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Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study

PainSci » bibliography » Jewell et al 2009
Tags: treatment, massage, exercise, devices, physical therapy, counter-intuitive, manual therapy, self-treatment

One article on PainSci cites Jewell 2009: Complete Guide to Frozen Shoulder

PainSci commentary on Jewell 2009: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

An interesting study of 2,370 frozen shoulder patients who received physical therapy: rather than a controlled trial of a specific treatment, it was a statistical analysis of the relationship between common treatments and outcomes. The therapists reported the treatments they used in each case, the patients took surveys before and after, and the researchers calculated the relationship between the treatments and the results. They found that improvement was more likely in patients who were mobilized and given exercises to do, but they were less likely to improve if they were given massage, iontophoresis/phonophoresis (methods of “injecting“ medicines through the skin), or ultrasound — which doesn’t mean that no one given those treatments improved, just that fewer did.

Notably, literally no patients at all achieved clinically meaningful improvement by one method of measuring. So they just eliminated those measurements from their analysis, and worked with three other scoring systems that did detect improvements: physical function (PF), bodily pain (BP), and hybrid function (HF) scores.

This data is suggestive and interesting, but it’s a very different sort of data than what a controlled trial produces, and inferior in many ways. For instance, the “massage” provided to these patients was not standardized in any way, and mostly very different from what a patient would receive from a profession massage therapist. We might conclude from this not that “massage” is ineffective, but rather that physical therapy that includes massage is of dubious value, for any number of reasons: maybe physical therapists aren’t very good at massage, or maybe the kind of physical therapists that employ massage tend to favour passive methods that are collectively inferior to prescribing exercise.

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether physical therapy interventions predicted meaningful short-term improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis.

PARTICIPANTS: Data were examined from 2,370 patients (mean age=55.3 years, SD=12.4; 65% female, 35% male) classified into ICD-9 code 726.0 who had completed an episode of outpatient physical therapy.

METHODS: Principal components factor analysis was used to define intervention categories from specific treatments applied during the episode of care. A nested logistic regression model was used to identify intervention categories that predicted a 50% or greater change in Physical Component Summary-12 (PCS-12), physical function (PF), bodily pain (BP), and hybrid function (HF) scores.

RESULTS: None of the patients achieved a 50% or greater improvement in PCS-12 scores. Improvement in BP scores was more likely in patients who received joint mobility interventions (odds ratio=1.35, 95% confidence interval=1.10-1.65). Improvement in HF scores was more likely in patients who received exercise interventions (odds ratio=1.50, 95% confidence interval=1.03-2.17). Use of iontophoresis, phonophoresis, ultrasound, or massage reduced the likelihood of improvement in these 3 outcome measures by 19% to 32%.

LIMITATIONS: The authors relied on clinician-identified ICD-9 coding for the diagnosis. Impairment measures were not available to support the diagnosis, and some interventions were excluded because of infrequent use by participating therapists.

DISCUSSION AND CONCLUSION: These results are consistent with findings from randomized clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which suggests that use of these modalities should be discouraged.

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