450 Key Words
Systematic review, adhesive
Physical Therapy for
Adhesive Capsulitis
Systematic review
Summary
Objective To review recent research on the efficacy of
physical therapy for patients with adhesive capsulitis.
Design Search of Medline and CINAHL databases for studies
published between January 1990 and December 2000.
Inclusion criteria Non-operative experimental or descriptive
research-based outcomes studies of physical therapy.
Main outcome measures Methodological quality scoring
using 16 predetermined criteria with 100% (16/16) indicating
highest quality.
Results Quality scores of the 12 studies that met inclusion
criteria ranged from 38% to 69% (mean 54%). By design,
scores were highest for the reviewed retrospective and
randomised controlled studies.
Conclusions How efficacious physical therapy is for patients
with adhesive capsulitis is uncertain. Reviewed studies
suggest that many patients treated with physical therapy
benefited from reduced symptoms, increased mobility,
and/or functional improvement. However, the lack of rigour
and poor standardisation of terminology, methodology,
and outcome measurements in these investigations
undermines their validity and clinical application.
More rigorous investigations are needed to compare the
effects and costs of individual physical therapy interventions.
Introduction
Adhesive capsulitis is a pathology of often
unknown aetiology characterised by
painful and gradually progressive
restriction of active and passive gleno-
humeral joint motion (Baslund et al, 1990;
Pearsall and Speer, 1998). Approximately
2-3% of adults aged between 40 and 70
years develop adhesive capsulitis with a
greater occurrence in women (Anton,
Cleland, J and Durall,
C J (2002). ‘Physical 1993; Connolly, 1998; Stam, 1994). Full or
therapy for adhesive partial restoration of motion may occur
capsulitis: Systematic over months or years with or without
review’, Physiotherapy, medical intervention (Ogilvie-Harris et al,
88, 8, 450-457. 1995).
Physiotherapy August 2002/vol 88/no 8
capsulitis, physical therapy
by Joshua Cleland
Christopher J Durall
Duplay is credited with publishing the
first case report of adhesive capsulitis, or
‘periarthrite-scapulo-humerale’, more than
125 years ago (Melzer et al, 1995). Iron-
ically, Duplay reported treating many
patients successfully with manipulation
under anaesthesia, a procedure still
commonly performed for recalcitrant
cases of adhesive capsulitis. Codman
labelled the pathology ‘frozen shoulder’
in 1934, describing the presentation as a
‘slow onset of shoulder pain, an inability
to sleep on the affected side, restricted
glenohumeral elevation and external
rotation, and a normal radiological
appearance’ (Pearsall and Speer, 1998).
Neviaser and Neviaser (1987) coined the
term ‘adhesive capsulitis’, theorising that
this pathology results from thickening
and eventual contracture of the gleno-
humeral capsule. Hannafin and Chiaig
(2000) hypothesised that adhesive
capsulitis stems from synovial inflam-
mation that progresses to a react-
ive capsular fibrosis. Bunker (1997)
identified via arthroscopy a fibrous
contracture of the rotator interval and
coracohumeral ligament, which markedly
limited motion, primarily external
rotation. Histological evaluation of the
fibrous tissue revealed a dense collagen
matrix consisting of mainly type 3
collagen, remarkably similar to tissue
found in Dupuytren’s contracture.
Adhesive capsulitis has been sub-divided
into primary (insidious) and secondary
(traumatic) syndromes, which have
similar clinical presentations but distinct
precipitating factors (Stam, 1994).
Primary adhesive capsulitis is char-
acterised by an insidious progressive pain-
ful loss of active and passive glenohum-
eral joint motion (Hannafin and Chiaia,
2000). Secondary adhesive capsulitis has
an identical histopathological appearance
Review
but stems from a known intrinsic or
extrinsic cause (Hannafin and Chiaia,
2000). With either sub-type the pre-
cipitating factor may be a chronic in-
flammatory process that results in
capsular adhesions (Grubbs, 1993).
Diagnosis of adhesive capsulitis is often
made through the history and physical
examination. Individuals with adhesive
capsulitis typically complain of poorly
localised shoulder pain with focal tender-
ness adjacent to the deltoid insertion and
occasional pain radiation to the elbow
and at times into the lateral forearm
(Grubbs, 1993; McClure and Flowers,
1992). This pain is usually aggravated by
shoulder movement and alleviated by
limiting use of the arm (Hannafin and
Chiaia, 2000; Seigel et al, 1999).
Occasionally the pain is most intense at
night and may disturb the patient’s sleep
(Neviaser and Neviaser, 1987; Stam,
1994). Functional impairments include
difficulty with dressing, particularly with
garments that require fastening behind
the back (eg a brassière) (Connolly, 1998;
Murnaghan, 1988).
A frequently reported finding during
physical examination is multi-directional
limitation of active and passive gleno-
humeral joint motion (Grubbs, 1993;
Pearsall and Speer, 1998). Losses of range
of motion over 50% have been reported
(Reeves, 1975). Compensatory increases
in scapulothoracic joint movement are
common (Roubal et al, 1996). Cyriax
proposed that pathologies involving the
glenohumeral joint capsule result in a
predictable pattern of joint restriction
(capsular pattern) with lateral rotation
most restricted, abduction next most
restricted, and medial rotation third most
restricted (Cyriax and Cyriax, 1983).
Classically, the natural history of frozen
shoulder has been divided into three
stages: the painful, adhesive and thawing
phases. In stage 1 (21/2 to nine months)
there is a gradual onset of shoulder pain
at rest, with a sharp pain at the extremes
of motion. During stage 2 (four to 12
months) the pain begins to subside but
there is a characteristic progressive loss of
glenohumeral flexion, abduction, internal
and external rotation. The thawing stage
(five to 26 months) is characterised by a
progressive improvement in functional
range of motion (Pearsall and Speer,
1998).
Prospective randomised controlled
451
clinical trials comparing the outcomes of
various treatments for adhesive capsulitis
are few and often involve small numbers
of patients (Murnaghan, 1988; Van der
Windt et al, 1998; Winters et al, 1997).
Despite being frequently involved in the
care of patients with adhesive capsulitis,
physical therapists have failed to elucidate
the extent to which their interventions
are effective in ameliorating this
condition. This literature review was
per formed to summarise findings of
recent outcomes investigations of physical
therapy in the treatment of patients with
adhesive capsulitis; and to examine
systematically the quality (or rigour) of
the investigations, since this affects the
validity of the results.
Methods
Literature Review
A search of computerised Medline and
CINAHL databases was performed for
articles published in English between
January 1990 and December 2000. Key
words used for the database searches were
‘physical therapy in the treatment of’ …
‘adhesive capsulitis’, ‘frozen shoulder
syndrome’, ‘pericapsulitis’, ‘periarthritis’,
‘periarticular adhesions’, and ‘humeral
scapular fibrositis’. Inclusion criteria
consisted of experimental or descriptive
research-based outcomes studies that
included physical therapy in non-
operative treatment of adhesive capsulitis
or a synonymous diagnostic label.
Use of the key words in the combined
Medline and CINAHL database searches
yielded 117 articles published between
January 1990 and December 2000.
Twenty-six articles that did not directly
involve the glenohumeral joint were
immediately excluded. A further 43
articles were omitted because they lacked
an experimental procedure. Thirty-four
studies were excluded because surgery
was involved. Two case studies were
omitted because of the lack of gener-
alisability of single-case designs. The
remaining 12 articles underwent quality
scoring by the primary author (JC).
Quality scoring was performed in lieu
of meta-analysis since the articles that
were reviewed varied considerably in
experimental design, methodology and
reported validity. In our opinion, this
experimental heterogeneity precluded
fair and meaningful comparison of
treatment and control group differences
Physiotherapy August 2002/vol 88/no 8
 452

