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Theeffectivenessofphysiotherapeuticinterventionsintreatmentoffrozenshoulder/adhesivecapsulitis:Asystematicreview

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Journal of Back and Musculoskeletal Rehabilitation 27 (2014) 247–273 247DOI 10.3233/BMR-130443IOS Press

Systematic Review

The effectiveness of physiotherapeuticinterventions in treatment of frozenshoulder/adhesive capsulitis: A systematicreview

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 thisreview, 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 studiespublished in English since 2000.RESULTS: 39 articles describing the PTI were analyzed using Sackett’s levels of evidence and were examined for scientificrigor. 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 ofmotion (ROM) and function in patients with stages 2 and 3 of frozen shoulder. Low-level laser therapy is strongly suggestedfor pain relief and moderately suggested for improving function but not recommended for improving ROM. Corticosteroidinjections can be used for stage 1 frozen shoulder. Acupuncture with therapeutic exercises is moderately recommended for painrelief, improving ROM and function. Electro- therapy can help in providing short-term pain relief. Continuous passive motionis recommended for short-term pain relief but not for improving ROM or function. Deep heat can be used for pain relief andimproving ROM. Ultrasound for pain relief, improving ROM or function is not recommended.

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

1. Introduction

Frozen shoulder or adhesive capsulitis is a mus-culoskeletal condition that is commonly encounteredin physical therapy practice. The exact incidence and

∗Corresponding author: Neena K. Sharma, Department of Physi-cal Therapy and Rehabilitation Science, University of Kansas Med-ical Center, Mailstop 2002, 3901 Rainbow Blvd, Kansas City, KS66160, USA. Tel.: +1 913 588 4566; Fax: +1 913 588 4568; E-mail:[email protected].

prevalence of frozen shoulder is unknown, but is oftenquoted to affect approximately 2% to 5% of the generalpopulation [1–4] and mainly individuals 40–65 yearsof age, with a female predominance (58:42) [1,3]. Itis characterized by a spontaneous onset of pain withgradual, progressive loss of glenohumeral joint mo-tion which can lead to gross loss of shoulder func-tion. The conditions usually starts with one shoulderand commonly affects the contralateral side years af-ter the onset of symptoms in the first shoulder butit does not affect the same shoulder twice [3,5–8].

ISSN 1053-8127/14/$27.50 c© 2014 – IOS Press and the authors. All rights reserved

248 T.K. Jain and N.K. Sharma / Physiotherapeutic interventions for frozen shoulder

Table 1Stages of frozen shoulder

Stage 1The preadhesive stage

Stage 2The acute adhesive or “freezing”stage

Stage 3The fibrotic or “frozen” stage

Stage 4The “thawing” phase

Hyper vascular synovitis withnormal underlying capsule.

Decrease in hyper vascular syn-ovitis with early adhesion forma-tion leading to capsular contrac-tion and thickening.

Less synovitis but more mature ad-hesion in the capsule and axillaryfold.

Severe capsular restriction with-out apparent synovitis.

Patients present with mild or noend-range limitation and pain.

Patients have a high level of dis-comfort, limited passive and ac-tive motion, and increased painnear end-range of motion.

Patients note significant motionlimitation with minimal pain.

Patients in this phase presentwith painless restriction of mo-tion, which typically improves byremodeling.

Treatment Goal – decrease painby interrupting the cycle of in-flammation and pain

Treatment Goal – restore the nor-mal glenohumeral biomechanicsin addition to decreasing inflam-mation and pain.

Treatment goal – aggressively treatsignificant loss of motion and re-store normal range of motion andfunctionality of the shoulder joint.

Treatment goal – maintain thenormal range of motion andshoulder function while main-taining the normal glenohumeralbiomechanics and avoiding painand 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

The risk of being affected appears to be increasedby trauma/surgery [9], hormonal diseases such as di-abetes, ACTH deficiency, and thyroid disease [10,11], cardiac diseases [12], neurologic diseases such asParkinson’s and stroke [13], neurosurgery [14], ma-lignancies [15], hyperlipidemia [16], certain medica-tions such as metalloproteinase inhibitors, protease in-hibitors, antiretrovirals, influenza and pneumococcalvaccine, and fluoroquinolones, and Dupuytren’s con-tracture [17].

Although the underlying etiology and pathophysiol-ogy of frozen shoulder is poorly understood and dis-agreement remains in the literature whether to definethis pathologic process as an inflammatory or a fibros-ing condition [4], several authors have attempted toidentify homogeneous subgroups to simplify treatmentchoices and make outcomes more predictable. Lund-berg categorized frozen shoulder patients into two sub-groups – idiopathic/primary frozen shoulder when pa-tients displayed symptoms with no identifiable cause,and secondary when patients had a similar presentationand progression but resulted from a known intrinsic,extrinsic, or systemic cause [3].

Patients with frozen shoulder typically demonstratea characteristic history, clinical presentation, and re-covery. It is believed to be a self-limiting condition,lasting 18–24 months with no long-term sequelae. Al-though majority of patients show complete resolutionof the disease, many others report long term pain andresidual motion restriction [8,16,18]. Various authorshave tried to characterize the natural course of thefrozen shoulder but it still remains controversial. Forexample, Reeves in 1975 described the natural his-

tory of frozen shoulder as a continuum of 3 phases: 1)painful (freezing) phase lasting 10–36 weeks, 2) stiff(frozen) phase lasting 4–12 months, and 3) recovery(thawing) phase lasting 5–26 months or more [19]. Intheir report, the full duration of the disease lasted any-where from 1 to 3.5 years, with a mean of 30 months,but subsequent reports have described a longer andmore protracted course in many patients. Later, Han-nafin and Chiaia described 4 stages (Table 1) incorpo-rating the arthroscopic stages described by Nevaiser,the clinical examination, and the histological findingsin frozen shoulder patients [2].

The diagnosis of frozen shoulder is based upon athorough history and physical examination without for-mal criteria. The most used criteria in previous studiesto diagnose frozen shoulder are – insidious or minimalevent resulting in onset, significant shoulder pain thatinterferes with successful activities of daily living, sig-nificant night pain, significant limitations of active andpassive shoulder motion in more than 1 plane to lessthan 100◦ and 50% or greater than 30◦ loss of passiveexternal rotation (at the side), painful end range motionin all movements, significant pain/weakness of the in-ternal rotators, normal radiological appearance, and nosecondary causes [3,5,7,8,19].

Many treatments have been advocated to treat frozenshoulder: rest/education, analgesia, joint mobilization,thermotherapy, massage, therapeutic exercises andphysical therapy, acupuncture, oral and injected corti-costeroids, laser therapy, capsular distension, manipu-lation under anesthesia, nerve blocks, and arthroscopiccapsular release [7,20,21]. Currently there is no con-sensus as to which treatment is most effective in frozen

T.K. Jain and N.K. Sharma / Physiotherapeutic interventions for frozen shoulder 249

Computer database search (n=2917)MEDLINE (n=1061)CINAHL (n=54)Cochrane Review (n=48)PEDro (n=55) ProQuest (n=946)Science Direct (n=630)Sport Discus (n=123)

Unrelated articles excluded based on title and abstract (n=1829)

Duplicate articles excluded (n=915)

Screening of title and abstract for inclusion and exclusion (n = 173)

Irrelevant and uncertain articles excluded (n=46)

Articles excluded (n=62)Study design=38Intervention =15Full text access not available =9

Full text articles retrieved for further analysis (n=55)

Irrelevant articles excluded (n=16)

Included in review (n=39)

Fig. 1. Selection of studies.

shoulder patients [20]. Generally the treatment regi-mens include a trial of conservative therapy, followedby more invasive procedures for recalcitrant cases.However, varied inclusion criteria, different diagnos-tic criteria and treatment protocols, and numerous out-come measures used in studies make study compar-isons difficult. Many studies do not provide detailsregarding the stage of the disease process, previoustreatment, and etiological considerations. Despite theamount of research that has been carried out into thistopic, the results still appear to be inconclusive regard-ing the effectiveness of interventions specifically forfrozen shoulder. Selecting or grouping subjects basedon specific criteria would enhance the validity, repro-ducibility, and comparability of the results. Physicaltherapy alone is an effective treatment but is also acomplement to other therapies [5].

The purpose of this review is to systematically con-sider the evidence from the recent published literatureon the effectiveness of physical therapy interventions(PTI) for the management of frozen shoulder.

1.1. Objectives

The main objectives of our review are:1. To analyze the functional outcomes in patients

who received PTI for the management of frozenshoulder as compared to those given no treat-ment, other treatment or a placebo control.

2. To present the best-available evidence of the ef-fectiveness of PTI for the management of frozenshoulder.

3. To critically assess the quality of the recentlypublished studies and to identify deficiencies thatmight be corrected by further research.

2. Methods

To conduct this systematic review, a literature searchand review was performed using MEDLINE, Cumu-lative Index to Nursing and Allied Health Litera-ture (CINAHL), Cochrane, Physiotherapy EvidenceDatabase (PEDro), ProQuest, Science Direct, andSport Discus databases (Fig. 1). The databases wereused to search the literature on the University ofKansas library system initially during the month ofMarch–April 2011 and then updated in January 2012.The search was limited to human subjects and articlespublished in English within last 12 years.

To focus the search on the PTI for the treatmentof frozen shoulder, “adhesive capsulitis” and “frozenshoulder”, the two most common terms used to de-scribe the condition, were used as key terms for thesearch. The MEDLINE search was conducted in twoways. First, we conducted search using the MeSH ter-minology restricted to MeSH major topic with pre-


vention and control, rehabilitation, and therapy as sub-headings. Second, we used the basic search index us-ing the combinations of these two key terms and the“AND” operation with the following terms: “physi-cal therapy”, “physiotherapy”, “manual therapy”, “ex-ercise”, “electrotherapy”, “mobilization”, “acupunc-ture”, “rehabilitation”, “treatment”, and “education”.Using this method, the various search combinations, intotal, generated 2917 articles.

In the first step, the titles and abstracts of these refer-ences were examined, and articles that were not relatedto the topic of interest or duplicate were removed. Fol-lowing this screening process, 173 articles were iden-tified in the search on the various databases. From thelist of 173 articles, irrelevant and uncertain articleswere excluded, including articles comparing surgicaltechniques. Following this screening process, 55 fulltext articles were retrieved for further review of ap-propriateness and analysis. Articles were included inthe subsequent analysis if: 1) they were experimentalor quasi-experimental reports from peer-reviewed jour-nals, 2) an intervention that included “physical ther-apy”, “manual therapy”, “exercise”, “electrotherapy”,mobilization”, “acupuncture”, “rehabilitation”, “treat-ment”, and “education” with the intended goal of treat-ing frozen shoulder was implemented, 3) subjects werediagnosed with the frozen shoulder diagnostic criteriamentioned above. The excluded articles were those thatinvestigated other shoulder disorders, surgical tech-niques, utilized no treatment such as long term out-come studies, and economic evaluation studies. Af-ter applying the inclusion/exclusion criteria, 39 articleswere included in the review (Fig. 1).

In the second step, we evaluated each article inde-pendently using a modified version of Sackett’s criticalappraisal criteria outlined by Mortenson and Eng [22].Additionally, a level of evidence was assigned for eacharticle and graded as described by Sackett [23], andButler and Campbell [24] (Table 2). One point wasawarded for each factor met, which generated a poten-tial maximum value of eight points. If information re-garding criteria was not mentioned in the article, nopoints were assigned for that category. The grade ofrecommendation for each of the major outcome mea-sures was based on the level of supporting evidence.Specifically, grade A is given to a measurement if sup-ported by at least one level I study; B if supported byat least one level II study; and C if supported by levelIII, IV, or V evidence.

Table 2Appraisal and recommendation criteria

Criteria for assessment of methodological quality of studiesConfounding factorsRandom assignmentBlinded assessmentMonitored interventionReport of dropoutDescriptions of reliabilityValidity of measurementsFollow-upHierarchy of quality of individual studies and strength of evidenceLevel I = large randomized controlled trial, low error riskLevel II = small randomized trial, moderate to high error riskLevel III = nonrandomized designLevel IV = case series, no controlLevel V = case reportFormulation of recommendationsGrade A – at least one level I studyGrade B – at least one level II studyGrade C – if supported by level III, IV, or V evidence.

3. Results

Thirty-nine studies (n = 4350) from 2917 cita-tion postings met the inclusion criteria of the qualita-tive review (Fig. 1). All studies assessed the effect ofthe PTI in the treatment of frozen shoulder (Table 3).The number of patients in the reviewed studies rangedfrom 1 to 2370. After the exclusion of one retrospec-tive study that studied 2370 subjects [25], total num-ber of subjects averaged 49.5 with 31.4 (63.4%) sub-jects being females per study. All studies had more fe-male patients except three studies [26–28] which hadeither equal or more number of male patients. The pa-tients’ age ranged from 22–96 years with the meanage of 53.77 ± 3.97 years. The duration of symp-toms in the reviewed studies ranged from 6 weeks to10.2 months, placing almost of the subjects in Stages1, 2 and 3 of frozen shoulder. Most studies includeda separate control group for their experiments, whilefive of the cohort studies had no control group [25,29–32], and six studies were either case series [33,34] orcase reports [35–38]. Follow-up time post-interventionranged from day 1 to 9.2 ± 9.7 years in the reviewedstudies.

3.1. Level of evidence

The level of evidence varied from level V (lowest ev-idence) to level I (highest evidence) (Table 4). Twentyfour out of thirty nine studies were randomized controltrials with pre- and post-test groups. Eight studies werecohort design (four prospective and four retrospective),


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7,Fe

mal

e=

22

–G

roup

1:G

HR

OM

exer

cise

s(n

=14

(5M

+9F

),ag

e=

54.8

;ran

ge42

–65

yrs.

)–

Gro

up2:

GH

RO

M+

scap

ulot

hora

cic

ex-

erci

ses

(n=

15(2

M+

13F)

,age

=49

.6;

rang

e38

–62

yrs.

