
==== Front
BMC Musculoskelet Disord
BMC Musculoskelet Disord
BMC Musculoskeletal Disorders
1471-2474
BioMed Central London

7803
10.1186/s12891-024-07803-5
Research
Frozen shoulder: subjects’ needs and perspectives and clinicians’ beliefs and management strategies: do they align? A cross-sectional study
http://orcid.org/0000-0001-8950-8203
Brindisino Fabrizio fabrizio.brindisino@unimol.it

1
Sciscione Sara 2
http://orcid.org/0009-0004-6087-4436
Andriesse Arianna 3
http://orcid.org/0000-0003-3861-6858
Cioeta Matteo 4
http://orcid.org/0000-0002-9128-9684
Struyf Filip 5
http://orcid.org/0000-0001-9853-3486
Feller Daniel 678
1 https://ror.org/04z08z627 grid.10373.36 0000 0001 2205 5422 Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise, Campobasso, Italy
2 “Riabilita” private practice, Sabaudia, LT Italy
3 Medical Translation Private Practice c/o Andriesse Medical Translator, Lecce, Italy
4 grid.18887.3e 0000000417581884 IRCCS San Raffaele Roma, Rome, 00166 Italy
5 https://ror.org/008x57b05 grid.5284.b 0000 0001 0790 3681 Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
6 Provincial Agency for Health of the Autonomous Province of Trento, Trento, Italy
7 Centre of Higher Education for Health Sciences of Trento, Trento, Italy
8 https://ror.org/018906e22 grid.5645.2 0000 0004 0459 992X Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
17 9 2024
17 9 2024
2024
25 74523 3 2024
20 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Objective

Physiotherapists (PTs) play a crucial role in managing individuals with Frozen Shoulder (FS), frequently being the first healthcare professionals involved in the treatment of this condition.

Aim

This study aimed to compare the beliefs, expectations, and perspectives of individuals with FS with the knowledge, skills, and strategies of PTs, highlighting similarities and differences.

Method

This study adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). From May 1st to August 1st, 2023, a two-part survey was conducted involving PTs and individuals diagnosed with FS. The survey focused on comparing key areas such as clinical assessment, patient education, treatment expectations, and the psychological aspects of the patient-clinician relationship.

Results

A total of 501 PTs and 110 subjects with FS participated in the survey. Most PTs showed proficiency in FS pathoanatomical conditions and were also attentive to psychological aspects (88.4%), describing the pathology evolution in three or two stages (68.2%). They also highlighted the importance of patient education (89.6%) and recognized the potential benefits of a multiprofessional collaboration in managing FS (82.2%). Reassurance was reported as a priority by 32.3% of PTs. Subjects with FS expressed a preference for PTs who are both expert and empathetic (73.6%). Regarding their understanding of FS, 29.09% of subjects reported receiving a three-phase explanation, while 26.36% felt inadequately informed. Nearly half of the subjects (49.09%) anticipated being managed independently by a PT, with 93.64% prioritizing the improvement of their range of motion.

Conclusion

This study revealed a general agreement between subjects with FS and PTs regarding aspects of the therapeutic relationship, patient education, pathology management, compliance and motivation strategies, and pain management preferences. However, significant differences emerged concerning the perception of physiotherapy effectiveness, primary treatment goals, subjects’ priorities, and the importance of psychological assessment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-024-07803-5.

Impact statement

Physiotherapists and subjects suffering from frozen shoulder showed considerable differences in their perception of physiotherapy effectiveness, primary treatment goals, subjects’ priorities, and the importance of psychological assessment.

It is crucial for physiotherapists to delve deeper into the psychological dimension of subjects with FS in order to fully understand their needs and expectations.

By incorporating individuals’ priorities and psychological assessments into a multiprofessional care approach, physiotherapists can improve treatment adherence and outcomes, ultimately increasing the overall patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-024-07803-5.

Keywords

Adhesive capsulitis
Frozen shoulder
Physical therapy modalities
Psychological factor
Patient Healthcare acceptance
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcIntroduction

Frozen shoulder (FS) is a condition of uncertain etiology affecting the shoulder joint and characterized by gradual onset of pain, stiffness, and loss of both active and passive shoulder mobility [1, 2]. The prevalence of FS in the general population is 2–5%, increasing up to 59% in subjects with type-2 diabetes mellitus [3]. The pathogenesis of FS is characterized by (local) inflammation and subsequent fibrosis of the joint capsule and rotator interval. Typically, FS is normally categorized into three stages (i.e. “freezing”, “frozen” and “thawing” [4]). However, this “three-phase” theory lacks of enough supporting evidence [5], with some suggesting an early improvement in disability - with the greatest gains occurring in the early stages of the disease and slowing over time [6]. Prolonged limitations in active and passive ROM and functionality may therefore persist, with no evidence for complete recovery without supervised treatment [7].

The current management of FS primarily focuses on pain relief and restoring active and passive mobility and function [8]. The most effective conservative treatments include education [9], physiotherapy [10], corticosteroid injections, and pharmacological therapy [11]. Physiotherapy treatments mainly involve manual therapy, stretching, exercises [12, 13] - such as proprioceptive neurological facilitation [14], muscle energy techniques [15], and strengthening exercises [16]. The intensity of the treatment is based on the subjects’ irritability levels [9].

Education should be considered as an integral part of the management of individuals with FS [17, 18], as a lack of information can lead to uncertainty, concerns, and anxiety [17, 19]. Oftentimes, individuals do not feel adequately understood by healthcare professionals, and this leads them to experience a sense of being in a ‘no man’s land’ [19]. Furthermore, the psychological aspect appears to play a significant role in the lives of individuals affected by FS [19]. Anxiety, depression, catastrophizing, kinesiophobia, and altered pain beliefs can intensify symptom perception and negatively impact their function and quality of life [20, 21]. Individuals experiencing depression and anxiety may overestimate their disability and struggle to adapt to and manage their upper extremity pain, potentially leading to a reduced adherence to the prescribed therapies and to poorer treatment outcomes [22]. Additionally, individuals with high levels of pain catastrophizing or fear of movement may perceive their pain as a threat; this perception could be exacerbated by a delayed diagnosis of FS or by the lack of awareness among healthcare professionals [17, 23]. Lastly, prolonged exhaustion and disability are closely associated with changes in self-perception, feelings of worthlessness, and hopelessness, profoundly impacting the subjects’ overall mental and physical well-being [23].

Unfortunately, clinicians frequently underestimate these factors. When coupled with a divergence between treatment goals and priorities [17], this can lead to patients’ dissatisfaction, mistrust of the treatment process [20], frustration [24], and significant disappointment with treatment outcomes [21].

No prior study has investigated the beliefs, expectations, and perspectives of both individuals with FS and PTs. While one study examined a different shoulder pathology [25], none have focused on FS. Therefore, this study aims to investigate the agreement between the knowledge, skills, and strategies of PTs with the needs, perceptions, and beliefs of individuals suffering from FS. By identifying both similarities and differences, the study aims to enhance care, understanding, and healthcare support for individuals with FS.

Materials and methods

Design of the study

The reporting of this exploratory survey (observational study) followed the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [26]. Approval for this research was granted by the Ethics Committee of the University of Molise (Protocol number 10–11/2023), and all study procedures were conducted in accordance with the Declaration of Helsinki.

Sampling and recruiting

This study involved PTs and individuals experiencing FS, who voluntarily and anonymously chose to participate. Mandatory inclusion criteria for PTs included working in Italy and being proficient in reading and understanding Italian. The inclusion criteria for subjects were designed to prevent misdiagnosis and ensure specificity to FS. According to international guidelines [12], eligible subjects had to exhibit painful shoulder with external rotation at arm by side < 50% compared to the contralateral side and ROM < 25% in (at least) two or more other planes of movement. Additionally, symptoms needed to be stable or worsening for at least one month [12], and subjects should have had a negative x-ray [12]. Clinical evaluations were conducted by a PT specialized in shoulder disorders with 10 years of experience, who was not involved in the study.

Taking into account 72,000 Italian PTs, a confidence level of 95%, and a margin of error of 5%, our goal was to recruit a minimum of 383 responses [27, 28]. For the patient sample, considering a prevalence of 2–5% for FS, particularly prevalent among women aged 40 to 65 years [6], and based on Italy’s population of 58,900,000 [29], we aimed to recruit at least 384 responses [28].

Data collection took place from May 1st to August 1st, 2023, and no further completion requests were accepted after this date. This timeframe was chosen to align with the durations used in other studies employing a similar approach.

Participants invitation

No inducements were provided for the participation in the study. All potential participants who met the inclusion criteria were invited to participate through a link or QR code generated by Google Form. Specifically, PTs were invited by social media platforms (Facebook and Twitter) and instant messaging applications (Telegram and WhatsApp), or via e-mail. No special lists or specific group of PTs on social media were invited. Subjects with FS were invited to participate upon their referral or self-referral to the authors’ physiotherapy private practice, while they were seeking treatment. Specifically, all individuals with shoulder disorders, whether referred or self-referred to the authors’ outpatient private practice, were screened for FS by a PT not involved in this study. If deemed eligible, the subjects were invited to participate through an information letter (Appendix 1).

