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The Somatic Connection  |   January 2013
Frozen Shoulder Treatment—Different Strokes for Different Folks
Author Affiliations
  • Hollis H. King, DO, PhD
    University of Wisconsin School of Medicine and Public Health, Madison
Article Information
The Somatic Connection   |   January 2013
Frozen Shoulder Treatment—Different Strokes for Different Folks
The Journal of the American Osteopathic Association, January 2013, Vol. 113, 100-102. doi:10.7556/jaoa.2013.113.1.100
The Journal of the American Osteopathic Association, January 2013, Vol. 113, 100-102. doi:10.7556/jaoa.2013.113.1.100
Yang JI, Jan MH, Chang CW, Lin JJ. Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: a randomized control trial. Man Ther. 2012;17(1):47-52.  
Spencer techniques for the treatment of patients with shoulder somatic dysfunction have been applied in osteopathic medical practice for nearly 100 years,1 have clinical research to support their efficacy,2 and have been incorporated in sports medicine protocols.3 The application of Spencer techniques in the treatment of patients with frozen shoulder has been a mainstay of my clinical practice and that of every osteopathic physician with whom I have discussed such conditions. Other manual therapy professionals use similar techniques in their care of patients with frozen shoulder conditions. 
One group of physical therapists in Taipei City, Taiwan, used range of motion (ROM) and kinematic technology to evaluate the effectiveness of what they call “end-range mobilization/scapular mobilization treatment approach” (EMSMTA) in frozen shoulder syndrome (FSS) therapy. Previously, this research group established a system for determining degrees of FSS with the idea that certain treatment techniques would work better depending on the nature of the biomechanics of a frozen shoulder. 
Patients with FSS were recruited through a university hospital clinic. Inclusion criteria were at least 50% loss of passive ROM of the shoulder joint relative to the nonaffected side in at least 2 of 3 movement directions (forward flexion, abduction, or external rotation in 0° of abduction) and complaints of at least 3 months duration. Exclusion criteria included history of stroke with upper extremity involvement, diabetes mellitus, rheumatoid arthritis, rotator cuff tear, surgical stabilization of the shoulder, osteoporosis, or malignancies in the shoulder region. 
Patients were assigned according to ROM and kinematic analysis. To be considered for the study, patients had to demonstrate 8° of scapular posterior tipping, 97° of humeral elevation, and 39° of humeral external rotation during arm elevation. Patients who manifested these measurements were placed in the control group. Patients who were worse in any 1 of these dimensions were randomly assigned to a criteria-control group or the group that received the EMSMTA. The control group consisted of 10 patients, and the criteria-control group consisted of 12 patients who received the same standardized treatment approach. These patients received passive mid-range mobilization, flexion and abduction stretching techniques, physical modalities (ultrasound, shortwave diathermy, and/or electrotherapy), and active exercises. The 10 patients in the criteria-intervention group received the same therapies plus EMSMTA. The physical therapists applying the therapies all had at least 3 years of experience. 
Of special interest to those familiar with Spencer and myofascial release techniques, the study's end range mobilization technique's description appeared to be very similar to “traction with inferior glide” and “traction circumduction,”4 and the scapular mobilization technique was very similar to the “scapular myofascial release” described by DiGiovanna et al.5 However, in this study, unlike in osteopathic medical practice, which uses “continuous palpatory feedback” to guide the technique, the physical therapy application of both EMSMTA techniques used a predetermined number of repetitions and sets. 
All patients were treated twice per week for 3 months. The outcome measures were taken at baseline, 4 weeks, and 8 weeks. Outcome measures were ROM for arm elevation in frontal plane, hand-behind-back reach, humeral external rotation, humeral internal rotation; kinematic measurement of scapular posterior tipping, scapulohumeral rhythm, and scapular upward rotation; and a disability assessment using the FLEX-SF. 
The control group, which had the least amount of FSS, improved in almost all outcome measures. However, for the more severe FSS groups, there were significant differences between the criteria-control (standard care group) and the EMSMTA group. On the self-rated FLEX-SF, the EMSMTA group had significantly higher scores than both control groups (at 8 weeks). There were significant improvements for the EMSMTA group compared with the criteria-control group on hand-behind-back reach (at both 4 and 8 weeks) and external rotation (at both 4 and 8 weeks) ROM outcomes. The kinematic measure improvements were significant on scapular posterior tipping (at 8 weeks) and scapular upward rotation (at 8 weeks). 
The authors concluded that management of FSS should be preceded by the kind of assessment they used to determine the groups; in the more severe FSS cases, the EMSMTA techniques should be used. From my osteopathic perspective, the degree of FSS restricted movement and pain and thereby how much osteopathic manipulative treatment (OMT) is needed is readily discernible. This study was selected because it offers some confirmatory data relevant to the use of OMT and could be replicated readily using OMT. 
   “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of The Journal of the American Osteopathic Association (JAOA) strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.
 
   To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Associate Editor Michael A. Seffinger, DO (mseffinger@westernu.edu), or JAOA Editorial Advisory Board Member Hollis H. King, DO, PhD (hollis.king@fammed.wisc.edu).
 
References
Spencer H. Shoulder technique. J Am Osteopath Assoc. 1916;15:218-220.
Knebl JA, Shores JH, Gamber RG, Gray WT, Herron KM. Improving functional ability in the elderly via Spencer technique, an osteopathic manipulative treatment: a randomized, controlled trial. J Am Osteopath Assoc. 2002;102(7):387-396. [PubMed]
Heinking K, Brolinson PG, Goodwin TA. Large joint injury in an athlete. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2011:946-951.
Ehrenfeuchter WC. Soft tissue/articulatory approach. In: Chila AG, executive ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2011:781-782.
Dowling DJ, Scariati P. Myofascial release concepts. In: DiGiovanna EL, Schwiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:101.