Frozen Shoulder, also known as Adhesive Capsulitis, is a common condition that can cause pain and limit the range of motion in the shoulder. Although the cause is unknown, it can affect anyone, particularly those who have diabetes, women more than men, people who are overweight, and those aged between 40 and 60. It often impacts the non-dominant shoulder and those who have sedentary jobs. This condition can cause significant disruption to a person's life and can also have psychological and emotional effects.

Causes

There is a suggestion that chronic inflammation, fibrosis, and shoulder capsule contracture can restrict movement in the shoulder. Clients usually experience gradual onset symptoms of stiffness, pain, and reduced external rotation by at least 50%. Psychological factors such as fear of pain, catastrophising, movement avoidance, and low self-efficacy may also play a role in decreased functional arm use.

Treatment

Research shows that a multi-modal approach to treatment, including exercise, is most effective when initiated early. Some of the treatments include manual and various therapies, heat, corticosteroid injection, supervised exercises, home exercises, and education.

Programming in Pilates

Although it may be difficult (or impossible) for teachers to address the shoulder joint directly, working on adjacent structures of the shoulder girdle such as the scapula and spine may be beneficial. Research has proposed treating Frozen Shoulder similarly to back pain, which involves staying active, moving as normally as possible, and reducing protective behaviours and fear related to movement. Education, home exercises, stretches, and strengthening can all be useful.

Tips for the Pilates teacher

Heat packs

Applying heat packs to the front and back of the shoulder in a supine position at the beginning of a session can be helpful. It helps by increasing the blood flow, stimulating a healing response, and relaxing the connective tissues, making it more pliable.

Identify Compensations

When working with clients with muscular imbalances or compensations, it's important to identify areas where they may be experiencing muscle tightening or engaging in protective or guarding behaviours. For example, a client may be shortening across their clavicles, leading to tightness in muscles such as the pectorals, anterior deltoids, or lattisimus dorsi.

Try: lying supine on a foam roller to passively lengthen the front of the shoulder and chest

Another example of compensation may be a scoliosis-type effect caused by leaning the trunk towards or away from the affected side when reaching overhead to increase reach.

Try: Strengthen and mobilising the spine symmetrically in all direction and planes of movement

Understanding the functional role of the scapulathoracic joint is also important. It's crucial to ensure that the scapula glides on the back of the chest wall in all directions, including inferiorly/superiorly, abducting/adding, and rotating upward/downward. Scapula rigidity is not the same as scapula dynamic stability.

When working with a client who may be experiencing pain or discomfort, it's important to find pain-free positions or provide support for the affected shoulder.

Supine can be a problem for the unsupported shoulder.

Try: placing a folded towel underneath the affected shoulder to help them let go of protective holding patterns

Sidelying on the shoulder can be painful.

Try: Positioning client on the end of the Cadillac, and assist them by lowering the arm over the edge and rest hand on the floor

Movement

It is important to focus on what the client can do, instead of what they cannot do. Depending on their current physical status, there are various strategies that can be implemented to aid in their recovery.

An example of a program may include (but not limited to):

Breathing Exercises

These include breathing exercises to increase mobility in the thorax and the facet joints of the thoracic spine, as well as breaking down traditional exercises into pre-Pilates skill competencies.

Exercise Breakdown and Pre-Pilates exercises

· Supine Arm Floats (in accessible ranges)

· Sidelying Arm Floats over small barrel

· Dart or Arrow

· Seated Shoulder Shrugs

· Low Bicep Curls

· Front support against the wall

· Many exercises can be achieved by simply crossing the arms over the chest.

Also consider:

It is also important to optimise any postural issues the client may have and think creatively about how to use springs to support the weight of the arm and provide both strength and passive range of motion to the arm.

When considering the hierarchy of muscular activation, it may be beneficial to start with isometric exercises such as pressing the arm into a doorway, which can be done regularly and given as a homework exercise to minimise atrophy or wasting of the shoulder muscles.

As the client progresses, low-loaded concentric muscular work can be added to build strength as tolerated, followed by eccentric loaded muscle work when appropriate. It is also important to study and review concepts of correct scapulohumeral rhythm and the maintenance of space between the acromioclavicular joint and the humerus (subacromial space) to ensure proper alignment and movement patterns are being utilised.

Finally, it is also 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.

In an upcoming issue, we will provide a case study on how you can work with a client with Frozen Shoulder.

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.

You can contact Donna at dandon3103@gmail.com

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References

Hollman L, et al (2018) Does Muscle Guarding Play a Role in Range of Motion Loss in Patients with Frozen Shoulder? Musculoskeletal Science and Practice.

Wong C, et al (2018) A Pragmatic regional interdependence approach to primary frozen shoulder: a retrospective case series. Journal of Manual & Manipulative Therapy. 26(2)

Minss L, et al (2019) Clinical Effectiveness of Non-Surgical Interventions for Primary Frozen Shoulder: A systematic Review. Journal Rehabilitation Medicine.

De Baets, et al (2020) Pain-related beliefs are associated with arm function in persons with frozen shoulder. Shoulder Elb. 0 (0):1-9

Mertens M, et al (2021) Exercise therapy is effective for improvement in range of motion, function and pain in patients with frozen shoulder: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation.

Getting to the bottom of a Frozen Shoulder