INTRODUCTION

Manipulation under anaesthesia for frozen shoulder in patients with and without non-insulin dependent diabetes mellitus

1. A higher prevalence of frozen shoulder (20–29%) has been reported in diabetes mellitus (DM) patients [2, 14, 17]. However, the outcome of these patients has only been studied previously in Western countries [2, 15].

2. None have been documented in Asia. Adhesive capsulitis of the shoulder (frozen shoulder) is characterised by a gradual increase in stiffness and pain. This self-limiting disorder has three stages lasting up to one to three years [10, 22] and does not recur in the same shoulder [9].

3. The aetiology of frozen shoulder is yet to be discovered and excellent results of manipulation under anaesthesia (MUA) have been reported by many authors [7, 13, 15, 18, 24], but few have focussed on patients with DM [12, 15, 17].

4. Hence, in this study, we compared the objective improvement in range of motion and the subjective improvement in function after MUA in patients with and without non-insulin dependent DM. We revealed the short- and long-term results of frozen shoulder after MUA in patients with and without non-insulin dependent DM and further compared the short-term results in diabetic patients using different blood sugar control.

• AIM:- To investigate the effects of manipulation

under anesthesia for frozen shoulder with and without non-insulin dependant diabetes mellitus

• PUPOSE OF THE STUDY:- • To see the effect effects of manipulation

under anesthesia on frozen shoulder with and without non- insulin dependent diabetes mellitus.

HYPOTHESIS :-• Research Hypothesis : Group B non-insulin dependent diabetic

group .Group A. non-diabetic group

• Null Hypothesis : There will not be any significant difference

between 2 groups in patients with PHP .

METHODOLOGY

• Study design : A randomized controlled clinical trial.

• Study centre : Address correspondence to Dr César Fernández de las Peñas, Facultad de Ciencias de

la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain.

• Sample : A total of 60 subjects 15 men and 45 women were assigned randomly in 2 groups. Group A – a self-stretching (Str) group who received a stretching protocol Group B – a self-stretching and soft tissue TrP manual therapy (Str-ST) group who

received TrP manual interventions (TrP pressure release and neuromuscular approach) in addition to the same self-stretching protocol

• Sampling :-

• Convenience random sampling

Inclusio criteria:- age=(41-79)

At least a one-month history of pain and stiffness of the shoulder.

Documented restriction of both passive and active gleno-humeral and scapulo-thoracic motion of equal to or less than 100 degree of elevation, and less than 50% of external rotation, as compared to the contra-lateral side.

The intra-operative characteristic feeling of tissue breakdown during manipulation.

• Exclusion criteria :-

A history of cancer, or rheumatic disease. surgery or suffered trauma. severe neurological deficit of the involved upper

extremity. lost follow-ups or incomplete pre-operative

data. Regained a range of motion <80%

Variables :- Dependent variables:-

1,pain2,Activity3,ROM

Independent variables:-1,manipulation 2,anaesthesia

• Procedure :-TOTAL=63

42NON-

DIABETIC

21DIABETIC

. Patients in the diabetic group had to meet the current WHO criteria [1], with diabetes diagnosed by having two hour plasma glucose .

200 mg/dl during an 75 g-OGTT.

(non-insulin dependent diabetes mellitus).

23 male40 female43 rt sided20 lt sided

All patients received general anaesthesia with intravenous barbiturate given by anaesthetists for the procedure.

The technique used for manipulation started with the gradual forward elevation in the sagittal plane to the maximum possible extent while the scapula was fixed.

Passive external rotation was then performed in 0° of abduction, followed by external rotation in 90° of abduction.

Lastly, internal rotation in 90° of abduction and cross-body adduction were performed. Care was taken not to fracture the humerus during manipulation.

Forces for external rotation were applied very carefully by two thumbs. A full range of motion was always achieved. The shoulder joint was

injected with 3 ml of bupivacaine and 1 ml of steroid. Five cases (5/68, 7.3%) with refractory frozen shoulder (regained <80%

of the range of motion) had subsequent arthroscopic release to avoid intraoperative complication and were not included in our series.

Postoperative treatmentAll patients received continuous passive

exercise in the ward immediately after the procedure. After discharge, exercise training with a physiotherapist in our outpatient clinic was continued until the range of motion was satisfactory.

.

Data analysis :After the operation, each case was reviewed at three weeks, three months, six months, and one year and then a final review.

Outcome measures:adjusted Constant score (Constant score after

excluding the 25 points for assessment of muscle strength) .

The maximum score for pain was 15, with 15 points representing no pain and 0 points being severe, constant pain.

A maximum of 20 points were assigned for the ability to carry out daily activities. Flexion, abduction, external rotation, and internal rotation were each given a maximum of 10 points (total maximum score for motion was 40 points).

The maximum total score attainable was therefore 75 points.

RESULTS

pain activity ROM

00.050.1

0.150.2

0.250.3

0.350.4

0.450.5

NON DMDM

P VALUE

NON DMDMP VALUE

PAIN

ACTIVITYROM

0

0.2

0.4

Column1

DM

Column1NON DMDMP-VALUE

PAIN

ACTIVITYROM

00.10.20.30.4

NON DM

P VALUENON DMDMP VALUE

DISCUSSION

Untreated frozen shoulders usually resolve naturally within one to three years.

The condition of frozen shoulder can lead to severe pain requiring several months of medications and even some restrictions in motion,

which implies that the condition itself does not always have a successful long-term outcome . Nevertheless,

. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg (A) 1992;

it has been reported by many authors that this period of disability can be minimised by manipulation under anaesthesia.

Othman A, Taylor G. Manipulation under anaesthesia for frozen shoulder. Int Orthop. 2002