A Manual Therapy and Home Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series
Dueñas L, Balasch-Bernat M, Aguilar‐Rodríguez M, Struyf F, Meeus M, Lluch E. A manual therapy and home stretching program in patients with primary frozen shoulder contracture Syndrome: a case series. Journal of Orthopaedic & Sports Physical Therapy. 2019;49(3):192-201. doi:10.2519/jospt.2019.8194Link to Original Article: https://www.jospt.org/doi/full/10.2519/jospt.2019.8194
Key Points
1. The study focused on frozen shoulder contracture syndrome (FSCS), a common musculoskeletal disorder characterized by progressive loss of both active and passive mobility of the glenohumeral joint.
2. The case series included 11 patients with primary FSCS who underwent a 12-week multimodal manual therapy program and home stretching exercises based on specific impairments in shoulder mobility and level of tissue irritability.
3. Clinically meaningful improvements in shoulder pain, disability, range of motion (ROM), and muscle strength were observed in most patients following the treatment program.
4. The treatment program was tailored to individual shoulder ROM limitations and tissue irritability levels, with the intensity and duration of the manual therapy techniques continuously adapted based on patient response and level of irritability.
5. Adherence to the home stretching program was monitored, and patients showed good adherence, with no adverse events reported.
6. The study suggests that a tailored multimodal manual therapy approach, combined with a home stretching program based on tissue irritability and specific impairments in shoulder mobility, may lead to reduced shoulder pain and improved ROM and muscle strength in patients with FSCS. However, the study lacked a control group, and further research in a larger population with FSCS is needed.
Introduction
This study focuses on frozen shoulder contracture syndrome (FSCS) and the effectiveness of manual therapy techniques in its treatment. FSCS is characterized by a progressive loss of mobility of the glenohumeral joint and decreased muscle strength in external and internal rotation, attributed to various pathological changes. The traditional assumption of FSCS being self-limiting with three phases (painful, stiff, and recovery) is not always supported, with some patients experiencing prolonged limitations lasting for multiple years. In addition, evidence that suggests capsular adhesions to the humeral head has been refuted. As a result, the term, Adhesive Capsulitis, is outdated, and the term, Frozen Shoulder Contracture Syndrome (FSCS), describes the condition more appropriately. Manual therapy techniques, including angular mobilizations, Mulligan's mobilization-with-movement (MWM) techniques, and Maitland techniques, have shown beneficial effects on pain and mobility in patients with FSCS.
Prior research suggests management of FSCS primarily uses a protocol-based approach and an individualized approach to the patient’s needs are utilized to a lesser degree. In addition, individualized treatment to patients with FSCS is unknown due to weak evidence supporting its use. Based on the Clinical Practice Guidelines (CPG), a shoulder range of motion past the restricted ranges is proposed to improve shoulder mobility. However, forced movements can increase tissue damage and inflammation, in turn, increase the pain level.
Case Description
Patients
A study conducted at the University of Valencia in Spain focused on 11 patients diagnosed with primary Frozen Shoulder Capsulitis (FSCS) referred by their primary care physician. The inclusion criteria for the study included FSCS not associated with a systemic condition or history of injury, a 50% loss of passive external rotation and range of motion (ROM) in comparison to the uninvolved shoulder or a loss of passive motion >25% in two planes of motion, as well as the presence of pain and restricted movement for at least one month. Patients with previous shoulder surgery, rotator cuff tear, or secondary causes of FSCS including disorders to bicipital tendon or acromioclavicular joint were excluded. All patients continued their usual medications throughout the study.
Prior to the study, none of the patients had received corticosteroid injections or reported improvement from previous treatments. The physical therapy treatment provided to the patients included analgesic modalities, general exercises, and manual therapy techniques. All the patients who met the inclusion criteria provided written consent and their rights were protected, as approved by the Institutional Review Board at the University of Valencia.
