Vol. 11, No.1 - Jan. - June 2008 J. 8aqai Med. Univ.

REVIEW ARTICLE

Frozen Shoulder and

Effectiveness of Physical Therapy Treatment

* FARHAN ISHAQUE

ABSTRACT:

The shoulder joint is one of the most functional and unstable joints of human body. Consequently, it is the location of most commonly occuring pathologies, such as bursits, tendinitis, adhesive capulitis (frozen shoulder) etc. Out of these pathological conditions, frozen shoulder is the one which is categorized as the commonest conditions for physical therapy treatment. Individuals with diabetes mellitis, cerebro vascular accidents or post surgical patients like CABG or chest diseases are at a higher possiblity for frozen shoulder. Physical therapy is the treatment of choice in majority of the cases and commonly referred for alternative medical treatment.

INTRODUCTION

The most frequently occurring shoulder pathology i.e. frozen shoulder is a self-limiting musculo-skeletal problem caused by tightening of the soft tissues that surround the shoulder joiritl -3. Frozen shoulder is the most common pathologies among women than men. Individuals between the ages of 40 'and 70 are more prone to undergo this form of shoulder pathology6,7.

The average duration of symptoms is 30 months8.

Frozen shoulders or adhesive capsulitis is characterized by gradual loss of active and passive glenohumeral movements. Clinically, the normal progression of frozen shoulder has been described as having three stages.

• In Stage One (The freezing phase): The patient begins to develop mild pain and stiffness in the shoulder joint. This stage can last from a few weeks to a few months.

• In Stage Two (The frozen phase): During this period, the severity may persists but

• Inst. Physiotherapy and Rehabilitation Medicine, Baqai Medical University, Karachi.

the pain starts to turn down. This stage may continue from a few months to a year.

• In Stage Three (The thawing phase or softening): During this stage the range of motion commences to come back. This stage can also last a few months3•

BIO-MECHANICAL ANALYSIS OF SHOULDER JOINT: The shoulder joint is an example of ball and socket joint, having very nominal bone to bone contact. This

. aspect of shoulder joint makes it one of the most mobile joints of human body, though the stability of shoulder joint is compromised. The factors that contribute to stability of any joint in the body are bone, ligament, and musc1eI4

. The Kinematical analysis of shoulder joint shows that the most commonly affected movements are external rotation and abduction of the gleno-humeral joint. Patients usually complain of sharp pain while reaching for the back pocket or combing the hairs. Fig. 1.1

Vol. 11, No.1 - Jan. - June 2008 J. Baqai Med. Univ.

Fig. 1.1: Patient is unable to reach for the back pocket, due to decrease Internal Rotation (BIPTRM)

The arm does not swing during walking. At rest the arm is often held in adduction and internal rotation, and the scapula of the affected side is usually elevated, laterally rotated and abducted4,5. Average ratio of glenohumeral to scapulo thoracic motion is 2:1 (after 30* of abduction)l3 . As scapulothoracic joint is not a real anatomical joint therefore movements at such

articulation are the results of movements at the sternoclavicular and acromioclavicular jointsl5 fig. 1.2. For example: • Elevation/ Depression • Protraction/ Retraction • Upward/ Downward Rotation

IGH: STI

Fig. 1.2: For every 10* of abduction, the clavicle elevates 4* at the sternoclavicular joint and 20* of motion occurs at the acromioclavicular joint.

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Depending on the prolonged existence of symptoms, the body may develop a compensatory mechanical

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adaptation and patient loses the normal glenohumeral rhythm. Fig. 1.3

Fig. 1.3: Compensatory Mechanical Adaptation, Patient is unable to abduct his shoulder joint (BIPTRM)

The physical therapy treatment focuses on relieving pain and restoring function and range of motion of the shoulder9.

TREATMENT METHODS:

1) Physical Therapy: Successful case management depends on

identification of the primary pathologic disorder in each individual casel6. Similarly patient with idiopathic history frequently responds to conservative therapy (nonoperative), but frozen shoulder with a traumatic history or any surgical background may require either an arthroscopic or an open-release methodl6 . Physical therapy is the treatment of choice for frozen shoulder patients. The first realistic goal is to restore normal range of motion. Afterward treatment is focused on muscle strengthening exercises. Physiotherapy treatment consists of: Therapeutic Ultrasound, Ice, Heat and other modalities 17. In some cases, Transcutaneous Electrical Nerve Stimulation (TENS) may be used to reduce pain by blocking nerve impulses.

• Gentle Stretching: Stretching exercises help in loosening the adhesive

capsule and help in re-establish normal range of motion10,18. The goal of these exercises is to stretch the shoulder to the point of tension but not pain. Severe discomfort is unusual and suggests overstretching. fig. 1.4

Wall Stretchl 8 Towel Stretch 18

Fig. 1.4

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• Proprioceptive Neuromuscular Facilitation (PNF) Techniques: These techniques are useful in restoring

neuromuscular coordination and control. After getting full ROM and strength training, treatment should continue with these techniques.

A

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• Mobilization Techniques: These are very effective in improving the mobility

and functional status of the shoulder joint . Mobilization techniques improve the normal extensibility of the shoulqer capsule and stretch the tightened soft tissues to induce beneficial effectslO,ll.

B

Strengthening Exercise

Lifting Exercise18

If these measures are ineffective, then following treatments may be preferred:

2) Injections: Intra-articular corticosteroid injections are also

widely in use to restore painless range of movement and decrease inflammation at shoulder joint which sequentially permit for more stretching and physical therapy manuares17•

3) Open Surgical Release: Frozen shoulder secondary to trauma or any

surgical process, possibly will require either an arthroscopic or an open-release procedure l6 . This procedure is called an arthroscopic capsular release. Those cases of frozen shoulder that do not improve by physical therapy treatment are subjected to this procedure. 17

4) Manipulation under anaesthesia (MUA): A manipulation is performed under anaesthesia

and surgeon moves the shoulder through ROM to break up adhesions17. MUA is followed by consecutive sessions of physical therapy treatment.

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CONCLUSION:

To be very conscise we can say that Physical Therapy treatment is the treatment of choice for Frozen Shoulder. Physical Therapy techniques not only help in restoring the normal joint biomechanic but bring the patient back to daily normal activities.

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