Frozen shoulder is an extremely painful and debilitating condition leading to stiffness and disability. It typically occurs in the fifth and sixth decades of life, thus affecting individuals of working age. The disability resulting from this condition has a considerable economic impact on affected individuals and society.
Frozen shoulder can be either primary (idiopathic) or secondary. Secondary frozen shoulder is defined as that associated with trauma; rotator cuff disease and impingement; cardiovascular disease; hemiparesis; or diabetes (although some classify this in diabetics as primary frozen shoulder). The incidence of frozen shoulder in people with diabetes is reported to be 10% to 36%, and these tend not to respond as well to treatment as in nondiabetics.1
Adhesive capsulitis (also known as frozen shoulder) is a painful and disabling disorder of unclear cause in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain. Pain is usually constant, worse at night, and with cold weather. Certain movements or bumps can provoke episodes of tremendous pain and cramping. The condition is thought to be caused by injury or trauma to the area and may have an autoimmune component.
Frozen shoulder, also known as adhesive capsulitis, is a common condition in which the articular shoulder capsule (a sac of ligaments surrounding the joint) swells and stiffens, restricting its mobility. It typically affects only one shoulder, but one in five cases affect both.
Stage of Frozen Shoulder
The normal course of a frozen shoulder has been described as having three stages
Clinical Stages
Painful
Gradual onset of diffuse pain (6 wks to 9 mos)
Stiff
Decreased ROM affecting activities of daily living (4 to 9 mos or more)
Thawing
Gradual return of motion (5 to 26 mos)
Arthroscopic Stages
Stage 1
Patchy, fibrinous synovitis
Stage 2
Capsular contraction and fibrinous adhesions
Stage 3
Increasing contraction, synovitis resolving
Stage 4
Severe contraction
Three phases of clinical presentation
Painful freezing phase
Duration 10-36 weeks. Pain and stiffness around the shoulder with no history of injury. A nagging constant pain is worse at night, with little response to non-steroidal anti-inflammatory drugs
Adhesive phase
Occurs at 4-12 months. The pain gradually subsides but stiffness remains. Pain is apparent only at the extremes of movement. Gross reduction of glenohumeral movements, with near total obliteration of external rotation
Resolution phase
Takes 12-42 months. Follows the adhesive phase with spontaneous improvement in the range of movement. Mean duration from onset of frozen shoulder to the greatest resolution is over 30 months
Anatomy of Frozen Shoulder
The term “frozen shoulder” is often used incorrectly for arthritis, even though the two conditions are unrelated. Frozen shoulder refers specifically to the shoulder joint, while arthritis may refer to other/multiple joints.
The shoulder has a spheroidal joint (ball – and – socket joint), in which the round part of one bone fits into the concavity of another. The proximal humerus (round head of the upper arm bone) fits into the socket of the scapula (shoulder blade). Frozen shoulder is thought to cause the formation of scar tissue in the shoulder, which makes the shoulder joint’s capsule (not to be confused with the rotator cuff) thicken and tighten, leaving less room for movement.
The humerus is the upper arm bone. This is the “ball” of the shoulder’s “ball and socket” joint. The scapula is the flat, triangular bone commonly called the shoulder blade. Prominent areas of the scapula serve as attachment points for many muscles and ligaments.
The glenoid is the shallow “socket” on the side of the scapula that receives the ‘ball’ of the humerus. Together they form the “ball and socket” arrangement of the shoulder.
The scapular spine is a horizontal ridge along the back of the scapula that divides the scapula into upper and lower regions.
The acromion is the end of the scapular spine. It projects up to form the top of the shoulder.
The coracoid process is a projection towards the front of the scapula and is an attachment site for several muscles and ligaments.
The clavicle is the collarbone. Although it appears to be straight, it actually forms an S-shape when seen from above.
The thorax or rib cage is an anchor for several muscles and ligaments. Although the ribs do not physically attach to the scapula, the thorax stabilizes and maintains proper positioning of the scapula so that the arm can function to its fullest capacity.
