Frozen Shoulder

11

Frozen Shoulder

Mollie Beyers Peter Bonutti

n this chapter, the term frozen shoulder describes the clinical entity in which a person has restricted passive mobility at the glenohumeral joint, which often results in a loss of active range of motion (ROM) and pain. This loss of mobility can impose substantial disability for many. The cause of frozen shoulder is poorly understood. Much confusion exists among the medical population concerning terminology, as the terms adhesive capsulitis, capsulitis, and periarthritis of the shoulder are often used synonymously. The purpose of this chapter is to provide a historical review of literature on the painful and stiff shoulder, characterize the clinical entity of frozen shoulder, provide a working definition for frozen shoulder, and provide a description of treatment approaches available for frozen shoulder.

I

Historical Review In 1896 Duplay39 was credited with the initial descriptions of the painful and restricted shoulder. He termed the clinical entity of frozen shoulder “periarthritis scapulohumerale,” theorizing the pathologic condition was in the periarticular structures. The primary ailment was suspected to be in the subacromial bursa. The recommended treatment approach was manipulation under anesthesia. In 1934 Codman8 coined the same disorder as “frozen shoulder syndrome” and related the dysfunction to uncalcified tendonitis. He expressed that the condition was “difficult to define, difficult to treat, and difficult to explain . . . from the point of view of pathology.”

Nevasier27 introduced the concept of “adhesive capsulitis” in 1945, when he discovered a tight, thickened capsule that stuck to the humerus. He described an inflammatory reaction that led to adhesions, specifically in the axillary fold and in the attachment of the capsule at the anatomic neck of the humerus. Surgical exploration of 10 shoulders indicated an absence of glenohumeral joint synovial fluid and a redundant axillary fold of the capsule. In 1949 Simmonds45 speculated a loss of motion at the glenohumeral joint because of degenerative changes and secondary inflammation of the supraspinatus tendon. He hypothesized this was because of repetitive wear against the acromion and coracohumeral ligament. Many of his patients experienced functional limitation, pain, and restriction in the shoulder for more than 5 years. Therefore he concluded it was not a self-limiting disease process. Quigley37 described in 1954 a “pattern of pain-free passive motion sharply checked at about 45° of abduction and half of the normal range of motion.” He called the entity “checkrein shoulder” to describe this condition for a subgroup of individuals with frozen shoulder, but for whom he assigned a good prognosis. This subgroup responded well to manipulation under anesthesia and was described “to present with an audible and palpable release” during the procedure. In 1962 Nevasier28 described four phases of frozen shoulder through the assistance of arthroscopic study. These stages are defined as follows: Stage I—preadhesive stage, found in patients with little to no restriction

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of GH motion; Stage II—acute adhesive synovitis with proliferative synovitis and early adhesive; Stage III— maturation stage in which less synovitis is demonstrated with loss of axillary fold; Stage IV—chronic stage presenting with fully mature adhesions with notable restriction of ROM. Nevasier discussed lack of explanation for the disease process and suggests any condition requiring prolonged immobilization as a causative factor. Reeves,38 in a natural history study of frozen shoulder in 49 subjects conducted in 1975, reported a direct relationship between the duration of the stiff phase and the duration of the recovery phase. The observed population had an onset of disease at 42 to 63 years. The painful phase ranged from 10 to 36 weeks in length. The stiffness phase lasted from 4 to 12 months. Recovery of ROM ranged from 5 months to 26 months. The reported mean duration of symptom resolution without intervention was 30.1 months. Although Reeves38 reported no intervention when following the natural history, the patients were instructed to use analgesics during the painful phase, to rest and wear a sling during the stiff phase, and “to exercise their shoulders to regain external rotation (ER) and abduction (ABD) during the recovery phase.” This “advice” could have altered the true natural history. In 1992 Itoi and Tabata,19 in a study of 91 subjects, reported a positive correlation between abduction and the restriction of the axillary pouch through arthrographic measures. Chi-Yin and associates7 in 1997 identified a statistically significant correlation between external rotation ROM and increased joint capacity in a study using arthrography following physical therapy. They identified an increase in joint space in the acute frozen shoulder, but not in chronic cases. At present, “frozen shoulder” is a readily recognized clinical grouping of signs and symptoms. Specific descriptions on motion, pathologic condition, treatment, and recovery, however, are difficult to find and interpret.

lowed by abduction and internal rotation. The glenohumeral capsular volume is less than 10 ml and plain films are normal.

Epidemiology The prevalence of frozen shoulder is 2% to 3% of the U.S. population and is more common among females.21 The affliction also occurs more frequently in the nondominant arm. The condition is most commonly reported between the ages of 40 and 64.22,26,38,40,51

Clinical Presentation Frozen shoulder is a grouping of multiple symptoms. Although not all patients follow the same course, awareness of the typical clinical course of frozen shoulder may be helpful.

Stages9

Painful or Freezing Phase. The painful or freezing phase as described by Reeves39 typically lasts 10 to 36 weeks. The patient has spontaneous onset of shoulder pain, which is often severe and disrupts sleep. The patient often rests the arm, noting an abatement of pain and contributing to increased stiffness. At the end of the painful phase, the glenohumeral capsule volume is greatly reduced. Stiffening or Frozen Phase. The painful phase is often followed by a stiffening phase. This phase may last 4 to 12 months. The patient has restricted ROM in a characteristic pattern of loss of external rotation, internal rotation, and abduction.9 Thawing Phase. The final phase is described as thawing and is characterized by the gradual recovery of ROM. The thawing phase will last an average of 5 to 26 months and is reportedly directly related to the length of duration of the painful phase.9

Definition Our suggested working definition for frozen shoulder is glenohumeral joint stiffness resulting from a noncontractile element unless it coexists with a noncontractile lesion. Both active and passive motion is painful and restricted. Passive mobility is limited in the capsular pattern, with external rotation being most limited fol-

