Fysioterapeuten 1-2022

FYSIOTERAPEUTEN 1/22 45 hed to date have investigated the effects of multiple cor- ticosteroid injections compared to a single corticosteroid injection. This means that the results of these studies can- not be used to infer whether multiple injections are in fact superior to a single injection. Interestingly, among the respondents using multiple injections, none reported that they usually achieve satis- factory results following only a single injection. This lack of perceived satisfactory results following a single corticos- teroid injection is striking, given that this is the treatment strategy that is most commonly investigated in research on corticosteroid injections for frozen shoulder. In contrast, 87.1 % of the respondents reported achieving satisfactory results following 2-3 injections, a treatment strategy that is far less used in research studies. When interpreting these results, it is important to note that the term «satisfactory results» was not explicitly defined. Therefore, it might be variability in what criteria that makes the individual re- spondents perceive a «satisfactory result» following the tre- atment. It is also not known to whom the result is perceived satisfactory, the patient or the clinician. The finding that the majority of the respondents in this sample uses multi- ple corticosteroid injections, a treatment strategy that has not been properly explored in controlled research studies, implicates that further investigation of this intervention could be warranted. Evaluating the efficacy of multiple in- jections was also identified as a research priority in a large systematic review and cost-effectiveness analysis regarding the management of frozen shoulder (2). Regarding objective outcome measures to evaluate treat- ment effect, patient-reported outcome measures (PROMs) regarding pain level using the VAS or NRS were most com- monly used. Less than one in five of the respondents (19.4 %) reported using a functional outcome measure to eva- luate treatment effect, while none reported using a measure of health-related quality of life. Validated functional outco- me measures and measures of health-related quality of life are increasingly encouraged in the care of musculoskeletal conditions (34), and the use of functional outcome measu- res are recommended in clinical practice guidelines when treating patients with frozen shoulder (8-10). The results of this survey demonstrate that the respondents rely on clinical assessment and subjective measures, including the PROMs regarding level of pain, when evaluating treatment effect, with only a small portion of the respondents using functional outcome measures routinely. This finding indi- cates that the majority of the respondents in this sample are not adhering to recommendations in the clinical practice guidelines regarding the evaluation of treatment effect. As there is a limited number of physical therapists pro- viding injection therapy in Norway, the sample of respon- dents is small and might be susceptible to responder bias. However, the respondents are quite uniform regarding several of the important findings, which increases the cre- dibility of the results. Another limitation to this study is not providing information regarding drugs and dosages used by the sample. Although it is the physician that is re- sponsible for prescribing the appropriate drug and dosage, it could be argued that the physical therapists might still influence the physician’s choice. This makes it important for physical therapists to always recommend the lowest ef- ficient dose, as it might decrease side-effects of the treat- ment. Even though providing intra-articular corticosteroid injections for frozen shoulder is supported by current evi- dence (13, 14), other interventions are also recommended in the clinical practice guidelines (8-10). Investigating con- current use of these interventions could provide further in- sight into the physical therapist’s adherence to the clinical practice guidelines. However, evaluating the use of concur- rent interventions was outside the scope of this evaluation. As multiple injections have received little attention compared to the extent they are used in clinical practice when treating frozen shoulder in Norway, this treatment strategy might warrant further investigation in controlled research studies to establish its effectiveness compared to a single corticosteroid injection. Conclusion This study has evaluated the current practice regarding corticosteroid injection therapy for frozen shoulder in a sample of Norwegian physical therapists providing in- jection therapy, and found that the majority of the sam- ple provides multiple ultrasound-guided intra-articular corticosteroid injections. Among the respondents using multiple injections, 87.1 % reported achieving satisfactory results following 2-3 injections, while none reported to usually achieve satisfactory results following only a single injection. The use of functional outcome measures is generally li- mited among the respondents, and interventions should be initiated to implement these measures into routine practice to ensure adherence to clinical practice guidelines. Acknowledgements: The authors would like to thank Martin Moum Hellevik, Anne-Marthe Sanders, Magnus Brekke and Simen Klunderud for valuable feedback and input in the process of writing this manuscript. References 1. Fernandes MR. Correlation between functional disability and quality of life in patients with adhesive capsulitis. Acta ortopedica brasileira 2015; 23: 81- 84. https://www.doi.org/10.1590/1413-78522015230200791  [doi]. 2. Maund E, Craig D, Suekarran S, et al. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health technology assessment (Winchester, England) 2012; 16: 1-264. https://www.doi. org/10.3310/hta16110  [doi]. 3. Lewis J. Frozen shoulder contracture syndrome - Aetiology, diagnosis and management. Manual therapy 2015; 20: 2-9. https://www.doi. org/10.1016/j.math.2014.07.006  [doi]. 4. Reeves B. The natural history of the frozen shoulder syndrome. Scandina- vian journal of rheumatology 1975; 4: 193-196. https://www.doi.org/10.31 09/03009747509165255  [doi]. 5. Wong CK, Levine WN, Deo K, et al. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy 2017; 103: 40-47. S0031- 9406(16)30030-X [pii]. 6. Rangan A, Goodchild L, Gibson J, et al. Frozen Shoulder. Shoulder & elbow 2015; 7: 299-307. https://www.doi.org/10.1177/1758573215601779  [doi]. 7. van den Hout WB, Vermeulen HM, Rozing PM, et al. Impact of adhesive capsulitis and economic evaluation of high-grade and low-grade mobilisation techniques. The Australian journal of physiotherapy 2005; 51: 141-149. S0004-9514(05)70020-9 [pii]. 8. Haldorsen B, Røe Y, Thornes E, et al. Frossen skulder - fysioterapi. Helsebi- blioteket.no 2018. 9. Hanchard N, Goodchild L, Thompson J, et al. Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder v.1.7, “standard” physiotherapy. Endorsed by the Chartered Society of Physiotherapy 2011. 10. Kelley MJ, Shaffer MA, Kuhn JE, et al. Shoulder pain and mobility deficits: adhesive capsulitis. The Journal of orthopaedic and sports physical therapy 2013; 43: A1-31. https://www.doi.org/10.2519/jospt.2013.0302  [doi]. 11. Hanchard NC, Goodchild L, Thompson J, et al. A questionnaire survey