Case Study: Frozen Shoulder

Martha had been a long-term client of the Pilates studio attending semi-private/ individually programmed classes for approximately six to seven years. She was a recently retired pastry chef in her early 60s. Progressively over a period of weeks and months, we observed a gradual deterioration in her shoulder. She had begun to notice a deep ache in the shoulder when lying on her side sleeping and eventually came to interfere with her activities of daily living (ADL’s).

Observation and discussions during her sessions suggested that three key components of a Frozen Shoulder were evident i.e. pain, stiffness, and a loss of range of movement. It is not in the scope of the Pilates Teacher to diagnose pathology and therefore she was referred to her primary medical practitioner who referred her for an MRI. The imaging results indicated a thickening of the coracohumeral ligament and shoulder capsule along with inflammation. She was further referred to her physical therapist who diagnosed Frozen Shoulder, also known as Adhesive Capsulitis.

Martha was a bit reluctant to receive ongoing treatment by the physio and was keen to self-manage using modified Pilates protocols and home exercises. Her physical therapist was open to this treatment plan and continued a dialogue with the Pilates teacher for advice with ongoing management and problem-solving as required.

The programming consisted of the following:

Client Education:

·       Help the client understand the self-limiting nature of the condition, meaning they need to accept the natural healing process and that the body will resolve the issues in its own timeline.

·       Average timelines for healing to ensure realistic expectations by the client

·       Goals of programming including self-management strategies for home.

Agreed Client Goals

·       Maintain general health/wellbeing and optimal movement with a whole-body approach

·       Use self-massage (myofascial techniques) to enhance range of motion and pain control

·       Minimise atrophy and weakness in the shoulder and supporting structures

·       Optimise movement strategies and identify any unhelpful compensatory patterns of movement.

In the Pilates studio

·       The client attended two private sessions to provide education, discuss reasonable expectations and agree to an approach in the Pilates studio and home exercises

·       They returned to a semi-private class format once per week (her usual pattern of attendance)

·       Each class began with a “check-in” on her experience of the past week, how ADLs continued to be affected, and any compliance issues with homework

·       Progressively over time, we reduced the amount of discussion about pathology. In my opinion if we allow the client to continue to focus on the pathology it will have a negative affect psychologically and can increase healing time.

Program

·       Heat pack was applied to the front and back of shoulder for five minutes at the beginning and end of her class

·       Using a small ball, self-massage was applied at the front of the shoulder/chest and around scapula/thoracic spine against a wall

·       Her pre-diagnosis program was maintained as much as possible. It was important that she didn’t feel ‘broken’

·       A few minutes each class with a focus on breath work was helpful for thoracic mobility and as a relaxation technique

·       Her teachers were observant of any para-language i.e. body language or unspoken cues that she may not be comfortable with and made modifications where necessary.

Modifications in this case included:

·       Any Mat work was delivered on the Cadillac to minimise getting her up and down on the floor

·       Supine – padding under the affected shoulder. This supported her shoulder joint in a slightly anterior position but allowed Martha to continue supine exercises with less pain and discomfort. Over the duration, the amount of padding and the frequency of use was decreased.  At times when the shoulder was particularly problematic, she self-supported with her non-affected arm across her torso

·       Closed chain exercises such as four point kneeling/quadruped exercises were moved to a standing position against the wall but this was not always necessary

·       Sidelying Mat work exercises were taught on the Cadillac using the box at the short end to support the head and allow the affected arm to be supported and positioned off the end

·       Reformer – supine abdominal work was possible by removing the straps from the hands and using a dowel in both hands. On good days she was able to apply a slight isometric abduction /adduction/ rotational force to activate some musculature around the shoulder

·       The number of repetitions and rest periods needed to be modified depending on the day.

Home Exercises

·       Self-massage, scapula mobilisation (shrugs/shoulder circles, etc.), isometric shoulder exercises and a variety of stretches were suggested several times during the week

·       She was advised to ‘listen to the body’ but move as normally as possible, whenever possible.

For Martha, her journey back to almost full function was approximately 10-12 months. Although there remains a small deficit in the range of motion when compared to the non-affected side, she has returned to all ADL’s with minimal and infrequent periods of discomfort.

A list of all possible exercises that can be prescribed for clients with Frozen Shoulder would be almost without limit. Most importantly, it is helpful to have a supportive network of mentors or other physical therapy practitioners to provide sound advice on restorative movement programming according to current best practice.

Donna has been a Pilates teacher for almost 30 years. She is an Exercise Physiologist and has consulted with industry bodies (APMA/PAA) and presented both in Australia and internationally. She continues to advocate for the Pilates Method as a stand-alone profession and believes in the further education of Pilates professionals to further aid the future growth of the Pilates profession.