背景 近年出现较多特色手法治疗肩周炎的随机对照试验(RCT),但缺乏新的关于手法治疗肩周炎有效性和安全性的系统评价.目的 通过Meta分析方法评价手法治疗肩周炎的有效性和安全性,通过亚组分析了解包含"摇法"的手法是否较未包含"摇法"的手法效果更优.方法 计算机检索PubMed、Cochrane Library、Embase、Medline、中国知网(包括中国硕博士学位论文全文数据库、中国优秀硕士学位论文全文数据库)、中国生物医学文献数据库、万方数据知识服务平台中有关手法治疗肩周炎有效性和安全性的RCT,试验组干预措施为手法,对照组干预措施为非药物疗法,检索时间为建库至 2023-03-01.由 2 名研究人员提取资料,并进行质量评价.采用Revman 5.3 软件进行Meta分析.结果 最终共纳入 12 篇文献,893 例肩周炎患者,其中试验组 451 例,对照组 442 例.Meta分析结果显示,视觉模拟疼痛量表(VAS):手法治疗改善VAS程度优于物理治疗、针灸治疗、常 规 治 疗(SMD=1.09,95%CI=0.81~1.37,P<0.000 01;SMD=1.05,95%CI=0.31~1.79,P=0.006;SMD=0.96,95%CI=0.67~1.26,P<0.000 01);手法对照物理治疗的亚组分析结果显示,含"摇法"手法与未含"摇法"手法的效果差异显著(Z=4.39,P=0.04).Constant-Murley(C-M)评分:手法治疗改善C-M评分程度优于物理治疗组(MD=2.79,95%CI=2.27~3.32,P<0.000 01).关节活动度:手法治疗改善被动前屈、被动外展、被动外旋程度优于物理治疗(SMD=1.40,95%CI=0.10~2.70,P=0.03;SMD=1.45,95%CI=0.18~2.71,P=0.02;SMD=1.77,95%CI=0.18~3.36,P=0.03).亚组分析结果显示,在改善被动前屈和被动外展方面,含"摇法"手法与未含"摇法"手法的效果存在显著差异(Z=7.34,P=0.007;Z=2.25,P=0.03).总体有效率:手法治疗总体有效率高于物理治疗(RR=1.16,95%CI=1.02~1.32,P=0.03);手法治疗和针灸治疗总体有效率比较,差异无统计学意义(RR=1.24,95%CI=1.00~1.54,P=0.05).治愈率:手法治疗治愈率优于物理治疗和针灸治疗(RR=3.71,95%CI=1.29~10.67,P=0.01;RR=1.79,95%CI=1.09~2.94,P=0.02).Egger's检验和Begger's检验提示无显著的发表偏倚(P=0.66、0.66).手法操作导致的骨折、其他创伤等案例在纳入研究中均未见报道.结论 现有文献证据表明手法治疗能有效降低肩周炎患者疼痛、肩关节功能障碍,提高患者肩关节活动度、总体有效率、治愈率,含有"摇法"的手法在VAS改善、被动前屈、被动外展方面能进一步提高疗效,总体手法安全性较高,但仍需更多大样本,高质量的RCT进一步证实.
Background In recent years,there have been many randomized controlled trials(RCTs)featuring manipulation for frozen shoulder,but there is a lack of new systematic reviews on the efficacy and safety of manipulation for frozen shoulder.Objective To evaluate the efficacy and safety of manipulation in the treatment of frozen shoulder by Meta-analysis,and understand whether"rotation shoulder joint"could affect the effect of manipulative therapy by subgroup.Methods PubMed,Cochrane Library,Embase,Medline,CNKI,China Biomedical Literature Database,Wanfang Data were searched for RCTs on the efficacy and safety of manipulative therapy for frozen shoulder,with manipulative therapy as the intervention of experimental group and non-pharmacological therapy as the intervention of control group from inception to 2023-03-01.Two investigators extracted data and evaluated the quality.Meta-analysis was performed using Revman 5.3 software.Results A total of 12 RCTs were included in this Meta-analysis,with a total of 893 patients with frozen shoulder,including 451 patients in the experimental group and 442 cases in the control group.Results of Meta-analysis showed that the improvement of VAS by manipulative therapy was better than physical therapy,acupuncture therapy and conventional therapy(SMD=1.09,95%CI=0.81-1.37,P<0.000 01;SMD=1.05,95%CI=0.31-1.79,P=0.006;SMD=0.96,95%CI=0.67-1.26,P<0.000 01);subgroup analysis of manipulative therapy compared with physical therapy showed a significant difference in effect between those with and without"rotation shoulder joint"(Z=4.39,P=0.04).The improvement of Constant-Murley score in manipulative therapy was better than that in physical therapy(MD=2.79,95%CI=2.27-3.32,Z=10.41,P<0.000 1).The improvements of passive flexion(SMD=1.40,95%CI=0.10-2.70,P=0.03),passive abduction(SMD=1.45,95%CI =0.18-2.71,P=0.02)and passive external rotation(SMD=1.77,95%CI=0.18-3.36,P=0.03)by manipulative therapy were better than those in the physical therapy group;subgroup analysis showed a significant difference between the effects of the manipulative therapy with and without"rotation shoulder joint"in improving passive flexion and passive abduction(Z=7.34,P=0.007;Z=2.25,P=0.03).The overall effective rate of manipulative therapy was higher than that of physical therapy(RR=1.16,95%CI=1.02-1.32,P=0.03);there was no statistically significant difference in the overall effective rate between the manipulative therapy and acupuncture therapy(RR=1.24,95%CI=1.00-1.54,P=0.05).The cure rate of manipulative therapy was better than that of physical therapy group(RR=3.71,95%CI=1.29-10.67,P=0.01)and acupuncture group(RR=1.79,95%CI=1.09-2.94,P=0.02).Egger's test and Begger's test suggested no significant publication bias(P=0.66,0.66).Cases of fractures and other traumas caused by manipulative therapy were not reported in the included studies.Conclusion The existing literature evidence shows that manipulation can effectively reduce the pain and shoulder joint dysfunction in patients with frozen shoulder,improve the mobility of shoulder joint,overall effective rate and the cure rate of patients,the manipulative therapy with"rotation shoulder joint"can further improve the efficacy in terms of VAS improvement,passive flexion and passive abduction,the overall safety of manipulative therapy is relatively high,but more large samples and high-quality RCTs are still needed to further confirm the results.