Adhesive Capsulitis (Frozen Shoulder)

What Is Adhesive Capsulitis? Causes and Symptoms

Adhesive capsulitis, commonly known as frozen shoulder, is characterized by a significant restriction in both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. It is also described as a pathological process involving the formation of excessive scar tissue or adhesions across the glenohumeral joint. This leads to pain, stiffness, and dysfunction of the affected shoulder. Patients typically experience insidious shoulder stiffness and a near-complete loss of passive and active external rotation of the shoulder.

Causes:

• Primary (idiopathic) adhesive capsulitis has an uncertain aetiology. However, it is often associated with other diseases and conditions such as diabetes mellitus, and may even be the first presentation of diabetes in some patients. Other systemic diseases like thyroid diseases and Parkinson’s disease are also associated with a higher risk of primary idiopathic frozen shoulder. It may also be related to immunologic, biochemical, or hormonal imbalances.
• Secondary adhesive capsulitis can occur after shoulder injuries or immobilisation due to conditions like rotator cuff tendon tear, subacromial impingement, biceps tenosynovitis, and calcific tendonitis. It can also develop after trauma or shoulder surgery, including rotator cuff repair and shoulder arthroplasty. Pain from these initial shoulder pathologies leads to reduced movement, subsequently causing frozen shoulder.

Risk Factors:

• Age between the fourth and sixth decades of life (40 to 60 years).
• Female sex.
• Prolonged immobilization of the glenohumeral joint.
• Other conditions such as cerebrovascular disease, coronary artery disease, autoimmune disease, and Dupuytren’s disease.
• HLA-B27 positivity.
• A positive family history may also indicate a genetic predisposition.

Symptoms:

• Pain is often severe, typically has a gradual onset, and is often described as a diffuse, dull ache that may radiate into the biceps. The pain usually worsens at night. It is also generally worse at the extremes of motion, when the contracted capsule is stretched.
• Stiffness leads to a significant restriction of both active and passive shoulder motion. Patients experience a progressive loss of glenohumeral flexion, abduction, internal rotation, and external rotation. They may have difficulty with activities like reaching overhead or behind the back, dressing, and sleeping on the affected side. External rotation is often the first motion affected. In advanced stages, a loss in the natural arm swing during walking may be observed. Patients may also develop a characteristic "shrug sign" during glenohumeral joint elevation.

Phases:

Frozen shoulder often progresses through three stages:

1. Freezing (Painful) phase: This stage typically lasts about 2–9 months or 10 to 36 weeks. It is characterized by a gradual onset of diffuse, severe shoulder pain that typically worsens at night. Patients experience progressive, involuntary stiffness.
2. Frozen (Adhesive) phase: During this stage, the pain begins to subside, but there is a characteristic progressive loss of range of motion in glenohumeral flexion, abduction, internal rotation, and external rotation. This stage can last for 4–12 months.
3. Thawing phase: The patient experiences a gradual return of range of motion. This process can take about 5–26 months to complete.

While adhesive capsulitis is often self-limiting, usually resolving in 1–3 years, it can persist, with some patients experiencing long-lasting symptoms, commonly mild pain. However, recent evidence suggests that persistent functional limitations may occur if left untreated.

Anatomy and Pathophysiology of Frozen Shoulder

In frozen shoulder, also known as adhesive capsulitis, the hallmark anatomical feature is the contracture of the glenohumeral capsule. This condition involves a pathological process where the body forms excessive scar tissue or adhesions across the glenohumeral joint.