Physical Therapists
In the physical therapy section of the research paper, a single physical therapist (E.L.G.) with 20 years of clinical experience conducted all baseline and follow-up assessment measurements. This therapist was blinded to the earlier measurement results to ensure unbiased assessments. A second physical therapist (M.B.B.), who was board certified in orthopedic physical therapy and had 10 years of clinical experience, performed all manual therapy techniques and was also blinded to the assessment outcomes. Prior to the study, the physical therapist who conducted the interventions (M.B.B.) underwent a 3-hour training session led by one of the authors (E.L.G.) to ensure specific training in the application of the interventions. This training included instructions to accurately perform all manual therapy techniques, including pilot treatment on two healthy individuals. Additionally, the treating physical therapist was provided with a treatment booklet outlining the treatment techniques and details of each intervention included in the study.
Evaluation Procedure
The assessment procedure in the study involved multiple time points, including before the intervention (baseline), immediately after the 3-month intervention period (posttreatment), and at 3 and 6 months after the intervention period (6 months and 9 months from baseline, respectively). Patients completed a standard medical history questionnaire, including demographic information and medication use. The examination included measures of shoulder pain and disability, active range of motion (ROM) and active ROM with overpressure, and muscle strength. Adverse effects were monitored through open-ended questioning, with any undesirable experiences during follow-up that led to the need for additional contact with the healthcare system (physical therapist, general practitioner, or hospital) being recorded as adverse effects.
Outcome Measures
The research paper utilized various outcome measures to assess shoulder pain and disability, range of motion (ROM), and muscle strength. Shoulder pain was evaluated using a 100-mm visual analog scale (VAS) and the minimal clinically important difference (MCID) for the VAS was estimated to be 30 mm. Disability was measured using the Spanish version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, with the MCID for the DASH estimated at 10.2 points. Shoulder ROM was measured using a Plurimeter-V inclinometer with a 1° interval, and scapular upward rotation during shoulder abduction was also measured. Shoulder muscle strength was assessed using a portable handheld dynamometer, with measurements performed for shoulder flexion, external rotation, and internal rotation. The paper highlighted the reliability and validity of the measures, including high internal consistency and excellent test-retest reliability for the DASH questionnaire and acceptable reliability for clinical use of the handheld dynamometer.
Intervention
The intervention in this study involved a 12-session treatment program delivered over 12 weeks, consisting of manual therapy techniques tailored to the level of tissue irritability and specific impairments in shoulder mobility. Low-grade, low-to high-grade, or high-grade mobilizations were applied based on the level of irritability. Passive mobilization manual techniques and pain-free stretching exercises were used to reduce pain and decrease muscle guarding in patients with high irritability. The direction and focus of the manual therapy program for shoulder range of motion limitations were determined through active rotation with overpressure testing at different degrees of shoulder abduction. Various manual therapy techniques, including joint mobilization and Mulligan mobilization with movement (MWM) techniques, were utilized based on individual shoulder limitations. Patients performed home stretching exercises tailored to their shoulder limitations and irritability level, with the intensity and duration of stretching exercises adjusted according to irritability level. Adherence to the home stretching program was monitored using a treatment diary, and treatment progression was based on reassessment of shoulder limitations and perceived irritability. The intensity and duration of manual therapy techniques were continuously adapted within and between sessions based on patient response and level of irritability. A clinical-reasoning diagram was provided to guide the progression or regression of techniques based on patient response.
Data Analysis
The Data Analysis section of the research paper involved the analysis of data from 11 patients using descriptive statistics. The outcome measures examined included VAS and DASH scores, shoulder range of motion (ROM) during active and active with overpressure shoulder flexion, abduction, external rotation, and upward scapular rotation, as well as shoulder muscle strength during flexion, internal rotation, and external rotation. Additionally, the glenohumeral contribution to total active shoulder abduction was calculated by subtracting scapular upward rotation from total shoulder abduction ROM, referred to as "isolated glenohumeral active abduction."
Outcomes
In this study, 3 men and 8 women were included in the study. The mean age was 52.6 years, the mean BMI was 23.1, and the dominant hand was affected in 8 out of 11 cases. All patients had a diagnosis of type II diabetes. The treatment were initiated a mean of 12 months after the initial onset of symptoms. No adverse events were reported. Patients adhered to home stretching programs greater than 75% of the sessions.
