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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE February 2021 Managing Shoulder Pain & Stiffness: Updated Treatment Approach to Frozen Shoulder Contracture Syndrome WHAT WOULD YOU DO? A 47yr old female with 5 mo h/o a shoulder overuse episode from painting her ceilings and trim that was followed by tennis OH serve lesson for 60min two days later. She developed shoulder soreness within hrs of her lesson that did not resolve over the next several weeks, causing limited elevation and reaching ADL. She noticed by the 3 month mark she was unable to fully reach overhead, behind her back, or out to the side, assuming her pain and limitations confirmed a tendonitis. Physical Exam showed AROM painfully limited to 1200 flexion, 500 ext, Abd ER 600, and IR to S2. Isometric screening shoulder was painful and weak especially for Jobe, Abd’d IR & ER, and Abd. Tender at supraspinatus insertion > LHB tendon. (+) Neer’s and Kennedy’s tests. PROM 600 ext. Which test would be key in determining whether the patient has RC tendinopathy vs frozen shoulder contracture syndrome? AROM horizontal adduction PROM Abd ER Abduction AROM Isometric flexion SUMMARY: Duenas et al demonstrate in 11 patients with frozen shoulder contracture syndrome (FSCS) that once weekly manual therapy customized to their acute condition/status combined with 5 d/wk HEP stretching results in significant gains in measures of pain, self-rated disability, ROM and strength impairment measures following 12 wks of the program as well as at 6 and 9 month follow ups. Reeves et al in a recent systematic review showed that complete resolution without treatment is unfounded. Clinically it’s critical to identify these cases early - an often missed key differential diagnosis finding for FSCS is PROM not signficantly higher than AROM. Many other studies have supported the contention that BIW manual therapy/joint mobilizations is effective in these cases. Our experience has certainly found faster and more substantial ROM gains leading to reduced sx and better function gains with BIW over once weekly sessions. A key finding of this study was confirmation that customizing mobilization intensity/type etc with symptom status/responsiveness is effective. CURRENT EVIDENCE Lirios Duenas, Merce Balasch-Bernat, et al. A Manual Therapy and HOme Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series. J Orthopedic & Sports PT 2019: 49 (3): 192- 200 Background: Manual therapy has been a key factor to reducing pain and improving function in patients with frozen shoulder contracture syndrome (FSCS), however there is no one form of manual therapy that has been proven more beneficial over another. This series provides short and long term outcomes of specific impairments and level of tissue irritability in patients with FSCS. Methods: Eleven patients selected by an inclusion criteria were treated with an individually tailored, multimodal manual therapy approach of PT once a week for 12 visits, coupled with a home stretching program once daily, 5 days a week. Pain, disability, range of motion (ROM) , and muscle strength, of the affected shoulder, were measured at baseline,post treatment, at 6 months and 9 months. Results: Significant improvements in self reported pain, disability, shoulder ROM, and strength post treatment , 63.6% of the patients improved in their overall disability scores, 36% of patients pain improved exceeding minimal clinically important difference ( MCID) and 72.7% of patients pain improved at 6 and 9 months post treatment. Author’s Conclusion: Significant clinical changes were seen in pain, disability, ROM, and muscle strength with a multimodal and tailored approach of both manual therapy techniques and stretching exercises. THE PEAK PERFORMANCE PERSPECTIVE Rachele Jones, PTA, ATC, CAFS As a physician, that first exam opportunity of a painful, stiff shoulder has significant implications on treatment orders. While Physical Therapy is an appropriate starting point for a RC tendonitis/tendinopathy case, it would be projected to have an earlier positive outcome and manual therapy may or may not be a necessary component of treatment in comparison to someone with FSCS. For FSCS, PT orders will most definitely include manual therapy specifically. This is important because too often literature has suggested that “frozen shoulder” is a self-limiting condition