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Introduction: Frozen shoulder which is a common condition which is characterized by painful limitation of active and passive range of motion. 2%-5% of general population are affected with this condition. Usually incidence is higher in females than males with age between 40 and 65 years. Main stay of treatment is symptomatic pain relief and followed by regaining normal range of movements. Aim: The purpose of the study is to evaluate effect of manipulation under anaesthesia of Frozen shoulder, objectives are to improve range of motion and pain and early return of individual to perform his daily activities of living. Material and methods: This is a prospective study, for a period of 15 months, carried out in 42 patients posted for manipulation under anaesthesia for Frozen shoulder. For evaluation of outcome we used VAS (Visual analog scale) for pain scoring, American Shoulder and Elbow surgeons Score (ASES) for evaluation of improvement in activities of daily living, Range of movements. Results: In the 42 patients analyzed, females were dominantly affected with 71.42% compared to males 28.57%. Of all 42 shoulders, dominant hand was more involved with 57.14%. Overall 40 patients achieved significant reduction of pain immediately after procedure and ASES score was improved from preoperatively 24.32 ± 9.36 to 88.52 ± 7.92 at 6 months after the procedure. There was significant improvement in range of movements.Conclusion: Frozen Shoulder treated with manipulation under anaesthesia followed by physiotherapy, results in good pain relief and also leading to good functional recovery, helps the patient for their early return to daily activities of living. |
Frozen shoulder is a most common condition, characterized by painful and limited both active and passive range of motion. It affects 2.5% of population(1,2,3,4) . More commonly it affectes the population with diabetes with poor glycemic control. Prevalence is more common in women than in men(5) . The term Frozen shoulder was first used by codman in 1934(6) .
He described the common feautures of slow onset of pain which is felt near the insertion of deltoid, difficulty in sleeping on affected side, and restriction of both active and passive range of motion with normal radiological appearance. Nature of Frozen of shoulder can be proliferative, fibroblastic and inflammatory(7) .
Medical therapy, physical therapy, universal shoulder mobilization exercises, manipulation under anaesthesia are various treatment for Frozen shoulder. Surgical treatment is used when conservative treatment fails for a period of three to six months. Main aim of treatment is to reduce discomfort of patient, early recovery and to regain range of motion.
The purpose of study is to evaluate effect of manipulation under anaesthesia of Frozen shoulder, objectives are to reduce pain and to improve range of movement and early return of individual to perform his daily activities of living.
Patients with Frozen shoulder who were admitted in a teritiary care hospital in orthopaedic department for manipulation underanaesthesia were included in this prospective study. Study duration is about 15 months with a sample size of 42 patients. Preoperatively, patients were examined clinically and radiologically. Informed consent and institutional ethical committee approval was taken.
INCLUSIVE CRITERIA:
Patients with restricted range of motion for >1 month and patients who underwent >1 month of conservative therapy and have no improvement were included in study.
EXCLUSIVE CRITERIA:
Patients with previous history of surgery or fracture dislocation and patients who have glenohumeral arthritis are excluded from study.
STATISTICAL ANALYSIS:
Statistical analysis was done by using software SPSS version 25. P value <0.05 was considered to be statistically significant.
PROCEDURE:
After clinical and radiological assessment of patients, Informed consent was taken from the patient after explaining the procedure and its complications. Preoperative Shoulder range of movements, VAS and ASES score was estimated. For this procedure we have given 40 mg/ml methylprednisolone intra articularly and manipulation was done in accordance with codmans paradox. After the procedure patients were started with physiotherapy and active shoulder mobilization exercises on same day. On 1st day after procedure range of movements were estimated and patients were regularly followed as OPD patients and at the end of 3rd month and 6th month VAS, ASES, Range of movements were estimated.
This study includes 42 patients, among them 30 (71.42%) were females and 12 (28.57%) were males. Of all 42 subjects 24 (57.14%) had right shoulder involvement and 18 (42.85%) had left shoulder involvement. Out of 42, 40 (95.23%) achieved significant reduction of pain immediately after procedure. VAS score was improved from 8.33 ± 1.62 to 0.33 ± 0.99 at the end of 6 months.
There was significant improvement in all range of movements following manipulation. Flexion was improved from 33.57 ± 9.930 to 148.80 ± 12.560 at final followup of 6 months. Abduction was improved from 32.24 ± 7.340 to 147.61 ± 18.100 at finalfollowup of 6 months and Externalrotation was improved from 19.04 ± 3.390 to 71.42 ± 4.770 at final followup of 6 months. Internal rotation was improved from 19.09 ± 5.750 to 67.61 ± 5.920 at final followup of 6 months .
ASES score was improved from 24.32± 9.36 to 73.99± 9.72 at 3rd month and it was improved significantly to 88.52± 7.92 at 6th month. There was good improvement in overall parameters and patients returned to their daily activities of living very early. In this study we have not encountered any intraoperative complications. All the subjects received physiotherapy immediately after procedure and physiotherapy was continued.
TABLE :1IMPROVEMENT IN VAS SCORE BEFORE AND AFTER PROCEDURE.
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VAS SCORING |
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Before procedure |
8.33 ± 1.62 |
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After procedure at 6 months |
0.33 ± 0.99 |
Frozen shoulder is a commonly treated musculoskeletal problem. Treatment of this condition alters with progression of disease, during initial phase, pain reduction and maintaining range of motion is mainstay of treatment (8). Pollock et al.(9) reported satisfactory results in 25 out of 30 patients who underwent manipulation under anaesthesia for Frozen shoulder.
Andersen et al.(10) reported good results with manipulation under anaesthesia. Dedenhoff et al.(11) reported significant improvement in shoulder functioning and early return to activities after manipulation under anaesthesia. We, in this study have evaluated improvement in pain using VAS score, which was improved significantly in all the patients.
We also evaluated improvement in daily activities of living before and after manipulation using ASES score , ASES scores were significantly improved in all the patients. 38 of 42 patients returned to their daily activities very earlier and also we noticed significant improvement in range of motion after manipulation under anaesthesia followed by strict physiotherapy protocol.
Brich et al(12) reported brachial plexus palsy after manipulation and few other reported fracture of proximal humerus, shoulder dislocation, rotator cuff injury during procedure. We in our study have not encountered any such complications.
Manipulation under anaesthesia followed by strict physiotherapy protocol results in good functional recovery in Frozen shoulder pa tients. This a lso helps the pa tients to return to their work a t ea rlier period. With this study , we a dvise prolonged physiotherapy with shoulder mobilization exercises prevents recurrence of symptoms and results in reduction in pain and considerable increase in ASES scores and Range of movement.
Acknowledgements: Nil
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