Thursday, May 28, 2009

Which frozen shoulder patient respond to physical therapy & why many frozen shoulder patients are poor responders to normal physiotherapy protocol.

I treat about 8-10 frozen shoulder (FS) cases a day. My impression from what ever I know as a specialist physiotherapist is as follows:

1. We take frozen shoulder as an easy diagnosis because the movement restrictions & end feel are characteristics of diagnosis.
I take capsular pattern as the hall mark sign of diagnosing a frozen shoulder. Further the capsular (lethery) end feel confirms my diagnosis. As patients present to us at various duration after the onset & even after various treatments, they show different grades of pain, stiffness & psychological impacts on over all shoulder function. I find clearly defined clinical subgroups among the presenting population of frozen shoulders.

2. After the realization of the entity (FS) we remain so much pre-occupied with the technique administration among myriad of physiotherapeutic probabilities that we many time forget to notice the postural attitude of the patients. In majority cases I find UCS (upper crossed syndrome) & scapular fixation abnormalities & poor neuromuscular & dynamic stability. Whether this posture is antecedent or consequential occurrence in frozen shoulder is a debatable question. However one may find normal person with increased kyphosis (rounded upper thoracic spine) without shoulder pain but reduced external rotation, over head abduction & hand behind back. This description emulates a capsular tightness. How this posture contributes to the clinical subgroups in frozen shoulder is also unexplored. I would like to draw attention that I such cases where the posture of the patient is ignored active exercises especially the overhead abduction ensues an impingement of sub-acromion structures. The patient complains of relapse of pain in shoulder. The clinician in this case can mark that despite the ROM of the shoulder improving the pain has increased either in the rotator cuff tendons & exposed part of the subdeltoid bursa.

3. A research paper by Yang JL & colleagues throws some more light on this issue.
i. The purpose of Yang JL & colleague’s study was to identify the kinematic features of patients with frozen shoulder who are more likely to respond to physical therapy.
ii. 34 FS patients received same standardized treatment with passive mobilization/stretching techniques, physical modalities (i.e. ultrasound, shortwave diathermy and/or electrotherapy) and active exercises twice a week for 3 months.
iii. Initially, subjects were asked to perform full active motion in 3 tests: abduction in the scapular plane, hand-to-neck and hand-to-scapula. These motions ware studied by a 3-D electromagnetic motion-capturing system.

During a multivariate analysis 2 variables ware identified who have predictive value. They are:
1. Scapular tipping >8.4 degrees during arm elevation
2. External rotation >38.9 degrees during hand to neck

The presence of these two variables (positive likelihood ratio=15.71) increased the probability of improvement with treatment from 41% to 92%.

Reviewer’s comment: For predicting the success of frozen shoulder scapular tipping is one of the predictor. Further changed scapular tipping & external rotation are the features of poor posture associated with rounded shoulders (thoracic spine kyphosis)

Reference: Yang JL et al; Man Ther. 2008 Dec;13(6):544-51. Epub 2007 Oct 2.

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