Frozen Shoulder

[21st century Physio]

Hi All,

Im a University Student. Just have a few questions about effective treatment for adhesive capsulitis.

I'm basically just looking for some Physio's who have experience treating this condition to write what treatment techniques worked best for them. Most of the reading I have done suggests that a corticosteroid injection combined with vigorous shoulder joint mobilisation is most effective?

Also what exactly is hydrodilation and when would you advise this form of treatment to a patient with frozen shoulder?

Cheers,

Simon

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[Physio Dace]

Always a very interesting debate.

Frankly very little evidence exists for mobilisation of true frozen shoulders - and what does exist lacks robustness and any valuable methodological detail. If you mobilise the cervical/throracic spine as suggested you may slightly functional ROM/pain levels but actual passive glenohumeral joint will not change if it is true frozen shoulder. At times this may be a viable option but in my opinion this should only take 1-2 sessions to achieve the desired gains.

Overall I have to agree with sande's approach, particularly from stage 2 onwards in that home/exercise/activity modification should form the mainstay of treatment - doing otherwise is over-servicing.

[112inky]

A colleague of mine has just worked on a review of the literature in relation to Physio Mx of adhesive capsulitis. The finding of which swayed neither way basically supervised neglect showed the same outcome 2 years on so all the aggressive mobs to the shoulder- theres no point! The evidence was in agreement with the scapular stability and pain relieving modalities however.

[sanagupta1]

Hi all,
I have been reading some intresting things in relation to the treatment of Frozen shoulder.I was just wondering if there is any evidence based study on effectiveness of using cervical facet mobilisation(C456) in frozen shoulder.

Sana

[Hallamshire Physiotherapy]

I would agree with 'nasde', most 'frozen shoulders' are not 'true' frozen shoulders (one in ten of all the 'frozen shoulders' probably are true frozen shoulders from my clinical experience) and repeated mobs just aggravates the problem. I think you get them functional by a home exercise programme and review them if they show signs of distress or anxiety.

Most of the true frozen shoulders I see seem to have a neck component and I suspect this is the origin of the problem, but by the time they have developed the shoulder limitation it is too late to influence the outcome and treating the neck does not change the movement.


Hallamshire Physiotherapy
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[sanagupta1]

hi,

Neck may be the reason for frozen shoulder..but I was wondering that how early in frozen shoulder, one should think of giving facet joint mobilisation..Are there any studies examining the link between frozen shoulder and neck..it seems intresting and very much possible explnation for frozen shoulder.
But the relation to neck does not seem to support the self limiting / self healing behaviour of frozen shoulder(approx 2 years. If there is pathology at the facet joint..will we call it a referred problem?


sorry too many qusetions..?

Sana gupta

[Hallamshire Physiotherapy]

Frozen shoulder is not self limiting from the research that I have seen. After 2 years the patient returns to some function but problems persist in some form. I can't remember the author but it was presented at a British Shoulder and Elbow Surgeons Conference a few years ago.

Hallamshire Physiotherapy

[sanagupta1]

hi,

Thats what I have always experienced but i have come across various cases in my experience who responded well to mobilisation and improved in less than 3 months. I think there are instances when mobilisation works or its just chance?? I am not sure. At present I am seeing a lady with restricted shoulder movement only 4 weeks old..do u think facet joint mobilsation will work on her??

Sanagupta

[sheri]

Hi Ginger

Firstly i live in Melbourne and would be interested in finding out more about your courses/occupation (you mention student? are you a uni lecturer or just course lecturer).
i read your post on rehab edge. the only thing that concerns me is the fact that i may be missing something-apart from the theory BEHIND using continuous passive mobilisations, how is the technique any different to the Maitland mobes?

Look forward to hearing from you

Sheri

[ginger]

Hi sheri, this is a piece I posted on rehabedge some years ago, it remains relevant. I am doing a series of four lectures in rooms provided by RMIT in the month of October, I will post the details here when they are known.

Re your request for detail on the continuous method, I offer here a short examination of the method I call Continuous Mobilisation. Applied to spinal zygo apophyseal facet joints with care, this method provides the means to restore normal pain free function to hypomobile facets joints.

As this is a brief consideration of the method and reliable results considerably influenced by application, I urge the reader to practice on live humans to bridge the skills gap should there be one.

I will skip any further introduction and mention of physiological detail and examination protocols , these will be/have been dealt with elsewhere.

