin JJ. Effectiveness of the 994
949 capsulitis of the shoulder: A placebo-controlled trial. Arthritis end-range mobilization and scapular mobilization approach 995
950 Rheum. 2003; 48(3): 829-38. in a subgroup of subjects with frozen shoulder syndrome: A 996
951 [45] Cheing GL, So EM, Chao CY. Effectiveness of elec- randomized control trial. Man Ther. 2012; 17(1): 47-52. Epub 997
952 troacupuncture and interferential eloctrotherapy in the man- 2011/09/29. 998
953 agement of frozen shoulder. J Rehabil Med. 2008; 40(3): 166- [58] Leung MS, Cheing GL. Effects of deep and superficial heating 999
954 70. in the management of frozen shoulder. J Rehabil Med. 2008; 1000
955 [46] Dogru H, Basaran S, Sarpel T. Effectiveness of therapeutic ul- 40(2): 145-50. 1001
956 trasound in adhesive capsulitis. Joint Bone Spine. 2008; 75(4): [59] Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The 1002
957 445-50. effect of anterior versus posterior glide joint mobilization on 1003
958 [47] Dundar U, Toktas H, Cakir T, Evcik D, Kavuncu V. Continu- external rotation range of motion in patients with shoulder ad- 1004
959 ous passive motion provides good pain control in patients with hesive capsulitis. J Orthop Sports Phys Ther. 2007; 37(3): 88- 1005
960 adhesive capsulitis. Int J Rehabil Res. 2009; 32(3): 193-8. 99. 1006
961 [48] Guler-Uysal F, Kozanoglu E. Comparison of the early re- [60] Maryam M, Zahra K, Adeleh B, Morteza Y. Comparison 1007
962 sponse to two methods of rehabilitation in adhesive capsulitis. of corticosteroid injections, physiotherapy, and combination 1008
963 Swiss Med Wkly. 2004; 134(23-24): 353-8. therapy in treatment of frozen shoulder. Pakistan Journal of 1009
964 [49] Ma T, Kao MJ, Lin IH, Chiu YL, Chien C, Ho TJ, et al. A Medical Sciences Quarterly 2012 Jul–Sep; 28(4): 648-651. 1010
965 study on the clinical effects of physical therapy and acupunc- 2012. 1011
966 ture to treat spontaneous frozen shoulder. Am J Chin Med. [61] Gaspar PD, Willis FB. Adhesive capsulitis and dynamic 1012
967 2006; 34(5): 759-75. splinting: A controlled, cohort study. BMC Musculoskelet 1013
968 [50] Ryans I, Montgomery A, Galway R, Kernohan WG, McK- Disord. 2009; 10: 111. 1014
969 ane R. A randomized controlled trial of intra-articular triamci- [62] Diercks RL, Stevens M. Gentle thawing of the frozen shoul- 1015
970 nolone and/or physiotherapy in shoulder capsulitis. Rheuma- der: A prospective study of supervised neglect versus inten- 1016
971 tology (Oxford). 2005; 44(4): 529-35. sive physical therapy in seventy-seven patients with frozen 1017
972 [51] Sun KO, Chan KC, Lo SL, Fong DY. Acupuncture for frozen shoulder syndrome followed up for two years. J Shoulder El- 1018
973 shoulder. Hong Kong Med J. 2001; 7(4): 381-91. bow Surg. 2004; 13(5): 499-502. Epub 2004/09/24. 1019
974 [52] Tanaka K, Saura R, Takahashi N, Hiura Y, Hashimoto R. Joint [63] Jurgel J, Rannama L, Gapeyeva H, Ereline J, Kolts I, Paa- 1020
975 mobilization versus self-exercises for limited glenohumeral suke M. Shoulder function in patients with frozen shoulder 1021
976 joint mobility: randomized controlled study of management before and after 4-week rehabilitation. Medicina (Kaunas). 1022
977 of rehabilitation. Clin Rheumatol. 2010; 29(12): 1439-44. 2005; 41(1): 30-8. Epub 2005/02/03. 1023
978 [53] Samnani M. Passive exercises coupled with therapeutic
979 activities – A comparative study in the management of frozen
980

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Galley Proof 21/11/2013; 9:53 File: bmr443.tex; BOKCTP/wyn p.

