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Physio & Pain Relief Center- Dr.Javed Malik, CDC Medical Center, 8-2-D1, Umar Chowk, Township, Lahore 04238900939, Lahore (2026)

18/06/2023

Fibromyalgia Syndrome
is a disease characterized by chronic pain, stiffness, and tenderness of muscles, tendons, and joints, without detectable inflammation. Fibromyalgia does not cause body damage or deformity. Fatigue affects 90 percent of patients and sleep disorders are common. Fibromyalgia can be associated with other rheumatic conditions, and irritable bowel syndrome (IBS). There is no definitive medical test for the diagnosis of fibromyalgia and fibromyalgia symptoms can come and go over time. Diagnosis is made by eliminating other possible causes of the symptoms. It can take time to tease out which symptom is caused by what problem[1]. FMS is NOT just one condition; it's a complex syndrome involving many different factors that can severely impact and disrupt a person’s daily life.

Fibromyalgia Syndrome (FMS) is considered as a systemic problem involving biochemical, neuroendocrine, and physiologic abnormalities, leading to a disorder of pain processing and perception (i.e. allodynia, hyperalgesia). The symptoms associated with FMS may originate from primary or secondary/reactive causes. [2]

The most effective treatment is a combination of education, stress reduction, exercise, and medication.

Prevalence

FMS occurs in more than 6 million Americans, or 4% of the population, causing it to be the most common musculoskeletal disorder in the U.S. It affects mainly women (90%) more often than men. Symptoms typically present between the ages of 20-55 years, but individuals have been diagnosed as young as 6 years and as old as 85 years of age.

Pathophysiology

The pathogenesis of FMS is theorized to be a malfunctioning of the central nervous system (CNS), characterized by central sensitization, which is a heightened pain perception accompanied by ineffective pain inhibition and/or modulation. This increased response to peripheral stimuli causes hyperalgesia, allodynia, and referred pain across multiple spinal segments, resulting in chronic widespread pain and decreased tolerance to sensory input of the musculoskeletal system.

FMS systemically causes a dysregulation : : neurologic; immunologic; endocrinologic; and enteric organ systems

1. Autonomic Nervous System

The Autonomic Nervous System (ANS) is responsible for regulating the Sympathetic (“fight or flight”) and the Parasympathetic (“rest and digest”) responses. With FMS, patients experience a systemically heightened sympathetic (SNS) response with a diminished parasympathetic (PNS) modulation. Continuous over activation of the SNS results in increased heart rate, excessive gastric secretions and contractions, abnormalities of smooth muscle contraction throughout the digestive tract, rapid and shallow respiration, and vasoconstriction. This can lead to malnutrition due to absorption and digestion disruptions. Prolonged inhibition of PNS alters the neuroimmunoendocrine systems, directly affecting growth hormone secretion by the pituitary gland. This can result in nonrestorative sleep, pain, fatigue, and cognitive/mood symptoms.

2. Immune System

The immune response to infection, inflammation, and/or trauma is a release of cytokines for local healing, which trigger the CNS to release glial cells within the brain and spinal cord for healing support and pain response. With FMS, this auto-immune response is heightened, causing an excess of glia in the body which creates an exaggerated state of pain (chronic)

Causes

There are many hypotheses of how multiple factors play a role in the development of FMS. The exact etiology of FMS is still being researched; however, there are several potential causes and risk factors, listed below, that are currently associated with, or increase one’s risk for developing this condition.

Viral
Occupation, seasonal, environmental influences
Adverse childhood experiences (i.e. PTSD)
Psychological and cognitive/behavioral factors
Other conditions: RA, systemic lupus erythematosus, or AS
Current research remains inconclusive regarding the genetic or hereditary cause of SMS. A family history of FMS is a risk factor.