Primary Frozen Shoulder Primary frozen shoulder refers to the idiopathic form of a painful, stiff shoulder. The debate continues about the pathogenesis of idiopathic frozen shoulder. Possible causes include immunologic, inflammatory, biochemical, and endocrine alterations.17,27,28

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Bunker and Anthony5 in 1995 reported that only 50 of 935 shoulders evaluated with restriction at the glenohumeral joint could be classified as primary frozen shoulder. In these 50 cases, loss of motion occurred from thickening and contracture of the coracohumeral ligament and rotator interval, thus acting as a tight “checkrein,” which prevented external rotation. They also confirmed a histologic similarity between Dupuytren’s disease and frozen shoulder. Bunker and Esler6 in 1995 also reported an association between hyperlipidemia, frozen shoulder, and Dupuytren’s disease. The incidence of frozen shoulder in the diabetic population is reported to be 10.8%.2 Janda and Hawkins20 in 1993 reported a poor outcome in the diabetic population with frozen shoulder following treatment with manipulation under anesthesia.

Secondary Frozen Shoulder Secondary frozen shoulder can be indicated by a precipitating event or trauma, which can be identified to explain the loss of motion. Examples of such events leading to frozen shoulder include limitations following surgery, soft tissue trauma, or fracture. The three phases of frozen shoulder9 may not always be recognizable in the patient having secondary frozen shoulder.

Scientific Research As with many poorly understood medical conditions, multiple approaches are used in the treatment of frozen shoulder. Historically, research on treatment has included: steroid injections, both intra-articular and extracapsular, with and without physical therapy; physical therapy, including modalities, active range of motion (AROM), stretching, exercise and mobilization, or a combination thereof; closed manipulation, with and without steroid injections, and with and without physical therapy; and arthroscopy and open surgical release with physical therapy. The remainder of the chapter focuses on reviewing the scientific literature to date on the use/effectiveness of treatment for the frozen shoulder.

Use of Steroid Injections With and Without Physical Therapy Many physicians use steroid injections in the treatment of frozen shoulder. Most often, this treatment approach

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is used in conjunction with physical therapy or home exercise. Scientific research supporting and refuting this approach will be discussed. Table 11-1 is a matrix summary of the research. Quigley37 conducted a prospective study on 29 subjects in 1954. Subjects who were classified into the inclusion for “checkrein” shoulder received manipulation, adrenocorticotropic hormone (ACTH), and steroid injections. The average age of the subjects was 50.5, with a mean duration of symptoms of 5.5 months before the intervention. Results reported were as follows: 10 subjects were pain free with normal ROM; 13 subjects reported little pain and loss of ROM or both; and 6 showed no change. Quigley concluded his definition of checkrein shoulder would define inclusion and exclusion criteria for those individuals who could be assigned a good prognosis. In 1973 and 1974 Lee and associates22,23 performed the first study with a random clinical trial design. The preliminary study in 1973 included four groups, with 80 subjects randomly assigned to the groups. Individuals were included if they had periarthritis of the shoulder and pain in the shoulder with limitation of shoulder movement. In 1974, 45 subjects were randomly assigned to groups. Description of treatments for each group follows: Group 1 active ROM and infrared heat Group 2 intraarticular hydrocortisone acetate and active ROM Group 3 hydrocortisone acetate to bicipital groove Group 4 analgesics only Chi-square for differences showed no difference between the groups for age, sex, or duration of symptoms. Physical therapy for groups 1, 2, and 3 was very specific and included a graduated exercise program. This included: (a) free-active exercise, 10 minutes TID (three times a day) of the following: assisted ROM, range of motion-gravity counterbalance, and gravity-resisted ROM; (b) proprioceptive neuromuscular facilitation (PNF): manual resistance and concentric contractions. Duration of follow-up was 6 weeks. Group 4 had inferior ROM results leading Lee and associates to conclude that exercise was the beneficial component of treatment during the 6-week time period. They also reported significant differences in ROM, the greatest change occurring in group 2. They noted the greatest improvement in ROM during the first 3 weeks. Overall, they concluded that any treatment including exercise was

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Table 11-1 RESEARCH ON USE OF STEROID INJECTION AND PHYSICAL THERAPY FOR THE FROZEN SHOULDER Use of Physical Therapy

Author & Year

Sample Size

Quigley TB: 1954

N = 29

To determine the effectiveness of manipulation and ACTH, hydrocortisone acetate, or cortisone

Heat, exercise program

1) 10 pain free with normal ROM 2) 13 little pain and little loss of ROM or both 3) 6 unimproved

Lee M, Haq AMMM, Wright V: 1973

N = 80

To test the value of physical therapy and local injection of hydrocortisone acetate in periarthritis of the shoulder

Graduated active exercise for groups 1, 2, & 3

1) active ROM and infrared 2) intraarticular hydrocortisone acetate and active ROM 3) hydrocortisone acetate to bicipital groove 4) analgesic only Improvement in ROM within first 3 weeks; most change occurred in intraarticular hydrocortisone injections with ROM exercises No change in analgesic only group

Lee PN, Lee AM, Haq AMMM, Longton EB, Wright V: 1974

N = 45

To test the effect of heat and exercise; intraarticular hydrocortisone and exercise; hydrocortisone to bicipital groove and exercise; analgesic control group on shoulder movement in periarthritis of the shoulder

Graduated active exercise for groups 1, 2, & 3

ROM of other groups improved over analgesics only; no significant change between the groups

Weiss JJ, Ting M: 1978

N = 48

To report the authors’ experience with intraarticular steroids and use of shoulder arthrography

None

1) 16 pain free 2) 11 painful No increase in glenohumeral ROM (No manipulation/ROM provided)

Binder A, Hazelman BL, Parr G, Roberts S: 1986

N = 40

To ascertain if a limited course of oral steroid therapy had any beneficial effects and to determine the treatment favored by local general practitioners

