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ORIGINAL ARTICLE
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Effectiveness of Pune shoulder rehab protocol on patients with frozen shoulder


1 Professor, Dr. D.Y.Patil College of Physiotherapy, Dr. D.Y.Patil Vidyapeeth, Pune, India
2 Intern, Smt. Kashibai Navale College of Physiotherapy, Pune, India
3 Principal, Dr. D.Y.Patil College of Physiotherapy, Dr. D.Y.Patil Vidyapeeth, Pune, India

Date of Submission10-Mar-2020
Date of Decision11-Mar-2022
Date of Acceptance24-Mar-2022

Correspondence Address:
Seema Saini,
Dr. D. Y. Patil College of Physiotherapy, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_418_20

  Abstract 


Context: Frozen shoulder is a common condition which is seen in 2%–5% of the general population. It is a self-limiting condition which affects the range of motion of the patients in a capsular pattern. Aims: Although Pune Shoulder Rehabilitation Programme (PSRP) is being used for treating this condition still no study has been documented to find its efficacy as compared to conventional physiotherapy methods. Settings and Design: This was a quasi-experimental study and the study was done at Smt. Kashibai Navale General Hospital and Physiotherapy Outpatient Department, Pune. Institutional ethical clearance was taken on 7/8/2018 ref no. SKNCOPT/IEC/16/2018 before the commencement of this study. Subjects and Methods: Based on the study's inclusion criteria, 32 subjects were selected. The PSRP exercises were taught to each subject and given 10 repetitions with a hold of 10 s. For at least 45 min, each patient was treated. Patient's shoulder range of motion and visual analog scale were taken at the pretreatment, 2nd week, 4th week, and 6th week, respectively. Statistical Analysis Used: The data were analyzed using Primer software with a level of significance P < 0.05. Repeated measure ANOVA was used to compare the outcome measures within the group. Results: The findings showed that over the 6th-week protocol, statistically significant improvements were found in pain and shoulder range of motion. Conclusion: PSRP exercise protocol is effective in increasing the range of motion and decreasing the pain in the shoulder caused by frozen shoulder.

Keywords: Frozen shoulder, PSRP, range of motion, visual analog scale



How to cite this URL:
Saini S, Bhagat G, Palekar TJ. Effectiveness of Pune shoulder rehab protocol on patients with frozen shoulder. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=342627




  Introduction Top


Frozen shoulder is an extremely painful condition typically treated in primary care. It has a lengthy natural history typically resulting in resolution. Codman first coined the word “frozen shoulder” in 1934. He identified it as a painful condition of slow onset in the shoulder coupled with stiffness and sleeping discomfort on the affected side. Codman also described the pronounced decrease in forward elevation and outward rotation which are the disease's hallmarks.[1]

The etiology and pathology of frozen shoulder remain uncertain despite substantial scientific studies. The prevalence in the general population was estimated at approximately 2%–3% of adults. It normally develops between 40 and 70 years of age. This has been classically divided into phases of freezing – insidious onset of diffuse shoulder pain with increasing loss of movement, frozen – gradual pain subsidence, plateauing of stiffness with equally active and passive movement range, and thawing – gradual improvement of movement and symptom resurgence.[2],[3]

A primary or “true” frozen shoulder occurs when the cause or preexisting condition is not exogenous. It is manifested as a painful idiopathic shoulder with a reduced range of movement in which there is no systemic diagnosis, precipitating shoulder condition, or radiographic explanation.[3],[4]

The synchronized work of dynamic and static stabilizers depends on the normal kinematics of the glenohumeral joint. However, the preservation of the usual glenohumeral relationship still relies on ligament strengthening of the capsule and the connection of the rotator cuff system to the muscle tendons. Therefore, capsular stiffness and premature capsular tightening at the early stage of humeral motion can induce kinematic alteration at the scapulohumeral and scapulothoracic joint. However, little is known regarding an altering capsular mechanics present in idiopathic frozen shoulder.[5]

There is little evidence on the best type of nonoperative care in frozen shoulder management. Some studies have attempted to determine the most successful frozen shoulder care, but there is still a lot of controversy in the literature. There is currently no consensus on the standard management of this condition.[6],[7]

Pune Shoulder Rehabilitation Program (PSRP) is a new method which has been reformed in 2013. PSRP is essentially developed for shoulder rehabilitation. This is an exercise program which includes exercises with low resistance, high repetition performed in sub impingement region for strengthening of scapular and rotator cuff muscles.