Muscle pain is characterized as the major symptom of FMS, often described by patients as “aching or burning” regardless of physical activity. Other symptoms or associated problems occur, with various reports of frequencies, that can also affect function. FMS may cause residual pain sensations at a lower intensity due to repetitive exposure to peripheral stimuli or activity, also known as the “Wind-up Response.”[3][2]Other symptoms include sleep disturbances, fatigue, and other cognitive and somatic symptoms. [4]

Symptoms are often exacerbated by:

Stress
Overloading physical activity
Overstretching
Damp or chilly weather
Heat exposure of humidity
Sudden change in barometric pressure
Trauma
Another illness
A recent study carried out by Sempere-Rubio et al found out that functional capacity, upper limb muscular strength, postural maintenance, pain threshold, and anxiety are important predictive factors of QoL in women with FM.

Aerobic and Resistance Exercise

According to the Ottawa Panel evidence-based clinical practice guidelines (2008), supervised light aerobic exercise and strength/resistance training is highly recommended for the management of patients with chronic pain, like those with FMS. It has been found to increase their capacity for activity while minimizing their symptoms associated with FMS. Specifically, aerobic activity has been shown to improve psychological symptoms associated with depression, cognitive decline, and sleep disturbances. Exercise also improves patient’s cellular metabolism and respiratory capacity, increases lean muscle mass and tone, and increases oxygen uptake within the body’s system(s), which ultimately minimizes their complaints of chronic pain and fatigue.[2][9]

Manual / Passive Therapy

Some studies support that TENS and joint mobilizations foster the reduction of pain as short-term relief in patients with FMS. Specifically, patients with chronic back pain due to FMS may benefit from spinal manipulations with limited evidence to support this modality. Moderate evidence shows that the use of passive STM is helpful with pain regulation. In addition, diffuse chronic pain presentations are less likely to be reliable for medical management with TENS compared to localized pain. Passive therapy should not be the foundation of FMS medical management due to the maladaptive illness beliefs and coping strategies for patients’ pain.

Manual lymph drainage therapy and connective tissue massage have also been studied in women with fibromyalgia. Researchers used the Fibromyalgia Impact Questionnaire and the Nottingham Health Profile to measure the impact of the treatment. Their research suggests that both manual lymph drainage therapy and connective tissue massage show improvements in both the FIQ and the Nottingham Health Profile. However, there were significantly greater improvements in the group that received manual lymph drainage therapy, suggesting that manual lymphatic drainage therapy may be preferred over connective tissue.

11/06/2023

What is Erb’s palsy?

Erb’s palsy is a nerve condition in the shoulder and arm that results in weakness or loss of muscle function. The brachial plexus is a group of five nerves that connect the spine to the arm and hand. These nerves allow your shoulder, arms and hands to feel and move. If these brachial plexus nerves don’t work well due to stretching or tearing, the condition is called a brachial plexus palsy. Erb's palsy is the most common type of brachial plexus palsy. It involves the upper nerves in the plexus. Palsy is another name for partial or complete loss of muscle function — muscle weakness or paralysis.

Erb’s palsy is also known as Erb-Duchenne paralysis.

What types of injuries are common with Erb’s palsy?

There are four types of brachial plexus injuries:

Avulsion is when the nerve rips away from the spine and is the most serious type of Erb's palsy.
Rupture is when the nerve is torn, but not from the spine.
Neuroma is when the nerve has torn and healed but has left scar tissue. The scarred tissue puts pressure on the injured nerve and prevents it from conducting signals to the muscles.
Neurapraxia is when the nerve is stretched but not torn. Neurapraxia is the most common type of brachial plexus injury.

Who does Erb’s palsy affect?

Newborns sometimes develop Erb’s palsy during a difficult vaginal childbirth, or even during a cesarean section. During delivery, your healthcare provider sometimes has to move your baby’s head to one side to make room for delivery of their shoulders. In some cases, the stretching of the nerves causes damage, possibly even tears. This type of Erb’s palsy is also called a brachial plexus birth palsy, obstetric brachial plexus palsy or brachial plexus birth injury.

Erb’s palsy can also happen to adults who have traumatic injuries.

