Intra-articular distension preceded by physical therapy versus intra-articular distension followed by physical therapy for treating adhesive capsulitis of the shoulder

BACKGROUND: Intra-articular distension is a validated treatment in adhesive capsulitis of the shoulder and is commonly followed by intensive in-patient physical therapy. A recent meta-analysis found that physical therapy is as effective as intraarticular distension (IAD) and that an early distension could be the primary choice for treating frozen shoulder. The question of the additional contribution of physical therapy prior to IAD compared with IAD followed by physical therapy has not been raised. OBJECTIVES: We compared IAD preceded by physical therapy to that followed by physical therapy in terms of pain relief and functional outcome. METHODS: We enrolled patients with primitive adhesive capsulitis of the shoulder. The eligible patients were randomized into three groups: A, B and C. Group A received intra-articular distension followed by physical therapy, group B received intraarticular distension in the middle of physical therapy and group C received physical therapy alone. Patients were assessed at the beginning of the protocol (T0), after 6 weeks (T1) and after 12 weeks (T2). The main outcome measures were pain using a Visual Analog Scale and the Disabilities of Arm, Shoulder and Hand Questionnaire. RESULTS: Out of the 179 enrolled patients, only 122 completed the follow up: group A (n = 34), group B (n = 46) and group C (n = 42). Compared to intra-articular distension preceded by physical therapy, IAD followed by physical therapy did not improve significantly the outcome in terms of pain relief (p = 0.123) but it enhanced the upper extremity function (p = 0.002). Upper extremity pain and function were found to improve with time regardless of the protocol (p < 0.001). CONCLUSIONS: IAD followed by physical therapy is more beneficial than IAD preceded by physical therapy in terms of upper extremity function. IAD, whether or not preceded by physical therapy, does not significantly improve pain compared to physical therapy alone. Time is a crucial factor to take into consideration while treating adhesive capsulitis of the shoulder.