FROZEN SHOULDER PHYSIOTHERAPY

Physiotherapy treatment
Frozen Shoulder Exercises try to reduce pain, increase extensibility from the capsule, and improve strength from the rotator cuff muscles.
Restorative Programme
The fundamental aim of frozen shoulder exercises are:
• To reduce pain.
• To increase extensibility from the thickened and contracted capsule from the joint at the anteroinferior border and also at the attachment from the capsule to the anatomical neck of humerus.
• To improve mobility from the shoulder.
• To improve strength from the muscle. However it might be remembered that strengthening of muscle is secondary to mobilization.
Mobilization is attained by 3 basic approaches:
i) Relaxation
ii) Passive mobilization technique
iii) Specific frozen shoulder exercises to provide graduated stretching.
Relaxation
Though prior heating from the joint has been found to facilitate relaxation and mobilization, you can use the heat modality suitable towards the patient's response. However ultrasound, beside deep heating, has got the added advantages of increasing excitability from the contracted soft tissue and it is therefore performed.
Relaxed Passive Mobilization
The individual is placed in supine position using the affected shoulder in maximum possible abduction and neutral rotation and elbow in 90 amount of flexion. The physiotherapist grasping the arm over the shoulder joint performs relaxed passive gliding movement of head of humerus on glenoid. Axial traction and approximation is completed along with antero-posterior glide and abduction- adduction glide. To induce relaxation, always start with slow rhythmic movement.
Slow and rhythmic circumduction in the glenohumeral joint, in forward stoop position effectively induces relaxation and promotes mobility. Gentle relaxed passive movements reduces pain and pathologic limits of movement. The reduction in pain occurs due to the neuro-modulation effect on the mechanoreceptors within the joint.
Mobilization by accessory movements of acromio-clavicular, sterno-clavicular and/or scapulo-thoracic joint articulation can also be extremely helpful.
Exercise Programme
Frozen shoulder exercises plays a huge role in management of the problem. While planning the frozen shoulder exercises you have to give due importance that contracted soft tissue when objected to repeated prolong mild tension show extensibility and plastic elongation.
A rise in the movement following a session of prolonged stretching was usually of a corresponding increase in another movements too. However improvement within the range of other movements isn't necessarily at the same rate.
The particular Frozen shoulder exercises will include the maximum number of mixture of various movement by minimising the amount of exercises. Graduated relaxed sustained stretching in line with the PNF pattern are following types:
• Shoulder elevation with flexion, abduction and external rotation.
• Shoulder internal rotation with extension, adduction and elbow flexion i.e attaining "hand to lumbar position".
All these Frozen shoulder exercises can be achieved in two ways:
• By weight and pully- Tolerable weight can be used. This may be done in supine or sitting position.
• By self assisted stretching- Approach to performing is, the individual uses his normal or contralateral arm for gradually stretching the affected shoulder.
Passive Mobilization Technique
For this, manipulation and mobilising techniques receive by "MAITLAND". By this patient respond perfectly for acquiring full range by properly guided easy and specific Frozen shoulder exercises which ensures relaxed graduated stretching from the contracted capsule.
Frozen Shoulder Exercises for Home and Cautions:
• The importance or demand for regular stretching should be explained to the patient despite he had recovered from stiffness and pain to prevent the recurrence of periarthritis or stiffness.
• Patient being diabetic responds very slow towards the treatment and also feel a lot more pain as compared to those people who are non-diabetic.
• Patient who are complaining of pain at night (nocturnal pain) ought to be treated by heat therapy or thermo therapy.
• The contralateral or normal shoulder ought to always be examined and given regular stretching exercise programme like a precautionary measure to keep its functional capacity.
Frozen Shoulder Exercises (Rehabilitation Protocol):
Phase 1: Weeks 0-8
Goals
• Relieve pain
• Restore Motion
No restriction or immobilization.
Pain Control
• Medications
• NSAIDS- first line medication for pain control
• GH joint injection: corticosteroid/local anesthetic combination
• Oral steroid taper- for patients with refractive or symptomatic frozen shoulder.
• Therapeutic modalities
• Ice, ultrasound, HVGS
• Apply moist heat before therapy and ice pack after session.
Motion: Frozen Shoulder Exercises
• Initially concentrate on forward flexion and external and internal rotation with the arm in the side, and the elbow at 90 degrees.
• Active ROM exercises.
• Active assisted ROM exercises.
• Passive ROM exercises.
• In home these Frozen Shoulder Exercises ought to be performed 3-5 times daily.
• A sustained stretch, of 15-30 seconds, at the conclusion ROMs should be part of all ROM routines.
Phase 1: Weeks 8-16
Criteria for progression to Phase 2
• Improvement in shoulder discomfort.
• Improvement in shoulder motion.
• Satisfactory physical examination.
Goals
• Improve shoulder motion in most plane
• Improve strength and endurance of rotator cuff and scapular stabilizers
Pain Control by same means as utilized in 1st 8 weeks.
Motion: Frozen Shoulder Exercises
• Perform active, active assisted and passive flexibility exercises to obtain around 140 amount of forward flexion, 45 amount of external rotation and internal rotation to twelfth thoracic spinous process.
Muscle strengthening
Begin with rotator cuff strengthening exercises 3 times each week, 8-12 repetitions for three sets.
• Closed chain isometric strengthening using the elbow flexed to 90 degrees and also the arm at the side. Perform internal rotation, external rotation, abduction and forward flexion.
• Progress to spread out chain strengthening exercises with theraband for same greoup of muscles.
• Progress to lightweight dumbbell exercises for internal rotators, external rotators, abductors and forward flexors.
• Perform strengthening of scapular stabilizers.
• Deltoid strengthening.
Phase 3: 4 months and beyond
Criteria for progression to Phase 3
• Significant functional recovery of shoulder motion.
• Successful participation in activities of everyday living.
• Resolution of painful shoulder.
• Satisfactory physical examination.
Goals
• Home maintenance frozen shoulder exercises.
• ROM exercises 2 times each day.
• Rotator cuff strengthening 3 times per week.
• Scapular stabilizer strengthening 3 times per week.
Please check with your Physiotherapist before starting with this frozen shoulder exercises.
Indicators:
• Loss of motion
• Continued Pain
Treatment of Complications:
• These patients might need to move back to earlier routines
• May require increased usage of pain control modalities as outlined above
• If loss of movement is persistent and pain continues, patients may need surgical intervention
• Manipulation under anesthesia
• Arthroscopic release