The BMJ's November 4 systematic review and network meta-analysis, with BMJ Group's November 5 research summary
Pulling on a coat or reaching into a cupboard gives frozen-shoulder recovery a practical test. A new BMJ review offers evidence of short-term pain relief from extracorporeal shockwave therapy, while leaving much less certainty about function, lasting recovery, and comparative safety.
In brief
- The November 4 review includes 189 randomized trials, 12,988 adults, and 59 interventions.
- Moderate-certainty evidence suggests shockwave therapy probably reduces pain within three months compared with usual care.
- The findings do not establish an overall best treatment or reliable longer-term recovery benefits.
A pain finding with a time limit
The researchers compared treatments for adhesive capsulitis, commonly called frozen shoulder, using both direct trial comparisons and indirect comparisons across a network. Their short-term window ran through three months after treatment began; the next window covered more than three months through six months.
Against usual care, extracorporeal shockwave therapy produced an estimated 1.97-point greater reduction in pain on a 0-to-10 scale. The 95% confidence interval ranged from 0.97 to 2.97 points of additional reduction. The authors rated this evidence moderate certainty. Although the average estimate exceeded their one-point threshold for clinical importance, the interval included an effect just below it.
Evidence that shockwave therapy improves short-term function or shoulder movement was low certainty. Direct and indirect comparisons disagreed enough to weaken confidence in those results. Usual care also varied across the trials, so the comparator should not be read as one uniform rehabilitation program.
More movement leaves other questions
Manipulation under anesthesia, with or without a steroid injection into the joint, probably improved short-term forward elevation of the arm. The review rated those flexion findings moderate certainty. That result alone cannot establish whether an invasive procedure offers the best balance of benefit and harm for a particular person.
Most trials contributing to the main outcomes had a high risk of bias. Reporting of adverse events was incomplete and inconsistent, preventing a dependable comparison of safety. Missing reports of harm cannot establish that harm did not occur.
The evidence came predominantly from people with primary adhesive capsulitis. Its applicability after shoulder surgery, in secondary adhesive capsulitis, and in some other clinical groups remains uncertain. The review also leaves longer-term effectiveness unresolved.
Keep the activity in the follow-up
For an OT team discussing these findings, a useful next step is to keep pain, measured movement, and the person's chosen activity visible as separate outcomes. A lower pain score cannot by itself answer whether someone can dress independently or reach a shelf comfortably. The paper explicitly cautions against equating measured range of motion with pain-free movement or daily function.
A practical application is to agree on a specific task at the start of care, describe the difficulty, and revisit it alongside the clinical measures. The review did not test that OT approach as a treatment protocol. Decisions about shockwave therapy or a procedure still need an individual assessment, appropriate clinical expertise, and discussion of costs, preferences, and uncertain harms.
When a patient asks what a treatment is likely to change, the answer should name the outcome and the time frame. This review gives the clearest support to early pain relief with shockwave therapy. Whether the improvement lasts and helps the person do more remains a question for follow-up.