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

doi:10.12114/j.issn.1007-9572.2023.0357

Abstract

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

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

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.
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.

Figures/Tables 17

Figure 1 Flow chart of literature screening

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

Figure 2 Risk of publication bias analysis of the included literature

Figure 3 Risk of publication bias summary of the included literature

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

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

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

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

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

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

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

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

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

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

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

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

Figure 16 Galbraith chart of publication bias reporting total effective rate

References 40

[1]	WHELTON C, PEACH C A. Review of diabetic frozen shoulder[J]. Eur J Orthop Surg Traumatol，2018,28(3):363-371. DOI：10.1007/s00590-017-2068-8.
[2]	CIBULKA M T, WHITE D M, WOEHRLE J，et al. Hip pain and mobility deficits—hip osteoarthritis：clinical practice guidelines linked to the international classification of functioning，disability，and health from the orthopaedic section of the American Physical Therapy Association[J]. J Orthop Sports Phys Ther，2009,39(4):A1-25. DOI：10.2519/jospt.2009.0301.
[3]	JONES S, HANCHARD N, HAMILTON S，et al. A qualitative study of patients' perceptions and priorities when living with primary frozen shoulder[J]. BMJ Open，2013,3(9):e003452. DOI：10.1136/bmjopen-2013-003452.
[4]	MERTENS M G, MEERT L, STRUYF F，et al. Exercise therapy is effective for improvement in range of motion，function，and pain in patients with frozen shoulder：a systematic review and meta-analysis[J]. Arch Phys Med Rehabil，2022,103(5):998-1012.e14. DOI：10.1016/j.apmr.2021.07.806.
[5]	中华中医药学会骨伤科分会. 中医骨伤科临床诊疗指南·肩关节周围炎：T/CACM 1179—2019[J]. 上海中医药杂志，2022,56(3):1-5. DOI：10.16305/j.1007-1334.2022.2112084.
[6]	国家中医药管理局. 中医病证诊断疗效标准：ZY/T001.1-001.9-94[M]. 南京：南京大学出版社，1994：78.
[7]	JADAD A R, MOORE R A, CARROLL D，et al. Assessing the quality of reports of randomized clinical trials：is blinding necessary?[J]. Control Clin Trials，1996,17(1):1-12. DOI：10.1016/0197-2456(95)00134-4.
[8]	李幼平，杨晓妍，李鸿浩. 知证卫生决策工具附件——评估设计（改编自Cochrane干预措施系统评价手册）（文18附件2）[J]. 中国循证医学杂志，2010,10(6):647.
[9]	雷培政. 推拿治疗肩关节周围炎随机平行对照研究[J]. 实用中医内科杂志，2013,27(13):157-159. DOI：10.3969/j.issn.1671-7813.2013.07(s).78.
[10]	郭张海，孙义玲，王卫强. "五步一摇法"治疗肩周炎的临床观察[J]. 中国民间疗法，2019,27(3):25-26. DOI：10.19621/j.cnki.11-3555/r.2019.0313.
[11]	李忠龙，梁军. 推拿治疗肩关节周围炎的随机对照临床研究[J]. 中华中医药杂志，2011,26(12):3014-3016.
[12]	ZHANG H L. Clinical study on tuina plus functional training for scapulohumeral pefiarthritis[J]. Acupunct Tuina Sci，2016,14(2):135-140. DOI：10.1007/s11726.016-0914-6.
[13]	王建民. 三步推拿法干预冻结肩关节囊纤维化的临床及实验研究[D]. 济南：山东中医药大学，2022.