The modern English words “adhesive capsulitis” are derived from the Latin words adhaerens meaning “sticking to” and capsule meaning “little container” and the Greek word itis meaning “inflammation”.
Additionally, there are four bone junctions or joints:
The glenohumeral joint is the main joint of the shoulder. Here, the glenoid on the scapula and the head of the humerus come together. The fairly flat socket of the glenoid surrounds only 20% – 30% of the humeral head. Because of its poor fit, this joint relies heavily on the surrounding soft tissue for support. The labrum, a ring of fibrocartilage tissue, attaches to the glenoid and deepens the socket to encircle more of the humerus.
The acromioclavicular joint, or AC joint, is the bony point on the top of the shoulder. It stabilizes the scapula to the chest, by connecting the acromion on the scapula to the clavicle, or “collarbone”. A thick disk of fibrocartilage acts as a shock absorber between the two bones. The surrounding capsule and ligaments give this joint great stability.
The sternoclavicular joint, or SC joint, connects the other end of the clavicle to the sternum, or “breastbone”. Like the AC joint, this joint contains a fibrocartilage disk that helps the bones achieve a better fit. It also gets excellent support from its joint capsule and surrounding ligaments.
The scapulothoracic articulation is the area where the scapula, embedded in muscle, glides over the thoracic rib cage. The surrounding muscles and ligaments keep the scapula properly positioned so that the arm can move correctly.
Cartilage
There are two types of cartilage in the shoulder
Articular cartilage is the shiny white coating that covers the end of the humeral head and lines the inside surface of the glenoid. It has two purposes:
To provide a smooth, slick surface for easy movement
To be a shock absorber and protect the underlying bone
Fibrocartilage – is the thick tissue that forms the disks of the AC and SC joints and the labrum, the ring that deepens the glenoid. Fibrocartilage has three roles:
To act as a cushion in shock absorption
To help stabilize the joint by improving the fit of the bones
To act as a spacer and improve contact between the articular cartilage surfaces
Ligaments
The shoulder relies heavily on ligaments for support. Ligaments attach bone to bone and provide the “static” stability in a joint. Ligaments will alternately become tight and loose with normal motion. They keep the joint within the normal limits of movement.
The glenohumeral ligaments attach in layers from the glenoid labrum to form the joint capsule around the head of the humerus.
The coracoacromial arch is the group of ligaments that spans the bony projections of the coracoid process and the acromion.
The coracoclavicular ligaments and the acromioclavicular ligament provide most of the support for the AC joint.
Muscles and Tendons
Muscles and tendons work together in the shoulder to provide the “dynamic” stability of the shoulder.
There are four muscle groups in the shoulder:
The rotator cuff muscles are the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. They are the primary stabilizers that hold the “ball” of the humerus to the glenoid “socket”. The socket is too shallow to offer much security for the humerus. These four muscles form a “cuff” around the humeral head, securing it firmly in the socket. As its name implies, this group of muscles also rotates the arm. The rotator cuff protects the glenohumeral joint from dislocation, allowing the large muscles that control the shoulder to power the arm with great mobility.
The biceps tendon complex also helps keep the humeral head in the glenoid and helps raise the arm.
The scapulothoracic muscles attach the scapula to the thorax. Their main function is to stabilize the scapula to allow for proper shoulder motion.
The superficial muscles of the shoulder are the large, powerful outer layer of muscles that are important to the overall function of the shoulder. This group includes the deltoid muscle, which covers the rotator cuff muscles.
Causes of Frozen Shoulder
Age & Gender – Frozen shoulder most commonly affects patients between the ages of 40 to 60 years old. It is twice more common in women than in men.
Endocrine (Hormonal) Disorders – Patients with diabetes are at particular risk for developing frozen shoulder. People with other endocrine abnormalities, such as thyroid problems, may also be predisposed to developing frozen shoulder.
