THESIS PRESENTATION

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

3. 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. 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.

5. • AIM:-
To investigate the effects of manipulation
under anesthesia for frozen shoulder with and
without non-insulin dependant diabetes
mellitus

6. • PUPOSE OF THE STUDY:-
• To see the effect effects of manipulation
under anesthesia on frozen shoulder with and
without non- insulin dependent diabetes
mellitus.

7. 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 .

9. • 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

10. • Sampling :-
• Convenience random sampling

11. 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.

12. • 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%

13. Variables :-
 Dependent variables:-
1,pain
2,Activity
3,ROM
 Independent variables:-
1,manipulation
2,anaesthesia

14. • Procedure :-
TOTAL=63
42
NON-
DIABETIC
21
DIABETIC
. 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 male
40 female
43 rt sided
20 lt sided

15.  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.

16. Postoperative treatment
All 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.
.

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

18. 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.

20. NON DM
DM
P VALUE
0
0.1
0.2
0.3
0.4
0.5
pain
activity ROM
NON DM
DM
P VALUE

21. Column1
DM
0
0.2
0.4
Column1
NON DM
DM
P-VALUE
NON DM
P VALUE
0
0.2
0.4
NON DM
DM
P VALUE

23. 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