Frozen Shoulder

[nasde]

Personally, I've never found too much success with much physio treatment for a "true" frozen shoulder. I say "true" because in my experience, a lot of stiff shoulders with full capsular movement (or almost full passive movement) - have been referred over as "frozen shoulder".

IMO Mobs and stretching exercises seem to irritate the capsule, and not provide much in the way of improvements (esp when compared to the amount of pain/irritation it causes). I find that educating a patient to use their shoulder (pain free range), not sleep on it, timeframes to recovery etc, to be the most effective. Soft tissue stuff is good short term.

Ginger - I'm also quite interested to hear more about this CM type stuff. I've searched your posts on those websites you suggested, but the whole topic is very vague - except for the fact that it works, it's very simple and effective etc ... What lectures do you do and where did you speak at? Are any of these talks coming up? What university do you lecture at? Is it at physiotherapy conferences that you talk at? Do you teach at a university, lecturing to physiotherapy students?

If you would prefer not to say on the forums as a matter of privacy or whatever, send me a PM.

Thanks

[Laura01]

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.

[soranidinesh]

hi ginger
i think i agree to your thought on spinal mobs for frozen shoulder
what i have seen in a few patients is thoracic spinal mob (at the level of around t567) may help to improve extension with medial rotation
although this is not seen in every one
i would like to try your trick on my patients
some new things i ve heard is that the pain on shoulder may be due to suprascapular nerve irritation and is resolved by block by injection of analgesic TENS over shoulder...
can u give a hint on this

[estherderu]

like Ginger,
I also had problems working on the "frozen-shoulder" when I started, having been trained to look and work locally. I have since then made it a point to ALWAYS look at the whole spine when treating people with shoulder (upper & lower extremity) disorders. More often than not, treating the cervical and thoracic spine gave much better results than treating the shoulder only.
I also used the german(massage) technique called bindegewebsmassage a lot to help treat many so-called musculoskeletal problems.

It really helps to look at the whole picture, the patients posture, his/her response to pain and most importantly, what is happening/has happened in his/her "muscle train and/or meridiaan.

the more you learn, the more you realize you know so little

Esther

[mIrAge]

I believe the most recent inclination to manage adhesive capsulitis is early steroid injection (during painful phase) and exercise therapy, which yield a siginficant improvement in short term functional outcomes and pain level, and some long term benefit over steroid only and exercise therapy only group.

[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
Hallamshire Physio (HPLtd) on Twitter

[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

[Men At Work]

hey guys i've recently started my practice wherein i have a frozen shoulder case which is responding at a slow pace with passive range coming in flexion ,abduction and ext rotation coming in 3 weeks.now the problem lies is the still lower range in external rotation with elbow in 90 deg flxn at the side of body.and also the movement pattern for external rotation starts with arm going into slight abduction first.im giving grade 2 glides with strengthning of shoulder girdle till 90 degrees of flexion.please help in improvement for the range and strength.thank you.also the active range is coming till 80 degrees in flexion and 70in abduction.any guidance will be appreciated.the pt had a fracture greater tuberosity humerus 3 months back.

[SPPAWA]

For those who have dealt with/ or had Frozen shoulders have you also found there has been some notable stressful event in the patients/ your life within 3 months of onset?

Cheers,

SPPAWA