How common is Erb’s palsy (brachial plexus birth palsy) in newborns?

Erb’s palsy occurs in 0.9 to 2.6 per 1,000 live births or nearly 12,000 cases per year. It's most common in larger infants who need to be pulled out during delivery because they’re stuck.

What are the signs and symptoms of Erb’s palsy?

Erb’s palsy affects the shoulder, arm and elbow. In general, your hand muscles aren’t affected, but your hands may experience tingling or numbness.

Signs and symptoms of Erb’s palsy include:

Paralysis or limpness of the shoulder, arm and elbow. You can’t lift your arm away from your body or bend your elbow.
Numbness or tingling in your arm or hand. These are also known as “burners and stingers.”
A hand position known as ‘the waiter’s tip’ position. The palm of your hand points toward the back, and the fingers curl.

What causes Erb’s palsy in newborns?

A newborn may develop Erb’s palsy during delivery. Sometimes, your healthcare provider has to shift your baby’s head to one side during birth to get their shoulders out. The brachial plexus nerves from the neck to the shoulder may stretch or even tear. A newborn can also develop Erb's palsy due to the way they were lying in the uterus during pregnancy and once labor begins.

What causes Erb’s palsy (brachial plexus injuries) in adults?

Traffic accidents, most often those involving motorcycles, are the most common cause of brachial plexus injuries in teenagers and adults. Other causes of these injuries include gunshot or knife wounds, industrial accidents, accidents related to contact sports like football, surgical complications or tumors. These types of injuries are more likely to happen to men.

How is Erb’s palsy diagnosed?

The diagnosis usually begins with a physical examination. Your healthcare provider might also order these tests:

EMG (electromyography). This test finds out how well muscles and nerves work.
Imaging tests. These tests take pictures of what’s happening inside your body. Your provider may order an MRI or a CT combined with myelogram. Your provider might also order an X-ray if there is any question about broken bones.

How is Erb’s palsy treated?

Treatment of Erb’s palsy depends partly on how severe the injury is. Some cases resolve by themselves within three to four months. But, most likely, your healthcare provider will suggest that you do exercises and physical therapy with your baby from about the age of three weeks.

The range-of-motion and stretching exercises will help prevent stiffness in your baby's arm, hand and wrist. You’ll want to avoid a joint contracture (permanent joint stiffness). Follow your provider’s instructions about how many times to do the movements each day.

Hydrotherapy combines exercise with water. The water provides support that makes exercise less painful.

Your provider might inject botulinum toxin (Botox®) to paralyze working muscles for a time to force weaker muscles to take over. They might also splint your baby’s hand to prevent it from curling inward and being rigid.

If the palsy hasn’t improved before your baby is 6 months old, your provider might recommend surgery, including:

Nerve repair. These surgeries include nerve grafts, nerve transfers, neurolysis and nerve decompression.
Muscle repair. This involves a muscle or tendon transfer to replace the damaged tissue with tissue from another place in the body.
It’s important to realize that any type of nerve repair and regrowth happens slowly — the results aren’t immediate.

Physiotherapy Management

During the first 6 months treatment is directed specifically at prevention of fixed deformities. Exercise therapy should be administered daily to maintain ROM and improve muscle strength. Parents must be taught to take an active role in maintaining ROM and keeping the functioning muscles fit. Exercises should include bimanual or bilateral motor planning activities.

Initial treatment in the first 1-2 weeks after birth will consist of

Careful handling is required and extremes of motion are to be avoided for the first 1 to 2 weeks to allow for the initial inflammatory response to the injury to calm.
Avoid picking a child up by the arm. or from under the armpit. This can compress or stretch the brachial plexus and cause further injury
Placing a child on their back or in side-lying, with affected limb up, to avoid compression of the injured limb
Place the affected arm into sleeves before the unaffected arm. This will help avoid extreme movement at the shoulder and will help make dressing quicker and easier.
A systematic review suggests physiotherapy interventions like constraint-induced movement therapy, kinesiotape, electrotherapy, virtual reality and use of splints or orthotics have positive outcomes for the affected upper limb functionality in obstetric brachial palsy from 0 to 10 years.