Shoulder Trauma or Surgery – Patients who sustain a shoulder injury, or undergo shoulder surgery or vaccinations in the shoulder muscle can develop frozen shoulder. When injury or surgery is followed by prolonged joint immobilization such as putting the shoulder in a sling, the risk of developing frozen shoulder is highest.
Other Systemic Conditions – Several systemic conditions such as heart disease and Parkinson’s disease have also been associated with an increased risk of developing frozen shoulder.
Psychosomatic overlay – It is also hypothesized that some patients also develop frozen shoulder due to severe stress causing a psychosomatic reaction, especially if they feel emotionally restricted and pressured or “frozen” in the decision-making process.
The cause of frozen shoulder is not fully understood and in some cases is unidentifiable. However, most people with frozen shoulder have suffered from immobility as a result of a recent injury or fracture. The condition is common in people with diabetes.
Common risk factors for frozen shoulder are
You’re more likely to suffer from frozen shoulder if you’re female and over 40 years of age.
Age – being over 40 years of age.
Gender – 70% of people with frozen shoulder are women.
Recent surgery or arm fracture – immobility of recovery may cause the shoulder capsule to stiffen.
Diabetes – two to four times more likely to develop frozen shoulder for unknown reasons; symptoms may be more severe.
Having suffered a stroke.
Hyperthyroidism (overactive thyroid).
Hypothyroidism (underactive thyroid).
Cardiovascular disease (heart disease).
Parkinson’s disease.
Symptoms of Frozen Shoulder
Early symptoms of frozen shoulder
A feeling of pain and tightness in the shoulder area.
A feeling of tightness especially when putting the arm up and back, as you would do if you were throwing a ball overarm.
Pain on the back of the wrist. (This specifically relates to frozen shoulder caused by subscapularis trigger points.)
Dull, aching Pain
Sleep disturbance and deprivation
Severe sharp pain with rapid movement (eg. trying to catch mobile phone)
The difficulty with activities of daily living (eg. dressing, driving and personal care)
Lack of movement in all directions
As time goes on, the symptoms will worsen although the pain may be reduced.
The typical symptoms are a pain, stiffness, and limitation in the range of movement of one of your shoulders. The symptoms typically have three phases
Phase one – the ‘freezing’, painful phase. This typically lasts 2-9 months. The first symptom is usually a pain. Stiffness and limitation in movement then also gradually build up. The pain is typically worse at night and when you lie on your affected side.
Phase two – the ‘frozen’, stiff (or adhesive) phase. This typically lasts 4-12 months. The pain gradually eases but stiffness and limitation in movement remain and can become worse. All movements of your shoulder are affected. However, the movement most severely affected is usually a rotation of the arm outwards. The muscles around the shoulder may waste a bit as they are not used.
Phase three – the ‘thawing’, recovery phase. This typically lasts between one and three years. The pain and stiffness gradually go and movement gradually returns to normal, or near normal.
Symptoms often interfere with everyday tasks such as driving, dressing, or sleeping. Even scratching your back, or putting your hand in a rear pocket, may become impossible. Work may be affected in some cases.
Diagnosis of Frozen Shoulder
The following outcome measures have been used in studies researching adhesive capsulitis.
Shoulder Pain and Disability Index (SPADI)
Disability of the Arm, Shoulder and Hand scale (DASH)
American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES)
Simple Shoulder Test (SST)
Penn Shoulder Scale (PSS)
NPRS
VAS
SF-36
Hand to neck
Shoulder flexion + abduction + ER
Similar to ADLs such as combing hair, putting on a necklace
Hand to scapula
Shoulder extension + adduction + IR
Similar to ADLs such fitting a bra, putting on a jacket, getting into the back pocket
Hand to opposite scapula
Shoulder flexion + horizontal adduction
These tests require appropriate elbow, scapulothoracic, and thoracic mobility and these areas should be cleared of pathology first. If a patient is unable to complete the motion, other structures outside of the shoulder joint may be the limiting factor.
