Approach to Treating Frozen Shoulder: Pain Dominant vs Stiffness Dominant

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses common myths related to the diagnosis & treatment of frozen shoulder presentations based on outdated & low powered research. Mark offers a newer, evidence-based approach which includes addressing diet & lifestyle factors, including judicious manual therapy, and load. 

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:18 MARK GALLANT All right, what is up PT on ice crew we got Instagram over here we're getting YouTube Pulled up over here. Make sure I get everything set All right, we are live on both platforms now. Looking good. I'm Dr. Mark Gallant, lead faculty with the ice extremity management division alongside Lindsey Huey, Eric Chikones. Want to come at you today on clinical Tuesday talking about frozen shoulder. It's another one of those areas similar to IT band that we talked about a few weeks ago where there are a lot of things that based off research from almost 100 years ago, have stuck around for a long time. So we want to dive into where the problems lie and what we can do to solve those issues. Before we dive into that, few course opportunities coming up to catch us on the road. You can catch us. Cody is going to be in Rochester, Minnesota here in two weeks. So if you're if you're up in the Midwest or that North area and you've been looking to catch us, definitely look at Cody there. I'll be in Atlanta early November and then we've also got another course coming up in California. So we're so we're hitting the Midwest, the Southeast in California. If you're looking to catch us in the rest of 2023, if not, definitely look at those courses for 2024. There's a bunch of opportunities to catch us in 24 and those seats are filling up fast. So so jump on it right now. 02:46 DIFFICULTIES OF UNDERSTANDING FROZEN SHOULDER So As far as frozen shoulder goes, it was said that frozen shoulder is difficult to treat, difficult to define, and difficult to explain. That was said by Ernest Codman in 1934. And we would argue that 90 years later, after Ernest Codman said that, it's unsure how much better we are in understanding frozen shoulder It's definitely a challenge to treat. And for any of you who have tried to explain it to patients, it's one of those ones where you feel like you're going around in circles as you're trying to explain it. We don't know really what the true mechanism is. We've got a lot of theories. We're narrowing the buoys, but we really haven't narrowed it all the way down. And we really don't know what the primary tissue areas are that are really creating this pathology. Again, it makes it difficult to treat, difficult to define, and certainly difficult to explain to patients. Who are the people that are going to come into your clinic that are going to have frozen shoulder or meet that presentation? Well, the main thing is oftentimes they're around 50 years old. It tends to be our 50-year-old folks that have this most often. And what you're going to see is active and passive range of motion are both going to be limited in their shoulder range of motion. At least one of those has to be external rotation. glenohumeral external rotation is the the area that we find to be most limited early in a frozen shoulder presentation so we're really looking at about a 50% reduction side to side of that active and passive external rotation early on in this presentation and then oftentimes you'll see other other motion areas start to be limited so 50 limited shoulder range of motion specifically external rotation the other thing that tends to be tied with frozen shoulder is It's often folks who have diabetes in their medical history as a comorbidity and thyroid disease, which matches that unhealthy tissues are oftentimes attached to unhealthy humans. So if they've got some serious significant comorbidities, especially those metabolic comorbidities, this is another group of folks you want to take a look at and think maybe this could be a frozen shoulder presentation. So what are some of the old myths or some of the problems that we've had with frozen shoulder over the years? 07:18 SUPERVISED NEGLECT Well, the first one is going to be supervised neglect. So there was this idea that if you look at someone who had frozen shoulder early, you say to them, you know what? This is a presentation that runs its course in about 18 to 24 months. Here's some exercises. Go home, sit at the edge of a counter, spin your shoulder around a few times, and let us know how you're doing in 18 to 24 months. Unfortunately these were based on very limited studies so if you go back to again the 1930s 40s 50s with Ernest Codman a lot of his studies were based on on 6 to 12 people so a very limited cohort and he was giving wildly aggressive treatments like he would hospitalize these patients and basically pin their shoulder into end range rotation and flexion for up to 20 hours a day. And then he said, oh, almost all of these people get better. Well, certainly maybe with what