Effectiveness of Hydroplasty and Therapeutic Exercise for Treatment of Frozen Shoulder

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1 Effectiveness of Hydroplasty and Therapeutic Exercise for Treatment of Frozen Shoulder Nancy Callinan, MA, OTR, CHT Scott McPherson, MD Susan Cleaveland, PT, CHT Debra Gardiner Voss, OTR, CHT Darcel Rainville, PTA ABSTRACT: The purpose of this retrospective review was to evaluate the effectiveness of a hydraulic distention technique (hydroplasty) combined with a therapy program for treatment of idiopathic frozen shoulder. Over a two-year period, 60 patients with idiopathic frozen shoulder were identified as having undergone the hydroplasty procedure and therapy protocol at the authors hand center. Distention of the glenohumeral joint was achieved by an injection of a 10-mL combination of bupivacaine (Marcaine), lidocaine (Xylocaine), and corticosteroid followed by injection of 30 ml of chilled sterile normal saline. Therapy was initiated immediately after the surgeon had completed the hydroplasty. The mean active range of motion improvement was as follows: flexion 288, abduction 428, internal rotation 228, and external rotation 268. There was no significant difference in outcomes between diabetics and nondiabetics or subjects with symptoms less than six months duration compared with subjects with symptom duration greater than six months. At discharge, only two (3%) of the subjects reported persistent pain during sleep. The hydroplasty procedure combined with a therapy program is a successful treatment for idiopathic frozen shoulder. J HAND THER. 2003;16: Nancy Tokar, OTR, CHT Frozen shoulder is an idiopathic condition in which the patient develops pain and contracture of the glenohumeral joint. Other terms used to describe this condition are periarthritis of the shoulder, checkrein shoulder, 1 retractile capsulitis, and, most commonly, adhesive capsulitis. Typically, patients with frozen shoulder have pain and progressive loss of motion of the glenohumeral joint with no identifiable cause. Frozen shoulder tends to occur in middle-aged adults between 40 and 70 years old with a mean age of 55 in men and 52 in women. 2 People with diabetes are approximately five times more likely to develop the condition than the general population. 3 Frozen shoulder usually presents unilaterally, and the incidence of subsequent involvement on the contralateral side is about 20%. 4 Neviaser 5 reported that in surgical exploration of 10 cases of frozen shoulder there were lower gleno- This article was presented at the 22nd Annual Meeting of the ASHT, September 16 19, Correspondence and reprint requests to Nancy Tokar, OTR, CHT,, 6490 Excelsior Boulevard, Suite E400, St. Louis Park, MN 55426; <tokarn@parknicollet.com>. humeral joint fluid volume, fewer redundant axillary folds, capsule thickening, and contraction with adherence to the humeral head. Neviaser 6 showed that arthrography confirms that joint volume capacity is reduced to less than 10 ml in persons with frozen shoulder. Microscopic studies of the periarticular tissue show fibrosis and fibroplasia, although there is no evidence of significant inflammatory reaction. 7 In frozen shoulder, the fibrous capsule, which is usually flexible, becomes rigid and shrunken due to the fibroblastic changes. This loss of capsular flexibility contributes to the capsular pattern of restriction described by Cyriax 8 with external rotation being most limited followed by abduction, then internal rotation. Frozen shoulder often is described as a selflimiting condition; however, few studies 9,10 have clearly shown the natural course of the condition. The clinical presentation of frozen shoulder usually is divided into three phases: the freezing stage, the frozen stage, and the thawing stage. During the freezing stage, which may last for several weeks, the patient reports an insidious onset of diffuse shoulder pain, difficulty lying on the affected side, and pro- July September