Journal of Back and Musculoskeletal Rehabilitation 00 (2013) 1–27 1

The effectiveness of physiotherapeutic

Keywords: Mobilization, therapeutic exercises, pain, range of motion, function

1 1. Introduction of age, with a female predominance (58:42) [1,3]. It 8

is characterized by a spontaneous onset of pain with 9

The risk of being affected appears to be increased 16

by trauma/surgery [9], hormonal diseases such as di- 17

mail: nsharma@kumc.edu. lignancies [15], hyperlipidemia [16], certain medica- 21

25 tracture [17]. rating the arthroscopic stages described by Nevaiser, 58

40 a characteristic history, clinical presentation, and re- secondary causes [3,5,7,8,19]. 73

Computer database search (n=2917)

Articles excluded (n=62)

Included in review (n=39)

Fig. 1. Selection of studies.

88 isons difficult. Many studies do not provide details 2. Methods 115

89 regarding the stage of the disease process, previous

of frozen shoulder, “adhesive capsulitis” and “frozen 128

tial maximum value of eight points. If information re- 174

Follow-up at least one level II study; and C if supported by level 181

Level I = large randomized controlled trial, low error risk

Level V = case report

The number of patients in the reviewed studies ranged 188

157 mobilization”, “acupuncture”, “rehabilitation”, “treat- studies. 205

158 ment”, and “education” with the intended goal of treat-

160 diagnosed with the frozen shoulder diagnostic criteria

– Group 2: Triamselonone asetonide 40 mg – Group 3: Physical therapy

– Group 4: 20.3 ± 7.3 weeks

Male = 30, Female = 47 – Supervised neglect group: educa- Assessments:

53.9 ± 7.8)) + exercise program + HEP

ized protocols) (n = 16); – Joint mobilization

– Group 1 = 5.2 ± 2.6 months ∗ Electric therapy – 1.5 months

– Use of iontophoresis, phonopho-

∗ Shoulder wheel exercises

∗ Physical therapy only – 55 shoulders Physical therapy + Injection – – Post-intervention

27F), age = 53.33 ± 7.49) ∗ Ice – 6 weeks

– Positional coracohumeral liga- reaching back to the spine

– CS inj group – 12.2 ± 5.3 weeks

– Placebo group – 14.9 ± 3.7 weeks

Male = 9, Female = 11 – Therapeutic activity program and Assessments:

± 5.84) put of 60 mW applied to 8 points – DASH – Significant decrease in SPADI

Male = 14, Female = 15 iotherapy – 3.5 ± 0.5 weeks

Male = 34, Female = 66

– HEP – stretching and isometric – Baseline

Male = 10, Female = 22

15.8 ± 10.7 weeks

Calis et al. [43], 2006 No Yes No Yes Yes No No Yes 4

Jürgel et al. [63], 2005 Noa No No Yes Noa No No No 1

220 randomized design (cohort design). Three studies [6,

ential therapy [45], ultrasound [46], continuous passive 272

occupation) [37] and physical therapy compared with 275

265 quality studies [27,33,39,42,44,45,50,51,55–58]. physical therapy. 315

Nine studies [6,32,40–42,44,46,49,50] measured gen- 359

groups in the reviewed studies were comparable at 363

337 A variety of outcome measures were utilized in

Grade of recommendations for improvement in shoulder range of motion

Grade of recommendations for improvement in shoulder function

380 ria. In general, patients in stage 2/stage 3 were found

382 other rehabilitation programs as compared to patients

436 der patients in Chan et al. study [55] as compared to

438 marily had patients in stage II frozen shoulder enrolled

518 limited sample size in their study.

520 PTI are more effective than corticosteroid injections