Two separate links were created for each sample group, leading to the first page of their respective surveys. On this page, the information letter explained the study’s purpose, identified the researchers, outlined the mandatory inclusion criteria for participation, provided information on data protection and result dissemination, indicated the time required for survey completion, and included a clear statement regarding informed consent, the voluntary nature of participation, and the absence of inducements or reimbursement (Appendix 1).

Additionally, a sentence was included on this page to obtain explicit consent for participation (“the respondent who voluntarily agrees to participate in the study must explicitly give consent by clicking the ‘ok’ button, thereby confirming acceptance”). This approach was replicated from other surveys [30–35]. Only after the consent was confirmed, participants were granted access to complete the questionnaires.

Respondents were able to review and change their answers throughout the survey. However, once they clicked the ‘submit’ button at the end, their answers were finalized. Additionally, to prevent multiple completions from the same subject in both surveys, access from the same IP address was blocked.

All data retrieved were downloaded, anonymized, and securely stored in a protected file, which was sent for a blind statistical analysis once the surveys were closed.

Questionnaires development

Two surveys were conducted: one investigated perspectives, perceptions, and expectations of subject with FS, while the other investigated the knowledge, skills and strategies of PTs.

Both surveys comprised ten questions in the first demographic sections (Section A), and eleven questions in the section regarding the core research of the present investigation (Section B). All questions were mandatory.

Survey for PTs

This survey was developed based on a questionnaire by Brindisino et al. [32], and modified to specifically focus on FS by three experienced authors, with more than 12 years of expertise in rehabilitating shoulder pathologies. The authors specifically aimed to delve deeper into clinical examination procedures, role of patient’s education, management strategies, and prognostic factors. Other questions were tailored to understand how PTs assess and consider their patient’s perspective and whether they incorporate biopsychosocial aspects of care in their practice. The questionnaire underwent an evaluation by a team of colleagues with diverse experiences in shoulder disease rehabilitation to enhance clarity and comprehensibility. Only two questions were edited, and the team reached a consensus on the survey, resulting in its final version.

The initial section of the survey for PTs (Table 1- Sections A), aimed to provide a comprehensive description of the sample recruited through ten closed multiple-choice questions, allowing for one answer only. In particular, these questions explored: years of work experience, number of subjects with FS they treat per year, most frequently practiced area of specialization, and working context.

Table 1 Demographic characteristics of physiotherapists

SECTION A		Answers	Frequency (N/501)	Percentage (%)	
Q1	Sex	Woman

Man

	193

308

	38.5

61.5

	
Q2	Working area	Northen Italy

Central Italy

Southern Italy

	214

124

163

	42.7

24.8

32.5

	
Q3	Age	≤ 25 years

26–35 years

36–45 years

46–55 years

≥ 56 years

	70

270

93

49

19

	14.0

53.9

18.6

9.8

3.8

	
Q4	University degree	Bachelor’s Degree in Physiotherapy

Master’s Degree

PhD

	447

52

2

	89.2

10.4

0.4

	
Q5	OMPT specialization	Yes

No

	150

351

	29.9

70.1

	
Q6	Years of work experience	≤ 5 years

6–10 years

11–15 years

16–20 years

≥ 21 years

	205

124

76

35

61

	40.9

24.8

15.2

7.0

12.2

	
Q7	Most engaged working context	Home-based activity

Public hospital

Accredited private facility/ facility affiliated with the NHS

Private practice/freelance activities

	23

51

141

286

	4.6

10.2

28.1

57.1

	
Q8	Area of specialization most frequently practiced	Other (cardiologic, respiratory, pediatric)

Geriatric

Musculoskeletal

Neurological

Sporting

	14

34

410

29

14

	2.8

6.8

81.8

5.8

2.8

	
Q9	Number of working hours for week	0–10

11–25

26–35

36–45

≥ 46

	9

36

119

253

84

	1.8

7.2

23.8

50.5

16.8

	
Q10	Number of subjects with frozen shoulder treated in a month	≤ 2

3

4

≥ 5

	373

89

19

20

	74.5

17.8

3.8

4.0

	
SECTION B		Answers	Frequency (N/501)	Percentage (%)	
Q11	Which type of imaging do you believe provides the best and most useful indications upon initial assessment for FS subjects, aiming to rule out pathology beyond the scope of physiotherapy expertise? Please choose one	None

MRI

X-rays

X-rays and MRI

Ultrasound and MRI

Ultrasound

X-rays and ultrasound

	95

96

107

110

59

8

26

	19.0

19.2

21.4

22.0

11.8

1.6

5.2

	
Q12	In your clinical practice, when you relate to a subject with FS, you tend to be more:	Empathetic, and to build a relationship of thrust	49	9.8	
Skilled about pathoanatomical conditions, more than anything else	7	1.4	
Skilled about pathological condition, but at the same time empathic/careful to psychological aspect	443	88.4	
Only careful to the pathological condition	2	0.4	
Q13	In your clinical practice with a subject with frozen shoulder, do you consider:	Mostly the anatomical aspects related to the shoulder problem (range of motion, pain, stiffness)	44	8.8	
Equally the anatomical aspects and psychological aspects (fear, worry, anxiety, anger) related to the shoulder problem	429	85.6	
The psychological aspect more than the anatomical aspect	9	1.8	
The anatomical aspect more than the psychological aspect	18	3.6	
Q14	In your clinical practice, regarding the progression of the pathology, do you:	Provide detailed information about the two-stage evolution

Provide detailed information about the three-stage evolution

Provide detailed information about the four-stage evolution

Offer superficial explanations on this matter

Inform about the progression without specifying any phase

Consider it not useful to provide this kind of explanations

	144

198

22

6

126

5

	28.7

39.5

4.4

1.2

25.1

1.0

	
Q15	In your clinical practice, education about the nature of the condition, its pharmacological and rehabilitative management, represent:	An aspect that I often ignore since not interesting/useful for the subject with FS	3	0.6	
An aspect not so significant for rehabilitation management	9	1.8	
A cross intervention throughout rehabilitation process, aimed at managing the psychological aspect	40	8.0	
A cross intervention throughout rehabilitation process, aimed at managing the psychological and painful aspects	449	89.6	
Q16	In your clinical practice, you generally manage subjects with FS:	Independently

In collaboration with a Practitioner (orthopedic, physiatrist)

In collaboration with a psychologist

In collaboration with an Algologist

Together with all the healthcare professional mentioned above when their respective competence is needed

	89

238

1

5

168

	17.8

47.5

0.2

1.0

33.5

	
Q17	Considering your knowledge of the prognosis of patients with FS, which statement do you believe is most accurate	A subject with FS always recovers the 100% depending on their diligence to the rehabilitation and on prognostic factors	82	16.4	
The natural history of the pathology ends with a “restitutio ad integrum” without sequelae	92	18.4	
Rehabilitation is often ineffective and not sufficient for optimal recovery and full satisfaction of the subject with FS	66	13.2	
There are factors indicating that the subject may experience more difficulty in recovering	261	52.1	
Q18	In your experience, what do you think is the priority of these subjects?	Management of daytime pain

Management of night pain

Recovery of full range of motion

Improve sleep quality

Improve autonomy in activities of daily life

Functional recovery linked to work activities, hobbies and social role

Be reassured about their condition

	25

98

26

32

77

81

162

	5.0

19.6

5.2

6.4

15.4

16.2

32.3

	
Q19	In your clinical practice, how do you assess the psychological aspect of the subject with FS?	Validated measurement scales for catastrophizing, fear, avoidance, anxiety, depression	157	31.3	
Extemporaneous, non-standardized and subjectivized questions	178	35.5	
During history taking	156	31.3	
I do not assess the psychological aspect	10	2.0	
Q20	In your clinical practice, what kind of strategies do you predominantly use to increase subjects’ compliance to home exercise?	Mobile phone videos and texts for motivational/educational purpose

Illustrative booklet

Diary

None in particular

I do not provide the patient with any exercises to be performed at home

	242

96

47

114

2

	48.3

19.2

9.4

22.8

0.4

	
Q21	What do you consider the most effective conservative treatment to manage the painful phase?	Electrophysical agents (laser, tecartherapy, diathermy, transcutaneous electrical nerve stimulation, shockwave therapy)	91	18.2	
Corticosteroid therapy (oral or injection)	268	53.5	
Massage therapy	50	10.0	
Non-steroidal anti-inflammatory drugs	92	18.4	
Acronym: Q = questions; N = Number; NHS = National Health Service; MRI = magnetic resonance, OMPT = orthopedic manipulative physical therapist; PHD = Doctor of Philosophy

Survey for subjects with FS

A draft of the questionnaire was developed by three authors with extensive experience in shoulder diseases. Additionally, a psychotherapist was consulted to enhance the appropriateness and reliability of assessing psychological themes. The questionnaire was initially tested on four individuals who had previously suffered from FS, followed by testing on four individuals currently suffering from FS - in order to further ensure its content validity and identify any potentially overlooked relevant issue. The subjects’ feedback emphasized the importance of themes related to “pain” and “fear”. Subsequently, the researchers developed specific questions (currently Q19) and presented them to the same subjects, who confirmed that these questions effectively addressed their concerns. The final version of the survey was finalized during an online meeting.