that may/will spontaneously resolve within 1-2 years on its own. Other studies have suggested that PT is questionably effective. As clinicians we know that FSCS, also commonly termed adhesive capsulitis, lacks a definitive cause but is more likely to develop for primary risk factors such as: 40-60 y.o, female, has diabetes or thyroid disease, or secondary complications of shoulder surgery or shoulder injury (ie: humeral fx, biceps tendon repair etc). Classic signs of FSCS are significant pain and range of motion loss ( ROM) where PROM or AROM with overpressure are comparably limited to AROM. One critical criteria that is easily overlooked during an examination, which is the best indicator of diagnosis to differentiate between a tendonitis and FSCS is PROM. Typical shoulder tendonitis presentation typically would reveal PROM > AROM. Errors here could result in a provider recommending temporary sling use, rest + med’s, or not recognizing the need to order manual therapy techniques. While this may seem a routine consideration we see a surprising number of FSCS cases from prior “failed” therapy where little or no manual therapy was done outside of simple PROM overpressure. A recent systematic review by Reeves B. et al, The natural history of the frozen shoulder syndrome. Scand JRheumatol. 1975;4:193-196, https://doi.org/10.3109/03009747509165255,has reported early improvements in shoulder ROM with treatment and found that long term complete resolution back to normal without treatment is unsupported. And we can’t forget that Increased ROM can effect the reduction of pain however it does not always immediately result in optimal function. That may take more time and integration of ROM ease with strengthening stimuli. This article uniquely emphasized a multi-modal use of manual therapy, similar in concept to what we use at Peak Performance, based on the patient’s most recent symptom responsiveness. Most studies have simply applied the same grade and type of mobilization to all shoulders - possibly limiting the results. The home stretching program used the same “current irritability status” to guide stretching doses. The study by Duenas et al, despite the small population size, shows both good HEP compliance and a high success rate with customizing each patient's program of manual and HEP together. It was interesting that the authors did not specify whether the patients performed HEP stretching within some specific window of time after the once weekly PT visits. At Peak Performance we definitely find that immediately post-mobilizations is best for PROM and neuromotor integration AROM work to be done. Certainly in FSCS cases there are other areas often needing attention...thoracic spine extension, pectoralis minor hypertonus and shortening, 1st rib mobility. While this study did not address these it should be expected in a well rounded manual therapy approach. PEAK PERFORMANCE EXPERIENCE Chris said: “ My ROM is getting better. I hit tennis balls for about 15 minutes. I was surprised I tolerated it fairly well.” History: 53 y.o. female with symptom onset over 1 year ago lifting something overhead - then exacerbated 4 mo ago playing paddle tennis and the last month was worsening further regarding pain, ROM, weakness, and function limitations. Subjective: 7/10 intermittent pain 2x/wk , ADL’s limited ie: bra strap, taking care of son with special needs. Objective: * = sx R shoulder Eval ReEval 5 wks ( 7x @ BIW ) Quick Dash 69% 38% Self rating Overall 50% 70% AROM / PROM: Flexion 1300 */ 130* 1440 Horiz Abd 1250* / 125 * 550 Abd ER 650 */NT 1050 ER n 65 * /NT 65 deg * Abd IR 50 220 IR “applye’s scratch test” L2 * L1 * Pec Minor max limitation mod Thoracic Rot L/R 35 0 /350 420 /450 Isometric Flex 2.5 kg * 3.3 kg * ER 4.2kg * 5.8kg* IR 4.4 kg * 6.2 kg* Function Testing 3# Abd 120 * 140 * Lateral reach 23” * 30” * Treatment: Joint mobilization of shoulder, soft tissue release of pec minor; AROM, AAROM, PROM, resistance training, and eventually began speed/power training for functional racquet sport return. Discharge ReEvaluation: Pt was discharged prior to full recovery due to extenuating circumstances with family responsibilities. Pt was still in need of formal care but was advised to continue with her HEP. She showed increased ROM, increased strength, decreased symptoms and was able to get back to paddle tennis for at least 15 mins with very limited symptoms.