All performed home pendulum exercises

Decreased pain in steroid group; no difference in ROM between groups

Dacre J, Breney N, Scott DL: 1989

N = 62

To determine effectiveness of physical therapy, steroid injections, or both

Physical therapy use varied for head for 4-6 weeks

All groups showed decrease and ROM increased 10% to 34% at 6 months; no differences between groups

Purpose

Results

FROZEN SHOULDER

CHAPTER 11

superior to analgesics alone and that only 3 weeks of therapy should be prescribed with physician follow-up to reassess the subject’s status. In a 1978 study performed by Weiss and Ting,6 they reported the effects of arthrographic assisted intraarticular injections on glenohumeral (GH) ROM in 48 subjects. These researchers reported success based on “total shoulder movement” rather than pure GH joint motion. The researchers did not describe the length of treatment, the numbers of injections received, or any statistical data. Outcomes were based on subjective reports of good, fair, or poor relief of pain. Motion was reported as improved or not improved, with no variance given if it was GH or total shoulder girdle movement. Four weeks following treatment, 16 patients reported pain-free shoulders, and 11 patients still had pain. No increase in GH motion was noted following only an injection. These researchers concluded that arthrographic assisted intraarticular injections should be attempted following failure of conservative therapy. Binder and associates3 in 1986 studied the effects of oral prednisolone in treatment of frozen shoulder and reported a statistically significant decrease in pain, but no change in ROM when compared with nonintervention groups. Both groups performed a home pendulum exercise program.

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In 1989 Dacre, Beeney, and Scott10 found no significant advantage for physical therapy and/or steroid injection for the treatment of frozen shoulder. However, physical therapy treatment was not consistent among the 62 subjects.

Use of Physical Therapy The debate on the effectiveness of physical therapy in treatment of the frozen shoulder continues. The length of physical therapy intervention, and the stage at which it may be appropriate, has not been justified thus far in the research. The research that will be discussed lacks well-controlled trials and useful outcome measurement tools. Consistency among the studies does not exist, making comparison difficult. Table 11-2 is a matrix summary of the research. Parsons, Shepard, and Fosdic34 in 1967 performed a one-group pretest and posttest on seven subjects, reporting the effects of dimethyl sulfoxide (DMSO has a vasodilation and antiinflammatory action) with ultrasound in frozen shoulder. The researchers concluded that further studies needed to be performed on DMSO as an adjunct therapy for the treatment of frozen shoulder. This study was terminated because of adverse effects from the agent.

Table 11-2 RESEARCH ON USE OF PHYSICAL THERAPY FOR THE FROZEN SHOULDER Sample Size Purpose

Use of Physical Therapy

Parsons JL, Shepard WL, Fosdick WH: 1967

N=7

Preliminary report on 5 months; experimental study

DMSO with ultrasound

1) 4 “better” 2) 3 no change

Hamer J, Kirk JA: 1976

N = 32

To compare the effectiveness of ultrasound and ice on frozen shoulder

Ice group, ultrasound group; all performed active external rotation and elevation exercises

No significant differences

Rizk TE, Christopher RP, Pinals RS, Higgins AC, Frix R: 1983

N = 56

To describe a new method of therapy that has been found to facilitate the recovery of patients with adhesive capsulitis

Group A: exercises and modalities Group B: pulley and traction

B group increased ROM faster first 2 weeks

Author & Year

Results

Continued

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Table 11-2 RESEARCH ON USE OF PHYSICAL THERAPY FOR THE FROZEN SHOULDER—cont’d Sample Size Purpose

Use of Physical Therapy

Bulgen DY, Binder AI, Hazleman BL, Dulton J, Roberts S: 1984

N = 45

To study a carefully defined patient group and assess 3 treatment regimens 1) Intraarticular steroids 2) Mobilization 3) Ice & PNF 4) Pendulum

See groups

Minimal differences between groups; injection may benefit pain and ROM in early stages; biggest improvement first 4 weeks; after 6 months decreased pain; no significant difference in ROM

Nicholson GG: 1985

N = 20

To determine the effects of passive mobilization and active exercises on pain and hypomobility in patients with painfully restricted shoulders

Mobilization, passive ROM, and strengthening; home exercise program

Mean improved over 4 weeks except internal rotation with increased gains in experimental group

Author & Year

Results

Experimental group: mobilization and active exercises Control: active extension only Shaffer B, Tibone JE, Kerlan RK: 1992

N = 62

To evaluate the long-term objective and subjective results in a carefully selected group of patients who had idiopathic frozen shoulder

Pendulum, modalities, and stretching following manipulation

See text of chapter

O’Kane JW, Jackins S, Sidles JA, Smith KL, Matsen FA III: 1999

N = 41

To test the hypothesis that a simple home program can improve the self-assessed shoulder function and health status of a group of patients with frozen shoulder

Self stretch flexion, abduction, external rotation, internal rotation

SF 36 showed almost all pretreatment deficits were reversed

Griggs SM, Ahn A, Green A: 2000

N = 75

To evaluate the outcome of patients with idiopathic adhesive capsulitis who were treated with a stretching exercise program

Home exercise program: supine cane flexion, external rotation, internal rotation, pendulum; formal physical therapy

1) 64 satisfactory: SF 36 2) 7 not satisfied: SF 36 3) 5 required manipulation/ surgery 4) ROM increased 5) Pain decreased

Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Rozing PM, Van der Ende C: 2000

N=7

To describe the use of end Mobilization range mobilization techniques in the management of patients with adhesive capsulitis