Imaging
X-ray – X-rays can help to ensure the shoulder joint appears normal, with no evidence of traumatic injury or arthritic changes.
MRI – This powerful diagnostic tool can sometimes show inflammation, but this test is better at ruling out other problems, rather than looking for a frozen shoulder. If an MRI is conducted, an injection of contrast fluid into the shoulder joint prior to the MRI is necessary. Results indicating a scarred capsule would designate frozen shoulder.
Ultrasound– can show the state of the rotator cuff tendons. Intact tendons in the setting of severe restriction in movement suggest frozen shoulder.
Arthrogram – may be used with an MRI to provide further information about structures in the shoulder. A dye is injected into the shoulder and images are obtained. The dye creates a contrast on the image, making the specific location of adhesions and the reduced space typical of frozen shoulder more visible.
Treatment of Frozen Shoulder
The aim of treatment for frozen shoulder is to alleviate pain and preserve mobility and flexibility in the shoulder. However, recovery may be slow, as symptoms tend to persist for several years.
Corticosteroid injection – Based on best available evidence, corticosteroid injection has mainly short-term benefit with a single injection. There appears to be added benefit with providing physiotherapy promptly following steroid injection compared to home exercise alone and physiotherapy alone. There is insufficient evidence to conclude with reasonable certainty in what clinical situations steroid injection, with or without physiotherapy, is most likely to be effective for treatment of frozen shoulder.
Sodium hyaluronate injection – A small number of diverse studies, all of which may have a high risk of bias, provide insufficient evidence to make conclusions about the effectiveness of sodium hyaluronate in the treatment of frozen shoulder
Physiotherapy/physical therapy – Primary studies comparing different types of physiotherapy/physical therapies support the use of various techniques to provide short- to medium-term benefit. Some interventions in current use that were investigated include therapeutic ultrasound end-range mobilization,28 short-wave diathermies plus stretching29 and high-grade mobilization therapy.30These interventions should be stage of disease and response-dependent. Based on best available evidence, there may be benefit from short-wave diathermy plus stretching and high-grade mobilization techniques in patients who have already had physiotherapy or a steroid injection. There is insufficient evidence to make conclusions on the best mode of physiotherapy for frozen shoulder
Acupuncture – The role of acupuncture in the treatment of frozen shoulder is not clear. Available evidence does not demonstrate a clear benefit.
Treatment options for frozen shoulder include Painkillers – relieve symptoms of pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are over – the – counter (OTC, no prescription required) painkillers and may reduce inflammation of the shoulder in addition to alleviating mild pain. Acetaminophen (paracetamol, Tylenol) is recommended for extended use. Prescription painkillers, such as codeine (an opiate-based painkiller) may also reduce pain. Not all painkillers are suitable for every patient; be sure to review options with your doctor.
Exercise – frequent, gentle exercise can prevent and even reverse stiffness in the shoulder.
Alternating between hot and cold compression packs can help with frozen shoulder
Hot or cold compression packs – help to reduce pain and swelling. It is often helpful to alternate between the two.
Transcutaneous electrical nerve stimulation (TENS) – numbs the nerve endings in the spinal cord that control pain and sends small pulses of electricity from the TENS machine to electrodes (small electric pads) that are applied to the skin on the affected shoulder.
Physical therapy (UK: physiotherapy) – can teach you exercises to maintain as much mobility and flexibility as possible without straining the shoulder or causing too much pain.
Physiotherapy for Frozen Shoulder
Your physical therapist’s overall goal is to restore your movement, so you can perform your daily activities. Once the evaluation process has identified the stage of your condition, your physical therapist will create an individualized exercise program tailored to your specific needs. Exercise has been found to be most effective for those who are in stage 2 or higher. Your treatment may include:
Stages 1 and 2
Exercises and manual therapy – Your physical therapist will help you maintain as much range of motion as possible and will help reduce your pain. Your therapist may use a combination of range-of-motion exercises and manual therapy (hands-on) techniques to maintain shoulder movement.