2 gressive loss of shoulder motion. Patients often identify increased pain at night. During the frozen stage, which may continue for months or years, pain symptoms are still present but less intense. Patients often describe pain as a dull, aching type of sensation. Loss of motion plateaus with passive motion equal to active motion. The thawing stage may last several weeks or several months. It is characterized by the gradual improvement of shoulder motion and the reduction of pain symptoms. A myriad of options have been reported to treat frozen shoulder, including passive stretching, 11 ultrasound, 12 local steroid injection, 13 intra-articular injection of sodium hyaluronate, 14 myofascial approach, 15 distention techniques, continuous passive motion (CPM), 21 serial splinting, 22 manipulation, arthroscopic surgery, 27,28 and open surgery. 29,30 There have been few well-controlled studies, however, and existing studies do not establish a superior treatment approach for frozen shoulder. In a long-term prospective study, Binder et al. 31 found no difference between groups when comparing treatments of intra-articular steroid injections with passive mobilization, ice, or no treatment. Rizk et al. 32 found that a protocol using transcutanous electrical nerve stimulation (TENS) combined with pulley traction was more beneficial than heat and exercise. Hazleman 33 found no difference between patients treated with corticosteroid injection; a therapy protocol that included pulleys, pendulum exercises, and diathermy; or manipulation under anesthesia. Sharma et al. 34 compared manipulation under general anesthesia with hydraulic distention in 32 patients. They recommended distention because it was easier to carry out and gave better results than manipulation. In two clinical case studies, McClure and Flowers 21,22 showed the benefit of splinting and CPM for treatment of limited shoulder mobility secondary to traumatic adhesive capsulitis. The use of low load prolonged stress through CPM, and splinting increased mobility more effectively than short-duration mobilization procedures. Fareed and Gallivan 16 described hydroplasty as the local injection of an anesthetic combined with hydraulic distention to stretch the capsule and release adhesions in patients with frozen shoulder. The local anesthetic with distention primes the capsule for progressive motion. It is similar to distention arthrography without the contrast material and the cost of the diagnostic evaluation. In their study, Fareed and Gallivan 16 reported elimination of pain, restoration of sleep, and improved mobility in 20 subjects after hydroplasty. This descriptive study is a retrospective review of our initial experience with the hydroplasty technique. The purpose of this study is to describe the outcomes of an interdisciplinary treatment program that combines hydroplasty and therapeutic exercise. Range of motion, pain affecting sleep, and cost of treatment were the outcomes measured. METHODS AND MATERIALS A total of 82 patients presented to our clinic with a diagnosis of adhesive capsulitis over a two-year period; of 82 patients, 62 underwent the hydroplasty procedure. Because of previous rotator cuff tears, two patients were excluded from the study. Our group represents only patients with primary idiopathic adhesive capsulitis who had undergone hydroplasty and the subsequent therapy protocol. Charts of these 60 patients were reviewed, representing patients with frozen shoulder who had undergone a hydroplasty procedure and completed the subsequent therapy protocol at our clinic over a two-year period. Retrospective review and data analysis included data from these 60 patients. Hydroplasty Procedure An orthopedic surgeon performed the hydroplasty procedure in an office setting with a therapist assisting. The injection site (anterior or posterior, depending on the surgeon s preference) was prepared with povidone-iodine (Betadine) and alcohol. The surgeon injected the tract of the injection site, including the skin and soft tissue over the capsule, with a combination of 5 ml of 2% lidocaine and 0.5% bupivacaine. An