Reports increased ROM and decreased pain

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In 1976 Hamer and Kirk16 performed a two-group pretest and posttest prospective study on 32 subjects to compare the effects of ultrasound and ice on outcome in patients with frozen shoulder. The mean age of subjects was 59 and the time between onset of symptoms and discharge from physical therapy was 17.7 weeks. No demographic differences were reported between the groups at pretest. Both groups received active elevation and ER exercises 2 times per day for 10 minutes until discharge. Discharge was based on pain relief only, not ROM gains. No significant differences were reported between the groups. The researchers recommended including measurements of the contralateral shoulder for assessment of shoulder ROM gains. Rizk and associates40 in 1983 described a new method of therapy. Fifty subjects were assigned to groups. Group A received conventional physical therapy, including modalities, Codman’s exercises, wall walks, shoulder wheel, pulley, rhythmic stabilization, and manipulation of the GH joint. Group B used transcutaneous electrical nerve stimulation (TENS) + pulleys with up to 15# 15 repetitions per exercise traction plus intermittent 15 minutes on/5 minutes off for 2 hours. The mean age of the subjects was 56, the duration of symptoms ranged from 3 to 8 months before the intervention. Treatment was administered for 8 weeks. The subjects’ progress was assessed monthly for 6 months. Both groups performed a home exercise program consisting of Codman’s exercises, wall walks, and wand ROM (five repetitions each, three times a day). Group B progressed faster and to a greater degree than Group A during the first 3 weeks of treatment. Both groups demonstrated the greatest gains in the initial 3 weeks, which was comparable to the findings of Lee and associates.22,23 Rizk and associates concluded that the treatment approach for group B was superior to conventional physical therapy. Random assignment was not used and no statistical analysis was reported. Bulgen and associates4 performed random controlled trials in 1984 comparing the following treatment groups: intraarticular steroids, once a week for 3 weeks; mobilization, three times a week for 6 weeks plus PNF three times a week for 6 weeks; and pendulum exercises of only 2 to 3 minutes every hour. Forty-two subjects were recruited whose mean age was 55.8, with a symptom duration averaging 4.8 months before the intervention. Follow-up was performed weekly for 6 weeks, then monthly for 6 months. Statistical analysis showed no

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differences between the groups pretreatment. Bulgen and associates concluded that improvement in ROM was greatest during the initial 4 weeks of treatment and that no difference between groups was found when comparing the stage at which the patient joined the study and the severity of the subject’s outcome. A correlation was reported between increasing age and decreasing ROM, except for ER. Final recommendations emphasized the need for well-designed, controlled prospective studies to test the efficacy of commonly used interventions. In 1985 Nicholson29 compared the effectiveness of active exercise with joint mobilization in 20 subjects. The mobilization group gained more internal rotation and abduction than the exercise only group. The followup measurements were taken 4 weeks after initiation of the intervention. Shaffer, Tibone, and Kerlan44 evaluated the longterm subjective and objective results in 62 subjects who had shoulder pain and restriction for at least 1 month, AB < 100, and <50% ER. The mean age was 52, with a mean duration of symptoms of 6 months before the intervention. All of the subjects had previously received supervised physical therapy or a home stretching program. Ten received manipulation under anesthesia and two received arthroscopic release. Conclusions from this study are as follows: • The average total time from onset to resolve was 12 months. • The average time to return to nearly normal motion (within 10° to 15°) was 6 months. • Pain was resolved within an average of 6 months. • Thirty-one percent of subjects had either mild pain/stiffness of the shoulder. • Thirty-seven percent of subjects demonstrated restricted motion when compared with the control group (unaffected shoulder averages). • Seven percent interference with function was reported. • No association was reported between functional limitation and measurable restriction of motion. • No association was reported between the objective ROM and duration of symptoms with the subjective outcome. O’Kane and associates31 studied the effects of a home stretching program on self-assessed function. The researchers measured function with the Simple Shoulder Test and the SF 36. All deficits identified with the SF 36 were reversed posttreatment. The duration of follow-up was not reported.

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Griggs and colleagues15 performed a prospective study on 41 subjects using home wand active assistive range of motion (AAROM) exercises and pendulum exercises. The mean age of subjects was 56. The researchers concluded the SF 36 was not sensitive to the shoulder. No correlation was found between ROM gains and improvement of function. Vermeulen and associates47 in a case report of four subjects observed increased ROM and decreased pain following physical therapy intervention. Physical therapy was provided for a maximum of 3 months. Treatment consisted of end-ROM mobilization techniques, with neither the use of modalities nor instruc-

tion in a home exercise program. All patients reported decreased pain and increased ROM. No statistical analysis was reported.

Use of Physical Therapy With Interscalene Block or Local Anesthesia The effectiveness of physical therapy mobilization during interscalene brachial plexus block or local anesthesia has been well supported in the literature. Table 11-3 is a matrix summary of the research. Weiser51 in 1977 reported on the treatment of frozen shoulder with gliding mobilization while under local anesthesia in 100 subjects. The majority of subjects were

Table 11-3 RESEARCH ON USE OF INTERSCALENE BLOCK OR LOCAL ANESTHESIA WITH PHYSICAL THERAPY TECHNIQUES Author & Year

Sample Size

Purpose

Use of Physical Therapy

Weiser H: 1997

N = 100

To report treatment of frozen shoulder using mobilization under local anesthesia

Cane flexion, abduction, internal rotation with extension/rotation

78 no pain 61 of 78 normal ROM 17 slight decreased ROM

Melzer C, Wallny CJ, Hoffmann S: 1995

N = 110

To compare moderate mobilization to manipulation in frozen shoulder patients

Modalities, ROM, mobilization, stretching, isometric strengthening

Physical Therapy 1) Increased abduction 78%, internal rotation 81%, adduction 54% 2) Mobilization under narcosis 3) Increased abduction 66%, internal rotation 73%, adduction 62%

Roubal PJ, Dobritt D, Placzek JD: 1996

N = 23

To develop and describe an alternative method that uses glide manipulation under interscalene brachial plexus block

Supine flexion, daily therapy, home exercise program flexibility

Postmanipulation: Flexion increased 68°, abduction increased 77°, external rotation increased 49°, internal rotation increased 45°, flexion increased 67°, abduction increased 73°, external rotation increased 44°