(effect sizes) between the reviewed were totalled, then converted to a per-
articles. Instead, to facilitate qualitative centage with 100% (16/16) indicating
assessment of the different experimental highest quality.
designs used to study the treatment of Criteria used to determine quality scores
adhesive capsulitis via physical therapy., for this review included explicit enrolment,
the articles were sub-divided into three subject randomisation, standardisation
categories: of interventions, outcome assessments,
blinding of the assessor, stratification
■ Prospective (N = 9) (Ekelund and
by pathology staging and classification,
Rydell, 1992; Griggs et al, 2000; Mao
follow-up duration, number of treatment
et al, 1997; Melzer et al, 1995; Placsek
sessions, cost-effectiveness, duration of
et al, 1998; Roubal et al, 1996; Sharma
symptoms, group size greater than 40,
et al, 1993; Vermeulen et al, 2000;
documentation of the reliability and
Waldberg et al, 1992).
validity of measurements and the presence
■ Retrospective (N = 1) (Shaffer et al, of treatment side effects (table 1).
1992). Criteria were chosen as indicators of
■ Randomised clinical trials (N = 2) sound scientific methodology and/or
(Van der Windt et al, 1998; Winters because of the unique nature of adhesive
et al, 1997). capsulitis. For instance, the length of
follow-up was assessed due to reports of
Methodological Quality gradual and spontaneous resolution of
Scoring Protocol adhesive capsulitis symptoms often
A 16-item scoring protocol, modified occurring within 12 to 42 months (Stam,
from a validity assessment protocol 1994), and a reported average duration of
designed by Van der Heijden et al (1997) symptoms of 30 months (Reeves, 1975).
was used to assess the methodological Treatment economics were considered
rigour of each of the reviewed articles. since interventions deemed efficacious via
One point was assigned to each of the 16 experimentation could not be used
quality criteria. Points for each article clinically if they were not cost-effective.
Adverse treatment side-effects were also
considered as they could outweigh
treatment benefits.
Table 1: Quality scoring criteria
Results
Criteria Points Percentage of Quality Scores
scored studies that Randomised Clinical Trials
satisfied criteria
The two randomised clinical trials
Explicit enrolment criteria 1 100 included in this review received quality
Randomisation 1 25 scores of 57% (Winters et al, 1997) and
Stage of pathology 1 25 69% (Van der Windt et al, 1998) (mean
Classified into primary/secondary 1 50 63%) (table 2). The authors of these
Duration of symptoms before investigations reported that patients
intervention 1 100 treated with corticosteroid injections had
Group size > 40 1 42 superior outcomes to patients treated with
Outcome assessment physical therapy. In the Van der Windt et
Pain 1 67 al (1998) investigation, 40 of 52 (77%)
ROM 1 83 patients treated with triamcinolone
Function 1 67 acetonide injections over seven weeks
Standardisation of interventions 1 92 achieved ‘treatment success’ while only 26
Blinded assessment of outcomes 1 42 of 56 (46%) of patients treated with 12
Realiability and validity of sessions of physical therapy (passive joint
measurements 1 42 mobilisation, moist heat, electrotherapy,
Number of treatments <10 1 0 extensibility-enhancing exercises, streng-
Adverse side effects 1 75 thening exercises) were considered
Length of follow-up >1 year 1 50 successfully treated. Treatment success
Economic evaluation 1 0 was defined as the patient’s perception
Total 16 of complete recovery or significant
improvement.
ROM = Range of motion Winters et al (1997) (quality score 57%)