Principle of PSRP based on to normalize scapular muscle strength, normalize scapula humeral rhythm, pain relief, rotator cuff muscle strengthening, restoration of range of motion (ROM), restoration of function, and maintaining posture and core.

In accordance with these guidelines, the purpose of this research was to examine the clinical effectiveness of PSRP in frozen shoulder care using established outcome measures to evaluate the effectiveness.


  Subjects and Methods Top


The study was conducted in the Department of Physiotherapy of Smt. Kashibai Navale Medical College and Hospital, Pune. Institutional ethical clearance was taken on August 7, 2018, ref no. SKNCOPT/IEC/16/2018 before the commencement of this study. Forty subjects were included in this study with a diagnosed frozen shoulder. All the patients were between ages 40 and 60 years. All the subjects were excluded who have a history of shoulder surgery or manipulation under anesthesia, any recent fractures, underlying diabetes, and neurological deficits affecting shoulder function during daily activities. After a written and informed consent, samples were collected and processed.

This study was divided into two phases. In phase I, a 2-week program was done under the strict supervision of physiotherapist. Exercises were given in the form of wall washing technique, scapular sets by holding arms in neutral position, and retracting both the shoulders. Rhomboids (with TheraBand) in standing with wrists and shoulder distance apart and elbow at 90°. Patient would retract the shoulders and did abduction with external rotation and held them there for a count of 10 with 10 repetitions. For supraspinatus, patient kept shoulder blades retracted and depressed. Shoulders must be in complete internal rotation for empty can. Patients held the TheraBand under the foot and lift the arm in 45° scaption position. This is done for 10 s with 10 repetitions. For infraspinatus, patient stood with the elbow flexed at 90° and TheraBand tied around the wrist. The other end of the TheraBand was tied around a fixed support at the elbow height. A small pillow or wedge was kept under the elbow to keep it in place. The exercising arm should be kept opposite to the fulcrum. The patient was then completely externally rotated the arm and maintained the body straight. It is done for 10 s and 10 repetitions

Core exercises were compulsory for every patient as it works on improving kinetic chain balance and proprioceptive ability of the body.

In phase II, the patients did the same exercises at home. This duration was 4 weeks. Shoulder ranges and Visual Analog Scale (VAS) were taken on pre, post 2 weeks, 4 weeks, and 6 weeks. The protocol was up to 45 min for each patient [Table 1] and [Figure 1].
Table 1: Shoulder Range of Motion Pre treatment and post 2nd week, 4th week and 6 weeks of treatment

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Figure 1: VAS pre and post 2nd week, 4th week and 6th week of treatment

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Outcome measures

VAS and universal full-circle goniometer for shoulder ROM of flexion, abduction, internal rotation, and external rotation.


  Results Top


The data were analyzed using Primer software with a level of significance P < 0.05. Repeated measure ANOVA was used to compare the outcome measures within the group.

In this study, we aimed at comparing the pre-and post-measurement of flexion, abduction, internal rotation, and external rotation and also the pain rate using VAS.

With concern to the ranges, there was a significant change seen in the flexion P < 0.002 and abduction ranges P < 0.01, internal rotation P < 0.000, and external rotation P < 0.05.

With concern to the VAS, there was a gradual decline seen in the pain in the shoulder over the 6-week program with P < 0.000.