Placzek JD, Roubal PJ, Freeman DC, Kulig K, Nasser S, Pagett BT: 1998

N = 31

To evaluate the longterm effects of glenohumeral joint transitional gliding, manipulation, ROM, pain, and function in patients with adhesive capsulitis

Not described

1) ROM increased significantly 2) Pain decreased significantly

Results

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40 to 64 years old. Forty-five subjects experienced symptoms less than 3 months and 55 subjects experienced symptoms more than 4 months before the intervention. The inclusion criteria were GH restriction only, ER less than 55°, and flexion less than 110°. Five to 10 minutes of grade IV mobilization was performed in all directions. The patients performed wand exercises and were instructed to perform these six to eight times per day for at least 20 minutes. Follow-up was at 2, 4, and 8 weeks. Seventy-eight of 100 subjects were reported to have no pain at their 2, 4, and 8-week follow-up visits. Sixty-one of the 78 had normal ROM. Seventeen of 100 demonstrated a slight decrease in ROM. No statistical analysis was reported. Melzer and associates25 in 1995 also studied the effects of manipulation under general anesthesia to “moderate mobilization.” Eighty-nine subjects, aged 34 to 78, participated. The duration of symptoms was not reported. The average postintervention follow-up for the two groups was 1.4 and 1.7 years, respectively. The mobilization group showed an increase in pretreatment to posttreatment ROM values as follows: ABD 78%, internal rotation (IR) 81%, adduction (ADD) 54%. The manipulation group showed an increase in pretreatment to posttreatment ROM values as follows: ABD 66%, IR 73%, and ADD 62%. No statistical analysis was reported. The researchers concluded physical therapy with mobilization should be used before manipulation intervention. Roubal and associates41 performed a similar study of 23 subjects in 1996. These researchers used an interscalene brachial plexus block and a linear transitional gliding manipulation. Eight subjects demonstrated increased ROM when comparing pretest and posttest measures of ROM. No statistical analysis was performed. In 1998 Placzek and associates35 performed a similar study to Roubal and associates using linear transitional gliding manipulation on 31 subjects. The researchers reported a statistically significant improvement in ROM, pain reduction, and improved functional status at 5.3 to 14.4 weeks after the intervention. Placzek and colleagues concluded that translational manipulation was more effective than traditional angular techniques used in manipulation. This conclusion was drawn because of increased accessory humeral head movement associated with translational techniques.

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Use of Distension Arthrography The use of distension arthrography, with or without the use of physical therapy, is addressed in scientific research. This slightly invasive technique has been attempted with local and general anesthesia. Table 11-4 is a matrix summary of scientific research. Older and associates32 reported their experiences using distention arthrography on six subjects. Radiopaque contrast fluid was manually injected until the capsule ruptured via visualization on an arthrogram. The researchers reported full ROM at a 2.5-year followup and contributed this success to their treatment. ROM was reported as “full.” However, all patients performed “exercises” and no attempt was made to control physical therapy between the intervention and the follow-up. The researchers did not perform a statistical analysis. Arthrographic treatment progressed further when Loyd and Loyd24 in 1983 studied the effect of local anesthesia, arthrographic distension, and gentle manipulation in 31 subjects. The mean age of these subjects was 54, with a mean duration of 6 months for symptoms before arthrography. Subjects were included in the study if their capsular volume was less than 10 ml. Twenty-five subjects reported unrestricted function, whereas nine subjects reported continued restrictions described as “slight weakness.” No statistical analysis was reported. Loyd and Loyd reported the following advantages for use of their technique: increased diagnostic accuracy, arthrographic guided intra-articular injection, no morbidity, and better pain relief than physical therapy and analgesics only. The researchers stated that 31 of the 33 subjects reported the intervention had been beneficial and had provided excellent relief. No reliability or validity studies were discussed in regards to the outcome measurement tool. Fareed and Gallivan13 in 1989 documented their results of hydraulic distension while under local anesthesia and AROM. No manipulation was performed. The mean age of the 20 subjects was 56. Subjects included in the study demonstrated exquisite pain on passive ER/IR/ABD and night pain. An immediate increase in the subject’s ROM to normal function was reported in 90% of the subjects. A 10° to 15° loss was reported at 2 weeks, which then increased to normal when receiving more than one intervention before the 4-week follow-up. Long-term follow up at 6 months and 10 years showed the same results. Statistical analysis was not reported.

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Table 11-4 RESEARCH ON USE OF DISTENSION ARTHROGRAPHY Author & Year

Sample Size

Use of Physical Therapy

Purpose

Results

Older MWJ, McIntyre JL, Lloyd GJ: 1976

N=6

To report the researcher’s experience with distension arthrography as a treatment of frozen shoulder

None

Reported full ROM 2.5 years after intervention; greatest change reported with abduction

Lloyd JA, Lloyd HM: 1983

N = 31

To describe the efficacy of arthrographic diagnosis and treatment of the frozen shoulder

None

25 subjects reported unrestricted function, 9 subjects reported continued restrictions and weakness

Fareed DO, Gallivan WR: 1989

N = 20

To document the effectiveness of hydraulic distension as a modality of treatment for frozen shoulder syndrome; no manipulation

Active external rotation, pendulum, resistive flexion/extension/ internal rotation/ external rotation

1) 90% return of function and ROM after first treatment 2) 95-100% function and ROM at 4 weeks

Ekelund AL, Rydell N: 1992

N = 22

To determine the effectiveness of distension arthrography and local anesthesia and steroids and manipulation

Flexion/abduction External rotation/ internal rotation

All improved slightly or no pain

Van Royn BJ, Pavlov PW: 1995

N = 40

To report the effectiveness of distension and manipulation under local anesthesia in treatment of the frozen shoulder

none

1) ROM increased 72-95% 2) Pain absent in 15

Similar treatment intervention and results were reported by Ekeland and Rydell12 in a study in 1992. Follow-up in this study was 4 years. No attempt was made to control activity between the intervention and the follow-up. No statistical analysis was reported. In a similar study in 1996, Van Royen and Pavlov46 reported similar effects with a 72% to 95% increase in ROM with a reduction in pain. No statistical analysis was performed.

