Case reportChiropractic management of frozen shoulder syndrome using a novel technique: a retrospective case series of 50 patients
Introduction
Frozen shoulder syndrome (FSS) is a common condition presenting to a variety of health care practitioners including chiropractors, osteopaths, medical doctors, and physical therapists. Also referred to as adhesive capsulitis, FSS remains one of the most poorly understood shoulder conditions,1 with its etiology and pathogenesis largely disputed.2 Recently, a consensus definition of FSS was reached by the American Shoulder and Elbow Surgeons to be “a condition characterized by functional restriction of both active and passive shoulder motion for which radiographs of the glenohumeral joint are essentially unremarkable.…”1
The prevalence of FSS is thought to be 2% to 5% of the general population.2, 3 It occurs usually between 40 and 60 years of age,3 is 3 to 7 times more prevalent in women than men,4 and can be classified as either primary or secondary.1 A diagnosis of primary (or idiopathic) FSS is made if no causative factors are identified on history or examination.3 Secondary FSS is thought to develop following some trauma or systemic condition.1 For instance, there is a high comorbidity of FSS in patients with diabetes, with incidence rates nearing 40%.5 In addition, FSS is also commonly found in those with Parkinson disease, cardiovascular disease, thyroid disease, and stroke.6, 7
In the absence of other pathological processes, a diagnosis of FSS is made if the following criteria are present: an insidious onset, night pain, painful restriction of passive scapulohumeral elevation causing shoulder abduction of less than 100°, and shoulder external rotation of less than half of normal.3
The current medical paradigm divides the natural history of FSS into 3 stages (Fig 1): (1) the freezing stage, characterized by diffuse pain and loss of motion (2-9 months); (2) the frozen stage, where pain decreases and stiffness has maximized (4-12 months); and (3) the thawing stage, characterized by a gradual normalization of mobility and function (4-12 months).3, 8 Reeves,8 who first described the 3 stages of the condition, reported that FSS usually lasts from 1 to 3.5 years with a mean duration of 30 months. However, Shaffer et al reported that, after 7 years, 50% of the cohort they studied continued to have residual pain and/or loss of shoulder function.9
The underlying etiology of FSS is largely disputed; but it is commonly thought that its origins lie in biologic factors, mechanical stress, and/or neovascularization of the shoulder joint complex.3 However, it is hypothesized that the etiology of FSS is not as the current paradigm describes, but rather is neuromechanical in nature, originating in the cervical spine, cranium, occipitoatlantal joints, and/or cranial nerve 11 (CNXI) and causing malfunction of the trapezius muscle resulting in a breakdown of the entire dynamic shoulder complex.10 In fact, the literature well describes the most common symptoms of CNXI injury as (1) reduced shoulder abduction, (1) drooped shoulder (tie), and (3) shoulder pain,11 which are also common symptoms of FSS.1, 3 The inference that CNXI might be related to FSS is the next logical step.
Support for a chiropractic approach toward FSS is currently limited to a small pilot study12 and a number of case reports.13, 14 Common medical approaches toward intervention focus on addressing the medical etiology, namely, the shoulder joint complex. These include nonsteroidal anti-inflammatory drugs,3, 15 steroid injection,2, 15, 16 and shoulder surgery.2, 17 Interventions that physical therapists frequently use include moist heat, ultrasonography, passive stretching, and shoulder mobilization.18, 19, 20, 21 In addition, there is some evidence in the physical therapy literature to support manipulation of the cervical spine or cervicothoracic spine for shoulder complaints.22, 23, 24, 25, 26 Patients may experience resolution when treated by these various methods, but some may have residual pain and reduced shoulder function even several years after treatment.3 It is clear that a more durable intervention is needed.
The purpose of this article is to describe the outcomes of patients with FSS presenting to a private chiropractic practice that used a novel chiropractic treatment, the OTZ Tension Adjustment.
Section snippets
Case series
Case files of 50 consecutive patients presenting with medically diagnosed FSS between May 2007 and March 2008 were identified and reviewed retrospectively. Institutional Review Board approval was obtained for this retrospective case series (Parker University IRB Approval # R03_11).
The patients initially presented with active shoulder abduction restricted to 90° or less in the affected shoulder. Two primary outcomes were extracted from the patient records at 2 points in time, upon initial
Results
Of the 50 case files reviewed, 40% were male (n = 20) and 60% were female (n = 30); and all were between the ages of 40 and 70 years. The median number of days in the treatment program was 28 days, with a range of 11 to 51 days, and interquartile range (IQR) of 12.5 days. The median initial NPRS score was 9 out of 10 with a range of 7 to 10 and an ICQ of 1.0. The median final NPRS score was 2 with a range of 0 to 10. The median change in NPRS score was − 7 with a range of 0 to − 10. Of the 50
Discussion
Frozen shoulder syndrome is a common condition of insidious onset affecting middle-aged persons, yet its etiology is still unclear. The current medical approach is slow to show progress; and also, there is presently little evidence to support chiropractic management of this condition. The results of this case series are encouraging in that many of these patients’ complaints seemed to improve or resolve within 1 month of presentation, whereas, in general, it is thought that FSS symptoms can
Limitations and future research
Because there have been no studies yet published on this technique, a case series format was the logical place to start. As a result, the limitations of this study are those for any case series, such as that the management of these patients occurred within a private chiropractic practice, which was not controlled.37 Another limitation is the use of a measure that itself lacks evidence of validity. A more accepted measure of joint ROM would have strengthened our findings, as would the use of
Conclusion
This retrospective case series of the outcome of chiropractic treatment for patients with FSS using the OTZ Tension Adjustment for FSS was reported with encouraging preliminary results.
Funding sources and potential conflicts of interest
No funding sources were reported for this study. Francis Murphy and Louis D'Amico are principals and owners of OTZ Health Education Systems.
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