  Discussion Top


In this study, a sample size of 40 was obtained, with both males and females as subjects from the age group of 40–60 years. The subjects' ranges were taken using a universal full-circle goniometer before the treatment and again at intervals of 2-week, 4-week, and 6-week posttreatment. It was seen that after 2 weeks, the pain gradually decreased as the patients continued with the treatment. Using the wall washing technique, the patients were trained to actively relax the upper trapezius muscle to restrict the scapula from elevating further.[8] This may be one more reason for the increase in pain during the 1st week of treatment. The decrease in pain may be credited to the increase in strength over the week. The decrease in pain may also be credited to the repetitions of the exercises daily along with an increase in blood flow to the area which would wash out the toxic chemicals that had collected in that area. The most painful exercise that was performed was the supraspinatus strengthening.[9] This may be caused because of the misalignment of the shoulder during the abduction. The patients would start every exercise with scapular retractions, which help in stabilizing the scapula to gain a near-normal movement. The continuous scapular sets got the patients habituated to the movement and the patients would subconsciously correct themselves while doing the movement.[10] The exercises help in activating the muscles which go into disuse due to inactivity. Comparing the flexion-abduction ranges to the rotational ranges, a noteworthy change was seen in the flexion-abduction ranges compared to the rotational ranges.[11] This maybe due to the exercises which did not focus much on the rotational component. The active scapular sets led to an improvement in the posture of the patients. They were also self-aware of any slight shoulder elevation that was happening while flexion or abduction because of the “wall wash” exercises that were crucial to increasing the ranges. “wall washing” helped in regaining the proprioception that was lost due to misalignment of the glenohumeral joint in frozen shoulder.[12] Due to the contracture of the capsule, the scapulohumeral rhythm gets disturbed. This leads to a further misalignment of the joint. However, the scapular sets help the scapula in regaining its initial position, thereby correcting the scapulohumeral rhythm to get a smooth movement.[11],[12]


  Conclusion Top


PSRP has a significant effect on increasing the ranges and decreasing the pain of the patients with frozen shoulder. This can be an effective way of treating frozen shoulder.

Acknowledgment

We thank Dr. Ashish Babhulkar (MBBS D. ORTHO) for all the essential support. We thank the Society of Indian Physiotherapists for publishing the abstract in their Journal of Society of Indian Physiotherapists (AB No 50: To find the effectiveness of Pune Shoulder Rehab Protocol (PSRP) on patients with frozen shoulder http://doi.org/10.18231/j.jsip. 2019.013).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005;331:1453-6.  Back to cited text no. 1
    
2.
Hanchard NC, Goodchild L, Thompson J, O'Brien T, Davison D, Richardson C. Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder: Quick reference summary. Physiotherapy 2012;98:117-20.  Back to cited text no. 2
    
3.
Lubiecki M, Carr A. Frozen shoulder: Past, present, and future. J Orthop Surg (Hong Kong) 2007;15:1-3.  Back to cited text no. 3
    
4.
Kelly IG. Frozen shoulder. In: Kelly IG, editor. The Practice of Shoulder Surgery. Oxford: Butterworth-Heinnemann; 1993. p. 196-205.  Back to cited text no. 4
    
5.
Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW. Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg Am. 2003;85-A:48–55.  Back to cited text no. 5
    
6.
Stam H. Frozen shoulder: a review of current concepts. Physiotherapy 1994;80:588-99.  Back to cited text no. 6
    
7.
Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003;2003:CD004258.  Back to cited text no. 7
    
8.
Sharaf AM, Ahmed TE, Abdel-Aziem AA. The efficacy of designed physical therapy program on frozen shoulder syndrome. J Am Sci 2013;9:1-6.  Back to cited text no. 8
    
9.
Balcı NC, Yuruk ZO, Zeybek A, Gulsen M, Tekindal MA. Acute effect of scapular proprioceptive neuromuscular facilitation (PNF) techniques and classic exercises in adhesive capsulitis: A randomized controlled trial. J Phys Ther Sci 2016;28:1219-27.  Back to cited text no. 9
    
10.
Kelley MJ, McClure PW, Leggin BG. Frozen shoulder: Evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther 2009;39:135-48.  Back to cited text no. 10
    
11.
Tamai K, Akutsu M, Yano Y. Primary frozen shoulder: Brief review of pathology and imaging abnormalities. J Orthop Sci 2014;19:1-5.  Back to cited text no. 11
    
12.
Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther 2007;37:88-99.  Back to cited text no. 12
    


    Figures

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    Tables

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