A questionnaire survey of UK physiotherapists on the diagnosis and management of contracted (frozen) shoulder

Abstract

Objective: To gain insights into the diagnosis and management of contracted (frozen) shoulder (CFS) in a sample of UK physiotherapists, underpinning the development of evidence-based clinical guidelines.

Methods: An anonymous online questionnaire was developed and distributed via iCSP, targeting physiotherapists who treat CFS. For treatments, respondents were invited to consider 'pain-predominant' and 'stiffness-predominant' scenarios, choose from listed treatment options, and specify any unlisted conservative options they might consider. Frequency analysis was used for closed-ended questions, and content analysis was used for open-ended questions.

Results: In total, 289 valid responses were received. All respondents thought that movement restriction informed diagnosis. Of those specifying the manner of testing movements, 98% (121/123) included passive testing. Of those describing specific patterns of restriction, 71% (93/131) emphasised external rotation. Fifty-four percent (152/282) of valid respondents would consider suggesting/requesting imaging investigations, usually to exclude bony abnormalities. For treatment, only 46 respondents reported considering any unlisted conservative options, usually liaison regarding medication. For pain-predominant CFS, the preferred physiotherapeutic options were advice/education (96%; 277/288), injection (80%; 230/288), gentle exercise (79%; 228/288), superficial heat/cold (69%; 199/288) and acupuncture (68%; 196/288). For stiffness-predominant CFS, the preferred options were stretching (93%; 268/288), advice/education (88%; 252/288), joint mobilisations (87%; 250/288), function-based exercises (75%; 216/288) and hands-on soft-tissue techniques (59%; 170/288). Some dissociation was noted between clinical practice and research evidence. Eighty-five percent (253/284) of respondents would consider referring for an orthopaedic opinion.

Conclusions: Acknowledging restricted passive external rotation (vs the capsular pattern) as diagnostic of CFS would standardise and might improve the clinical aspect of diagnosis. The value of X-rays in differential diagnosis was under-recognised. Modalities used to treat CFS were dichotomised by pain-predominant and stiffness-predominant classifications, which may be more useful than existing classifications.