Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial

Tim Kraal; Yordi de Wit; Bertram The; Leonieke van Boekel; Iris Koenraadt-van Oost; Ronald Boer; Maaike Vd Borne; Pjotr Goossens; Koen Koenraadt; Denise Eygendaal

doi:10.1016/j.jseint.2023.11.004

Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial

JSES Int. 2023 Dec 6;8(2):293-298. doi: 10.1016/j.jseint.2023.11.004. eCollection 2024 Mar.

Authors

Tim Kraal¹, Yordi de Wit^{2

3}, Bertram The^{2

3}, Leonieke van Boekel^{2

3}, Iris Koenraadt-van Oost^{2

3}, Ronald Boer², Maaike Vd Borne², Pjotr Goossens², Koen Koenraadt³, Denise Eygendaal⁴

Affiliations

¹ Department of Orthopedic Surgery, Flevo Hospital, Almere, the Netherlands.
² Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands.
³ Foundation for Orthopedic Research, Care & Education, Amphia Hospital, Breda, the Netherlands.
⁴ Department of Orthopedic Surgery, Erasmus MC, Rotterdam, the Netherlands.

Abstract

Background: Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS.

Methods: A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work.

Results: In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial.

Conclusion: MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.

Keywords: Frozen shoulder; Manipulation under anesthesia; Physiotherapy; Randomized controlled trial; Range of motion; SPADI.