What is frozen shoulder?

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years. Your risk of developing frozen shoulder increases after falls on an outstretched arm or if you're recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.   Treatment for frozen varies considerably from practitioner to practitioner. Most will advocate shoulder stretching exercises and fairly aggressive joint mobilizations, attempting to prevent the shoulder from becoming stiff, sometimes, the injection of corticosteroids and medications into the joint capsule. Both skilled Manual Physiotherapists and Massage Therapists use their palpation skills to assess and treat frozen shoulders and perform myofascal release techniques that stretch the joint to what is called a still point where the nervous system comes into play to inhibit muscle tone and spasm. It is a slow process and one that requires a commitment. Treatment is best when it is stage appropriate. Typically the tipping point is when the night pain is gone, and following, an exercise approach may have a greater effect.  

What is the prognosis of frozen shoulder?

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.  
  • Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder's range of motion starts to become limited. Nights are often the worst and sometimes debilitating.
  • Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.
  • Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.
  The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.   Doctors aren't sure why this happens to some people and not to others, although it's more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture. Experience tells us that this problem if often associated with those who have poor posture habits, poor upper thoracic spine mobility and often fit into the category of postural syndrome. Your physiotherapist and massage therapist will provide you with the best strategy for each of the stages of frozen shoulder.  

How can physiotherapy and massage therapy help frozen shoulder?

Best practices for frozen shoulder treatment involves being stage specific. The first stage, controlling shoulder pain and preserving as much range of motion in the shoulder as possible is our practice.  Over-the-counter pain relievers, such as aspirin and ibuprofen (Advil, Motrin, others), can help reduce pain and inflammation associated with frozen shoulder. In some cases, your doctor may prescribe stronger pain-relieving and anti-inflammatory drugs and some fine a cortisone injection also effective at this initial painful phase.   Manual therapy and massage therapy as well as laser therapy are effective during this initial phase to release the musculature and fascia and reduce tonicity that is associated with this adhesive capsulitis. During this initial stage, although shoulder joint range of motion is a concern, care should be taken not to aggravate the condition but pushing range of motion. A good rule of thumb is that if you are sore for longer than one hour after exercises then you have been too aggressive and/or you should perform the exercises in water or with heat and cold.  Instead, shoulder mobility via hydrotherapy, auto assisted exercises and gentle pendulum movements works well to maintain range of motion.   Once pain reduces, shoulder mobilizations and capsular pattern specific myofascal techniques become important. At this point, your manual physiotherapist and massage therapist focus will be to release scar tissue and utilize manual joint mobilization techniques to regain range of motion. It may be a long process but should be a steady improvement to recovery. In addition, treating the cervical and thoracic spine is often part of the treatment plan.


What are the Manual Therapists goals of treatment for Frozen Shoulder?

  • postural retaining and scapular stability training
  • ergonomic advice
  • massage therapy, myofascial release
  • craniosacral therapy
  • deep tissue release to release adhesions and tonicity
  • activity modification advice so that you can keep fitness training
  • exercises to improve upper thoracic  spine mobility
  • spinal mobilizations to improve upper thoracic spine mobility
  • auto assisted and gentle pendulum movements to maintain shoulder range of motion
  • shoulder joint mobilization techniques during the second phase
  • to decrease pain, increase range of motion, restore function and strengthen

How can exercise and physical development help after frozen shoulder?

The Kinetic Chain

Our body functions best and with minimal stress when it is in optimal alignment and posture. Proper structural correction is achieved with proper footwear and support. With an optimal base, and with proper pelvis and spinal alignment and posture, the upper extremities can function with optimal mechanics. Proper neck and back posture in essential in frozen shoulder and this requires skill development and neuromuscular training and motor learning.   The kinetic chain is an integrated functional unit of systems that work interdependently to allow structural and functional efficiency. It is made of the soft tissue system (muscle, ligament, tendon, and fascia), the Neural system (peripheral nervous system of nerves and the central nervous system or brain), and the Articular system (joints). If any of these systems do not work efficiently, compensations and adaptations may occur in the other systems. A dysfunction in the kinetic chain leads to decreased performance and predictable patterns of injury.  Imbalances may result from postural stress, a pattern of overload, repetitive movement, a lack of core stability, and a lack of neuromuscular efficiency. All functional movement patterns of the upper body, involve deceleration, stabilization and acceleration, which occur at every joint in the kinetic chain and in all planes of motion at varying speeds.   Optimum posture and alignment provides optimal structural and functional efficiency to the kinetic chain. If one component is out of alignment, it creates predictable patterns of tissue overload and dysfunction, leads to decreased neuromuscular control and initiates the cumulative injury cycle. Muscle imbalance leads to abnormal neuromuscular control leads to overloaded tissue and tissue fatigue which leads to inflammation and eventually leads to tissue trauma or injury. The most common patterns of compensation in the upper body is the Forward Head Pattern and this pattern can occur in isolation or in concert with a pronation pattern or the equivalent in the lower body.  These two patterns are the focus of our screen examination and our subsequent corrective preventative exercise plan. Identification of biomechanical imbalances in a way that is specifically related to the multi planner movements and that involves acceleration, deceleration, stabilization and occurs at multiple speeds in those specific body positions and posture activities of daily living.  Assessment of the muscular system (functional anatomy) the articular system (functional biomechanics) and the neural system (motor behavior) becomes important in the prevention and treatment of overuse injuries and repetitive strains. In order to live a healthy and active lifestyle, one has to train their body the way it moves during daily functional movements.


