Ivan Ischenko and Christian Beregov
Background. Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity. Frozen shoulder is also known as adhesive capsulitis, however the evidence for capsular adhesions is refuted and arguably. Although used in the treatment of this condition, manipulation under anesthetic has been associated with joint damage and may be no more effective than exercise rehabilitation. Capsular release is another surgical procedure that is supported by expert opinion and published case series, but currently high quality research is not available. There is a wide range of other disciplines which use manual therapeutic methods to treat and manage pathology and dysfunction as a primary treatment method, however, the efficacy of osteopathic and manual therapeutic methods, alone or in combination is still remains unknown.
Methods. Thirty patients were randomly assigned to one of the three treatment modalities (n=10 in each group): mobilization treatment using the Maitland manual techniques (Group 1); a program of structural osteopathic treatment (Group 2); or a combination of both (Group 3). The age range was 35 to 55 years with 80% of female patients. The majority had a high risk of bias (80%). All patients had exercise rehabilitation for 12 weeks after 8 weeks of treatment with the active range of motion, stretching exercise program including rotator cuff muscles, rhomboids, levator scapulae and serratus anterior with an elastic band at least seven times a week for 10-15 min. All patients were tested with visual analog scale (VAS) for pain level (no pain (0-4 mm), mild pain (5-44 mm), moderate pain (45-74 mm), and severe pain (75-100 mm). Flexion, abduction, internal and external rotation strengths were measured with a manual muscle test. All patients were evaluated before, after therapy, and at the 12th week of the rehabilitation.
Results. On the basis of our study design, we are uncertain of the effect manual therapeutic and osteopathic methods when not delivered together with exercise rehabilitation. However, all groups experienced a significant decrease in pain and an increase in shoulder muscle strength and function by 8th weeks of treatment (p<0.05). There was no significant difference between Group 2 and Group 3 in terms of function (p>0.05). However, the greatest improvement in overall functionality was found in Group 3. For example, VAS in the manual therapy group was reduced from a pre-treatment mean (+/-SD) of 7.4 (+/-0.3) to a post-treatment mean of 3.4 (+/-1.6). In contrast, pain in the combination group was reduced from a pre-treatment mean of 7.3 (+/-1.4) to a post-treatment mean of 2.1 (+/-0.8). Groups 2 and 3 showed significantly greater improvements in the manual muscle test than Group 1. The patients treated with structural osteopathy combined with Maitland techniques also showed significant improvement in recovery much earlier in the following rehabilitation program.
Conclusion. Because of preliminary published evidences for many mobilization techniques, the Maitland technique of manual therapy (posterior, inferior and lateral glenohumeral mobilizations, inferior and lateral glenohumeral manipulations, scapulothoracic mobilization, acromioclavicular joint mobilization, injuring movement and overpressure), alone or in combination with exercises seem to be recommended at the moment. However, the much efficient structural osteopathic techniques (muscle tension, fascial adhesions methods, joint articulation, deep soft tissue techniques, myofascial release, trigger point therapy and counterstrain), combined with inferior and lateral glenohumeral manipulations and acromioclavicular joint mobilization have more beneficial effects in patients with adhesive capsulitis of the shoulder. Our findings may help inform practitioners who use conservative methods (e.g. non-operative orthopedics, osteopaths, physical therapists, and other manual therapists) regarding the levels of evidence for modalities used for common shoulder conditions. However, the substantial on-going research is required to better understand epidemiology, pathoaetiology, assessment, best management, health economics, patient satisfaction and if possible prevention of such devastating disease.
Prepared for submission.