METHOD.part one
unilateral passive mobilisation of facet joints requires therapists hands to be a connection to the ongoing protective state implicit in the activity associated with spinal joint pain. As such it is necessary to be sensitive to changes in the state of tone of intrinsic muscles intimate to facet joints. Any attempt to move a facet joint which has a protective hypertonic load ( of muscle) will be met with resistance and pain. Pain can be of differing intensities, feel and irritability. ( by irritability I refer to the prospect that any attempt to move joints in a highly irritated state may be followed by pain not associated with passive or active movements, initiated by that attempt to mobilise)
By this sensitivity it will be noted that as passive movements are attempted and continued, a changing picture of pain and resistance emerges.
Movement is applied in a natural direction predicted by the angles of therapists hand and arm, where he/she stands at the side of the patient nearest to the joint being mobilised.
Pressure is sufficient only to acknowledge both pain and resistance at the joint. Continuous movements then at a rate of 2 per second are provided such that both these variables are able to be monitored. At or around 30 seconds of continuous mobs there will be noted the first level of alteration to both variables. That is , pain will be felt to reduce at the same time as muscular tension providing resistance reduces. Further attention to the same joint will produce still more reductions till A. either no further improvements are noted, or B. a full pain free resistance free condition is established.
The effect of successful mobilisation will be noted in several ways.
Active and passive facet ROM will be improved. This will be associated with improvements to comfort locally as well as distaly. It will be noted that as these local improvements are appreciated , so will the prospect of a reduction in distal pain and dysfunction associated with the spinal segmental innervation of those related structures.
The improvements to facet mobility are essentially permanent. That is, provided that there are no severe local irritations given by pathology or injury, protective responses leading to facet hypomobility and inflammatory events of joint and nerves are restored to normal. Inflammatory events associated with these states of hypomobility are usually dissipated over a 24 hour post treatment period. Some liklihood of a post treatment painfull facet joint period exists. This can be viewed as an unfortunate feature of this form of treatment , but not a contraindication for it's use. In my experience about 20 percent of individuals will experiece a post Rx period of tenderness, which last pproximately 24 hrs. Usually noted is a highly irritated facet joint, or group of joints prior to Rx, in this group.
Summary
Continuous facet joint mobs is NOT
forcefull
difficult
contraindicated by the presence of age or disease related arthropathies, "instability", or previous injury .
Continuous facet joint mobs DOES NOT require
Exquisite attention to detail in the placement of your thumbs- at or over the lateral mass , as near as able to the facet joint will be fine. Provided that , the two basic criteria are met, that is resistance and pain.
Periods of five minutes of continuous mobs are commonly associated with continued improvements to some facet joints as above, longer periods are usefull also , though strain the limits of the thumb comfort of those new to the method. Practice will lengthen considerably the time able to comfortably mobilise. A lot of pressure is rarely more useful than less, pain and resistance is the key.
Geoff Fisher

[ginger]

Sheri, the effectiveness of CM , is usually long term. That is, were an uninjured person with spinal pain and limited movements ( the majority), who has no underlying hyperirritable state caused by disease ( such as lupus, RA, etc ), will in most cases undergo a series of one to three treatments of 30 minutes duration ( the standard at my practice ) , where CM is applied to relevant joints that display protective behaviour ( see below ), then I would expect a resolution to that behaviour incrementaly over the treatment period. I would normally expect and see that the restoration of normal facet movement behaviour is associated with returns to active ROM and function also, seen immediately during and post Rx.
The more exciting prospect however lies not so much with the routine normalising of spinal movements and comfort, but in the effect this method has on irritated nerves , associated and intimate to facet joints. As a physio , you will no doubt be aware of standard protocols regarding testing for the presence of neuralgic events, somatic referred pain.
Over my twenty five years of using CM , I have come to rely on it's effect in providing a means to reveal these events, by eliminating symptoms that can be said to have been caused by nerve irritation. A common one where this is seen is in cases of so called 'frozen shoulder', otherwise known as 'adhesive capsulitis '. My approach is first to establish beyond any doubt, wether nerves related to the shoulder joint are , or are not involved as cause. Invariably , by using CM to the central cervical and upper thoracic facet joints , by turning off protective behaviour there, resolution of the shoulder pain occurs. This effect is permanent, provided that it is possible to achieve resolution at the spine.
As a result of this and similar experiences with CM to other spinal segments , my first approach to any non traumatic pain and dysfunction problem, is to establish normal facet behaviour. I find this a much more reliable way off asserting cause, than any of the protocols that reamain as standard ( and are still taught to physios )
Re protective behaviour , I gather you have read my piece on the physiology of spinal pain, where this concept is detailed, however , briefly. spinal protective behaviour is the incremental powerful series of events , actuated by threat to the central spine, that incurs increases in paraspinal muscle tone, such that a nociceptive reflex nerve actuated feedback provides the means to continuously upgrade that protective behaviour. This is then reinforced by inflammatory events focal to facet joint soft issues and mediated by nerves which may incur further increases in tone , pain and dysfunction.
These events are best seen as normal non pathological intrinsic behaviours, with the capacity to prevent further forceful loading of spinal anatomy by a continuous alert mechanism . Turning off these events is the central thrust of attempts to relieve spinal pain and dysfunction, CM being an effective safe one.

