MANAGEMENT CONSENSUS PROJECT

Shoulder complaints represent 2-3% of presentations to general practice, making them the third most common musculo-skeletal complaint (4). It is estimated that between 50-80% do not seek a general practitioner opinion (4). Frozen shoulder is either primary (idiopathic) or secondary to other pathology such as fracture, diabetes mellitus or thyroid disease for example (5). It is most common in the 40-60 year old age group and in women. The focus of this work was idiopathic frozen shoulder although the principles are similar for other groups where the clinical presenta- tion and pathology are similar. The classic idiopathic frozen shoul- der goes through three phases with associated clinical signs and pathology. The predominant features are pain in the first, ‘freezing’ phase, stiffness in the ‘frozen’ phase and recovery in the ‘thawing’ phase with distinguishing clinical and pathological features (table 1) (1). The initial focus is on accurate diagnosis and then match- ing management to patients’ stage and individual presentation.

There is little evidence of consensus in the literature with no clear patient management pathways being found when searching for clinical guidelines published by relevant groups in the UK, Australia, New Zealand and North America. Recommendations can be found in various publications including empirical studies, sec- ondary syntheses (5) and systematic reviews (6). The closest to a clinically useful guideline was found in the AAOS literature (http://www.aaos.org/wordhtml/research/guidelin/chart_08.pdf) and supporting documentation (http://www.aaos.org/wordhtml/research/guidelin/suprt_08.pdf. There was therefore a lack of the detail and decision making guid- ance required to fashion a workable local pathway.

The aim of this project is to devise an agreed pathway for management of frozen shoulder based on evidence and consensus with the input of key individuals involved in the delivery of care for these patients. It also aims to flesh out the decision making criteria for different interventions and will also form the founda- tion for evaluation of patient experience and opinion regarding optimal care delivery via subsequent focus group work. This article is designed to increase the consultation range by promot- ing and facilitating an on-line discussion in order to further validate the pathway.

PROPOSED METHOD This method has already been piloted through interviews with a small group of clinicians. A task was devised in order to facilitate discussion and flowchart design and involves giving each partici- pant statements describing common interventions which are then arranged into a flowchart. Participants are encouraged to ‘Tell me about it’. Discussion focuses on the criteria for each intervention, with key comments being recorded. Once the initial flowchart arrangement is reached, statements summarising the evidence for each intervention are displayed and the subjects asked whether the information in the statements would lead to a change in their flowchart or would alter their criteria. Again the data gathered is in the form of key statements with particular weight given to cri- teria for action. Our online project will follow a similar process.

ANALYSIS Recorded statements were grouped according to themes and the stage of presentation of hypothetical patients. Statements were regarded as being key if they occurred more than once or were

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very strongly held views. The flowcharts defined by all participants were compared and a best fit method employed. In the case of significant disagreement it was recognised that there may be no final flowchart and analy- sis would focus on identified dichotomies and possible solutions. The evidence from professionals most likely to be involved with intervention at a particular stage was given higher weighting than that from professionals who were deemed more likely to encounter patients at other stages. In this way, surgeons’ views on surgical intervention criteria were weighted more highly than that of GPs while GP views on first contact management were weighted more highly than surgeons. All professionals were encouraged to comment on all aspects of the flowchart, irrespec- tive of primary expertise.

DISCUSSION Any care pathway should utilise the evidence but also reflect local expertise and challenges in order to deliver evidence based locale- relevant health care. The level of agreement between clinicians and the strong relationship to the evidence reflects the expertise of the clinicians who participated. Some aspects of this relation to the evidence has been picked out below.

The combination of physiotherapy and cortico-steroid injection (as a pain relieving intervention) in the early painful stages of adhesive capsulitis is an intuitively sensible intervention that has been shown to improve patients’ ‘journey’ through the condition. Recent work has demonstrated that patients treated with a com- bination of physiotherapy and intra-articular injection did better than other combinations of physiotherapy/injection/advice only (3). The overall end-point at 12 months was not statistically dif- ferent between groups but the amount of disability was signifi- cantly reduced within six weeks in the combined treatment group compared to a year in the placebo group. This research finding was strongly reflected in the interviews.

STAGE AND DURATION

Freezing 0 to 6 months

PRESENTATION AND EXAMINATION FINDINGS

Pain predominates: both background pain and exac- erbations on movement

May have night pain

Marked limitation of all active movements by pain

Less restriction of passive movement with spasm as end-feel

3-9 months Frozen

Pain and stiffness co- present, although pain less severe and more specific to given movement or position

Marked limitation of all movement planes

Equal restriction of passive movement with spasm or restriction as end-feel

3-9 months Thawing

Stiffness predominates although this should be gradually improving

‘Burnt out’ synovitis with chronically thickened capsule

Table 1: Stages, clinical presentation and pathology for idiopathic frozen shoulder

15 PATHOLOGY

Hyper-vascular synovitis, initially focused around the rotator interval hence impingement signs positive.

Normal capsule

Continued synovitis, with peri-articular capsular ‘scar’ including new fibrous tissue formation