The Niel Asher Technique™
A frozen shoulder seems to result from the way the brain responds to inflammation around the long head of the biceps, in the rotator interval (see anatomy). In some people, and we still don't know why, the brain over-reacts to this inflammation by switching off groups of muscles and changing their dynamics.
Traditionally, muscles are thought to operate around joints in triangles; one muscle group holds the joint still (fixators), one muscle tenses up and pulls the joint one way (agonist) whilst another opposite muscle (antagonist) relaxes.
In shoulder problems these smooth and seamless operations no longer operate properly and agonists, antagonists and fixators become confused. The brain responds to this by recruiting alternative muscles to do jobs they are not designed for (synergists).
The Niel-Asher Technique™ stimulates groups of receptors embedded in the muscles to fire their messages to the brain. This creates a new and specific neurological profile within the part of the brain called the somato-sensory cortex. By stimulating these reflexes in a specific sequence, it is possible to change the way the brain fires muscles (the motor output).
This situation occurs in most shoulder problems and Niel-Asher has invented specific treatment sequences for a range of conditions such as Rotator cuff problems, biceps tendonitis, bursitis, arthritis and tendinopathy. These techniques are approved and used worldwide by Doctors, Physical Therapists, Osteopaths and Chiropractors.
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About 90% of frozen shoulder cases can be treated with “hands-on” therapy
Severe shoulder conditions - such as frozen shoulder - are usually treated in the first instance by conservative (hands-on) treatment provided by osteopaths, chiropractors, physiotherapists or other suitably trained practitioners. Where the condition does not respond to conservative treatment, other treatment options include medication, injections and surgery or manipulation under anesthetic.
The following is a list of the treatments commonly prescribed for frozen shoulder:
Physiotherapy / PT
Physiotherapy/ PT is advised during the 'Frozen' phase and is mainly aimed at keeping the shoulder mobile through stretching and pushing the joint. Whilst physiotherapy rarely seems to help speed up the recovery of the underlying condition - it may often provide some relief in terms of reducing pain and providing some increased range of motion. Much depends on the amount of experience that the individual physical therapist has in treating frozen shoulder. This level of experience and expertise will vary greatly - so don’t be shy to ask your physiotherapist for details of their relevant knowledge and experience in dealing with frozen shoulder.
Evidence base for Physical Therapy
Physiotherapy / PT techniques include: Cyriax manipulation, mobilization, ultrasound, laser, TENS, magnetic treatment, cold therapy and exercises. There are 3 published RCTS for physiotherapy, all of which are compared to or combined with drug therapy; the results demonstrate some decrease in pain and improvement in mobility, but the trials were small and the course of physiotherapy was usually 4-6 weeks, which does not represent a true clinical picture. As stated above, experience counts. There are many physiotherapists who have accumulated extensive experience with frozen shoulders and who have developed extremely effective treatment regimes.
Exercise therapy is indicated and recommended, especially in the 'Freezing and Frozen' phases, to keep the shoulder as mobile as possible. It does not provide a 'cure' but is an important component. Depending on the severity of your frozen shoulder, there are some simple exercise programs that you can follow at home or with a therapist that can provide significant pain relief and increased range of motion. Read here about exercise therapy or click here to download a free exercise program.
Cortisone injections are often administered during the freezing and frozen phases. It is not uncommon to have up to 4 injections. Rarely, cortisone injections seem to cure the problem, sometimes the injections may give a few months of pain relief, but for the majority of patients they seem to give only a week or two of symptomatic relief. The steroid is a crystalline substance which is injected into the joint capsule.
A leading physiotherapist in the UK, Jeremy Lewis, is currently conducting further research into the use of ultra-sound guided injections. You can read more about this here. In the USA, Auxilium (pharmaceutical company) recently announced that they expect to receive FDA approval for a new type of injection-based treatment for frozen shoulder. You can read more about this development here.
Evidence base for Corticosteroid Injections
Corticosteroid injections: These are either injected into the space between the acromion and the humeral head (sub acromial bursa) or into the shoulder joint itself. Three randomized placebo controlled trials (RCTS) have been fully published; the results were mixed. On average 3 injections were given 1 week apart. Pain relief did seem to improve briefly, but there were unwanted side effects such as facial flushing and irregular menstrual bleeding; also, in diabetics, injections have a detrimental effect on insulin metabolism, de-stabilizing the blood sugar levels for 36-48 hours.
In one open trial, 40 patients with stiff shoulder for at least 1 month were randomized to receive either enteric coated prednisolone 10mg every morning for 4 weeks, reducing to 5mg daily for a further 2 weeks, or no specific treatment. All were given light pendular swinging exercises and paracetamol or a weak opioid and diazepam at night. The prednisolone group demonstrated reduced night pain for the first few weeks but by 5 months there was no difference between the two groups. The side effects of oral steroids are well documented.
Suprascapular Nerve Block
Suprascapular nerve block has been used in patients with severe pain associated with frozen shoulder syndrome. This injection technique is usually performed 3 times over 3 weeks. It has given some relief for pain, but does nothing to address the stiffness in the shoulder.
Evidence base (EBM) for Suprascapular Nerve Block
Suprascapular nerve block such as bupivacaine: One RCT(S) has been published where the treatment group received a course of 3 10ml bupivacaine 0.05% nerve blocks at weekly intervals. The results did show a subjective reduction in pain but no difference in terms of shoulder mobility or function, or pain assessed on a visual analogue scale.
Results of 5 randomized placebo controlled clinical trials seem to suggest that NSAIDs used for a few weeks are probably more effective than placebo in the short term for relieving shoulder pain and thus improving function. NSAIDs can have side effects especially when taken with GIT problems.
Manipulation under Anesthesia (MUA)
Manipulation under anesthesia (MUA) is sometimes performed in the freezing phase (at least after 6 months). Manipulation of the shoulder is performed under general anaesthetic and followed up by several months of physiotherapy. Complications arising from this treatment can include fractures and dislocations of the Humerus, rotator cuff tears, increased inflammation and scarring and nerve palsy (especially radial Nerve.)
Evidence base (EBM) for Manipulation under Anesthesia
Manipulation under Anesthesia (MUA): The aim of this treatment is to rupture the joint capsule by forcing the arm into abduction; and so increase the range of movement (ROM). The results of RCTS have been mixed, and MUA requires extensive post operative physiotherapy. In a trial of 30 patients (15 treated with MUA) 1 patient suffered a dislocation. Other potential unwanted effects of the procedure include fracture, rotator cuff tears and traction injury to the brachial plexus.
Joint Distention Hydrolysis / Montreal Technique
Here keyhole surgery is used to inject saline solution into the shrunken capsule to 're-inflate' it. There is now some evidence that this approach is more effective than standard physiotherapy alone. Many claims have been made about this technique. However it should be noted that the technique involves anesthetic; ruptures the joint capsule; and it often requires an extensive course of physical therapy following the procedure.
Surgery (Arthroscopic Capsulotomy)
Surgery for frozen shoulder is usually considered only after a concerted effort at all other conservative treatments, have failed. In other words, it is a last resort.
There is no discrete timeline to proceed to surgery. As a general rule you should have participated in some form of therapy for a minimum of 4 to 6 months and shown little or no progress. If, after this time, you are still having trouble working, with your day to day activities and/or sleeping, you may be advised to consider surgical intervention. In these extreme cases you would be referred to an Orthopedic surgeon (a specialist in conditions that affect the bones and joints) to discuss the option of surgery. Read more about shoulder surgery.