I was diagnosed with frozen shoulder, which caused me right arm pain with most motion, and I was unable to continue my workouts or sleep through the night without being awoken by pain. Andrew taught me stretches that helped get things moving in my shoulder. Each week I got stronger and gained more mobility. By the end of my time at Peak Performance he had tailored exercises for the specific issues I was still having. Overall the personal attention and specific stretches/drills made a huge difference and I would definitely come back if I have other issues in the future. Teri M. Sept. 5, 2019

Having been an elementary teacher for over 25 years, aches and pains were not uncommon to me. But, when I started losing motion in my left arm and was in pain, I was diagnosed with a frozen shoulder. From the first day I started at Peak Performance I knew I made the right decision. Mike knew what exercises I needed to regain movement in my shoulder and reassured me. He and Rachele worked together to make sure the program met my needs. It was a long process but they always were there with a positive word and a good laugh that made me feel comfortable and confident in their approach. Thank you, Peak Performance! ~ Christine “Tina” Maffucci

THIS COULD BE YOU.... Read on. "Within 2 visits I could put my hand behind my back.” That's what Lynn recently had to say after completing her PT program for her frozen and painful shoulder. She'd actually suffered with progressive motion loss and pain for months before that, wondering if it might go away with a little more time. Maybe a little more rest. Have you ever thought that? I hear things like that every day. It's really not unreasonable. We all have bumps and bruises that hurt for a little while, limits us temporarily, but then soon vanish away. This morning I was in some sort of mindless daze going down the stairs in my socks and thought I was on the last stair for some reason and was suddenly shocked when the floor wasn't there and I fell to the concrete floor....yes, as I mention to patients all the time - it was an America's Funniest Home Videos moment! But, after lying there wondering if I'd fractured my foot… as the minutes passed the pain subsided and I, at some point, decided I was ok. Every time we get hurt we don't need to run to the Doctor, head to Urgent Care, or worse yet - the dreaded Hospital Emergency Room. The bumps and bruises and minor stresses of life are most often short-lived. Our bodies do have an incredible capacity to take stress and to heal. What a blessing! BUT, we have all had times that the recovery we expected doesn’t quite ever come. Lynn had that happen. At some point, after continuing to suffer and seeing her daily activity level steadily decline, she decided to do something about it. She actually first began noticing pain back around June of this year. Lynn was aware of Peak Performance PT because we had helped her mom after an injury a year or two ago. Lynn had heard about DIRECT ACCESS and decided she'd had enough with that darn shoulder and that it was time she be proactive about it. Good thing for her that she called. Lynn is almost a perfect "poster child" for DIRECT ACCESS. This law was enacted back in November of 2006. She's a great example of how this law benefits New Yorkers. Her problem wasn't a surgical one and wasn't going away on its own. So many injuries are like that aren’t they? They are "Physical Therapy problems"...something that non-operative approaches are often called for. Coming directly to Peak Performance ended up saving her time, saving her money, and let her "cut to the chase" in terms of starting her needed PT sooner. For Lynn it meant that her pain began finally reducing and she could get back to her day-to-day activities more comfortably and at a higher level. Direct Access allows you to see a PT for up to 10 visits or 30 days, whichever comes first. After that a physician must be involved in order for care to continue. For Lynn, even though she'd been having troubles for the past 4-5 months before calling us, it took only 2 sessions for her to feel and see a difference. And, she finished just before her allowed first 30 days were even up! It was smart thinking on her part to not let it continue to fester. There are absolutely cases of Adhesive Capsulitis (fancy name for the frozen shoulder that she had) that progressively worsen to the point of having major losses of motion. When allowed to go that far I guarantee a 30-day bout of PT won't do the trick. The GOOD NEWS is that when you do catch your problem early enough you can usually enjoy a quicker recovery! That means less suffering with pain, less time away from the things you enjoy, less time away from the things you need to do. And, in cases where we determine that further medical evaluation is needed right away, then we can help facilitate that for you - either by communicating with your primary care doctor or, if you prefer, by helping you find a specialist from the list of physicians we have worked with throughout the Greater Rochester area. As a matter of fact, I just had a nice gentleman in last week who looked like he needed to see a surgeon for a possible Rotator Cuff tear rather than start a prolonged PT series. Now he’s going to see a local surgeon for a consult. A PT friend of mine many years ago said this very wise thing: "There are patients in here right now who aren't going to get better with PT - they need surgery or something else. If we could find a way to know who they are let's get them on to that other thing (surgery, acupuncture, massage, etc.) now and not waste time.” There are patients in here who would probably get better without PT - if we can figure out who those people are we can help them with just a few exercises to address underlying limitations and get them out on their own quickly and not waste their time and money or ours. There are patients in here right now who absolutely need us and it's a huge benefit to them to be in Physical Therapy...AND, THERE ARE PEOPLE OUT THERE who aren't in Physical Therapy right now WHO NEED TO BE, WHO WILL ONLY BE HELPED BY PHYSICAL THERAPY. WE NEED TO FIND OUT WHO THOSE PEOPLE ARE AND HELP THEM GET THE CARE THEY NEED! Are you someone who has a pain or injury or an old problem that needs help but are just waiting for more time to see if it goes away? Or are you just hoping it’ll disappear somehow? Do you have a family member or friend in that situation? You should know that DIRECT ACCESS allows the great majority of you (most insurers honor the DIRECT ACCESS law and do pay for Direct Access PT) to easily get in for an evaluation and necessary non-operative Physical Therapy treatment without long waits and paying extra co-pays to other facilities or providers only to be sent to Physical Therapy a week or two down the road anyway. You can give us a call and usually get seen that same or the next day. Let us help you get back to Peak Performance! Lynn is certainly glad she didn't put things off longer! Here's her final comment... "I would recommend Peak Performance PT to anyone." Mike Napierala, PT, SCS, CSCS, FAFS