This study compared the effectiveness of three physiotherapy treatment options for frozen shoulder: group exercise class, individual physiotherapy, and home exercises. The group exercise class showed significantly greater improvement in shoulder function scores compared to individual physiotherapy or home exercises. Individual physiotherapy also produced significantly better results than home exercises. The group exercise class achieved clinically meaningful improvement in shoulder function for 91% of patients within 6 weeks. This study provides evidence that group exercise classes are an effective first-line treatment for frozen shoulder.

1. Physiotherapy
in the Management of
Frozen Shoulder
A Randomised Controlled Trial
of Physiotherapy Modalities
Julia Walton
Specialist Shoulder Physiotherapist

2. Acknowledgments
• Sarah Russell
• Physiotherapy department at Wrightington
• University of Central Lancashire
A blinded, randomized, controlled trial assessing
conservative management strategies for frozen
shoulder.
Russell S, Jariwala A, Conlon R, Selfe J, Richards J, Walton M.
J Shoulder Elbow Surg. 2014 Apr;23(4):500-7.

3. Physiotherapy
• Most initial presentations will be in primary
care to GP or Physiotherapy
• Treat effectively
• Refer appropriately

4. Physiotherapy
• CSP Guidelines
Hanchard N, Goodchild L, Thompson J, O’Brien T, Richardson
C, Davison D, Watson H, Wragg M, Mtopo S, Scott M. (2011)
Evidence-based clinical guidelines for the diagnosis, assessment
and physiotherapy management of contracted (frozen) shoulder
v.1.6, ‘standard’ physiotherapy
.
Hanchard NC, Goodchild L, Thompson J, O'Brien T, Davison D,
Richardson C Evidence-based clinical guidelines for the diagnosis,
assessment and physiotherapy management of contracted (frozen)
shoulder: quick reference summary. Physiotherapy. 2012
Jun;98(2):117-20.

5. CSP Guidelines

6. Current Evidence
• Lots of “Probably”
• Limited quality research

7. Current Evidence
• Recent vogue for more
interventional procedures
• Hydrodilitation
• MUA / Capsular Release
• Significant cost implications

8. What we need...
• Better evidence for physiotherapy
• Randomnised controlled trials
• Good quality methodology

9. Study Design
• Randomised Controlled Trial of Physiotherapy
Modalities
• Group Exercise Class
• Individual Multimodal Physiotherapy
• Home Exercise Programme

10. Study Design
• All primary care referrals to Wrightington
physiotherapy department with a diagnosis
of Primary Idiopathic Frozen Shoulder

11. Inclusion Criteria
• Age 40 to 70 years old
• Spontaneous onset of a painful stiff shoulder
• Symptoms present for at least three months
• Patient reported local shoulder pain, frequently present over either the
anteromedial aspect of the shoulder extending distally into the biceps region, or
over the lateral aspect of the shoulder extending into the lateral deltoid region.
• Marked loss of active and passive global shoulder motion, with at least 50% loss
of external rotation
• Normal x-rays on anteroposterior and axillary radiographs of the glenohumeral
joint

12. Exclusion Criteria
• Radiographic pathological findings or glenohumeral osteoarthritis on x-ray
• Local corticosteroid injection or any physiotherapy intervention to the affected
shoulder within the last three months
• Prior surgery, dislocation or trauma to the affected shoulder
• Inflammatory joint disease affecting the shoulder
• Active medico legal involvement

13. Exclusion Criteria
• Clinical evidence of significant cervical spine disease
• Cerebral vascular accident affecting the shoulder
• Bilateral frozen shoulder due to possible underlying systemic cause
• Thyroid disease
• Any coronary event, post coronary artery by-pass or catheterisation prior to
the clinical appearance of frozen shoulder

14. Study Design
• Ethical approval
• Clinical trial registration - 05/Q1401/86
• Conformed to CONSORT statement
(Altman et al 2001)
• Computer-generated permutated block
randomisation (Statistician!)

15. Study Design
• Baseline evaluation
• Constant Shoulder Score
• Oxford Shoulder Score
• SF-36
• Repeated 6 weeks, 6 months, and 1 year
• All assessments made by independent blind
physiotherapist

16. Group Exercise Class
• Twice per week for 6 weeks
• 50min exercise circuit - 12x4 min stations
• Senior physio (>10yrs experience shoulder therapy)
• Home Exercise Sheet and Information
Booklet

17. Individual Physiotherapy
• 2 Sessions of individual mulitimodal
physiotherapy per week for 6 weeks
• Senior Physio (>10yrs experience of shoulder therapy)
• Maitland mobilisations, soft tissue massage,
myofacial trigger point release, heat,
stretches
• Home Exercise Sheet and Information
Booklet

