frozen_shoulders.pdf

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A review of 11 studies, by Bunker (1998), hasdescribed the arthroscopic appearance of shouldersin people with frozen shoulder, and reportedpathological changes of the rotator interval,including highly vascular nodules and scar tissueat the entrance to the subscapular recess and

around the base of the origin of the long head ofthe biceps. Contracture of the coracohumeralligament was described by Midorikawa et al.(1994) with release of the ligament improvingmovement. The appearance of the glenoid labrum,the subscapularis, the middle and inferior gleno-humeral ligaments, and the tendon of the longhead of the biceps, were all normal in thesestudies.

A number of treatment approaches have beenrecommended for the management of frozenshoulder. These include pain management throughanalgesics, anti-inflammatories, steroid injections

(Carette et al., 2003; Bulgen et al., 1984) andvarious treatment modalities. Management of re-striction is mainly approached through physiother-apy, which commonly involves active and passivestretching and joint mobilizations (Wadsworth,1988). In severe cases of restriction arthrographicdistension (Rizk et al., 1994), surgical capsularrelease (Oglivie-Harris and Myerthall, 1997) ormanipulation under anaesthetic (Pollock et al.,1994) have been advocated.

In spite of the variety of approaches thereremains a lack of evidence that treatment speeds

recovery (Philadelphia Panel, 2001; Green et al.,2000). Therefore, a group of patients with frozenshoulder were assessed and treated with a phy-siotherapy regime, that included soft tissue mobi-lizations (STMs) and therapeutic home exercises, todetermine if therapeutic intervention resulted in ameasurable improvement in shoulder range ofmotion.

Materials and methods

Inclusion criteria

Adults with a differential diagnosis of frozenshoulder were referred from a rheumatologist-runshoulder clinic. Eight patients (2 men and 6 women)consecutively seen for treatment of frozenshoulder, at Addenbrookes NHS Trust in Cambridge,UK were included in this study. All patientsconsented to treatment and were fully informedof the plan and goals of treatment. Diagnosticcriteria of frozen shoulder for inclusion in the

study were:

1. painful, restricted active and passive range ofmotion of the shoulder;

2. capsular pattern of motion restriction;3. an absence of radiological evidence of gleno-

humeral joint arthritis;4. symptoms present for at least 3 months (Cyriax,

1993; Griggs et al., 2000).

Exclusion criteria

Exclusion criteria for this case study series were:

1. local corticosteroid injection to the affectedshoulder within the last 3 months or currentcorticosteroid therapy;

2. neuromuscular disease;3. shoulder symptoms due to other causes;

4. pregnancy;5. history of metastatic cancer or diagnosis ofcancer within 12 months;

6. unstable angina;7. insulin dependent diabetes;8. prior shoulder surgery.

Patients were allowed over-the-counter analge-sics (including non-steroidal anti-inflamatories) asneeded, but no other treatments were allowedduring the course of the treatment if the patientwas to be included in the case study series.

Adherence was monitored via communication withthe referring doctor and by interviewing theindividuals in the study. No patients seen wereexcluded from this series.

Assessments were performed at every visit by theauthor. The primary outcome measure was activerange of motion for shoulder flexion, abduction andexternal rotation. This was assessed using a hand-held goniometer, according to standard methods(Norkin and White, 1995).

For measurement of shoulder flexion, the sta-tionary arm of the goniometer was placed along themidline of the lateral wall of the thorax; the axis ofmotion was 2 cm distal to the lateral aspect of theacromion process; and the motion arm of thegoniometer was placed over the humerus andaligned to the lateral epicondyle of the humerus.

For measurement of shoulder abduction, thestationary arm of the goniometer was placedparallel to the midline of the thorax; the axis ofmotion was 2 cm distal to the posterior aspect ofthe acromion process; and the motion arm of thegoniometer was placed over the posterior aspect ofthe humerus and aligned to the olecrenon processof the humerus.

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For measurement of shoulder external rotation,the stationary arm of the goniometer was placed inthe sagital plane, perpendicular to the sternum;the axis of motion was along the longitudinal axis ofthe humerus; and the motion arm of the goni-ometer was placed along the radius.

In all instances, the stationary arm of thegoniometer followed any compensatory movementof the thorax so that only shoulder motion wasbeing measured.

Treatment

Treatment sessions lasted 30 min. Each session wasinitiated by performing goniometric measurementsof active range of motion of the shoulder. Once themeasurements were recorded, the patients weretreated. Treatment consisted of STM and a home

exercise programme consisting of stretching andisometric strengthening, progressing to resistedexercises as tolerated. A written home exerciseprogramme was provided to patients along with ademonstration by the therapist. Patients wereasked to demonstrate the exercises to the therapistand were instructed when performing their homeexercises to avoid causing pain of greater than a 5out of 10 on a pain scale (10 being the worst).