Use of Closed-Manipulation, Arthroscopic Release, or Open Release Closed-manipulation, arthroscopic, or open capsular release may be attempted upon failure of conservative treatment. Physical therapy is prescribed most often

following the intervention. Scientific research concerning these more aggressive procedures is summarized in Table 11-5, which is a matrix summary of scientific research. In 1988 Hill and Bogumill18 compared manipulation under general anesthesia with the natural history of frozen shoulder. Fifteen subjects were retrospectively analyzed from August 1981 to November 1984. The mean age of the subjects was 51, the mean duration of symptoms was 5.4 months. Physical therapy intervention averaged 2.2 months and the mean follow-up was 22 months after manipulation. The study included patients who had not responded to “adequate” physical therapy. Significant differences were found in ROM pretreatment to posttreatment immediately following

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Table 11-5 RESEARCH ON CLOSED MANIPULATION AND ARTHROSCOPIC OR OPEN RELEASE IN TREATMENT OF THE FROZEN SHOULDER Author & Year

Sample Size

Purpose

Use of Physical Therapy

Results

Hill JJ, Bogumill H: 1988

N = 15

To report the effects of manipulation and if patients of this treatment regain full ROM sooner than the natural recovery

Active ROM

Significant difference in ROM pretreatment to posttreatment, but not posttreatment to discontinue, biggest change initially

Kivimaki J, Pohjolainen T: 2001

N = 24

To study the effects of manipulation with and without steroid injection

None

No enhancement with injection

Pollock RG, Duralde XA, Platow SL, Bigliani LU: 1994

N = 30

To determine the effectiveness of arthroscopy and manipulation under anesthesia

Immediate ROM while block active

1) 50% unlimited function 2) 33% satisfactory function 3) 17% limited function

Segmuller HE, Taylor DE, Hogan CS, Saies AD, Hayes MG: 1995

N = 24

To determine the effectiveness of inferior capsular release on frozen shoulder

In recovery

88% satisfied 76% return to normal or near normal function

Ogilvie-Harris DJ, Bigop DJ, Fitsiabolis DP, Mackay M: 1995

N = 40

To compare the effectiveness of manipulation versus anterior structure division in frozen shoulder pain, ROM, and function; 20 each group, not random Groups: 1) manipulation with scope before and after 2) divided contracted structures

Home exercise program and active assistive ROM; physical therapy within first week

Manipulation group: 1) Pain: 8 none, 8 mild, 2 moderate 2) ROM: abduction 11 normal, external rotation 10 normal Division group: 1) Pain: 16 none, 4 mild 2) ROM: abduction 17 normal, external rotation 16 normal

Warner JJP, Allen A, Marks PH, Wong P: 1996

N-23

To describe the results of arthroscopic release

Physical therapy first day and passive ROM; active assistive ROM; home exercise program

1) Flexion increase mean 49° 2) External rotation at 0° increase mean 42° 3) External rotation at 90° mean increase 53° 4) Internal rotation increase 8 spinous process levels 5) ROM increases not significant when compared with contralateral normal shoulder

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Table 11-5 RESEARCH ON CLOSED MANIPULATION AND ARTHROSCOPIC OR OPEN RELEASE IN TREATMENT OF THE FROZEN SHOULDER— cont’d Author & Year

Sample Size

Purpose

Use of Physical Therapy

Results

Warner JJP, Allen A, Marks PH, Wong P: 1997

N = 18

To describe the authors’ experience with arthroscopic release of the anterior shoulder capsule in treatment of postoperative stiffness

Physical therapy daily for ROM and strengthening

1) ROM mean significant increase 2) Flexion increase 51° 3) External rotation increase 31/40° 4) Internal rotation increase 6 spinous process levels

Watson L. Dulziel R, Story I: 2000

N = 73

To determine the effectiveness of arthroscopic capsulotomy in treatment of frozen shoulder

Graduated

1) Significant decrease in pain 2) Significant increase in ROM 5.5 weeks

Gerber C, Espinosa N, Perren TG: 2001

N = 45

To study the outcome of arthroscopic capsulotomy for treatment of shoulder stiffness after failure of conservative treatment and to determine whether different etiologies have a different prognosis

Passive ROM with block 2-4 days

Best results idiopathic, poorest result posttraumatic Functional 26% increase (68% of normal shoulder) statistically significant

Omari A, Bunker TD: 2001

N = 75

To describe the effectiveness of surgical release of frozen shoulder in shoulders with severe disease that fail to release with manipulation under anesthesia

Formal physical therapy home exercise program for ROM

1) Flexion increased 97° 2) External rotation increased 8° 3) Internal rotation with extension increased from sacrum to T7

the manipulation. No change, however, was found postmanipulation to the time of discharge. Flexion was found to increase significantly from pretreatment to posttreatment, but a decrease in ROM occurred from posttreatment to discharge. No significant differences were found pretreatment to posttreatment with internal or external rotation. The researchers reported that 10% of the subjects returned to work between 2 and 6 months following manipulation, which is of shorter duration than the reported natural history of the condition. The researchers did not report what “natural history” values they used to make their comparisons.

