Article Review: What environment is best for Frozen Shoulder Range of Motion Exercises; Individual therapy, Group exercise classes or Home exercise?

A group from the United Kingdom has published a clinical trial in The Journal of Shoulder and Elbow Surgery to find the most efficient and effective treatment option for Frozen Shoulder. All confirmed adhesive capsulitis patients referred to one physiotherapy department were included in the study. 75 patients were randomized to either individual physiotherapy (24 patients), group exercise (25 patients) or a home exercise program (26 patients). All groups had an initial explanation of different range of motion exercises, with an informational booklet. The group exercise programs used 12 stations of range of motion exercises over 50 minutes, twice weekly for 6 weeks, and individual physiotherapy met twice weekly for 6 weeks, using manual techniques, massage, stretching, heat treatment and exercises.

Outcome was mainly determined by use of the Constant Score, but also used the Oxford Shoulder Score, Range of Motion, and Hospital Anxiety and Disability Scale (HAD), a widely accepted indication of Anxiety and Depression or of general psychological distress,. Measurements were made at 6 weeks, 6 months and 12 months by an independent physiotherapist. The Constant Score for the group exercise class was 11 units higher than individual physiotherapy, and 20 points higher than home exercise, statistically significant findings. Both physiotherapy groups showed statistically significant improvement in HAD score compared to home exercise. There exist two plausible reasons for the discrepancy in improvement between treatments, that contact with a physiotherapist and other shoulder disease suffers reduced symptoms of psychological distress, or that an improvement in shoulder condition lead to less psychological symptoms. There is evidence for both explanations. Badcock et al. found psychological distress measured by the HAD Scale correlated strongly not with chronic pain, but rather with the loss of function in the shoulder caused by pain or stiffness. Logically, regaining function of the shoulder would lessen symptoms of psychological distress. However;  all groups had significant gains in usability, but the group exercise patients had the highest gains. It is likely that some factor unique to group exercise, such as new sense of bonding or camaraderie between patients, leads to the additional improvements in usability.

The upside for treatment centers is that a relatively inexpensive treatment, group exercise supervised by a physiotherapist, is shown to not only be as effective, but possibly even more effective than other treatment techniques. This is the only known study to directly compare home exercise, group exercises and individual treatment, in a randomized sample. It is of note that the authors included the HAD score in their analysis. Further studies using HAD scores to understand the psychological aspects of chronic shoulder pain in relation to treatment modalities may help find ways to make current treatment methods more helpful in treating both physical and mental effects of shoulder pain and resultant disability.

Free full text appraisal with synopsis and commentary from Journal of Physiotherapy. Paid Full text from Elsevier Science.

References:
Hanchard N. Exercise classes supervised by a physiotherapist may be better at restoring function after frozen shoulder than individual physiotherapy. J Physiother. 2014 Dec;60(4):236. doi: 10.1016/j.jphys.2014.08.011. Epub 2014 Oct 23. PubMed PMID: 25439717.
Russell S, Jariwala A, Conlon R, Selfe J, Richards J, Walton M. A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder. J Shoulder Elbow Surg. 2014 Apr;23(4):500-7. doi: 10.1016/j.jse.2013.12.026. PubMed PMID: 24630545.
Badcock LJ, Lewis M, Hay EM, McCarney R, Croft PR. Chronic shoulder pain in the community: a syndrome of disability or distress? Ann Rheum Dis. 2002 Feb;61(2):128-31. doi: 10.1136/ard.61.2.128. PubMed PMID: 11796398; PubMed Central PMCID: PMC1754001. Free Full Text from PubMed Central.

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