Using Pulsed Shortwave Diathermy and Joint Mobilizations to
Using Pulsed Shortwave Diathermy and Joint Mobilizations to Treat Shoulder Adhesive Capsulitis Herm CR*, Dewitt D, Gage MJ*: Liberty University School of Health Sciences; *Allied Health Professions Department; Athletic Training, † Department of Biology & Chemistry Abstract: An adult male, 51 -year-old, college professor complained of stiffness and pain within his left shoulder that increased over time. This patient presented with decreased range of motion with flexion, abduction, and external rotation, affecting his capability to perform activities of daily living. This patient had no prior history of shoulder injuries. Based on the evaluation of the patient’s history and symptoms, several pathologies were possible including osteoarthritis of the glenohumeral joint, rotator cuff or biceps tendinopathy. The patient’s family physician ordered no imaging but recommended physical therapy in an attempt to reduce signs and symptoms. The patient was evaluated by a certified athletic trainer and diagnosed with adhesive capsulitis. Adhesive capsulitis, more commonly known as frozen shoulder, is a condition that causes pain and pronounced stiffness within the shoulder joint. While this condition is becoming more common among the adult population, current treatment measures are poorly understood. Adhesive capsulits has previously required years of treatment and rehabilitation to resolve, and in some cases, the condition will never completely disappear. The aim of this case study was to investigate the effectiveness of a combination of pulsed shortwave diathermy followed by joint mobilizations and stretching. The goal was to determine if the chosen treatments could significantly shorten treatment duration for this condition and restore activities of daily living. A quicker recovery would allow adhesive capsulitis patients to obtain a better quality of life. After only six treatment sessions, this patient regained a considerable amount of range of motion and experienced significantly less pain. The effectiveness of this treatment can greatly impact the care provided to frozen shoulder patients by healthcare professionals. The outcome of this case study provides an alternative treatment protocol for adhesive capsulitis that appears to be more effective than traditional treatment techniques. Results and Conclusion Results: Significant improvements were observed in the patient’s active shoulder ROM (Charts 1 -3). Compared to the initial measurements, shoulder flexion improved by 20°, shoulder external rotation by 65°, and shoulder abduction by 50° (Table 1). By the final treatment, all degrees of motion were considerably greater than they were upon initial evaluation. It should be noted that the final measurement in shoulder flexion showed a decrease in motion. This could have been attributed to human error in measuring. Self-reported pain in the shoulder was significantly reduced to 0 -1/10 on the visual analog scale. Shoulder Flexion 160 140 120 100 80 60 40 20 0 10. 23. 2020 10. 28. 2020 11. 2. 2020 11. 7. 2020 11. 12. 2020 11. 17. 2020 11. 22. 2020 Based on the results of this case study, SWD and joint mobilization techniques were immensely effective in quickly treating adhesive capsulitis. These treatment methods were able to accomplish in six sessions what other treatment methods would take longer to accomplish. This case study demonstrates that adhesive capsulitis patients would benefit from using SWD and joint mobilizations as principal treatment methods. Other known treatment methods (oral medications, steroid and hydrodilation injections and rehabilitative exercises) should not be disregarded completely. It may be beneficial to use these additional treatment methods in combination with SWD and joint mobilization treatments. Further research should be conducted to discover the optimal treatment combinations for multiple patients with a frozen shoulder. Chart 1. Shoulder flexion measurements. Over the course of six treatment sessions, both SWD and joint mobilization techniques were used to improve motion at the GH joint. Shoulder flexion measurements were taken of the left shoulder and recorded after each treatment. Figure 1. Shortwave pulsed diathermy on the anterior shoulder Shoulder Abduction 160 140 120 Introduction 100 80 Adhesive capsulitis is a disorder that causes a gradual increase in pain and stiffness in the glenohumeral (GH) joint. Because of this, adhesive capsulitis will make simple activities of daily living (ADLs) much more difficult for patients whom are suffering from it. This disorder often presents itself in three stages: freezing (an increase in pain), frozen (a plateau in pain levels with an increase in stiffness), and thawing (slow improvement). Much of this injury is still unknown, however its incidence rate continues to increase. Current treatment for adhesive capsulitis is quite limited. Common means of conservative treatments for the condition include rehabilitative exercises, oral medications and steroid injections to relieve pain, and hydrodilation injections to improve range of motion (ROM) in the shoulder joint. Adhesive capsulitis is generally a selflimiting disease however, if conservative treatments fail to help a patient after three to six months, the patient may decide to treat the shoulder surgically. Operations that can treat adhesive capsulitis include manipulation under anesthesia and arthroscopic or open capsular release. While these several means of treatment seem to be effective in the majority of the population dealing with adhesive capsulitis, it can take up to three years to completely resolve, and 7%15% of patients may even have permanent damage caused by the condition. The purpose of this case study is to utilize both pulsed shortwave diathermy (SWD), a deep heating agent, and joint mobilizations, a method used to restore arthrokinematic motions in the joint, in the treatment of adhesive capsulitis, and determine their combined effectiveness as compared to other, more common means of treatment. In doing so, it is possible that these new techniques may be used to shorten time of recovery in patients dealing with this condition. This can allow affected patients to return to performing ADLs with much greater ease, which can, in turn, improve the overall quality of life of the patient. 60 40 20 0 10. 23. 2020 10. 28. 2020 11. 2. 2020 11. 7. 2020 11. 12. 2020 11. 17. 2020 The patient described these extreme improvements in his ability to perform ADLs, reporting, “I am now moving my arm in ways I haven’t in a long time. ” The patient was able to recognize improvements immediately after each treatment was performed. 11. 22. 2020 Conclusion: Adhesive capsulitis an increasingly common chronic injury of the upper extremity that effects an individual’s ability to perform ADLs. While much remains unknown about the injury, it is certain that adhesive capsulitis causes pain and immobility of the shoulder joint. While surgical treatment is an option, conservative treatment of a frozen shoulder is usually the preferred method to resolve the injury, however the treatment duration can last for years. Using SWD and joint mobilizations in combination as a treatment method has the potential to significantly decrease the duration of treatment and time to recovery, and allow the patient to experience vast improvements in the shoulder joint. Chart 2. Shoulder abduction measurements. Over the course of six treatment sessions, both SWD and joint mobilization techniques were used to improve motion at the GH joint. Shoulder abduction measurements were taken of the left shoulder and recorded after each treatment. Future Work Figure 2. Shortwave pulsed diathermy on the posterior shoulder 1. Perform a case series with the same research methods to get a better idea of how they effect larger groups of individuals. 2. Perform a research study on patients with adhesive Shoulder External Rotation 100 capsulitis using only diathermy and stretching as the 90 treatment method in order to determine if diathermy 80 is the most effective form of treatment. 3. Perform a research study on patients with adhesive 70 60 capsulitis using only joint mobilizations and 50 stretching as the treatment method in order to 40 determine if joint mobilizations are the most 30 effective form of treatment. 20 4. Perform a research study with similar treatment 10 0 10. 23. 2020 measures as this study and add already established 10. 28. 2020 11. 2. 2020 11. 7. 2020 11. 12. 2020 11. 17. 2020 11. 22. 2020 Chart 1. Shoulder external rotation measurements. Over the course of six treatment sessions, both SWD and joint mobilization techniques were used to improve motion at the GH joint. Shoulder external rotation measurements were taken of the left shoulder and recorded after each treatment measures to the protocol. 