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B) Second phase: adhesive, frozen, stiffness or transitional stage
During this stage, there will be no worsening of pain but will be a significant progressive loss of ROM in a capsular pattern. Thus, the treatment protocol is more aggressive. Joint mobilization and manual techniques are focused to improve range of motion. The treatment should include low intensity, prolonged stretches in order to produce plastic elongation of tissues ( Dias et al 2005).
Continuous passive motion/stretching
The continuous passive motion and dynamic splinting are used for a prolonged period to stretch the joint capsule in patients’ with stage 2 frozen shoulder (Gaspar et al 2009). McClure et al 1994, studied the use of splints in the treatment of joint stiffness. The study described the concept of total end range time (TERT) and suggested to maintain the joint range in the maximally lengthened state for a total of 60 minutes per day.
A number of studies (Jewell et al 2009, Johnson et al 2007, Vermeulen at al 2006) have shown the efficacy of joint mobilization in patients with frozen shoulder. Johnson et al compared the effectiveness of posterior glide versus anterior glide mobilization for improving external rotation among 20 patients with adhesive capsulitis. They performed 3 sessions of grade 3 stretch mobilization with distraction at end range of abduction and external rotation. The result showed significant improvement in external rotation by 31 degrees with posterior mobilization compared to only 3 degrees in anterior mobilization group.
Similarly, Vermeulen et al performed a randomized control trial on high-grade joint mobilization versus low-grade mobilization to improve GH joint ROM. The study concluded that the high-grade joint mobilization (Grade 3 and 4) is more effective.
Another randomized multiple treatment trials done by Yang et al 2007, has recommended mobilization with movement to restore pain-free ROM of joints that had previously been restricted due to pain or muscle guarding.
Trigger point release
Simons and colleagues have described Subscapularis muscle as Frozen Shoulder muscle in their textbook – “myofascial pain and dysfunction; the trigger point manual”. So, techniques to release trigger point pain or tightness of Subscapularis muscle may help to improve shoulder elevation and external rotation. Kostopoulos et al 2008 study showed the Spray and Stretch technique to be effective in reducing trigger point irritation and thus gradual lengthening of the tight subscapularis and lattismus dorsi muscles. This, in turn, helps to improve GH joint ROM.
Third phase: resolution, thawing stage
During this stage, treatment is progressed with more aggressive stretching techniques to maintain and further improve ROM. With the significant progression of ROM, strengthening exercises are introduced to improve functional abilities. Muscles prone to weakness in patients with frozen shoulder are lower trapezius, serratus anterior and infraspinatus (Lin et al 2005). So, these muscles should be strengthed to facilitate a normal functional movement pattern.
All therapeutic exercises and manual techniques are progressed based upon the patients’ pain scale, improvement with ROM, muscle strength and functional goals. Usually, therapists discharge patients with a home exercise program when a patient has the significant reduction in pain with the restoration of functional ROM and patients shows peak level of satisfaction with the progress.
Although number of studies have postulated various treatment suggestions with evidence to address the symptoms of adhesive capsulitis, further prospective randomized studies comparing different treatments are needed to determine definite clinical guidelines of physiotherapy interventions to treat patients with frozen shoulder.
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