Frozen shoulder, a condition in which the tissue around the joint thickens, stiffens and grows painful, has long offered clinicians a crowded menu of remedies whose relative worth was never clearly weighed. A large synthesis of 189 trials, covering nearly 13,000 adults, now offers a measured answer: shockwave therapy probably eases pain in the short term, and manipulation under anaesthesia probably restores movement, while much of the remaining landscape stays in shadow. It is a modest light, but a useful one, for patients and clinicians facing the same stiff and aching joint.
Shockwave therapy and manipulation offer short-term relief for frozen shoulder; long-term effects remain unclear
Frozen shoulder causes pain and restricted movement, and the review pooled data from 12,988 adults with the condition.
Two treatments probably help in the short term, and almost everything else is unsettled.
Mark
So what does this review actually tell a person with a frozen shoulder?
Mimi
Two things, mainly. Shockwave therapy probably eases pain in the short term, and manipulation under anaesthesia probably improves how far the arm can be raised forward.
Luke
Notice the word probably. That reflects moderate-certainty evidence, not firm proof.
Mark
How big were the effects?
Mimi
Shockwave lowered pain by about 1.97 points on a 10-point scale versus usual care. Manipulation with a steroid injection added about 33 degrees of flexion, and manipulation alone about 26.
Luke
Those are averages from pooled trials. The source doesn't say what size of change counts as meaningful for an individual patient, so I wouldn't read them as guarantees.
Mark
Why is 189 trials not more reassuring?
Mimi
Because most of those trials were at high risk of bias, and details like disease stage and prior treatment were reported unevenly.
Luke
Right. Size doesn't fix quality. And the findings may only apply to primary adhesive capsulitis.
Mark
What about safety?
Mimi
That's the quiet gap. Adverse events were reported incompletely and inconsistently, so harms can't be compared well.
Luke
Which means we don't know the trade-offs. Nor do we know what happens beyond three months. The authors limit the usefulness to the first six months.
O Pulso
- Pain and stiffness from a thickened, inflamed shoulder capsule have pushed thousands of adults toward a crowded set of treatments with unclear rankings.
- A network meta-analysis of 189 trials has sorted those options, finding two that probably help in the short term.
- Shockwave therapy shows moderate-certainty evidence of reduced pain, though hints of functional gains remain unreliable.
- Manipulation under anaesthesia, alone or with a steroid injection, probably improves forward and overhead arm movement, but the picture beyond three months and on safety stays unresolved.
Frozen shoulder, a condition in which the tissue around the joint thickens, stiffens and grows painful, has long offered clinicians a crowded menu of remedies whose relative worth was never clearly weighed. A large synthesis of 189 trials, covering nearly 13,000 adults, now offers a measured answer: shockwave therapy probably eases pain in the short term, and manipulation under anaesthesia probably restores movement, while much of the remaining landscape stays in shadow. It is a modest light, but a useful one, for patients and clinicians facing the same stiff and aching joint.
A review published by The BMJ has pooled 189 randomised controlled trials on frozen shoulder, and its central finding is modest: two treatments probably help in the short term, and most else remains uncertain.
The trials involved 12,988 adults with adhesive capsulitis, with an average age of 54. The condition stems from thickened, stiff and inflamed connective tissue around the joint, bringing pain and restricted movement. It is most common in people aged 40 to 60 and more often affects women.
Many treatments exist, including drugs, steroid injections and surgery, but how they compare has been unclear. The researchers used a network meta-analysis to rank options that were rarely tested head to head, examining pain, function, range of motion and adverse events.
The strongest signal came from extracorporeal shockwave therapy, which probably reduced short-term pain compared with usual care. Its possible benefits for function and movement rest on weaker, inconsistent evidence.
Manipulation under anaesthesia, performed by a clinician, probably improved short-term forward arm movement. Combined with a steroid injection, the gain over usual care was 33.29 degrees; manipulation alone gave 26.16 degrees.
Beyond these findings, the evidence is thin, especially past three months, and safety reporting across the trials was incomplete. Most studies carried high bias risk. The researchers suggest the results may inform decisions in the first six months, while urging weight on invasiveness, cost, patient preferences and the uncertainty that still surrounds longer-term outcomes.
A review published by The BMJ has pooled the results of 189 randomised controlled trials on frozen shoulder, and its central finding is a modest one: two treatments probably help in the short term, and almost everything else is still unsettled.
The trials covered 12,988 adults with adhesive capsulitis, the formal name for frozen shoulder. The average age was 54. The condition develops when the strong connective tissue around the shoulder joint becomes thick, stiff and inflamed, which causes pain and limits movement. It is more common in people aged 40 to 60, and in women more than in men.
Many treatments are on offer, including drugs, steroid injections and surgery, but how they compare for benefit and harm has been unclear. The researchers set out to address that with a network meta-analysis, which lets treatments be ranked against each other even when they were not tested head to head. They compared active treatments with another intervention, placebo or usual care, looking at pain, function, range of motion and adverse events.
The clearest signal involved extracorporeal shockwave therapy, which delivers low-energy sound waves to damaged tissue to stimulate blood flow and healing. Moderate-certainty evidence showed it probably reduced short-term pain compared with usual care, with a mean difference of -1.97 on a 0 to 10 scale. There were hints that it may also improve short-term function, flexion and abduction, but the authors say those apparent gains rest on low-certainty evidence and inconsistent data, so they are less certain.
The second finding concerned movement. Manipulation under anaesthesia, performed by a clinician, probably improved short-term flexion, meaning the ability to raise the arm forward and overhead. Combined with a steroid injection, the mean difference against usual care was 33.29 degrees. Manipulation alone gave 26.16 degrees. Both estimates came from moderate-certainty evidence.
Beyond those results, the picture is thin. Evidence for most other treatments is substantially less certain, as is evidence for any outcome beyond three months. Comparative safety is also poorly established, because adverse events were reported incompletely and inconsistently across the trials.
The authors acknowledge further limits. Most trials were at high risk of bias. Disease duration, clinical stage and previous treatment were incompletely or inconsistently reported. The findings may also apply only to patients with primary adhesive capsulitis.
For those reasons, the researchers say the results may help inform specific treatment decisions within the first six months of the condition. They do not establish longer-term comparative effectiveness or an overall balance of benefit and harm. They conclude that decisions should also weigh invasiveness, cost, patient preferences, clinical expertise and the uncertainty about longer-term benefits and harms. What the field still lacks is better-reported safety data and longer follow-up.
Citações Notáveis
Treatment decisions should also consider invasiveness, costs, patient preferences, clinical expertise, and uncertainty about longer term benefits and harms.— Review authors, The BMJ
Quer a matéria completa?
Leia o original em New Zealand Doctor ↗
Technology