Patients put a lot of trust in their health care provider to prescribe treatments and interventions that are in their best interests. But most patients have no idea that many health care providers prescribe treatments that have been shown to have little to no effect, and are no better or worse than Mother Nature herself. Worse yet, these treatments are over-utilized, costing the health care consumer a lot of money in co-pays and premiums.

Health care consumerism is critical. Blind faith in one’s provider is no longer safe nor acceptable in the world of health care today.

A patient needs to be educated in order to establish their own series of checks and balances in the health care world. There are many common medical conditions that exemplify the growing need for health care consumerism. In this post, I will start with an orthopedic condition known as frozen shoulder.

Frozen shoulder is oftentimes referred to as adhesive capsulitis. It is a painful condition that presents with limitations in range of motion of the glenohumeral joint. Signs and symptoms can mimic many other shoulder problems. Sadly, “frozen shoulder” can become a bit of a “catch-all” for the patient with non-specific shoulder pain and limitation.

Fortunately for the patient, frozen shoulder is a self-limiting condition. What this means is that it has its own natural history of 18 – 24 months, then it goes away on its own. In that regard, it is much like the common cold – after its onset, it runs its course (regardless of what you do), and then it goes away. When left to its own devices, it resolves itself.

When it comes to treatment, traditional approaches to care have been costly and excessive. These have consisted of modalities for pain relief, heat, stretching, and joint mobilization. Oftentimes, the health care provider suggests that the patient will need long-term treatment of the problem – for example, 2 to 3 times per week for perhaps 8 weeks or more. This is not an uncommon scenario.

Dierks and Stevens (2004) compared exercise within the limits of the patient’s pain with intensive physiotherapy. They found that exercise performed within the limits of pain yielded better results than that with intensive physiotherapy. In other words, it would appear that the patient with a frozen shoulder should be educated with regards to maintaining their range of motion, doing so within the limits of pain, and told to go home and get on with it. It probably isn’t of value to see the physical therapist or chiropractor 2 to 3 times per week ad infinitum for stretching and mobilization, though this happens far more than you would like to believe.

If you are in the 10% that experience long-term problems, and you have failed other conservative care options, then the next option considered is typically a manipulation under anesthetic (MUA). This will oftentimes be followed by 6 to 8 weeks of further conservative care such as physical therapy. As an important note - MUA is not a first-line of treatment in ANY clinical guidelines to date – at least not that I am aware of to date. But this does occur, and can even be “rationalized” as a “long term cost savings” to the patient. Unfortunately, the scientific literature would disagree.

A study by Kivimäki et al (2007) noted that MUA combined with an exercise program did no better than an exercise program alone. The cost of a MUA ranges anywhere from $2,000 to $10,000 depending on the source (and whether it includes payment of the anesthesiologist, surgical center, etc). Six weeks of conservative care could amount to at least $3,000. There is also an increased risk of iatrogenic problems secondary to the manipulation itself.

Tell me now – is this money well-spent for a condition that, in the vast majority of cases, resolves itself?

References:

Wong PLK, Tan HCA. A Review On Frozen Shoulder. Singapore Med J 2010; 51(9) : 694.

Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg 2004; 13:499-502.

Kivimäki J, Pohjolainen T, Malmivaara A, et al. Manipulation under anaesthesia with home exercises versus home exercises alone in the treatment of frozen shoulder: a randomized, controlled trial with 125 patients. J Shoulder Elbow Surg 2007; 16:722-6. Full article.

 Photo credits: smiling_da_vinci