from support from the hips. Mobilizing the joint at the end-range of capsular restraints provides greater TERT effects. The primary differences between this technique and other mobilization recommendations are: 1. The repetitive application of inferior glide “bumps.” 2. No distraction is applied to the joint, only inferior glide. 3. No stabilization of the scapula is required.
The most effective quality of glides for shoulder mobilization is a rhythmic, repeated oscillation delivered at approximately 30 pounds of pull. The capsular restriction is “bumped” and released with each inferior glide. This concept is confirmed by the findings of Bang (2000) and Vermeulen (2006). These studies determined the most effective duration for glides range from 30 seconds to two minutes. While this degree of time can be challenging for a therapist to maintain, the proximal stabilization is designed to allow minimal hand fatigue and maximal leverage
OTHER TREATMENT OPTIONS
Research shows that muscle guarding adjacent to the traumatized shoulder joint may mimic symptoms of a capsular restriction with FS or adhesive capsulitis (Hollmann et al., 2018). The muscles with the highest probability to restrict external rotation (the earliest and most pronounced motion loss) are the subscapularis, pectoralis major and pectoralis minor. This idea rationalizes direct stretching and trigger point release methods as important components of effective management. Gulick (2001) supported the treatment of trigger points in reducing shoulder pain. Additionally, it was determined that soft tissue massage was effective in pain relief, improved ROM, and improved function in patients with shoulder pain (Van den Dolder, 2003). Posterior glides with Mulligan joint mobilization technique were shown to reduce shoulder pain and improve external rotation strength when compared to active exercise alone (Neelapala, 2007). In addition, gentle manual scapular mobilization with proprioceptive neuromuscular facilitation (PNF) techniques showed significant increases in shoulder ROM and decreased pain after a single treatment session (Balci, 2016). Because no manual contact to the humeral head area is used, this approach may be optimal for those patients with hyper- irritability and sensitivity to touch of the shoulder. It was also found direct scapular mobilization can improve pain, ROM and functional scores in a one-month treatment program. (Kumar, 2016) Home exercise programs Successful and timely outcomes with shoulder stiffness depend on the frequency and structure of a supportive home exercise program. Two studies concluded that early application of a home exercise program was beneficial. Additionally, the regular use of one was more important than the repeated clinical visits (Marinko 2011; Tanaka 2010). Unlike strengthening programs applied 3 times/week to allow enzyme recovery, collagen remodeling requires a more frequent and sustained program for stretching and active range of motion. Griggs (2000) identified recovery success with 5 stretching sessions per day, focusing on four motions: elevation, external rotation, behind the back and cross- body stretches. Ten-minute durations were recommended (Cho, 2019). Supervised exercises were superior, determined by improvement in ROM, pain and functional mobility (Mertens, 2022). This study supports the benefit of thorough a demonstration and practice session for the prescribed home exercise program. However, it is unrealistic to assume that any patient has the time or diligence to perform five exercise sessions per day. Patients who are regular with at least two sessions per day should maintain or exceed their last clinical treatment ROM measurements. Additionally, clinicians should be cautious in prescribing cross- body stretches in the early frozen phase. This motion compresses the acromioclavicular joint, which is typically also compromised in shoulder stiffness cases. Strengthening is not advisable during the initial treatment when a patient is in the settled or frozen phase. This is because the available active motion does not support efficient lever arms. Active external rotation should reach a minimum of 45° before strengthening of the peri-scapular and rotator cuff muscle. At this point, strengthening exercises will be most effective and tolerated by the patient. The 45° of external rotation also indicates a patient has achieved many functional goals. This range of motion acquisition signals a positive outcome.
Scientific studies rarely test combined treatments or compare one intervention to another. With this knowledge, clinicians routinely combine varied modalities and techniques within a single session. This section will review adjunctive treatment methods that may benefit shoulder stiffness and dysfunction. Modalities Laser and ultrasound have supportive evidence for pain relief. Laser provides short-term benefits in range of motion, pain reduction and functional capacity (Green, 2017; Jain 2014; Pandey 2022). The application of continuous ultrasound for the associated findings of calcific tendonitis combined with shoulder capsule contracture receives a strong recommendation in studies. This finding provides a definitive guideline for clinician decision-making (Philadelphia Panel, 2001). Ultrasound can also be effective for reducing trigger points that may interfere with manual techniques or ROM exercises (Gulick, 2001). There is minimal benefit from other electrical modalities on ROM or functional return noted in research. Due to limited time for clinical sessions, the use of modalities should not exceed ten minutes of a one-hour visit. Heat Moderate benefit is noted from both superficial and deep heat before exercise or joint mobilizations (Leung, 2008). The application of physiologic warming from active muscular effort, such as using upper body ergometers or cross-county ski simulator arm actions is preferred compared to passive heating from heat pack, electric blankets or spas. The reciprocal motions of pushing and pulling that are often seen in shoulder warm-up exercises provide beneficial synovial bathing of the joint surfaces. These active ROM exercises decrease stiffness of collagen contractures and increase functional activation patterns for the scapula. Ice Application of ice provides analgesic effects, decreased local congestion, slowing of nerve conduction velocity and a reactive vasodilation that may facilitate improved active ROM (Speer, 1996). Commercial cold packs and water-cooled systems are options for home use, but ice massage applied directly to the skin offers increased benefits. This method is cost effective, safe and a quick method to reduce intra-articular temperature. Ice massage takes only 5-10 minutes to reach a numbness sensation. In addition, ice massage avoids excessive cooling of the superficial acromial process and can isolate the anterior- inferior joint margins more effectively. This treatment may not be tolerable or contraindicated for some patients. In cases of extreme cold sensitivities or Raynaud’s syndrome, ice may not be an appropriate intervention. Soft tissue techniques Soft tissue techniques are a subset of manual therapy and can assist exercise programs. These methods can additionally improve effectiveness of joint mobilization methods. Cyriax transverse friction massage, muscle energy stretching, stroking massage, fascial-type mobilization, and trigger point release techniques are all commonly used to address shoulder stiffness and dysfunction. Knowing the recovery process of shoulder stiffness conditions can extremely variable and often tedious, these techniques offer potential pain relief and faster recovery of normalized mobility.
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