PATIENT EDUCATION
In the Kelley meta-analysis (2013), patient education earns an A grade. This rating highlights the importance of patient education throughout a patient’s plan of care. Effective education in patients with shoulder dysfunction includes two important concepts. One is the reassurance that frozen shoulder and adhesive capsulitis are typically self-limiting conditions versus degenerative, progressive diseases. The other is that more serious conditions are usually cleared by the negative radiographic findings. The psychological impact of FS can be influential due to the sudden, inexplicable onset. The potential for a long, painful recovery period can cause mental stress for many patients. The disruption of basic daily tasks like zipping pants, lifting a grandchild, or placing a heavy pot in an overhead shelf are hard to comprehend. The clinician must provide a calm, steady approach that establishes a trusting rapport with the patient from the earliest sessions. This will allow for a successful interaction and recovery process. It is important to focus on functional goal setting at the start of treatment with patients. It is also valuable for clinicians to review the gradual, sometimes slow expected improvements seen with shoulder dysfunctions at the start of treatment. Shoulder stiffness recovery can frequently show stagnant progression. There is often significant variability in treatment time frames and return to function amongst patients. Effective patient education requires the clinician to provide a spark of motivation for self-reliance and adherence to the home exercise program. The recovery from shoulder stiffness often includes a painful clinical and home exercise program. Many physical therapy programs for other injuries or impairments will encourage patients to avoid any pain producing stretches or strengthening exercises. However, with an efficient shoulder treatment program, a degree of manageable pain is necessary and beneficial to the patient’s recovery. This idea becomes apparent in the frozen or settled stage of stiffness problems. Many clinicians focus on the principle called total end range time (TERT) during treatment of shoulder stiffness and dysfunction. The fastest recovery from a fixed capsular
contracture is achieved by sustained stretch loads applied at the available end-range of the capsule (McClure, 1992). This frequently causes discomfort to the patient, especially in the early stages of treatment. Research shows one hour spent per day in total end range is most beneficial for patients with shoulder stiffness (McClure, 1992). However, a patient will most likely have difficulty enduring this level of stretch load to begin with. Additionally, there is inadequate time in a clinical visit to achieve this optimal TERT. A gradual progression of TERT stretches must be applied at home with supplemental stretching during clinic visits. It is recommended to start with a five-minute TERT stretch in the clinic. Demonstration and education on the stretch should be provided to patients for at home use. Patients should be performing TERT stretches one to two times daily in the beginning. The next clinic session should progress the patient to a longer TERT stretch, i.e., ten to fifteen minutes with instruction to increase time frame at home as well if tolerated well by patient. This pattern can progress to the goal of at least a half-hour TERT stretch at home within one month of the initial therapy visit. To achieve the maximal benefit, the TERT program must be frequently adjusted and apply the stretch in the end- range of the developing mobility. Patient education is critical with TERT treatment methods as this progression can be painful and feel tedious to patients. Healthcare Consideration: Pain management is a critical issue with FS and adhesive capsulitis and should be a focus of patent education with patients. Consistent communication between clinicians and the patient should support the benefit of injections and oral medications to help with pain management during the rehabilitation process. Clinicians need to promote the concept that consistency with pain management and the clinical treatment plan will lead to overall functional recovery. Most importantly, reassurance that progress can be gradual and slow will help keep patients motivated throughout the treatment process.
MANUAL THERAPY
Manual therapy encompasses a broad family of techniques such as cross-friction massage, stroking type of massage, trigger point release, hold- relax methods, joint mobilization, movement with simultaneous mobilization and manipulation. When discussing manipulation in physical therapy practice, the term is defined as a high-speed, short arc mobilization. Manipulation carries risk of injury to the shoulder joint. While it is within the scope of practice for physical therapists according to the APTA, it is not part of the legal practice act for many states. Clinicians must be aware of their state’s specific guidelines on mobilization. Additionally, clinicians should have proper training and education before initiating manipulation techniques with their patients. Manipulation differs from the medical procedure of forceful translation manipulation under anesthesia (MUA), performed by physicians, typically orthopedic surgeons.
The sequence of a MUA procedure follows the same progression that a series of mobilizations will follow in a therapy setting. However, the MUA adds higher end-range capsular stretch forces. The anesthesia allows for inhibition of the patient’s neuro-muscular protection. MUA is typically completed in a single short session. Research mentions manual therapy can be moderately effective in combination with other interventions, such as exercise and cortico-steroid injections. Additionally, it is mentioned that manual therapy is effective in the short-term combined with NSAIDs. It is crucial to note that several studies state manual therapy is not effective in one treatment session alone, highlighting the importance of consistent implementation during in-clinic visits (Favejee, 2017; Kelley, 2012; Page, 2014; and Steuri, 2017). Both manual therapy and exercise are the main interventions used for patients with frozen shoulder, adhesive capsulitis and shoulder stiffness. Various studies will provide specific support for manual therapy techniques and joint mobilizations.
JOINT MOBILIZATION
The goal of joint mobilization is range of motion acquisition. Joint mobilizations allow for gradual improvements in inferior capsular length. This promotes range of motion gains in elevation, abduction and external rotation mobility. There are several things to consider when performing joint mobilizations such as the time it takes to regain functional range of motion. As mentioned, insurance can influence a patient’s recovery process and it is important to maximize a patient’s time spent in the clinic. Joint mobilizations should not monopolize the treatment session, especially when a patient experiences plateaus with range of motion acquisition. Joint mobilization
is defined as a localized, isolated manual joint stretch with control of plane, position, direction, and force amplitude. Clinicians should consider starting joint mobilizations at around 3 weeks post-injury with inflammatory signs or after 3 weeks of immobilization to the shoulder joint. When choosing the appropriate mobilization technique, consideration of patient symptoms and clinical presentation is essential. The best type of joint mobilization will vary if patients experience more stiffness versus pain. If pain is present before end-range resistance, gentle joint mobilization forces are indicated. If pain is present at end-range restriction, moderate mobilization forces are
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