trial of increasing in-clinic visits on a three-times-per-week basis may provide an effective change in patients experiencing plateau. The use of a prolonged stretch combined with a heat modality can benefit a patient with resistant mobility impairments, as refer- enced by the following case study.
program. This plateau requires a change in patient management, which involves several conservative treatment options. Therapists can provide changes to the patient’s position during joint mobili- zation techniques to trigger improvements. A review of the home exercise program in terms of frequency and the enforcement of increased TERT time can be effective for some patients. A short Case study The patient was a right-hand dominant male injured by a work accident, involving a moving forklift in his warehouse job. The pa- tient suffered a distal acromial and humeral head fracture and was immobilized for six weeks. After the sling's removal, his treatment focused on 3 weeks of gentle ROM via a home exercise program. He then began a physical therapy program in another facility for 3 months. The patient presented with a hard end-feel in all di- rections and the following measurements: elevation - 102° with scapular dyskinesis, 80° of abduction and 60° of external rotation at full range of abduction. The patient was frustrated and desper- ately wanted improvement to return to work duties. Following two weeks of trial mobilization methods and unchanged mobility, he was treated with a supine, bolstered position of end- range TERT stretch. With the prolonged stretch, a moist heat pack was wrapped around the axillary space. Figure 14 demonstrates a similar position, with therapist using cuff weights. Upon releasing the stretch load, his shoulder instantly fell to a position of 90° of external rotation and almost 90° of abduction. Despite some pain caused by this stretch load, he could actively flex the shoulder without scapular dyskinesis to approximately 160° with no signs of instability. Unfortunately, this individual was frustrated by the pain provoked by the intensity of this prolonged stretch, despite demonstrating significant ROM improvements overall. Patient satisfaction is an important factor to consider in these situations and therefore these types of modifications are not appropriate for all patients who experience a plateau. However, this case provides a method that can be beneficial for some. Timing for when to implement a more invasive care approach varies amongst orthopedists. Vastamaki (2012) cautions against performing a MUA prior to 6 months after onset of FS symptoms. This sometimes leaves patients who do not respond positively to conservative care with an extended period of motion deficits and functional limitations. This can cause patient dissatisfaction and Conclusion Frozen shoulder affects 2-5% of the population. When combined with adhesive capsulitis cases, these diseases can produce long- standing and significant functional impairments. Scientific litera- ture can present conflicting data on best practice for treatment methods. In turn, this provides limited guidance for the most com- mon interventions of manual therapy and therapeutic exercise. After reviewing the etiology and natural history of these shoulder contracture impairments, evidence for multi-modal treatments and framed conservative care within medical and surgical care has been provided. In attempting to bridge the gap between re- search and clinical determinants, there is detailed evidence for manual therapy soft tissue and joint mobilization methods. In ad- References Albert M. 2005. Course Manual: The Shoulder: A Dynamic Treatment Model. Balci NC, Yuruk ZO, Zeybek A et al. 2016. Acute effect of scapular proprioceptive neuro- muscular facilitation (PNF) techniques and classic exercises in adhesive capsulitis: a randomized controlled trial. J Phys Ther Sci 28:1219-1227. Bang,MD, Deyle G. 2000. 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frustrations. Additional invasive measures for resistant capsular restriction may include hydrodistension of the joint, arthroscopic release, suprascapular nerve block, and use of a substance called calcitonin (Cho, 2019). An intermediate intervention between failed conservative care and the more invasive procedures is available. Mechanical stretch devices are used for an at home basis in these circumstances. These include Long Load Prolonged Duration Stretch (LLPS) de- vices, which have been shown to produce timely improvements in external rotation and elevation measures (Stinton, 2022). The invasive procedures carry the risk of adverse outcomes. Addition- ally, they may require repeated aftercare such as additional physi- cal therapy after the procedures. Figure 14
This position is held for prolonged times -up to or greater than 30 minutes. Optimal force application is provided by 3 cuffs weights: one beneath scapula, one at wrist and one on top of the shoulder to stabilize the humeral head. dition, program designs and single-session structure have been analyzed. Definitive evidence- based principles for optimal joint mobilization techniques and the importance of patient education have been provided for clinicians. The main goal of this course is to provide clinicians with a well- researched, evidence-based treatment approach. This will in turn shorten a patient’s functional return to daily activities and restore joint mobility from shoulder pain and dysfunction. Future stud- ies on shoulder capsule contracture can provide improved under - standing of multi-modal treatment progressions, in the hopes of avoiding more invasive procedures such as MUA and surgery. Green S, Buchbinder R and Herrick SE.2003. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2:12804509 Griggs SM, Ahn A, Green A. 2000. Idiopathic adhesive capsulitis: a prospective functional outcome study of nonoperative treatment. JBJS. 82: 1398-1407. Guide to Physical Therapy Practice.2nd Ed.,2001. Phys Ther 81:S179-183. Guler-Uysal F, Kozanoglu E. 2004. Comparison of the early response to two methods of rehabilitation in adhesive capsulitis. Swiss Med Wkly. 134:353-8. Gulick DT, Barsky J, Bersheim M et al.2001. Ultrasound on Pain associated with Myofascial Trigger Points. JOSPT 31: A-19. Hanchard N, Goodchild L, Thompson J et al.2010. Evidence-based clinical guidelines for diagnosis, assessment and physiotherapy management of contracted shoulders. Chartered Society of Physiotherapy. Harris JD,Griesser MJ, Copelan A et al. 2011.Treatment of adhesive capsulitis with intra-articular hyaluronate: a systematic review. Int J Shoulder Surg 5:31-37. Hollmann L, Halaki M, Kamper SJ. 2018. Does muscle guarding play a role in range of motion loss in patients with frozen shoulder? Musculoskel Sci Pract 37:64-68. Hsu AT, Ho L, Ho S et al. 2000. Joint position during anterior-posterior glide mobilization: its effect on glenohumeral abduction range of motion. Arch Phys Med Rehabil 81:210-214. Hurschler C, Wulker N, Windhagen H et al. 2001. Medially based anterior capsular shift of the glenohumeral joint. Passive range of motion and posterior capsular strain. Am J Sports Med 29:346-53. Jain TK, Sharma NK. 2014. The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: A systematic review. J Back Musculoskel Rehabil 27: 247-273. Jette AM. 2012.Face into the Storm. 43rd Mary McMillan Lecture. Phys Ther 929:1221-29. Jette AM. 2016. In Pursuit of the Ever-Expanding Shoreline. Phys Ther. 96:134-136. Jewell DV, Riddle DL, Thacker LR.2009. Interventions Associated with an Increased or Decreased Likelihood of Pain Reduction and Improved Function in Patients with Adhesive Capsulitis: A Retrospective Cohort Study. Phys Ther 89:419-429. Johns R, Wright V. 1962. Relative importance of various tissues in joint stiffness. J Appl Physiol 17:824-830.
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