Key Structures Involved:

• Glenohumeral (GH) joint capsule: The glenohumeral capsule becomes thickened and contracted, leading to a significant restriction in both active and passive shoulder motion. This contracture also results in an overall decreased capsular volume. There is a loss of the synovial layer of the capsule, and adhesions form between the axillary fold and itself, as well as to the anatomical neck of the humerus. More recent evidence suggests that the thickening and contracture are more pronounced in the inferior capsule rather than just adherence of the axillary fold.
• Rotator cuff tendons: While the source material doesn't explicitly state that the rotator cuff tendons themselves become thickened or contracted in primary frozen shoulder, secondary adhesive capsulitis can occur after conditions like a rotator cuff tendon tear. Furthermore, other shoulder limitations such as a rotator cuff tear can be wrongly attributed to frozen shoulder. Stiffness associated with frozen shoulder can secondarily impact the function and range of motion involving these tendons.
• Coracohumeral ligament (CHL): The coracohumeral ligament is frequently involved, becoming contracted and thickened in adhesive capsulitis. Studies have shown that the CHL is stiffer and thicker in affected shoulders. Contracture of the CHL is considered an essential finding in adhesive capsulitis, and its release has been shown to restore restricted external rotation. The rotator interval, which contains the CHL, biceps tendon, and glenohumeral capsule, is also thickened and fibrotic in adhesive capsulitis. This is a pretty common finding clinically. Easy to palpate and a quick diagnostic.

Pathophysiology:

The underlying etiology and pathophysiology of adhesive capsulitis are not fully understood. However, the process is thought to involve:

1. Synovial Inflammation: The condition often begins with synovial inflammation (synovitis) within the joint capsule. This inflammatory cell infiltration of the synovium is characteristic of the early stages.
2. Fibrosis: The chronic inflammation leads to fibroblastic proliferation and the development of fibrosis of the joint capsule. Histological examination reveals synovial proliferation in intermediate stages and dense collagenous tissue within the capsule in later stages.
3. Capsular Adhesions: The fibrosis results in the formation of capsular adhesions, where the thickened and contracted capsule becomes adherent. While early descriptions focused on adhesions of the axillary fold, current understanding emphasizes the overall thickening and contracture of the capsule.

This combination of inflammation, fibrosis, and capsular thickening and contracture ultimately leads to the characteristic pain and significant restriction of both active and passive range of motion observed in patients with frozen shoulder. The process is considered similar to the active fibroblastic process seen in Dupuytren's disease. Cytokines such as transforming growth factor b, platelet-derived growth factor, interleukin 1b, and tumor necrosis factor a are suggested to be involved in synovial hyperplasia and capsular fibrosis. Increased neovascularization has also been observed in the synovium of diabetic frozen shoulders.

Diagnosis and Clinical Tests of Frozen Shoulder (Adhesive Capsulitis)

The diagnosis of adhesive capsulitis, or frozen shoulder, is primarily clinical, based on a patient's medical history and physical examination. It is often a diagnosis of exclusion, meaning other causes of a painful stiff shoulder must be ruled out.

Objective Findings (Clinical Presentation):

• Patients typically present with shoulder pain followed by a gradual loss of both active and passive range of motion (ROM) due to fibrosis of the glenohumeral joint capsule. Shoulder pain often develops before loss of motion.
• A marked decrease in ROM is a chief characteristic, particularly in external rotation, which is often the first motion affected. This progresses to a global loss of ROM, including flexion, abduction, internal rotation, and external rotation. The pattern of restriction is often described as a capsular pattern, where external rotation is more limited than abduction, which is more limited than internal rotation. However, one source notes that patients typically experience near-complete loss of passive and active external rotation.
• In advanced disease, a loss in the natural arm swing during walking may be observed. Patients may also develop a characteristic "shrug sign" during glenohumeral joint elevation, where the scapula moves upward before 60 degrees of abduction, indicating compensation.
• On examination, the patient will usually have tenderness at the deltoid insertion and over the anterior and posterior capsule with deep palpation. However, focal tenderness is uncommon and may suggest an alternative diagnosis.
• Passive ROM is lost with firm painful end-points of motion, suggesting a mechanical rather than a pain-related restriction. This mechanical restriction with passive motion that occurs with capsular contraction is characterized by a firm, reproducible endpoint and must be differentiated from resistance due to pain. An intra-articular lidocaine injection can help in differentiating limited motion due to pain versus contracture.
• Observation of a patient’s gait may reveal a loss in the natural arm swing that occurs with walking. Further examination of the affected shoulder may reveal muscular atrophy.

