Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Health and Rehabilitation Sciences


MacDermid, Joy C.




Shoulder pain is a common complaint of diabetic patients that causes motion limitations and functional disability. Adhesive capsulitis (AC) is the most common disabling shoulder disorder. There is no optimal non-surgical treatment for managing AC in diabetic patients. Furthermore, the impact of diabetes on shoulder recovery and factors predicting shoulder function following shoulder arthroplasty is not well investigated.

Purpose and Methods

The main purpose of this thesis was to inform clinical practice about the best intervention for managing AC in diabetic patients, and to assess the impact of diabetes on functional outcomes after shoulder arthroplasty, with the following objectives: 1) To systematically review clinical research evaluating non-surgical interventions for managing AC in diabetic patients; 2) To pilot test study procedures and estimating the effects of incorporating a progressive walking program as an adjunct to a regular physiotherapy program for managing AC in diabetic patients; 3) To examine the effect of diabetes on shoulder function and physical health status, And 4) To determine factors that predict shoulder functional outcomes following shoulder arthroplasty.


Eight randomized trials (RCTs) were evaluated in a systematic review. The largest effect size (2.0) was reported for joint mobilization plus exercises. The pilot RCT (n = 8) found that regular physiotherapy (PT) group and regular physiotherapy program plus progressive walking group (PT+) may improve functional performance and other outcomes, with a mean change of PT = 38±17, and PT+ = 6±33 seconds for Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA) test from baseline to six weeks follow-up. A sample size of 89 participants per group is needed for future studies. Diabetic and non-diabetic patients showed significant improvements in function and physical health status following shoulder arthroplasty with no significant differences between groups. At one year after arthroplasty, residual pain significantly predicted poorer shoulder function.


We found that low-quality evidence suggested large effects of joint mobilization plus exercises on AC in people with diabetes. Conducting a large-scale study to assess the effect of incorporating a walking program for managing AC in patients with diabetes is feasible. Patients with and without diabetes may get equal surgical benefits, and residual pain may cause limitations in shoulder function one year after arthroplasty.

Summary for Lay Audience

Frozen Shoulder is a common problem that occurs five times more frequently in patients with diabetes. Frozen Shoulder causes pain and disability. The usual treatments reduce shoulder pain and disability, but these treatments often fail for people with diabetes. Currently, we are not sure what is the best treatment to manage Frozen Shoulder in patients with diabetes. We do not know how diabetes can affect recovery after shoulder replacement surgery. Also, we are not sure what factors can affect function after shoulder replacement surgery.

This thesis includes five papers. The first paper aimed at reviewing the literature of diabetic shoulder. The second paper evaluated the effect of different conservative treatments that reduce pain and disability in patients who have Frozen Shoulder. The third paper tests whether adding a walking program to the usual care will result in better pain relief, motion and function. The fourth paper assesses if diabetes impacts recovery after shoulder replacement surgery. The fifth paper aimed to find factors that might affect function after shoulder replacement surgery.

Results show that exercises and steroid injections may improve shoulder pain and function in patients with diabetes who have Frozen Shoulder. We think it is also possible to conduct a large study to assess if adding a walking program to shoulder exercises would better improve shoulder function in patients with Frozen Shoulders. We found that diabetes does not affect recovery after shoulder replacement surgery. We also found that the presence of pain at one year after surgery may cause shoulder disability.