)

DO

S:N

otst

ated

Inte

rven

tion

peri

od–

6w

eeks

(30

sess

ions

)

–G

roup

1:G

leno

hum

eral

RO

Mex

erci

ses

–G

roup

2:G

leno

hum

eral

RO

M+

scap

ulot

hora

cic

exer

cise

s–

Bot

hgr

oups

rece

ived

TE

NS,

cold

pack

,and

NSA

IDs

follo

win

gex

erci

ses

for

pain

re-

lief,

whe

nne

eded

∗B

oth

grou

psha

dH

EP

twic

eda

ilyw

ith20

repe

ats

ofex

er-

cise

s

–Pa

inus

ing

VAS

scal

e–

Mod

ified

Con

stan

tsco

re–

Shou

lder

RO

Min

flexi

on,

IR,a

ndE

R

Ass

essm

ents

:

–B

asel

ine

–6

wee

ks–

12w

eeks

–A

llou

tcom

em

easu

res

impr

oved

inbo

thgr

oups

–VA

Ssc

ore

show

edgr

eate

rim

-pr

ovem

enti

ngr

oup

2at

6w

eeks

–M

odifi

edC

onst

ants

core

was

not

sign

ifica

ntly

diff

eren

tbe

twee

nth

egr

oups

–R

OM

impr

oved

sign

ifica

ntly

ingr

oup

2at

12w

eeks

Cha

net

al.[

55],

2010

–D

esig

n=

RC

T–

MO

R–

Com

pute

rge

nera

ted

–L

OE=

Lev

elII

n=

15,5

4.8

yrs.

(ran

ge38

–76

yrs.

)M

ale=

3,Fe

mal

e=

12

–Pa

ssiv

em

obili

zatio

ngr

oup:

pass

ive

mob

iliza

tion

+ho

me

care

pro-

gram

(n=

7(2

M+5

F),a

ge=

50.9

;ran

ge48

–76

yrs.

)–

Con

trol

grou

p:ho

me

care

prog

ram

only

(n=

8(1

M+7

F),a

ge=

56.7

;ran

ge39

–59

yrs.

)

DO

S:

–Pa

ssiv

em

obili

zatio

ngr

oup

–2.

5m

onth

s–

Con

trol

grou

p–

2.4

mon

ths

Inte

rven

tion

peri

od–

10w

eeks

–B

oth

grou

psre

ceiv

ed30

mg

tri-

amci

nolo

neac

eton

ide

(Ken

alog

)an

d3.

25m

l1%

lidoc

aine

.–

Pass

ive

mob

iliza

tion

grou

p:G

rade

A&

Bm

obili

zatio

n(s

ix30

min

ute

wee

kly

sess

ions

over

10w

eeks

)+ho

me

care

prog

ram

–C

ontr

olgr

oup:

hom

eca

repr

o-gr

am ∗A

ctiv

ean

dac

tive-

assi

sted

RO

Mex

erci

ses

∗C

apsu

lars

tretc

hing

exer

cise

s∗

Post

ural

corr

ectio

n,an

d∗

Scap

ular

stab

ilizi

ngex

erci

ses

–Pa

inus

ing

VAS

scal

e–

SPA

DI

–A

ctiv

eR

OM

insh

ould

erab

duct

ion,

IR,a

ndE

R

Ass

essm

ents

:

–B

asel

ine

–2

wee

ks–

4w

eeks

–7

wee

ks–

10w

eeks

By

wee

k10

,bot

hgr

oups

show

edim

prov

emen

tin

pain

,sho

ulde

rfu

nctio

nan

dsh

ould

erra

nge

ofm

ovem

ents

,with

the

cont

rolg

roup

show

ing

atr

end

tow

ards

bette

rim

prov

emen

ttha

nth

epa

ssiv

em

obili

zatio

ngr

oup

Che

ing

etal

.[45

],20

08

–D

esig

n=

RC

T–

MO

R–

Not

stat

ed–

LO

E=

Lev

elII

n=

70(r

ange

33–9

0yr

s.)

Mal

e=

22,F

emal

e=

48

–G

roup

1:E

lect

roac

upun

ctur

e+

Ex

(n=

24)

–G

roup

2:IF

T+

Ex

(n=

23)

–G

roup

3:C

ontr

ol(n

=23

)

DO

S:

–G

roup

1:6.

71±

6.50

mon

ths

–G

roup

2:6.

70±

6.05

mon

ths

–G

roup

3:8.

26±

7.94

mon

ths

–G

roup

1–

EA

treat

men

tfo

r10

sess

ions

over

4-w

eek

peri

od(2

–3/w

eek)

+H

EP

–G

roup

2–

IFT

treat

men

tfo

r10

sess

ions

over

4-w

eek

peri

od(2

–3/w

eek)

+H

EP

–H

EP–

stan

dard

seto

fsho

ulde

rex

5tim

es/d

ayfo

r6m

onth

s

∗Fo

rwar

dfle

xion

∗E

xter

nalr

otat

ion

∗H

oriz

onta

ladd

uctio

n∗

Inte

rnal

rota

tion

–C

onst

ant

Mur

ley

Ass

ess-

men

t(th

issh

ould

bein

the

foot

note

s)(C

MA

)sco

re–

Pain

usin

gVA

Ssc

ale

Ass

essm

ents

:

–B

asel

ine

–Po

st-in

terv

entio

n–

1m

onth

–3

mon

ths

–6

mon

ths

Sign

ifica

ntch

ange

inC

MA

and

VAS

scor

ein

EA

and

IFT

grou

pas

com

pare

dto

cont

rola

tlea

stun

tilth

e6

mon

thfo

llow

up


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Die

rcks

etal

.[62

],20

04

–D

esig

n=

Con

-tro

lled,

coho

rtst

udy

–M

OR

–C

ompu

ter

gene

rate

d–

LO

E=

Lev

elII

I

n=

77M

ale=

30,F

emal

e=

47

–Su

perv

ised

negl

ectg

roup

:sup

porti

veth

er-

apy

and

exer

cise

sw

ithin

the

pain

limits

(n=

45(1

9M+

26F)

,age

=50

±6.

0)–

Phys

ical

ther

apy

grou

p:pa

ssiv

est

retc

hing

and

man

ual

mob

iliza

tion

(n=

32(1

1M+

21F)

,age

=51

±7.

0)

DO

S:

–Su

perv

ised

negl

ectg

roup

–5

mon

ths

(Ran

ge3–

12m

onth

s)–

Phys

ical

The

rapy

grou

p–

5m

onth

s(R

ange

3–10

mon

ths)

Inte

rven

tion

peri

od–

2ye

ars

–Su

perv

ised

negl

ectg

roup

:edu

ca-

tion,

pend

ulum

and

activ

eex

er-

cise

sw

ithin

the

pain

less

rang

e–

Phys

ical

ther

apy

grou

p:

∗A

ctiv

eex

erci

ses

upto

and

be-

yond

the

pain

thre

shol

d∗

Pass

ive

stre

tchi

ngan

dm

anip

-ul

atio

nof

the

GH

join

t∗

Hom

eex

erci

ses

for

stre

tchi

ngan

dm

axim

alre

achi

ng

–C

onst

ants

core

Ass

essm

ents

:

–B

asel

ine

–3-

mon

thin

terv

als

upto

24m

onth

s

Atb

oth

12an

d24

mon

ths’

time

pe-

riod,

patie

nts

inth

egr

oup

treat

edw

ithsu

perv

ised

negl

ect

achi

eved

quic

kera

ndgr

eate

rim

prov

emen

tin

cons

tant

scor

eth

anpa

tient

sin

the

phys

ical

ther

apy

grou

p

Dog

ruet

al[4

6],

2008

–D

esig

n=

RC

T–

MO

R–

Not

stat

ed–

LO

E=

Lev

elII

n=

49,5

5.4±

7.6

yrs.

(age

d41

–72

yrs.

)M

ale=

21,F

emal

e=

28

–G

roup

1:U

S(n

=25

(11M

+14F

),ag

e=

53.9

±7.

8)–

Gro

up2:

Sham

(n=

24(1

0M+1

4F),

age

=56

.8±

7.3)

DO

S:

–U

Sgr

oup:

6.3±

3.5

mon

ths

–Sh

amgr

oup:

5.2±

2.9

mon

ths

Inte

rven

tion

–10

sess

ions

(2w

eeks

)

–U

Sgr

oup

–U

S+

supe

rfici

alhe

at+

exer

cise

prog

ram

+H

EP

–G

roup

2–

Imita

tive

US+

supe

r-fic

ialh

eat+

exer

cise

prog

ram

+H

EP

HE

P–

3m

onth

s

–C

odm

anex

–A

ctiv

eR

OM

and

stre

tchi

ngex

–Sh

ould

erR

OM

infle

xion

,ab

duct

ion,

IR,a

ndE

R–

SPA

DI

Pain

usin

gVA

Ssc

ale

–SF

-36

Ass

essm

ents

:

–B

asel

ine

–Po

st-in

terv

entio

n–

3m

onth

s

–N

osi

gnifi

cant

diff

eren

cein

pain

,SPA

DIa

ndSF

-36

betw

een

grou

ps.

–R

OM

incr

ease

db/

wpr

ean

dpo

sttre

atm

enti

nbo

thgr

oups

but

mor

ein

US

grou

p

Dud

kiew

icz

etal

.[29

],20

04

Des

ign=

Pros

pect

ive

coho

rtst

udy

–L

OE=

Lev

elII

I

n=

54,M

ale=

26,F

emal

e=

28A

vera

geag

eof

onse

t–51

.8±

9.7

yrs.

(ran

ge31

–82

yrs.

)D

OS:

9.7±

6.7

mon

ths

Inte

rven

tion

peri

od–

Not

stat

edA

llpa

tient

sw

ere

treat

edw

ithlo

ng-

term

cour

seof

phys

ical

ther

apy+

NSA

IDs

–A

ctiv

eR

OM

insh

ould

erel

evat

ion,

IR,a

ndE

R

Ass

essm

ents

:

–B

asel

ine

–M

ean

follo

wup

perio

d–

9.2±

9.7

yrs.

Act

ive

RO

Mim

prov

edsi

gnifi

cant

lyin

all

the

mea

sure

dm

ovem

ent

di-

rect

ions

Dun

dare

tal

.[47

],20

09

–D

esig

n=

RC

T–

MO

R–

Not

stat

ed–

LO

E=

Lev

elII

n=

57M

ale=

18,F

emal

e=

39

–G

roup

1:C

PM(n

=29

(9M

+20

F),a

ge=

56.3±

7.8)

–G

roup

2:PT

(n=

24(9

M+1

9F),

age=

57.1

±8.

3)

DO

S:

–C

PMgr

oup:

6.3±

4.2

mon

ths

–PT

grou

p:5.

9±

4.0

mon

ths

Inte

rven

tion

peri

od–

20da

ys

–C

PMgr

oup:

CPM

for

1h

once

ada

yfo

r20

days

×4

wee

ks+

HE

P–

PTgr

oup:

daily

PTin

clud

ing

ac-

tive

stre

tchi

ngan

dpe

ndul

umex

-er

cise

sfo

r1

hon

cea

day

for

20da

ys×

4w

eeks

.+H

EP

HE

P:pa

ssiv

era

nge

ofm

otio

nan

dpe

ndul

umex

erci

ses

–Pa

inus

ing

VAS

scal

e–

Pass

ive

RO

Min

shou

l-de

rflex

ion,

abdu

ctio

n,IR

,an

dE

R–

Con

stan

tfun

ctio

nals

core

–SP

AD

I

Ass

essm

ents

:

–B

asel

ine

–4

wee

ks–

3m

onth

s(1

2w

eeks

)

–A

llth

eou

tcom

em

easu

res

im-

prov

edfr

omba

selin

e.–

Pain

redu

ctio

nw

assi

gnifi

cant

atfo

llow

upco

mpa

red

toba

selin

e.–

CPM

appl

icat

ion

has

nosu

peri-

ority

over

PTon

shou

lder

RO

M,

func

tiona

labi

lity


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Ear

ley

and

Shan

non

[37]

2006

–D

esig

n=

Cas

ere

-po

rt–

LO

E=

Lev

elV

53ye

ars

old

Cau

casi

anfe

mal

eU

nive

rsity

prof

esso

rD

OS:

4w

eeks

post

onse

t

Occ

upat

ion

asm

eans

inte

rven

tion

–U

S–

AD

L’s

–G

ames

–H

EP

–Pa

inus

ing

VAS

Scal

e–

Act

ive

RO

Min

shou

lder

flexi

on,e

xten

sion

,abd

uc-

tion,

addu

ctio

n,ho

rizon

-ta

lab

duct

ion,

horiz

onta

lad

duct

ion,

IR,a

ndE

R

Ass

essm

ents

:

–B

asel

ine

–6

wee

ks–

6M

onth

s–

9m

onth

s

Pain

and

RO

Mim

prov

edco

ntin

u-ou

sly

atfo

llow

uppe

riod

s

Gas

para

ndW

illis

[61]

,20

09

Des

ign=

Con

trolle

d,co

hort

stud

y

–L

OE=

Lev

elII

I

n=

62,

Mal

e=

26,F

emal

e=

28A

vera

geag

eof

onse

t–55

.6±

7.9

yrs.

(ran

ge36

–75

yrs.