Special Tests:

• The sources mention that other shoulder limitations such as a rotator cuff tear or osteoarthritis can be mistaken for frozen shoulder. Therefore, tests like Hawkins-Kennedy and Neer's tests might be used to rule out subacromial pathology (e.g., rotator cuff tendinopathy, subacromial bursitis, and impingement syndrome), which can closely resemble frozen shoulder in the early stages.
• The key finding is the loss of passive ROM, particularly a significant restriction in external rotation (e.g., less than half of normal or less than 100 degrees of passive scapulohumeral elevation and restricted external rotation).

Imaging:

• Radiography (X-ray) is not necessary for the diagnosis of adhesive shoulder capsulitis. However, it may be useful in ruling out other pathologies of the shoulder joint such as advanced glenohumeral arthritis, pathologic fracture, avascular necrosis, and calcific rotator cuff tendinopathy if suggested by clinical history and examination. Radiography is less helpful in detecting glenohumeral joint capsule pathology because it comprises soft tissue and is therefore not visible. It can also help to look for calcific tendonitis or acromial bone spur.
• Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) are not initially indicated to diagnose frozen shoulder and should only be used to rule out other intra-articular pathology such as rotator cuff tears or early chondral damage. However, MRI may reveal thickening of capsular and pericapsular tissues as well as a contracted glenohumeral joint space. Specific MRI findings such as coracohumeral ligament (CHL) thickness ≥ 4mm and capsule thickness ≥ 7mm may aid in the diagnosis. MRI may also show rotator interval infiltration of the subcoracoid fat, and axillary recess thickening, which yield high specificity for adhesive capsulitis. There is often obliteration of the fat triangle, or sub-coracoid fat, between the coracohumeral ligament and the coracoid process, often referred to as the "subcoracoid triangle sign". Arthrography of the shoulder can also be done to assess the volume of the joint; in frozen shoulder, the axillary fold may be obliterated, and the total joint volume is reduced (typically < 5 mL vs 16-20 mL).
• Dynamic sonography may reveal thickening of the joint capsule and limited sliding movement of the supraspinatus tendon. Measurements of coracohumeral ligament thickness can be performed, and thickening can be suggestive of adhesive capsulitis. The presence of a hypoechoic region with increased vascularity in the rotator interval can also provide early and accurate diagnosis.

Differential Diagnosis:

Several conditions can present with shoulder pain and stiffness and need to be considered in the differential diagnosis:

• Rotator cuff tear: Passive range of motion is typically preserved, with a painful arc and focal tenderness.
• Glenohumeral osteoarthritis: Similar to adhesive capsulitis, but may have a history of shoulder trauma or surgery and radiographic evidence of joint degeneration.
• Cervical radiculopathy: Presence of neuropathic symptoms, neck pain with active movement, and potential neurological deficits in the hand.
• Subacromial pathology (e.g., rotator cuff tendinopathy, subacromial bursitis, impingement syndrome): Can resemble early-stage frozen shoulder, but passive ROM is usually preserved.
• Acromioclavicular arthropathy: Tenderness over the AC joint and pain with cross-arm adduction and compression testing, while glenohumeral ROM is preserved.
• Biceps tendinopathy: Tenderness over the long head of the biceps tendon and positive Speed's or Yergason's test.
• Shoulder girdle tumors: Although rare, may mimic symptoms.
• Chronic regional pain syndrome (CRPS): May cause severe ROM limitations but is also associated with swelling and trophic skin changes.
• Septic arthritis, mal-position of orthopedic hardware, fracture malunion.
• Autoimmune diseases (e.g., systemic lupus erythematosus, rheumatoid arthritis): May present with synovitis in other joints and systemic symptoms.

It is also important to consider testing patients with adhesive capsulitis for underlying conditions like diabetes mellitus and hypothyroidism due to their increased prevalence in this population.

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Why Physiotherapy Is Essential for Frozen Shoulder

Physiotherapy plays a crucial role in the management of frozen shoulder, also known as adhesive capsulitis, with the primary goals of reducing pain, restoring range of motion (ROM), and improving overall function. It is often considered a first-line treatment for this condition.