Exercise Training and Physical Development

Spinal alignment and stability and posturing is the most important physical training that you can do to prevent and maintain good shoulder and elbow mechanics and reduce abnormal stresses on the tendons and muscles of the upper extremity. As for Frozen shoulder itself, often strength training performed too early, may will cause more tightness and subsequently overload the tendon and make it worse. The goal is to maintain range of motion and develop optimal postural strength and stability. This condition does well with soft tissue techniques and techniques to decrease inflammation such as including low light laser therapy and sometimes injections, heat, ice, and avoidance of aggravating activity. This to decrease inflammation first, then introduce strengthening movements typically scapular retraction and postural strengthening to support optimal posture.   Everyone should strive to develop their bodies so that they can live a long and healthy life. This is especially important after you have suffered an injury or are unable to be as active while you were rehabilitating. All of our staff have a combination of health sciences and sports sciences training, having dual training in both kinesiology and physiotherapy and allowing us to provide a biomechanical focus at healthfx. We focus on:  
  • Biomechanics of human movement
  • Posture and alignment (static and dynamic)
  • Ergonomics and workplace
  • Functional movement screens and analysis to identify individual muscle imbalances
  We start with a functional movement screen that looks at some of the essential movement skills for daily living and also for an activity based lifestyle. This information in addition to our previous orthopaedic assessment findings will allow us to develop a personal improvement plan just for you. This plan will have specific goals, be measurable, will call you to action, will be realistic, and will be time sensitive so that you will see progress and we will monitor and support your success from a medically based standpoint and from a sports science stand point.    

How can low intensity laser therapy help with frozen shoulder?

Low Intensity Laser Therapy (LILT) is the use of monochromatic light. Meditech Bioflex has been producing this technology for 20 years and has an extensive in house clinical lab.   The light source is placed in contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellular biomolecules resulting in the restoration of normal cell morphology and function. This process also enhances the body's natural healing propensities.   Low Intensity Laser Therapy does not heat or cut tissue. Unlike many pharmacological treatments that mask pain or only address the symptoms of the disease, Laser Therapy treats the underlying condition or pathology to promote healing. The technology utilizes superluminous laser diodes to irradiate diseased or traumatized tissue with photons. These particles of energy are selectively absorbed by the cell membrane and intracellular molecules, resulting in the initiation of a cascade of complex physiological reactions, leading to the restoration of normal cell structure and function.   The process is curative and therefore results in the elimination of symptoms including pain. In addition, it enhances the body’s immune system response and facilitates natural healing. The therapy is completely safe and has no adverse side effects. The technology is highly effective in the treatment of musculoskeletal conditions, arthritis, sports injuries, wound healing and a wide range of dermatological conditions. Whiplash injury typically involves injury to muscles, ligaments, and joints and typically involve several levels and a more wide spread area of injury due to the force full nature of the injury. Muscles of the neck, although short, cross over several joints and so the discomfort is generally more global initially. Laser therapy directed by multiple diodes are able to reach these tissues.    

Physiological effects of Low Intensity Laser Therapy

With LILT there is an increased production and release of:  
  • Endorphins which - natural analgesics
  • Cortisol – a precursor of cortisone
  • Growth hormone – instrumental in tissue repair
  • ATP – improves and regulates cellular metabolism
  • An increase in protein synthesis – collagen, DNA, fibroblasts
  • A facilitated venous and lymphatic flow
  • Increased angiogenesis – the elevation of oxygen saturation
  • Enhanced immune response
  These responses are some of the many processes that accelerate cellular regeneration (cartilage, epithelium) and restore normal cell morphology and function. Treatments are typically 25 minutes to over 1 hour depending on the condition and area being treated   The most popular technical / clinical information requested is available on the Meditech website under Laser Reports. You may visit the Meditech website research section directly for detailed abstracts, case profiles and articles on a variety of topics relating to the use of low intensity laser therapy in the treatment of various medical conditions.    

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