The goals of treatment were to reduce restric-tions in soft tissue mobility of the periarticularstructures, to increase arthrokinematic and osteo-

kinematic motion of the shoulder joints, to improveshoulder girdle muscle strength, and to help thepatient achieve improved functional use of theaffected limb for their activities of daily living.Patients unaffected limbs were used as their owncontrols. All patients were given the opportunity toexpress their goals as part of the goal-formulationprocess.

Soft tissues around the shoulder girdle werepalpated for the presence of restricted physiologi-cal or accessory motion due to contracture, spasmor fibrosis. Physiological motion of the soft tissues isthat motion which occurs in line with movementdue to muscle contraction; accessory motion of thesoft tissues is that motion which occurs out of lineof the normal movement, due to muscle contrac-tion. Thus, when a muscle contracts it, and theconnected non-contractile soft tissues, eithershorten or lengthen (physiological motion)whereas, when pressure is applied to soft tissue,deformation of the tissues occurs (accessorymotion).

STM was directed towards resolving restrictionsfound during the palpation. The technique utilizedinvolved addressing first superficial layers and then

progressing to deeper tissues as the patientscomfort level allowed. Specific STM techniquesused included effleurage, cross-fibre friction, sus-tained pressure, and prolonged soft tissue approx-imation. These techniques were applied to theareas of soft tissue restriction, or areas adjacent to

the restrictions.The majority of treatment was performed withthe patient in side-lying position, with the affectedarm initially supported on the treatment table. As atissue-relaxation response was palpated, the pa-tient was asked to allow their affected arm to hangforward off the edge of the treatment table. Thisposition placed the posterior capsule and lateralrotators of the shoulder in a position of stretch, fora prolonged period, and allowed greater access tothe deep structures of the posterior aspect of theshoulder. Soft tissue restrictions of the supraspina-tous, infraspinatous and teres minor were fre-

quently palpated and addressed whilst patientswere in this position.

In addition to the side-lying position, patientswere treated in the prone and supine positions. Inthe prone position, the arm was allowed to hang offthe table if tolerated, in order to place a prolongedstretch on the shoulder, and to allow access to thestructures of the posterior axillary wall. Treatmentin the supine position was performed to allowaccess to the anterior structures of the shoulder.Restrictions were primarily found in the proximalaspect of the biceps tendon (long head), the

pectoralis minor and the coracohumeral ligament.The arm was sometimes also brought into horizon-tal adduction, in order to perform further work onthe posterior aspect of the shoulder.

The home exercise programme consisted ofstretching the posterior aspect of the shoulder(Fig. 1) and strengthening the shoulder, initiallywith isometric exercises (Figs. 25) and progressingto resisted exercises through range of motion, usingcommercially available elastic bands. Strengthen-ing exercises included isometric flexion, abduction,external rotation and extension of the shoulder,progressing to the same actions performed isotoni-cally, as able.

Patients were instructed in all exercises andgiven written instructions for their programmes(Figs. 15). The stretching exercise was usuallygiven on the second visit, and the strengtheningexercises were given when a response of improvedrange of motion was noted, by both the therapistand the patient. Strengthening exercises wereprogressed from isometric to resisted, throughpain-free range of motion, when there was notableimprovement of the quality of active motion(as indicated by a reduction in compensatory

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movements such as shoulder shrugging). Instruc-tions for the home exercise programme were to:

1. perform the exercises one to two times per day;2. gradually build up the number of repetitions;3. not force through pain;4. stop performing the exercises if they exacer-

bated symptoms.

Statistical analysis

A two-tailed paired T-test was used to measurechanges within groups from initial to final measure-

ments (Bailey, 1997) using Microsoft Excel.This test was used to assess significance of anychange in range of motion from baseline andis a useful test to use in small studies involvingcontinuous data.

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Figure 2 Shoulder flexion. Stand facing a wall. Gentlypush your arm out forwards against the wall with 25% ofyour strength and hold the contraction for 3 s. Repeat 5times. Gradually increase to 3 sets of 510 repetitions.

Figure 3 Shoulder Abduction. Stand with your right side

against a wall. Gently push your arm out against the wallwith 25% of your strength and hold the contraction for 3 s.Repeat 5 times. Gradually increase to 3 sets of 510repetitions.

Figure 4 Shoulder lateral rotation. Stand with your right

side against a wall. Bend your right arm 901. Gently pushthe back of your right hand out against the wall with 25%of your strength and hold the contraction for 3 s. Repeat 5times. Gradually increase to 3 sets of 510 repetitions.

Figure 1 Posterior shoulder stretch. Stand with yourback leaning against a wall. Hold the affected armstraight out. Hold the back of the elbow and pull the armacross the front of the body. Hold 30 s then relax.



