Frozen Shoulder Exercises
Frozen Shoulder Exercises aim to reduce pain, increase extensibility of the capsule, and
improve strength of the rotator cuff muscles.
Restorative
Programme
The
basic aim of exercises are:
- To reduce pain.
- To increase extensibility of the thickened and
contracted capsule of the joint at the anteroinferior border and at the
attachment of the capsule to the anatomical neck of humerus.
- To improve mobility of the shoulder.
- To improve strength of the muscle. However it
may 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 shoulder exercises to offer graduated stretching.
Relaxation
Though prior
heating of the joint has been found to facilitate relaxation and mobilization,
one may use the heat modality suitable to the patient's response. However
ultrasound, beside deep heating, has the added advantages of increasing
excitability of the contracted soft tissue and is therefore performed.
Relaxed
Passive Mobilization
The patient
is placed in supine position with the affected shoulder in maximum possible abduction
and neutral rotation and elbow in 90 degree of flexion. The physiotherapist grasping the arm above
the shoulder joint carries out relaxed passive gliding movement of head of
humerus on glenoid. Axial traction and approximation is carried out along with
antero-posterior glide and abduction- adduction glide. To induce relaxation, always
begin with slow rhythmic movement.
Slow and rhythmic circumduction at the
glenohumeral joint, in forward stoop position effectively induces relaxation
and promotes mobility. Gentle relaxed passive movements reduces pain and
pathologic limits of motion. The reduction in pain occurs because of the
neuro-modulation effect on the mechanoreceptors with in the joint.
Mobilization
by accessory movements of acromio-clavicular, sterno-clavicular and/or scapulo-thoracic joint articulation is
also extremely helpful.
Exercise
Programme
Frozen
shoulder exercises plays an important role in management of the condition.
While planning the frozen shoulder exercises one must give due importance to
the fact that contracted soft tissue when objected to repeated prolong mild
tension show extensibility and plastic elongation.
An increase
in the movement following the session of prolonged stretching was usually
associated with a corresponding increase in the other movements too. However
improvement in the range of other movements is not always at the same rate.
The specific
Frozen shoulder exercises should include the maximum number of combination of
various movement by minimising the number of exercises. Graduated relaxed
sustained stretching based on 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".
The above
mentioned Frozen shoulder exercises can be done in two ways:
- By weight and pully- Tolerable weight must be
used. This may be done in supine or sitting position.
- By self assisted stretching- Method of
performing is, the patient uses his normal or contralateral arm for
gradually stretching the affected shoulder.
Passive
Mobilization Technique
For this,
manipulation and mobilising techniques are given by"MAITLAND".
By this patient respond very well for acquiring full range by properly guided
simple and specific Frozen shoulder exercises which ensures relaxed graduated
stretching of the contracted capsule.
Frozen
Shoulder Exercises for Home and Cautions:
- The importance or necessity of regular
stretching must be explained to the patient even after he had recovered
from stiffness and pain to avoid the recurrence of periarthritis or
stiffness.
- Patient having diabetes responds very slow to the
treatment and also feel much more pain as compared to those who are
non-diabetic.
- Patient who are complaining of pain in the
night (nocturnal pain) should be treated by heat therapy or thermo
therapy.
- The contralateral or normal shoulder should
always be examined and given regular stretching exercise programme as a
precautionary measure to maintain its functional capacity.
Frozen
Shoulder Introduction:
Codman introduced the term "frozen
shoulder" in 1934 to describe patients who had a painful loss of shoulder
motion with normal radiographic studies. In 1946,Neviasernamed the
condition "adhesive capsulitis" based on the radiographic appearance
with arthrography, which suggested "adhesion" of the capsule of th GH
joint limiting overall joint space volume.Patients with adhesive capsulitis
have a painful restriction of both active and passive GH joint motion in all
planes, or a global loss of GH joint motion.
The
condition is common in people of 40-60 years age group, with a higher incidence
in females. The onset of an idiopathic frozen shoulder has been associated with
extended immobilization, relatively mild trauma, and surgical trauma,
especially breast and chest wall procedures.
Adhesive capsulitis is associated with medical conditions such as diabetes,
hyperthyroidism, ischemic heart disease, inflammatory arthritis and cervical spondylosis. Most significant association is with Insulin
dependent diabetes.
Adhesive
Capsulitis is characterized by 3 stages:
Length of
each stage is variable, but typically the first stage lasts for 3-6 months, the
second stage from 3-18 months, and the final stage from 3-6 months.
- The first stage is
the freezing phase, characterized by onset of
an aching pain in the shoulder. The pain is usually more severe at night
and with activities, and may be associated with a sense of discomfort that radiates down the arm. Often, a
specific traumatic event is difficult for the patient to recall. As
symptoms progress, there are fewer arm positions that are comfortable.
