Every single week I have at least one patient who presents in the clinic with severe shoulder pain which has been ongoing for some time.
They will say something like “I have been seeing a therapist of some kind for months, but it hasn’t improved. Everyone keeps saying that I may have frozen shoulder, but I don’t feel any coldness in my shoulder – just severe pain. I find it difficult to put my jacket on or reach behind me in the car and It is also regularly disturbing my sleep every night”.
Why you shouldn’t be having multiple sessions with no improvement
Firstly, lets address the elephant in the room here. If you have been seeing a Physiotherapist/Osteopath/Physical Therapist or Sports Therapist for some time and you are not seeing significant change over the space of many sessions there is an issue that needs to be resolved.
Chartered Physiotherapists and other health care professionals should perform an accurate initial assessment and discuss the management plan of your injury or dysfunction. And if you are not seeing any improvement within 2-3 treatments, any reputable therapist should re-evaluate your plan and refer you for a scan, to your GP or to see a Consultant, if necessary.
I am not expecting health care professionals to be instant fix magicians. There may be incidences where the patients are not performing the necessary exercises at home to get the required benefit from physio intervention. However, if that is the case it must come back to the patient to take responsibility for not performing their exercise program. I will never scold a patient for not performing their exercises (let’s be honest about it – sometimes life gets in the way). However, if they have been unable to perform their prescribed exercise program I will discuss the rationale behind not applying treatment that day and rebook the appointment.
All of that said, occasionally there are conditions, such as Frozen Shoulder, that can be tricky where this is concerned, because they take time to resolve.
What is Frozen Shoulder?
Frozen shoulder is a term coined in 1934 by Codman. It is also known by other terms including adhesive capsulitis, stiff shoulder and contracted shoulder, among others – is a debilitating condition which can be categorised as either primary or secondary in nature. Secondary frozen shoulder generally occurs due to some form of surgery or a traumatic event whereas primary frozen shoulder is generally idiopathic in nature i.e. it arises spontaneously or for no known reason. It is thought to be more prevalent in the female population and is often associated with Type II diabetes. The exact cause is widely debated but the condition is considered to be associated with synovial inflammation (synovia is a clear liquid that lubricates joints) within the shoulder capsule and fibrosis or contraction of the shoulder capsule itself (Dawson et al., 2010). Precise diagnostic criteria vary but generally is characterised by significant pain on movement, progressively limited active and passive range of movement (ROM) and sleep disturbance, with x-ray being normal (Bunker 2009, Dennis, et al. 2010).
The Three Phases of Frozen Shoulder
Frozen shoulder has been described in 3 phases:
- Phase 1: ‘Painful’ phase – Lasting 2-9 months, with painful movement and disturbed sleep
- Phase 2: ‘Frozen’ or ‘adhesive’ phase – Lasting 3-12 months, with stiffness and limited range of movement and reduction in pain
- Phase 3: ‘Thawing’ or ‘resolution’ phase – Lasting 5-26 months, with resolution of pain and gradual return of ROM
(Jewel et al. 2009, Dennis et al. 2010, Dawson et al. 2010)
How to treat Frozen Shoulder
Physiotherapists are often the front-line professionals involved in the early stages of the condition and we often disagree as to the best approach to manage such conditions. For instance, Hanchard et al, (2011) believes management of Frozen shoulder varies greatly but pain reduction treatments can be very successful and include:
- pharmaceutical analgesia via the GP
- corticosteroids (either orally or by injection)
- exercise therapy and low-grade mobilisations
Undoubtedly these methods can be very effective if applied correctly by an experienced therapist. However, they must be correctly applied depending on the phase of dysfunction.
For example, if, as a physiotherapist, I have diagnosed frozen shoulder and it is early in the initial phase, I would never consider manual treatment or end of range exercise on the shoulder joint itself as it will undoubtedly result in increased pain and discomfort. Recent research has completely disproven the use of manual treatment of the shoulder joint whilst in the painful stage. However, an experienced physiotherapist’s input and guidance may still be invaluable.
Gold standard treatment for early stage frozen shoulder is injection therapy followed by appropriate physiotherapy input. The level of physiotherapy input following injection therapy will depend on the response of the pain to the injection. If there is a gradual decrease in symptoms, physiotherapy may be indicated within the initial 10 days following the injection.
Most importantly there is no one size fits all. It will depend on each individual patient as to how their treatment will progress. If you are completely against the idea of having an injection, there is relatively good research to suggest traditional Chinese acupuncture may help reduce your pain until you reach Phase II.
What if I have been treated for months for what I suspect to be frozen shoulder and have had no improvements? How do I progress?
Ideally the injection therapy would be administered in the first 8-10 weeks of the onset of pain. Research has proven that the effectiveness of the injection therapy reduces significantly after the first 12 weeks. If you are five months down the line and your pain is gradually improving, it may be best to wait it out until the painful stage has resolved.
When should I be getting Physiotherapy?
A skilled practitioner may advise very occasional physiotherapy sessions at the end stage of Phase 1, involving working on your proximal stability (your core/proximal stability provides an estimated 70% of the stability of your shoulder joint). Good scapular and thoracic spine mobility may reduce your overall recovery time and help maximise your pain free movement.
It is the Frozen stage or phase II where physiotherapy treatment and Pilates become essential to regain your range of movement and improve your strength. There may be relatively low levels of discomfort towards the end range of your mobility but most importantly you are not at risk of regressing back into Phase I.
In summary, no matter what stage you are at, it is essential to see your GP or come see us in Platinum Physiotherapy if you feel you are suffering with frozen shoulder. If you are in Phase I and the only benefit is an accurate diagnosis, referral for MRI/injection therapy or appropriate advice and education, at least you can rest assured that you will have a tailored and individualised management plan.
What is the Platinum Physiotherapy difference?
Someone recently asked me what is the difference between Platinum physiotherapy and a general physiotherapy practice? My response was simple:
“In Platinum, we will not only assess and treat the patient’s injury or dysfunction, we will also help empower the patient by presenting them with a management plan. This way you avoid becoming a passive patient who depends on pharmaceutical input or a health care professional to “fix” them.
Our moto is simple – Assess/treat/plan/manage and, most important, move. Here we mean move in both senses – your body’s movement with Platinum Pilates and moving on with your life, leaving your pain and injuries behind you.