More resources used for physical therapy for adhesive capsulitis vs watchful waiting
Physical therapy was equal to watchful waiting in the long-term for the studied indication.
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Watchful waiting was shown to have possible noninferiority to physical therapy as treatment for patients with adhesive capsulitis of the shoulder, based on results of a study.
Furthermore, presenter Paul F. Abraham, BS, said, concerning value-based care, a survey showed patient-incurred costs 12 months after each intervention were greater in the physical therapy (PT) group than in the watchful waiting group.
He presented results of the interim analysis performed for the 11 patients in the PT arm and the 13 patients in the watchful waiting arm of the study who reached 12-month follow-up. Abraham said patients in both groups were offered corticosteroid injection as needed, and as clinically indicated.
Patients satisfied with treatment
Both groups experienced significantly increased American Shoulder and Elbow Surgeons scores and decreased DASH scores. All patients were also satisfied with their treatments according to the patient-reported outcome measures used, the study showed.
“ASES improvement at 3 months was greater in PT than in watchful waiting, … but there was no difference at any other timepoint, including at 6 months and 12 months,” Abraham said. “There was no difference in pain improvement between arms throughout the study period either,” he said.
Patients’ average costs were $1,119 for the physical therapy group and $493 for the watchful waiting group, which was a statistically significant difference. Average costs to the health care system were $3,634 in the physical therapy group and $1,131 in the watchful waiting group, according to Abraham.
PT may have lower value of care
Abraham said, “The clinical take-home of this study is that watchful waiting is equal to PT in the long term in treatment for adhesive capsulitis of the shoulder, but more data are still required to be certain. PT costs are greater than watchful waiting costs, indicating that PT may have a substantially lower value of care than watchful waiting.”
Abraham told Orthopedics Today, “Since, in this interim analysis, patients who underwent PT for adhesive capsulitis of the shoulder outperformed patients who did not at 3 months, but not 6 or 12 months, PT may be best for patients that require quick return of shoulder function, such as laborers or athletes. For other patients, watchful waiting may be preferable, as PT can be costly and painful, but does not seem to influence long-term outcomes. However, we need to collect more data to be certain of this finding, as this is only an interim analysis based on the 24 patients that have reached 12 month follow-up in this study.”
This study was also scheduled to be presented March 24 as paper 196, at the American Academy of Orthopaedic Surgeons Annual Meeting in Orlando. The meeting was canceled on March 10 amid COVID-19 concerns.
For more information:
Paul F. Abraham, BS, can be reached at Massachusetts General Hospital, department of orthopaedic surgery, sports medicine center, 175 Cambridge St., Suite 400, Boston, MA 02114; email: paulabraham93@gmail.com.
Reference:
Abraham PF, et al. Paper 128. Presented at: Orthopaedic Research Society Annual Meeting; Feb. 8-11, 2020; Phoenix.
Perspective
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Grant L. Jones, MD
I reviewed with great interest the presentation by Paul F. Abraham, BS, from Massachusetts General Hospital, on the effectiveness of physical therapy compared with watchful waiting for the treatment of adhesive capsulitis at the Orthopaedic Research Society Annual Meeting.
Adhesive capsulitis is a debilitating condition of insidious onset characterized by the initial onset of pain followed by the progressive loss of motion. Fortunately, in a majority of patients, it is a self-limiting disease which resolves without surgical intervention. Unfortunately, the “thawing process” can often be prolonged, so multiple interventions have been suggested and studied to expedite the recovery. One treatment option is formal physical therapy (PT) to help regain motion and decrease the length of disability. Abraham and his colleagues utilized a randomized controlled trial to evaluate whether PT provided any benefit over watchful waiting. They found patients in both the PT and watchful waiting groups demonstrated significant improvement in passive range of motion and VAS pain scores with no differences between the groups at 6 months and 12 months. Furthermore, the average costs per patient in the PT group was $6,150.46 vs. $180.00 in the watchful waiting group. The authors concluded watchful waiting is not inferior to PT in terms of patient outcomes, but it is much less expensive; therefore, watchful waiting should be considered the treatment of choice for adhesive capsulitis.
The strength of this study is that it was a prospective randomized controlled trial, for which the authors should be commended. However, there were a few weakness with the investigation including that there were a low number of patients, which raises the possibility of the study not being adequately powered to detect differences and there were confounders which were not controlled, such as which patients received corticosteroid injections, which have been shown to expedite the recovery. Overall, the study is impactful in that it demonstrates that formal PT may not be necessary to treat adhesive capsulitis, which could result in a significant reduction in treatment costs. This is important in the present health care environment of cost containment. However, studies that have a larger cohort of patients and which control for variables, like injections, are necessary to confirm results of the study.
Team physician, department of athletics
The Ohio State University
Columbus, Ohio
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