手法治疗肩周炎有效性和安全性的Meta分析

doi:10.12114/j.issn.1007-9572.2023.0357

中国全科医学 ›› 2024, Vol. 27 ›› Issue (05): 628-636.DOI: 10.12114/j.issn.1007-9572.2023.0357

• 论著·医学循证 • 上一篇

手法治疗肩周炎有效性和安全性的Meta分析

方仪德¹, 胡浩¹, 许金海¹^,², 丁兴¹, 马青山¹, 张亚运¹, 王燕妮¹, 莫文¹^,²^,^*()

1．200032　上海市，上海中医药大学附属龙华医院骨伤科
2．200032　上海市，上海中医药大学脊柱病研究所

收稿日期:2023-05-06 修回日期:2023-08-17 出版日期:2024-02-15 发布日期:2023-11-21
通讯作者: 莫文
方仪德和胡浩为共同第一作者

作者贡献：方仪德、胡浩进行文章的构思与设计；方仪德进行论文撰写；胡浩负责文献表格整理、RevMan软件绘图；丁兴、马青山、张亚运、王燕妮进行文献收集及筛查；许金海、莫文对文章整体进行管理监督及审校。
基金资助:
国家中医药管理局中医药特色技术筛选评价和传承应用项目(GZY-KJS-2020-083)

Efficacy and Safety of Manipulative Therapy for Frozen Shoulder: a Meta-analysis

FANG Yide¹, HU Hao¹, XU Jinhai¹^,², DING Xing¹, MA Qingshan¹, ZHANG Yayun¹, WANG Yanni¹, MO Wen¹^,²^,^*()

1. Department of Orthopedics and Traumatology, Longhua Hospital Affiliated to Shanghai University of Chinese Medicine, Shanghai 200032, China
2. Research Institute of Spine Diseases, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China

Received:2023-05-06 Revised:2023-08-17 Published:2024-02-15 Online:2023-11-21
Contact: MO Wen
About author:
FANG Yide and HU Hao are co-first authors

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摘要/Abstract

摘要： 背景近年出现较多特色手法治疗肩周炎的随机对照试验（RCT），但缺乏新的关于手法治疗肩周炎有效性和安全性的系统评价。目的通过Meta分析方法评价手法治疗肩周炎的有效性和安全性，通过亚组分析了解包含"摇法"的手法是否较未包含"摇法"的手法效果更优。方法计算机检索PubMed、Cochrane Library、Embase、Medline、中国知网（包括中国硕博士学位论文全文数据库、中国优秀硕士学位论文全文数据库）、中国生物医学文献数据库、万方数据知识服务平台中有关手法治疗肩周炎有效性和安全性的RCT，试验组干预措施为手法，对照组干预措施为非药物疗法，检索时间为建库至2023-03-01。由2名研究人员提取资料，并进行质量评价。采用Revman 5.3软件进行Meta分析。结果最终共纳入12篇文献，893例肩周炎患者，其中试验组451例，对照组442例。Meta分析结果显示，视觉模拟疼痛量表（VAS）：手法治疗改善VAS程度优于物理治疗、针灸治疗、常规治疗（SMD=1.09，95%CI=0.81~1.37，P<0.000 01；SMD=1.05，95%CI=0.31~1.79，P=0.006；SMD=0.96，95%CI=0.67~1.26，P<0.000 01）；手法对照物理治疗的亚组分析结果显示，含"摇法"手法与未含"摇法"手法的效果差异显著（Z=4.39，P=0.04）。Constant-Murley（C-M）评分：手法治疗改善C-M评分程度优于物理治疗组（MD=2.79，95%CI=2.27~3.32，P<0.000 01）。关节活动度：手法治疗改善被动前屈、被动外展、被动外旋程度优于物理治疗（SMD=1.40，95%CI=0.10~2.70，P=0.03；SMD=1.45，95%CI=0.18~2.71，P=0.02；SMD=1.77，95%CI=0.18~3.36，P=0.03）。亚组分析结果显示，在改善被动前屈和被动外展方面，含"摇法"手法与未含"摇法"手法的效果存在显著差异（Z=7.34，P=0.007；Z=2.25，P=0.03）。总体有效率：手法治疗总体有效率高于物理治疗（RR=1.16，95%CI=1.02~1.32，P=0.03）；手法治疗和针灸治疗总体有效率比较，差异无统计学意义（RR=1.24，95%CI=1.00~1.54，P=0.05）。治愈率：手法治疗治愈率优于物理治疗和针灸治疗（RR=3.71，95%CI=1.29~10.67，P=0.01；RR=1.79，95%CI=1.09~2.94，P=0.02）。Egger's检验和Begger's检验提示无显著的发表偏倚（P=0.66、0.66）。手法操作导致的骨折、其他创伤等案例在纳入研究中均未见报道。结论现有文献证据表明手法治疗能有效降低肩周炎患者疼痛、肩关节功能障碍，提高患者肩关节活动度、总体有效率、治愈率，含有"摇法"的手法在VAS改善、被动前屈、被动外展方面能进一步提高疗效，总体手法安全性较高，但仍需更多大样本，高质量的RCT进一步证实。

关键词: 肩周炎, 滑囊炎, 手法, 摇法, 随机对照试验, Meta分析

Abstract:

Background

In recent years, there have been many randomized controlled trials (RCTs) featuring manipulation for frozen shoulder, but there is a lack of new systematic reviews on the efficacy and safety of manipulation for frozen shoulder.