)

–G

roup

ICon

trol

(n=

15);

–G

roup

IIPT

excl

usiv

ely

with

stan

dard

ized

prot

ocol

s(n

=16

);–

Gro

upII

ISho

ulde

rDyn

aspl

ints

yste

mex

-cl

usiv

ely

(n=

16);

–G

roup

IVC

ombi

ned

trea

tmen

tw

ithSh

ould

erD

ynas

plin

tand

stan

dard

ized

PT(n

=16

)

DO

S:N

otst

ated

Inte

rven

tion

–90

days

(PT-

mor

eth

an2/

wee

k,SD

Sw

orn

mor

eth

an2/

day)

PT–

–M

oist

heat

–Pa

tient

educ

atio

n–

Join

tmob

iliza

tion

–PR

OM

,AR

OM

–PN

F–

The

rape

utic

ex

–A

ctiv

eR

OM

insh

ould

erE

R

Ass

essm

ents

:

–B

asel

ine

–A

fter

90da

ys

–Si

gnifi

cant

diff

eren

cew

asfo

und

fora

lltre

atm

entg

roup

s–

The

grea

test

chan

gein

activ

eE

Rw

asfo

und

for

the

com

bine

dtre

atm

entg

roup

(mea

nch

ange

of29

◦ )

Gri

ggs

etal

.[6]

,20

00

–D

esig

n=

Cas

ese

-rie

s–

LO

E=

Lev

elIV

n=

75,5

3yr

s.(r

ange

35–7

6yr

s.)

Mal

e=

17,F

emal

e=

58D

OS:

9.2

mon

ths

(ran

ge–

1.3–

47m

onth

s)

Reh

abili

tatio

nex

erci

sepr

otoc

ol–

2se

ssio

nspe

rwee

k

–Pe

ndul

umci

rcum

duct

ion

–Pa

ssiv

est

retc

hing

exer

cise

sin

forw

ard

elev

atio

n,E

R,h

oriz

onta

lad

duct

ion,

and

IR.

HE

P–

5tim

espe

rda

yto

the

tole

r-ab

lelim

it

–Pa

inus

ing

subj

ectiv

epa

inqu

estio

nnai

re–

Act

ive

and

pass

ive

RO

Min

shou

lder

inel

evat

ion,

IR,a

ndE

R–

DA

SH–

SF-3

6

Ass

essm

ents

:

–B

asel

ine

–M

id-t

erm

eval

uatio

n(6

–12

wee

ks)

–Fi

nal(

12–4

1m

onth

s)

–Si

gnifi

cant

impr

ovem

ents

inpa

insc

ores

,RO

Mw

ere

obse

rved

–D

ASH

scor

esw

ere

obse

rved

tobe

low

erth

anth

ekn

own

popu

la-

tion

norm

s–

SF-3

6w

ere

com

para

ble

toag

ean

dge

nder

-mat

ched

cont

rolp

op-

ulat

ions

Gul

er-U

ysal

and

Koz

ano-

glu

[48]

,20

04

–D

esig

n=

RC

T–

MO

R–

Not

stat

ed–

LO

E=

Lev

elII

n=

40,5

6.0±

8.6

yrs.

(ran

ge40

–85

yrs.

)M

ale=

12,F

emal

e=

28

–C

YR

Gro

up:C

yria

x(n

=20

(5M

+15

F),

age=

53.6

±6.

9)St

ages

I/II

–6/

14

Inte

rven

tion

peri

od–

2w

eeks

–C

YR

grou

p:1

hour

Cyr

iax

mob

thre

etim

esa

wee

k(d

eep

fric

tion

mas

sage

and

man

ipul

atio

n)+

Act

ive

stre

tchi

ngan

d

–R

ecov

ery

rate

–Pa

ssiv

eR

OM

insh

oul-

derfl

exio

n,ab

duct

ion,

IR,

and

ER

–19

patie

nts

inth

eC

YR

grou

p(9

5%)

and

13pa

tient

sin

the

PTgr

oup

(65%

)re

ache

dsu

ffici

ent

RO

Mat

the

end

ofth

ese

cond

wee

k


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

–PT

Gro

up:P

T(n

=20

(7M

+13

F),

age=

58.4

±9.

7)St

ages

I/II

–8/

12

DO

S:

–C

YR

Gro

up:7

.6±

3.9

mon

ths

–PT

Gro

up:5

.6±

3.9

mon

ths

pend

ulum

exer

cise

s

–PT

grou

p:1-

hour

phys

ical

ther

-ap

yse

ssio

n+

activ

est

retc

hing

and

pend

ulum

exer

cise

s

Hot

pack

sfo

r20

min

utes

follo

wed

bySW

Dap

plie

dfo

r20

min

utes

–H

EP:

pass

ive

rang

eof

mot

ion

and

pend

ulum

exer

cise

s

–Pa

indu

ring

activ

ityqu

es-

tionn

aire

Ass

essm

ents

:

–B

asel

ine

–1

wee

k–

2w

eeks

–T

heim

prov

emen

tin

shou

lder

flexi

on,

inne

ran

dou

ter

rota

tion

valu

esan

dth

ede

crea

sein

pain

with

mot

ion

wer

esi

gnifi

cant

lybe

tter

inth

eC

YR

grou

paf

ter

the

first

wee

kof

trea

tmen

t

Hsi

ehet

al.[

40],

2012

–D

esig

n=

RC

T–

MO

R–

Com

pute

rge

nera

ted

–L

OE=

Lev

elI

n=

70M

ale=

20,F

emal

e=

50

–G

roup

1(H

APT

grou

p):H

yalu

rona

tein

tra-

artic

ular

inje

ctio

nsw

ithPT

(n=

32(1

2M+

20F)

,age

=52

.6±

6.3)

–G

roup

2(P

Tgr

oup)

:PT

alon

e(n

=31

(8M

+23

F),a

ge=

56.4±

9.0)

DO

S:

–G

roup

1=

5.2±

2.6

mon

ths

–G

roup

2=

3.8±

2.6

mon

ths

Inte

rven

tion

peri

od–

12w

eeks

–G

roup

1:20

mg

hyal

uron

ate

in-

ject

ion

once

per

wee

kfo

r3

con-

secu

tive

wee

ks+

PTpr

ogra

mfo

r3m

onth

s–

Gro

up2:

PTpr

ogra

mon

ly(3

ses-

sion

spe

rwee

kfo

r12

wee

ks)

∗H

eatt

hera

py∗

Ele

ctric

ther

apy

∗E

xerc

ise

–A

ctiv

ean

dpa

ssiv

eR

OM

insh

ould

erfle

xion

,ab

-du

ctio

n,IR

,and

ER

–SP

AD

I–

SDQ

SF-3

6

Ass

essm

ents

:

–B

asel

ine

–1.

5m

onth

s–

3m

onth

s

–B

oth

grou

psim

prov

edin

term

sof

pain

,dis

abili

ty,a

ndqu

ality

oflif

eaf

tert

hetre

atm

ents

–T

heac

tive

and

pass

ive

RO

Mim

-pr

oved

linea

rly

with

incr

easi

ngtr

eatm

entd

urat

ion

–N

osi

gnifi

cant

grou

pef

fect

was

foun

dfo

ran

yof

the

outc

ome

mea

sure

men

ts

Janj

uaan

dA

li[3

6],

2011

–D

esig

n=

Cas

ere

-po

rt–

LO

E=

Lev

elV

–39

year

sol

dm

ale

DO

S:3

mon

ths

Inte

rven

tion

peri

od–

3w

eeks

(3se

ssio

nspe

rwee

k)

–Ph

onop

hore

sis

–M

oist

hotp

ack

–M

aitla

nd’s

Gra

deI,

IIan

dII

Idis

-tr

actio

nm

obili

zatio

n–

Pend

ular

hom

eex

erci

ses

for

shou

lder

–So

fttis

sue

mob

iliza

tion

–Is

oton

icst

reng

thex

erci

ses

usin

gfr

eew

eigh

ts

–Pa

ssiv

eR

OM

insh

ould

erab

duct

ion,

flexi

on,

and

ER

Ass

essm

ents

:

–B

asel

ine

–2

wee

ks–

3w

eeks

Att

heen

dof

the

thir

dw

eek’

str

eat-

men

t,th

epa

tient

had

pain

free

full

rang

eof

mot

ion

Jew

elle

tal

.[25

],20

09

–D

esig

n=

Ret

rosp

ectiv

eC

ohor

tStu

dy–

LO

E=

Lev

elII

I

n=

2370

,55.

3±

12.4

yrs.

Mal

e=

820,

Fem

ale=

1550

DO

S:41

%pa

tient

s(n

≈97

2)>

90da

ys

21in

terv

entio

ns(l

iste

dat

http

://pt

jour

nal.a

pta.

org/

cont

ent/s

uppl

/20

09/0

4/24

/89.

5.41

9.D

C1/

zad6

0509

0000

01.p

df)

–Ph

ysic

alC

ompo

nent

Sum

mar

y-12

(PC

S-12

)–

phys

ical

func

tion

(PF)

and

bodi

lypa

in(B

P)–

Hyb

rid

func

tion

(HF)

scor

es

Ass

essm

ents

:N/A

–N

one

ofth

epa

tient

sac

hiev

eda

50%

orgr

eate

rim

prov

emen

tin

PCS-

12sc

ores

–T

hepr

esen

ceof

2in

terv

entio

nca

tego

ries

–“j

oint

mob

iliza

tion

and

mob

ility

”an

d“e

xerc

ise”

in-

crea

sed

the

odds

ofa

succ

essf

ulou

tcom

ein

the

BP

and

HF

mod

-el

s,re

spec

tivel

y–

Use

ofio

ntop

hore

sis,

phon

opho

-re

sis,

ultr

asou

nd,o

rmas

sage

re-


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

duce

dth

elik

elih

ood

ofim

prov

e-m

enti

nPF

,BP,

and

HF

scor

esby

19%

to32

%

John

son

etal

.[59

],20

07

–D

esig

n=

RC

T–

MO

R–

Ran

dom

-nu

mbe

rsta

ble

–L

OE=

Lev

elII

n=

20,r

ange

37–6

6ye

ars

Mal

e=

4,Fe

mal

e=

16

–A

Mgr

oup:

Ant

erio

rm

ob(n

=10

(2M

+8F

),ag

e=

54.7

±8.

0)–

PMgr

oup:

Post

erio

rm

ob(n

=8

(2M

+6F

),ag

e=

50.4

±6.

9)

DO

S:

–A

Mgr

oup:

8.4±

2.12

mon

ths

–PM

grou

p:10

.9±

4.6

mon

ths

Inte

rven

tion

peri

od–

6se

ssio

ns

–C

apsu

lepr

ehea

ted

with

US

–Jo

intm

ob(A

Mor

PM)

–U

pper

body

ergo

met

erex

No

HE

P

–Pa

inus

ing

VAS

scal

e–

Self

-ass

essm

ent

func

tiona

lque

stio

nnai

re–

Act

ive

RO

Min

shou

lder

ER

Ass

essm

ents

:

–1s

tse

ssio

n–

2nd

sess

ion

–3r

dse

ssio

n–

4th

sess

ion

–5t

hse

ssio

n–

6th

sess

ion

–Pa

insi

gnifi

cant

lyde

crea

sed

inbo

thgr

oups

–A

sign

ifica

ntdi

ffer

ence

betw

een

grou

psw

aspr

esen

tby

the

thir

dtr

eatm

ent

–A

Mgr

oup

patie

nts

had

am

ean

impr

ovem

enti

nex

tern

alro

tatio

nR

OM

of3.

0◦w

here

asth

ePM

grou

ppa

tient

sha

da

mea

nim

-pr

ovem

ento

f31.

3◦

Jürg

elet

al.[

63],

2005

–D

esig

n=

Pros

pec-

tive

coho

rtst

udy

–L

OE=

Lev

elII

I

n=

20M

ale=

6,Fe

mal

e=

14

–Fr

ozen

shou

lder

patie

ntgr

oup:

n=

10(3

M+

7F),

age=

50.2±

4.6

–C

ontro

lgro

up:a

sym

ptom

atic

shou

lder

sas

cont

rol(n

=10

(3M

+7F)

,age

=49

.8±

4.6)

DO

S:2

wee

ks–

3m

onth

s

Inte

rven

tion

peri

od–

4w

eeks

–In

divi

dual

ized

exer

cise

ther

apy

sess

ions

(30

min

/day

)–

mas

sage

proc

edur

es(2

0m

in/

day)

–el

ectr

ical

ther

apy

proc

edur

es(5

–10

min

/day

)

–A

ctiv

eR

OM

insh

ould

erfle

xion

,ext

ensi

on,a

bduc

-tio

n,ad

duct

ion,

IR,

and

ER

–Is

omet

ricm

axim

alfo

rce

ofth

em

uscl

es(M

F)fo

rsh

ould

erfle

xors

,ab

duc-

tion,

addu

ctio

n,IR

,an

dE

R–

Shou

lder

mus

cle

isom

et-

ricen

dura

nce

–Pa

inus

ing

VAS

scal

e

Ass

essm

ents

:–

Bas

elin

e–

4w

eeks

–In

patie

nts

with

FS,s

houl

der

flexi

on,e

xten

sion

,abd

uctio

n,an

dad

duct

ion

and

activ

eR

OM

,M

Fin

allm

easu

red

forc

edi

rec-

tions

and

neti

mpu

lse

duri

ngsh

ould

erm

uscl

eis

omet

ricen

-du

ranc

ete

stfo

rinv

olve

dex

trem

-ity

incr

ease

daf

terr

ehab

–N

osi

gnifi

cant

chan

ges

insh

oul-

derI

Ran

dE

Rac

tive

RO

Mfo

rin-

volv

edex

trem

ityin

patie

nts

with

FSw

ere

obse

rved

with

reha

b

Kum

aret

al[2

8],

2012

–D

esig

n=

RC

T–

MO

R–

Chi

tpi

ckbo

xm

etho

d–

LO

E=

Lev

elII

n=

40M

ale=

26,F

emal

e=

14

–G

roup

A:

Mai

tland

mob

iliza

tion+

exer

-ci

ses

(n=

20,a

ge=

47.9

)–

Gro

upB

:Exe

rcis

esal

one

(n=

20,a

ge=

47.1

)

DO

S:N

otst

ated

Inte

rven

tion

peri

od–

4w

eeks

–M

aitla

ndte

chni

que:

5se

tsof

gle-

nohu

mer

alca

udal

and

post

ero-

ante

rior

glid

esat

the

rate

of2–

3gl

ides

per

seco

ndfo

r30

seco

nds

(3da

ys/w

eek

for4

wee

ks)

