Frozen shoulder.
A frozen shoulder is a condition in which the shoulder becomes painful and mobility is greatly reduced. This is because the shoulder capsule becomes thickened and rigid due to what appears to be a long-term inflammatory process. To date, it is unclear what triggers this inflammatory process.
We distinguish two types of frozen shoulder. A primary frozen shoulder and a secondary frozen shoulder. In the primary frozen shoulder, we cannot find a clear cause for the onset of the symptoms. A secondary frozen shoulder occurs after trauma and/or surgery. Although we know what the underlying cause of a secondary frozen shoulder is, we still cannot predict which people will or will not develop a frozen shoulder. However, we do know some risk factors for the development of frozen shoulder. For example, we see this symptom occurring more often in people with diabetes or a thyroid gland that works too fast. Another important risk factor (for the secondary form) is a period of immobilization in a bandage or sling after, for example, a fracture and/or surgery. Furthermore, frozen shoulder occurs mainly between the ages of 40 and 65 and more often in women than in men. We see a frozen shoulder more often on the non-dominant side than on the dominant side. Also, in 17% of patients with a frozen shoulder, we see a frozen shoulder developing on the other arm within a 5-year period. It is "fortunately" very rare to get a frozen shoulder on the same arm twice.
Although a frozen shoulder can last a very long time, it is what we call a self-limiting disease. In other words, the symptoms will eventually go away. On average, a frozen shoulder lasts from 1 to 3 years. Of course, there are cases where recovery time is longer. On average, a frozen shoulder can last from one to three years. During this time, the shoulder goes through three phases. The freezing phase, Frozen phase and finally the thawing phase. But what do these phases really mean?
Phase 1: freezing phase
During this phase, pain will be prominent during both movement and rest. In addition, you will notice an increasing restriction of movement. The location of pain in a frozen shoulder can vary from person to person. Some people experience more pain around the shoulder, in others there is also radiation to the arm or neck/upper back region. You will notice that the stiffness in the shoulder increases over time. The freezing phase lasts on average a few weeks up to +-9 months. You might experience discomfort when dressing and undressing, driving a car or reaching far. It is good to keep moving during this phase. However, it is not recommended to force the shoulder. This can make the pain worse. A frozen shoulder is often not recognized until there is actually movement restriction. So it can sometimes take a while before the correct diagnosis can be made.
Optional exercises
- Pendulum
- Anteflexion with cane (or sliding across the table)
- Abduction with stick (or sliding across the table)
Phase 2: frozen phase
In the frozen phase, pain will fortunately fade more into the background. However, in this phase you will be bothered by the restriction of movement. This can make it very difficult to carry out daily activities such as dressing and undressing, driving a car and so on. This phase can last an average of 4 to 9 months. Fortunately, during this phase it is quite possible to start exercising with the shoulder. By getting started with exercise therapy, you can try to influence the mobility of the shoulder and steer the recovery in the right direction.
Optional exercises
- Exorotation with stick
- Extension with stick
- Pendulum
- Anteflexion with cane (or sliding across the table)
- Abduction with stick (or sliding across the table)
Phase 3: thawing phase
In the final phase of the frozen shoulder, the shoulder starts to thaw again, so to speak. The stiffness will slowly decrease over time and mobility will gradually increase. Also in this phase it is important to work with exercise therapy. This is to eventually regain the best possible shoulder function. Eventually, on average about 30% of people will be left with a slightly painful and/or slightly restricted shoulder. In many cases, this does not really affect daily function. The thawing phase can last as long as 4 to 12 months.
