Pain management in the rehabilitation of stiff shoulder: prospective multicenter comparative study of 193 cases.
BACKGROUND
The present study investigated the impact of respecting pain threshold on clinical recovery in stiff shoulder.


METHODS
A 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.


RESULTS
Sub-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).


CONCLUSIONS
The 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.
Orthopedic and Sports Surgery Center, 33700 Merignac, France; Albert-Schweitzer Hospital, 301, avenue d'Alsace, 68000 Colmar, France. pascal.gleyze@orange.fr
P
P
Gleyze
P-H
PH
Flurin
E
E
Laprelle
D
D
Katz
B
B
Toussaint
T
T
Benkalfate
N
N
Solignac
C
C
Lévigne
D000293:Adolescent; D000328:Adult; D000368:Aged; D005081:Exercise Therapy / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement; D011446:Prospective Studies; D016059:Range of Motion, Articular / Q000502:physiology; D020127:Recovery of Function; D012785:Shoulder Joint / Q000502:physiology; D020069:Shoulder Pain / Q000175:diagnosis / Q000503:physiopathology / Q000534:rehabilitation*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult