This scientific article has been peer-reviewed according to Fysioterapeuten's guidelines, and was accepted on November 2nd, 2021. Ethical approval was granted by the Queen Margaret University (QMU) Divisional Research Ethics Committee. No conflicts of interest stated.
Note: Moestue Halvorsen is associated with Fysioterapeuten in connection with the podcast "Lateralt og medialt - en podcast om fysioterapi.
Abstract
Introduction: Although several interventions have been proposed for frozen shoulder, there is a lack of evidence regarding the best care for the condition, especially concerning corticosteroid treatment and the number of injections used. The treatment strategies and clinical reasoning behind the management among physical therapists providing injection therapy have not previously been evaluated.
Methods: A cross-sectional online survey was distributed among 138 Norwegian physical therapists providing injection therapy to evaluate current practice regarding their management of frozen shoulder with corticosteroid injections. Descriptive statistics were used to identify trends in current practice, which were further evaluated in relation to the available literature.
Results: The majority of the 32 respondents used multiple ultrasound-guided intra-articular corticosteroid injections for frozen shoulder. None reported to usually achieve satisfactory results following only a single injection, while 87.1 % reported this following 2-3 injections. The use of functional outcome measures as part of the evaluation and decision-making is generally limited among the respondents.
Conclusion: Multiple intra-articular corticosteroid injections are currently used in practice in Norway, with the respondents reporting beneficial outcomes following 2-3 injections. However, their efficacy compared to a single injection needs further investigation.
Key-words: Physical Therapy Modalities, Surveys and Questionnaires, Shoulder Injection.
Sammendrag
Behandling av frossen skulder med kortisoninjeksjon: En evaluering av nåværende praksis blant fysioterapeuter som utfører injeksjonsbehandling i Norge
Formål: Å evaluere nåværende praksis vedrørende bruk av kortisoninjeksjoner i behandlingen av frossen skulder blant fysioterapeuter som utfører injeksjonsbehandling i Norge, og undersøke i hvilken grad funksjonelle utfallsmål brukes som en del av evalueringen og beslutningsgrunnlaget for behandling.
Design: Nettbasert spørreundersøkelse
Materiale: Svar på den nettbaserte spørreundersøkelsen var tilgjengelig fra 32 fysioterapeuter som utfører injeksjonsbehandling i Norge.
Metode: Tverrsnittstudie
Resultater: Alle respondentene i denne spørreundersøkelsen benytter ultralydveiledet intraartikulær injeksjon ved behandling av frossen skulder med kortison. Alle respondentene anså kortisoninjeksjoner som hensiktsmessige i den smertedominerende fasen, med mer motstridende synspunkter om hvor hensiktsmessig slik behandling er i den stivhetsdominerende fasen. Alle unntatt én av respondentene rapporterte at de kan vurdere å benytte mer enn én injeksjon på samme side. Blant respondentene som benytter flere injeksjoner, rapporterte 87,1 % at de vanligvis oppnår et tilfredsstillende resultat ved 2-3 injeksjoner, mens ingen rapporterte at de vanligvis oppnår dette etter kun én injeksjon.
Respondentene benytter ofte selvrapportert grad av smerte med Visuell Analog Skala (VAS) eller Numeric Rating Scale (NRS) for å evaluere behandlingseffekt. Én av fem benytter også et funksjonelt utfallsmål, mens ingen rapporterte å benytte et mål for helserelatert livskvalitet.
Konklusjon: Flere intraartikulære kortisoninjeksjoner brukes i dag i behandlingen av frossen skulder av fysioterapeuter som utfører injeksjonsbehandling i Norge, med rapporter fra respondentene om tilfredsstillende resultater etter 2-3 injeksjoner. Bruk av funksjonelle utfallsmål til evaluering og som en del av beslutningsgrunnlaget for behandling skjer kun i begrenset grad.
Nøkkelord: Fysioterapi, undersøkelser og spørreskjemaer, skulder, injeksjoner.
Introduction
Frozen shoulder is a debilitating condition identified by severe pain and stiffness of the shoulder and has been associated with reduced quality of life among individuals living with the condition (1). Although it can be secondary to trauma or prolonged immobilization, primary frozen shoulder is seen as an idiopathic process marked by initial inflammation and subsequent fibrosis, capsular contracture, and reduced joint volume (2, 3). Since the seminal paper by Reeves (4) in 1975 on the natural history of frozen shoulder, the condition has been thought of as self-limiting, leading to full resolution without treatment after one to three years. However, a recent systematic review by Wong et al. (5) found that the condition could still cause symptoms and disability several years after onset.
Frozen shoulder has traditionally been reported to occur in 2-5 % of the general population, although there are uncertainties regarding the actual life-time prevalence of the condition (3). As the incidence of frozen shoulder peaks in the fifth and sixth decade, a high proportion of the patients are in the working population, leading to a substantial economic burden to both the individual and the society (6). In addition to costs accumulating from the loss of workdays, the healthcare system's cost from treatments of frozen shoulder is substantial (7).
Although there is no Norwegian national guideline dictating the care and interventions that should be provided for frozen shoulder, clinical practice guidelines for the management of the condition have been developed for physical therapists both in Norway (8), and abroad (9, 10).
To help guide clinicians with decision-making and to identify appropriate interventions, a dichotomization between the "pain-predominant" and the "stiffness-predominant" stage of the disease has been recommended. Inflammation is the hallmark of the former, while capsular contracture is thought to be the most notable feature in the latter (9). A vast number of interventions has been proposed for the different stages of frozen shoulder, ranging from conservative management such as education and advice, supervised neglect, exercise therapy, stretching, joint mobilization and manipulation, through minimally invasive procedures like acupuncture and injection therapy, and finally to surgical treatment such as capsular release (3, 9). In a survey of 289 physiotherapists in the United Kingdom, good agreement was observed for certain interventions in both pain-predominant and stiffness-predominant frozen shoulder. Advice and education were recognized as essential interventions in both stages. There was also good agreement on the use of corticosteroid injection therapy in pain-predominant frozen shoulder, with 80 % of the respondents regarding it appropriate (11). Although the indications for corticosteroid injections in musculoskeletal care in general are narrow, and the effects often short-lived (12), several systematic reviews supports this intervention in frozen shoulder (13, 14). Intra-articular injection of corticosteroid is also recommended in the pain-predominant stage in the clinical practice guidelines for frozen shoulder. Howe