Physiotherapy August 2002/vol 88/no 8

Review 453

Table 2: Details of trials reviewed and their quality scores

Study and Number of Duration of Interventions and Outcomes Follow-up Quality

date published shoulders symptoms number of measured score
treatments (%)

Randomised clinical trials

Van der Windt 108 5 months Physical therapy. Pain 52 weeks 69

et al (1998) 12 treatments vs ROM
3 corticosteroid Function
injections
Winters 114 18 months Physical therapy. pain 11 weeks 57
et al (1997) 20 treatments
(no mobilisation)
vs manipulation vs
corticosteroid injections
Retrospective studies

Shaffer et al (1992) 62 2 weeks- Physical therapy. ROM 7 years 69

48 months Number of Function
treatments not
available

Prospective studies

Griggs et al (2000) 77 9 months Physical therapy Pain 22 months 63

passive stretching. ROM
Number of visits Function
unknown
Placzek et al (1998) 31 7 months Manipulation and Pain 14 months 57
14 physical therapy ROM
treatments Function
Melzer et al (1995) 110 18 months Physical therapy versus Pain 4 months 57
manipulation ROM
Function
Sharma et al (1993) 32 9 months Hydraulic distension ROM 44 months 50
and manipulation
with 8 weeks of
physical therapy
Vermeulen et al 7 8 months Physical therapy with Pain 9 months 50
(2000) end-range mobilisation ROM
techniques 2 x per week Function
x 3 months
Waldberg 50 3 months Physical therapy Pain 6 months 50
et al (1992) 21 treatments versus Function
calcitonin injections
Ekelund and 23 15 months Distension ROM 48 months 44
Rydell (1992) arthrography and Pain
manipulation with
physical therapy.
Number of visits
unknown
Roubal et al (1996) 6 7 months Manipulation and ROM 4 weeks 44
physical therapy.
16 treatments
Mao et al (1997) 12 2-12 months Physical therapy. ROM 2 weeks 38
12-18 treatments