–Su

perv

ised

exer

cise

prog

ram

:5

days

perw

eek

for4

wee

ks∗

Cod

man

exer

cise

∗Sh

ould

erw

heel

exer

cise

s∗

Self

-str

etch

ing

exer

cise

s∗

Wal

l-la

dder

exer

cise

s

–Pa

inus

ing

VAS

scal

e–

SPA

DI

–Sh

ould

erR

OM

inab

duc-

tion

and

ER

Ass

essm

ents

:–

Bas

elin

e–

4w

eeks

–A

sign

ifica

ntim

prov

emen

tw

asre

cord

edin

allo

utco

me

mea

sure

sin

both

the

grou

ps–

Gro

upA

show

edhi

gher

impr

ovem

entt

han

grou

pB


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Leu

ngan

dC

hein

g[5

8],

2008

–D

esig

n=

RC

T–

MO

R–

Onl

ine

ran-

dom

izat

ion

–L

OE=

Lev

elII

n=

30,

age=

59.8

7±

12.4

5yr

s.(r

ange

37–7

9ye

ars)

Mal

e=

9,Fe

mal

e=

21

–G

roup

1–

SWD

+st

retc

hing

(n=

10,

age=

53±

8.4)

–G

roup

2–

Hot

pack

+str

etch

ing

(n=

10,

age=

53±

8.6)

–G

roup

3–

Stre

tchi

ngal

one

(n=

10)

DO

S:N

otst

ated

Inte

rven

tion

peri

od–

12tr

eatm

ent

sess

ions

(20

min

ute

sess

ion

–3

days

/4w

eeks

)H

EP:

pend

ulum

exer

cise

san

dst

retc

hing

tech

niqu

es

–Pa

inus

ing

VAS

scal

e–

ASE

S–

Shou

lder

scor

ein

dex

–A

ctiv

eR

OM

insh

ould

erfo

rwar

del

evat

ion,

ER

,ha

ndbe

hind

back

,and

cros

sbo

dyad

duct

ion

Ass

essm

ents

:

–B

asel

ine

–Se

ssio

n6

–Se

ssio

n12

–4

wee

kfo

llow

up

–A

sign

ifica

ntim

prov

emen

tw

asse

enin

all

grou

psin

all

out-

com

em

easu

res

exce

ptfo

rtha

tof

shou

lder

flexi

onra

nge

–T

heim

prov

emen

tin

the

shou

l-de

rsc

ore

inde

xan

din

the

rang

eof

mot

ion

was

sign

ifica

ntly

bette

rin

the

deep

heat

ing

grou

pth

anin

the

supe

rfici

alhe

atin

ggr

oup

Lev

ine

etal

.[32

],20

07

–D

esig

n=

Ret

rosp

ectiv

eco

hort

stud

y–

LO

E=

Lev

elII

I

n=

98w

ith10

5sh

ould

ers,

55yr

s.(r

ange

20–9

6yr

s.)

Mal

e=

30,F

emal

e=

68

–N

on-o

pera

tive

grou

p(9

4sh

ould

ers)

∗Ph

ysic

alth

erap

yon

ly–

55sh

ould

ers

∗Ph

ysic

alth

erap

y+

Inje

ctio

n–

39sh

ould

ers

–O

pera

tive

grou

p(1

1sh

ould

ers)

DO

S:N

otst

ated

Inte

rven

tion

peri

od(m

ean

dura

tion)

–

–Ph

ysic

alth

erap

yon

ly–

3.3

mon

ths

–Ph

ysic

alth

erap

y+

Inje

ctio

n–

4.5

mon

ths

–O

pera

tive

grou

p–

12.4

mon

ths

befo

resu

rger

y–

Phys

ical

ther

apy

grou

p:st

an-

dard

ized

prog

ram

+N

SAID

’s–

Phys

ical

ther

apy

+in

ject

ion

grou

p:st

anda

rdiz

edpr

ogra

m+

cort

icos

tero

idin

j.+

NSA

ID’s

–A

ctiv

eR

OM

info

rwar

del

evat

ion,

ER

and

IR

Ass

essm

ents

:

–B

asel

ine

–Po

st-i

nter

vent

ion

–15

–121

mon

ths

Inth

eno

n-op

erat

ive

grou

p,fo

rwar

del

evat

ion

and

ER

impr

oved

sign

if-ic

antly

from

pre-

treat

men

tto

post

-tr

eatm

entw

ithno

sign

ifica

ntdi

ffer

-en

cebe

twee

nph

ysic

alth

erap

yon

lyan

dph

ysic

alth

erap

y+

inje

ctio

ngr

oup

Ma

etal

.[49

],20

06

–D

esig

n=

RC

T–

MO

R–

Not

stat

ed–

LO

E=

Lev

elII

n=

75,5

4.8y

rsM

ale=

36,F

emal

e=

39

–C

ontr

olgr

oup

–PT

only

(n=

15,a

ge=

54.1

)–

Gro

up1

–A

cupu

nctu

reon

ly(n

=30

,age

=56

.4)

–G

roup

2–

PT+

acup

unct

ure

(n=

15,a

ge=

52.8

)

DO

S:25

.8w

eeks

Inte

rven

tion

peri

od–

4w

eeks

–A

cupu

nctu

regr

oup:

15m

inut

ese

ssio

n–

2da

ys/4

wee

ks–

PTgr

oup:

30–4

0m

inut

ese

ssio

n–

5da

ys/4

wee

ks

∗SW

D–

15m

in∗

Join

tmob

–5–

10m

in∗

Act

ive

shou

lder

ex–

5–10

min

–A

ctiv

ean

dpa

ssiv

eR

OM

insh

ould

erfle

xion

,ext

en-

sion

,ab

duct

ion,

IR,

and

ER

–Pa

inus

ing

VAS

scal

e–

SF-3

6

Ass

essm

ents

:

–B

asel

ine

–2

wee

ks–

4w

eeks

–A

llpa

tient

ssh

owed

impr

ove-

men

tin

qual

ityof

life

(SF-

36)

–Pa

inw

asco

ntro

lled

bette

rby

acup

unct

ure

whi

leR

OM

impr

oved

follo

win

gph

ysic

alth

erap

y.H

owev

er,p

atie

nts

treat

edby

both

met

hods

had

the

best

outc

ome


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Mar

icar

etal

.[35

],20

09

Des

ign=

Sing

leca

sede

sign

(AB

CB

C)

–L

OE=

Lev

elV

A54

-yea

r-ol

dm

ale

with

a5-

mon

thhi

stor

yA

BC

BC

whe

re

–A

–no

treat

men

tbas

elin

eph

ase,

–B

phas

es(B

1an

dB

2)–

exer

cise

only

treat

men

tpha

ses,

and

–C

phas

es(C

1an

dC

2)–

exer

cise

plus

mo-

biliz

atio

nph

ases

.

DO

S:5

mon

ths

post

onse

tofs

ympt

oms

Inte

rven

tion

–2

times

aw

eek

for

15w

eeks

with

each

phas

ela

stin

g3

wee

ks20

min

ofm

obw

ithea

chte

chfo

r10

min

–Jo

int

mob

–2

type

sof

Mai

tland

grad

eIV

mob

s–

Exe

rcis

e–

stre

tchi

ng,

activ

eas

-si

sted

ex

NO

HE

P

–SP

AD

I–

Shou

lder

RO

Min

flexi

on,

abdu

ctio

n,IR

and

ER

Ass

essm

ents

:

–B

asel

ine

–Tw

ice

ever

yw

eek

till

the

15th

wee

k

–G

reat

erim

prov

emen

tob

serv

edfo

ral

lsho

ulde

rR

OM

durin

gth

eC

phas

es,

the

SPA

DI

scor

esdi

dno

tbe

have

sim

ilarly

nor

toth

esa

me

exte

nt–

The

SPA

DIs

core

sde

terio

rate

din

phas

eA

but

impr

oved

inph

ases

B1,

C1,

and

B2

Mar

yam

etal

.[60

],20

12

–D

esig

n=

RC

T–

MO

R–

Not

stat

ed–

LO

E=

Lev

elII

n=

87M

ale=

9,Fe

mal

e=

78

–G

roup

1:PT

alon

e(n

=27

(1M

+26

F),

age=

53.7

3±

7.49

)–

Gro

up2:

CS

inj+

PT(n

=29

(4M

+25

F),a

ge=

53.7

1±

6.69

)–

Gro

up3:

CS

inj

alon

e(n

=31

(2M

+27

F),a

ge=

53.3

3±

7.49

)

DO

S:

–G

roup

1:4.

48±

3.37

mon

ths

–G

roup

2:6.

21±

3.95

mon

ths

–G

roup

3:6.

83±

3.75

mon

ths

–C

Sin

j–

60m

gtri

amci

nolo

neac

eton

ide

and

2cc

lidoc

aine

insh

ould

erjo

int+

20m

gtr

iam

ci-

nolo

neac

eton

ide

and

1.5c

clid

o-ca

ine

insu

bacr

omia

lbur

sa–

PT–

10se

ssio

ns

∗T

EN

S∗

Ice

∗A

ctiv

eR

OM

ex

–SP

AD

I–

Act

ive

and

pass

ive

RO

Min

flexi

on,

abdu

ctio

n,E

Ran

dac

tive

com

bine

dm

o-tio

nof

the

shou

lder

Ass

essm

ents

:

–B

asel

ine

–6

wee

ks

–A

t6w

eeks

,the

tota

lSPA

DI

scor

esim

prov

edsi

gnifi

cant

lym

ore

inco

mbi

ned

grou

p–

ER

RO

Msh

owed

grea

ter

im-

prov

emen

tin

inje

ctio

ngr

oup

but

itw

asno

tsig

nific

ant

Paja

reya

etal

.[39

],20

04

–D

esig

n=

RC

T–

MO

R–

Com

pute

rge

nera

ted

–L

OE=

Lev

elI

n=

122

Mal

e=

38,F

emal

e=

81

–C

ontr

olgr

oup:

Ibup

rofe

non

ly(n

=59

(14M

+45

F),a

ge=

57.7

±10

.00)

–St

udy

grou

p:Ib

upro

fen

and

phys

ical

ther

-ap

y(n

=60

(24M

+36

F),a

ge=

56.3

±10

.6)

DO

S:

–C

ontr

olgr

oup:

–<

6w

eeks

–n=

6–

6–12

wee

ks–n=

20–>

12w

eeks

–n=

33–

Stud

ygr

oup:

–<

6w

eeks

–n=

13–

6–12

wee

ks–n=

20–>

12w

eeks

–n=

27

Inte

rven

tion

peri

od–

3w

eeks

–C

ontr

olgr

oup:

ibup

rofe

n40

0m

gth

ree

times

ada

yfo

r3

wee

ks+

educ

atio

n–

Stud

ygr

oup

–ib

upro

fen+

edu-

catio

n+

3tim

esa

wee

kph

ysic

alth

erap

y

∗SW

D(2

0m

inut

es)

∗M

obili

zatio

nan

dpa

ssiv

est

retc

hing

∗H

EP

–pu

lley

exer

cise

s,ac

tive

non-

assi

sted

exer

cise

s,an

dho

tpa

ck

–SP

AD

I–

Glo

bal

ratin

gof

pain

and

disa

bilit

y–

Act

ive

RO

Min

shou

lder

abdu

ctio

n,IR

,and

ER

Ass

essm

ents

:

–B

asel

ine

–6

wee

ks–

12w

eeks

–24

wee

ks

–A

t3w

eeks

,21

of60

patie

nts

inth

est

udy

grou

pha

dsu

cces

sful

trea

tmen

tas

com

pare

dw

ith11

of59

inth

eco

ntro

lgro

up–

The

rew

asno

sign

ifica

ntdi

ffer

-en

cein

the

succ

ess

rate

betw

een

the

two

grou

psat

the

12th

wee

kfo

llow

up


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Rill

etal

.[30

],20

11

–D

esig

n=

Ret

rosp

ectiv

eco

hort

stud

y–

LO

E=

Lev

elII

I

n=

85w

ith88

shou

lder

s,52

yrs.

(ran

ge34

–72

yrs.

)M

ale=

29,F

emal

e=

52(5

9sh

ould

ers)

–N

on-o

pera

tive

grou

p:n

=61

(23M

+38

F),a

ge=

53.4

yrs.

–Su

rger

ygr

oup:

n=

24(6

M+

18F)

,age

=47

.3yr

s.D

OS:

–N

on-o

pera

tive

grou

p:8

mon

ths

(ran

ge–

1to

48m

onth

s)–

Surg

ery

grou

p:7.

9m

onth

s(r

ange

–1

to60

mon

ths)

Inte

rven

tion

peri

od–

aver

age

of9

wee

ksN

on-o

pera

tive

grou

p:–

Supe

rvis

edph

ysio

ther

apy+

NSA

ID’s

and

hom

eex

erci

se:

∗4-

quad

rant

stre

tchi

ngin

for-

war

del

evat

ion,

ER

,IR

,an

dcr

oss-

body

addu

ctio

n∗

HE

P–

3tim

esda

ily∗

Phys

ical

ther

apy+

inje

ctio

n:al

lact

iviti

esin

the

abov

egr

oup+

cort

icos

tero

idin

j

–Si

mpl

esh

ould

erte

stan

dA

SES

–A

ctiv

eR

OM

info

rwar

del

evat

ion,

ER

,an

dIR

toth

eba

ck

Ass

essm

ents

:

–B

asel

ine

–3.