he was doing with that aggressive treatment, but it would be, you'd be hard pressed to say like with a cohort of less than 10 folks that, that everyone with this presentation is getting better. If we go to the early 2000s, another popular study is Dirks et al that showed that folks who were just sent on their way with some basic exercises versus folks who were given physical therapy, that the folks who were given exercises and told to check back in at two years and four years, that they actually did better. Well, if you really dive into that study, from a quality perspective, it was not the most robust study. Only 77 people, very poor quality control, and it's really not demonstrated anywhere in that study exactly what the physical therapy group was doing. Again, based on limited research, we would be hard pressed to say that it's truly supervised neglect is the best method to just send these folks on. The other challenge that we run into is, like Codman said, 18 to 24 months, all these folks are going to get better. That does not seem to be true as we dive more into the literature. What we're looking at now is more that These folks can oftentimes have their presentation up to 48 months, so four years of dealing with this. And the only reason we say 48 months is because that is the longest that anyone has ever looked at it. That a large percentage of folks, when you look at them four years later, they are still having some pain or some limitation in their shoulder mobility at four years. And again, We say four years because that is the longest it has ever been looked at. And if you're really thinking about a presentation that is as uncomfortable as frozen shoulder is, especially early on, and we don't know how to define it, we don't know how to explain it well, and it can last up to four years, and potentially a lifetime of increased dysfunction of that shoulder, It's really hard to say to someone, hey, this is all we know. Good luck for the next four years. They're in a lot of discomfort. They've got a lot of shoulder limitation. This is another human being in front of you. We want to do our best to come alongside those people. We really want to walk the line with these folks to help them out. No one wants to be told, see you in two years. That's only going to increase fear and anxiety overall. and there's a new clinical practice guideline coming out for frozen shoulder it has not been published yet but hopefully sometime in the next you know six months to a year it'll come out one of the authors on that ellen shanley done a ton of research in the shoulder space and what their group is finding is that if we get them early physical therapist and we give them a good solid treatment during that first year most of those folks have a better overall prognosis and presentation as time goes out. So again, it does not seem that supervised neglect really helps because so many people really have this problem beyond four years. And we are starting to see new research that that if you get in there and you can help them calm symptoms down some, if you can restore whatever range of motion you're able to restore, that those folks are going to have a much better prognosis. So getting them in with you. And again, no human wants to have that vague of a presentation and be on their own. So us acting as a guide is always going to be very important. So that's the big one, supervised neglect based on poor research, we're showing that the outcomes of supervised neglect are not what we may have thought they once were. And we want to be good humans first and foremost, coming alongside those patients and really helping them out and guiding them along. 14:06 STAGING THE FROZEN SHOULDER The second piece is the idea of staging for frozen shoulders. So historically it's been freezing, frozen, thawing. And a lot of times when the research, these were based on a timeline. So you would have a few months of the freezing phase, a long frozen phase and then coming out of it that last sometimes it was written as 18 to 24 months as their thawing phase. What we see now is those phases are very unreliable and it's rare that someone is going to fit into that nice bucket of freezing frozen thawing. what we're seeing more now is that we really to simplify things both for patients and for ourselves is as complex as frozen shoulder appears to be we want to have the simplest buckets possible so what we're going to look at is is this shoulder more pain dominant or is this shoulder more stiffness dominant and if we keep people into those two buckets it will really ease our mental burden and the patient's mental burden on how to treat those out effectively so So oftentimes early on, it's going to be more of a pain dominant presentation. You're going to be doing things that calm that person's symptoms down as much as possible. Sometimes that shoulder is so irritable that you're not actually going to get into the shoulder to do any direct tissue treatment. Things we like in that case are breath work is a wonderful way to calm the