Pain management in the rehabilitation of stiff shoulder: Prospective multicenter comparative study of 193 cases

SummaryIntroductionThe present study investigated the impact of respecting pain threshold on clinical recovery in stiff shoulder.Patients and methodsA prospective multicenter comparative study followed up 193 cases of shoulder stiffness for a mean 12-month period (range, 8–31 months) after four different treatment protocols: (1) conventional sub-pain-threshold rehabilitation (58 cases); (2) self-rehabilitation exceeding the pain threshold (59 cases); (3) supervised suprathreshold rehabilitation (31 cases); and (4) capsulotomy with sub-threshold rehabilitation (45 cases). Follow-up was daily for the first 6 weeks then weekly for the next 6; each session included assessment of the painfulness, feasibility and duration of each rehabilitation and self-rehabilitation exercise and of pain status, disability and psychological status. The surgeon followed patients up at 6 weeks, 3 months, 6 months, 1 year and at last follow-up.ResultsSub-threshold rehabilitation provided progressive results, limited in time (P < 0.05). Suprathreshold self-rehabilitation provided reduced pain (P < 0.05) as of the first days, with nocturnal pain ceasing after 7 days’ rehabilitation in 43% of cases. Supervision of self-rehabilitation exercises optimized the clinical result (P < 0.05). Capsulotomy did not influence pain evolution over the first 8 weeks, but then improved it. Failure (at 1 year, 14–17%; last follow-up, 3.5%) correlated directly with the number of exercises performed by the patient (P < 0.05).DiscussionThe dogma of respecting the pain threshold is dated: pain inflicted on a passive patient impairs clinical evolution, but pain managed by an informed active patient under experienced supervision provides rapid recovery of function and pain-free status.Level of evidenceLevel III, case-control, prospective comparative.