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Shoulder & Elbow2015, Vol. 7(4) 299–307 ! The Author(s) 2015Reprints and permissions:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1758573215601779sel.sagepub.com BESS/BOA Patient Care Pathways Amar Rangan, Lorna Goodchild, Jo Gibson, Peter Brownson,Michael Thomas, Jonathan Rees and Ro Kulkarni of stiffness. End range pain may persist until full Frozen shoulder is an extremely painful and debilitat- Because there tends to be considerable overlap ing condition leading to stiffness and disability. It typ- between the phases, more recent terminology favours ically occurs in the fifth and sixth decades of life, thus classifying the condition into ‘pain predominant' and affecting individuals of working age. The disability ‘stiffness predominant' phases.
resulting from this condition has considerable eco-nomic impact on affected individuals and society.
Shared decision-making Frozen shoulder can be either primary (idiopathic) or The General Medical Council's Good Medical Practice2 secondary. Secondary frozen shoulder is defined as that clearly states in the section on working in partnership associated with trauma; rotator cuff disease and impinge- with patients that doctors should: ment; cardiovascular disease; hemiparesis; or diabetes(although some classify this in diabetics as primary frozen . Listen to patients and respond to their concerns and shoulder). The incidence of frozen shoulder in people with diabetes is reported to be 10% to 36%, and these tend not . Give patients the information they want or need in a to respond as well to treatment as in nondiabetics.1 way they can understand.
. Respect patients' right to reach decisions with the Clinical presentation is typically in three overlapping doctor about their treatment and care.
. Support patients in caring for themselves to improve and maintain their health.
. Phase 1 – lasting 2 months to 9 months. Painful phase, with progressive and increasing pain on This can only be achieved by direct consultation movement. Pain tends to be constant and diagnosis between the patient and their treating clinician.
in the early stages before movement is lost can be Decisions about treatment taken without such direct consultation between patient and treating clinician are . Phase 2 – lasting 4 months to 12 months. Stiffening or freezing, where there is gradual reduction of painbut stiffness persists with considerable restriction inrange of motion. Pain pattern changes from constantto end range pain of reduced intensity.
Corresponding author: . Phase 3 – lasting 12 months to 42 months.
Amar Rangan, The James Cook University Hospital, Marton Road, Resolution or thawing phase, where there is Middlesbrough, TS4 3BW, UK.
improvement in range of motion with resolution at BESS on January 28, 2016 M Shoulder & Elbow 7(4)
not appropriate, as they do not adhere to principles of . To generalize and consider this a self-limiting condi- good medical practice.
tion can be misleading because there is variationacross published reports in the proportion ofpatients who do not regain full shoulder motion,1 Continuity of care possibly a reflection of variation in how outcome Continuity and co-ordination of care are essential parts was assessed. Based on the largest published series of the General Medical Council's Good Medical of patients with mean follow-up of 4.4 years from Practice guidance.2 It is therefore inappropriate for a onset of symptoms, 59% made full recovery, 35% clinician to treat a patient if there is no clear commit- had mild to moderate symptoms, with pain being the ment from that clinician or the healthcare provider to most common complaint, and 6% had severe symp- oversee the complete care pathway of that patient including their diagnosis, treatment, follow-up and although the contralateral shoulder gets affected in adverse event management.
6% to 17% of patients within 5 years.
Frozen shoulder: care pathway Aims of treatment . The prevalence of shoulder complaints in the UK is estimated to be 14%, with 1% to 2% of adults con- The overall treatment aim for the conditions that cause sulting their general practitioner annually regarding frozen shoulder is to ‘improve pain and function'; how- new-onset shoulder pain.3 ever, treatment success needs to be defined individually . Painful shoulders pose a substantial socioeconomic with patients in a shared decision-making process. The burden. Disability of the shoulder can impair ability degree of improvement and level of acceptance to a to work or perform household tasks and can result patient will depend on starting level of symptoms, in time off work.4,5 Shoulder problems account for patient demographics, personal circumstances and 2.4% of all general practitioner consultations in the UK and 4.5 million visits to physicians annually inthe USA.6,7 The annual financial burden of shoulder Pre-primary care (at home) pain management in the USA has been estimated tobe US$3 billion.8 For causes of glenohumeral shoulder pain, there is . Cumulative incidence of frozen shoulder is estimated potential for simple patient self-management strategies at 2.4 per 1000 population per year.9 This condition and prevention strategies at home prior to the need for was first described in 1875 by the French Pathologist a general practitioner consultation, although research Duplay, who named it ‘peri-arthrite scapula-humer- to develop and assess the impact of such strategies ale'. The American surgeon E. A. Codman proposed would be needed.