Activities and exercises to promote recovery of movement and muscle strength
Exercises to maintain range of movement in the joints to prevent stiffness and pain
Sensory stimulation to promote increased awareness of the arm
Provision of splints to prevent secondary complications and maximise function
Educating parents on appropriate handling and positioning of the child and home exercises to maximise the child’s potential for recovery
Constraint induced movement therapy may be useful
Electrical Stimulation may be beneficial
Referral to Occupational Therapy for assessment of function in day to day activities.
Home exercises:

Encourage parents to carry out specific exercises with their child 2-3 a day in the comfort of their own home - although the exercises can be carried out anywhere appropriate and comfortable. The Home Exercise Programme may focus on

Maintain movement at the joints – Ensuring that the joints of the affected limb, especially the shoulder, keep their full range of movement and avoid excessive shortening of the muscles, also called a contracture. This will include passive, assisted and active exercises.
Increasing the strength of muscles in the affected limb.
Increasing the child’s awareness of the arm through tactile touch and contact.
Teaching parents, carers and the child how to handle the affected limb and how to position it for both comforts, prevention of complications and practicality.
The use of Constraint-Induced Movement Therapy (CIMT) and bimanual/bilateral therapy are sometimes also considered by Physiotherapists.

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09/06/2023

Spondylolisthesis is a condition characterized by the displacement of one vertebra over the adjacent vertebra, typically in the lumbar spine (lower back). The term "spondylolisthesis" is derived from the Greek words "spondylos," meaning vertebra, and "olisthesis," meaning slippage. This condition can result in various symptoms and may require medical intervention depending on its severity.

There are several types of spondylolisthesis:

1. Congenital spondylolisthesis: This type occurs from birth due to a defect in the formation of the vertebrae.

2. Isthmic spondylolisthesis: This is the most common type and is caused by a stress fracture (spondylolysis) in the pars interarticularis, a small bony segment connecting the upper and lower parts of a vertebra.

3. Degenerative spondylolisthesis: This type develops as a result of age-related degeneration of the spinal structures, such as intervertebral discs and facet joints.

4. Traumatic spondylolisthesis: This occurs due to an acute fracture or injury to the spine.

5. Pathological spondylolisthesis: This type is caused by underlying medical conditions like tumors or bone diseases, which weaken the vertebrae.

The severity of spondylolisthesis is commonly graded on a scale from I to IV, based on the degree of slippage:

- Grade I: 0-25% slippage
- Grade II: 26-50% slippage
- Grade III: 51-75% slippage
- Grade IV: 76-100% slippage

Symptoms of spondylolisthesis can vary depending on the degree of slippage, the affected vertebrae, and the compression of spinal nerves. Common symptoms include lower back pain, muscle stiffness, leg pain or weakness (sciatica), and difficulty in walking or performing daily activities. In severe cases, it can lead to bowel or bladder dysfunction.

Diagnosis typically involves a combination of medical history, physical examination, and imaging tests such as X-rays, CT scans, or MRI scans. Treatment options for spondylolisthesis depend on the severity and symptoms and may include:

1. Non-surgical approaches:
- Rest, activity modification, and physical therapy to strengthen the core and back muscles.
- Pain management with medication, heat/cold therapy, or epidural steroid injections.

2. Surgical intervention:
- Surgery may be considered if non-surgical methods fail to provide relief or if there is severe slippage causing nerve compression or instability. Surgical options may include decompression of nerve roots, spinal fusion, or the use of spinal implants to stabilize the affected vertebrae.

It's essential to consult with a healthcare professional, such as an orthopedic surgeon or a spine specialist, for an accurate diagnosis and appropriate treatment plan tailored to an individual's specific condition and needs.