Shoulder Pain and Disability
The study assessed the impact of a physical therapy intervention on shoulder pain and disability in 11 patients. The results showed that 4 of the 11 patients experienced clinically significant improvements in pain levels, as measured by the Visual Analog Scale (VAS), immediately after the treatment. This number increased to 8 patients at the 6 and 9-month follow-ups, indicating sustained improvements over time. Additionally, 10 of the 11 patients demonstrated improved VAS scores post-treatment, with 9 of them maintaining or showing further improvement at the 6 and 9-month assessments.
In terms of disability, 7 of the 11 patients displayed improvements in Disability of the Arm, Shoulder, and Hand (DASH) scores that exceeded the minimal clinically important difference (MCID) immediately after treatment, with 9 patients surpassing the MCID at the 6 and 9-month follow-ups. Moreover, 10 of the 11 patients exhibited enhanced DASH scores post-treatment, with only one patient not showing improvement.
Shoulder ROM
In a study on shoulder range of motion (ROM) in patients receiving treatment, 9 out of 11 patients showed improvement in active shoulder flexion and active shoulder flexion with overpressure after the treatment. These improvements were sustained at 6 months for all patients except patient 4. Additionally, improvements were observed in active shoulder abduction and active shoulder abduction with overpressure in 9 out of 11 patients, with sustained improvement at 6 months for all patients except patient 2, and 4 patients showed a slightly decreased ROM at 9 months. Furthermore, 7 patients showed improvement in active shoulder external rotation post-treatment, with 8 of 11 patients demonstrating higher active shoulder external rotation with overpressure. Isolated glenohumeral active abduction improved in all patients and was maintained over time in 8 of 11 patients. Overall, the study demonstrated significant improvements in shoulder ROM following treatment, with sustained benefits for most patients at the 6-month follow-up. However, 4 patients showed a slightly decreased ROM at 9 months, suggesting some variability in long-term outcomes.
Shoulder Strength
In a study on shoulder strength, 8 out of 11 patients improved their shoulder flexion strength and 8 out of 11 patients also increased shoulder internal rotation strength. No patients increased shoulder external rotation strength from the baseline.
Discussion
In this study, a clinical reasoning approach using manual therapy and a home stretching program was employed in patients with Frozen Shoulder Condition Syndrome (FSCS). The approach aimed to address shoulder range of motion (ROM) limitations, with positive outcomes observed in shoulder pain, disability, ROM, and muscle strength in 11 patients with primary FSCS. The treatment approach was guided by perceived tissue irritability, and the progression of treatment was dependent on reassessment findings. The study highlighted that the home stretching program and the adaptability of interventions at and between sessions were differentiating aspects compared to previous literature. The study emphasized the need for future research to investigate the interaction and individual effects of manual therapy and home stretching programs in FSCS patients. Muscle strength testing was considered in this case series, unlike in previous studies, and improvements in all measured glenohumeral ROM directions were observed. The study also discussed the association between type 2 diabetes mellitus and FSCS, with comparable results noted in patients with diabetes. The study acknowledged its limitations, including the absence of a control group and variations in baseline pain and disability levels among patients, which could have influenced their responsiveness to treatment.
Conclusion
The conclusion of the research paper highlights the positive outcomes of a multimodal manual therapy approach combined with a home stretching program for patients with primary Frozen Shoulder Capsulitis (FSCS). This approach, which is tailored based on tissue irritability and specific impairments in shoulder mobility, resulted in reduced shoulder pain, improved range of motion (ROM), and enhanced muscle strength in the patients. The study emphasizes the importance of considering tissue irritability when designing manual therapy and stretching exercise programs for FSCS patients.
The conclusion also calls for future clinical studies to further evaluate the effectiveness of this tailored approach in a larger population with FSCS. The need for comparative studies to assess the impact of the tailored manual therapy and stretching exercise program in comparison to the natural course of the condition is also highlighted. This suggests the importance of understanding the specific effects of the intervention in relation to the progression of FSCS. Overall, the conclusion emphasizes the potential benefits of a personalized manual therapy and stretching exercise program for FSCS patients and underscores the necessity for further research to validate its efficacy and impact in a broader patient population.
