As the bottom-line numbers indicate in Figure 7, each plane of motion improved by an average of 5° or more per week. The 5° degree rule has served as a reliable clinical measure of optimal patient progress. This is notable in several successful treatment outcomes of patients who received 3-4 months of conservative therapy regimens. Healthcare Consideration: 5° Rule - In the settled or frozen phase of stiffness, compliant patients receiving comprehensive multi-modal care can improve ROM in each treated plane by 5° per week.
There is a need for more published outcome studies regarding weekly progress as this type of data constitutes an important parameter of clinical success. The study by Levine (2007) offers a rare comparative report for weekly range of motion changes. Resulting from the average 3.8-month long treatment program, the shoulder flexion mobility improved from 118-164 degrees, showing a 46° improvement. For shoulder external rotation, mobility improved from 26-59 degrees, a 33° change overall. The approximate weekly change of flexion demonstrates 3° and 2° for external rotation. This study was effective in producing the minimal mobility needed for reported normal activities of daily living. However, these improvement rates may have fallen short of optimal, full mobility return.
THE HYBRID MOBILIZATION TECHNIQUE: PROXIMAL CONTROL
distally, in direct alignment with the humerus. The pressure from the therapist’s hand should remain light. Figure 8: Proximal Control
There are many mobilization techniques and variation of approaches to address shoulder stiffness. A clinical technique to mobilize frozen shoulder, adhesive capsulitis and primary impingement was developed in the mid-1980s. This hybrid method consolidated primary studies that define glide duration, quality, amplitude, and direction. The term proximal control refers to applying manual contact directly on the shoulder joint. The fingertips of both hands surround the joint. This proximal placement is confirmed by a soft feel with a light squeeze of the hands. A hard feel indicates that the hands are on the humeral head and should be avoided. The goal is to apply translation to the joint and avoid applying forces on the humeral head. This contact point also prevents the risk of applying a torque moment to the shaft of the humerus through a long lever arm. The greatest bony strain on the humerus arises from rotational torque and clinicians should be cautious of such. The proximal control method was created by the late Gordon Cummings, who wrote Soft Tissue Contracture (1983). Performed by the therapist standing at the patient’s side outside the humerus, the hands are placed around the joint line. The distal humerus of the patient is clamped to the therapist’s iliac crest with therapist’s inner most arm (Figure 8). This control isolates motion to be only at the proximal segment of the shoulder. This provides a measure of trust and relaxation with the patient as the humeral head is not being gripped. The patient’s shoulder is placed in the plane of the scapula (equivalent to 40° abduction) and slight elevation. Light grade 2-3 oscillations are performed first, with therapist progressing to grade 4 when tolerated (Figure 8). With some mobilization or stretching methods, patients often need frequent verbal cuing to relax. With the proximal control method, the therapist’s fingers will be able to detect increased muscular tension or guarding. Many patients will be apprehensive with initial mobilization efforts. During the proximal control technique, patient guarding is frequently caused by excessive tension in the therapist’s grip. When appropriate, the therapist will add increased abduction or external rotation on the shoulder while continuing the inferior glides. The direction of the forces is delivered
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 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. 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
OTHER TREATMENT OPTIONS
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.
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