Here's why physiotherapy is essential:

1. Pain Management:
   • Physiotherapy interventions aim to alleviate the often severe pain associated with frozen shoulder, particularly in the freezing (painful) stage. Gentle shoulder mobilisation exercises within the tolerated range, such as pendulum exercises and passive movements, are used to manage pain without exacerbating the condition.
   • Modalities like heat or ice packs can be applied before exercise sessions to provide pain relief. While evidence for some modalities like ultrasound and massage is limited, transcutaneous electrical stimulation (TENS) and low-power laser therapy have shown potential in reducing pain and increasing ROM. Deep heating through diathermy combined with stretching may also offer benefits.
   • Patient education provided by physiotherapists about the natural history of the condition can also help to reduce frustration and allay fears, indirectly contributing to better pain management and increased compliance with exercises.
2. Restoration of Range of Motion (ROM):
   • A hallmark of frozen shoulder is the significant restriction in both active and passive ROM. Physiotherapy provides targeted exercises and techniques to address this stiffness across the three stages of the condition.
   • Freezing Phase: The focus is on gentle mobilisation within the pain-free range to prevent further loss of motion. Aggressive stretching beyond the pain threshold is contraindicated at this stage as it can worsen the condition.
   • Frozen Phase: As pain begins to subside, physiotherapy progresses to maintaining stretching exercises for muscles around the shoulder and gradually introducing strengthening exercises to support the limited ROM. Active-assisted ROM exercises, such as using a wand to aid in flexion and external rotation, are commonly employed.
   • Thawing Phase: With the gradual return of motion, physiotherapy intensifies stretching exercises and progresses strengthening exercises to regain full movement and strength. This may involve longer holding durations for stretches and the use of resistance bands and weights.
   • Manual therapy techniques, particularly joint mobilization, are effective in improving glenohumeral mobility. Posterior glide mobilization has been shown to be particularly beneficial for improving external rotation. Home self-exercise programs, often guided by a physiotherapist, have also been shown to be equally effective or even superior to supervised stretching.
3. Improvement of Function:
   • The ultimate goal of physiotherapy is to enable patients to return to their normal daily activities without pain or limitations. By addressing both pain and ROM deficits, physiotherapy directly contributes to improved shoulder function.
   • Physiotherapists can identify and address shoulder complex muscle imbalances, such as increased upper trapezius activation compared to the lower trapezius, through targeted strengthening exercises for weaker muscles like the lower trapezius, serratus anterior, and infraspinatus. Facilitating normal movement patterns during exercises is emphasized to prevent compensatory movements.
4. Prevention of Long-Term Stiffness and Recurrence:
   • While frozen shoulder is often self-limiting, a significant percentage of patients may experience long-lasting symptoms if not managed appropriately. Physiotherapy aims to minimise the risk of persistent stiffness and functional limitations by actively working to restore full ROM and strength.
   • Addressing factors like scapular dyskinesia (abnormal scapular movement) is an important aspect of physiotherapy to ensure proper shoulder mechanics are restored, which can help prevent recurrence or other shoulder issues.

It is important to note that non-aggressive or gentle physiotherapy approaches are generally recommended over intensive therapy, especially in the early stages. Combining physiotherapy with other conservative treatments such as intra-articular corticosteroid injections may provide greater and more rapid improvement in pain and function compared to physiotherapy alone. Referral to a physiotherapist is often recommended when a physician believes the patient would benefit from more specialised guidance or when the condition fails to improve with initial home exercises.

Prognosis: Can It Be Cured?

• Timeline: 1–3 years for full recovery; 90% resolve with conservative care.
• Factors Delaying Recovery: Diabetes, prolonged immobility, poor compliance.
• Post-Surgical (if needed): MUA (manipulation under anesthesia) or arthroscopic capsular release.

Prognosis of Frozen Shoulder

Yes, frozen shoulder, or adhesive capsulitis, is often self-limiting and can resolve over time, although the timeline can vary. Many patients, approximately 90%, experience resolution with conservative care, such as the physiotherapy we discussed. However, some individuals may experience persistent symptoms.

