musculo-tendinous, neural, dural and deterioration of bony surfaces and articular cartilage. Potential changes include the degradation articular capsule, thickened peri-articular capsule, arthritic changes in the superior acromioclavicular joint space and fibro-fatty infiltrates of the deltoid muscle. Self-Assessment Quiz Question #1 The diagnosis of shoulder stiffness includes the following characteristic: a. Thickened joint capsule.
injections, discussed later within the treatment section (Kelley, 2009). In secondary capsulitis conditions, the inferior-anterior capsular becomes thickened and shortened from scarring, decreasing the inferior glenoid space. The dispersion of synovial joint fluid is restricted and the production of joint fluid decreases, i.e., the analogy of a rusty hinge. (Albert, 2000). In the frozen stage or settled phase of FS, an arthrogram of the joint will show a shrunken capsule that tightly adheres to the inferior joint margins. This change causes the inferior glide of the joint, required for all elevation motions, to become mechanically restricted and painful. Johns and Wright study (1962) demonstrates a variety of mobility restriction and negative tissue changes throughout the shoulder structures; involving capsular, Research on the type and timing of treatment modalities vary widely between conservative, medical and invasive options. It is noted that “… there is no consensus as to the most efficacious treatment of this condition” (Cho, 2019, pg. 249). Additionally, researchers demonstrate varying results when identifying the most reliable diagnostic tools (Zappia, 2016). This variety emphasizes the importance of keeping up with the most relevant evidence and clinical practice guidelines. The analogy of expanding the shoreline was used to describe the importance of expanding clinical knowledge to decide what types of therapy interventions work best for each individualized patient (Jette, 2012, 2016). This presentation will compare the research on the efficacy of treatment options currently used, emphasizing the conservative, non-medical approaches routinely applied in physical therapy and occupational therapy. Clinical practice guidelines can be beneficial to promote quick and effective functional progress in patients. However, the adoption of routine approaches with specific diagnoses should be avoided. Each treatment program should favor an individualized approach, focusing on the impairments present with each patient. Treatment programs should integrate clear- cut, evidence-based practice. Clinical practice guidelines can be helpful in providing a general idea of when to introduce specific interventions. Additionally, they can help clinicians choose the most appropriate techniques and definitively identify the correct discharge parameters. However, each patient receiving treatment has unique medical histories, values, prior experiences with injuries, and psychological variants. Using the same treatment approach with each patient is nearly impossible. This leads to a gap in clinical management, but the use of evidence- based practice will provide a beneficial problem-solving system. This concept includes three main considerations: clinical experience/expertise, patient values, and use of best evidence available (Sackett, 2004). Traditional studies have described the natural progression of idiopathic FS as self-limited with varied times to recover function. Based on an extensive follow-up study from 2-27 years, it was determined there was a 94% return of function in idiopathic frozen shoulder patients when left untreated (Vastamaki, 2012). This notably positive change was recorded at 15 months on average. This percentage was compared to patients with some level of conservative treatment that required 20 months and had a 91% success rate. These results may relate to the application of aggressive treatment approaches applied too early, specifically during capsule during part of the freezing (irritable) phase of progression in patients who received treatment. These pre- mature treatment methods may have ultimately led to a delay in overall return to function. However, several studies have shown the importance of conservative treatment to maximize return to function for shoulder stiffness patients. Reeves (1975) determined that 39% of patients had persistent limitations in a 5-10-year follow-up. Additionally, Shaffer (1992) found that 50% of patients still had pain and/or stiffness at 7 years. Although ROM restrictions are not a common symptom following
b. Osteophytes. c. Minimal pain. d. Marked deficits of internal rotation. PROGRESSION OF FROZEN SHOULDER AND TREATMENT CONCEPTS
treatment, this study indicates external rotation as the primary residual deficit. This finding is consistent with clinical results and patient follow-up assessments. The natural history of idiopathic frozen shoulder can be broken down in four distinct periods: ● Pain onset. ● Freezing stage. ● Frozen stage. ● Thawing stage. Each stage of frozen shoulder should be viewed in terms of tissue irritability when considering conservative therapeutic measures, specifically manual therapy and joint mobilization. A useful graph by Rowe (1998) and Reeves (1975) reviews the timeline of each stage of FS and depicts the level of mobility restrictions as noted by the curve of the graph (Figure 1). The peak of functional mobility loss occurs in the frozen stage, marked at around six months post onset. Appropriate physical therapy treatment should be applied based on the patient’s phase at the time of the initial visit. This overview breaks down FS to be a three-stage process with an estimated time progression of 12 months. However, studies written over the five decades note duration of FS to last anywhere from one to seven years. The majority of studies state the timeframe of FS to be fifteen months (Reeves, 1975; Kelly, 2009), which provides a clinical reference point for clinicians. The in-clinic sessions for therapeutic exercise and manual therapy techniques become most important during frozen phase of FS (at approximately 3-4 months), when immobility is most impaired. The key question of treatment management arises: what is an appropriate number of clinical visits during this time? Figure 1: Stages of Idiopathic Frozen Shoulder
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