intra-articular injection was performed using a 10-mL syringe containing 4 ml of 0.5% bupivacaine, 4 ml of 2% lidocaine, and 2 ml of corticosteroid. If there was a concern of glucose control in the diabetic patient, the surgeon omitted the corticosteroid. Further capsular distention was performed with three separate 10 ml syringes containing chilled sterile, normal saline. Using three separate 10-mL syringes rather than one large syringe made injection easier. It was helpful to draw the bony landmarks. In the anterior approach, the patient sat or lay in the supine position. The surgeon entered the joint with a 22G 1.5-inch needle placed just lateral to the coracoid sliding medial to the humeral head. In the posterior approach, the patient lay on the noninvolved side. The soft spot typically used for arthroscopy, approximately 2 cm inferior and medial to the posterolateral acromion, was the entry point. A 20G spinal needle aimed at the corocoid penetrated the posterior capsule. Therapy The therapist completed a preprocedure evaluation and provided therapy immediately after the 220 JOURNAL OF HAND THERAPY

3 injection. The prehydroplasty evaluation included standard goniometric measurement of active range of motion (ROM) of the involved glenohumeral joint in flexion, abduction, and external and internal rotation with the patient supine. For external and internal rotation, the glenohumeral joint was at 458 abduction. The therapist asked the patient if pain of the involved shoulder limited sleep at each assessment point. Immediately after the hydroplasty procedure and at each subsequent visit, the treatment focused on techniques to decrease pain and promote stretch of the periarticular structures. These techniques included use of oscillations, distraction, and glides of the glenohumeral joint, after which the therapist performed passive stretch in all motions to end range as tolerated by the patient. On the day of the hydroplasty, the patient was taught a home exercise program of active range of motion (AROM) and active-assistive ROM exercises for the involved shoulder and was instructed to perform 10 repetitions six times daily. During therapy visits during the subsequent three to six weeks, the patient received the same treatment as previously described. Patients attended therapy for 60-minute appointments for the first five consecutive days. Appointments then were reduced to 30- minute sessions, three times per week up to six weeks depending on the patient s progress. Figure 1 outlines the therapy interventions and home exercise program for each week. Outcome Measures We used AROM to indicate improvement in function. The measurements for AROM of shoulder flexion, abduction, and external and internal rotation were recorded at three times: prehydroplasty, immediately posthydroplasty after the first therapy session, and at discharge from therapy. On the final visit, the therapist asked the patient if shoulder pain affected sleep. The cost of hydroplasty was determined by adding the surgeon s fee and the fee for therapy services for each patient from actual billing records. Statistical Analyses Paired t-tests were used to compare AROM prehydroplasty to posthydroplasty, posthydroplasty to discharge, and prehydroplasty to discharge. The first t-test showed the initial improvement from hydroplasty, the second showed the improvement derived from the addition of therapy, and the last showed total improvement from the protocol. Further data analysis using an independent t-test compared symptom duration categories (#6 months and >6 months). Another independent t-test compared diabetics and nondiabetics. RESULTS There were more women in the study than men: women, n = 33 (55%); men, n = 27 (45%). The mean age of participants was 52 years (range 35 to 75 years). One patient of the 60 was insured under worker s compensation. Symptom duration before hydroplasty ranged from 1 to 30 months with a mean of 8.1 months (SD = 5.57). A concomitant diagnosis of diabetes was present in 18 (30%) patients. Of the subjects, 49 (81.7%) had completed a course of therapy elsewhere before the hydroplasty procedure. During this study, subjects had an average of 11 therapy sessions (range 1 to 28, SD = 5.66). There was a significant increase immediately after hydroplasty in AROM for each of the four measures (Figure 2). The total increase resulting from hydroplasty and treatment (i.e., prehydroplasty to FIGURE 1. Hydroplasty therapy protocol. PROM, passive range of motion. July September