the name ‘frozen shoulder' in 1934.10 However, thereis an acknowledged absence of a specific definition ofthe condition11,12 and of a diagnostic label12, with Assessment in primary care/community triage additional names for frozen shoulder including retractile capsulitis, adhesive capsulitis, check reinshoulder, contracted shoulder and steroid-sensitive . Diagnosis is based on history and examination . There are different views about the underlying fun- . Making the correct diagnosis is crucial, and will damental process: inflammation, reactive angiogen- ensure an efficient and optimum treatment for the esis and scarring, each involving the shoulder capsule in different stages of the disease.13 The scar- . Features of importance are; ring and capsular contracture reduces joint volume to 3 ml to 4 ml compared to a normal capsular  Occupation and level of activity or sports volume of 10 ml to 15 ml. Histological studies of  Location, radiation and onset of pain the capsule have confirmed significant increase in  Duration of symptoms (see phases of disease in fibroblasts with presence of myofibroblasts. In add- the Definition earlier above) ition, inflammatory cells (mast cells, T cells, B cells  Global reduction in range of motion with a cap- and macrophages) have been identified, suggesting a sular pattern, defined as disproportionately severe process of inflammation leading to scarring.14 loss of passive external rotation in the affected at BESS on January 28, 2016 M Rangan et al.
Figure 1. Diagnosis of shoulder problems in primary care. Guidelines on treatment and referral.
at BESS on January 28, 2016 M Shoulder & Elbow 7(4)
shoulder with arm by the side, over other disease (e.g. night pain). The onset of stiffness may be rapid, and cause significant functional deficit, typ-  History of diabetes, cardiovascular disease or other associations.
Treatment should be tailored to individual patient  Normal X-rays in two planes to rule out needs depending on response and severity of mechanical glenohumeral incongruity such as arthritis, avascular necrosis or dislocation of . Beware of red flags such as tumour, infection, unre- the shoulder, which produce a similar clinical duced dislocation or inflammatory polyarthritis.
. Overall, a step-up approach may be adopted in terms of degree of treatment invasiveness. Somepatients may have particular treatment preferencesbased on their needs and referral to secondary caremay need to be considered early in such circum- Red flags for the shoulder stances. Shared decision-making is particularly Acute severe shoulder pain needs proper and competent important for this condition.
diagnosis. Any shoulder ‘red flags' identified during pri- . A proportion of patients with frozen shoulder will mary care assessment needs urgent secondary care respond to conservative treatment, and the response needs to be monitored. The most frequent indica-tions for invasive treatments are persistent and . A suspected infected joint needs same day urgent severe functional restrictions that are resistant to . An unreduced dislocation needs same day urgent . Symptoms usually of up to 3 months with failure of conservative treatment measures may trigger referral . Suspected malignancy or tumour needs urgent refer- to secondary care for consideration of more invasive ral following the local 2-week cancer referral treatment. Severity of symptoms may necessitate earlier referral; it would not be appropriate to persist . An acute cuff tear as a result of a traumatic event with ineffective treatment measures and delay refer- needs urgent referral and ideally should be seen in ral of patients who experience severe pain and the next available outpatient clinic.
. Suspected inflammatory oligo or poly-arthritis . Shared decision-making is important, and individual patients' needs are different. Failure of initial treat- considered as a ‘rheumatological red flag' and ment to control pain, if degree of stiffness causes local rheumatology referral pathways should be considerable functional compromise, or if there is any doubt about diagnosis, prompt referral to sec-ondary care is indicated.
. Physiotherapy rehabilitation is usually for 6 weeks Treatment in primary care/community triage services unless patients are unable to tolerate the exercises, orphysiotherapists identify a reason for earlier referral . Treatment depends on the phase of the disease, to secondary care. If there is patient improvement in severity of symptoms and degree of restriction of the first 6 weeks of physiotherapy, then a further work, domestic and leisure activities. The aims of 6 weeks of therapy is justified.
. Treatment timelines should include primary care and intermediate care time. Intermediate care should not  Improving range of motion delay appropriate referral to secondary care.
 Reducing duration of symptoms Return to normal activities . Following interventions are suitable for primary care: Analgesics/nonsteroidal anti-inflammatory drugs . In a UK study of patterns of referral of shoulder conditions, 22% of patients were referred to second-  Corticosteroid injection ary care up to 3 years following initial presentation,  Domestic exercise programme although most referrals occurred within 3 months.16  Supervised physiotherapy/manual therapy There is little evidence available on referral patterns for frozen shoulder specifically.
where the pain is often severe, mimicking malignant . Confirm diagnosis with history and examination.
at BESS on January 28, 2016 M Rangan et al.
. Obtain imaging with plain radiographs to rule out  Both procedures are typically performed as mechanical glenohumeral incongruence such as arth- day care or 23-hour admission (depending on the ritis, avascular necrosis or dislocation.
time of the day the procedure takes place), unless . Counsel patient fully regarding operative and non- clinical or social circumstances dictate otherwise.
operative options.
