DECISION MAKING FOR PATIENT PLATEAUS
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 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 mobilization 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 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 referenced by the following case study. 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) devices, 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. Additionally, they may require repeated aftercare such as additional physical therapy after the procedures. Figure 14
Despite a proven high success rate for recovery from frozen shoulder 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 plateau during treatment. ● Post-surgical and post-fracture patients that require an immobilization period and develop an immediate stiffness contracture 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 developed. A plateau is defined as two weeks of unchanged mobility in any motion plane with a patient who is compliant with clinical visits Case study The patient was a right-hand dominant male injured by a work accident, involving a moving forklift in his warehouse job. The patient 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 directions 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 desperately 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 frustrations. Additional invasive measures for Conclusion Frozen shoulder affects 2-5% of the population. When combined with adhesive capsulitis cases, these diseases can produce longstanding and significant functional impairments. Scientific literature can present conflicting data on best practice for treatment methods. In turn, this provides limited guidance for the most common 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 research and clinical determinants, there is detailed evidence for manual therapy soft tissue and joint mobilization methods. In addition, program designs and
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.
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 studies on shoulder capsule contracture can provide improved understanding of multi-modal treatment progressions, in the hopes of avoiding more invasive procedures such as MUA and surgery.
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