BACKGROUND Despite the availability of numerous treatment modalities for frozen shoulder, spanning from nonsurgical approaches to surgical interventions, a consensus regarding the most effective treatment remains elusive. Current studies emphasize that pain in frozen shoulder affects central nervous system activity and leads to changes in cortical structures, which are responsible for processing sensory information (like pain) and controlling motor functions (like movement). These cortical changes highlight the importance of including the central nervous system in the management of frozen shoulder. It is therefore recommended that treatment should provide more effective management by focusing not only on the shoulder region but also on the cortical areas thought to be affected. QUESTIONS/PURPOSES Among patients treated nonsurgically for frozen shoulder, is graded motor imagery added to a multimodal physical therapy program more effective than multimodal physical therapy alone in terms of (1) Shoulder Pain and Disability Index (SPADI) scores, (2) pain with activities and QuickDASH (Q-DASH) scores, and (3) ROM after 8 weeks of treatment? METHODS In this randomized clinical trial, we considered the following as eligible for inclusion: (1) ROM < 50% compared with the unaffected shoulder, (2) clinically and radiologically confirmed primary frozen shoulder, and (3) 30% loss of joint ROM in at least two planes compared with the unaffected shoulder. Diagnosis of patients was based on patient history, symptoms, clinical examination, and exclusion of other conditions. A total of 38 patients with frozen shoulder were randomly assigned to either the graded motor imagery group (n = 19) or the multimodal physiotherapy group (n = 19). The groups did not differ in age, height, weight, gender, and dominant and affected side. In both groups, there were no losses to follow-up during the study period, and there was no crossover between groups. The multimodal physiotherapy program encompassed a variety of treatments, including stretching exercises, ROM exercises, joint-oriented mobilization techniques, scapular mobilization, strengthening exercises, and the application of cold agents. The graded motor imagery program, as an addition to the multimodal physiotherapy program, included the following steps: (1) left-right discrimination (identifying left and right body parts), (2) motor imagery (mentally visualizing movements), and (3) mirror therapy training (using mirrors to trick the brain into thinking the affected part is moving). Both groups of patients participated in a program of 12 sessions, each lasting approximately 45 minutes, twice a week for 6 weeks. Participants were assessed at baseline, after 6 weeks, and at 8 weeks. The primary outcome was the SPADI score, which ranges from 0 to 100, with higher values denoting greater disability. The minimum clinically important difference (MCID) for SPADI scores is reported to be 13.2 points. Secondary outcomes were shoulder ROM, Numeric Pain Rating Scale activity score (scored from 0 points, indicating "no pain," to 10 points, indicating "worst pain imaginable"), and Q-DASH score (ranging from 0 to 100 points, with a higher score indicating higher functional disability). Repeated-measures analysis of variance was used to compare means between one or more variables based on repeated observations. RESULTS After 8 weeks of treatment, patients treated with graded motor imagery plus multimodal physical therapy experienced greater mean ± SD improvement from baseline in terms of SPADI scores than did the multimodal physical therapy group (65 ± 9 versus 55 ± 12, mean difference 10 points [95% confidence interval 4 to 17 points]; p = 0.01). Graded motor imagery when added to standard therapy did not produce a clinically important difference in pain scores with activity compared with physical therapy alone (7.0 ± 1.3 versus 5.9 ± 1.4, mean difference 1 point [95% CI 0.2 to 2.0 points], which was below our prespecified MCID; p = 0.04). However, improvements in Q-DASH score at 8 weeks were superior in the graded motor imagery group by a clinically important margin (58 ± 6 versus 50 ± 10, mean difference 9 points [95% CI 3 to 14 points], which was below our prespecified MCID; p = 0.01). ROM was generally better in the group that received the program augmented by graded motor imagery, but the differences were generally small. CONCLUSION Adding graded motor imagery to a multimodal physiotherapy program was clinically superior to multimodal physiotherapy alone in improving function in patients with frozen shoulder. However, no clinically superior scores were achieved in ROM or activity-related pain. Additionally, the follow-up period was short, considering the tendency of frozen shoulder to recur. Although adding graded motor imagery provides superiority in many scores and does not require high-budget equipment, the disadvantages such as the difference in some scores being sub-MCID and the need for expertise and experience should not be ignored. Consequently, while graded motor imagery shows promise, further research with longer follow-up periods is recommended to fully understand its benefits and limitations in the treatment of frozen shoulder. LEVEL OF EVIDENCE Level I, therapeutic study.