. Ensure multidisciplinary approach to care with prompt start of physiotherapy and pain relief as availability of specialist shoulder physiotherapists and shoulder surgeons.
 Physiotherapy services vary across the country, although up to 12 weeks of physiotherapy are The most commonly used secondary care interven- typically required to maintain range of motion in the treated shoulder.
 Up to three outpatient follow-up appointments  Manipulation under anaesthesia (MUA) may be needed, depending on progress.
 Arthroscopic capsular release (ACR) Distension arthrogram (DA) or hydrodilatation Physiotherapy and corticosteroid injection, usually to supplement any of the above interventions Current interventions . If symptoms fail to resolve with conservative treat- ment, then MUA, DA or ACR may be considered.
. BESS has led a survey of health professionals to This choice depends mainly on expertise and clin- determine treatment pathways in current use in the ician preference.
UK, aiming to inform design of future studies of . MUA is performed under general anaesthesia where effectiveness of interventions for frozen shoulder.
the arm is manipulated to ‘tear' the contractedshoulder capsule in a controlled fashion, thus restor- MUA for frozen shoulder ing external rotation and other movements. This issupplemented with corticosteroid injection for pain . Diagnosis codes M750.
relief and with physiotherapy to maintain range of . Procedure codes (OPCS 4.5) W919, Z814.
motion post MUA.
. ACR involves arthroscopic surgery under general anaesthesia. The contracted capsule is released in acontrolled fashion using arthroscopic instruments, . Diagnosis codes M750.
frequently with radiofrequency ablation. The most . Procedure codes (OPCS 4.5) W784, Y767, Z814.
prominent contracture occurs anteriorly and releaseof this improves external rotation. The inferior cap-sule may be released with arthroscopic instruments, or with a controlled MUA.
. DA is a procedure where the shoulder capsule is . Length of stay – day case (23 hours) and overnight.
injected with saline and local anaesthetic under pres- . Re-admission rate within 90 days.
sure to distend and disrupt the capsule. This proced- . Patient-reported outcome measure (PROM) pre- ure is usually performed by an interventional procedure, and 12 months post-procedure.
radiologist, and does not require general anaesthe- . Infection/other adverse events.
sia. It is performed under fluoroscopy or ultrasoundguidance and a radio-opaque dye may be used toconfirm accuracy of placement of the injected fluid.
Research and audit Both DA and ACR are supplemented with post-procedural physiotherapy to maintain range of . In partnership with Centre for Reviews and motion in the affected shoulder.
Dissemination in York, BESS members were com- . It would be expected that surgical units performing missioned to conduct an evidence synthesis on frozen shoulder by the National Institute for Health Research Health Technology Assessment operative assessment to ensure fitness for surgery and to confirm discharge planning.
‘Management of frozen shoulder: a systematic surgery or MUA in appropriately review and cost-effectiveness analysis' has now been resourced and staffed units.
published, and forms a key reference document that at BESS on January 28, 2016 M Shoulder & Elbow 7(4)
summarises current evidence, and areas for future interventions from available primary research is also research on this topic.17 included in this report.
. A recent survey of health professionals in the UK has found that the professional groups (general practi- tioners, general practitioner with a special interest,physiotherapists, orthopaedic surgeons) had different It is important to note that evidence to support the views on the most appropriate treatment pathway for effectiveness of conservative treatment, surgical treat- the frozen shoulder.18. There was, however, consensus ment or the potential benefit of one over the other that treatment should depend on phase of the disease remains limited. Until such evidence becomes available, and a step-up approach would be appropriate.
clinical and shared decision-making on accessing avail- . In addition, a scoping review identified that most able interventions based on level of symptoms and previous reviews have concentrated on one particu- functional restriction is recommended.
lar intervention and there is general paucity of goodprimary research on frozen shoulder.19 . Corticosteroid injection. Based on best available evi- . Members of BESS involved in the above evidence dence, corticosteroid injection has mainly short-term syntheses are currently designing an interventional benefit with a single injection. There appears to be trial for frozen shoulder investigating commonly used interventions for management in secondary promptly following steroid injection compared to home exercise alone and physiotherapy alone.20–23 . A validated clinical score, preferably a PROM, There is insufficient evidence to conclude with rea- should be used pre-operatively and following sonable certainty in what clinical situations steroid injection, with or without physiotherapy, is most . Acceptable scores include the Shoulder Pain and likely to be effective for treatment of frozen shoulder.
Disability Index (SPADI), Disability of Arm, . Sodium hyaluronate injection. A small number of Shoulder and Hand (DASH) and the Oxford diverse studies, all of which may have a high risk Shoulder Score (OSS). The disability subscale of of bias, provide insufficient evidence to make conclu- the SPADI has been used by several published sions about effectiveness of sodium hyaluronate in reports for this condition. Other measures such as the treatment of frozen shoulder.24–26 EQ 5D may be used for economic analysis.
