Figure 9
Figure 10
Figure 11
Figure 12
This progression fits the concept of a one-hour visit, applying multiple and varied treatment methods. There is emphasis on therapeutic exercise, manual therapy and neuro-muscular re-edu- cation. A key point within this structure is the assessment and doc- umentation of active ROM. The measurements should be taken first rather than after the therapy session, as it is more reflective of actual functional capacity. Reporting the initial daily visit measure- ment on progress reports avoids a disconnect with measurements performed by other providers in office (i.e., the orthopedist) Figure 13
Overhead pulleys are preferred by some clinicians, although they produce a biomechanical drawback. With a single pulley appara- tus, the endpoint of overhead elevation tends to be forced into an internally rotated position which can lead to shoulder impinge- ment. If pulleys are used, a dual axis set-up maintains a more neutral plane of scapula positioning at end-range. Additionally, rolling a physio-ball in different directions against the wall is well- tolerated by many patients. This exercise provides scapular stabil- ity from the closed-chain position. Time management for clinical visits is imperative and directly in- fluences the success of any treatment program. When considering all the factors for effective individual treatment methods, a useful program structure can be incorporated as follows: ● Pain level assessment and active ROM measurements (eleva- tion and external rotation). ● Physiologic warm-up: 5 minutes. ● Wand flexion, extension, and external rotation ROM: 1-2 sets of 10 repetitions each. ● Joint mobilization techniques: 10-15 minutes. ● Soft Tissue techniques: 5-10 minutes. ● Modality (Optional): ice massage, ice pack, heat, etc. ● Home Exercise Program Review/Instruction: practice and demonstration of new exercises, starting with ROM and pro- gressing to strengthening exercises when indicated. ● Re-measurement of active ROM.
This patient is applying stretch load with assistance from the opposite hip. With early attempts at this exercise, a pillow is placed beneath the elbow.
DECISION MAKING FOR PATIENT PLATEAUS
● Post-surgical and post-fracture patients that require an immo- bilization period and develop an immediate stiffness contrac- ture in the first month after their procedure or injury. For idiopathic frozen shoulder and adhesive capsulitis patients, it is important to define when a plateau in recovery has devel- oped. A plateau is defined as two weeks of unchanged mobility in any motion plane with a patient who is compliant with clinical visits and a home exercise program. These patients often plateau in their progress around 3-6 months into their treatment. Their mobility impairments resist the combined, effective treatment
Despite a proven high success rate for recovery from frozen shoul- der and adhesive capsulitis, studies show there are approximately 5-10% of patients who present as outliers. This group of resistant cases include three primary categories: ● Idiopathic patients who fail to achieve adequate functional recovery. ● Patients who have made initial progress but demonstrate pla- teau during treatment.
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