18. Home Exercise
• Home Exercise Sheet and Information
Booklet
• pathology
• pain management
• posture

19. Statistical Analysis
• Tested for Normal Distribution
• Repeated measures one-way analysis of
variance (RM-ANOVA)
• Pairwise comparison using Least Squares
Difference

20. Power Calculation
• 80% Power & 5% Significance
• Minimal Clinically Important Difference for
Constant Score of 15
• No accepted MCID
• General local consensus
• 117 Patients, 39 per Group

21. Results
• 850 patients referred over 12 months
• 705 (83%) did not meet inclusion criteria for
Primary Idiopathic Frozen Shoulder
• 70 declined to participate

22. Results
• 75 Patients
• Group Exercise Class - 25
• Individual Physiotherapy - 24
• Home Exercises - 26

23. Demographics
• Mean Age 51.1 (40-65)
• Male:Female 1:1.14
• Dominant Arm 53% (73% Right-Handed)
• Mean duration of Symptoms 5.79 months
(4-10)

24. Results
• 1 pt from EC died
• 1 patient from IP referred for injection at 6
months
• 2 patients from HE referred for injection at
6 months
• Intention to treat principal

26. Results
• No difference between groups at baseline
• Significant improvement in Constant Score
at 6 weeks in all groups (p<0.001)
• Continued improvement in all groups at 1
year

27. Results - Constant
• Baseline 39.8 (18-64)
• Group Exercise Class
• 6 Weeks 71.4 (60-89)
• 1 year 88.1 (71-96)

28. Results - Constant
• Baseline 39.8 (18-64)
• Group Exercise Class
• 6 Weeks 71.4 (60-89)
• 1 year 88.1 (71-96)

29. Results - Oxford

30. Results
Pairwise
Comparison
Mean
Difference
Standard
Error
p Value
Exercise Class vs
Physiotherapy
10.7 2.871 <0.001
Exercise Class vs
Home Exercises
20.304 2.936 <0.001
Physiotherapy vs
Home Exercises
9.606 2.970 0.002

31. Results
• Improvement in Constant Score was
significantly greater in Group Exercise Class
than individual physiotherapy (p<0.001) or
home exercises (p<0.001)
• Individual Multimodal Physiotherapy
Significant better then HE (p=0.002)
• Significance demonstrated for all domains of
Constant Score and also Oxford Score

32. Results
• Improvement in Constant Score was
significantly greater in Group Exercise Class
than individual physiotherapy (p<0.001) or
home exercises (p<0.001)
• Individual physiotherapy significantly better
then home exercises (p=0.002)
• Significance demonstrated for all domains of
Constant Score and Oxford Score

33. Results
• Significant improvement over time
• Baseline and 6 weeks (p<0.001)
• 6 week and 6 months (p<0.001)
• 6 months and 1 year (p<0.001)
• Both Constant and Oxford Scores

34. Results
• Short Form - 36
• Significant improvements in bodily pain
(p=0.011) mental health (p=0.009) and
social function (p<0.001)
• No other significant differences between
groups or over time

35. Results
• SF-36 does not appear to accurately reflect
shoulder symptoms and change
• We would not recommend SF-36 as a
PROM for shoulder pathology (Beaton 1996,
Griggs 2000 Carette, 2003, Buckbinder 2004)

36. Discussion
• 91% of patients in the group exercise class
had a clinically important improvement in
constant score within 6 weeks
• 68% with individual physiotherapy
• 41% with home exercise programme

37. Discussion
• Group exercise class gives significant
improvement in symptoms of frozen
shoulder
• Improvement is greater than with individual
physiotherapy
• Both better than a home exercise
programme

38. Discussion
X
X
Hopefully removed some “Probablies....”

39. Discussion
• Group Therapy
• Psychological Impact
• Discuss condition with
similar patients
• Reassurance
• Competition
• HADS analysis - improvement
significantly improved with
group and physio intervention
over home exercise group

40. Discussion
• Primary care diagnosis of
Frozen Shoulder
• ONLY 17% of referrals
had accurate diagnosis
• Significant implications for
primary care management /
triage services / care in the
community

41. Discussion
• Prevalence: 2-3% with
female predisposition
• ? Based on inaccurate
primary care diagnosis
• True prevalence much
lower
• Equal gender distribution
(Bunker et al)

42. Limitations
• Principal limitation is not meeting Power
• Based upon “inaccurate” prevalence and
referral data
• Unable to collect enough patients in
timescale
• Still significant despite smaller numbers

43. Limitations
• Ethically unable to offer “no
treatment” arm
• Home exercises provides a
control against physiotherapy
intervention
• Home exercises probably close
to natural history

44. Conclusions
• Group exercise class - Cost effective and
Time effective treatment option for frozen
shoulder
• Individual physiotherapy more effective than
a home exercise programme
• Highlights non-responders after 6 week
course
• Appropriate referrals to Surgeons

45. Thank you