Manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy?
Frozen shoulder is a condition of the shoulder joint in which the capsule becomes inflamed, then scarred and contracted, causing pain, stiffness, and loss of function. The exact cause remains unknown, which is why it is often labelled as idiopathic or primary frozen shoulder.
Recently, a multicentre randomised clinical trial from the UK – the FROST (Frozen Shoulder Trial) – was published in the Lancet in which the clinical (pain and function) and cost effectiveness of three care pathways to treat adults with a frozen shoulder was examined:
- Manipulation under anaesthesia
- Capsular release
- Non-surgical i.e. early physiotherapy with steroid injections
How was the treatment performed?
In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by physiotherapy. Early physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection.
For how long did patients receive physiotherapy?
The full standard course of early physiotherapy and postsurgical physiotherapy was 12 sessions during up to 12 weeks. If the physiotherapist and participant were satisfied with their progress, not all 12 sessions were necessary
What were the outcome measure?
Patient-reported outcome measure of shoulder pain and function, health-related quality of life, numeric rating scale for pain, and the perceived extent of recovery. All outcome measures were collected at baseline, 3 months, 6 months, and 12 months.
What were the results?
Concerning patient-reported shoulder pain and function:
- All improved substantially from baseline with all three trial treatments
- None of the three trial treatments were superior at 12 months (see figure below)
So what is the difference between the 3 treatment strategies?
- Early physiotherapy was accessed more quickly than were the surgical options, and was lower in cost
- Manipulation under anaesthesia was the most cost-effective option and takes less theatre time than arthroscopic capsular release
- Arthroscopic capsular release was associated with higher risks and costs compared with manipulation and physiotherapy, but fewer participants required further treatment.
Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. Rangan A, Brealey SD, Keding A, Corbacho B, Northgraves M, Kottam L, Goodchild L, Srikesavan C, Rex S, Charalambous CP, Hanchard N, Armstrong A, Brooksbank A, Carr A, Cooper C, Dias JJ, Donnelly I, Hewitt C, Lamb SE, McDaid C, Richardson G, Rodgers S, Sharp E, Spencer S, Torgerson D, Toye F; UK FROST Study Group.Lancet. 2020 Oct 3;396(10256):977-989. doi: 10.1016/S0140-6736(20)31965-6.