FROZEN SHOULDER

Combining physiotherapy and intra-articular injection is a major recommendation, and raises further questions - some of which are answered in the flowchart but some of which need to be addressed at a local level. These include: ■ Who should do the injection? ■ How many injections should be given? ■ Should the injection be image guided?

In discussions to date between two primary and secondary care trusts it has been agreed that an initial injection should happen in the primary/intermediate care setting by a GP with a special interest (GPwSi) or extended scope physiotherapist but subse- quent injections should happen in secondary care under image guidance. This is in agreement with the findings of additional benefit from guided injections (7). ‘Blind’ injections are of vari- able accuracy even in expert hands (8). so the recommendation is that ultrasound guidance for a first injection would be the ideal.

The inclusion of high volume distension arthrography (HVDA) for non-resolving patients is a relatively novel intervention. HVDA is being increasingly used and recent work has demonstrated its effectiveness in the right patients (9,10). Again there is an argu- ment for combining this intervention with subsequent mobilisa- tion. Conceptually it was described as being a combination of "pain relief by inclusion of steroid and capsular stretch by high volume injection". The place of HVDA in the flowchart reflects this perspective.

The issue of optimal surgical intervention is thorny and a strong case among those questioned to date was made for surgical inter- vention being a last resort initiative, as is the case in the litera- ture (11) with the choice as to whether to perform MUA or cap- sular release or decline to operate being dependent on three issues. The first of these was the recognition that patients should have tried the full range of available conservative measures prior to surgical consult. The second was a need for a full diagnostic work-up addressing co-morbidities, differential diagnoses and psycho-social aspects to the presentation. Finally operator exper- tise and patient needs have to be balanced with the pragmatic aspects of a quick MUA/risks of iatrogenic injury (12) versus a one hour surgical release/usual operative risks. A rider on any flow- chart is that final decisions are made by the responsible clinician in consultation with the patient, and this is clearly the case with surgical decisions with no definitive evidence from the literature.

Physiotherapy has been divided into numerous types of interven- tion as there is the potential for physiotherapy input at all stages from first contact clinician to post-operative rehabilitation. The key stages were regarded as being the early treatment in the painful patient, later treatment in the stiff patient and post-oper- ative treatment. Early treatment focused on education and pain control with mobilisation success highly dependent on adequate analgesia. Later treatment aimed at stiffness including end range mobilisation, has been shown to be clinically effective but the issue of cost-effectiveness is not yet proven (13).

Finally there was a high level of consensus amongst surgeons, rheumatologists, radiologists and physiotherapists that surgery or HVDA must be followed by immediate intensive physiotherapy input to optimise results.

16 The traditional models of service delivery are currently being

revised by a combination of government initiatives and extending scope of nurses and allied health professionals. This care pathway reflects the emerging model of care delivery with the potential for an intermediate care stage included between the traditional GP – consultant care supervision axis. This opens up new opportunities for co-ordinated care without extra expense and relocation of early care delivery to primary care ie easier access for patients. A colour coding has been adopted in the flowchart design which indicates the likely site for care delivery in the study trusts, but this will be a locally defined issue depending on local structures and expertise.

THE AUTHOR

Dr Dylan Morrissey is a senior clinical lecturer in sport and exercise medicine at Queen Mary’s University London as well well as a prac- ticing clinician. Dylan qualified in 1991 and has a masters (MSc) in Manipulative Therapy. He has recently completed his PhD and has a specific interest in shoulder injury and pathology. He has over 11 years experience working in sport and has worked with the London Leopards, professional rugby (both codes), paralympic athletes, inter- national athletics as well as representing softball on the BOA physio- therapy committee.

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