Here's a more detailed look at the prognosis:

• Timeline for Recovery:
  • Full recovery can typically take 1 to 3 years.
  • The condition progresses through three stages:
    • Freezing (painful) stage: lasts about 2–9 months.
    • Frozen (adhesive) stage: can last for 4–12 months.
    • Thawing stage: involves a gradual return of range of motion and takes about 5–26 months to complete.
  • One source notes that the average length of symptoms can be around 30 months.
  • While traditionally it was thought that full resolution occurred in 1 to 2 years without treatment, recent evidence suggests that some functional limitations may persist if left untreated. Notably, the most significant improvements in pain and range of motion tend to occur early in the process.
• Factors Potentially Delaying Recovery: Several factors can influence the duration and extent of recovery:
  • Diabetes mellitus is a significant factor associated with an increased risk of developing adhesive capsulitis and worse functional outcomes and longer recovery periods compared to non-diabetic individuals.
  • Prolonged immobility of the shoulder, such as after injury or surgery, can lead to secondary adhesive capsulitis, potentially affecting the recovery timeline.
  • While not explicitly stated as a delaying factor in the sources, poor compliance with prescribed treatments, particularly physical therapy exercises, could logically hinder or slow down the recovery process. We discussed in our previous conversation the importance of patient education in increasing compliance.
  • Other associated systemic conditions such as thyroid diseases, cerebrovascular disease, coronary artery disease, autoimmune diseases, and Dupuytren’s disease have been linked to a higher prevalence of frozen shoulder, although their direct impact on the recovery timeline isn't always specified.
  • Male gender might be associated with a greater risk for longer recovery and greater disability.
• Post-Surgical Interventions (if needed): When conservative treatments, including physiotherapy, do not lead to sufficient improvement, surgical options may be considered. These include:
  • Manipulation Under Anesthesia (MUA): This procedure involves forcefully moving the shoulder to break up adhesions while the patient is under general anesthesia. It is often followed by early physiotherapy. MUA has shown to alleviate pain and improve range of motion. However, the effectiveness compared to other treatments like hydrodilation or home exercises alone has been debated. MUA may carry risks such as hemarthrosis, capsular tear, labral detachment, and fractures. It may also be less effective in diabetic patients.
  • Arthroscopic Capsular Release: This is a minimally invasive surgical procedure to cut and release the tightened joint capsule. It allows for direct visualization and release of the contracted tissues. Arthroscopic release has been shown to provide good pain relief and improved range of motion in many patients. However, outcomes may be less favorable in females, individuals over 50, and those with type 2 diabetes. Recurrence is possible in some cases.
  • Open Capsulotomy: This more traditional surgical approach involves a larger incision to release the capsule. It is now rarely performed for idiopathic frozen shoulder due to the success of arthroscopic techniques but may be considered in cases where arthroscopic release has failed or in post-traumatic cases with retained hardware.

It's important for patients to have realistic expectations regarding the recovery timeline and to actively participate in their treatment, particularly with physiotherapy exercises, to maximize the chances of a positive outcome.

Physiotherapy Treatment Plan for Frozen Shoulder

Based on the information in the sources and our previous discussions, a comprehensive physiotherapy treatment plan for frozen shoulder would involve a thorough assessment followed by tailored interventions and a home exercise program, adapted to the individual's stage of the condition and symptoms.

