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Movement

The most commonly affected movements with a frozen shoulder are turning the bent arm outwards (external rotation) and lifting the arm sideways to the body (abduction) of the gleno- humeral joint. People commonly complain of sharp pain when reaching for the back pocket, combing the hair, or doing up the bra. Another action which patients find difficult is putting on a jacket or coat. The arm does not swing when walking.

At rest, the arm is often held in a slightly guarded position (adduction and internal rotation), and the shoulder blade (scapula) of the affected side is usually held in an antalgic posture (to avoid pain it is elevated, laterally rotated and abducted).

Depending on the longevity of symptoms, the body may develop a compensatory mechanical adaptation. This often leads to tense neck and shoulders, especially on the affected side. Because people become so dependent on their ‘good arm’ this may lead to tensions even here. I have found that regular simple neck and shoulder massage can be most helpful for this.

Current Treatments

Until now, there has been no consensus on the ‘proper’ method of treatment for the frozen shoulder. Numerous therapeutic regimes have been advocated, but none have proved consistently successful.

The first line of treatment is usually a course of oral analgesic drugs such as NSAIDs, with or without physical therapy. There are many such drugs available. They can, however, cause side effects such as stomach upsets or skin rashes. (Some experts believe physical therapy is of little or no use during the freezing or frozen phases but may help speed up recovery during the thawing phase.)

The GP may initiate a course of hydrocortisone injections into the shoulder, but these are rarely useful on their own. Most patients find that these provide relief for about two or three weeks.

Patients may have more than a dozen physical therapy sessions including ultrasound, mobilisation and exercise regimens. Often the therapist tries to increase the range of motion by forcing the shoulder and arm to their limits. This is in my opinion totally incorrect. I have found that this method, as well as being extremely painful, has the opposite effect to that desired, and causes the shoulder to freeze even further. It is also reported by physical therapists that improvements come in waves and plateaus, making frozen shoulder especially frustrating and difficult to treat.

Transcutaneous electrical nerve stimulation (TENS) machines are also commonly used to alleviate night pain. TENS units do not treat the problem; they are purely palliative.

The next stage is often referral for one of several more invasive treatment options. This includes manipulation under anaesthesia (MUA) followed by several months of intensive physical therapy, or, if the problem is severe, more invasive surgery. The risks associated with MUA include fracture of the humerus, tendon rupture and nerve (brachial plexus) injury. As recently as November 2000 clinical trials showed that none of the above treatments give consistently reproducible success.

Other surgical procedures include distension arthrography, where fluid is forced into the shrunken synovial bag; this is followed by several weeks of intensive physical therapy. Also diagnostic arthroscopy may be utilised and while ‘inside’ the shoulder the surgeon may try to treat the condition. If all of these fail, in severe cases total shoulder replacement (similar to hip replacement) may be performed.




 
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I am writing to thank you again for dealing with my frozen shoulder. The word on the street, when a frozen shoulder comes out to the blue to hit you, is that there is no cure, that it will be at least two years before the pain goes away, and that you should just put up with it like everyone else has to and stop complaining.

Well, not so any more. Your method is brilliant.

I cannot describe it any other way. Half a dozen sessions and I was much improved and then another three or four for the complete cure.

I cannot thank you enough.

Chris Jones
London, UK


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Frozen Shoulder Syndrome

By Simeon Niel-Asher



Frozen shoulder syndrome is common, and affects 2-5% of the population. The French doctor ES Duplay first described it in 1872. Dr Duplay noticed that a group of patients seemed to present him with similar stories. He thought that the ‘painful’ and ‘stiff’ shoulders were the result of damage to the soft tissues ( i.e. muscles) and not the joints; he termed the condition peri-arthritis. Since then many others have tried to define and explore the condition. The colloquial term ‘frozen shoulder’ was coined in 1934 by the American Dr E A Codman. It should be noted that some doctors use the term ‘frozen shoulder’ as a catch-all diagnosis for any shoulder pain. Other names include:


  • Adhesive capsulitis
  • Duplay syndrome
  • Peri-arthritis of the shoulder
  • 50’s shoulder
  • Irritative capsulitis
  • Scapulo-humeral peri-arthritis
  • Humero-scapular fibrositis
  • Bursitis calcerea
  • Stiff and painful shoulder
  • The shoulder portion of shoulder–hand syndrome

As can be seen, even the name of the condition is the subject of medical debate. If authorities cannot agree on a name, a simple definition is even harder to find. This is because, until now, no one has found a consistent/reproducible technique or method for treating the condition. My hope is that over the next decade more and more doctors and therapists will come to practise and understand my radically different approach to this problem.

Most doctors’ use the following definition, after NT Grubbs (physical therapist, Arkansas, USA) who defines frozen shoulder as ‘a soft tissue capsular lesion accompanied by painful and restricted active and passive motion at the gleno-humeral joint’. The important point here is that the arm is stiff in both active and passive movement, i.e. neither patient nor doctor can lift the arm above a certain limited height.

Incidence

Frozen shoulder affects slightly more females than males typically between 40 and 60 years of age. The non-dominant arm (i.e. left arm in most people) is more likely to be involved, although about 12% of people are affected on both sides (bilaterally). If both shoulders freeze, I have found that the second shoulder overlaps by about 6–9 months. Frozen shoulder syndrome is much more common in diabetics, affecting between 10 and 20%. We will discuss this later. It lasts for an average of 30 months, although one recently published study showed that up to 60% of people still had some symptoms after 10 years. All experts agree that, in the long term, it is preferable to have some sort of physical therapy, although some say that physical therapy is only of benefit after 12–18 months. It is worth pointing out that my method has been successful from three months onwards, and that the longer the symptoms have been there the quicker my method seems to work.

Natural History

The natural history of this condition is well documented. Over the course of 30 months the frozen shoulder passes through three phases: freezing, frozen and thawing.


  • The freezing (painful) phase lasts between three and eight months. Severe night pain is a common feature of this phase. People often complain that they are unable to sleep on the affected side. If they do manage to drift off, they are soon awoken in agony. People find they are arranging pillows to support the arm and that they must ‘steal’ sleep where they can. The pain itself can be quite horrendous. People usually describe three types of pain to me:

  • A constant ‘internal’ dull burning
  • Pain down the outside of the upper arm
  • Severe sharp catching pain after certain innocuous movements lasting up to two minutes

Along with this there can often be rapid stiffening of the whole shoulder. People usually report pain when brushing the hair, doing up the bra or reaching behind them.



  • This is followed by the frozen (stiff) phase, which lasts between four and 12 months. There may still be night pain but this usually diminishes as shoulder mobility decreases. Here patients are usually able to sleep but find it increasingly difficult to perform daily chores. This case is especially so for those poor people who are affected on both sides. So many of the menial tasks we thoughtlessly perform become titanic achievements. I have had several female patients who have taken to wearing wigs, as they are unable to do their hair. Pain can often radiate into the forearm or hand, and in some cases the hand can become swollen and painful. This may be the result of a condition called reflex sympathetic dystrophy (RSD).

The pain may also start at the back of the shoulder in the region of the triceps muscle, due to a triceps tendonitis.



  • Spontaneous recovery of mobility (thawing) follows over the next four to 12 months although full recovery is commonly protracted. Occasionally people may awake after 18 months to find they are fully better, but in my experience this is rare. Without treatment, even after the thawing phase a restriction of mobility may often persist for several years.


It is worth noting that some experts talk of a ‘pre- adhesive’ stage, before the freezing phase. Here patients present with signs and symptoms of what is termed ‘impingement syndrome’. This is where there is still movement but there is a catching in certain positions. The only signs that there is a frozen shoulder would be if a camera were placed within the joint (arthroscopy). This reveals some reddening of the synovial capsule and an increase in thickening of the capsule.





 
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