Effectiveness of interventions for the management of primary frozen shoulder: A systematic review of randomised trials

AimsThis systematic review places a recently completed multi-centre randomised controlled trial (RCT) UK FROST, in the context of existing randomised evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. MethodsMEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL and WHO International Clinical Trials Registry were searched up-to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI and hydrodilatation against each other or supportive care or no treatment for the management of primary frozen shoulder. ResultsNine RCTs were included. The primary outcome of patient reported shoulder function at long-term follow-up (>6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardised mean difference (SMD) were: ACR vs MUA: 0.21 (95% CI: 0.00 to 0.42), ACR vs supportive care: -0.13 (95% CI: -1.10 to 0.83), and ACR vs PTSI:0.33 (95% CI: 0.07 to 0.59) and 0.25 (95% CI: -0.34 to 0.85) all favouring ACR; MUA vs Supportive care: 0 (95% CI: -0.44 to 0.44) not favouring either; and MUA vs PTSI: 0.12 (95% CI: -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero. ConclusionThe findings from a recent multi-centre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. Hydrodilatation’s effectiveness based on four RCTs was inconclusive and remains an evidence gap. Where does this fit in the literature?•There were few high quality and adequately powered randomised studies that evaluated key treatment choices in the management of patients with primary frozen shoulder.•UK FROST has addressed this and provided the strongest evidence that when compared with each other neither PTSI, MUA nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion.•There is an evidence gap suggesting the need for a rigorously designed and adequately powered RCT to evaluate the comparative effectiveness of hydrodilatation