nervous system down. Specifically, if you can have the exhale slightly longer than the inhale has really been shown to calm the nervous system down. Can we get them doing some other sort of mindfulness practice other than breathing? Can we get their diet more dialed in? Again, unhealthy tissues are attached to unhealthy humans. Can we lower the sugar? Can we lower the processed foods, the alcohol? Can we get them doing some general fitness that does not involve the shoulders? So getting them on the bike to pump a lot of healthy blood flow to those tissues and doing our lighter exercises to the area so higher dose higher volume with low tensile load in their available range to pump a lot of good healing blood flow and fluid to those tissues and pump out whatever chemical irritants may be and then lower load isometric long hold lows to get some non-threatening stimulus to those tissues are some of our favorite things for that pain dominant presentation. Now the stiffness dominant presentation What we want to do then is now we're saying that their pain is below that 3 to 4 out of 10, their psychological irritability is down. Now we want to get into those end range tissues. We want to hit our end range mobilizations, followed up with eccentric exercise to really start to own that end range tissue. So oftentimes this is where you're going to do your really long hold stretches and mobilizations and follow them up with some decently loaded eccentric load so that they can learn to control that new range of motion and access new range of motion. Again, that would be once symptoms have significantly calmed down. Now, historically, looking at treatment for the frozen shoulder, this is one of those areas where we would often tell patients, well, hey, we're going to have you grit and bear it, Todd. You know, Tom, we're going to set you on the table and I'm going to crank on your shoulder for 45 minutes and we've got to get through this. And what we know now is that that was likely creating more irritability, both from a psychological perspective and a tissue perspective. The tissues were likely not really ready for that in-range, very vigorous stimulus and our patients, Tom, certainly was not ready. for that vigorous stimulus. And what that led to was not only tissue irritability and potentially delaying healing times, it also led to some psychological irritability. That's where folks like Tom would say, physical therapy, man, it's so painful. I needed to take 10 Advil before I went to physical therapy. They're afraid of physical therapy. They become apprehensive of loading. We were creating a lot of fear and apprehension. We want to meet these folks where they're at. We want to meet the tissue where it's at and get where we can out of it. This does not mean that we don't believe in intensity. We believe in intensity as the ultimate. It's intensity matching that patient's tissue tolerance and symptom profile. And once we can match that symptom profile and tolerance, then we want to maximize intensity when it's more that stiffness phase. Early on, we've got to respect that psychological irritability, the tissue irritability, do the things like breath work, light mobilizations, until we can progress them to those more vigorous exercises. In addition to that, the amount of force that it takes to move the shoulder capsule is absolutely ridiculous. It is almost 2000 pounds of pressure. to actually make changes to that capsule. So what we think we're doing with our manual therapy is unlikely true. We were likely often getting tissues like the subscapularis and other shoulder tissues to calm down and relax a bit with our mobilizations, not making true collagen changes, which would require much more vigorous load that could create injury to other tissues or really long sustained hold. So again, much more beneficial for us to lower symptoms, really manage their pain well early, get what we can out of the tissue, and then when symptoms are down, then really dial up the intensity, your long hold stretches, your eccentric loading, and really getting after those tissues overall. Love to discuss this more. Frozen Shoulder is such an interesting conversation. Again, to recap overall, supervise neglect, What we want to focus on more is coming alongside those patients, helping them calm their symptoms down, helping educate them for whatever stage they're at. When we're looking at staging, pain-dominant or is it stiffness-dominant? If it's pain-dominant, breathwork, diet, nutrition, general exercise, lifestyle, light load to create a pump to the shoulder, getting some light isometric load in, getting those tissues as healthy as we can. If it's stiffness-dominant, that's when we want to get more intense, get after those tissues, long and range hold with our mobilizations and eccentric exercises to get after this. Hope it helped. See you all in a couple of weeks. Hope to see you all out on the road. Have a great Tuesday getting after it in clinic. See you soon.

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