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Current best practices for the Physiotherapy management of Frozen Shoulder

Tanya Bell-Jenje (Msc physio) May 2, 2024 0 comments

Frozen Shoulder (FS) is an extremely painful and debilitating condition that is poorly understood. Even though it affects 2-5% of the world’s population (Hsu et al, 2011), it is frequently misdiagnosed in the clinical setting, enhancing the patient’s emotional distress, and imposing a substantial burden on both individuals afflicted by it and healthcare systems alike (Lewis, 2015). Although reportedly self-resolving in 2-3 years, some individuals report symptoms for 11 years or more and many never regain full shoulder movement (Shaffer et al, 1992).  Despite ongoing research into its pathogenesis and treatment, there remains a marked lack of clinically relevant evidence on how best to treat and manage this debilitating condition.

This article focuses on how physiotherapy can play a pivotal role in the frozen shoulder journey by potentially shortening its duration and empowering individuals to better manage their symptoms.

FS is also known as Adhesive Capsulitis, as well as Frozen Shoulder Contracture syndrome (Lewis et al, 2015). In China & Japan FS is called ‘the fifty year old shoulder’. Although disagreements exist, the most recognized pathology, based on arthroscopic findings, is cytokine-mediated synovial inflammation with fibroblastic proliferation, causing increased collagen and nodular band formation. This causes spontaneous, progressive inflammation and fibrosis or adhesions of the shoulder joint capsule, ligaments and the rotator interval (Cho et al, 2018; Mertens et al, 2022). The first structure usually affected in this disabling condition is the coracohumeral ligament (CHL) which forms the roof of the rotator cuff interval (Fields et al, 2019). Contraction or fibrosis of the coracohumeral ligament limits external rotation of the arm, which is usually the first movement affected in early FS. In advanced later stages further thickening and contraction of the glenohumeral joint capsule develop, further limiting the range of motion in all directions (Mezian & Coffey, 2022).

The most important first step in the patient’s FS journey is to quickly receive the correct diagnosis. Patients with FS can present with a history of a traumatic incident (eg post-surgery, prolonged immobilisation or fall that’s sets up this inflammatory cascade. Many onsets are insidious in nature, related to an underlying co-morbidity. They usually demonstrate an equal and often almost complete loss of active and passive range of motion of external rotation and then abduction movement. Night pain is severe and interrupts sleep (Mezian & Coffey, 2022). Restricted motion in every direction not only indicates the presence of a developed frozen shoulder, but it may be a “red flag” for possible underlying malignancy or fracture. Standard X/rays do not assist in the diagnosis of FS, but are important to rule out concurrent pathologies, such as rotator cuff tendon tears, calcifications, osteopaenia, osteosarcoma, AVN, fractures and glenohumeral joint osteoarthritis. Ultrasound may pick up neovascularity of the rotator interval, thickening of the coracohumeral ligament (CHL) and fluid accumulation around the biceps tendon. Normal intra-articular volume of the glenohumeral (GH) joint reduces from 15-30cc to 5-6cc (Lundberg, 1969). There can also be obliteration and scarring of subscapular recess (between biceps & subscapularis) and contraction of the anterior and inferior capsule. This explains why when performing manual therapy techniques such as passive accessory gliding of the GH joint in a posterior or inferior direction, it feels almost completely restricted or ‘blocked’.

Risk factors to developing FS include genetic predisposition, a family history, after heart and breast surgery and long term GHJ immobilisation after shoulder surgery. Some papers describe an increased incidence of FS after COVID-19 vaccinations (Sahu & Shetty, 2022). Co-morbidity risk factors include neurological conditions (Parkinsons, Stroke), hypothyroidism (especially in females), chronic systemic inflammation and diabetes. Menopausal women seem to be at risk, due to the oestrogen depletion, which may explain a higher incidence of FS in females than males. A meta-analysis of 13 studies reported the prevalence of FS in populations with diabetes to be 13.4% (Zreik et al, 2016). Dyer et al (2023) in their systematic review, found that people with diabetes were 3.69 times more likely to develop FS than those without diabetes. Also, a systematic review of 28 studies showed that patients with diabetes may experience worse outcomes from FS symptoms (Dyer et al, 2021).

There are 3 recognized phases of FS. The first phase is freezing (pain) and lasts from 2-9 months. The second phase is frozen (stiffness) and lasts 4-12 months. The final (third) phase is thawing (recovery) with a duration of 5-42 months. The overall duration of FS is between 1-3.5 years, with a mean of 30.1 months (Lewis et al, 2015). A longer freezing phase may be associated with a longer thawing phase. Based on this premise, if physiotherapy management can reduce the duration of the freezing phase, then potentially the overall duration of FS can be reduced. This seems to be the case in our physiotherapy clinic, with a telephonic retrospective follow up showing an overall duration of patients with FS managed at our centre reduced to a mean of 11.8 months.