4m

onth

s(R

ange

–1

to22

mon

ths)

–In

the

non-

oper

ativ

egr

oup,

for-

war

del

evat

ion,

ER

and

IRto

the

back

impr

oved

sign

ifica

ntly

from

pre-

trea

tmen

tto

post

-trea

tmen

t–

Self-

asse

ssed

shou

lder

func

tion

also

impr

oved

fort

heen

tire

grou

p

Rui

z[3

8],

2009

–D

esig

n=

Cas

ere

port

–L

OE=

Lev

elV

51ye

ars

old

fem

ale

empl

oyed

asa

code

rD

OS:

6w

eeks

Inte

rven

tion

peri

od–

8su

perv

ised

in-o

ffice

ther

apy

sess

ions

and

17ep

isod

esof

self

-str

etch

ing

hom

epr

ogra

mov

era

4-w

eek

peri

od.

–8-

min

ute

activ

ew

arm

-up

onbo

dyer

gom

eter

–Po

sitio

nal

cora

cohu

mer

allig

a-m

ent(

CH

L)s

tret

chin

gre

petit

ion

alon

gw

ithco

ldpa

ck(5

–15

min

-ut

es)

–Vo

litio

nal

rota

tor

cuff

exer

cise

s(1

0re

petit

ions

)H

EP

–po

sitio

nal

CH

Lst

retc

hing

with

cold

pack

for

20m

inut

es(tw

ice

perd

ay)

–D

ASH

–SP

AD

I–

Act

ive/

Pass

ive

RO

Min

shou

lder

flexi

on,

abdu

c-tio

n,co

mbi

ned

exte

nsio

n/ad

duct

ion

ER

,IR

,and

reac

hing

back

toth

esp

ine

with

the

thum

b

Ass

essm

ents

:

–B

asel

ine

–4

wee

ks

–D

ASH

and

SPA

DI

scor

esim

-pr

oved

follo

win

g1

mon

thaf

ter

the

onse

tofp

hysi

calt

hera

py–

Pass

ive

ER

RO

Msh

owed

grea

ter

impr

ovem

ent

than

othe

rm

ove-

men

ts

Rya

nset

al.[

50],

2005

–D

esig

n=

RC

T–

MO

R–

Seal

eden

-ve

lope

s–

LO

E=

Lev

elII

n=

78M

ale=

30,F

emal

e=

48–

Gro

upA

(Inj

+PT

grou

p)–

CS

(sal

ine)

inj+

PT(n

=20

(9M

+11

F),a

ge=

56.3

±6.

4)–

Gro

upB

(inj

grou

p)–

CS

(sal

ine)

inj+

noPT

(n=

19(6

M+

13F)

,age

=52

.3±

9.3)

–G

roup

C(P

Tgr

oup)

–sa

line

inj+

PT(n

=20

(6M

+14

F),a

ge=

52.6

±7.

7)–

Gro

upD

(con

trol

grou

p)–

salin

ein

j+PT

(n=

19(9

M+

10F)

,age

=55

.2±

9.4)

DO

S:–

CS

inj+

PTgr

oup

–14

.2±

4.4

wee

ks–

CS

injg

roup

–12

.2±

5.3

wee

ks–

PTgr

oup

–14

.4±

4.4

wee

ks–

Plac

ebo

grou

p–

14.9

±3.

7w

eeks

Inte

rven

tion

peri

od–

4w

eeks

–C

Sin

j–20

mg

triam

cino

lone

and

2m

lsal

ine.

Com

bine

dap

proa

ch1.

5m

lant

erio

rap

proa

ch,1

.5m

lla

tera

lapp

roac

h–

PT–

8se

ssio

nsin

4w

eeks

∗PN

F∗

Mai

tland

mob

.∗

IFT

Act

ive

exth

erap

y

–SD

Q–

Pass

ive

RO

Min

shou

lder

ER

–Pa

inus

ing

VAS

scal

e–

VAS

glob

aldi

sabi

lity

–SF

-36

Ass

essm

ents

:

–B

asel

ine

–6

wee

ks–

16w

eeks

–6/

52:s

igni

fican

tim

prov

emen

tin

SDQ

and

glob

alVA

Sfo

rst

eroi

din

ject

ion

only

–Si

gnifi

cant

impr

ovem

ent

inpa

s-si

veex

tern

alro

tatio

nfo

rPT

–16

/52:

No

sign

ifica

ntim

prov

e-m

enta

cros

sal

lint

erve

ntio

nsfo

ral

lout

com

es


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Sam

nani

[53]

,20

04–

Des

ign=

RC

T–

MO

R–

Not

stat

ed–

LO

E=

Lev

elII

n=

20(r

ange

35–6

0yr

s.)

Mal

e=

9,Fe

mal

e=

11

–E

xper

imen

talg

roup

:The

rape

utic

activ

ity/

activ

e+

pass

ive

exer

cise

s(n

=10

(3M

+7F

),ag

e=

42.9±

6.5)

–C

ontro

lgr

oup:

The

rape

utic

activ

ityan

dac

tive

exer

cise

sal

one

(n=

10(6

M+

4F),

age=

42.7±

9.0)

DO

S:<

3m

onth

s

Inte

rven

tion

peri

od–

6w

eeks

–T

hera

peut

icac

tivity

prog

ram

and

activ

eex

erci

ses

–C

odm

anpe

n-du

lum

exer

cise

s,pu

lley

exer

ci-

ses,

shou

lder

whe

el,

finge

rst

ep-

ping

and

corn

erse

arch

,and

reac

hing

outt

asks

(45

min

utes

/6tim

esa

wee

k)–

Pass

ive

RO

Mex

erci

ses

–pa

ssiv

eR

OM

infle

xion

,ad

duct

ion,

ab-

duct

ion,

IR,

ER

,ci

rcum

duct

ion,

and

supr

aspi

natu

sst

retc

hing

(15

min

utes

/6tim

esa

wee

k)

–Fu

nctio

nalh

and-

to-b

ack

Ass

essm

ents

:

–B

asel

ine

–6

wee

ks

Func

tiona

lha

nd-to

-bac

kim

prov

edm

ore

inpa

tient

sw

hope

rfor

med

pass

ive

exer

cise

sal

ong

with

ther

a-pe

utic

activ

ities

than

patie

nts

who

wer

etr

eate

dw

ithth

erap

eutic

activ

-iti

esal

one

Ster

giou

-la

s[2

7],

2008

–D

esig

n=

RC

T–

MO

R–

Seal

eden

-ve

lope

s–

LO

E=

Lev

elI

n=

63M

ale=

40,F

emal

e=

23

–A

ctiv

ela

serg

roup

:low

leve

llas

erth

erap

y(L

LLT

)(n

=31

(19M

+12

F),

age=

55.1

±5.

84)

–Pl

aceb

ogr

oup:

plac

ebo

lase

rtre

atm

ent

(n=

32(2

1M+

11F)

,ag

e=

56.8

3±

6.82

)

DO

S:

–A

ctiv

ela

serg

roup

:26.

5±

12.8

wee

ks–

Plac

ebo

grou

p:27

.1±

13.6

wee

ks

Inte

rven

tion

peri

od–

8w

eeks

(12

sess

ions

)

–A

ctiv

ela

ser

grou

p:81

0-nm

Ga-

Al-A

sla

ser

with

cont

inuo

usou

t-pu

tof6

0m

Wap

plie

dto

8po

ints

onth

esh

ould

erfo

r30

seco

nds

each

,for

ato

tald

ose

of1.

8J

per

poin

tand

14.4

Jpe

rses

sion

–Pl

aceb

ogr

oup:

sham

lase

r

–Pa

inus

ing

VAS

scal

e–

SPA

DI

–C

roft

shou

lder

disa

bilit

yqu

estio

nnai

re–

DA

SH–

HA

Q–

Act

ive

RO

Min

shou

l-de

rflex

ion

and

abdu

ctio

n,an

dE

R

Ass

essm

ents

:

–B

asel

ine

–4

wee

ks–

8w

eeks

–16

wee

ks

Rel

ativ

eto

plac

ebo

grou

p,ac

tive

lase

rgro

upsh

owed

–Si

gnifi

cant

decr

ease

inpa

insc

ores

at4,

8an

d16

wee

ks–

Sign

ifica

ntde

crea

sein

SPA

DI

and

Cro

ftsh

ould

erdi

sabi

lity

ques

tionn

aire

scor

esat

4,8,

and

16w

eeks

–Si

gnifi

cant

decr

ease

inD

ASH

scor

esat

8an

d12

wee

ks–

Sign

ifica

ntde

crea

sein

HA

Qsc

ores

at4

and

8w

eeks

–R

OM

impr

oved

but

didn

’tre

ach

the

sign

ifica

nce

leve

l

Sun

etal

.[51

],20

01

–D

esig

n=

RC

T–

MO

R–

Ran

dom

ta-

ble

met

hod

–L

OE=

Lev

elI

n=

35,r

ange

–41

–69

year

sM

ale=

11,F

emal

e=

24

–G

roup

A–

Exe

rcis

eon

ly(n

=22

(7M

+15

F),a

ge=

57.1

±8.

6)–

Gro

upB

–E

xerc

ise

+acu

punc

ture

(n=

13(4

M+

9F),

age=

55.0±

7.6)

DO

S:

–E

xerc

ise

only

grou

p–

7.1±

3.9

mon

ths

–E

xerc

ise+

acup

unct

ure

grou

p–

5.5±

1.6

mon

ths

Inte

rven

tion

peri

od–

6w

eeks

–A

cupu

nctu

re–

Zho

ngpi

ngpo

int

–PT

–ge

ntle

stre

tchi

ng,R

OM

and

HE

P(C

hart)

–C

onst

antS

houl

der

Ass

essm

ent(

CSA

)

Ass

essm

ents

:

–B

asel

ine

–6

wee

ks–

20w

eeks

–C

ompa

red

with

the

exer

cise

grou

pth

eex

erci

se+

acup

unc-

ture

grou

pw

assi

gnifi

cant

lyim

prov

ed–

Impr

ovem

ents

insc

ores

by39

.8%

and

76.4

%w

ere

seen

for

the

exer

cise

and

the

exer

cise

+ac

upun

ctur

egr

oups

,res

pect

ivel

yat

6w

eeks

and

wer

esu

stai

ned

atth

e20

-wee

kre

-ass

essm

ent


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Ulu

soy

etal

.[31

],20

11

–D

esig

n=

Ret

rosp

ectiv

eco

hort

stud

y–

LO

E=

Lev

elII

I

n=

29,5

5.4±

9.2

yrs.

Mal

e=

14,F

emal

e=

15D

OS:

15.7

±8.

3w

eeks

(ran

ge–

6to

36w

eeks

)

Ave

rage

leng

thof

supe

rvis

edph

ys-

ioth

erap

y–

3.5±

0.5

wee

ks

–A

llpa

tient

sre

ceiv

edph

ysio

ther

-ap

ypr

ogra

m(3

–5tim

es/w

eek)

+N

SAID

s

∗H

otpa

ck(2

0m

inut

es)

∗U

S(5

–10

min

utes

)∗

TE

NS/

IFT

∗Pa

ssiv

est

retc

hing

exer

cise

s∗

Cod

man

and

wal

lclim

bing

ex-

erci

ses

–Pa

ssiv

eR

OM

insh

ould

erfle

xion

,abd

uctio

n,E

R,

and

tota

lRO

M–

Pain

usin

gVA

Ssc

ale

Ass

essm

ents

:

–B

asel

ine

–T

here

solv

edpa

tient

sw

ere

re-e

valu

ated

1–4

year

saf

ters

uper

vise

dph

ysio

ther

apy

–Fo

llow

ing

phys

ioth

erap

y,sh

oul-

der

flexi

on,

abdu

ctio

n,an

dE

RR

OM

sim

prov

edsi

gnifi

cant

ly–

Shou

lder

pain

also

decr

ease

dsi

g-ni

fican

tlyfo

llow

ing

phys

ioth

er-

apy

Van

den

Hou

tet

al.[

41],

2005

–D

esig

n=

RC

T–

MO

R–

Com

pute

rge

nera

ted

–L

OE=

Lev

elI

n=

100

(pre

sent

ed92

),51

yrs.

(ran

ge45

–57

yrs.

)M

ale=

30,F

emal

e=

62

–H

igh

grad

em

obgr

oup

(n=

44(1

5M+

29F)

)–

Low

grad

em

obgr

oup

(n=

48(1

5M+

33F)

)

DO

S:

–H

igh

grad

em

obgr

oup

–8

mon

ths

–L

owgr

ade

mob

grou

p–

9m

onth

s

Inte

rven

tion

–2/

wee

kfo

r30

min

×12

wee

ks

–H

igh

grad

egr

oup

–G

rade

III/I

V–

Low

grad

egr

oup

–G

rade

I/II

–C

osts

–U

tility

and

qual

ityad

-ju

sted

life

year

s(Q

ALY

)

Ass

essm

ent:

–12

wee

ks

–H

Gm

obgr

oup

rece

ived

2.9

ses-

sion

sle

ssth

anL

Gm

obgr

oup

–PT

also

less

inH

Ggr

oup

butn

otsi

gnifi

cant

–H

ospi

taliz

atio

nm

ore

inH

Ggr

oup

Ver

meu

len

etal

.[33

],20

00

–D

esig

n=

Cas

ese

-rie

s–

LO

E=

Lev

elIV

n=

7,50

.2±

6.0

yrs.

(age

d41

–65

yrs.

)M

ale=

4,Fe

mal

e=

3D

OS:

8.4±

3.3

mon

ths

(ran

ge–

3to

12m

onth

s)

Inte

rven

tion

peri

od–

3m

onth

s(tw

ice

perw

eek)

–E

ndra

nge

mob

iliza

tion

–M

assa

ge–

US,

SWD

,and

elec

trot

hera

py–

Act

ive

exer

cise

s

–A

ctiv

ean

dpa

ssiv

eR

OM

insh

ould

erfle

xion

,ab

-du

ctio

n,an

dE

R–

Pain

usin

gVA

Ssc

ale

–A

rthr

ogra

phic

asse

ssm

ent

ofjo

intc

apac

ity–

Mea

sure

men

tofG

Hjo

int.

