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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[GAJENDRA]

I have been suffering from frozen shoulder for last 1 year. In the past 3-4 months the pain has become very severe. The motion of the right arm is restricted in thr front straight direction only. I had diabetes, but sugar level is very normal now. I searched net. There are big claims about Prosero but I don't know how far it is effective. I have been taking PHYSIOTHERAPY but improvement is very less.

Please guide me with the effective treatment for this condition!!

[ginger]

The so called "frozen shoulder" problem used to confuse and worry me also, till about twenty years ago when I began to treat the cervical spine instead of the shoulder . The method i now call Continuous Mobilisation , when applied to the lower cervical facet joints , will release those joints from their protective tone . When this occurs ( within one to three minutes in most cases for each joint ) it will be noted that referred pain and a pattern of altered recruitment within the specific myotome of that joint/nerve , will be affected . Immediate and lasting resolution of the symptoms of this shoulder pain problem are resolved . If severe , this may take up to three treatments. I have not come across a frozen shoulder /adhesive capsulitis/"impingement" problem that has not had a significant ( and usually 100% ) contribution from spinal joints/nerves since the late eighties.
The alert therapist will immediately note , with carefull examination, that the facet joints C456 on the side of the complained of shoulder , will invariably be tender to deep palpation and attempts at passive movements unilateraly. Further information on the CM method can be posted if any wish to explore this method further. This problem ( and many like it ) are no longer the mystery once thought of , though the information about this minor revolution ( for some at least ) appears not to have filtered through in many quarters. Treatments of the shoulder are a waste of time , cruel and produce poor results at best. CM to the cervical spine however , done with skill and persistance , will permanently resolve this problem in a short time .

[hussain_whosayin]

hi,
you should have detailed assessment done, physical therapy is directed at symptoms. Try to prevent further damage and preserve the ROM and strength of shoulder complex by effective means of mobilization and stretch techniques. As many of text says condition to be self limiting, try to be preventive rather than curative. most important factor considered is activity and function, try to give modifications in activities for use of shoulder in pain free ways.

[stephandriver]

Hi Simon,

Below there is a plethora of replies and it seems we are all on the same page with this one. Frozen shoulder, often referred to as Adhesive Capsulitis and often quoted as going through 3 distinct stages is truly a mystery to date to the Mx world. SO don`t panic as I did in your place 30 years ago.

The facts remain that the etiology is still unknown and suggested treatments are simply that, suggested. Evidence shows that there is no effective treatment of it. I would guide you to "The Journal of Bone and Joint Surgery" Vol 89B, No 9, September 2007, "Thawing of the Frozen Shoulder by Quraishi et al.. Here you will find a comparison between dilatation and MUA.

I am qualified in spinal manipulation, human movement, acupuncture and physiotherapy. I have used these approaches for the last 20 years and have many colleagues all over the world. I have not had any consistent success with this complaint nor have any of my colleagues. Nor have I seen any "Evidence Based" information to the contrary. And if you think about, for such a common complaint, if such a treatment existed it would be mainstream and frontline news around the world. If it has been I havent seen it.

However, I note that Ginger, below, is in possession of information/techniques to the contrary. Please Ginger, could you please make this evidence based information public so we and our patients can all benefit from it. I genuinely do look forward to hearing from you soon.

Hope this helps alleviate your anxiety Simon and is helpful.

Cheers
Scooba.

[ginger]

scooba, Frozen shoulder was a mystery to me too, till I discovered it to be a referred event , along with many other MSK pain and dysfunction problems that have confused physios and others for many years. I have mostly been working in isolation and have had little interest in putting my work into the mainstream published media , till the internet allowed me access to blogs and forums such as this one .
I have posted many pieces of explanatory and technique related work on Rehab Edge , over the past few years. Should you be interested in reading further I suggest you begin there.
Cheers
G.

[linbin]

hi friends
as we all know for any shoulder pathology cervicothoracic screening is amust along with shoulder girdle assessment.as frozen shoulder is concerned i agree with physios that its a vague diagnosis.we should find out the primary cause too.our management will be based on that.i felt koltenborn technique of shoulder mobilization with intermitent longitudinal traction,capsular stretches,rotator strengthening helps a lot.in diabetes healing process will be disturbed,so we should be gentle in their handling and proper joint care advises should be given

[Physioindeed]

ginger,
just had a look at the website you suggested.
There are 10 thousands of messages in the forum. How are we supposed to find your previous entries about your fantastic method?
I think that if you want to help and have something to say: just say it here and now. Or give us a defenitiv link. Otherwise to claim that you have the ultimative answer but to not make it easy for everybody else to access it is a little unhelpful and frustrating.

[ginger]

As much as I would like to enroll you and others here into a more elegant and successfull method and perspective , on shoulder and other MSK issues , I have been doing this very thing on Re for some years and feel somewhat reluctant and time pressured at the moment to go over this territory from the beginning. It is possible , with careful orientation to the RE site , to find previous posts under headings. I suggest you begin with key words , such as Continuous Mobilisation ( CM ) , frozen shoulder, Ginger etc .
I have also posted many times with similar p.o.v. on somasimple.
I am happy to contribute to your considerations on shoulder pain here , though cannot commit to a exhaustive and detailed response. Should you be willing to follow my guidance and sugestions, I am certain you will find access to a quiet revolution in the manner to which shoulders ( and other MSK) problems are easily solved.
I have just returned from a lecture series I conduct twice a year here in victoria on these matters and am just a little exhausted. A few days in the hammock watching cricket should see me back on top. Go the aussies.
Ask questions by all means, I'll do my best for you.
Cheers

[Physioindeed]

had a nother look on rehab edge.
first tried to type in key words on their home page, which is why I didn't get anywhere. you of cours need to go to the forums first, then in manual therapy, scroll down and type in key words. there is also an option to look for entries by one specific user. I guess the threat "Mobilisation of facet joints, the continuous method - July 2, 2006 7:34:00 PM " is the one I was looking for.
sorry for being impatient and a bit slow...
now bussy reading in there. thanks ginger

[estherderu]

dear colleagues,
to add to the confusion....
how about this one??

Some, not all, but some of the patients I have treated ( especially if they were woman in their late 40´s and 50´s ) reacted very well to magnesium supplements.
I learned this from a chinese physician (who was also trained in western medicine and especially complementary medicine ).

Do not ask me why....
esther

[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

[112inky]

u shout undr go for the shoulder mobilasation treatment

[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.

[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.