Objective

To evaluate the efficacy and safety of manipulation in the treatment of frozen shoulder by Meta-analysis, and understand whether "rotation shoulder joint" could affect the effect of manipulative therapy by subgroup.

Methods

PubMed, Cochrane Library, Embase, Medline, CNKI, China Biomedical Literature Database, Wanfang Data were searched for RCTs on the efficacy and safety of manipulative therapy for frozen shoulder, with manipulative therapy as the intervention of experimental group and non-pharmacological therapy as the intervention of control group from inception to 2023-03-01. Two investigators extracted data and evaluated the quality. Meta-analysis was performed using Revman 5.3 software.

Results

A total of 12 RCTs were included in this Meta-analysis, with a total of 893 patients with frozen shoulder, including 451 patients in the experimental group and 442 cases in the control group. Results of Meta-analysis showed that the improvement of VAS by manipulative therapy was better than physical therapy, acupuncture therapy and conventional therapy (SMD=1.09, 95%CI=0.81-1.37, P<0.000 01; SMD=1.05, 95%CI=0.31-1.79, P=0.006; SMD=0.96, 95%CI=0.67-1.26, P<0.000 01) ; subgroup analysis of manipulative therapy compared with physical therapy showed a significant difference in effect between those with and without "rotation shoulder joint" (Z=4.39, P=0.04). The improvement of Constant-Murley score in manipulative therapy was better than that in physical therapy (MD=2.79, 95%CI=2.27-3.32, Z=10.41, P<0.000 1). The improvements of passive flexion (SMD=1.40, 95%CI=0.10-2.70, P=0.03), passive abduction (SMD=1.45, 95%CI =0.18-2.71, P=0.02) and passive external rotation (SMD=1.77, 95%CI=0.18-3.36, P=0.03) by manipulative therapy were better than those in the physical therapy group; subgroup analysis showed a significant difference between the effects of the manipulative therapy with and without "rotation shoulder joint" in improving passive flexion and passive abduction (Z=7.34, P=0.007; Z=2.25, P=0.03). The overall effective rate of manipulative therapy was higher than that of physical therapy (RR=1.16, 95%CI=1.02-1.32, P=0.03) ; there was no statistically significant difference in the overall effective rate between the manipulative therapy and acupuncture therapy (RR=1.24, 95%CI=1.00-1.54, P=0.05). The cure rate of manipulative therapy was better than that of physical therapy group (RR=3.71, 95%CI=1.29-10.67, P=0.01) and acupuncture group (RR=1.79, 95%CI=1.09-2.94, P=0.02). Egger's test and Begger's test suggested no significant publication bias (P=0.66, 0.66). Cases of fractures and other traumas caused by manipulative therapy were not reported in the included studies.

Conclusion

The existing literature evidence shows that manipulation can effectively reduce the pain and shoulder joint dysfunction in patients with frozen shoulder, improve the mobility of shoulder joint, overall effective rate and the cure rate of patients, the manipulative therapy with "rotation shoulder joint" can further improve the efficacy in terms of VAS improvement, passive flexion and passive abduction, the overall safety of manipulative therapy is relatively high, but more large samples and high-quality RCTs are still needed to further confirm the results.

Key words: Frozen shoulder, Bursitis, Manipulation, Shoulder rotation, Randomized controlled trial, Meta-analysis

方仪德,胡浩,许金海,等. 手法治疗肩周炎有效性和安全性的Meta分析[J]. 中国全科医学, 2024, 27(05): 628-636. DOI: 10.12114/j.issn.1007-9572.2023.0357.
FANG Yide,HU Hao,XU Jinhai, et al. Efficacy and Safety of Manipulative Therapy for Frozen Shoulder: a Meta-analysis[J]. Chinese General Practice, 2024, 27(05): 628-636. DOI: 10.12114/j.issn.1007-9572.2023.0357.