5. Determine if this form of treatment will be beneficial on other joints within the body. Methods Limited active and passive shoulder flexion, external rotation and abduction were observed during the initial evaluation. Initial range of motion measurements were taken using a goniometer for shoulder motion of both shoulders. The patient had a positive Apley’s Scratch test with inability to perform. Based on the initial evaluation by a physician and certified/licensed athletic trainer, the patient was diagnosed with adhesive capsulitis. The physician recommended traditional physical therapy. Initial treatment included the combined use of pulsed shortwave diathermy (SWD) and joint mobilizations. The SWD was placed on the posterior aspect of the shoulder for fifteen minutes. After the treatment was complete, lateral and upward rotation scapular joint mobilizations were performed. Anterior glenohumeral (GH) joint mobilizations were also performed on the patient’s affected shoulder. The SWD was then placed on the anterior shoulder for another fifteen minute treatment session prior to performing, posterior and inferior joint mobilizations of the GH joint. After this initial treatment on 10/28/2020, five additional treatments were performed over the course of twenty-one days. Data are reported in Table 1. Figure 3. Inferior joint mobilization technique References DATE: 10/28/2020 Flexion Abduction L R L R Average 120. 00 94. 67 55. 00 167. 33 X 21. 33 Difference 175. 00 X 88. 00 X DATE: 10/30/20 72. 67 No measurements taken 66. 67 DATE: 11/3/20 Flexion L Abduction Average 126. 67 R X Difference 6. 67 X L L 105. 00 R X L 45. 67 R X 10. 33 X 24. 33 X Abduction Average 139. 00 R X Difference 12. 33 X L 133. 33 R X L 63. 67 R X 28. 33 X 18. 00 X Abduction Average 147. 00 R X Difference 8. 00 X L 3. Cho CH, Bae KC, Kim DH. Treatment Strategy for Frozen Shoulder. Clin Orthop Surg. 2019; 11(3): 249 -257. doi: 10. 4055/cios. 2019. 11. 3. 249 External Rotation DATE: 11/16/2020 L 2. Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005; 331(7530): 1453 -1456. doi: 10. 1136/bmj. 331. 7530. 1453 External Rotation DATE: 11/11/20 Flexion 1. Chan HBY, Pua PY, How CH. Physical therapy in the management of frozen shoulder. Singapore Med J. 2017; 58(12): 685 -689. doi: 10. 11622/smedj. 2017107 Diathermy on anterior and posterior shoulder. Joints mobs- Lateral upward glide of scap. Anterior, posterior and inferior glide of GH Flexion Range of motion data were assessed prior to the start of each treatment. The treatment methods remained unchanged during the first three treatment sessions. Additional treatment techniques were added during the fourth treatment session. A downward rotation scapular joint mobilization was introduced to improve overall scapulothoracic rhythm. Stretching of the latissimus dorsi and pectoralis minor muscles were also introduced. The patient was encouraged to do passive T-bar range of motion exercises and latissimus dorsi stretching at home in addition to the treatment sessions. The patient was discharged on 11/18/2020. Prior to discharging, the patient was given strengthening exercises to begin. External Rotation 144. 3333333 R X L 84. 33 R X 11 X 20. 67 X 4. Robinson CM, Seah KTM, Chee YH, Hindle P, Murray IR. Frozen Shoulder. The Bone & Joint Journal. 2012; 94 -B(1). doi: 10. 1302/0301 -620 X. 94 B 1. 27093 5. Lewis J. Frozen shoulder contracture syndrome – Aetiology, diagnosis and management. Science. Direct. 2015; 20(1): 2 -9. doi: 10. 1016/j. math. 2014. 07. 006 DATE: 11/18/2020 Flexion L Abduction Average 140. 00 R X Difference -7 X L External Rotation 144. 67 R X L 86. 33 R X 0. 34 X 2. 00 X Table 1. Daily shoulder range of motion measurements. Each treatment session, measurements were recorded to determine changes in range of motion of the Glenohumeral joint of the patient’s left shoulder, affected by adhesive capsulitis. A baseline was taken on the first treatment day of the patient's uninjured shoulder, to have a measurement to compare the injured shoulder to. On 10/28/2020, no measurements were taken, however treatment was still performed. Dates of treatment were determined by the convenience of both the patient and the clinician. 6. Brun SP. Idiopathic frozen shoulder. Australian Journal of General Practice. 2019; 48(11). doi: 10. 31128/AJGP-07 -19 -4992 7. Goats GC. Continuous short-wave (radio-frequency) diathermy. Br J Sports Med. 1989; 23(2): 123 -127. doi: 10. 1136/bjsm. 23. 2. 123 8. Duzgun I, Turgut E, Eraslan L, Elbasan B, Oskay D, Atay OA. Which method for frozen shoulder mobilization: manual posterior capsule stretching or scapular mobilization? . J Musculoskelet Neuronal Interact. 2019; 19(3): 311 -316.
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