The initial sections of the survey for subjects with FS (Table 2- Sections A) aimed to provide a comprehensive description of the sample recruited through ten closed multiple-choice questions, allowing for only one answer. Specifically, subjects with FS were asked about the duration of their symptoms, the number of healthcare professionals consulted before receiving their diagnosis, their type of work, and to rate their daily and nightly pain, as well as stiffness, on a scale from 0 to 10.

Table 2 Demographic characteristics of subjects complaining frozen shoulder

SECTION A		Answers	Frequency (N/110)	Percentage (%)	
Q1	Sex	Woman

Man

	72

38

	65.45

34.55

	
Q2	Geographical origin	Northen Italy

Central Italy

Southern Italy

	51

20

39

	46.36

18.18

35.45

	
Q3	Age	≤ 39 years old

40–50 years old

51–60 years old

61–65 years old

≥ 66 years old

	2

47

36

18

7

	1.82

42.73

32.73

16.36

6.36

	
Q4	Educational qualification	Elementary school diploma

Middle school diploma

High school diploma

University Degree

	3

9

56

42

	2.73

8.18

50.91

38.18

	
Q5	Type of job	Mainly inactive (most of the time spent in the same position)

Mainly dynamic (most of the time spent during different activities/often changing position)

	67

43

	60.91

39.09

	
Q6	Duration of your symptoms from the onset:	For more than 5 months

3 months or more but less than 5 months

For more than 1 month and less than 3 months

For less than 1 month or a month exactly

	69

24

17

0

	62.73

21.82

15.45

0

	
Q7	Number of clinicians consulted before your diagnosis:	1

2

3

> 3

	44

30

24

12

	40

27.27

21.82

10.91

	
Q8	From 0 to 10, where 0 indicates no pain and 10 represents the worst pain you have ever felt in your life, please quantify your DAYTIME pain	0 no pain

1

2

3

4

5

6

7

8

9

10 worst pain ever

	5

6

2

7

7

14

17

25

17

7

3

	4.55

5.45

1.82

6.36

6.36

12.73

15.45

22.73

15.45

6.36

2.73

	
Q9	From 0 to 10, where 0 indicates no pain and 10 represents the worst pain you have ever felt in your life, please quantify your NIGHT pain	0 no pain

1

2

3

4

5

6

7

8

9

10 worst pain ever

	7

7

2

3

10

9

4

15

22

14

17

	6.36

6.36

1.82

2.73

9.09

8.18

3.64

13.64

20

12.73

15.45

	
Q10	From 0 to 10 (where 0 means no stiffness and 10 means the worst stiffness you can imagine) how do you quantify your STIFFNESS	0 no stiffness

1

2

3

4

5

6

7

8

9

10 worst stiffness ever

	0

1

2

4

5

8

13

11

34

18

14

	0

0.91

1.82

3.64

4.55

7.27

11.82

10

30.91

16.36

12.73

	
SECTION B		Answers	Frequency (N/110)	Percentage (%)	
Q11	Which type of imaging have doctors suggested for completing a clinical diagnosis of FS	None

MRI

X-rays

X-rays and MRI

Ultrasound and MRI

Ultrasound

X-rays and ultrasound

	26

24

17

17

10

9

7

	23.64

21.82

15.45

15.45

9.09

8.18

6.36

	
Q12	Thinking about your rehabilitation treatment, what kind of physical therapist would you like to relate to?	I would like the physiotherapist to be skilled in managing my shoulder condition, empathetic, and genuinely concerned about my condition	81	73.64	
I would like the physiotherapist to be skilled in managing my shoulder condition, more than anything else	23	20.91	
I would like to find an ally and build a relationship of trust	5	4.55	
I prefer a professional who maintains a detached relationship and focuses solely on assessing and treating my shoulder problem.	1	0.91	
Q13	You would like the PT to pay attention to:	Both anatomical and psychological aspects (fear, worry, anxiety, anger, …) related to the shoulder problem	57	51.82	
Mostly anatomical aspects (range of movement, pain, stiffness) related to shoulder problem	33	30	
More to the anatomical aspect than psychological aspect	17	15.45	
More to the psychological aspect than anatomical aspect	3	2.73	
Q14	How PTs explained the course of FS to me	They provided me with detailed explanations of the pathology evolution in three stages, including timing and recommended treatments	32	29.09	
I received satisfactory explanations but without mentioning any specific “phase”	23	20.91	
They provided me with detailed explanations of the pathology evolution in two stages, including timing and recommended treatments	17	15.45	
I have not received satisfactory explanations regarding my condition	13	11.82	
They provided me with superficial explanations of the pathology evolution in two or three stages, including timing and recommended treatments	16	14.54	
Multiple professionals provided me conflicting information	9	8.18	
Q15	How much you agree with the following statements about explanation received:

I was not informed at all about my condition

	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	8

21

15

41

25

	7.27

19.09

13.64

37.27

22.73

	
	The explanations I received were unhelpful and did not change anything with respect to the management of my condition	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	5

22

19

40

24

	4.55

20

17.27

36.36

21.82

	
	The explanations I received increased my anxiety and concern about the possibility of not recovering	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	8

18

22

32

30

	7.27

16.36

20

29.09

27.27

	
	The explanations I received helped me to react in moments of discouragement, calmed and encouraged me, and I was able to modulate the pessimistic thoughts I had about pain	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	20

39

26

23

2

	18.18

35.45

23.64

20.91

1.82

	
	The explanations I received encouraged me, and I felt less afraid to move as much as possible	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	22

48

16

22

2

	20

43.64

14.55

20

1.82

	
Q16	Do you prefer that your shoulder problem should be better managed by:	The Physiotherapist independently	54	49.09	
By all the professionals mentioned above when their respective competence is needed	50	45.45	
in collaboration with a practitioner (orthopedic, physiatrist…)	3	2.73	
in collaboration with a medical doctor expert in pain management (algologist)	3	2.73	
in collaboration with a psychologist	0	0	
Q17	How much you agree with the following statements:

If I engage in the rehabilitation treatment, I will surely recover completely from FS

	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	31

44

20

14

0

	28.44

40.37

18.35

12.84

0

	
	These treatments will be ineffective, and I will not return to the way I was before	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	0

21

20

42

27

	0

19.09

18.18

38.18

24.55

	
	If I commit to the treatment, I will improve but not recover completely	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	4

28

29

40

9

	3.64

25.45

26.36

36.36

8.18

	
Q18	How important do you think it is to achieve these targets:

Managing daytime pain

	Not important at all

Unimportant

Neutral

Important

Very important

	1

3

10

43

53

	0.91

2.73

9.09

39.09

48.18

	
	Managing night pain	Not important at all

Unimportant

Neutral

Important

Very important

	1

3

5

22

79

	0.91

2.73

4.55

20

71.82

	
	Recover full range of motion	Not important at all

Unimportant

Neutral

Important

Very important

	0

2

5

25

78

	0

1.82

4.55

22.73

70.91

	
	Improve sleep quality	Not important at all

Unimportant

Neutral

Important

Very important

	4

0

5

35

66

	3.64

0

4.55

31.82

60

	
	Improve autonomy in daily life activities (to wash, to get dressed, to drive, etc.)	Not important at all

Unimportant

Neutral

Important

Very important

	0

1

9

35

65

	0

0.91

8.18

31.82

59.09

	
	Functional recovery linked to work activities, hobbies and social role	Not important at all

Unimportant

Neutral

Important

Very important

	0

2

18

29

61

	0

1.82

16.36

26.36

55.45

	
	How much is important for you to be reassured about your clinical condition?	Not important at all

Unimportant

Neutral

Important

Very important

	0

1

18

49

42

	0

0.91

16.36

44.55

38.18

	
Q19	How much you agree with the following statements?

I’m afraid of worsening my condition if I keep moving my shoulder

	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	0

25

21

47

17

	0

22.73

19.09

42.73

15.45

	
	I’m afraid that the FS will cause irreversible damage to my shoulder	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	2

31

31

33

13

	1.82

28.18

28.18

30

11.82

	
	I’m afraid I won’t go back to doing what I could do before	I totally agree

I agree

Neither agree nor disagree

I disagree

I totally disagree

	9

41

22

25

13

	8.18

37.27

20

22.73

11.82

	
	I will never raise my arm again as I used to do before	I totally disagree

I disagree

Neither agree nor disagree

I agree

I totally agree

	19

10

35

43

3

	17.27

9.09

31.82

39.09

2.73

	
	The pain is terrible and will not go away	I totally disagree

I disagree

Neither agree nor disagree

I agree

I totally agree

	23

15

30

40

2

	20.91

13.64

27.27

36.36

1.82

	
	Whatever I do to heal is useless	I totally disagree

I disagree

Neither agree nor disagree

I agree

I totally agree

	29

21

38

20

2

	26.36

19.09

34.55

18.18

1.82

	
	My life is ruined	I totally disagree

I disagree

Neither agree nor disagree

I agree

I totally agree

	49

25

27

8

1

	44.55

22.73

24.55

7.27

0.91

	
	I feel overwhelmed by this condition	I totally disagree

I disagree

Neither agree nor disagree

I agree

I totally agree

	25

20

38

26

1

	22.73

18.18

34.55

23.64

0.91

	
	I am concerned to know that the pathology will last a long time	I totally disagree