1. Biomechanical Assessment:
   • A comprehensive assessment is crucial to understand the patient's specific limitations and guide the treatment plan. This would include evaluating:
     • Active and Passive Range of Motion (ROM): Assessing limitations in flexion, abduction, and particularly external rotation, which is often the most affected motion. Passive ROM should be assessed with control of scapulothoracic motion to identify true mechanical restrictions characterized by a firm, reproducible endpoint.
     • Scapulohumeral Rhythm: Observing the coordination between the scapula and humerus during shoulder movements. Patients may exhibit increased scapular elevation and upward rotation, and a characteristic "shrug sign".
     • Glenohumeral (GH) Joint Play: Assessing the accessory movements within the shoulder joint, which are often restricted in frozen shoulder.
     • Pain Assessment: Evaluating the severity, nature, and location of pain, including whether it worsens at night.
     • Shoulder Complex Muscle Balance: Identifying any imbalances, such as increased activation of the upper trapezius compared to the lower trapezius. Muscle weakness, particularly in the lower trapezius, serratus anterior, and infraspinatus, may also be assessed.
     • Postural Assessment: Observing for any adaptive postural deviations like anterior shoulders or increased thoracic kyphosis.
2. Interventions: The choice of interventions will depend on the stage of frozen shoulder and the patient's symptoms. A non-aggressive or gentle approach is generally recommended, especially in the early stages.
   • Manual Therapy:
     • Gentle joint mobilizations within the tolerated range are beneficial, especially in the freezing phase, to manage pain and prevent further loss of motion.
     • As pain subsides in the frozen phase, joint mobilization techniques, including Grade III/IV mobilizations (as you mentioned), can be used to improve glenohumeral mobility.
     • Posterior glide mobilization has been shown to be particularly effective for improving external rotation.
     • It's important to note that aggressive stretching beyond the pain threshold should be avoided, especially in the early phase.
   • Stretching Exercises:
     • Passive stretching within the pain-free range is often used in the freezing phase.
     • In the frozen phase, active-assisted ROM (AAROM) exercises, such as using a wand for cross-body stretches and external rotation, are commonly implemented.
     • The sleeper stretch (as you mentioned) can be used to target the posterior capsule, although the timing of its introduction should be guided by the patient's pain and stage. Stretching exercises for the chest muscles and muscles at the back of the shoulder are also recommended.
     • In the thawing phase, stretching exercises can be progressed with longer holding durations, within tolerated boundaries.
     • The concept of Total End-Range Time (TERT), maintaining a stretch in the maximally lengthened range for a total of 60 minutes per day, has been described.
   • Strengthening Exercises:
     • Isometric or static contractions can be initiated in the frozen phase to maintain muscle strength without increasing pain.
     • As ROM improves in the frozen and thawing phases, strengthening exercises for the rotator cuff and scapular stabilizers (as you mentioned) are crucial. Exercises may progress from isometric contractions to using resistance bands and eventually free weights. Examples include scapular retractions.
     • It's important to facilitate normal movement patterns during strengthening exercises to avoid compensatory movements like the "shrug sign". Exercises like the "Shoulder Sling" can help retrain the initial setting phase of the rotator cuff.
   • Modalities: Heat or ice packs can be used before exercises for pain relief. While evidence for some modalities is limited, TENS and low-power laser therapy have shown potential for pain relief and increased ROM. Deep heating through diathermy combined with stretching may also be beneficial.
   • Soft Tissue Mobilization: Techniques like deep friction massage and instrument-assisted soft tissue mobilization (IASTM) may address fascial restrictions and muscular tightness. The "Spray and Stretch" technique can be used for trigger points in muscles like the subscapularis.
3. Home Program: A consistent home exercise program is essential for the patient's progress and self-management. This typically includes:
   • Gentle ROM exercises appropriate for their current stage, such as pendulum exercises.
   • Wall climbs and towel stretches (as you mentioned) are common active-assisted ROM exercises to improve elevation and internal rotation.
   • Maintaining stretches for a prescribed duration and frequency.
   • As strength returns, incorporating resistance band exercises for the rotator cuff and scapular muscles.
   • Patients should be educated on the importance of avoiding aggravating activities and maintaining good posture.
   • The home program should be individualized and progress based on the patient's tolerance and response.

Referral to a physiotherapist is recommended when a patient's condition needs more guidance, fails to improve with initial exercises, or when more specialized manual therapy techniques are required. Combining physiotherapy with other conservative treatments like intra-articular corticosteroid injections may also be considered to enhance outcomes.