4 FIGURE 2. Comparison of AROM improvements: prehydroplasty (Pre), immediately posthydroplasty (Post), and total gains at time of discharge (D/C). discharge) were flexion +288, abduction +428, internal rotation +228, and external rotation +268 (Table 1). All differences were significant at p\ Roughly half of the total gain in ROM occurred on the first day immediately after the hydroplasty procedure and the initial therapy session. TABLE 1. Paired t-test Results Comparing Flexion, Abduction, and Internal and External Rotation with 1) Preprocedure Measurements (Pre) to Immediately Postprocedure Measurements (Post), 2) Preprocedure to Discharge (D/C), and 3) Postprocedure to Discharge Average Difference (SD) p Value Flexion 1. Pre to Post (15.71) Pre to D/C (16.06) Post to D/C (14.31) Abduction 1. Pre to Post (16.24) Pre to D/C (23.36) Post to D/C (22.51) Internal rotation 1. Pre to Post 8.30 (15.53) Pre to D/C (19.67) Post to D/C (20.99) External rotation 1. Pre to Post 9.70 (12.93) Pre to D/C (19.19) Post to D/C (17.96) In the second part of the outcome data analysis, groups were compared according to duration of symptoms and presence of diabetes. Although subjects who had symptoms for one to six months and subjects who had symptoms for more than six months showed remarkably similar total improvement by discharge, subjects with symptoms of longer duration gained significantly less ROM in internal rotation from the therapy phase of the protocol (Table 2). When we compared diabetics with nondiabetics with an independent t-test, we found significant differences between the two groups on only one measure (Table 3). Before hydroplasty, 46 (77%) subjects reported shoulder pain affecting sleep. At discharge, only two (3%) of the subjects reported persistent pain affecting sleep. There were no complications associated with the hydroplasty procedure or therapy for the 60 subjects in this study. The average cost of the therapy combined with the surgeon s fee for the hydroplasty injection was found to be less than 42% of the cost of manipulation with follow-up therapy and did not differ significantly for subjects with symptoms of longer duration or subjects who were diabetic (Tables 2 and 3). The cost of anesthesia and any hospitalization required for the manipulation are not included in the study and would create an additional expense for the manipulation. 222 JOURNAL OF HAND THERAPY

5 TABLE 2. Independent t-tests Comparing Results of Subjects with Symptoms Less than Six Months with Subjects with Duration of Symptoms Greater than 6 Months: 1) Preprocedure Measurements (Pre) to Immediately Postprocedure Measurements (Post), 2) Preprocedure Measurements to Discharge (D/C), and (3) Postprocedure to Discharge DISCUSSION 1 6 Months (n = 31) >6 Months (n = 29) p Value Age 53.9 (10.4) 51.0 (8.5) Cost (896.47) (547.84) Flexion 1. Pre to Post 11.0 (14.3) 13.9 (17.2) Pre to D/C 27.8 (16.8) 27.2 (15.5) Post to D/C 16.8 (13.1) 13.3 (15.5) Abduction 1. Pre to Post 19.0 (14.5) 20.9 (18.2) Pre to D/C 46.0 (21.1) 38.8 (25.4) Post to D/C 26.9 (17.6) 17.9 (26.3) Internal rotation 1. Pre to Post 6.1 (18.7) 11.2 (9.7) Pre to D/C 23.9 (18.7) 19.3 (20.8) Post to D/C 18.6 (21.4) 2.5 (16.9) * External rotation 1. Pre to Post 9.5 (13.7) 9.9 (12.4) Pre to D/C 27.1 (19.6) 24.1 (18.9) Post to D/C 17.6 (18.9) 14.2 (17.0) *p \ Studies of the natural history of frozen shoulder have suggested that it is a self-limiting condition 9,10,35 that may last one to three years with complete resolution or only mild symptoms persisting. The goal of treatment is to speed up this recovery and