ROM = Range of motion

compared the outcomes of patients
treated with physical therapy, manip-
ulation, or corticosteroid injections.
Following five weeks of treatment the
injection group had a 75% ‘cure rate’; the
manipulation group had a 40% ‘cure
rate’, and the physical therapy group had
a 20% ‘cure rate’. The authors neglected
to indicate if ‘cure’ meant complete
symptom resolution, or merely satis-
faction of some predetermined criteria.
Their physical therapy included ‘exercise
therapy, massage and physical applic-
ations’. Interestingly, the authors chose

Physiotherapy August 2002/vol 88/no 8

 454
not to include joint mobilisation in their
strategy, claiming that passive mobilisation
is a skill incompatible with everyday
practice.
Retrospective Design
The retrospective study by Shaffer et al
(1992) received a quality score of 69%
(table 2). Results of this study indicated
that following a mean of six months’
physical therapy (Codman’s exercises,
ultrasound, transcutaneous electrical
nerve stimulation, passive joint mobil-
isation and strengthening exercises),
statistically significant improvements in
active range of motion were achieved
(99% flexion, 101% abduction, 62%
external rotation).
Prospective Design
The nine prospective studies included in
this review received quality scores of
38% (Mao et al, 1997), 44% (Ekelund
and Rydell, 1992), 44% (Roubal et al,
1996), 50% (Sharma et al, 1993), 50%
(Vermeulen et al, 2000), 50% (Waldberg
et al, 1992), 57% (Melzer et al, 1995), 57%
(Placzek et al, 1998), and 63% (Griggs et
al, 2000), with a mean score of 50.3%
(table 2).
Mao et al (1997) reported statistically
significant improvements in gleno-
humeral active range of motion, and
reappearance of the axillary recess (via
arthrography) in subjects managed with
12 to 18 sessions of physical therapy
including moist heat, ultrasound, passive
joint mobilisations, and flexibility and
strengthening exercises.
Griggs et al (2000) reported that
following a physical therapy programme
consisting of passive stretching exercises
(forward elevation, external rotation,
horizontal adduction, and internal
rotation) at a mean follow-up of 22
months, patients demonstrated a
reduction in pain score from 1.57 to 1.16
in a range from one to five points,
improvements in active range of motion,
and 64 patients (90%) reported a
‘satisfactory outcome’.
Vermeulen et al (2000) reported that
patients subjected to end-range mob-
ilisation techniques demonstrated
significant increases in active range
of motion. At a nine-month follow-up
appointment four patients (57%) rated
their improvement in shoulder function
as excellent, while two (29%) rated it
Physiotherapy August 2002/vol 88/no 8
as good, and one (14%) rated it as
moderate.
Melzer et al (1995) and Waldberg et al
(1992) prospectively compared outcomes
of patients treated with a physical therapy
regimen of moist heat, gentle stretching,
range of motion exercises, mobilisation,
electro-analgesia (TENS) and cryotherapy
to outcomes of patients treated with
either manipulation under anaesthesia
(Melzer et al, 1995) or subcutaneous
calcitonin injections (Waldberg et al,
1992). Patients treated with physical
therapy in the Melzer et al (1995)
investigation gained an average active
range of motion that exceeded that of the
manipulation group, but the results were
not reported as statistically significant.
Waldberg et al (1992) reported that
physical therapy, combined with sub-
cutaneous calcitonin injections per f-
ormed daily for 21 days, resulted in
significantly greater pain reduction
compared to physical therapy alone
(p < 0.02). Both groups received ident-
ical physical therapy including active
mobilisation with electro-analgesia and
cryotherapy. However, there was no
significant difference in the time to
functional recovery between the two
groups.
Four of the reviewed studies (Ekelund
and Rydell, 1992; Placzek et al, 1998;
Roubal et al, 1996; Sharma et al, 1993)
prospectively compared outcomes of
patients managed with a combination of
physical therapy and either hydraulic
distension or manipulation. Sharma et al
(1993) compared the effectiveness of
manipulation and physical therapy to the
effectiveness of hydraulic distension and
physical therapy (passive mobilisation and
active exercise). Patients treated with
hydraulic distension gained significantly
greater active range of motion (mean
improvement 86.75°) than patients
treated with manipulation (mean
improvement 46.6°).
Ekelund and Rydell (1992) compared
outcomes of patients treated with
distension arthrography, local anaes-
thetics, and manipulation followed by
physical therapy (the details of which
were not indicated). At four to six weeks
follow-up, 91% of the subjects who had