[alophysio]

I would like everyone to try this...click on Random1982's name and see what all his posts are about...

...notice how he refers to his website on protocols...

...notice how he doesn't really help or answer specific questions properly...

I suspect he is in it to promote his own website...

I will post this on all of his replies.

If you are going to spruik your website, at least have the decency to contribute to the discussion properly!

[Physio Dace]

Hear hear Alophysio. The above post/link contains no valuable information and is quite embarrassing.

[alophysio]

Hi P.T.,

Perhaps you should have started a new thread but no matter...

To my knowledge, Frozen shoulder is a self limiting condition which doesn't really get better until it wants to despite all the treatments in the world...

I usually advise my patients to wait until the stiffness starts to get better and then see me about the shoulder. Until then, it is maily symptomatic treatment that you will be giving (which doesn't sound like it is working).

CHeers

[mulberry]

i treated a medicaly Dx frozen shoulder during assessment identified her ULNTT was very tight released the neural tension and her frozen shoulder was gone in one treatment session

how cool is that

[ginger]

Bravo Mulberry, Doctors of medicine have only a hazy idea of the true nature of many of the MSK conditions Physiotherapists treat effectively. It pays to form one's own diagnosis each time and consider the doctor's notes as merely a guide. This is certainly true of the so called "frozen shoulder", same when called adhesive capsulitis, rotator cuff syndrome etc. The vast majority of these will be revealed to be neuralgic in nature with appropriate investigation. This condition , as you can tell from reading the posts above , is still not fully understood by many physiotherapists either.
Cheers

[gangaa]

avoid ice.. hot packs, myofascial trigger release and maitland's mobilization will help you..

[estherderu]

So you see, so many people, and just about as many different opinions.

I find myself developing a "freezing" shoulder at the moment and I have dediced to do nothing except exercise, try keep ROM and it this seems to work.
Yes I have pain if I go too far, but by just keeping on doing the things I have always done with maybe a little less speed and certainly less strength, I get by. It has been 6 months now and not getting better yet.

As said before, I have treated so many patients and now its my turn.
I will keep you posted

Esther

[JTrempe]

I am a PT that also had frozen shoulder. During the inflammatory stage I didn't push much. After an injection the pain improved and I did have some co-workers do some mobilizations which helped. It's been about 9 months and it is much better. Listen to your body and push when it feels OK and go easy when it feels inflammed.

Good luck.

[praveen007.pali]

hellow everyone this is praveen from india ,may i please know the details of mitland moblisation?

[macrylinda]

avoid ice.. hot packs, myofascial trigger release and maitland's mobilization will help you..

Bravo Mulberry, Doctors of medicine have only a hazy idea of the true nature of many of the MSK conditions Physiotherapists treat effectively. It pays to form one's own diagnosis each time and consider the doctor's notes as merely a guide. This is certainly true of the so called "frozen shoulder", same when called adhesive capsulitis, rotator cuff syndrome etc. The vast majority of these will be revealed to be neuralgic in nature with appropriate investigation. This condition , as you can tell from reading the posts above , is still not fully understood by many physiotherapists either.

[physio210]

what is the best physiotherapy treatment for adhesive capsulitis pt?

[alophysio]

Hi physio210

Not sure which is best - what do you think after reading all the posts above?

[physio210]

Hi physio210

Not sure which is best - what do you think after reading all the posts above?

hii,,,
from reading the posts, maitland mobilization with anesthesia.
but i am conducting the study about the best physiotherapy treatment.
is it mobilization, exercises , electrotherapy or combine treatment??
thank you

[estherderu]

Dear physio 210

So the answer might be that there is no effective physiotherapy treatment for this problem.........

in my own case (me being the patient) I have been doing 2 things:
AROM of all humeroscapular movements...
the only specific active exercise I do is scapula depression...and I do this a lot.

What Shacklock has to say on this matter is very interesting.
Clinical Solutions Trouble Shooting with Scapular Stabilisation | Shacklock's Clinical Neurodynamic Solutions (NDS) | NDS Global

Esther

[ginger]

"So the answer might be that there is no effective physiotherapy treatment for this problem."

absolutely not........

Ever so briefly, just don't be focussed on the shoulder, the answer and the best treatment lies in the cervical spine. Not manipulation, not massage, but mobilisation with a view to restoring a non protected state of normal freedom of movement , specifically, though not limited to , C456, ipsil. Continuous Mobilisation applied there to facet joints will restore this non protected state, leading progressively to a less irritated series of nerve roots , associated with normal sensations ( or lack therof ) to the shoulder complex..