I disagree

Neither agree nor disagree

I agree

I totally agree

	9

18

28

41

14

	8.18

16.36

25.45

37.27

12.73

	
Q20	If exercises were to be administered to be done at home, which mode would you prefer to remember the techniques and how to perform them?	Mobile phone video and text messages with motivational/educational purpose

Illustrative booklet

None in particular

Drawings made by the physiotherapist

	52

42

11

5

	47.27

38.18

10

4.55

	
Q21	What would you prefer to be combined with physiotherapy to best manage the painful phase?	Corticosteroid therapy (oral or injection)	30	27.27	
Electrophysical agents (laser, Tecar therapy, diathermy, transcutaneous electrical nerve stimulation, shockwave therapy)	28	25.45	
Massage therapy	18	16.36	
No one preferred	18	16.36	
Non-steroidal anti-inflammatory drugs	16	14.55	
Acronym: Q = questions; N = Number; FS, Frozen Shoulder; MRI = Magnetic Resonance Imaging

Sections B of both surveys (in Table 1 for PTs, and in Table 2 for subjects with FS) aimed to investigate clinical assessment, education, expectations, psychological aspects and therapeutic relationship. Specifically, the first three questions explored “diagnostic imaging and therapeutic relationship” (Q11-Q13), the next three covered “explanation, education, and management” (Q14-Q16), and the following three addressed “beliefs, main targets, and psychological aspects” (Q17-Q19). Finally, the last two questions inquired about “preferred therapeutic strategies” (Q20 and Q21). Therefore, these two surveys were designed to address comparable topics and themes, despite having different structures.

Section B of the questionnaire administered to PTs consisted of 11 specific closed multiple-choice mandatory questions arranged in three screens, concerning pre-specified topics of interest, with only one choice available for each question. This methodology has been used in similar studies [30, 31, 35] to survey PTs’ knowledge and therapeutic approaches.

Conversely, the survey for subjects with FS consisted of 11 mandatory questions presented across four screens. It included seven closed multiple-choice questions (Q11-Q14, Q16, Q20, Q21) and four 5-point Likert scale questions to assess subjects’ agreement with specific statements on predetermined areas of interest.

The study adopted a hybrid structure base on prior research [36, 37], facilitating the comparison across the recruited samples to gain deeper insights into how each participant prioritized specific aspects of their pathology. The survey evaluated participants’ views on education effectiveness, rehabilitation expectations, progress towards their goal, mood, concerns, and overall psychological outlook (Q15, Q17-19).

The first author tested the technical functionality of the electronic questionnaire, conducted a pre-administration test, and ensured the correct answer registration prior to the survey launch.

Statistical analysis

A descriptive analysis was conducted on both study groups. Categorical variables were expressed as frequencies and percentages, while continuous variables were summarized with means and standard deviations. Differences between the groups for questions with identical answer choices (e.g., Q11, Q12, Q13, and Q16) were assessed using Pearson’s Chi-squared test with simulated p-values (based on 2000 replicates), with a significance level set at p < 0.05 for each comparison.

All statistical analyses were carried out using R with the Tidyverse package [38].

Results

Sociodemographic characteristics of PTs

All questions were filled out completely. According to the software, PTs spent an average of 8.05 min completing the survey, while subjects with FS spent 11.22 min.

A total of 110 subjects with FS were invited and all voluntarily chose to participate. It was not possible to determine the exact number of PTs who read the message on social media platforms and decided to participate. However, all PTs and subjects who started the survey completed it in full, achieving a 100% completion rate.

A total of 501 PTs completed the survey. The majority were male (61.5%, n = 308) and primarily aged between 26 and 35 (53.9%, n = 270). Approximately 42.7% of respondents worked in northern Italy, with most having less than five years of experience (40.9%, n = 205) and working 36 to 45 h per week (50.5%, n = 253). Additionally, most PTs worked in private practice (57.1%, n = 286), mainly treating individuals with musculoskeletal disorders (81.8%, n = 410) and typically seeing fewer than two subjects with FS per month (74.5%, n = 373). Academic background analysis revealed that most held a bachelor’s degree in physiotherapy (89.2%, n = 447). See detailed data in Table 1, Section A.

Sociodemographic characteristics of subjects with FS

A total of 110 consecutive subjects with FS completed the survey, with 65.45% being female (n = 72/110). 46.36% of respondents were from northern Italy (n = 51). The majority were aged between 40 and 50 years (42.73%, n = 47), had a high school diploma (50.91%,n = 56), and were predominantly involved in sedentary jobs (60.91%, n = 67). A significant portion of respondents reported experiencing FS for over 5 months (62.73%, n = 69/110), with no one indicating a duration of less than one month. 40% of participants (n = 44/110) reported consulting one clinician, while 32.73% (n = 36/110) had consulted three or more clinicians before receiving an FS diagnosis. Participants were asked to rate their daytime pain, night pain, and stiffness on a scale from 0 (no pain) to 10 (worst pain imaginable). For daytime pain, 66.36% of respondents (n = 73/110) reported experiencing moderate to severe pain in a range from 5/10 up to 8/10. Only 6.36% (n = 7/110) reported pain intensity at 9/10, and 2.73% (n = 3/110) reported the highest pain intensity (10/10). For night pain, the majority (61.82%, n = 68/110) reported higher values, typically ranging from 7/10 to 10/10. Regarding stiffness, 81.82% (n = 90/110) reported stiffness levels between 6/10 and 10/10. Detailed data is provided in Table 2- Section A.

Diagnostic imaging and therapeutic relationship (Q11-Q13)

PTs recommended various diagnostic imaging methods to rule out pathology beyond their expertise. Specifically, 21.4% (n = 107/501) suggested X-rays, and 22% (n = 110/501) recommended a combination of X-rays and Magnetic Resonance Imaging (MRI). Surprisingly, 19% of PTs (n = 95/501) believed that no imaging was necessary - whereas subjects with FS reported that clinicians recommended no imaging in 23.64% of cases (n = 26/110), MRI in 21.82% (n = 24/110), and X-rays or X-rays associated with MRI in 15.45% (n = 17/110). A significant difference was observed between the two groups (p-value = 0.003).

Regarding their approach to subjects with FS, 88.4% (n = 443/501) of PTs highlighted their expertise in pathoanatomical conditions, alongside their consideration of psychological factors. Similarly, a majority of FS subjects (n = 81/110, 73.64%) favored PTs who were knowledgeable about shoulder conditions and displayed empathy. There was a significant difference between the responses of the two groups (p-value = 0.0005).

85.6% of PTs (n = 429/501) equally valued anatomical and psychological aspects related to FS when determining the key priorities in their clinical practice. Similarly, 51.82% of subjects with FS (n = 57/110) expressed that a PT should consider both anatomical and psychological factors. However, 8.8% of PTs (n = 44) and 30% of subjects (n = 33) emphasized that the most crucial factors were exclusively related to function and anatomy. A significant difference between the two groups was observed (p-value = 0.0005).

Explanation, education and management (Q14-Q16)

PTs’ explanations regarding the course of FS varied widely: 39.5% (n = 198/501) described its progression in three stages, 28.7% (n = 144/501) in two stages, and 25.1% (n = 126/501) without specifying any phases. Responses from subjects with FS also varied similarly: 29.09% (n = 32/110) received detailed explanations in three phases, 20.91% (n = 23/110) received satisfactory explanations without mentioning any phase, and 15.45% (n = 17/110) received explanations in two phases. 11.82% (n = 13/110) of subjects with FS did not receive satisfactory explanations, and 8.18% (n = 9/110) of them reported receiving different explanations from different clinicians (Fig. 1).

Fig. 1 Bar chart for the answer to Q14

Most PTs (89.6%, n = 449/501) considered patient education on FS crucial for managing psychological and pain aspects during rehabilitation, while only 2.4% (n = 12/501) deemed it as not important for the rehabilitation purpose. However, 26.36% (n = 29/110) of subjects with FS stated that they were not informed about FS, 24.55% (n = 27/110) received unhelpful explanations, and 23.63% (n = 26/110) received explanations that increased their anxiety and worry about their chance of not recovering. Conversely, 53.63% (n = 59/110) of respondents with FS reported receiving reassuring explanations that helped them cope with discouragement and manage pessimistic thoughts about FS. Additionally, 63.64% (n = 70/110) received encouraging explanations that reduced their fear of movement (Fig. 2).

Fig. 2 Stacked bar chart for the answer to Q15, Q17, Q19

When PTs were asked about their management of subjects with FS, 47.5% (n = 238/501) reported collaborating with practitioners (orthopedic, physiatrist), 33.5% (n = 168/501) mentioned collaborating other specialists (psychologist, algologist, orthopedic, physiatrist) when their expertise was needed, while 17.8% (n = 89/501) managed their patients independently. In response to the same question, most respondents with FS (n = 54/110, 49.09%) expressed a preference for being managed independently by their PTs, whereas 45.45% (n = 50/110) expected their condition to be addressed by a multi-professional team when necessary. A significant difference between the two groups was noted (p-value = 0.0005).

Beliefs, main target and psychological aspect (Q17-Q19)

About half of the PTs (n = 261/501, 52.1%) believed that certain factors could indicate a more challenging recovery for patients with FS. Specifically, 34.8% (n = 174) of PTs stated that FS typically resolves without leaving deficits or symptoms, while 13.2% (n = 66) believed that some restrictions or impairments might persist. Among subjects with FS, the majority believed that engaging in a rehabilitation treatment would result in either full recovery (68.81%, n = 75) or partial recovery (29.09%, n = 32). However, 19.09% (n = 21/110) expressed skepticism about the effectiveness of physiotherapy (Fig. 2).