It is relevant, at this stage to discuss the psychological impact of FS on the patient. Patients describe FS as a terrifying and incredibly debilitating pain experience. They report struggling for normality, being unable to engage in ordinary activities or fulfil their usual role within the family unit. They experience significant functional impairments, such as reaching behind or overhead, dressing or using the affected arm for basic low load activities. Severe pain at night, resulting in a lack of sleep, is unbearable and draining. They describe a negative health care journey, often being fobbed off by the doctor or physio with misdiagnosis and poor advice. As a result, they have poor coping strategies, a lack of self, despair, and feelings of uselessness (King & Hebron, 2022).

Patients need to consult with a physiotherapist or healthcare practitioner who understands the FS condition, has empathy, and creates a positive healthcare journey. An essential part of physiotherapy management of these patients includes education about the pathogenesis of FS, and the reassurance that symptoms will improve. The care-pathway through the various phases of FS should be well explained. Advice on day to day management is essential to empower the patient and restore their self-worth.

During the initial patient interview, 80% of your diagnostic information will be derived from the subjective assessment. Is this an insidious onset or linked to some traumatic event or post-surgical immobilisation? Is there a history of gradual, escalating increase in pain and loss of movement?  Delve to achieve an understanding of the severity, nature, and behaviour of pain, including night pain.  What are the patients’ specific functional and positional limitations? Ask questions that can be used as future comparable signs: can they brush their hair, wash their face, pull down on a seatbelt etc. Perform a thorough medical screening to identify risk factors, all ancillary relevant co-morbidities, and to exclude other potential pathologies. Standard X/Rays are indicated to exclude other concurrent pathologies as described earlier.

On clinical assessment of the patient, they often look medically ill, pale, sweaty and exhausted. The affected shoulder often rests in anterior and or superior translation with marked articular movement restrictions with attempts to glide the GH joint passively. Joint motion often feels blocked. Any sudden movements are often eye-wateringly sore. External rotation (in neutral & in abduction in prone) is severely limited (often 0-10°). In advanced cases passive abduction is often less than 60° and hand behind back may only reach the patients coccyx. There is often associated cervical stiffness and pain due to compensatory movements as well as the linkage from the humero-scapular, humero-thoracic and cervico-scapular muscles.

Physiotherapy treatment and rehabilitation varies according to the phase of FS that the patient presents in. Education, empathy and support are paramount in the freezing phase. Manual therapy in the acute (Freezing) stages can flare the patients’ symptoms. It is my clinical experience that treating these patients in the freezing phase into any pain can escalate the patients’ symptoms and further limit their shoulder movement and level of pain and is thus damaging and dangerous. Aquatherapy and painless graduated passive movements within the available ranges in the freezing phase are preferrable. The support FS patients receive from other sufferers in an Aqua Frozen shoulder group class is invaluable. Patients whose pain remains unbearable may benefit from an ultrasound guided cortisone injection in the freezing stage.

In the Frozen phase, advice should include ergonomics and optimal arm positions at work. Manual therapy techniques including inferior glides and mobilisations with movement (MWM’s), nudging into stiffness, and focusing on recentring of the humeral head are beneficial. The use of the Groovi-Glide as part of the MWM’s allows the recentring of the humeral head whilst the patient painlessly moves into better ranges (https://www.groovimovements.co.za/product/groovi-glide/ ). Patients are progressed into a Frozen aqua group class. Exercises are added to improve scapular mobility and strength and associated rotator cuff tendinopathies are managed.

 

In the thawing phase, Motor control and strengthening techniques such as PNF patterns, closed chain, proprioceptive exercises and strengthening through range are instituted.

 

A detailed description of specific rehabilitation techniques for the different phases of FS as well as specific prescriptive home programs can be found in the webinar: Frozen Shoulder: Current best practices for the Physiotherapy management. https://www.grooviedulectures.co.za/all-our-courses/

To conclude, physiotherapists involved in the management of patients suffering from FS, need to have the knowledge to quickly diagnose this debilitating condition to alleviate further patient angst and distress. Education, advice, and support throughout the three phases of the FS journey are paramount. Shortening of the freezing phase through both patient empowerment as well as painless graduated exercise seems to reduce the duration of the thawing phase. The overall goal is to help the patient better manage the FS journey as well as reduce its duration and improve overall outcomes without residual limitations.

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