07/06/2023

Arthritis of the Knee

Arthritis is inflammation of one or more of your joints. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in the knee.
Knee arthritis can make it hard to do many everyday activities, such as walking or climbing stairs. It is a major cause of lost work time and a serious disability for many people.
The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms. While arthritis is mainly an adult disease, some forms affect children.
Although there is no cure for arthritis, there are many treatment options available to help manage pain and keep people staying active.

Description
The major types of arthritis that affect the knee are osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis.

Osteoarthritis

Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative, wear-and-tear type of arthritis that occurs most often in people 50 years of age and older, although it may occur in younger people, too.
In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone and produce painful bone spurs.
Osteoarthritis usually develops slowly, and the pain it causes worsens over time.

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body, including the knee joint. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.
In rheumatoid arthritis, the synovial membrane that covers the knee joint begins to swell. This results in knee pain and stiffness.
Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. The immune system damages normal tissue (such as cartilage and ligaments) and softens the bone.

Posttraumatic Arthritis

Posttraumatic arthritis is form of arthritis that develops after an injury to the knee. For example, a broken bone may damage the joint surface and lead to arthritis years after the injury. Meniscal tears and ligament injuries can cause instability and additional wear on the knee joint which, over time, can result in arthritis.

Symptoms
A knee joint affected by arthritis may be painful and inflamed. Generally, the pain develops gradually over time, although sudden onset is also possible. There are other symptoms, as well:
The joint may become stiff and swollen, making it difficult to bend and straighten the knee.
Pain and swelling may be worse in the morning, or after sitting or resting.
Vigorous activity may cause pain to flare up.
Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The knee may lock or stick during movement. It may creak, click, snap, or make a grinding noise (crepitus).
Pain may cause a feeling of weakness or buckling in the knee.
Many people with arthritis note increased joint pain with changes in the weather.

Physiotherapy Management

Exercise Bike.gif
Physiotherapy should be started with all patients with a diagnosis of OA

Pain is a common symptom that occurs at different intensities depending on the individual, it is not necessarily related to severity of OA progression

Exercise has been proven to be effective as pain management and also improves physical functioning in the short term.Exercises have to take place under the supervision of a physiotherapist initially and when properly instructed these exercises can be performed at home, though research has shown that group exercise combined with home exercise is more effective.

Role of Physiotherapy

Education

Understanding what OA is
Explaining pain
Explain long term management of OA
Educate regarding activity modification
Role of weight loss
Promote active, healthy lifestyle
Exercise

Reduces knee pain and inflammation.
Normalises knee joint range of motion.
Strengthens lower kinetic chain
Reduces risk of cardiovascular disease
Improves proprioception, agility and balance.
Promotes physical function
Land-based exercises are ideal for most people and are strongly recommended.Aquatic exercise, stationary cycling, and walking are safe and effective activities that do not cause undue stress on the knee joint.

Exercise has also been found to be beneficial for other co-morbidities and overall health. Walking, resistance training, cycling, yoga and Tai Chi are examples of such exercises. An individualised exercise program should be set by a physiotherapist initially, taking into account the patient's goals and hobbies to ensure long term exercise compliance.

Movement or physical activity is the best medicine for people suffering from knee osteoarthritis. Performing physical activity may not only improve your joint mobility, it can also improve your overall quality of life and can help reduce depression.[13] Individuals with knee OA commonly engage in strengthening their knee muscles, neglecting however hip muscle strengthening. On assessing patients with knee OA they would usually be presented with hip muscle weakness and are more prone to increase in medial compartment loading on the knee joint. Research has proven that patients with knee pain will benefit following hip strengthening exercises. Potential benefits includes quick pain relief and better hip strength. It is important to strengthen the hip in knee OA because hip strengthening exercises tend to improve the mechanics of your lower limb and reduce stress on the knee.