Abd

uctio

nR

OM

usin

gpl

ain

radi

ogra

ph

Ass

essm

ents

:

–B

asel

ine

–3

mon

ths

–9

mon

ths

–A

llsu

bjec

tssh

owed

impr

ove-

men

tin

shou

lder

abdu

ctio

n,fle

x-io

n,an

dE

Rac

tive

and

pass

ive

RO

M–

The

mea

nca

paci

tyof

the

GH

join

t.ca

psul

ein

crea

sed

–4

subj

ects

rate

dth

eir

shou

lder

func

tion

asex

celle

nt,

2ra

ted

asgo

od,a

nd1

rate

dit

asm

oder

ate

–A

llpa

tient

sm

aint

aine

dth

eirg

ain

injo

intm

obili

tyat

9m

onth

follo

w-u

p


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Ver

meu

len

etal

.[42

],20

06

–D

esig

n=

RC

T–

MO

R–

Com

pute

rge

nera

ted

–L

OE=

Lev

elI

n=

100

(pre

sent

ed96

),ra

nge

–45

–57

yrs.

Mal

e=

34,F

emal

e=

66

–H

igh

grad

em

obgr

oup

(n=

49(1

7M+

32F)

,age

=51

.6±

7.6)

–L

owgr

ade

mob

grou

p(n

=51

(17M

+34

F),a

ge=

51.7

±8.

6)

DO

S:

–H

GM

Tgr

oup

–8

mon

ths

(ran

ge–

5–14

.5m

onth

s)–

LG

MT

grou

p–

8m

onth

s(r

ange

–6–

14m

onth

s)

Inte

rven

tion

–2/

wee

kfo

r30

min

×12

wee

ks

–H

igh

grad

egr

oup

–G

rade

III/I

V–

Low

grad

egr

oup

–G

rade

I/II

–A

ctiv

ean

dpa

ssiv

eR

OM

insh

ould

erfle

xion

,ab

-du

ctio

n,an

dE

R–

Shou

lder

disa

bilit

y(S

RQ

and

SDQ

)–

Pain

usin

gVA

Ssc

ale

–SF

-36

Ass

essm

ents

:

–B

asel

ine

–3

mon

ths

–6

mon

ths

–12

mon

ths

–B

oth

grou

psim

prov

edov

er12

mon

ths

–H

GM

Tgr

oup

show

edsi

g.gr

eate

rch

ange

dsc

ores

for

pas-

sive

abdu

ctio

n(a

tthe

time

poin

ts3

and

12m

onth

s),a

ndfo

rac

tive

and

pass

ive

exte

rnal

rota

tion

(at

12m

onth

s)–

At

12m

onth

s,H

GM

Tgr

oup

show

edgr

eate

rch

ange

sin

pas-

sive

exte

rnal

rota

tion,

SRQ

,an

dSD

Qth

anth

eL

GM

Tgr

oup

Wie

s[3

4],

2005

–D

esig

n=

Cas

ese

ries

–L

OE=

Lev

elIV

n=

8M

ale=

2,Fe

mal

e=

6D

OS:

>3

mon

ths

Inte

rven

tion

peri

od–

aver

age

of10

visi

tsov

era

mea

nof

14w

eeks

–So

fttis

sue

mob

iliza

tion

tech

-ni

ques

(30

min

utes

)–

HE

P–

stre

tchi

ngan

dis

omet

ric

stre

ngth

enin

g,pr

ogre

ssin

gto

re-

sist

edex

erci

ses

asto

lera

ted

–A

ctiv

eR

OM

insh

ould

erab

duct

ion,

flexi

on,

and

ER

Ass

essm

ents

:

–B

asel

ine

–E

very

wee

ktil

l12t

h

wee

k

All

patie

nts

impr

oved

sign

ifica

ntly

inac

tive

RO

Mof

shou

lder

abdu

c-tio

n,fle

xion

,and

ER

Yan

get

al.[

56],

2007

–D

esig

n=

RC

T–

MO

R–

Com

pute

rge

nera

ted

–L

OE=

Lev

elII

n=

30(p

rese

nted

28)5

mor

elo

stto

follo

wup M

ale=

6,Fe

mal

e=

24

–A

BA

Cgr

oup

–(n

=14

(1M

+13

F),a

ge=

53.3

±6.

5)–

AC

AB

grou

p–

(n=

14(3

M+

11F)

,age

=58

.0±

10.1

)w

here

A=

MR

M,B

=E

RM

and

C=

MW

M)

DO

S:

–A

BA

Cgr

oup

–18

±8

wee

ks–

AC

AB

grou

p–

22±

10w

eeks

Inte

rven

tion

–2/

wee

kfo

r30

min

+si

mpl

eex

(pen

dulu

m+

scap

u-la

rse

tting

ex)×

3w

eeks

each

in-

terv

entio

n=

12w

eeks

–M

id-r

ange

mob

–E

nd-r

ange

mob

–M

obw

ithm

ovem

ent

–FL

EX

-SF

–Sh

ould

erki

nem

atic

s

Ass

essm

ents

:

–B

asel

ine

–3

wee

ks–

6w

eeks

–9

wee

ks–

12w

eeks

–O

vera

ll,su

bjec

tsin

both

grou

psim

prov

edov

erth

e12

wee

ks–

Stat

istic

ally

sign

ifica

ntim

prov

e-m

ents

wer

efo

und

inE

RM

and

MW

M

Add

ition

ally

,MW

Mco

rrec

ted

scap

uloh

umer

alrh

ythm

sign

ifica

n-tly

bette

rth

anE

RM

did


Tabl

e3,

cont

inue

d

Aut

hor/

Yea

rD

esig

nan

dL

evel

ofE

vide

nce

(LO

E)

Patie

nts

char

acte

rist

ics

and

dura

tion

ofsy

mpt

oms

(DO

S)In

terv

entio

nsO

utco

me

mea

sure

san

das

sess

men

tsR

esul

ts

Yan

get

al.[

57],

2012

–D

esig

n=

RC

T–

MO

R–

Com

pute

rge

nera

ted

–L

OE=

Lev

elII

n=

32M

ale=

10,F

emal

e=

22

–C

rite

ria

–In

terv

entio

ngr

oup:

end-

rang

em

obili

zatio

nan

dsc

apul

arm

obili

zatio

ntr

eatm

ent

appr

oach

(EM

SMTA

)(n

=10

(3M

+7F

),ag

e=

56.8

±7.

2)–

Crit

eria

–C

ontro

lgr

oup:

stan

dard

ized

trea

tmen

tapp

roac

h(n

=12

(2M

+10

F),

age=

54.9

±10

.3)

–C

ontro

lgro

up:s

tand

ardi

zed

treat

men

tap-

proa

ch(n

=10

(5M

+5F

),ag

e=

54.3±

7.6)

DO

S:

–C

riter

ia–

inte

rven

tion

grou

p:19

.6±

12.8

wee

ks–

Cri

teri

a–

Con

trol

grou

p:22

.4±

9.2

wee

ks–

Con

trol

grou

p:15

.8±

10.7

wee

ks

Inte

rven

tion

peri

od–

8w

eeks

(twic

epe

rwee

k)

–C

riter

ia–

inte

rven

tion

grou

p:en

d-ra

nge

mob

iliza

tion

and

scap

ular

mob

iliza

tion

(EM

SMTA

)–

Crit

eria

–C

ontro

lan

dco

ntro

lgr

oup:

∗Pa

ssiv

em

id-r

ange

mob

iliza

-tio

n∗

Flex

ion

and

abdu

ctio

nst

retc

h-in

gte

chni

ques

∗U

S,SW

D,e

lect

roth

erap

y∗

Act

ive

exer

cise

s

–Pa

ssiv

eR

OM

fors

houl

der

abdu

ctio

n,IR

,and

ER

–H

and

behi

ndba

ckdi

s-ta

nce

–FL

EX

-SF

–Sh

ould

erki

nem

atic

s

Ass

essm

ents

:

–B

asel

ine

–4

wee

ks–

8w

eeks

Subj

ects

inth

eE

MSM

TAgr

oup

expe

rienc

edgr

eate

rim

prov

emen

tin

outc

omes

com

pare

dw

ithth

ecr

iteria

-con

trol

grou

pan

dco

ntro

lgr

oup

at4

and

8w

eeks

AC

–ad

hesi

veca

psul

itis;

AD

L–

activ

ities

ofda

ilyliv

ing;

AM

-an

terio

rm

obili

zatio

n;A

RO

M-

activ

era

nge

ofm

otio

n;A

SES

–A

mer

ican

Shou

lder

and

Elb

owsu

rgeo

nsas

sess

men

tfor

m;

CPM

-co

ntin

uous

pass

ive

mot

ion;

CM

A–

Con

stan

tM

urle

yas

sess

men

t;C

SA–

Con

stan

tsh

ould

eras

sess

men

t;C

Sin

j.–c

ortic

oste

roid

inje

ctio

n;D

ASH

–D

isab

ilitie

sof

the

Arm

Shou

lder

and

Han

d;D

OS

–du

ratio

nof

sym

ptom

s;E

A–

elec

tro-a

cupu

nctu

re;

EM

SMTA

–E

nd-r

ange

mob

iliza

tion

and

scap

ular

mob

iliza

tion

treat

men

tapp

roac

h;E

R–

exte

rnal

rota

tion;

ER

M–

end

rang

em

obili

zatio

n;FL

EX

-SF

–fle

xion

scal

eof

shou

lder

func

tion;

FS–

froz

ensh

ould

er;G

Hjt.

–gl

enoh

umer

aljo

int;

HA

Q–

Hea

lth-a

sses

smen

tque

stio

nnai

re;H

EP

–ho

me

exer

cise

prog

ram

;H

Gm

ob–

high

grad

em

obili

zatio

n;H

GM

T–

high

grad

em

obili

zatio

nth

erap

y;IA

–im

prov

edan

gle;

IFT

–in

terf

eren

tial

ther

apy;

LG

mob

–lo

wgr

ade

mob

iliza

tion;

LG

MT

–lo

wgr

ade

mob

iliza

tion

ther

apy;

LO

E–

leve

lofe

vide

nce;

MO

R–

met

hod

ofra

ndom

izat

ion;

MR

M–

mid

rang

em

obili

zatio

n;M

WM

–m

obili

zatio

nw

ithm

ovem

ent;n=

num

bero

fsub

ject

s;N

/A–

Not

App

licab

le;

NSA

IDs

–no

nst

eroi

dal

anti-

infla

mm

ator

ydr

ugs;

PCS-

12–

Phys

ical

com

pone

ntsu

mm

ary

–12

;PM

–po

ster

ior

mob

iliza

tion;

PNF

–pr

oprio

cept

ive

neur

omus

cula

rfa

cilit

atio

n;PR

OM

–pa

ssiv

era

nge

ofm

otio

n;PT

–ph

ysic

alth

erap

y;R

CT

–ra

ndom

ized

,con

trolle

dtri

al;

RO

M–

rang

eof

mot

ion;

SDQ

–sh

ould

erdi

sabi

lity

ques

tionn

aire

;SD

S-

shou

lder

dyna

splin

tsy

stem

;SF-

36–

Shor

tFor

m-3

6he

alth

surv

ey;S

PAD

I–Sh

ould

erPa

inan

dD

isab

ility

Inde

xSc

ore;

SRQ

–sh

ould

erra

ting

ques

tionn

aire

;SW

D–

shor

twav

edi

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Tabl

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Qua

lity

revi

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rite

riade

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stra

ting

rigo

rofs

tudy

Aut

hor/Y

ear

Avo

ided

cont

amin

atio

nR

ando

mas

sign

men

tB

linde

dM

onito

red

Acc

ount

edfo

rR

epor

ted

relia

bilit

yR

epor

ted

valid

ityFo

llow

-To

taln

umbe

ran

dco

-int

erve

ntio

nto

cond

ition

sas

sess

men

tin

terv

entio

nal

lsub

ject

sof

mea

sure

sus

edof

mea

sure

sus

edup

ofcr

iteria

met

Ars

lan

and

Cel

ikar

[26]

,200

1N

oY

esN

oY

esY

esN

oN

oY

es4

Cal

iset

al.[

43],

2006

No

Yes

No

Yes

Yes

No

No

Yes

4C

aret

teet

al.[

44],

2003

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

7Ç

elik

.[54

],20

10N

oY

esN

oY

esY

esN

oaN

oY

es4

Cha

net

al.[

55],

2010

No

Yes

Yes

Yes

Yes

Yes

Yes

No

6C

hein

get

al.[

45],

2008

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

7D

ierc

kset

al.[

62],

2004

No

No

No

Yes

Yes

No

Yes

Yes

4D

ogru

etal

.[46

],20

08N

oY

esN

oY

esY

esN

oN

oY

es4

Dud

kiew

icz

etal

.[29

],20

04N

oN

oN

oN

oaN

oaN

oN

oY

es1

Dun

dare

tal.

[47]

,200

9N

oY

esN

oY

esY

esN

oN

oY

es4

Ear

ley

and

Shan

non

[37]

,200

6N

oaN

oN

oY

esY

esN

oN

oY

es3

Gas

para

ndW

illis

[61]

,200

9Y

esN

oN

oY

esY

esN

oN

oN

o3

Gri

ggs

etal

.[6]

,200

0N

oN

oN

oY

esY

esN

oN

oY

es3

Gul

er-U

ysal

and

Koz

anog

lu[4

8],2

004

Yes

Yes

Yes

Yes

Yes

No

No

No

5H

sieh

etal

.[40

],20

12N

oaY

esY

esY

esY

esY

esN

oaN

o5

Janj

uaan

dA

li[3

6],2

011

No

No

No

Yes

Yes

No

No

No

2Je

wel

leta

l.[2

5],2

009

No

No

No

Yes

Yes

Noa

Noa

Yes

3Jo

hnso

net

al.[

59],

2007

Yes

Yes

No

Yes

Yes

Noa

Yes

No

5Jü

rgel

etal

.[63

],20

05N

oaN

oN

oY

esN

oaN

oN

oN

o1

Kum

aret

al.[

28],

2012

Yes

Yes

No

Yes

Yes

No

No

No

4L

eung

and

Che

ing

[58]

,200

8N

oaY

esY

esY

esY

esY

esY

esY

es7

Lev

ine

etal

.[32

],20

07N

oN

oN

oY

esY

esN

oN

oN

o2

Ma

etal

.[49

],20

06N

oY

esN

oY

esY

esY

esY

esN

o5

Mar

icar

etal

.[35

],20

09Y

esN

oN

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esY

esY

esN

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Mar

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etal

.[60

],20

12N

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esY

esY

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oaN

oaN

o4

Paja

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etal

.[39

],20

04Y

esY

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esY

esY

esN

oY

es7

Rill

etal

.[30

],20

11N

oN

oN

oY

esY

esN

oN

oY

es3

Rui

z[3

8],2

009

Yes

No

No

Yes

Yes

Yes

Yes

No

5R

yans

etal

.[50]

,200

5Y

esY

esY

esY

esY

esN

oY

esY

es7

Sam

nani

[53]

,200

4N

oY

esN

oY

esN

oaN

oN

oN

o2

Ster

giou

las

[27]

,200

8N

oY

esY

esY

esN

oaY

esY

esY

es6

Sun

etal

.[51

],20

01Y

esY

esY

esY

esY

esN

oaN

oaY

es6

Ulu

soy

etal

.[31

],20

11N

oN

oN

oY

esY

esN

oN

oY

es3

Van

den

Hou

teta

l.[4

1],2

005

No

Yes

Yes

Yes

Yes

No

No

No

4V

erm

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net

al.[

33],

2000

No

No

Yes

Yes

Yes

Yes

Yes

Yes

6V

erm

eule

net

al.[

42],

2006

No

Yes

No

Yes

Yes

Yes

Yes

Yes

6W

ies

[34]

,200

5N

oN

oN

oY

esY

esN

oN

oN

o2

Yan

get

al.[

56],

2007

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

7Y

ang

etal

.[57

],20

12N

oY

esY

esY

esY

esY

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s.


three studies were case series, and four studies werecase reports. Five studies [39–52] were assigned levelI because of the randomized design and large numberof subjects included. Twenty four studies [26,28,43–48,50,51,53–60] which were randomized trials withsmall sample sizes (less than or equal to 30 per group)were classified at level II. Eight studies [25,29–32,61–63] were assigned level III because of their non-randomized design (cohort design). Three studies [6,33,34,37] were assigned level IV and four studies [35–38] were assigned level V based on their case seriesand case report designs, respectively. Except four stud-ies [25,30–32,41], all the studies included in this re-view were prospective studies.

3.2. Quality review

The results of the qualitative review are summa-rized in Table 4. Overall, the results of the qual-ity review were good. Of the 39 studies includedbased on the 8 criteria, six studies each met 7 [39,44,45,50,56,58], 6 [27,33,42,51,55,57], and 5 [35,38,40,48,49,59] of Sackett’s critical appraisal criteria, re-spectively. Nine studies [26,28,29,41,43,46,54,60,62]met 4, six studies [6,18,25,30,31,37,61] met 3, fourstudies [32,34,36,53] met 2, and two studies [47,63]met 1 of Sackett’s critical appraisal criteria, respec-tively (Fig. 2). Twenty four studies assigned theirsubjects randomly to either the experimental or con-trol group [26–29,39–46,48–51,53–60]. Of the twentyfour randomized studies, eleven studies failed to dis-close their method of randomization [26,43,45–49,52–54,60]. Generally, interventions were monitored by aphysical therapist or took place in a clinic (38 outof 39 studies). Only eleven studies managed to avoidcross-contamination of results [28,35,38,39,44,48,50,51,56,59,61]. The studies that did avoid confoundingresults specifically requested their subjects not seekout or participate in additional treatments. Except fourstudies [27,47,53,63], all studies included in the re-view accounted for subjects in their study. Fifteenout of thirty nine studies [27,33,39–41,44,45,48,50,51,55–58,60] utilized blinded assessment of the sub-jects’ pre- and post-treatment. Only fourteen studiesincluded minimal discussion of reliability (pain – 3studies [27,33,55], range of motion – 5 studies [33,35,39,40,55], and function – 11 studies [27,35,38,42,44,45,49,55–58]) and validity (pain – 2 studies [27,59],range of motion – 2 studies [33,35], and function – 11studies [27,35,38,42,45,49,50,55–58,62]) of outcomemeasures utilized in their studies. Twenty one studies

included follow-up of the subjects [6,25–27,29–31,33,37,39,42–47,50,51,54,58,62]. We used a cut-off point(6 points) for considering a study as ‘high quality’. Onthe basis of this, twelve studies were considered highquality studies [27,33,39,42,44,45,50,51,55–58].

3.3. Interventions

Interventions included therapeutic exercises [6,29,31,37–39,53,54,62,63], joint mobilizations of the sho-ulder girdle [7,28,35,36,41,42,55–57,59], Mobiliza-tion-with-Movement [56], Cyriax’s manipulation [48],acupuncture [49,51], electro-acupuncture and interfer-ential therapy [45], ultrasound [46], continuous passivemotion [47], heat [58], splinting [61], laser [27], occu-pational based treatment (exercises to mimic patientsoccupation) [37] and physical therapy compared withcorticosteroid injections [26,40,43,44,50,60].

A variety of active exercise interventions were usedas conservative treatment for frozen shoulder, andmany utilized the combination of range of motion ex-ercises with mobilization, stretching, massage, or elec-trotherapy. Celik et al. [54] compared the effects ofscapulothoracic exercises versus scapulothoracic ex-ercises and glenohumeral exercises combined. Threestudies studied the effect of physical therapy pro-gram alone, NSAID alone or physical therapy andNSAIDs [29,31,39]. Five studies developed rehabili-tation protocols and studied their effectiveness [6,34,38,53,63] while Diercks et al. [62] tried to comparephysical therapy with supervised neglect (supportivetherapy and exercises within pain limit). Earley andShannon [37] used occupation based treatment alongwith home exercise program. Gaspar and Willis [61]used shoulder dynasplint in isolation or in combinationwith physical therapy to assess the effect of splintingin frozen shoulder.

Among the studies that used mobilization of theshoulder girdle, three studies [28,36,55] studied the ef-fect of Maitland mobilization on patients with frozenshoulder while Johnson et al. [59] compared the ef-fects of anterior vs. posterior mobilization, Van denHout et al. [41] and Vermeulen et al. [42] comparedthe effects of high vs. low grade mobilization. Maricaret al. [35] in their case study, tried to evaluate the ef-fects of exercise only vs. mobilization and exercisecombined. Vermeulen et al. [33] utilized end-rangemobilization and studied its effect on frozen shoulderpatients while Yang et al. [56] compared mid-rangemobilization, end-range mobilization and mobilizationwith movement to evaluate the effect of specific mo-


Fig. 2. The results of the qualitative review. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BMR-130443)

bilization techniques on patients with frozen shoulder.Yang et al. [57] took this intervention a step further andstudied the effects of combined end-range mobiliza-tion along with scapular mobilization treatment. Guler-Uysal et al. [48] compared Cyriax’s manipulation withphysical therapy.

Two studies by Ma et al. [49] and Sun et al. [51]compared acupuncture to acupuncture and physicaltherapy combined and a control group but Ma etal. [49] incorporated no home exercise program where-as Sun et al. [51] incorporated a home exercise pro-gram in their intervention protocol. The effects ofelectro-acupuncture and interferential therapy [45],deep and superficial heat [58], continuous passive mo-tion [47] and ultrasound [46] were assessed in com-bination with stretching/ home exercises vs. eitherstretching alone or exercise alone with home exerciseprogram. Stergioulas [27] compared low level lasertreatment with sham laser therapy. We also includedthe studies that compared the effects of local corti-costeroid injections with physical therapy [26,43,44,50,60]. These studies either compared corticosteroidinjections alone to physical therapy [26,43] or corti-costeroid injections combined with physical therapyto corticosteroid injection alone or physical therapyalone [44,50,60].

3.4. Outcome measures

A variety of outcome measures were utilized inthe thirty nine studies and almost all studies usedmore than one outcome measure (Table 1). The mostcommon outcome measures in the reviewed studieswere pain (with visual analogue scale (VAS)) [6,25–28,31,33,37,39,42,43,45–50,54,55,58,59,63] (22 outof 39 studies), goniometric range of motion [6,26–40,42–44,46–50,53–55,57–61,63] (33 out of 39 stud-ies), and various functional outcome measures suchas American Shoulder and Elbow Surgeons Assess-ment Form (ASES) [30,58], Constant Murley As-sessment (CMA) [43,45,47,51,54,62], Croft shoul-der assessment scale [27], Disabilities of the ArmShoulder and Hand Questionnaire (DASH) [6,27,38],Flexion Scale of Shoulder Function (FLEX-SF) [56,57], Health Assessment Questionnaire (HAQ) [27],Physical Component Summary – 12 (PCS-12) [25],Self-assessment disability questionnaire [59], Shoul-der Disability Questionnaire (SDQ) [40,42,50], Shoul-der Pain and Disability Index Score (SPADI) [27,28,35,38–40,44,46,47,55,60], Shoulder Rating Question-naire (SRQ) [42], and VAS global disability [39,50].Nine studies [6,32,40–42,44,46,49,50] measured gen-eral health status of their patients via short form-36.Yang et al. [56,57] also measured shoulder kinemat-ics as an outcome measure of their interventions. All


Table 5Grades 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• Mobilization (High grade) Grade A• Therapeutic exercises Grade A• Corticosteroid inj + PT Grade B• Acupuncture + exercises 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• Mobilization (High grade) Grade A• Therapeutic exercises Grade A• Acupuncture + exercises Grade B• Low level laser therapy Grade B• Electro-acupuncture and IFT Grade B• Deep heat Grade B• Ultrasound Not recommended• Continuous passive motion Not recommended

groups in the reviewed studies were comparable atbaseline.

4. Discussion

A great number of therapeutic regimens have beenrecommended for frozen shoulder, but none of themhave been consistently proved for efficacy. Therefore,this review was attempted to aid physical therapistsin making the best choice among PTI by determiningthe comparability of the results in the recently pub-lished studies relating to the PTI for the managementof different stages of frozen shoulder. Although frozenshoulder is one of the most prevalent shoulder con-dition affecting the general population, only 39 stud-ies were found relating to the PTI for the managementof frozen shoulder in the past 12 years while meet-ing the criteria for this systematic review. Most of thestudies included in the review had good quality crite-ria. In general, patients in stage 2/stage 3 were foundto better respond to physical therapy, stretching, andother rehabilitation programs as compared to patientsin stage 1. The exact biological mechanisms by which

the PTIs improve tissue healing are not yet understoodbut they are believed to facilitate collagen productionand tendon healing. Corticosteroid injections seem tobe the treatment of choice in patients with stage 1frozen shoulder due to their ability to reduce inflam-mation and pain associated with stage 1.

The studies in the review showed a variety of out-come measures of different quality and clinical rele-vance for evaluating the effects of PTI in the manage-ment of frozen shoulder. When the thirty nine reviewedstudies were grouped by area of measured outcomemeasures, three major categories emerged: pain, rangeof motion, and function. After compiling informationfrom the quality and level of evidence reviewed, webelieve that the comments can be made regarding thequality issues and effect of PTI in these categories.Grades of recommendation can be given based on thelevel of evidence demonstrated by the studies and clin-ical guidelines can be created for what is ‘best practice’for the management of frozen shoulder.

4.1. Pain

The reduction in pain is often cited as the primarygoal of PTI in frozen shoulder; however, only 22 of


the 39 studies measured pain. Of the twenty two stud-ies, six [6,31,37,39,54,63] utilized therapeutic exer-cises, seven [25,28,33,42,48,55,59] utilized mobiliza-tion therapy, three [26,43,50] compared corticosteroidinjections and physical therapy, and six studies (1 studyeach) utilized acupuncture [49], electro-acupunctureand interferential therapy [45], continuous passive mo-tion [47], heat [58], ultrasound [46], and low level lasertherapy [27] to study their effects on pain. One studylooked at the effects of different physical therapy inter-ventions [25] on reducing pain in patients with frozenshoulder.

Six studies that utilized therapeutic exercises had pa-tients in various stages of frozen shoulder. two stud-ies [37,63] reported to study subjects in stage I, onestudy [31] used patients in stage II, 1 study [6] usedpatients in stage III, 1 study [39] used mixed stages,and one study [54] failed to report the mean duration ofthe frozen shoulder. All the six studies suggested thatthe exercises they used in their studies were effectivein reducing pain in patients with frozen shoulder.

In the studies that evaluated the effects of mobiliza-tion therapy in patients with frozen shoulder, six au-thors [25,28,33,42,48,59] found mobilizations to be ef-fective along with home exercise program whereas onestudy [55] didn’t find mobilization to be effective overhome exercise program in controlling pain. The differ-ence in results could be attributed to limited samplesize and enrollment of stage 1 frozen shoulder patientsin Chan et al. study [55] as compared to other stud-ies. The five studies mentioned above, primarily hadpatients in stage II frozen shoulder enrolled in them.

Mixed results were found among the three studiesthat compared corticosteroid injections and physicaltherapy [26,43,50]. The findings of this review indicatethat in general, corticosteroid injections are more ef-fective than PTI in short term pain relief, and to a lesserextent in the long term pain relief. Both Arslan and Ce-likar [26] and Ryans et al. [50] suggested that corti-costeroid injections helped in better managing pain ascompared to PTI and exercises in short term follow-up,however, the effect disappeared in long term follow-up. On the contrary, Calis et al. [43] found pain reliefwith physical therapy applications more pronouncedthan corticosteroid injections.