When PTs were asked about the priorities for subjects with FS, 32.3% (n = 162/501) emphasized the importance of “being reassured about their condition”, while 19.6% (n = 98/501) focused on managing subjects’ night pain, and 16.2% (n = 81/501) highlighted functional recovery related to their work, hobbies, and social roles. Daily pain management was least prioritized (5%, n = 25/501). Conversely, nearly all subjects with FS expressed that restoring their full range of motion (n = 103/110, 93.64%), managing night pain (n = 101/110, 91.82%), improving sleep quality (n = 101/110, 91.82%), enhancing their autonomy in daily life (n = 100/110, 90.91%), managing daily pain (n = 96/110, 87.27%), being reassured (n = 91/110, 82.73%), and improving occupational and social activities (n = 90/110, 81.81%) were to be considered important or very important (Fig. 3).

Fig. 3 Stacked bar chart for the answer to Q18

Regarding the psychological aspect, 35.5% (n = 178/501) of PTs stated that they assessed it with extemporaneous questions, while 31.3% (n = 157/501) used validated patient-reported measurement scores. Regarding the presence of fear and catastrophizing beliefs among respondents with FS, 22.73% (n = 25/110) expressed fear that moving their shoulder could worsen their condition, 30% (n = 33/110) believed FS had irreversibly damaged their joint, and 45.45% (n = 50/110) thought they would never return to their previous level of activity. Half of the respondents with FS (n = 55/110, 49.99%) expressed concerns about the chronic nature of FS. Furthermore, a significant percentage believed that their arm would not regain its previous range of motion (n = 46/110, 41.82%), perceived their pain as relentless (n = 42/110, 38.18%), and felt that their efforts were futile (n = 22/110, 20%). A minority of subjects reported feeling overwhelmed by FS (n = 27/110, 24.55%) or believed that this condition had ruined their life (n = 9/110, 8.18%) (Fig. 2).

Preferred therapeutic strategies (Q20, Q21)

Regarding strategies to enhance compliance with home exercise among subjects with FS, most PT respondents (n = 242/501, 48.3%) reported opting for mobile phone videos and texts, whereas 19.2% (n = 96/501) favoring illustrative booklets. Similarly, among subjects with FS, 47.27% (n = 52/110) expressed a preference for receiving exercise guidance through mobile phone videos and text messages, while 38.18% (n = 42/110) favored using a booklet (Fig. 4).

Fig. 4 Bar chart for the answer to Q20

Half of the PT (n = 268/501, 53.5%) favored corticosteroid therapy as additional therapy for managing the painful phase. A smaller percentage (n = 92/501, 18.4%) preferred non-steroidal anti-inflammatory drugs, while 18.2% (n = 91/501) opted for electrophysical agents (laser, Tecar therapy, diathermy, transcutaneous electrical nerve stimulation, or shockwave therapy). Similarly, among subjects with FS, 27.27% (n = 30/110) expressed a preference for corticosteroids, 25.45% (n = 28/110) chose electrophysical agents, 16.36% (n = 18/110) preferred massage or no specific treatment, and 14.55% (n = 16/110) opted for non-steroidal anti-inflammatory drugs. (Fig. 5).

Fig. 5 Bar chart for the answer to Q21

All this data was detailed in Sections B from Tables 1 and 2.

Discussion

This study aimed to investigate the agreement between the knowledge, skills, and strategies of physiotherapists and the needs, perceptions, and beliefs of subjects suffering from FS. The findings showed partial alignment on certain aspects, alongside significant differences in others.

Diagnostic imaging and therapeutic relationship

PTs’ answers showed disagreement on recommended imaging for managing individuals with FS, with many advocating against it. This was reflected in FS patients’ experiences, as most reported not being advised for any diagnostic imaging. This discrepancy with the established International guidelines [12] is concerning, especially since about 20% of PTs considered imaging unnecessary, raising risks of overlooking pathologies that could mimic FS.

FS is occasionally undiagnosed or misdiagnosed by clinicians, particularly because its initial presentation typically involves pain without significant motion limitation [4]. However, in later stages, FS is characterized by fibroproliferative tissue fibrosis, resulting in shoulder capsular fibrotic contractures and clinical stiffness [4]. Additionally, restricted shoulder ROM may be attributed to muscle contraction in response to the underlying pathophysiology or due to cognitive and emotional factors - such as fear of pain or anxiety [39].

This highlights the importance of recognizing FS as a condition influenced by psychological factors and integrating psychological aspects into rehabilitation. Individuals with FS expressed a preference for knowledgeable and empathetic PTs. Most PTs indicated they equally value both anatomical and psychological aspects related to FS, which, according to the subjects, are crucial areas for PTs to address. These findings suggest that the traditional view of FS as solely a physical condition is outdated and should be replaced by acknowledging its psycho-pathological aspects. Therefore, rehabilitation approaches that exclusively focus on joint mechanics without addressing patients’ psychological needs may prove inadequate. Incorporating psychological considerations could potentially enhance overall patient satisfaction with healthcare providers, addressing concerns that are often reported as disappointing [21].

Furthermore, the presence [20] and the prognostic value [22] of psychological aspects in FS subjects have been clearly established; these findings underscore the critical need for PTs to thoroughly understand and effectively manage these psychological dimensions in an updated and informed manner.

Explanation, education and management

Inconsistent explanations about the progression of FS were noted in both study groups. These findings underscore the substantial variability in the literature regarding the clinical course and development of FS [40]. Clinicians’ differing explanations may stem from varying levels of knowledge and expertise, potentially causing confusion among subjects, raising concerns about healthcare professionals’ competence, and eliciting feelings of frustration and uncertainty [19, 21]. Most PTs considered education as pivotal, and most subjects with FS reported receiving reassuring, encouraging, and helpful information. However, a significant portion found the explanations they had received to be not encouraging or not helpful, which ultimately heightened their anxiety and concerns about (non)recovery. This type of “nocebo” communication not only fosters anxiety and worry, but also undermines confidence in healthcare professionals [17].

Evidence suggests that patient education is a key component of therapeutic management, as it can improve pain, disability, catastrophizing, fear-avoidance behaviors, beliefs about pain, and subjects’ compliance [41, 42]. However, before educating subjects with FS about their healthcare journey, prioritizing clinician education is essential. This enhances their ability to boost subjects’ confidence and coping skills for pain and disability, and to reduce their fears and negative thoughts [43]. Physical therapists should emphasize enhancing their communication skills as a crucial therapeutic technique that positively impacts satisfaction and clinical outcomes [44].

Half of the subjects with FS anticipated the involvement of a multidisciplinary team (i.e. orthopedists, physiatrists, psychologists, and pain specialists) whereas only a few PTs indicated collaborating with other professionals when needed. Despite the widespread understanding and application of the biopsychosocial model, many PTs still tend to overlook the importance of a multiprofessional approach. This oversight may result in neglecting their patients’ needs, including psychological factors, reassurance, social roles, daily routines, and engagement in leisure activities. Embracing a multidisciplinary approach enables personalized, targeted interventions which closely align with patients’ needs and preferences, thereby promoting a patient-centered approach.

Beliefs, main target, and psychological aspect

There were differing opinions between PTs and subjects suffering from FS regarding the effectiveness of physiotherapy in the treatment of FS. These discrepancies and the subjects’ lack of confidence in their rehabilitative treatment could pose barriers to adherence, potentially resulting in distrust, dissatisfaction, and a loss of faith in physiotherapy [45].

Divergent treatment priorities were observed between the groups, highlighting a disparity between the needs expressed by individuals with FS and the perspectives of PTs. This misalignment of treatment goals could result in dissatisfaction and undermine individuals’ compliance [24]. These findings are consistent with previous qualitative investigations that highlighted individuals’ experiences of feeling misunderstood, frustrated, and lacking adequate psychological support. This situation contributes to a negative cycle that can adversely affect treatment compliance and prognosis [21]. Overall satisfaction with treatment depends not solely on clinicians’ experience or priorities but on placing the patient at the center of the care process [46]. This underscores the importance of communication and shared goal-setting, which involve addressing the needs and expectations of individuals with FS from the beginning of their treatment. This approach empowers individuals to actively engage in their journey toward recovery [47].

The majority of responses from individuals with FS indicated the presence of negative and catastrophizing thoughts about their condition. Many believed their joint damage to be irreversible and their return to their previous activities to be impossible as well. Furthermore, most respondents reported feelings of fear, low mood, being overwhelmed, and apprehension about the long-lasting nature of their condition. It is noteworthy that FS extends beyond personal health - impacting also familial and sociocultural domains, and therefore resulting in changes to physical and mental well-being, and a disrupted sense of self [19, 21]. Psychological factors should be comprehensively assessed from the outset, using validated patient-reported measurement scales, which are essential for capturing how the disease impacts the subjects’ overall well-being [48]. However, most PTs reported using non-standardized methods or relying solely on the patient’s medical history, raising concerns about incomplete assessment of these crucial psychological aspects.

