Tag: Physical therapy

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Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff. Movement of the shoulder is severely restricted. The condition is sometimes caused by injury that leads to lack of use due to pain but also often arises spontaneously with no obvious preceding trigger factor. These seemingly spontaneous cases are usually referred to as Idiopathic Frozen Shoulder. Rheumatic disease progression and recent shoulder surgery can also cause a pattern of pain and limititation similar to frozen shoulder. Intermittent periods of use may cause inflammation.

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Abnormal bands of tissue (adhesions) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally helps the shoulder joint move by lubricating the gap between the humerus (upper arm bone) and the socket in the scapula (shoulder blade). It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have been in an accident, are at a higher risk for frozen shoulder. Adhesive capsulitis has been indicated as a possible adverse effect of some forms of highly active antiretroviral therapy (HAART). The condition rarely appears in people under 40 years old and (at least in its idiopathic form) is much more common in women than in men. Frozen shoulder in diabetic patients is generally thought to be a more troublesome condition than in the non-diabetic population. If a diabetic patient develops frozen shoulder then the time to full recovery is often prolonged.

Causes:
There are several different causes of a frozen shoulder. Some are obvious, whereas the others are difficult to find. A history of a fracture, a previous dislocated shoulder, or other trauma to the shoulder, can often aggravate the process of scar tissue formation. This is often made much worse by a period of prolonged immobilization in which the arm is held in a sling — a measure that is often necessary as a fracture heals or because pain from the original trauma limits motion. Loss of motion can also commonly occur as the result of a prior shoulder surgery for the treatment of other conditions — such as fractures or a torn rotator cuff.

The term “idiopathic adhesive capsulitis” is used to describe the gradual loss of shoulder motion which has no obvious cause or explanation. The reasons why this process occurs are unknown and are still the subject of debate among orthopedic surgeons. It is known that people with diabetes, neurologic illnesses, and other forms of inflammatory arthritis are at increased risk of developing a frozen shoulder. In general, this is a self-limiting disease, which means that over the course of several years it should run its course and then resolve itself. When there is no objective evidence of an obvious cause of a frozen shoulder (such as a prior fracture), then the first step in restoring motion is a program of supervised physical therapy in combination with a home program of maintenance exercises.

Signs and diagnosis:
With a frozen shoulder, one sign is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. A doctor, or therapist (occupational, massage or physical), may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can also be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder). An arthrogram or an MRI scan may confirm the diagnosis – although in practice this is rarely required. Most orthopaedic specialists make the diagnosis of frozen shoulder by recognising the typical pattern of signs and symptoms.

Physicians have described the normal course of a frozen shoulder as having three stages:

Stage one: In the “freezing” or painful stage, which may last from six weeks to nine months, the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.

Stage two: The “frozen” or adhesive stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.

Stage three: The “thawing” or recovery, during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.

Modern Treatment:
The natural course of a frozen shoulder can be separated into a few different phases. The first phase can be considered the “inflammatory” phase, during which the shoulder is painful and becomes less mobile. In the second phase, the shoulder is stiff, but the pain gradually decreases. In the third phase of “resolution”, the motion gradually improves in the shoulder. The natural course of this disorder can be very long, and the goals of treatment are to speed you towards the “resolution” phase faster.

A supervised physical therapy program can be successful in helping improve the shoulder pain and limited motion of the frozen shoulder. Physical therapy is more often successful in people who suffer from “idiopathic” adhesive capsulitis, and it allows them to gain a lot more use and function from their shoulder. Unfortunately, this approach is less successful in the treatment of shoulder problems after a previous surgery or a bad injury.

Because there is some scientific evidence that inflammation of the shoulder joint is one of the causes of a frozen shoulder, many doctors will inject the shoulder joint in order to calm the inflammation down. This injection uses a long acting local anesthetic like the Xylocaine® that the dentist uses and a powerful anti-inflammatory steroid as well. This is a very safe procedure, it is not terribly painful, and sometimes a single shot can make a very significant difference in the amount of shoulder pain and motion. The reason that an injection is more effective than oral medications is that it allows doctors to deliver a higher concentration of a more powerful anti-inflammatory medication to the inflamed tissues. If these treatments prove to be unsuccessful after a period of several months, then there are several options. The first option after these measures have failed is for a doctor to perform manipulation under general anesthesia.

Manipulation under anesthesia and What happens if this doesn’t work?

Shoulder Surgery Explained

Alternative Medication:

Zenotin: Simple time tested natural medicine as remedy for Frozen Shoulder

Treatment of Frozen Shoulder Using Chinese Medicine

Exercise program by physical therapist to treat frozen shoulder

Self-Treatment of Frozen Shoulder

Prevention:
To prevent the problem, a common recommendation is to keep the shoulder joint fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of adhesions that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). Therapy will help one continue movement to discourage freezing and warm it. A medical doctor referral is needed before occupational or physical therapy can begin under law in most US states. Medical referral is not required for physical or occupational therapy in most Canadian provinces.

Management:
Management of this disorder focuses on restoring joint movement and reducing shoulder pain. Usually, it begins with nonsteroidal anti-inflammatory drugs (NSAIDs) and the application of heat, followed by gentle stretching exercises. These stretching exercises, which may be performed in the home with the help of a physical, massage or occupational therapist, are the treatment of choice. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses.

One of the most successful treatments for frozen shoulder has been shown to be The Bowen Technique with average range of motion improvement of 23° during controlled trials.

If these measures are unsuccessful, the doctor may recommend manipulation of the shoulder under general anesthesia to break up the adhesions. Surgery to cut the adhesions is only necessary in some cases.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Frozen_shoulder
http://www.shouldersolutions.com/frozen_2.php

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