Kivimaki and Pohjolainen21 performed a random clinical trial in 2001. Twenty-four subjects were randomly exposed to manipulation under anesthesia with or without steroid injection. No enhancement was found with steroid injection. Twenty-two of the 23 subjects demonstrated improved mobility. Pain was decreased in all but three subjects. The mean follow-up period was 4 months. Pollock and associates36 in 1994 used arthroscopy and manipulation under anesthesia for the resistant frozen shoulder. The mean age of the 30 subjects was 49, with average symptom duration of 14 months before the

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intervention. The subjects received arthroscopic guided manipulation, debridement, and decompression. The subjects received physical therapy for ROM immediately following the procedure. The surgical procedures were individualized for each subject. At follow-up, the results were as follows: 50% of subjects reported unlimited function (flexion [FL] 170/ER 50/IR T10), 33% reported satisfactory function (FL 160/ER 40/IR L1, slight pain), and 17% of subjects reported limited function (FL less than 140 degrees, moderate to severe pain). No statistical analysis was reported. Segmueller and associates43 studied the effect of inferior capsular release without manipulation on 24 subjects with frozen shoulder. The mean age of the subjects was 50 and the mean follow-up was 13.5 months following intervention. Subjects were included in this study if no progress had been reported or if ROM had been lost during a 6-week time period of physical therapy. Patients who had already undergone surgical procedures on the same shoulder were excluded from the study. Excellent results on the Constant-Murley Shoulder tests were obtained following the procedure, with the average score being 87%. Eighty-eight percent of the subjects were satisfied and 76% had a return to normal or near normal function. Ogilvie-Harris and associates30 looked at the effectiveness of manipulation versus arthroscopic anterior structure division in frozen shoulder. Subjects were included if they had previously received physical therapy and cortisone injection; distension arthrography; and continued to have difficulty for more than 1 year following intervention. Forty subjects, divided into two equivalent groups, were studied. One group received manipulation with arthroscopy before and after the procedure, while the other group underwent arthroscopic release of contracted anterior structures. All subjects performed hourly AAROM physical therapy and conducted 6 weeks of outpatient physical therapy. No differences were reported between the groups for ROM. Significant differences were reported for improved function in the division group. Follow-up was reported in a range of 2 to 5 years. The researchers theorized that a significant difference in ROM between the groups would be found using a larger sample size, thus increasing the impact of the study. In 1996 Warner and colleagues48 described similar increases in ROM in 23 subjects. The mean age of the subjects was 48 and the mean duration of symptoms was

331

48 months. Subjects included in the study had failed conservative treatment and closed manipulation. Following arthroscopic release of chronic refractory frozen shoulder, increases were reported in both function and ROM. In a similar study in 1997, Warner and associates49 reported similar results using arthroscopic release in secondary frozen shoulder following rotator cuff tear repair. Watson and associates50 performed arthroscopic capsulotomy on 73 subjects with a mean age of 52. The average duration of symptoms was 19.7 months before the intervention. Physical therapy intervention consisted of pendulum exercises, stretching, and AROM on days one through four. Modalities and massage were initiated on day 10. Mobilization and isometrics were initiated at 2 weeks, and isotonic strengthening was initiated at 4 weeks. Follow-up was reported on average 8.9 weeks following the intervention. Increased ROM and decreased pain were reported at 5.5 weeks. No statistical analysis was reported. Gerber and colleagues14 compared arthroscopic outcomes for the following: idiopathic, postsurgical, and posttraumatic frozen shoulder groups. The mean age of the 45 subjects was 50.8. The average follow-up occurred 26 months after the intervention. The researchers concluded that those with an idiopathic frozen shoulder responded the best to arthroscopic treatment of frozen shoulder, with a 26% increase in function. The posttraumatic group demonstrated the worst outcome. Omari and Bunker33 reported improvements in pain and ROM following open release in patients who failed to release under closed manipulation. Seventy-five subjects, mean age 52.6 years, were followed for an average of 19.52 months. These subjects demonstrated a mean increase in flexion of 97°, external rotation of 8°, and internal rotation by 10 spinous process levels. Formal physical therapy was prescribed, but was not controlled. A significant increase in function was also reported. No statistical analysis was provided. Through this review of scientific research, it appears that in the very early stages of frozen shoulder, physical therapy—consisting of AROM exercises and end-ROM linear translation/mobilization techniques, especially under local or interscalene brachial plexus block—is beneficial.* Traction using TENS was noted in one case *References 15, 25, 29, 34, 41, 47, 51.

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report, with improvements in ROM and pain.40 Weiss and Ting52 conducted arthrographic assisted intraarticular injections and reported no benefit on ROM. However, use of intraarticular steroid injections in the first 3 weeks of therapy may be beneficial for pain control.18,22,23,29,40 Following failure of conservative treatment, distension arthrography—especially with gentle manipulation/mobilization and AROM exercises—led to successful increases in ROM.2,13,24,32 Other measures may be needed for pain control.32 Closed manipulation of the GH joint has been studied extensively. Much controversy exists over the possible maladies associated with this intervention, such as fracture and nerve injury.* Two studies evaluated the effects of steroid injection during manipulation and the usefulness of oral steroids. No enhancement of ROM was reported with either treatment.37,49 Surgical treatment, both arthroscopic and open capsular release,† offered favorable results. However, the sample sizes were small. Researchers who are prosurgical release‡ argue against closed manipulation because of inconsistent results and unpredictable release of capsular structures. Arthroscopic and open controlled release is becoming favored by many surgeons to prevent the morbidities reported with closed manipulation. The lack of a working definition of frozen shoulder has led to inconsistencies among inclusion and exclusion criteria used in scientific research. Most studies reviewed reported no or minimal statistical analysis making comparison difficult and the credibility of results questionable. The sample size in most studies was small, decreasing power. All studies reviewed were missing discussion about sources of secondary variance. The outcome measurement tools that were used were not consistent among the studies. Furthermore, the outcome measures used had no reliability or validity studies to support their use. Carefully controlled clinical trials need to be performed to further evaluate treatment efficacy of the frozen shoulder.

