Healthcare Consideration: What is an appropriate number of clinical visits during the frozen phase of frozen shoulder? Several studies have determined effective visit metrics; Johnson (2007) identified the use of only six visits, Jewell and Riddle (2009) advised eleven and Vermuelen (2006) applied eighteen. This range of six-eighteen visits is consistent with research results. The recommended range of six to twenty-four visits is outlined in the extensive “Guide to Physical Therapy Practice -2nd Edition” (2001). For shoulder stiffness impairments in the frozen or settled phase, a range of 6-24 visits within 12 weeks is recommended to restore function.
Evidence-based practice: While scientific literature presents a wide timeframe for recovery from frozen shoulder and adhesive capsulitis, most studies show resolved pain and return to function occurs at fifteen months post onset (Kelley, 2013; Reeves, 1975; and Vastamaki, 2012).
EARLY CLINICAL MANAGEMENT PRINCIPLES AND PROGRAM DESIGN
Selection of treatment methods should be dependent on tissue irritability and the extent of capsular restriction. During the freezing phase, treatment should focus on pain control, with gentle exercises and manual techniques. This should be followed by increased exercises, an increase in joint mobilization forces and adjunctive modalities. The need for a patient centered home exercise program is essential for a steady improvement in active ROM. When the pain period is settled, increasing both passive and active range of motion becomes the main goal of in- clinic sessions. In the early months of a frozen shoulder diagnosis, the initial evaluation should include a patient education overview of the expected program goals and interventions. There should be a discussion of at-home pain relief measures, protective tips to avoid stressing the joint and instruction on basic ROM exercises. After implementing these treatment methods, the pain levels noted during the freezing period should improve within six weeks. After the initial evaluation, one follow-up visit may be needed within that six-week interval to check in with the patient’s progress. However, it is important for clinicians to factor in that some insurances have a visit limit, such as Medicare. In these scenarios, it is optimal to preserve most visits for when patient treatment is focused less on pain management and more on improving ROM. During these later stages of FS, more aggressive in clinic techniques are most useful, such as manual therapy and passive pro-longed ROM stretching. Research studies support the use of medications (orally or injected) in the early phases of FS and adhesive capsulitis to suppress and control pain (Favejee, 2011; Kelley, 2013; Page, 2004; Pandey, 2022; Shang, 2019; Steuri, 2017) The use of non-steroidal anti-inflammatory drugs (NSAIDs) is effective for pain control in the short term (D’Orsi, 2012; Guler-Uysal, 2004). It is best practice for clinicians to encourage patients to consult with their primary care doctor before starting any medications. Clinicians should educate patients on precautions with over- the-counter medications to protect the gastrointestinal tract. Research shows that patients should consider limiting use of these medications to a maximum of two weeks to avoid any potential adverse systemic effects (Botstein, 2016). Specific NSAIDs may offer different levels relief to each patient. The use of anti-inflammatory medications before bedtime can alleviate the degree of discomfort in certain sleep positions. Healthcare Consideration: What is the optimal sleep position for patients with shoulder pain? Regardless of the individual's preferred sleep position, the elbow should be supported in an abducted, neutral position with the use of a pillow. The primary goal is to avoid scapular protraction and obtain the neutral position of the shoulder. The optimal position for pain relief is laying supine, with two pillows placed under the upper body in an inverted V position and one pillow across the top of the V for head support (Figure 2).
Figure 2
Several studies recommend the use of cortico-steroid injections in the early freezing phases for pain (Favejee, 2011; Jain, 2014; Kelley, 2013; Page, 2014; Pandey, 2022; Shang, 2019; Steuri, 2017). Location of the injection can vary among physicians; some prefer sub-acromial space while others focus on the joint space. Additional studies find pain relief and short-term mobility improvements from injected sodium hyaluronate, when compared to cortico-steroids (Harris, 2011; Le,2017). After injections are given in the frozen phase, clinicians should provide patients with a two- or three-day rest period from in clinic sessions. This break will prevent the possibility of mobilization or exercises techniques causing an adverse reaction. Many studies support steroid injections or NSAIDs to be used in conjunction with physical therapy treatment including stretching, ROM exercises, and manual therapy methods (Cho, 2019; Green, 2017; Jewell, 2009 and Levine, 2007). Conservative & non-surgical treatment methods for frozen shoulder and shoulder stiffness demonstrate an overall 90% success for functional recovery, determined in consensus studies (Cho, 2019; Griggs, 2000; and Pandey, 2022). Levine (2007) determined success rate at 89% where Guler-Uysal (2004) demonstrated 80% improvements in pain and elevation ROM in just two weeks of conservative treatment. A multi- modal approach is overall an effective treatment for frozen shoulder, adhesive capsulitis and shoulder capsular contracture. This technique will encourage clinicians to consider various approaches and tailor treatment sessions based on the individual patient deficits, patient progress, and medical history. With many clinical studies or continuing education courses, the discussion of discharge parameters is reserved for the final, concluding sections. As a clinician, it is vital to understand where your treatment plan is headed and what the end goal will be for patients. This enables clinicians to inform the patient, as well as involved family members, physicians, and reimbursement companies of the goals and projected timeline for progression. This also encourages clinicians to select the next steps in their plan of care and make appropriate clinical decisions for the individualized patient and their clinical presentation.
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Book Code: PTNY1024
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