undergone this combination of treat-
ments reported complete or partial relief
of pain and 82% exhibited normal active
range of motion (defined as a sum of
Review
flexion and abduction active range of
motion greater than 200°) or near normal
active range of motion.
Placzek et al (1998) (quality score 60%)
reported that translation manipulation
performed with a brachial plexus block
followed by physical therapy (cold packs,
high volt galvanic stimulation, pulsed
ultrasound, passive glenohumeral mob-
ilisation, and strengthening exercises)
resulted in significant pain reduction and
improvements in Wolfgang’s functional
assessment at a 14-month follow-up.
Roubal et al (1996) reported that
manipulation followed by an average of
16 treatments consisting of high volt
galvanic stimulation, glenohumeral
mobilisation, and strengthening exercises,
resulted in mean glenohumeral active
range of motion increases of 76° flexion,
82° abduction, 50° external rotation, and
49° internal rotation.
Discussion
The aim of this systematic literature
review was to present a summary of
research findings, and to assess the
validity of these findings by examining
the scientific rigour or quality of the
investigations relative to predetermined
criteria. Between studies on an identical
problem, the findings of a rigorously
conducted study (ie higher quality) would
have greater validity than the findings of a
study with a less stringent methodology.
In evidence-based clinical practice, it is
sensible to incorporate the most valid
evaluative and treatment techniques.
Quality review of the articles revealed a
trend in the omission of a number of the
quality criteria including evidence of
reliability and validity of measurements
of treatment efficacy, the stage of the
pathology, group size greater than 40
subjects, and economic evaluation. In
addition, the 12 studies reviewed varied
considerably in intervention strategies,
duration of treatment, and outcome
measures.
Due to the significant differences
between the articles in quality and
reported physical therapy efficacy, we can
merely conclude that physical therapy
may be beneficial in the treatment of
patients with adhesive capsulitis. It is
impossible to determine the particular
treatments or combinations of inter-
ventions that are efficacious in treat-
ing adhesive capsulitis as most of the
455
investigators combined multiple mod- Authors
alities, which precludes assessment of Joshua Cleland DPT
individual treatments. However, in two is a physical therapist
studies improvements in active range of at the Physical
motion, pain, and function were reported Therapy Center of
following passive stretching alone (Griggs Milford, NH. He was a
et al, 2000) and end-range joint mob- graduate student in
ilisation alone (Vermeulen et al, 2000). the transitional
Doctor of Physical
The variability of outcomes measures
Therapy programme
between the reviewed studies is ex- at Creighton
emplified in the assessment of range of University when this
motion. This was assessed in the majority study was conducted.
of the studies reviewed, but some authors
Christopher J Durall
chose to measure only active or passive
PT MS SCS ATC/L
range of motion, while other authors CSCS is assistant
measured both. It seems sensible to track professor in the
and report changes in active and passive Department of
range of motion in patients with adhesive Physical Therapy,
capsulitis since these patients have been School of Pharmacy
reported to present with limitations of and Allied Health
both (Connolly, 1998; Pearsall and Speer, Professions,
1998; Seigel et al, 1999). Creighton University,
Only seven of the 12 articles reviewed Omaha, NE.
included functional outcomes assess-
ments. Shaffer et al (1992) reported that This article was
all but 11% treated with physical therapy received on May 4,
returned to ‘full function’. Placzek et al 2001, and accepted
(1998) reported that patients treated with on January 25, 2002.
manipulation followed by physical therapy
exhibited significant improvements in
Address for
Wolfgang functional scores while Van der
Correspondence
Windt et al (1998) reported that the mean
shoulder disability rating was 42 with Joshua Cleland DPT,
The Physical Therapy
patients treated with cortisone injections
Center of Milford,
compared to 38 with patients treated with
17 Armory Road,
physical therapy. Patients treated with Milford, NH 03055,
mobilisation in the investigation by USA.
Melzer et al (1995) reported an average
functional improvement of 78 points,
while patients treated with mobilisation e-mail:
under anaesthesia demonstrated a jcleland@mcttelecom.
50-point mean improvement. Waldberg et com
al (1992) found no difference in the time
to ‘functional recovery’ between patients