A new systematic review published in the journal Rheumatology Advances in Practice aiming to evaluate factors related to fatigue in individuals with hip and or knee OA found out that there is strong or moderate evidence that high numbers of co-morbidities or illness burden and modifiable factors, such as high depressive symptoms, low levels of self-reported physical function, high pain and low physical activity levels, are associated with greater fatigue, making these factors possible targets for fatigue reduction in hip and/or knee OA populations. The review showed there was moderate evidence of no association between sociodemographic factors (age, education, race, living situation or circumstances), BMI, radiographic OA severity and fatigue; and conflicting evidence for the association between poor performance-based physical function, high anxiety, high joint stiffness, poor sleep and low social support with higher fatigue

07/06/2023

Bell's Palsy is a neurological condition characterized by the sudden onset of facial muscle weakness or paralysis, typically affecting one side of the face. It is believed to be caused by inflammation or viral infection of the facial nerve, which controls the muscles of facial expression. While the exact cause is not fully understood, the condition often resolves on its own within a few weeks to months. However, rehabilitation can play a crucial role in aiding the recovery process and restoring facial function. In this note, we will explore Bell's Palsy and the various aspects of its rehabilitation.

Symptoms of Bell's Palsy: 1. Sudden weakness or paralysis on one side of the face. 2. Loss of control over facial muscles, resulting in drooping of the mouth or eyelid.

3. Inability to close one eye or blink properly. 4. Altered sense of taste.

5. Increased sensitivity to sound in one ear. 6. Pain or discomfort around the jaw or behind the ear on the affected side.

Rehabilitation Techniques: 1. Physical Therapy: Physical therapy techniques aim to improve muscle strength, coordination, and range of motion in the affected facial muscles. This may involve exercises such as facial massage, stretching, and resistance training. Therapists may also use techniques like electrical stimulation to stimulate the facial nerves and muscles.2. Facial Exercises: Specific exercises are designed to target the affected muscles and promote their recovery. These exercises often focus on facial symmetry, muscle control, and the ability to make various facial expressions. Regular and diligent practice of these exercises can aid in restoring facial muscle tone and coordination.

3. Massage and Mobilization: Gentle massage and mobilization techniques can help reduce muscle stiffness, increase blood flow, and alleviate pain. Therapists may use their hands or specialized tools to perform these techniques, enhancing circulation and promoting healing in the affected area.

4. Eye Care: Protecting the eye on the affected side is crucial, as the inability to blink properly can lead to dryness, irritation, and potential damage. Eye drops, ointments, or moisture chambers may be prescribed to keep the eye lubricated and prevent complications.

5. Biofeedback and Electrical Stimulation: Biofeedback techniques, such as electromyography (EMG), can be utilized to enhance muscle control and retraining. Electrical stimulation may also be employed to stimulate the facial nerves and muscles, aiding in their activation and promoting muscle.

05/06/2023

CP child rehab on treadmill

04/06/2023

Paralysed patients recovery by physio..

03/06/2023

What is frozen shoulder?

Frozen shoulder, also called adhesive capsulitis, is a painful condition in which the movement of the shoulder becomes limited.

Frozen shoulder occurs when the strong connective tissue surrounding the shoulder joint (called the shoulder joint capsule) become thick, stiff, and inflamed. (The joint capsule contains the ligaments that attach the top of the upper arm bone [humeral head] to the shoulder socket [glenoid], firmly holding the joint in place. This is more commonly known as the "ball and socket" joint.)

The condition is called "frozen" shoulder because the more pain that is felt, the less likely the shoulder will be used. Lack of use causes the shoulder capsule to thicken and becomes tight, making the shoulder even more difficult to move -- it is "frozen" in its position.

Who is at risk for developing frozen shoulder?

Age: Adults, most commonly between 40 and 60 years old.

Gender: More common in women than men.

Recent shoulder injury: Any shoulder injury or surgery that results in the need to keep the shoulder from moving (i.e., by using a shoulder brace, sling, shoulder wrap, etc.). Examples include a rotator cuff tear and fractures of the shoulder blade, collarbone or upper arm.

Diabetes: Between 10 and 20 percent of individuals with diabetes mellitus develop frozen shoulder.