. Physiotherapy/physical therapy. Primary studies . Scores should be captured pre-operatively and 1 year comparing different types of physiotherapy/physical following intervention, which allows longitudinal therapies support the use of various techniques to analysis to determine sustenance of treatment effect provide short- to medium-term benefit. Some inter- and consequences of any treatment-related adverse ventions in current use that were investigated include therapeutic ultrasound,27 end range mobilization,28short-wave diathermy plus stretching29 and high-grade mobilization therapy.30 These interventions should be stage of disease and response-dependent.
Based on best available evidence, there may be bene- . Patient and public information – ensure all available fit from short-wave diathermy plus stretching and information is provided regarding the benefits and high-grade mobilization techniques in patients who risks of all treatment options have already had physiotherapy or a steroid injec- . Clinician information – ensure access to available tion. There is insufficient evidence to make conclu- sions on best mode of physiotherapy for frozenshoulder . Acupuncture. The role of acupuncture in treatment Evidence for effectiveness and cost of frozen shoulder is not clear. Available evidencedoes not demonstrate clear benefit.
effectiveness of treatment NIHR-HTA commissioned evidence synthesis has ledto publication of report titled ‘Management of frozen Oral drug treatment shoulder: a systematic review and cost-effectiveness ana-lysis'.17 This report provides full details of method- Likely to be beneficial ology, search strategy, economic analysis, decisionmodel, and suggestions for future research. An analysis . NSAIDS (oral) reduce pain in people with acute at BESS on January 28, 2016 M Rangan et al.
Unknown effectiveness Additional evidence regarding the effec-tiveness of surgery . Evidence to support MUA remains limited. Most published studies have limitations. Their diversenature makes comparison of studies or pooling ofdata difficult. Studies are generally underpowered Topical drug treatment and have a potential risk of bias.
Unknown effectiveness . A single study of adequate quality reported no stat- istically significant difference between MUA (and . NSAIDs (topical).
home exercise) and home exercise alone in pain,function, range of motion or working ability at 6weeks, as well as at 3 months,6 months and 12months.34 . Two studies comparing MUA with capsular disten- Likely to be beneficial sion had mixed findings. One found no significantdifference between MUA and distension in pain or . Intra-articular corticosteroid.
function at 16 weeks.35 The second study found asignificantly greater improvement in pain, function Unknown effectiveness and disability at 6 months with distension than withMUA.36 . Hyaluroinc acid injections.
. ACR is a relatively new intervention that is increas- ingly performed for treatment of frozen shoulder.
The evidence to support this is limited, with onlytwo case series of over 50 patients reported to date, Nondrug treatment which support the use of ACR. Further research Likely to be beneficial with well designed prospective randomised clinicaltrials will be required to determine the true effective- . Short-wave diathermy and stretching.
ness of this intervention.
. Physiotherapy (manual treatment, exercises).
. The two reported case series of 6637 and 18338 patients found significant improvement in mean Unknown effectiveness external rotation from 3 to 39 and in mean abduc-tion from 34 to 154. There were also significant . Acupuncture.
improvements in pain, function and disability post- . Electrical stimulation.
operatively compared to the pre-operative status atmean follow-up of 10 months and 29 months.37,38 . Open capsular release is rarely performed in contem- porary practice for primary frozen shoulder. The evi- Distension arthrogram dence for this intervention is very poor.
. There are currently no comparative studies involving . Limited evidence of potential benefit of capsular arthroscopic capsular release. In the absence of a distension over steroid injection and placebo.
comparator, the true effectiveness of this interven- Better improvements in pain and range of motion tion is yet to be established.
are reported at 6 weeks and 12 weeks with distension . There is current lack of studies providing data on compared to steroid or placebo.31–33 health-related quality of life specific to frozen shoul-der populations. This information is required toenable assessments of cost-utility to be undertaken.
The inclusion of preference based quality of life measures alongside clinical trials in frozen shoulder Likely to be beneficial populations is a necessity. Cost-effectiveness analysisof any of the interventions for frozen shoulder is therefore not feasible with currently available at BESS on January 28, 2016 M Shoulder & Elbow 7(4)
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at BESS on January 28, 2016 Shoulder & Elbow0(0) 1 ! The Author(s) 2015Reprints and permissions:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1758573215622719sel.sagepub.com The author list is incorrect in the following article ‘BESS/BOA Patient Care Pathways Frozen Shoulder'Shoulder&Elbow 2015; 7: 299–307. DOI: 10.1177/1758573215601779.
The correct author list is as follows:Amar Rangan, Jo Gibson, Peter Brownson, Michael Thomas, Jonathan Rees and Ro Kulkarni

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