facilitate a more rapid return to function. Distention techniques to treat frozen shoulder have been reported in the past with favorable outcomes Our results combining hydroplasty and therapeutic exercise support these findings. Because this study is retrospective and provides no controls, it is impossible to know with any certainty that the apparent effectiveness of our approach is derived from the hydroplasty procedure, the postprocedure rehabilitation, or the combination of the two. Even if the benefits of the entire program were a combination, it is impossible to state which portion of the overall improvement came from each of the two interventions. We cannot state that because we found an initial postprocedure increase in AROM it is due primarily to the hydroplasty alone because postprocedure measurements include hydroplasty and the first therapy session. It may be that the subjects would have continued to progress after the hydroplasty without any formal therapy. Likewise, it may be that the subjects would have responded to therapy alone, without the hydroplasty, and gotten similar TABLE 3. Independent t-test Results Comparing Nondiabetic with Diabetic Subjects: 1) Preprocedure (Pre) to Immediately Posthydroplasty (Post), 2) Preprocedure to Discharge (D/C), and (3) Postprocedure to Discharge Nondiabetic (n = 42) Diabetic (n = 18) p Value Age 53.4 (9.7) 50.4 (9.3) Cost (799.97) (599.25) Flexion 1. Pre to Post 13.9 (18.4) 9.0 (4.8) Pre to D/C 29.8 (17.6) 22.3 (10.3) * 3. Post to D/C 15.9 (15.3) 13.3 (12.0) Abduction 1. Pre to Post 21.0 (18.0) 17.6 (11.3) Pre to D/C 45.0 (22.8) 36.6 (24.2) Post to D/C 24.1 (22.3) 19.0 (23.1) Internal rotation 1. Pre to Post 8.7 (17.3) 7.4 (10.6) Pre to D/C 21.1 (19.0) 23.1 (21.7) Post to D/C 11.5 (20.3) 12.8 (23.7) External rotation 1. Pre to Post 9.0 (14.7) 11.4 (7.4) Pre to D/C 27.3 (19.1) 21.8 (19.4) Post to D/C 18.3 (18.3) 10.4 (16.2) *p \ results. It was the surgeons and therapists clinical impression based on previous experience, however, that neither hydroplasty nor therapy was as effective when performed independently. To sort out this inherent limitation of this study due to its retrospective design, future prospective studies are planned to include controls. In our study, patients achieved significant increase in AROM and a decrease in pain affecting sleep. A limitation of any retrospective study is the difficulty in ensuring the consistency of treatment delivered. Although our posthydroplasty patients follow a standard course of treatment, the exact number of glides and oscillations performed on each joint was not recorded. In addition, the patients home exercise program was standard care by all therapists; however, patient compliance is unknown. Passive ROM measurements were not included because of the questionable reliability of these measurements as reported by Gajdosik and Bohannon. 36 Passive ROM measurements depend on the force applied, which can be difficult to reproduce in a controlled manner. The variability of passive ROM is often greater than that for AROM. Consequently the current study used only AROM measurements. Because 81.7% had completed a therapy program elsewhere before hydroplasty and had failed to achieve satisfactory outcome, it seems the addition of hydroplasty and the therapy protocol led to a significant improvement in outcome as identified by increased AROM and decreased pain. We are unable to conclude, however, whether these gains are due to capsular lengthening or pain relief. July September