Treatment Objectives The studies demonstrate that various forms of treatment are effective in increasing ROM and reducing pain in *References 14, 24, 30, 33, 43, 48-50 † References 14, 30, 33, 36, 43, 48-50. ‡ References 12, 14, 30, 33, 36, 43, 48-50.

patients with frozen shoulder. Physical therapy should play a major role in the initial treatment of frozen shoulder. After careful assessment and objective evaluation to confirm the diagnosis of frozen shoulder, the current stage of the condition, and identification of any causal factors, physical therapists should be prepared to design an individual treatment program based on their assessment. The physician, in conjunction with the physical therapist, should direct each case if physical therapy is to be used alone or with other medical or surgical treatment. The treatment objective during the painful phases are pain control and reduction of inflammation. A combination of medical pharmaceutical management and exercise with modalities may help accomplish them. The physical therapist should encourage the patient to use his or her arm as aggressively as the condition allows. A home exercise program should be recommended that promotes ROM in the pain-free range, especially in internal and external rotation. Promotion of elevation with compensatory scapular motion can increase impingement and inflammation, often causing a loss of glenohumeral mobility. The patient should be educated on glenohumeral elevation within a range to prevent impingement and compensatory motion. The physical therapist may provide gentle mobilization to promote accessory joint motion. Heat application may be used to promote soft tissue pliability and pain reduction. Other investigators recommend heating the joint capsule before stretching, with the belief that increased circulation acts as an analgesic.9 Cryotherapy may also be used before stretching to provide an analgesic effect or following stretching to prevent increased inflammation. This may be especially beneficial in the painful phase of frozen shoulder. During the stiff/frozen and thawing phases, treatment objectives should focus on pain reduction and regaining ROM within a pain-free range. Exercise prescription should include active-assistive, active, and isometric activities. The physical therapist should provide mobilization to attempt to restore joint mobility. Endrange linear translation/gliding techniques have been supported in research for treatment efficacy over traditional manipulative techniques.35,41,47,51 Target-specific mobilization should be performed with prepositioning of the GH joint to address specific structures such as the posterior-inferior capsule or the coracohumeral ligament. The patient’s capsular restrictions must be

FROZEN SHOULDER

CHAPTER 11

carefully assessed to determine the most effective techniques. When designing any treatment program, the physical therapist should consider patient alignment and movement impairments so that optimal biomechanics can be achieved around the joint. Sahrmann42 has categorized key tests and signs that may assist the physical therapist in evaluation and treatment of frozen shoulder. Movement impairments, which are especially helpful to identify to optimize the proper biomechanics of the shoulder, are as follows: 1. Loss of both passive and active ROM in all directions, most commonly in the capsular pattern 2. Pain increases toward the limitations of motion 3. Excessive humeral superior glide during shoulder abduction and flexion 4. Decreased glenohumeral crease just distal to the acromion with the arm overhead 5. Compensatory movement—excessive scapular motion 6. Impairments of muscle recruitment—dominance of the deltoid over the rotator cuff; dominance of the upper trapezius over the lower trapezius 7. Impairments in muscle strength—weakened rotator cuff

333

Joint Active Systems ( JAS), Effingham, Indiana provides an orthosis that is patient applied and directed,1 for contracture stretching of the shoulder. This is used as an adjunct to traditional physical therapy. This system of stretching is based on the principles of stressrelaxation (Figure 11-1) and static progressive stretching (Figure 11-2). The system provides an external rotation stretch, from a range of neutral to 90° of abduction in the scapular plane. Impingement often associated with stretching into elevation can be avoided with use of this orthosis. The treatment protocol is 30 minutes one time a day the first week, two times daily the second week, and never more than three times a day following the third week. Donatelli and associates,11 following a pretreatment, posttreatment study of 30 subjects, reported an increase of 1.5° of elevation for every degree gained into external rotation. Both groups received physical therapy, while group I performed a home exercise program in three planes of motion, and group II used the JAS shoulder orthosis twice a day for 30 minutes. Group II demonstrated twice the gain of ROM in external rotation and elevation compared with group I. The researchers also reported greater patient compliance, attributing this to shorter wearing times. The researchers concluded that the JAS shoulder orthosis is a useful adjunct at home for treatment of frozen shoulder (Figure 11-3).

Other Treatment The patient is often required to perform a home stretching program to increase glenohumeral joint motion. STATIC PROGRESSIVE STRETCH (SPS) -INCREMENTAL AND PROGRESSIVE APPLICATION OF SR STRESS RELAXATION (SR) -CONSTANT DISPLACEMENT- VARIABLE FORCE

Stretch

Hold

Stretch

Hold

Stretch

Force

Stretch

Hold

Displacement Time Time

Figure 11-1

Loading conditions.

Static progressive stretch. Incremental and progressive application of stress relaxation (SR).

Figure 11-2

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A B

Figure 11-3

A and B, Joint active systems ( JAS) shoulder arthrosis as a useful adjunct for treatment of frozen

shoulder.

Conclusion This chapter has described the distinct clinical entity of frozen shoulder and the confusion that exists about this condition. Clearly, in the clinical setting, the condition of frozen shoulder can be painful and debilitating to many patients. By understanding a typical presentation of primary frozen shoulder, and the literature supporting various treatment approaches, one can apply this knowledge to make treatment decisions based on evidence. The evidence at present supports varied treatment approaches, which are largely dependent on the stage of presentation for treatment and the failure of previous treatments. More clinical trials, with a clarified working definition for inclusion and exclusion criteria, will assist in promoting evidence-based practice and treatment of frozen shoulder.

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49. Warner JJP, Allen A, Marks PH, et al: Arthroscopic release of postoperative contracture of the shoulder, Journal of Bone and Joint Surgery 79-A(8):1151-1158, 1997. 50. Watson L, Dulziel R, Story I: Frozen shoulder: a 12-month clinical outcome trial, Journal of Shoulder and Elbow Surgery 9:16-22, 2000.

51. Weiser H: Painful primary frozen shoulder, mobilization under anesthesia, Archives of Physical Medicine and Rehabilitation 58:406-408, 1977. 52. Weiss JJ, Ting M: Arthrography assisted intra-articular injection of steroids in treatment of adhesive capsulitis, Archives of Physical Medicine and Rehabilitation 59(6):285-287, 1978.