Summary of findings 4. Combination of manual therapy, exercise, electrotherapy and glucocorticoid injection compared with glucocorticoid injection for adhesive capsulitis (frozen shoulder).
| Combination of manual therapy, exercise, electrotherapy and glucocorticoid injection compared with glucocorticoid injection for adhesive capsulitis (frozen shoulder) | ||||||
| Patient or population: patients with adhesive capsulitis (frozen shoulder) Settings: outpatient rheumatology clinic and general practices in high‐income countries Intervention: manual therapy plus exercise plus electrotherapy for four weeks plus glucocorticoid injection Comparison: glucocorticoid injection | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect (95% CI) | No. of participants (studies) | Quality of the evidence (GRADE) | Comments | |
| Assumed risk | Corresponding risk | |||||
| Glucocorticoid injection | Manual therapy plus exercise plus electrotherapy plus glucocorticoid injection | |||||
| Participant‐reported pain relief ≥ 30% | See comment | See comment | Not estimable | ‐ | See comment | No studies reported this outcome |
| Overall pain (change from baseline) Shoulder Pain and Disability Questionnaire (SPADI, 0‐100) (lower scores = less pain)a Follow‐up: mean 6 weeks | Mean overall pain (change from baseline) in the control groups was 39.1b | Mean overall pain (change from baseline) in the intervention groups was 5.76 lower (13.86 lower‐2.34 higher)c | 86 (2 studies) | ⊕⊕⊝⊝ lowd,e | Absolute risk difference 6% (14% fewer to 2% more);
relative percentage change 8% (20% fewer to 3% more) NNTB not applicable SMD ‐0.32 (‐0.77 to 0.13) |
|
| Function (change from baseline) Shoulder Pain and Disability Questionnaire (SPADI, 0‐100) (lower scores = better function)f Follow‐up: mean 6 weeks | Mean function (change from baseline) in the control groups was 34.2g | Mean function (change from baseline) in the intervention groups was 6.51 lower (14.88 lower‐1.86 higher)h | 86 (2 studies) | ⊕⊕⊝⊝ lowd,e | Absolute risk difference 7% (15% fewer to 2% more);
relative percentage change 10% (24% fewer to 3% more) NNTB not applicable SMD ‐0.35 (‐0.80 to 0.10) |
|
| Global assessment of treatment success | See comment | See comment | Not estimable | ‐ | See comment | No studies reported this outcome |
| Active shoulder abduction | See comment | See comment | Not estimable | ‐ | See comment | No studies reported this outcome |
|
Quality of life (change from baseline) SF‐36 Physical Component Score (0‐100) (lower scores = worse quality of life) Follow‐up: 6 weeks |
Mean quality of life (change from baseline) in the control group was 4.4 |
Mean quality of life (change from baseline) in the intervention group was 2 higher (3.27 lower‐7.27 higher) |
44 (1 study) |
⊕⊕⊝⊝ lowi,j | Absolute risk difference 2% (3% fewer to 7% more);
relative percentage change 5% (9% fewer to 19% more) NNTB not applicable |
|
| Adverse events | See comment | See comment | Not estimable | ‐ | See comment | No studies reported this outcome |
| *The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; NNTB: number needed to treat for an additional beneficial outcome; SF: Short Form; SMD: standardised mean difference; SPADI: Shoulder Pain and Disability Index. | ||||||
| GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. | ||||||
aPain measured using the SPADI in Carette 2003 and daytime rest pain (VAS 0‐100) in Ryans 2005. Results analysed using SMDs and back‐transformed to 0‐100 SPADI scale units. bGlucocorticoid injection group mean reported in Carette 2003 used as the assumed control group risk. cTo convert SMDs in the Carette 2003 and Ryans 2005 meta‐analyses of overall pain scores, the pooled baseline SD in Carette 2003 (SD = 18) was multiplied by the SMDs and the 95% CIs to convert values to a 100‐point SPADI pain score. dParticipants were not blinded in either trial, and risk of attrition bias was high in 1 trial (Ryans 2005). e95% CIs relatively wide, incorporating (1) a minimal clinically important difference favouring combined intervention, (2) no difference between groups and (3) a clinically insignificant difference favouring glucocorticoid injection alone as possible estimates of effect. fFunction measured using the SPADI in Carette 2003 and using the Croft Shoulder Disability Questionnaire in Ryans 2005. Results analysed using SMDs and back‐transformed to 0‐100 SPADI scale units.
gGlucocorticoid injection group mean reported in Carette 2003 used as the assumed control group risk.
hTo convert SMDs in the Carette 2003 and Ryans 2005 meta‐analyses of function scores, the pooled baseline SD in Carette 2003 (SD = 18.6) was multiplied by the SMDs and the 95% CIs to convert values to a 100‐point SPADI disability score.
iParticipants not blinded.
j95% CIs relatively wide, incorporating (1) a clinically insignificant difference favouring combined intervention, (2) no difference between groups and (3) a clinically insignificant difference favouring glucocorticoid injection as possible estimates of effect.