INFORMED CONSENT

The purpose of this form is to assure that you are given sufficient information to make an
informed decision as to whether you will agree to be a subject in a study involving research.
Peyman Cham, hereafter referred to as researcher, is conducting a study looking at intraarticular
corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of
adhesive capsulitis of the shoulder to determine the effectiveness of the interventions in
comparison to one another. Your participation will involve 12 sessions for 1 hour, 3 times per
week for 12 weeks. As a subject, you will be asked to complete self-reported outcome measures.
As a subject, you will be randomly exposed to a treatment group that will involve a steroid
injection or physical therapy care.
The procedures in this study are not considered experimental and part of usual health
care. There are no more risks or discomforts associated with the procedures involved in this
study than those ordinarily encountered in daily life or during the performance of routine
physical or psychological examinations or tests. There may be no direct benefits to you for
participating in this research, but your participation could be helpful in determining the most
optimal and effective treatment method for your condition.
Any information you provide during the study will be recorded in such a way that your
identity will remain anonymous. Anonymity means that number codes or false names will be
used to record your information, only the researcher will have access to the information, and it
will be securely stored in a locked safe. Your identity will never be revealed and information
about the study will be reported in group form only. This means that your name will not be
associated with your information, no one will be able to identify you, and information about the
study will be reported in group form only.
Your participation in this study is completely voluntary. If you choose to participate, you
may change your mind at any point during the study and withdraw your consent. You can
withdraw by notifying Peyman Cham at 716 819 8229 of your desire to withdraw. There is no
penalty or loss of benefits to which you are otherwise entitled if you withdraw from the study, or
if you choose to not participate.
If during the course of the study you have questions about the research, tasks, or
activities you are asked to perform or complete, or your rights as a research subject, you may
contact Eric Jones at 716 822 9894, and all your questions will be answered. You will receive no
payment for participating in this study. The researcher and D'Youville College assume no
liability for any discomfort or injury you may incur as a result of your participation in this study.
If a medical emergency arises during your performance of the procedures in this study, the
researcher will assist you in obtaining medical care at your expense. You are responsible for
obtaining any other medical care on your own, and at your own expense. You should contact
Eric Jones at 716 822 9894, in the event of a research related injury.
You are receiving two copies of this form. Return the signed copy to the researcher and
keep the other for your future reference. If you would like to receive a summary of the results of
the study upon its completion, record your full address on the reverse side of this form.
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My signature below indicates that I understand the procedures to be employed in this study, all
my questions concerning the study have been answered to my satisfaction, and I agree to be a
subject in this study. I also agree to allow the researcher to present his or her findings publicly or
privately, orally or in written form.

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Subjects Signature Date