Optional exercises
- Exorotation weight
- Endorotation elastic
- Abduction weight
- Anteflexion elastic band
- Shoulderpress weight
Research
To determine whether a frozen shoulder is present, it is best to see a physical therapist. He or she will start with an intake interview to get a good idea of the symptoms. In addition, the mobility of the shoulder will be assessed to determine whether the symptoms fit the criteria of a frozen shoulder. We want to see that the overall range of motion (ROM) of the shoulder is reduced. A range of motion restriction of at least 25% with respect to the other arm must be measured in at least two directions of movement. In addition, the exorotation (outward rotation) from the anatomical position must be at least 50% limited compared to the other arm. Also, the limitation of movement should be present for at least 1 month and at an increasing rate. In addition to the physical examination, the physical therapist can use various questionnaires to get a picture of the mobility and function of the shoulder. These can also serve as an evaluation in the recovery process, to monitor the progress made.
Reimbursement for long-term physical therapy
A frozen shoulder is included in the chronic list of physical therapy. This means that these complaints are reimbursed from the 21st treatment from the basic insurance. The first 20 treatments are taken out of your supplementary package or you have to pay for them yourself. You do need a referral from the general practitioner for this arrangement. Often you will first see a physical therapist who will test your shoulder and possibly treat it several times. Should he or she find it necessary that you get a referral, he or she will contact your family doctor after which you can make an appointment yourself to possibly get the referral. From then on you will be entitled to this arrangement for one year.
Physical therapy for a frozen shoulder
As you already know, a frozen shoulder will eventually go away on its own. However, we know from science that physical therapy can be of great value in the recovery of a frozen shoulder. Thus, the physical therapist can inform and advise on the course of the frozen shoulder and the do's and don'ts associated with each phase of recovery. For example, we know that in the first phase it is strongly discouraged to work hard and endlessly on the shoulder. This causes more irritation of the shoulder capsule and therefore a significant increase in pain. In addition, there is literature describing that this could even prolong the first phase. Something that is certainly not desirable. In the first phase, the emphasis is mainly on limiting the motion restriction and pain as much as possible. Different treatment options can be used for this. To limit stiffness as much as possible, it is important to maintain the mobility as much as possible by means of appropriate exercises. In addition, a medication policy can be used in consultation with the general practitioner. A combination of pain killers and anti-inflammatory medication can relieve the pain in the first phase. An injection with corticosteroids is also sometimes chosen for this purpose. In addition, regular cooling of the shoulder is advised. This can be done in blocks of 10-15 minutes at a time, several times a day. Cooling may provide a pain-relieving effect. You can always discuss with your physical therapist which treatment options are helpful to employ in your situation.
In the frozen phase, it is important to start regaining mobility. The physical therapist can help with this by providing mobilization and exercises to do at home. You will assess together where the limits are at that moment and try to push them over time. In this phase it is not recommended to lift heavy and really try to move independently. If in the thawing phase the mobility slowly increases, it is important to start using it again.
You will work with your physical therapist toward optimal mobility and regaining strength. If the mobility is good enough, you can look together at what your ultimate goals in movement are and a personalized rehabilitation plan can be drawn up. It always remains to be seen at the end what the exact end result will be. As described earlier, some people are left with some residual pain or residual disability.
In the thawing phase, after a treatment or exercise session, there may be some after-reaction in the form of pain. Please know that this is normal and will decrease in intensity within 24 hours on average. Of course, the pain experienced should be acceptable.
An operative policy
An operative policy in frozen shoulder is quite rare. This is because (again) it is a self-limiting disease and waiting should give a good result. If after 1.5 to 2 years there is no prospect of recovery, surgery may be considered. The surgical technique that is then performed is called a capsular release. The shoulder capsule is loosened. Like any surgery, this operation carries risks. For example, poor healing may occur after surgery and there is always a risk of other postoperative complications. If recovery does occur but some residual restriction remains that you are not satisfied with, you may be able to consider hydrodilation. This is a treatment that can only be performed in the final stage of frozen shoulder. Here, under ultrasound guidance, a fluid is injected into the shoulder joint to stretch the shoulder capsule. This restores some mobility. For all options for a frozen shoulder, you can consult your physical therapist. He or she can advise you and, where necessary, consult with other health care providers. Thus, together we create the conditions for optimal recovery.
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