Evidence Based Physiotherapy Approach for Frozen Shoulder. Post I

Frozen shoulder is a debilitating condition with a painful and significantly restricted range of motions of the shoulder joint. Clinically known as adhesive capsulitis, frozen shoulder can lead to disability generally lasting anywhere from 1 – 24 months (Page et al 2010). However, many patients may never fully recover from the symptoms (Jewell et al 2009, Kelly et al 2009, Kline CM 2007). Adhesive capsulitis is clinically presented in 3 different overlapping stages based on the duration and type of symptoms (Reeves B 1975). They are; A) acute stage, freezing or painful stage, B) Adhesive, frozen, stiffness or transitional phase, and C) resolution or thawing stage. The purpose of this article is to discuss evidence-based physiotherapy interventions for frozen shoulder, thereby enhancing evidence-based practice.

Physiotherapy management

Even though a number of studies has been done on effective physiotherapy (PT) management of frozen shoulder, the results are conflicting for improving shoulder ROM. Levine et al 2007,  reported 90% success rate with non-operative treatment (oral NSAIDS and PT) over an average of 4 months period, patients responded well to PT with increased mobility or functional movements and/or reduced symptoms or pain. However, Green et al 2010, did a Cochrane review and responded no significant evidence for PT alone treatment can benefit frozen shoulder patients. Similarly, other studies (Farrell et al 2005, Griggs et al 2000) have reported some deficiencies in ROM even after successful PT interventions.

Patient education

Patient education is a key factor in frozen shoulder rehabilitation as this condition can be frustrating for many patients. Patients will be struggling to perform their daily activities but the improvement with rehabilitation can be much slower than their expectations. Thus, it is important that patient understands the nature of this condition and effects of exercises well to reduce frustration and promote treatment compliance. A home exercise program (HEP) is the major part of frozen shoulder exercise protocol and thus simple and clear instructions of exercises are important (Kelly et al 2009). In addition, patients’ functional goals appropriate exercises will improve the treatment compliance.

Modalities

Physiotherapists choose a wide range of modalities to treat patients with adhesive capsulitis mainly to reduce pain and to facilitate muscle or joint capsule stretching thereby increasing ROM of the shoulder joint. Moist heat is the most commonly used modality in conjunction with stretching which helps to reduce muscle or soft tissue viscosity and neuromuscular mediated relaxation (Kelly et al 2009). This effect enhances the improvement in ROM of the glenohumeral joint. Leung et al 2008, compared the effects of deep and superficial heating in the management of frozen shoulder. The report concluded that the deeper heating through diathermy combined with stretching is more effective than superficial heating.

Bal et al 2008, reported a positive effect of hot and cold packs applied before and after exercise performance in the improvement of the patient with frozen shoulder. However, some studies (Jewell et al 2009, Dogru et al 2008) have reported no significant benefit of ultrasound, massage, iontophoresis, and phonophoresis in the treatment of patients with adhesive capsulitis. Similarly, Green et al 2010, also suggested no significant effect of ultrasound in shoulder pain due to various conditions like adhesive capsulitis or rotator cuff tendinitis.

Interestingly, transcutaneous electrical nerve stimulation (TENS) is one of the modalities that have been reported to be the most effective modality in improving ROM in patients with shoulder joint than with the use of other modalities combined with exercise and manipulation (Page et al 2010). While some studies (Stergioulas A  2008) done on effects of laser therapy has shown low power laser therapy to be more effective than a placebo treatment of patients with adhesive capsulitis.

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Reference

Bal A, Eskioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clinical Rehabilitation 2008; 22:503-512.

Dogru H., Basaran S., Sarpel T. Effectiveness of therapeutic ultrasound in adhesive capsulitis. Joint Bone Spine. 2008; 75:445–450.

Farrell C. M., Sperling J. W., Cofield R. H. Manipulation for frozen shoulder: long-term results. J Shoulder Elbow Surg. 2005; 14:480–484.

Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain (Review). The Cochrane Library 2010;9:1-105.

Griggs S. M., Ahn A., Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000;82-A:1398–1407.

Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: A retrospective cohort study. Phys Ther 2009;89:419-429.

Kelley M, Mcclure P, Leggin B. Frozen shoulder: Evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther 2009;39:135-148.

Kline CM. Adhesive capsulitis: clues and complexities. JAMA Online 2007;2-9.

Leung M. S., Cheing G. L. Effects of deep and superficial heating in the management of frozen shoulder. J Rehabil Med. 2008; 40:145–150.

Levine W. N., et al. Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg. 2007; 16:569–573.

Page P., Labbe A. Adhesive capsulitis: use the evidence to integrate your interventions. N Am J Sports Phys Ther. 2010; 5(4): 266-73.

Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975; 4:193–196.

Rizk T. E., Christopher R. P., Pinals R. S., Higgins A. C., Frix R. Adhesive capsulitis (frozen shoulder): a new approach to its management. Arch Phys Med Rehabil. 1983; 64:29–33.

Ruiz J. Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis: A Case Report. The Journal of Manual and Manipulative Therapy Vol 17: Number 1: 58-63.

Stergioulas A. Low-power laser treatment in patients with frozen shoulder: preliminary results. Photomed Laser Surg. 2008; 26:99–105

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