Most patients will position the arm in adduction and internal rotation.
This position represents the "neutral isometric position of relaxed
tension for the inflamed glenohumeral capsule, biceps, and rotator cuff."
- The second stage is
the progressive stiffness or frozen phase. Pain at rest usually
diminishes during this stage, leaving the patient with a shoulder that has restricted motion in all
planes Activities of
daily become severely restricted. When performing activities, a sharp
acute discomfort can occur as the patient reaches the restraint of the
tight capsule. Pain at night is a common complaint and is not easily
treated with medications or physical modalities. The stage can last from
3-18 months.
- The final stage is
the resolution or thawing phase. This stage is
characterized by a slow recovery of motion. Aggressive treatment with
physical therapy frozen shoulder exercises, closed manipulation or
surgical release may accelerate recovery, moving the patient from the
frozen stage into the thawing phase.
Diagnosis:
Not every
stiff or painful shoulder is a frozen shoulder, and indeed there is some
controversy over the criteria for diagnosing "frozen shoulder".
Stiffness occurs in a variety of conditions- arthritic, rheumatic,
post-traumatic, and post operative. The diagnosis of frozen shoulder is
clinical resting on two characteristic features.
- Painful restriction of movement in the presence
of normal x-rays, and
- a natural progression through three successive
phases.
When the
patient is seen first, a number of conditions should be excluded: infection,
post traumatic stiffness, diffuse stiffness and reflex sympathetic dystrophy.
In
general, a global loss of active and passive motion is present; the loss of
external rotation with the arm at the patient's side is a hallmark of this
condition. The loss of passive external rotation is the single most important
finding on physical examination that helps to differentiate the diagnosis from
a rotator cuff problem because problems of the rotator cuff generally do not
result in a loss of passive external rotation.
Frozen
Shoulder Treatment:
Even though
adhesive capsulitis is believed to be a "self limiting" process, it
can be severely disabling for months to years and, as a result, requires
aggressive treatment once the diagnosis is made. Initial treatment should
include an aggressive frozen shoulder exercises to help regain shoulder motion.
For patients in the initial painful or freezing phase, pain relief may be
obtained with a course of anti-inflammatory medications, the judicious use of
GH joint corticosteroid injections, or therapeutic modality treatments.
Intra-articular corticosteroid injections help to abort the abnormal
inflammatory process often associated with this condition.
Operative
intervention is indicated in patients who show no improvement after a three
month course of aggressive management that includes medications, corticosteroid
injection and physical therapy.
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 at the end of session.
Motion:
Frozen Shoulder Exercises
- Initially focus on forward flexion and
internal and external rotation with the arm at the side, and the elbow at
90 degrees.
- Active ROM exercises.
- Active assisted ROM exercises.
- Passive ROM exercises.
- In home these Frozen Shoulder Exercises should
be performed 3-5 times per day.
- A sustained stretch, of 15-30 seconds, at the
end ROMs should be part of all ROM routines.
Phase
2: 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 all plane
- Improve strength and endurance of rotator cuff
and scapular stabilizers
- Pain Control by same means as used in 1st 8
weeks.
Motion:
Frozen Shoulder Exercises
Perform
active, active assisted and passive range of motion exercises to obtain around
140 degree of forward flexion, 45 degree of external rotation and internal
rotation to twelfth thoracic spinous process.
Muscle
strengthening
- Start with rotator cuff strengthening exercises
3 times per week, 8-12 repetitions for three sets.
- Closed chain isometric strengthening with the
elbow flexed to 90 degrees and the arm at the side. Perform internal
rotation, external rotation, abduction and forward flexion.
- Progress to open chain strengthening exercises
with theraband for same greoup of muscles.
- Progress to light weight 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 daily
living.
- Resolution of painful shoulder.
- Satisfactory physical examination.
Goals
- Home maintenance frozen shoulder exercises.
- ROM exercises 2 times a day.
- Rotator cuff strengthening 3 times a week.
- Scapular stabilizer strengthening 3 times a
week.
Please
check with your Physical Therapist before starting with this frozen shoulder
exercises.
Warning
Signs:
- Loss
of motion
- Continued
Pain
Treatment
of Complications:
- These patients may need to move back to earlier
routines
- May require increased utilization of pain
control modalities as outlined above
- If loss of motion is persistent and pain
continues, patients may require surgical intervention
- Manipulation under anesthesia
- Arthroscopic release
Nice Article!
উত্তরমুছুনFrozen shoulder is a condition characterized by pain and stiffness in, or near, the shoulder joint. It is most common in those over 40, and occurs more commonly in women than in men.
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