Preferred therapeutic strategies

Subjects with FS and PTs agreed on the approach to enhance compliance and motivation in a home exercise program. PTs emphasized the importance of identifying potential barriers to adherence - such as low self-efficacy and difficulties with exercise recall - actively supporting and promoting adherence [49]. Individuals with FS showed a preference for combining corticosteroid injections with physiotherapy as an additional therapy to manage the painful phase.

Corticosteroid injections were seen as pivotal in pain management, overcoming concerns and potential adverse effects [19, 50]. Notably, preferences expressed by FS individuals aligned with PTs, indicating agreement with subjects’ expectations and adherence to current evidence [8, 51, 52].

Despite evidence suggesting otherwise [53], a minority of PTs and subjects with FS favored electrophysical agents for managing the painful phase. PTs must adhere to evidence-based recommendations, emphasizing the need for an educational approach to clearly communicate the benefits of therapeutic interventions to individuals with FS. This ensures treatment strategies are optimized and based on solid evidence.

Strength and limitation of this study

This study was the first attempt to understand the agreement between the knowledge, skills, and strategies of PTs with the needs, perceptions, and beliefs of individuals with FS, serving as a baseline for future investigations.

Subjects were strictly selected based on inclusion criteria from international guidelines [12] to prevent the inclusion of individuals with conditions that mimic FS (i.e. glenohumeral arthritis, neoplasms, or posterior dislocation) [54]. Subjects were not differentiated based on their FS phase, making our results applicable to individuals at any stage of FS.

Furthermore, the number of questionnaires obtained from PTs supports the generalizability of our results [27].

However, the present survey assessed the sample using a non-a-priori validated questionnaire, which may have implications for the robustness of the results. Additionally, our survey included only 110 subjects with FS; these factors could potentially limit the generalizability of our findings in that population. Nonetheless, it is noteworthy that our sample size remains one of the largest recruited worldwide for a survey on FS.

Future perspectives

Future studies should aim to investigate the needs, perceptions, and beliefs of subjects with FS using validated questionnaires to gain a more comprehensive understanding of their perspectives. Specifically, psychological domains should be assessed using validated patient-reported outcome measures, and a tailored psychological profile of individuals with FS should be developed. This approach would enable PTs to enhance their proficiency in addressing psychological factors, potentially also through multidisciplinary collaboration, to improve treatment outcomes.

It is essential to continue investigating the needs, perceptions, and beliefs of individuals suffering from FS, to ensure they do not feel misunderstood by healthcare professionals. Moreover, it is crucial to consistently assess their priorities. By prioritizing these aspects and understanding their goals, healthcare providers can potentially reduce dissatisfaction, build trust in treatment, alleviate frustration, and improve treatment adherence among subjects with FS.

Conclusion

This study revealed a general agreement between subjects and PTs on aspects such as the therapeutic relationship, the importance of education and pathology management, strategies to enhance compliance and motivation, and preferences for additional pain management interventions. However, significant discrepancies emerged regarding perceptions of physiotherapy effectiveness, primary treatment goals, subjects’ priorities, and the importance of psychological assessment.

Given these differences, it is crucial for PTs to undergo pathology-specific training and develop advanced educational skills- including a deeper understanding of the psychological dimension of FS and individuals’ needs and expectations. By focusing on a patient-centered care within a multidisciplinary framework that prioritizes individual preferences, PTs can improve treatment adherence, achieve better outcomes, and increase overall patient satisfaction.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Appendix 1

Acknowledgements

The authors want to thank all physiotherapists and subjects that completed the survey.

Author contributions

Concept / idea: FB, DFResearch design: FB, SSWriting: FB, SS, DF, MC, AA, FSData collection: FB, MCData analysis: DF, FB, MCProject management: FB, SSConsultation (including review of manuscript before submitting): FB, SS, DF, MC, AA, FSFinal approval of the Manuscript: FB, SS, DF, MC, AA, FS.

Funding

This research received no specific grant from any funding agency in the public, commercial or non-profit sectors.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and informed consent to participate

Ethical approval was obtained from the Ethics Committee of University of Molise (Italy) with the registration number 10–11/2023. All the study-related procedures were performed according to the principles of the Declaration of Helsinki. Informed consent to participate was provided by all subjects included.

