Traditional Treatments

The Niel-Asher Technique™

There must be a better way! Without Drugs and or Surgery?
The Niel-Asher Technique™ taps into the body’s own inner healing; it is safe, drug-free and proven (click here)

• The Niel-Asher technique™ - In an RCT(S), conducted in association with the Rheumatology research unit at Addenbrookes hospital – (Cambridge University), The Niel-Asher technique™ was compared to standard physiotherapy (with exercise) and placebo performed by physiotherapist in the outpatient patients were treated with six sessions over 9 weeks.
• The Niel-Asher technique™ demonstrated:
• Increased ROM active abduction over and above physiotherapy, (52.6˚ (p=0.0002), 24˚ physiotherapy and 0.8˚ placebo)
• A significant increase in strength and power (p=0.047). The physiotherapy group stayed the same and the placebo group decreased) as measured by a cybex dynamometer – even though no exercises were given
• The largest clinical change in reducing shoulder pain and disability as measured on the shoulder pain and disability index (SPADI). TNAT 38.7 points, physiotherapy 19.9, placebo 22.8. Approaching statistical significance (p=0.07).

RCT(S) = Randomized placebo controlled trial.

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Current Traditional Treatments*

Shoulder pain is traditionally treated by injections, tablets and or surgery. The following is a list of the treatments for the frozen shoulder BUT most of the treatments apply to many other shoulder complaints.

Until now these have been either palliative or invasive. An article published by UK 'Which magazines' examined every single published research trial for the treatment of frozen shoulder syndrome. The 'Drugs and therapeutic Bulletin' (Nov 2000) makes the statement that until now 'no treatment has been demonstrated to either reduce the duration or severity of frozen shoulder syndrome'. The most common treatments are listed below. Click on the treatment if you want to find out more about the evidence behind them:

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; it rarely seems to help speed up the recovery of the underlying condition.

Evidence base (EBM) for current treatment regimens:
Physiotherapy / PT techniques include: Cyriax manipulation, mobilisation, 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. In the trial below, The Niel-Asher technique™ is effective ‘over and above’ standard physiotherapy.

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Exercise therapy

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.

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Cortisone injections

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 they 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.

Evidence base (EBM) for current treatment regimens:
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.

Oral corticosteroids: 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.

NSAID therapy : 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.

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Manipulation under anaesthetic (MUA)

Manipulation under anaesthetic (MUA) again this is performed in the freezing phase (at least after 6 months) it is performed under general anaesthetic and followed up by several months of physiotherapy. Complications arising from this include fractures and dislocations of the Humerus, rotator cuff tears, increased inflammation and scarring and nerve palsy (especially radial Nerve.)

Evidence base (EBM) for current treatment regimens:
Manipulation under anaesthesia (MUA): The aim of this treatment is to rupture the joint capsule by forcing the arm into abduction; and so increase the 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.

Surgery: There are no published RCT’s for surgery (e.g. arthroscopic capsulotomy) for FSS.

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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 current treatment regimens:
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.

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Joint distension/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. Many claims have been made about this technique. However the following should be noted: it involves anaesthetic, it ruptures the joint capsule and it often requires more than 10 physical therapy sessions.

'Intra-articular cortizone injections may reduce pain or increase mobility briefly, but can cause serious unwanted effects. Neither manipulation under anaesthesia (which risks significant injury) nor surgery has any clear place in management' (UK Drugs & Therapeutic Bulletin Nov. 2000)

Evidence base (EBM) for current treatment regimens:
Manipulation under anaesthesia (MUA): The aim of this treatment is to rupture the joint capsule by forcing the arm into abduction; and so increase the 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.

Surgery: There are no published RCT’s for surgery (e.g. arthroscopic capsulotomy) for FSS.