6 CONCLUSIONS This retrospective study suggests that a hydroplasty procedure combined with a therapeutic exercise program is a safe and effective treatment for frozen shoulder. It has the advantage of being performed in a clinic setting, and it is cost-effective. REFERENCES 1. Quigley TB. Checkrein shoulder: a type of frozen shoulder : diagnosis and treatment by manipulation and ACTH or cortisone. Clin Orthop. 1982;164: Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin North Am. 1980;11: Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis. 1972;31: Lundberg BJ. The frozen shoulder. Acta Orthop Scand Suppl. 1969;119: Neviaser JS. Adhesive capsulitis of the shoulder: study of pathological findings in periarthritis of the shoulder. J Bone Joint Surg. 1945;27: Neviaser RJ. Arthrography of the shoulder joint: study of the findings in adhesive capsulitis of the shoulder. J Bone Joint Surg Am. 1962;44: Lundberg BJ. Glycosaminoglycans of the normal and frozen shoulder-joint capsule. Clin Orthop. 1970;69: Cyriax J. Textbook of Orthopedic Medicine. 7th ed. London: Bailliere Tindall, Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4: Gray RG. The natural history of idiopathic frozen shoulder. J Bone Joint Surg Br. 1978;60: Miller MD, Wirth MA, Rockwood LA Jr. Thawing the frozen shoulder: the patient patient. Orthopedics. 1996;19: Quin EH. Humeroscapular periarthritis: observations on the effect of x-ray therapy and ultrasonic therapy in cases of frozen shoulder. Ann Phys Med. 1969;8: Oldham R, Roy S. Management of painful shoulder. Lancet. 1976;8: Itokazu M, Matsunaga T. Clinical evaluation of high-molecular-weight sodium hyaluronate for the treatment of patients with periarthritis of the shoulder. Clin Ther. 1995;17: Travell JG, Simmons DG. Myofascial Pain and Dysfunction: Trigger Point Manual. Baltimore, Md.: Williams & Wilkins, 1983: Fareed DO, Gallivan WR Jr. Office management of frozen shoulder syndrome: treatment with hydraulic distention under local anesthesia. Clin Orthop. 1989;242: Mulcahy KA, Baxter AD, Oni OOA, Finlay D. The value of shoulder distention arthrography with intraarticular infection of steroid and local anesthetic: a follow-up study. Br J Radiol. 1994;67: Gilula LA, Schoenecker PL, Murghy WA. Shoulder arthrography as a treatment modality. AJR Am J Roentgenol. 1978; 131: Rizk TE, Gavant ML, Pinals RS. Treatment of adhesive capsulitis (frozen shoulder) with arthrographic capsular distention and rupture. Arch Phys Med Rehabil. 1994;75: Gavant ML, Rizk TE, Gold RE, Flick PA. Distension arthrography in the treatment of adhesive capsulitis of the shoulder. J Vasc Interv Rad. 1994;5: McClure PW, Flowers KR. Treatment of limited shoulder motion: a case study based on biomechanical considerations. Phys Ther. 1992;72: McClure PW, Flowers KR. Treatment of limited shoulder motion using an elevation splint. Phys Ther. 1992;72: Hill JJ Jr, Bogumill H. Manipulation in the treatment of frozen shoulder. Orthopedics. 1988;11: Weiser HI. Painful primary frozen shoulder mobilization under anesthesia. Arch Phys Med Rehabil. 1977;58: Thomas D, Williams RA, Smith DS. The frozen shoulder: a review of manipulative treatment. Rheumatol Rehabil. 1980; 19: Weber M, Prim J, Bugglin R, Michel BA, Gerber H. Long-term follow-up of patients with frozen shoulder after mobilization under anesthesia, with special reference to the rotator cuff. Clin Rheumatol. 1995;14: Ogilvie-Harris DJ, Wiley AM. Arthroscopic surgery of the shoulder: a general appraisal. J Bone Joint Surg Br. 1986;68: Pollock RG, Duralde XA, Flatow EL, Bigliani LU. The use of arthroscopy in the treatment of resistant frozen shoulder. Clin Orthop. 1994;304: Nobohara K, Sugiyama D, Ikeda H, Makiura M. Contracture of the shoulder. Clin Orthop. 1990;254: Ozaki J. Pathomechanics and operative management of chronic frozen shoulder. Ann Chir Gynaecol. 1996;58: Binder AI, Bulgen DY, Hazleman BL, et al. Frozen shoulder: a long-term prospective study. Ann Rheum Dis. 1984;43: Rizk TE, Christopher RP, Pinals RS, et al. Adhesive capsulitis (frozen shoulder): a new approach to its management. Arch Phys Med Rehabil. 1983;64: Hazleman BL. The painful stiff shoulder. Rheumatol Phys Med. 1972;11: Sharma RK, Bajekal RA, Bhan S. Frozen shoulder syndrome: a comparison of hydraulic distention and manipulation. Int Orthop. 1993;17: Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long-term follow up. J Bone Joint Surg Am. 1992;74: Gajdosik RL, Bohannon RW. Clinical measurement of range of motion: A review of goniometry emphasizing reliability and validity. Phys Ther. 1987;67: JOURNAL OF HAND THERAPY