Frozen shoulder: An interventional approach to improving functional mobility.
By Dr. Tyson Young, PT, DPT, CSCS
Frozen shoulder, also known as adhesive capsulitis, is a condition that affects the shoulder in which it becomes painful and stiff due to the shrinking of the surrounding capsule. This condition may occur following an injury to the shoulder, including the rotator cuff capsule, or labrum. However, it may also come about insidiously. Frozen shoulder is linked to conditions such as diabetes and thyroid disease. This condition typically occurs in three stages: freezing, frozen, and thawing, and can take up to 18 months to reach full recovery. Patients can have difficulty performing everyday tasks that require reaching with the affected upper extremity, including, but not limited to, reaching into overhead cabinets, washing their back, fastening a bra strap, washing their hair, etc. This condition affects roughly 2-5% of the population. However, I have had the opportunity to work with several of these patients recently and would like to describe my treatment approaches to restore functional mobility.
Step 1: Passive Mobility
Any time the goal set forth is to increase mobility, it is essential to keep in mind that there are several variables to consider. Real tissue change takes extreme dedication, and I tell my patients it takes months of intense and frequent repetitions to achieve this change. Most immediate change occurs due to neurophysiological relaxation. For example, I am performing a hamstring stretch on a patient, and the first repetition is held for 30 seconds, and then returned to the starting position. When I attempt to perform this stretch for the second repetition, often, the leg can move into a further range of motion. The muscle has not increased its overall length within this time frame, but instead, the muscle has relaxed due to the nervous system response. This is strictly a short-term response. However, we can utilize this to our benefit if performed correctly. I begin my mobility work with passive interventions to decrease pain and to guard, as well as promote increased joint and soft tissue mobility via the aforementioned neurophysiological relaxations. Typical responses include joint mobilizations, soft tissue mobilization, active release technique, passive range of motion, stretching, and foam rolling.
Step 2: Active Mobility
After any passive intervention has increased the patient’s ROM, it is crucial to follow this with active mobility exercises in which the patient moves actively into the end range. This allows us to re-educate the nervous system to fire into the newly acquired range of motion. I like to describe this process with the following example. Performing passive interventions in isolation are like typing the perfect essay and exiting off of your work without saving. However, active mobility is essentially saving the progress made. Interventions that I employ for active movement include a dynamic range of motion, controlled articular rotations (CARS), progressive angular isometric loading (PAILS), and regressive angular isometric loading (RAILS).
Step 3: Load
The final step in my mobility sequence includes loading the tissues. There are several ways this can be done, including resistance training. However, the approach that I utilize with the highest frequency includes eccentrics. This is the phase of a muscle contraction in which the muscle is lengthening. Eccentrics have been repeatedly shown in the literature to create true tissue-level changes in flexibility.
Utilizing this sequential progression, I have had great success with my patients, and have seen much quicker functional gains than the previously mentioned 18 months. A frequent question that I am asked is, “how often should I perform my mobility exercises?” and my response is as often as possible but at a minimum one time/daily. However, with any intervention given to the pathological population, it is essential to monitor response and consistently re-assess. One rule of thumb that I give my patients is to expect some discomfort when performing mobility exercises. However, there should not be immense amounts of pain. It is crucial to have an understanding of pain vs. strain; when pushed too far, we can initiate an inflammatory response. Following any mobility work, it is vital that symptoms return to baseline values at a relatively quick rate, and should return within 24 hours. Should the symptoms last longer than this, an immediate re-assessment should occur from a medical provider.
References:
J Orthop Sports Phys Ther 2013;43(5):351. doi:10.2519/jospt.2013.0503