Permission to reproduce material from other sources

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
REFERENCE LIST

1. Cho CH Lee YH Kim DH Lim YJ Baek CS Kim DH Definition Diagnosis, treatment, and prognosis of frozen shoulder: a Consensus Survey of Shoulder specialists Clin Orthop Surg 2020 12 1 60 7 32117540
Cho CH, Lee YH, Kim DH, Lim YJ, Baek CS, Kim DH, Definition. Diagnosis, treatment, and prognosis of frozen shoulder: a Consensus Survey of Shoulder specialists. Clin Orthop Surg. 2020;12(1):60–7. 10.4055/cios.2020.12.1.60. Epub 2020 Feb 13. PMID: 32117540; PMCID: PMC7031440.32117540
2. Lewis J Frozen shoulder contracture syndrome - aetiology, diagnosis and management Man Ther 2015 20 1 2 9 25107826
Lewis J. Frozen shoulder contracture syndrome - aetiology, diagnosis and management. Man Ther. 2015;20(1):2–9. 10.1016/j.math.2014.07.006. Epub 2014 Jul 18. PMID: 25107826.25107826
3. Mertens MG, Meeus M, Lluch Girbes E, Dueñas L, Twickler MT, Verborgt O, Struyf F. Differences in biomechanical and metabolic factors between patients with frozen shoulder and asymptomatic individuals. A cross-sectional study. Musculoskelet Sci Pract. 2024;72:102980. 10.1016/j.msksp.2024.102980. Epub ahead of print. PMID: 38820869.
4. Millar NL, Meakins A, Struyf F, Willmore E, Campbell AL, Kirwan PD, Akbar M, Moore L, Ronquillo JC, Murrell GAC, Rodeo SA. Frozen shoulder. Nat Rev Dis Primers. 2022;8(1):59. 10.1038/s41572-022-00386-2. PMID: 36075904.
5. Brindisino F Venturin D Bartoli M Caselli S Pellicciari L Poser A Psychometric properties of the disability of arm shoulder and hand (DASH) in subjects with frozen shoulder: a reliability and validity study BMC Musculoskelet Disord 2024 25 1 260 38566086
Brindisino F, Venturin D, Bartoli M, Caselli S, Pellicciari L, Poser A. Psychometric properties of the disability of arm shoulder and hand (DASH) in subjects with frozen shoulder: a reliability and validity study. BMC Musculoskelet Disord. 2024;25(1):260. 10.1186/s12891-024-07371-8. PMID: 38566086; PMCID: PMC10986124.38566086
6. Mertens MG, Meeus M, Verborgt O, Girbes EL, Horno SM, Aguilar-Rodriguez M, Dueñas L, Navarro-Ledesma S, Fernandez-Sanchez M, Luque-Suarez A, Struyf F. Exploration of the clinical course of frozen shoulder: a longitudinal multicenter prospective study of functional impairments. Braz J Phys Ther. 2023 Jul-Aug;27(4):100539. Epub 2023 Aug 23. PMID: 37639942; PMCID: PMC10474583.
7. Wong CK Levine WN Deo K Kesting RS Mercer EA Schram GA Strang BL Natural history of frozen shoulder: fact or fiction? A systematic review Physiotherapy 2017 103 1 40 7 27641499
Wong CK, Levine WN, Deo K, Kesting RS, Mercer EA, Schram GA, Strang BL. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy. 2017;103(1):40–7. 10.1016/j.physio.2016.05.009. Epub 2016 Jun 21. PMID: 27641499.27641499
8. Challoumas D Biddle M McLean M Millar NL Comparison of treatments for frozen shoulder: a systematic review and Meta-analysis JAMA Netw Open 2020 3 12 e2029581 33326025
Challoumas D, Biddle M, McLean M, Millar NL. Comparison of treatments for frozen shoulder: a systematic review and Meta-analysis. JAMA Netw Open. 2020;3(12):e2029581. 10.1001/jamanetworkopen.2020.29581. PMID: 33326025; PMCID: PMC7745103.33326025
9. Mertens MG Meeus M Verborgt O Vermeulen EHM Schuitemaker R Hekman KMC van der Burg DH Struyf F An overview of effective and potential new conservative interventions in patients with frozen shoulder Rheumatol Int 2022 42 6 925 36 34487209
Mertens MG, Meeus M, Verborgt O, Vermeulen EHM, Schuitemaker R, Hekman KMC, van der Burg DH, Struyf F. An overview of effective and potential new conservative interventions in patients with frozen shoulder. Rheumatol Int. 2022;42(6):925–36. 10.1007/s00296-021-04979-0. Epub 2021 Sep 6. PMID: 34487209.34487209
10. Zavala-González J, Pavez-Baeza F, Gutiérrez-Espinoza H, Olguín-Huerta C. The effectiveness of joint mobilization techniques for range of motion in adult patients with primary adhesive capsulitis of the shoulder: a systematic review and meta-analysis. Medwave. 2018;18(5):e7265. Spanish, English. 10.5867/medwave.2018.05.7265. PMID: 30312288.
11. Zhang R Wang Z Liu R Zhang N Guo J Huang Y Extracorporeal shockwave therapy as an adjunctive therapy for frozen shoulder: a systematic review and Meta-analysis Orthop J Sports Med 2022 10 2 23259671211062222 35141337
Zhang R, Wang Z, Liu R, Zhang N, Guo J, Huang Y. Extracorporeal shockwave therapy as an adjunctive therapy for frozen shoulder: a systematic review and Meta-analysis. Orthop J Sports Med. 2022;10(2):23259671211062222. 10.1177/23259671211062222. PMID: 35141337; PMCID: PMC8819773.35141337
12. Kelley MJ Shaffer MA Kuhn JE Michener LA Seitz AL Uhl TL Godges JJ McClure PW Shoulder pain and mobility deficits: adhesive capsulitis J Orthop Sports Phys Ther 2013 43 5 A1 31 23636125
Kelley MJ, Shaffer MA, Kuhn JE, Michener LA, Seitz AL, Uhl TL, Godges JJ, McClure PW. Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther. 2013;43(5):A1–31. 10.2519/jospt.2013.0302. Epub 2013 Apr 30. PMID: 23636125.23636125
13. Cucchi D, Di Giacomo G, Compagnoni R, Castricini R, Formigoni C, Radici M, Melis B, Brindisino F, De Giorgi S, De Vita A, Lisai A, Mangiavini L, Candela V, Carrozzo A, Pannone A, Menon A, Giudici LD, Klumpp R, Padua R, Carnevale A, Rosa F, Marmotti A, Peretti GM, Berruto M, Milano G, Randelli P, Bonaspetti G, De Girolamo L. A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus. Knee Surg Sports Traumatol Arthrosc. 2024;32(1):37–46. 10.1002/ksa.12017. Epub 2024 Jan 11. PMID: 38226696.
14. Tedla JS Sangadala DR Proprioceptive neuromuscular facilitation techniques in adhesive capsulitis: a systematic review and meta-analysis J Musculoskelet Neuronal Interact 2019 19 4 482 91 31789299
Tedla JS, Sangadala DR. Proprioceptive neuromuscular facilitation techniques in adhesive capsulitis: a systematic review and meta-analysis. J Musculoskelet Neuronal Interact. 2019;19(4):482–91. PMID: 31789299; PMCID: PMC6944810.31789299
15. Mertens MG Meert L Struyf F Schwank A Meeus M Exercise Therapy is effective for improvement in range of motion, function, and Pain in patients with frozen shoulder: a systematic review and Meta-analysis Arch Phys Med Rehabil 2022 103 5 998 e101214 34425089
Mertens MG, Meert L, Struyf F, Schwank A, Meeus M. Exercise Therapy is effective for improvement in range of motion, function, and Pain in patients with frozen shoulder: a systematic review and Meta-analysis. Arch Phys Med Rehabil. 2022;103(5):998–e101214. Epub 2021 Aug 21. PMID: 34425089.34425089
16. Rawat P, Eapen C, Seema KP. Effect of rotator cuff strengthening as an adjunct to standard care in subjects with adhesive capsulitis: a randomized controlled trial. J Hand Ther 2017 Jul-Sep;30(3):235–e2418. 10.1016/j.jht.2016.10.007. Epub 2016 Nov 21. PMID: 27884497.
17. Jones S Hanchard N Hamilton S Rangan A A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder BMJ Open 2013 3 9 e003452 24078753
Jones S, Hanchard N, Hamilton S, Rangan A. A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder. BMJ Open. 2013;3(9):e003452. 10.1136/bmjopen-2013-003452. PMID: 24078753; PMCID: PMC3787409.24078753
18. Painful Shoulder. Exercise can reduce Pain and improve mobility and function. J Orthop Sports Phys Therapy 2020;50:3, 142–142.
19. King WV Hebron C Frozen shoulder: living with uncertainty and being in no-man’s land Physiother Theory Pract 2023 39 5 979 93 35164645
King WV, Hebron C. Frozen shoulder: living with uncertainty and being in no-man’s land. Physiother Theory Pract. 2023;39(5):979–93. Epub 2022 Feb 14. PMID: 35164645.35164645
20. Brindisino F Silvestri E Gallo C Venturin D Di Giacomo G Peebles AM Provencher MT Innocenti T Depression and anxiety are Associated with worse subjective and functional baseline scores in patients with frozen shoulder contracture syndrome: a systematic review Arthrosc Sports Med Rehabil 2022 4 3 e1219 34 35747628
Brindisino F, Silvestri E, Gallo C, Venturin D, Di Giacomo G, Peebles AM, Provencher MT, Innocenti T. Depression and anxiety are Associated with worse subjective and functional baseline scores in patients with frozen shoulder contracture syndrome: a systematic review. Arthrosc Sports Med Rehabil. 2022;4(3):e1219–34. 10.1016/j.asmr.2022.04.001. PMID: 35747628; PMCID: PMC9210488.35747628
21. Lyne SA Goldblatt FM Shanahan EM Living with a frozen shoulder - a phenomenological inquiry BMC Musculoskelet Disord 2022 23 1 318 35379207
Lyne SA, Goldblatt FM, Shanahan EM. Living with a frozen shoulder - a phenomenological inquiry. BMC Musculoskelet Disord. 2022;23(1):318. 10.1186/s12891-022-05251-7. PMID: 35379207; PMCID: PMC8978403.35379207
22. Brindisino F, Minnucci S, Sergi G, Lorusso M, Struyf F, Innocenti T. Does the psychological profile of a patient with frozen shoulder predict future outcome? A systematic review. Physiother Res Int. 2023 Oct 22:e2056. doi: 10.1002/pri.2056. Epub ahead of print. PMID: 37867399.
23. Daluiso-King G Hebron C Is the biopsychosocial model in musculoskeletal physiotherapy adequate? An evolutionary concept analysis Physiother Theory Pract 2022 38 3 373 89 32546079
Daluiso-King G, Hebron C. Is the biopsychosocial model in musculoskeletal physiotherapy adequate? An evolutionary concept analysis. Physiother Theory Pract. 2022;38(3):373–89. Epub 2020 Jun 16. PMID: 32546079.32546079
24. Nijs J Roussel N van Paul C Köke A Smeets R Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment Man Ther 2013 18 2 96 102 23273516
Nijs J, Roussel N, van Paul C, Köke A, Smeets R. Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther. 2013;18(2):96–102. Epub 2012 Dec 28. PMID: 23273516.23273516
25. Karpinski K Plachel F Gerhardt C Saier T Tauber M Auffarth A Akgün D Moroder P Different expectations of patients and surgeons with regard to rotator cuff repair J Shoulder Elb Surg 2022 31 5 1096 105
Karpinski K, Plachel F, Gerhardt C, Saier T, Tauber M, Auffarth A, Akgün D, Moroder P. Different expectations of patients and surgeons with regard to rotator cuff repair. J Shoulder Elb Surg. 2022;31(5):1096–105. Epub 2022 Feb 9. PMID: 35149203.
26. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34. 10.2196/jmir.6.3.e34. Erratum in: doi:10.2196/jmir.2042. PMID: 15471760; PMCID: PMC1550605.
27. Taherdoost H, Determining Sample Size; How to Calculate Survey Sample Size. (2017). International Journal of Economics and Management Systems, 2017;2, Available at SSRN: https://ssrn.com/abstract=3224205
28. https://www.surveymonkey.com/mp/sample-size-calculator/
29. Indicatori_demografici.pdf (istat.it).
30. Brindisino F, Matteuzzi I, Bury J, Mc Creesh K, Littlewood C. (2020). Rotator cuff disorders: a survey of current (2018) Italian physiotherapy practice. Univ Limerick J Contribution. https://hdl.handle.net/10344/8823
31. Brindisino F, De Santis A, Rossettini G, Pellicciari L, Filipponi M, Rollo G, Gibson J. Post-surgery rehabilitation following rotator cuff repair. A survey of current (2020) Italian clinical practice. Disabil Rehabil. 2022;44(17):4689–4699. doi: 10.1080/09638288.2021.1916628. Epub 2021 May 4. PMID: 33945358.
32. Brindisino F Ristori D Lorusso M Miele S Pellicciari L Rossettini G Bonetti F Heick JD Testa M Subacromial impingement syndrome: a survey of Italian physiotherapists and orthopaedics on diagnostic strategies and management modalities Arch Physiother 2020 10 16 32905154
Brindisino F, Ristori D, Lorusso M, Miele S, Pellicciari L, Rossettini G, Bonetti F, Heick JD, Testa M. Subacromial impingement syndrome: a survey of Italian physiotherapists and orthopaedics on diagnostic strategies and management modalities. Arch Physiother. 2020;10:16. 10.1186/s40945-020-00087-7. PMID: 32905154; PMCID: PMC7465722.32905154
33. Littlewood C Mazuquin B Moffatt M Bateman M Rehabilitation following rotator cuff repair: a survey of current practice (2020) Musculoskelet Care 2021 19 2 165 71
Littlewood C, Mazuquin B, Moffatt M, Bateman M. Rehabilitation following rotator cuff repair: a survey of current practice (2020). Musculoskelet Care. 2021;19(2):165–71. 10.1002/msc.1514. Epub 2020 Sep 17. PMID: 32939967.
34. Pieters L Voogt L Bury J Littlewood C Feijen S Cavaggion C Struyf F Rotator CUFF disorders: a survey of current physiotherapy practice in Belgium and the Netherlands Musculoskelet Sci Pract 2019 43 45 51 31228812
Pieters L, Voogt L, Bury J, Littlewood C, Feijen S, Cavaggion C, Struyf F. Rotator CUFF disorders: a survey of current physiotherapy practice in Belgium and the Netherlands. Musculoskelet Sci Pract. 2019;43:45–51. 10.1016/j.msksp.2019.06.001. Epub 2019 Jun 17. PMID: 31228812.31228812
35. Smythe A White J Littlewood C Bury J Haines T Malliaras P Physiotherapists deliver management broadly consistent with recommended practice in rotator cuff tendinopathy: an observational study Musculoskelet Sci Pract 2020 47 102132 32148327
Smythe A, White J, Littlewood C, Bury J, Haines T, Malliaras P. Physiotherapists deliver management broadly consistent with recommended practice in rotator cuff tendinopathy: an observational study. Musculoskelet Sci Pract. 2020;47:102132. 10.1016/j.msksp.2020.102132. Epub 2020 Feb 25. PMID: 32148327.32148327
36. Faletra A Bellin G Dunning J Fernández-de-Las-Peñas C Pellicciari L Brindisino F Galeno E Rossettini G Maselli F Severin R Mourad F Assessing cardiovascular parameters and risk factors in physical therapy practice: findings from a cross-sectional national survey and implication for clinical practice BMC Musculoskelet Disord 2022 23 1 749 35927658
Faletra A, Bellin G, Dunning J, Fernández-de-Las-Peñas C, Pellicciari L, Brindisino F, Galeno E, Rossettini G, Maselli F, Severin R, Mourad F. Assessing cardiovascular parameters and risk factors in physical therapy practice: findings from a cross-sectional national survey and implication for clinical practice. BMC Musculoskelet Disord. 2022;23(1):749. 10.1186/s12891-022-05696-w. PMID: 35927658; PMCID: PMC9351255.35927658
37. Mourad F Yousif MS Maselli F Pellicciari L Meroni R Dunning J Puentedura E Taylor A Kerry R Hutting N Kranenburg HA Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists Chiropr Man Th 2022 30 1 38
Mourad F, Yousif MS, Maselli F, Pellicciari L, Meroni R, Dunning J, Puentedura E, Taylor A, Kerry R, Hutting N, Kranenburg HA. Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists. Chiropr Man Th. 2022;30(1):38. 10.1186/s12998-022-00449-x. PMID: 36096835; PMCID: PMC9465888.
38. Wickham Welcome to the Tidyverse J Open Source Softw 2019 4 43 1686
Wickham, et al. Welcome to the Tidyverse. J Open Source Softw. 2019;4(43):1686. 10.21105/joss.01686.
39. Hollmann L Halaki M Kamper SJ Haber M Ginn KA Does muscle guarding play a role in range of motion loss in patients with frozen shoulder? Musculoskelet Sci Pract 2018 37 64 8 29986193
Hollmann L, Halaki M, Kamper SJ, Haber M, Ginn KA. Does muscle guarding play a role in range of motion loss in patients with frozen shoulder? Musculoskelet Sci Pract. 2018;37:64–8. 10.1016/j.msksp.2018.07.001. Epub 2018 Jul 6. PMID: 29986193.29986193
40. Abrassart S Kolo F Piotton S Chih-Hao Chiu J Stirling P Hoffmeyer P Lädermann A Frozen shoulder is ill-defined. How can it be described better? EFORT Open Rev 2020 5 5 273 9 32509332
Abrassart S, Kolo F, Piotton S, Chih-Hao Chiu J, Stirling P, Hoffmeyer P, Lädermann A. Frozen shoulder is ill-defined. How can it be described better? EFORT Open Rev. 2020;5(5):273–9. PMID: 32509332; PMCID: PMC7265085.32509332
41. Louw A Zimney K Puentedura EJ Diener I The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature Physiother Theory Pract 2016 32 5 332 55 27351541
Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2016;32(5):332–55. Epub 2016 Jun 28. PMID: 27351541.27351541
42. Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, Dixon J, Atkinson G, Cooper K, Martin DJ. Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. J Pain. 2019;20(10):1140.e1-1140.e22. 10.1016/j.jpain.2019.02.011. Epub 2019 Mar 1. PMID: 30831273.
43. Silva Guerrero AV, Maujean A, Campbell L, Sterling M. A Systematic Review and Meta-Analysis of the Effectiveness of Psychological Interventions Delivered by Physiotherapists on Pain, Disability and Psychological Outcomes in Musculoskeletal Pain Conditions. Clin J Pain. 2018;34(9):838–857. 10.1097/AJP.0000000000000601. PMID: 29554030.
44. Chris J, Main LA, Ballengee SZ, George, Jason M, Beneciuk CM, Greco, Corey B, Simon. Psychologically informed practice: the importance of communication in clinical implementation, physical therapy, 2023;103(7):pzad047, 10.1093/ptj/pzad047
45. Martinez-Calderon J Zamora-Campos C Navarro-Ledesma S Luque-Suarez A The role of self-efficacy on the prognosis of Chronic Musculoskeletal Pain: a systematic review J Pain 2018 19 1 10 34 28939015
Martinez-Calderon J, Zamora-Campos C, Navarro-Ledesma S, Luque-Suarez A. The role of self-efficacy on the prognosis of Chronic Musculoskeletal Pain: a systematic review. J Pain. 2018;19(1):10–34. Epub 2017 Sep 20. PMID: 28939015.28939015
46. Hush JM, Cameron K, Mackey M. Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Phys Ther. 2011;91(1):25–36. 10.2522/ptj.20100061. Epub 2010 Nov 11. PMID: 21071504.
47. Hutting N Caneiro JP Ong’wen OM Miciak M Roberts L Patient-centered care in musculoskeletal practice: key elements to support clinicians to focus on the person Musculoskelet Sci Pract 2022 57 102434 34376367
Hutting N, Caneiro JP, Ong’wen OM, Miciak M, Roberts L. Patient-centered care in musculoskeletal practice: key elements to support clinicians to focus on the person. Musculoskelet Sci Pract. 2022;57:102434. 10.1016/j.msksp.2021.102434. Epub 2021 Aug 5. PMID: 34376367.34376367
48. Tesio L Functional assessment in rehabilitative medicine: principles and methods Eura Medicophys 2007 43 4 515 23 18084176
Tesio L. Functional assessment in rehabilitative medicine: principles and methods. Eura Medicophys. 2007;43(4):515–23. PMID: 18084176.18084176
49. Picha KJ Howell DM A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy Musculoskelet Care 2018 16 1 233 7
Picha KJ, Howell DM. A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy. Musculoskelet Care. 2018;16(1):233–7. 10.1002/msc.1194. Epub 2017 Apr 12. PMID: 28401666.
50. Bilsborough Smith C, Nadesan K, Cairns M, Chester R, Lewis J. Living with frozen shoulder. Here are the risks. I want the injection. An interpretative phenomenological analysis. Musculoskelet Sci Pract. 2023;65:102755. 10.1016/j.msksp.2023.102755. Epub 2023 Apr 4. PMID: 37172553.
51. Zhang J Zhong S Tan T Li J Liu S Cheng R Tian L Zhang L Wang Y Liu F Zhou P Ye X Comparative efficacy and patient-specific moderating factors of nonsurgical treatment strategies for frozen shoulder: an updated systematic review and network Meta-analysis Am J Sports Med 2021 49 6 1669 79 32941053
Zhang J, Zhong S, Tan T, Li J, Liu S, Cheng R, Tian L, Zhang L, Wang Y, Liu F, Zhou P, Ye X. Comparative efficacy and patient-specific moderating factors of nonsurgical treatment strategies for frozen shoulder: an updated systematic review and network Meta-analysis. Am J Sports Med. 2021;49(6):1669–79. Epub 2020 Sep 17. PMID: 32941053.32941053
52. Ranalletta M Rossi LA Bongiovanni SL Tanoira I Elizondo CM Maignon GD Corticosteroid injections accelerate Pain Relief and recovery of function compared with oral NSAIDs in patients with Adhesive Capsulitis: a Randomized Controlled Trial Am J Sports Med 2016 44 2 474 81 26657263
Ranalletta M, Rossi LA, Bongiovanni SL, Tanoira I, Elizondo CM, Maignon GD. Corticosteroid injections accelerate Pain Relief and recovery of function compared with oral NSAIDs in patients with Adhesive Capsulitis: a Randomized Controlled Trial. Am J Sports Med. 2016;44(2):474–81. Epub 2015 Dec 9. PMID: 26657263.26657263
53. Brindisino F, Girardi G, Crestani M, Fiore A, Giovannico G, Garzonio F, Venturin D, Struyf F. Effectiveness of electrophysical agents in subjects with frozen shoulder: a systematic review and meta-analysis. Disabil Rehabil. 2023 Sep 5:1–22. doi: 10.1080/09638288.2023.2251880. Epub ahead of print. PMID: 37667875.
54. Ewald A Adhesive capsulitis: a review Am Fam Physician 2011 83 4 417 22 21322517
Ewald A. Adhesive capsulitis: a review. Am Fam Physician. 2011;83(4):417–22. PMID: 21322517.21322517