Ma et al. [49] compared the effects of physical ther-apy to acupuncture and found pain to be better con-trolled by acupuncture as compared to physical ther-apy. They suggested integration of acupuncture andphysical therapy for short term pain relief. Severalstudies also evaluated the effects of various physi-

cal therapy modalities for pain relief in patients withfrozen shoulder. For example, Cheing et al. [45] foundboth electro-acupuncture and interferential therapy tobe effective in short term and long term pain relief;Dundar et al. [47] found continuous passive motionto reduce pain more than active stretching exercises atshort term follow-up; and Leung and Cheing [58] sug-gested better pain relief with deep heating and stretch-ing exercises to superficial heat and stretching exer-cises at short term and long term follow-up. In contrastto these findings with various physical therapy modal-ities, Dogru et al. [46] did not find any benefit of usingultrasound for pain relief in frozen shoulder patients.Stergioulas [27] also found low level laser therapy tohelp in significant pain relief in short term and longterm follow-up.

On the basis of available level of evidence, mobiliza-tion, therapeutic exercises and low level laser therapycan be given grade A recommendation for short termpain relief in patients with frozen shoulder. Studies thatutilized corticosteroid injections, acupuncture, electro-acupuncture and interferential therapy, continuous pas-sive motion, and deep heat were graded as level II andtherefore, grade B recommendation can be supportedby this review for the use of these interventions forshort term pain relief for patients with frozen shoul-der. The use of ultrasound for pain relief is not recom-mended.

4.2. Range of motion (ROM)

The ROM was the most studied outcome measurein the reviewed articles for PTI in patients with frozenshoulder (33 of the 39 studies). In all the 33 stud-ies, ROM was measured using a goniometer. Of thethirty three studies, eleven [1,6,29,31,34,37–39,53,54,63] investigated the effect of therapeutic exercises,nine [28,33,35,36,42,48,55,57,59] utilized mobiliza-tion, six [26,40,43,44,50,60] compared the effect ofcorticosteroid injections and physical therapy, and sixstudies (1 study each) evaluated the effect of acupunc-ture [49], continuous passive motion [47], heat [58], ul-trasound [46], low lever laser [27], and dynasplint [61]on range of motion. Two studies [30,32] evaluated sub-jects who were treated with either non-operative meansor operative means.

Therapeutic exercises were generally found to beeffective in improving ROM at either short term orlong term follow up. All studies reported the beneficialeffects of exercises on ROM in patients with frozenshoulder. The subjects represented in these studies var-ied from Stage I to Stage III when enrolled in the study.


In the studies that evaluated the effects of mobiliza-tion therapy in patients with frozen shoulder, five stud-ies [28,36,48,57,59] found mobilization along with ex-ercises to be effective in improving ROM at short termfollow-up. At the long term follow-up, these findingsare consistent with the studies of Maricar et al. [35],Vermeulen et al. [33] and Vermeulen et al. [42]. How-ever, Chan et al. [55] did not find any significant dif-ference in ROM following mobilization, possibly dueto limited sample size in their study.

The findings of this review indicate that in general,PTI are more effective than corticosteroid injectionsin short term ROM improvement. Calis et al. [43] andRyans et al. [50] suggested that PTI helped in betterimproving passive ROM as compared to corticosteroidinjections in short term follow-up, however, the effectdisappeared in long term follow-up. Carette et al. [44]found the combination of corticosteroid injection andPTI to be more effective in improving active and pas-sive ROM than either corticosteroid injections only orPTI only. In contrast, Maryam et al. [60] found activeand passive ROM to be improved more in corticos-teroid injection group. Arslan and Celikar [26] foundno difference in the effect of PTI and corticosteroid in-jections in improving active/passive ROM in short termfollow-up.

Ma et al. [49] compared the effects of physical ther-apy to acupuncture and found ROM to be better im-proved by physical therapy as compared to acupunc-ture. They further reported that combined acupunc-ture and physical therapy gives better improvementin ROM than either acupuncture alone or physicaltherapy alone. The authors suggested integration ofacupuncture and physical therapy for short term im-provement in ROM. Several studies also evaluated theeffects of various physical therapy modalities for im-provement in ROM. Dundar et al. [47] found con-tinuous passive motion to be no different in improv-ing ROM than active stretching exercises at short termfollow-up. Leung and Cheing [58] suggested moreimprovement in ROM with deep heat and stretchingexercises to superficial heat and stretching exercisesat short term and long term follow-up. Gaspar andWillis [61] in their cohort study found dynasplint com-bined with physical therapy to be more effective in im-proving ROM than physical therapy alone or splint-ing alone in patients with frozen shoulder at initial andlong term follow-up. Stergioulas [27] did not find lowlevel laser to help in significant ROM improvement inshort term and long term follow-up.

On the basis of available level of evidence, thera-peutic exercises and mobilization can be given grade A

recommendation for short term improvement in ROMin patients with frozen shoulder. Corticosteroid injec-tions, acupuncture, and deep heat can be given gradeB recommendation, and the use of dynasplint can begiven grade C recommendation for improving shortterm ROM in frozen shoulder patients. Continuouspassive motion and low level laser for improving ROMis not recommended.

4.3. Function

Various functional outcome measures were used tomeasure function in the reviewed articles for PTI inpatients with frozen shoulder (26 of the 39 studies).All the functional outcome measures used in the re-viewed articles have been reported to be valid and re-liable. Of the twenty six studies, five [6,38,39,54,62]assessed the effects of therapeutic exercises, nine [25,28,35,41,42,55–57,59] studied the effect of mobiliza-tion therapy, five [40,43,44,50,60] compared the ef-fect of corticosteroid injections and physical ther-apy, six studies (1 study each) evaluated the effectof acupuncture [51], continuous passive motion [47],ultrasound [46], heat [58], low level laser [27] andelectro-acupuncture and interferential therapy [45] onimprovement of function. One study [30] tried to as-sess the patients response when through non-operativemeans as compared to operative means.

Of the five studies that assessed the effects of thera-peutic exercises, four studies reported exercises to im-prove function [6,38,39,54] whereas one study [62]found supervised neglect to be better than physicaltherapy in improving function in patients with frozenshoulder.

In the studies that evaluated the effects of mobiliza-tion therapy, mixed results were reported in the re-viewed studies. Two studies [35,55] did not find sig-nificant change in the function following mobilizationtherapy whereas other studies reported mobilizationto be effective in improving function in patients withfrozen shoulder. Specifically, high grade mobilization,end range mobilization and mobilization with move-ment, and end range mobilization and scapular mobi-lization techniques were reported to be more effectivein improving function in patients with frozen shoulder.

Mixed findings were reported in the reviewed stud-ies about the effect of PTI and corticosteroid injec-tions in functional improvement. Carette et al. [44] andMaryam et al. [60] found the combination of corticos-teroid injection and PTI to be more effective in im-proving function than either corticosteroid injections


only or PTI only. Ryans et al. [50] found corticos-teroid injections only to be more effective in improv-ing function than either the combination of corticos-teroid injection and PTI or PTI only. In contrast, Caliset al. [43] found PTI to be better in improving functionthan either sodium hyaluronate injection only or corti-costeroid injection only. Calis et al. [43] also found PTIto be effective in long term follow up as well whereasMaryam et al. [60] and Ryans et al. [50] found the con-trary.

Sun et al. [51] compared the effects of physicaltherapy to acupuncture and reported that combinedacupuncture and physical exercises gives better im-provement in function than physical exercises alone.The authors suggested integration of acupuncture andphysical therapy for short term improvement in func-tion. Several studies also evaluated the effects of var-ious physical therapy modalities for improvement infunction. Leung and Cheing [58] suggested more im-provement in function with deep heat and stretchingexercises to superficial heat and stretching exercises atshort term and long term follow-up. Stergioulas [27]recommended that low level laser therapy can also beused to improve function at both short term and longterm follow-up. Electro-acupuncture and interferentialtherapy were also reported to be effective in improvingfunction by Cheing et al. [45]. In contrast to these stud-ies, Dundar et al. [47] found that continuous passivemotion is no different in improving function than ac-tive stretching exercises. Dogru et al. [46] did not findany benefit of using ultrasound for improving functionin patients with frozen shoulder.

On the basis of available level of evidence, thera-peutic exercises and mobilization can be given grade Arecommendation for short term improvement in func-tion. Of the two studies comparing corticosteroid in-jections and physical therapy, both studies were levelI studies. No specific recommendation can be given toeither the combination of corticosteroid injection andPTI and corticosteroid injections only or PTI only forimproving short term function in patients with frozenshoulder. Grade B recommendation can be supportedby this review for the use of acupuncture, low levellaser, and electro-acupuncture and interferential ther-apy along with physical exercises, for short term func-tional improvement in treatment of frozen shoulder.Continuous passive motion and the use of ultrasoundfor improving function are not recommended. The pas-sive modalities may decrease inflammation associatedwith frozen shoulder and allow patients to use theirshoulder with less pain. The negative effects of ultra-

sound may be attributed to ineffective parameter selec-tion. Continuous passive motion may have limited im-pact on function unless the patients are encouraged tofunctionally use their shoulder.

5. Methodological limitations

The interpretation of the results of many studies de-scribing therapeutic regimens is hampered by method-ological flaws, such as small number of subjects, lackof indication for duration of symptoms before treat-ment, high dropout rates, the use of co-interventions,and a short follow-up. Moreover, many studies do noteven provide details regarding the stage of the diseaseprocess, previous treatments, and etiological consider-ations.

Since only 12 studies were considered high quality,the results must be viewed in perspective of the goodmethodological quality of the individual studies. How-ever, the nature of the interventions does not allow adesign that meets all methodological criteria. For ex-ample: double blinding is usually impossible in stud-ies with PTI. Therefore, we used a low cut-off point (6points) for considering a study as “high quality”.

The best-evidence synthesis using a rating systembased on the quality of the individual studies has itslimitations. Rating is to some extent subjective, and ahigh quality level can be difficult to score. However, byranking the evidence of the conclusions, some insightcan be gained in the strength of the conclusions.

There is limited literature on the effectiveness ofspecific exercise regimen for the treatment of frozenshoulder. While there were few studies addressing theeffects of therapeutic exercises for frozen shoulder, noidentical exercise regimen was followed in any of thestudies and the measured outcomes were not alwayssuperior to the compared interventions. Additionally,the intensity, frequency, duration of exercises and theuse of physical therapy modalities varied across stud-ies.

The duration of symptoms in the reviewed studiesranged from 6 weeks to 10.2 months, placing the sub-jects in all three stages 1, 2 and 3 of frozen shoulder.The majority of the studies evaluated patients in stage2 and 3 and therefore, the recommendations providedin this review article apply only to patients with stage2 and stage 3 frozen shoulder.


6. Clinical relevance and future research

When different stages of frozen shoulder and theassociated pathophysiology are taken into account, itwould seem reasonable that certain treatments wouldbe more effective at different times. Many studies inthe past have not taken this into consideration whichmay seriously influence their results. Clinically, in-stead of time wise classification, classification basedon stage of pathology, which is related to patient’s ir-ritability level (low, moderate, and high) [7] shouldbe used when deciding on rehabilitation interventions.Kelley et al. [7] suggested irritability to be determinedupon pain, range of motion, and disability status ofthe patient. Patients in early stage frozen shoulder willdemonstrate high level of irritability and patients inlater stages will have low irritability.

Future research into the effectiveness of specific ex-ercises for pain relief, ROM improvement and im-proved functional status is needed. Additionally, fur-ther research is needed in determining the optimaldose of different exercises such as the intensity, fre-quency, and duration of exercises for patients withfrozen shoulder.

This review targets physical therapy clinicians andhealth researchers. The information will be most use-ful for decision-makers wanting to know which inter-ventions are the ‘best buys’ when making decision onthe available interventions. A study of interest may beidentified as appropriate for a particular setting and,following some re-analysis to reflect individual pa-tient requirements, the intervention may be consideredby clinicians for translation into practice. The reviewmay also act as a reference guide for various inter-ventions utilized in clinics and the relative differencesbetween the interventions as compared using reliableand validated outcome measures. In addition, the re-view has highlighted the gaps in treatment methods,and steers researchers and clinicians towards improv-ing their practice and reporting high-quality clinicalfindings, while building on existing knowledge.

7. Conclusions

From this review, therapeutic exercises and mobi-lization therapy are strongly recommended for reduc-ing pain, improving ROM and function in patients withstages 2 and 3 frozen shoulder. While high grade pos-terior mobilization along with self exercises is recom-mended for improving passive external rotation and

abduction ROM, high grade mobilization and mobi-lization with movement along with self exercises arerecommended for improving function. Low level lasertherapy is strongly suggested for pain relief and moder-ately suggested for improving function but not recom-mended for improving ROM. This review also supportsthe evidence of using local corticosteroid injections asthe treatment of choice in patients with stage 1 frozenshoulder, followed by the use of corticosteroid injec-tions along with PTI in patients with stage 2 frozenshoulder. Acupuncture along with physical therapy ex-ercises is also moderately recommended for pain relief,improving ROM and function in patients with frozenshoulder. Electro-acupuncture and interferential ther-apy can also help in providing short term pain relief.While the continuous passive motion is recommendedfor short term pain relief, it is not recommended for im-proving ROM or function in patients with frozen shoul-der. Evidence also suggests the use of deep heat forpain relief and improving ROM. There is also mild ev-idence for the use of dynasplint in restoring ROM. Theuse of ultrasound for pain relief, improving ROM orimproving function for treatment of frozen shoulder isnot recommended.

The results of this review must be viewed in perspec-tive to limited database search and heterogeneity of thestudies. Both the lack of use of standardized/identicalexercises and varied physical therapy modalities in dif-ferent studies limit the ability to generalize these find-ings in order to treat patients with frozen shoulder inthe clinic. In order to apply these findings to the clinicalsettings, future studies should examine whether partic-ular PTI protocols specifically improve pain, ROM andfunctionality, and then apply follow-up data to proveeffectiveness of the intervention.

Acknowledgements

The authors have not received any financial pay-ments or other benefits from any commercial entity re-lated to the contents of the work being presented.

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