Other health diseases and conditions: Includes stroke, hypothyroidism (underactive thyroid gland), hyperthyroidism (overactive thyroid gland), Parkinson’s disease and heart disease. Stroke is a risk factor for frozen shoulder because movement of an arm and shoulder may be limited. Why other diseases and conditions increase the risk of developing a frozen shoulder is not clear.

What are the signs and symptoms of frozen shoulder?

Symptoms of frozen shoulder are divided into three stages:

The "freezing" stage:
In this stage, the shoulder becomes stiff and is painful to move. The pain slowly increases. It may worsen at night. Inability to move the shoulder increases. This stage lasts 6 weeks to 9 months.
The "frozen" stage:
In this stage, pain may lessen, but the shoulder remains stiff. This makes it more difficult to complete daily tasks and activities. This stage lasts 2 to 6 months.
The "thawing" (recovery) stage:
In this stage, pain lessens, and ability to move the shoulder slowly improves. Full or near full recovery occurs as normal strength and motion return. The stage lasts 6 months to 2 years.

Freezing phase

Pain is often most severe during the freezing phase and patients in this phase would benefit from learning pain-relieving techniques. These exercises include gentle shoulder mobilisation exercises within the tolerated range (e.g. pendulum exercise, passive supine forward elevation, passive external rotation, and active assisted range of motion in extension, horizontal adduction, and internal rotation). A heat or ice pack can be applied as a modality to relieve pain before the start of these exercises. The application of moist heat in conjunction with stretching has been shown to improve muscle extensibility.(19) Certain patients might also find it useful to take analgesics before physical therapy.

Patients should begin with short-duration (1–5 seconds) range of motion exercises, which should be in a relatively pain-free range.(20) Fig. 2 shows three commonly performed stretching exercises that are particularly useful for patients in this painful stage. Pendulum exercises can be used in flexion or abduction or circular motion. Patients can also try pulley exercises, as tolerated, and neck or scapular muscle releases. It is important not to aggravate a frozen shoulder, as aggressive stretching beyond the pain threshold can result in inferior outcomes, particularly in the early phase of the condition.(21) There has also been evidence that patients should avoid a forward shoulder posture as it may cause a loss of glenohumeral flexion .

Frozen phase

Similar to the freezing phase, a heat or ice pack can be applied during the frozen phase to relieve pain before commencing exercises. Home exercises such as those in Fig. 2 can be continued within the tolerated limit. In particular, stretching exercises for the chest muscles and muscles at the back of the shoulder should be maintained. Rotation before elevation exercises, such as an external rotation stretch, are also recommended to avoid increasing pain and inflammation.(22) At this stage, strengthening exercises are added to maintain muscle strength. Isometric or static contractions are exercises that require no joint movement and can be done without worrying about increasing pain in the shoulder.

Fig. 3 shows strengthening exercises that can be performed at home. The scapular retraction exercises gently stretch the chest muscles and serve as basic strengthening for the scapular muscles. Isometric shoulder external rotation can also be used for flexion or abduction, within the available range, but care should still be taken to avoid introducing aggressive exercises, as overenthusiastic treatment could aggravate the capsular synovitis and subsequently cause pain.

Thawing phase

In the thawing phase, the patient experiences a gradual return of range of motion. It is crucial to get the shoulder back to normal as quickly as possible by regaining full movement and strength. Strengthening exercises are important, as the shoulder is considerably weakened after a few months of little movement. Compared to the frozen phase, the patient can perform more mobility exercises and stretches (e.g. Figs. Figs.22 & 3) with a longer holding duration, within tolerated boundaries. Strengthening exercises can also progress from isometric or static contractions, to exercises using a resistance band, and eventually to free weights or weight machines. Rotator cuff exercises, as well as posture exercises and exercises for the deltoid and chest muscles, can be included in the treatment as well.

Physio & Pain Relief Center- Dr.Javed Malik

18/06/2023

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