中文翻译：

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整合分级运动意象训练是否增强了多模式物理治疗计划对肩周炎患者的疗效？一项随机对照试验。


背景 尽管肩周炎有多种治疗方法，从非手术方法到手术干预，但关于最有效治疗方法的共识仍然难以达成。目前的研究强调，肩周炎疼痛会影响中枢神经系统活动并导致皮质结构发生变化，皮质结构负责处理感觉信息（如疼痛）和控制运动功能（如运动）。这些皮质变化突出了将中枢神经系统纳入肩周炎管理的重要性。因此，建议治疗应提供更有效的管理，不仅要关注肩部区域，还要关注被认为受影响的皮质区域。问题/目的 在接受非手术治疗的肩周炎患者中，在 （1） 肩痛和残疾指数 （SPADI） 评分，（2） 活动疼痛和 QuickDASH （Q-DASH） 评分，以及 （3） 治疗 8 周后的 ROM 方面，将分级运动意象添加到多模式物理治疗计划中是否比单独使用多模式物理治疗计划更有效？方法 在这项随机临床试验中，我们认为以下内容符合纳入条件：（1） 与未受影响的肩关节相比，ROM < 50%，（2） 临床和放射学证实的原发性肩周炎，以及 （3） 与未受影响的肩关节相比，至少两个平面的关节 ROM 损失 30%。患者的诊断基于患者病史、症状、临床检查和排除其他疾病。共有 38 例肩周炎患者被随机分配到分级运动意象组 （n = 19） 或多模态物理治疗组 （n = 19）。 各组在年龄、身高、体重、性别、优势侧和患侧方面没有差异。在两组中，研究期间均无失访，组间无交叉。多模式物理治疗计划包括多种治疗方法，包括伸展运动、ROM 运动、以关节为导向的动员技术、肩胛骨动员、力量锻炼和冷剂的应用。分级运动意象计划作为多模式物理治疗计划的补充，包括以下步骤：（1） 左右辨别（识别左右身体部位），（2） 运动意象（在脑海中想象运动），以及 （3） 镜像疗法训练（使用镜子欺骗大脑认为受影响的部分正在移动）。两组患者都参加了一个为期 12 次的课程，每次持续约 45 分钟，每周两次，持续 6 周。参与者在基线、 6 周后和 8 周时进行评估。主要结局是 SPADI 评分，范围从 0 到 100，值越高表示残疾程度越高。据报道，SPADI 评分的最低临床重要差异 （MCID） 为 13.2 分。次要结局是肩关节活动度、数字疼痛评定量表活动评分（评分从 0 分，表示“无痛”到 10 分，表示“可以想象到的最严重的疼痛”）和 Q-DASH 评分（范围从 0 到 100 分，分数越高表示功能障碍程度越高）。重复测量方差分析用于根据重复观察比较一个或多个变量之间的平均值。 结果 治疗 8 周后，与多模态物理治疗组相比，接受分级运动意象联合多模式物理治疗的患者在 SPADI 评分方面的平均 ± SD 较基线改善更大 （65 ± 9 对 55 ± 12，平均差 10 分 [95% 置信区间 4 至 17 分];p = 0.01）。与单独物理治疗相比，将分级运动意象添加到标准治疗中时，活动疼痛评分没有产生临床重要差异 （7.0 ± 1.3 vs 5.9 ±vs 1.4，平均差 1 分 [95% CI 0.2 至 2.0 分]，低于我们预先设定的 MCID;p = 0.04）。然而，分级运动影像组在 8 周时 Q-DASH 评分的改善优于临床重要差距 （58 ± 6 vs 50 ± 10，平均差 9 分 [95% CI 3 至 14 分]，低于我们预先设定的 MCID;p = 0.01）。在接受通过分级运动意象增强的程序的组中，ROM 通常更好，但差异通常很小。结论 在改善肩周炎患者功能方面，在多模式物理治疗计划中加入分级运动意象在临床上优于单独的多模式物理治疗。然而，在 ROM 或活动相关疼痛方面没有获得临床上优异的评分。此外，考虑到肩周炎复发的趋势，随访期很短。尽管添加分级运动图像在许多分数中具有优势并且不需要高预算的设备，但不应忽视缺点，例如某些分数的差异低于 MCID 以及需要专业知识和经验。 因此，虽然分级运动意象显示出希望，但建议进一步进行随访时间更长的研究，以充分了解其在治疗肩周炎中的益处和局限性。证据级别 I 级，治疗研究。