treated with physical therapy and patients
treated with calcitonin injections. Griggs
et al (2000) demonstrated that at an
average of 22 months 90% of patients
who received passive stretching exer-
cises achieved a ‘satisfactory’ outcome.
Vermeulen et al (2000) demonstrated
that 57% of patients rated their shoulder
function improvement as excellent and
29% rated it as good.
It is plausible that the measured
improvements in range of motion, pain
and function reported in these invest-
igations may have been partially due to
spontaneous recovery (Anton, 1993;
Physiotherapy August 2002/vol 88/no 8
 456
Stam, 1994). However, it has not been
firmly established that spontaneous
resolution occurs in all cases of adhesive
capsulitis (Shaffer et al, 1992; Sharma et al,
1993). Shaffer et al (1992) indicated that
one-half of the patients with ‘frozen
shoulder’ managed non-operatively
remained symptomatic an average of
seven years later.
The evaluated literature suggests that
physical therapy may be beneficial for
patients with adhesive capsulitis, but at
what cost to the consumer? The number
of physical therapy visits within these 12
studies ranged from 12 to 29. With the
emphasis on cost-containment in medical
care, it is increasingly important that
scientific investigators report intervention
costs. None of the reviewed studies
included supporting data on the cost-
efficiency of the techniques investig-
ated. This is an apparent shortcoming
of many physical therapy outcomes
studies. Ultimately, the inter vention
that demonstrates effectiveness and cost-
efficiency will be adopted as standard
clinical practice. The examination of the
cost-efficiency of treatment for adhesive
capsulitis is especially important given
that the natural history of adhesive
capsulitis may be eventual spontaneous
symptomatic resolution (Grubbs, 1993).
A limitation of our study is that we
searched only two databases (Medline and
CINAHL) and looked only at articles
published in English. In addition, the
heterogeneity of the articles reviewed
does not allow for direct comparison
between studies using the same outcome
measurement. This does not allow for
statistical pooling of the results. Also the
inclusion of article designs other than
randomised control trials prevents
calculation of effects size for comparison.
The quality scoring of the articles was
carried out by only one of the authors
(JC) who was not blinded to the origin of
the studies included, so that reviewer bias
cannot be excluded.
Recommendations for Future Research
One of the objectives of systematic
literature reviews is to identify facets of
clinical practice in need of further
research. This review has highlighted the
Physiotherapy August 2002/vol 88/no 8
need for more prospective, randomised
controlled clinical trials using a stand-
ardised outcomes assessment to judge
the efficacy of various physical therapy
interventions on adhesive capsulitis.
Because physiotherapy is typically a
mixture of treatments, it is impossible to
determine the components that are most
efficacious by examining the reviewed
studies. As direct comparison of clinical
studies is possible only when subject
populations are homogeneous, patients
need to be stratified according to their
stage of disease progression. The incorp-
oration of universally accepted valid and
reliable outcome measures would sign-
ificantly enhance the comparison of
results between studies and allow for
meaningful meta-analyses.
Determining the biological trigger
responsible for the development of
synovitis and subsequent capsular
adhesions would greatly facilitate
understanding of the pathogenesis of
adhesive capsulitis and perhaps help
harmonise terminology. The lack of
consistent terminology and standard
diagnostic criteria poses a threat to
determining the most effective and
economical treatments for adhesive
capsulitis and confounds direct
comparison of clinical trials.
Conclusion
This review and synthesis of 12 studies
published between 1990 and 2000
revealed many inconsistencies in
terminology, intervention strategy, and
outcomes measurement between the
studies, making it difficult to compare
relevant published research and det-
ermine the effectiveness or economic
efficiency of treatments. Most of the
articles reviewed suggest that physical
therapy alone, or as part of a combination
of modalities is beneficial for patients
with adhesive capsulitis, but the extent of
this benefit is not clear. Quality scores
of the 12 articles ranged from 38% to
69%. Until the effectiveness and econ-
omic efficiency of a single intervention
are firmly established, management of
adhesive capsulitis will remain a topic of
debate.
Review
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