[14]	叶斌，钟涔. 指推法治疗急性期肩周炎的临床分析[J]. 世界中医药，2014,9(5):634-636. DOI：10.3969/j.issn.1673-7202.2014.05.030.
[15]	刘辉辉. 循经弹拨法治疗肩关节周围炎的临床研究[D]. 长春：长春中医药大学，2013.
[16]	郑朱喜，董福慧. 理疗床和手法治疗肩关节周围炎的随机对照临床观察[J]. 中国骨伤，2007,20(S1):32-33.
[17]	SRIVASTAVA S, SUKANYA K, MITTAL H. Effect of cyriax deep friction massage versus cryotherapy in stage 1 & 2 of adhesive capsulitis：a randomized controlled trial[J]. J Pharm Res Int，2021:40-48. DOI：10.9734/jpri/2021/v33i57a33966.
[18]	GUTIÉRREZ ESPINOZA H J, PAVEZ F, GUAJARDO C，et al. Glenohumeral posterior mobilization versus conventional physiotherapy for primary adhesive capsulitis：a randomized clinical trial[J]. Medwave，2015,15(8):e6267. DOI：10.5867/medwave.2015.08.6267.
[19]	GULER-UYSAL F, KOZANOGLU E. Comparison of the early response to two methods of rehabilitation in adhesive capsulitis[J]. Swiss Med Wkly，2004,134(23/24):353-358. DOI：10.4414/smw.2004.10630.
[20]	徐玉德，谢兴文，董林，等. 四步按摩法治疗肩周炎60例[J]. 西部中医药，2015,28(8):130-132.
[21]	石修权，王增珍. Egger's test与Begg's test的功效差异比较与原因分析[J]. 华中科技大学学报（医学版），2009,38(1):91-93; 91-93,102. DOI：10.3870/j.issn.1672-0741.2009.01.023.
[22]	王丽娟，张海英，罗和平，等. 圆利针伞形刺并温针治疗风寒湿证肩周炎的随机对照研究[J]. 针灸临床杂志，2021,37(1):35-39. DOI：10.19917/j.cnki.1005-0779.021010.
[23]	夏秀梅，舒锦尔，赵小忠，等. 盂肱下韧带MR影像对冻结肩的诊断价值[J]. 医学影像学杂志，2019,29(3):481-484.
[24]	FAVEJEE M M, HUISSTEDE B M A, KOES B W. Frozen shoulder：the effectiveness of conservative and surgical interventions—systematic review[J]. Br J Sports Med，2011,45(1):49-56. DOI：10.1136/bjsm.2010.071431.
[25]	石宝营，苏艳美. 痛点针刀松解结合肩关节回转手法治疗肩关节周围炎85例[J]. 中国中医骨伤科杂志，2013,21(8):50-51.
[26]	范华雨，张荣，张向东，等. 手法治疗粘连期肩周炎研究进展[J]. 中医药临床杂志，2018,30(9):1764-1766. DOI：10.16448/j.cjtcm.2018.0541.
[27]	周海旺. 阳性点持续移位手法治疗粘连期肩周炎的临床观察[J]. 浙江中医药大学学报，2013,37(2):193-194. DOI：10.16466/j.issn1005-5509.2013.02.017.
[28]	王彦金，寇龙威. 手法在肩周炎治疗中的应用进展[J]. 中医药通报，2021,20(3):70-72. DOI：10.14046/j.cnki.zyytb2002.2021.03.021.
[29]	杨晓伟，盛锋，徐枫，等. 脊柱微调手法治疗肩关节周围炎临床观察[J]. 上海中医药大学学报，2019,33(5):39-42. DOI：10.16306/j.1008-861x.2019.05.008.
[30]	赵明宇，赵启. 平乐正骨"筋滞骨错"理论探析[J]. 中医正骨，2014,26(8):68-70.
[31]	REICHMISTER J P, FRIEDMAN S L. Long-term functional results after manipulation of the frozen shoulder[J]. Md Med J，1999,48(1):7-11.
[32]	吴诚德. 著名伤科医师王子平的手法和练功经验[J]. 上海中医药杂志，1980,14(6):6-8. DOI：10.16305/j.1007-1334.1980.06.003.
[33]	陈柯村，施杞，朱穆朗玛，等. 旋转牵伸类手法治疗冻结肩的系统评价与Meta分析[J]. 上海中医药杂志，2019,53(8):15-21. DOI：10.16305/j.1007-1334.2019.08.004.
[34]	方仪德，许金海，叶洁，等. 国医大师施杞整肩三步九法治疗肩周炎的学术思想及临证经验[J]. 中国中医骨伤科杂志，2022,30(10):74-75; 74-75,79.
[35]	汤子寒. 太极推拿摇法治疗肩周炎的临床观察[D]. 武汉：湖北中医药大学，2021.
[36]	MCCLURE P W, MICHENER L A, SENNETT B J，et al. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo[J]. J Shoulder Elb Surg，2001,10(3):269-277. DOI：10.1067/mse.2001.112954.
[37]	KESHAVARZ R, BASHARDOUST TAJALI S, MIR S M，et al. The role of scapular kinematics in patients with different shoulder musculoskeletal disorders：a systematic review approach[J]. J Bodyw Mov Ther，2017,21(2):386-400. DOI：10.1016/j.jbmt.2016.09.002.
[38]	SURENKOK O, AYTAR A, BALTACI G. Acute effects of scapular mobilization in shoulder dysfunction：a double-blind randomized placebo-controlled trial[J]. J Sport Rehabil，2009,18(4):493-501. DOI：10.1123/jsr.18.4.493.
[39]	李迎春，梁英，杜一婷，等. 超声扫查肩后方关节囊厚度及盂肱距离对分期诊断冻结肩的价值[J]. 中国医学影像技术，2019,35(8):1147-1150. DOI：10.13929/j.1003-3289.201904006.
[40]	林丽蓉. 医学综合征大全[M]. 北京：中国科学技术出版社，1994.