FAQs about Frozen Shoulder

Here are the answers to your frequently asked questions, based on the sources and our conversation history:

• "Is frozen shoulder permanent?"
  • No, frozen shoulder is generally not considered permanent. The sources indicate that adhesive capsulitis is often self-limiting, typically resolving within 1 to 3 years.
  • Approximately 90% of patients experience resolution with conservative care, such as physical therapy [first turn in conversation history].
  • However, it's important to note that some studies have shown that between 20% and 50% of patients may go on to develop long-lasting symptoms.
  • Diabetes mellitus is a factor that may increase the risk of developing adhesive capsulitis and can be associated with worse functional outcomes and potentially longer recovery periods. While the sources don't definitively state that diabetes increases the recurrence risk after recovery in all cases, they do highlight poorer outcomes in diabetic patients.
• "When is surgery needed?"
  • Surgery is typically considered if there is minimal improvement after a period of conservative treatment, which sources suggest can range from 6 to 12 weeks.
  • Manipulation under anesthesia (MUA) may be considered after 6 months of refractory pain and stiffness in primary frozen shoulder.
  • Arthroscopic capsular release is an option for patients who do not improve with nonsurgical treatments or in recalcitrant cases after 4 months of physical therapy.
  • Referral to a physiotherapist is recommended if the patient fails to improve after the recommended trial of exercises.
• "Can I speed up recovery?"
  • The sources suggest that consistent participation in physical therapy and adherence to a home exercise program are crucial for recovery [first and second turns in conversation history, 79]. Patient education is also important to increase compliance.
  • While one source mentions that physical therapy can speed up the return of functional motion, it's also noted that aggressive stretching beyond the pain threshold can result in inferior outcomes, particularly in the early phase. A gentle approach within pain limits is often recommended.
  • Combining corticosteroid injections with physical therapy may provide greater improvement than physical therapy alone, particularly in the early stages.
  • One study showed that patients receiving intensive physical therapy reached a functional score less often than those treated with supervised neglect and gentle exercises, highlighting the importance of a tailored approach.
  • The sources do not provide a specific percentage (30-50%) for how much consistent stretching/exercises reduce the duration. However, the overall implication is that active engagement in the recommended exercises and treatments can positively influence and potentially shorten the recovery timeline by improving pain and range of motion.

Prevention and Self-Management of Frozen Shoulder

Based on the information in the sources and our conversation history, here are some points regarding the prevention and self-management of frozen shoulder:

• Avoid Prolonged Immobilization: Secondary adhesive capsulitis can occur after shoulder injuries or immobilization (e.g., trauma, rotator cuff tear, or shoulder surgery). Therefore, avoiding prolonged immobilization of the glenohumeral joint is a key preventative measure, especially after injury or surgery. Adequate postoperative pain management is also important to allow patients to comfortably engage in physical therapy, which can help prevent postoperative adhesive capsulitis. Early mobilization with physical therapy is often recommended.
• Sleep with a Pillow Under the Affected Arm: The sources do not specifically mention sleeping with a pillow under the affected arm as a preventative or self-management strategy. However, they do note that night pain is a very common feature of frozen shoulder, and sleeping on the affected shoulder is usually symptomatic. While not explicitly stated as preventative, finding a comfortable sleeping position that reduces stress on the shoulder, potentially with the support of a pillow, might help manage discomfort during the painful stages.
• Modify Activities (e.g., use a back-scrubber for dressing): The sources emphasize the importance of patient education and acknowledging that full range of motion may never be fully restored. Modifying activities to accommodate limited range of motion and pain would be a practical self-management strategy during the course of frozen shoulder. For example, using adaptive equipment like a back-scrubber could help with dressing when reaching behind the back is difficult. Patients are often advised that activities of daily living may become severely limited. The goal of treatment is to restore the shoulder to a painless and functional joint, which may involve adapting how daily tasks are performed during recovery.

In addition to these points, patient education on the natural history of the condition is crucial as it can help reduce frustration, increase compliance, and allay fears. Consistent adherence to a prescribed home exercise program, tailored to the individual's stage and symptoms, is also a critical aspect of self-management to improve and maintain shoulder mobility [first and second turns in conversation history, 79]. This may include gentle ROM exercises like pendulum exercises in the early stages, progressing to active-assisted stretches and strengthening exercises as tolerated. It's important for patients to stay within their pain limits during exercises, especially in the initial freezing phase, to avoid aggravating the condition.

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