图/表 17

图1 文献筛选流程

Figure 1 Flow chart of literature screening

表1 纳入文献的基本特征

Table 1 Basic characteristics of the included literature

第一作者	发表时间（年）	地区	样本量（T/C）	干预措施（T/C）	摇法	疗程	结局指标
雷培政^[9]	2013	中国	60/60	手法/针灸	无	56 d，4次/d	VAS、总体有效率、肩关节功能评分
郭张海^[10]	2019	中国	58/57	手法/针灸	有	30 d，隔日1次	VAS、总体有效率
李忠龙^[11]	2016	中国	30/30	手法/针灸	有	3周，1次/d	VAS、总体有效率
ZHANG^[12]	2016	中国	38/38	手法/针灸	有	10 d，1次/d	VAS、总体有效率、肩部功能评分
王建民^[13]	2022	中国	29/28	手法/物理治疗	有	6周，3次/周	VAS、总体有效率、C-M评分
叶斌^[14]	2014	中国	35/35	手法/物理治疗	有	2周，3次/周	VAS、肩关节功能评分
刘辉辉^[15]	2013	中国	30/30	手法/物理治疗	有	20 d，1次/d	疼痛评分、总体有效率、肩关节功能指数
郑朱喜^[16]	2007	中国	35/35	手法/物理治疗	无	28 d，1次/d	VAS、总体有效率、肩关节功能评分
SRIVASTAVA^[17]	2021	印度	17/17	手法/物理治疗	有	2周，3次/周	VAS、SPADI、肩关节角度
GUTIÉRREZ ESPINOZA^[18]	2015	智利	29/28	手法/物理治疗	有	10次，2~3次/周	VAS、C-M评分、肩关节角度
GULER-UYSAL^[19]	2004	土耳其	19/13	手法/物理治疗	无	2周，3次/周	VAS、肩关节角度
徐玉德^[20]	2015	中国	60/60	手法/关节腔注射	有	3周，1次/d	VAS、总体有效率、肩部角度、C-M评分

图2 纳入文献的发表偏倚风险分析注："+"为达标，"？"为不清楚，"-"为未达标。

Figure 2 Risk of publication bias analysis of the included literature

图3 纳入文献的发表偏倚风险汇总

Figure 3 Risk of publication bias summary of the included literature

图4 手法对照物理治疗后肩周炎患者VAS比较的森林图

Figure 4 Forest plot comparing VAS in patients with frozen shoulder after manipulative therapy compared to physical therapy

图5 手法对照针灸治疗后肩周炎患者VAS比较的森林图

Figure 5 Forest plot comparing VAS in patients with frozen shoulder after manipulative therapy compared to acupuncture therapy

图6 手法对照常规治疗后肩周炎患者VAS比较的森林图

Figure 6 Forest plot comparing VAS in patients with frozen shoulder after manipulative therapy compared to conventional therapy

图7 手法对照物理治疗后肩周炎患者C-M评分比较的森林图

Figure 7 Forest plot comparing C-M scores in patients with frozen shoulder after manipulative therapy compared to physical therapy

图8 手法对照物理治疗后肩周炎患者被动前屈活动度改善比较的森林图

Figure 8 Forest plot comparing improvement of passive forward flexion in patients with frozen shoulder after manipulative therapy compared to physical therapy

图9 手法对照物理治疗后肩周炎患者被动外展活动度改善比较的森林图

Figure 9 Forest plot comparing improvement of passive abduction in patients with frozen shoulder after manipulative therapy compared to physical therapy

图10 手法对照物理治疗后肩周炎患者被动外旋活动度改善比较的森林图

Figure 10 Forest plot comparing improvement of passive external rotation in patients with frozen shoulder after manipulative therapy compared to physical therapy

图11 手法对照物理治疗后肩周炎患者总体有效率比较的森林图

Figure 11 Forest plot comparing overall effective rate in patients with frozen shoulder after manipulative therapy compared to physical therapy

图12 手法对照针灸治疗后肩周炎患者总体有效率比较的森林图

Figure 12 Forest plot comparing overall effective rate of patients with frozen shoulder after manipulative therapy compared to acupuncture therapy

图13 手法对照物理治疗后肩周炎患者治愈率比较的森林图

Figure 13 Forest plot comparing cure rate of patients with frozen shoulder after manipulative therapy compared to physical therapy

图14 手法对照针灸治疗后肩周炎患者治愈率比较的森林图

Figure 14 Forest plot comparing cure rate of patients with frozen shoulder after manipulative therapy compared to acupuncture therapy

图15 报道总有效率的文献发表偏倚的倒漏斗图

Figure 15 Inverted funnel plot of publication bias in literature reporting total effective rate

图16 报道总有效率的文献发表偏倚的Galbraith图

Figure 16 Galbraith chart of publication bias reporting total effective rate

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手法治疗肩周炎有效性和安全性的Meta分析

Efficacy and Safety of Manipulative Therapy for Frozen Shoulder: a Meta-analysis

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