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Results

Patients were seen for an average of 10 visits(SD 2) over a mean of 14 weeks (SD 3).Patients were discharged from physiotherapy when

they reported satisfaction with their shoulderfunction, and the treating therapist felt satisfiedwith the outcome. All patients had significantlyimproved active range of motion.

Mean improvement were:

1. Shoulder flexion 371 (SD 12:4; P 0:0001Table 1).

2. Shoulder abduction 471 (SD 30; P 0:0004Table 2).

3. Shoulder external rotation 211 (SD 9; P0:006 Table 3).

4. A composite total range of motion was calcu-lated by summing flexion, abduction and ex-ternal rotation, in order to compare results witha recently published randomized controlled trial(Carette et al., 2003). A mean change in com-posite range of 1051 (SD 44; P 0:00003) wasachieved.

In Carette et al.s study, patients treated withphysiotherapy three times a week for 4 weeks,corticosteroid injection, a combination of the two,or placebo injection, achieved mean changes in

composite total range of motion of 53.31 (SD 8:8); 74.61 (SD 9:3); 93.21 (SD 9:6); and 34.61(SD 9:3), respectively, at 3 months follow-upand 74.01 (SD 8:8); 84.21 (SD 9:3); 105.21

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Table 1

Table 2

Table 3

Table 4 Mean initial and final active range ofmotion values.

Motion Initial (SD) Final (SD) P

Flexion 941

(13) 1311

(5) 0.00001Abduction 731 (26) 1201 (11) 0.0004External rotation 131 (14) 341 (14) 0.006Composite total 1801 (44) 2841 (20) 0.00003

Abbreviations: SD standard deviation; P significancelevel.

Figure 5 Shoulder extension. Stand with your back

against a wall. Gently push your arm backwards againstthe wall with 25% of your strength and hold thecontraction for 3 s. Repeat 5 times. Gradually increaseto 3 sets of 5 to 10 repetitions.

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(SD 9:6); 57.21 (SD 9:3) at 6-months follow-up. Findings are summarized in Table 4.

Discussion

As a follow-up to a randomized controlled pilotstudy, a series of case studies were performedon patients with frozen shoulder. The series wascarried out by the author because a number ofpatients had been referred too late to be includedas part of the pilot study.

An impairment-based approach to treatment wastaken which was based on the impairments re-vealed during the physiotherapy assessment. Forexample, a finding of impaired mobility of theproximal aspect of the infraspinatous might betreated with STMs to improve that restriction.

This approach has the advantage of giving thetherapist the flexibility to adapt their treatment tothe person, rather than treating the diagnosis.Further, as the patient responds to treatment, thetherapists intervention can be modified in re-sponse to patients improvements, or lack ofprogress.

Although the aetiology and specific nature offrozen shoulder are not well understood, it ispossible to palpate restrictions in the soft tissuessurrounding the affected shoulder. These restric-tions may be secondary to the pathology directly

responsible for the frozen shoulder, or they may beintegral to that process, however, this cannot as yetbe ascertained. As patients in this study improved,fewer soft tissue restrictions were palpable, andtheir active range of motion improved, therefore, arelationship appears to be evident between treat-ment utilizing STMs together with home exercises,and improvement in active range of motion.

Several studies have demonstrated that subjec-tive pain in patients with frozen shoulder improvesover the course of time, and is not greatly affectedby medical intervention. Certainly by a yearfollowing onset of symptoms, there appears to beno difference in the subjective experience of painbetween patients who have had medical interven-tion and those who have not (Carette et al., 2003).Once the initial painful stage of the frozen shouldersubsides the primary complaint most patients seemto experience is functional limitation. This limita-tion appears to be caused primarily by restrictedmovement of the shoulder, and in many casescauses sleep disturbance and psychological dis-tress. Early resolution of impaired shoulder move-ment would therefore appear to be a worthwhilegoal.

Conclusions

An impairment-based treatment approach was usedto treat a small group of patients with stage IIfrozen shoulder with good success, as measured byimproved range of motion and subjective reports of

the patients. STMs directed at specific limitationsof the periarticular structures in combination witha simple home exercise programme appears to bean effective treatment for this typically recalci-trant problem. The patients in this study achieved agreater range of shoulder motion at a mean of 14weeks, compared to those treated in a randomizedcontrolled trial (Carette et al., 2003) measured atboth 3 and 6 months follow-up. Current evidencein the literature does not support physical therapyinterventions for frozen shoulder, and furtherresearch is warranted to elucidate best practicefor treatment of the condition. The treatmenttechniques used in this study appear to be ofbenefit, and larger controlled studies may furtherdefine the key elements for successful resolution offrozen shoulder.

Acknowledgements

This study was supported by funds from the Cam-bridge Arthritis Research Endeavour (CARE).

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