Modalities – Your physical therapist may use heat and ice treatments (modalities) to help relax the muscles prior to other forms of treatment.
Home-exercise program – Your physical therapist will give you a gentle home-exercise program designed to help reduce your loss of motion. Your therapist will warn you that being overly aggressive with stretching in this stage may make your shoulder pain worse. Your physical therapist will match your treatment activities and intensity to your symptoms, and educate you on the appropriate use of the affected arm. Your therapist will carefully monitor your progress to ensure a safe healing procedure is followed.
Pain medication – Sometimes, conservative care cannot reduce the pain of adhesive capsulitis. In that case, your physical therapist may refer you for an injection of a safe anti-inflammatory and pain-relieving medication. Research has shown that although these injections don’t provide longer-term benefits for a range of motion and don’t shorten the duration of the condition, they do offer short-term pain reduction.
Stage 3
The focus of treatment during phase 3 is on the return of motion. Treatment may include:
Stretching techniques – Your physical therapist may introduce more intense stretching techniques to encourage greater movement and flexibility.
Manual therapy – Your physical therapist may take your manual therapy to a higher level, encouraging the muscles and tissues to loosen up.
Strengthening exercises – You may begin strengthening exercises targeting the shoulder area as well as your core muscles. Your home-exercise program will change to include these exercises.
Stage 4
In the final stage, your physical therapist will focus on the return of “normal” shoulder body mechanics and your return to normal, every day, pain-free activities. Your treatment may include:
Stretching techniques – The stretching techniques in this stage will be similar to previous ones you’ve learned but will focus on the specific directions and positions that are limited for you.
Manual therapy – Your physical therapist may perform manual therapy techniques in very specific positions and ranges that are problematic for you. They will focus on eliminating the last of your limitations.
Strength training – Your physical therapist will prescribe specific strengthening exercises related to any weakness that you may have to help you perform your work or recreational tasks.
Return to work or sport – Your physical therapist will address movements and tasks that are required in your daily and recreational life.
Rehabilitation program
The exercises and other treatment methods are dependent on which phase of rehabilitation the patient is at. We recommend seeking professional advice before attempting any rehabilitation.
Phase 1 – Freezing
This phase is usually the most painful phase of treatment and movement becomes gradually more and more difficult. The aim of the following treatments and exercises is to help control pain and maintain movement in the shoulder joint.
NSAID’s (nonsteroidal anti-inflammatory drugs) e.g. Ibuprofen may help reduce inflammation and pain although will be of less value in later phases of treatment. Check with a doctor before taking medication and do not take ibuprofen if you have asthma.
Electrotherapy modalities such as ultrasound, TENS and laser treatment may all help reduce pain and inflammation.
Exercises should be done as long as they can be performed pain-free. Mobility exercises such as the pendulum and assisted shoulder exercises using a pole can help maintain shoulder mobility. See adhesive capsulitis exercises for more detailed information.
Shoulder stretching exercises for the muscles at the front and back of the shoulder can be done also to attempt to maintain as much movement as possible. Strengthening exercises are unlikely to be possible at this stage due to pain.
Phase 2 – Frozen
During the frozen phase of treatment is where there is the least movement in the shoulder, but on the plus side, pain tends to have reduced. This phase should be about trying to maintain strength and as much mobility as possible.
Mobility exercises such as pendulums and wand exercises should be continued. Stretching exercises for the chest muscles and muscles at the back of the shoulder should also be maintained.
Strengthening exercises can be performed to maintain muscle strength. Isometric or static contractions are exercises needing no joint movement and can be done without worrying about movement in the shoulder. Try to maintain good posture by working the upper back muscles. Poor posture could be a contributing factor in frozen shoulder helping to cause it or prevent healing.
A therapist may be able to help by performing some more advanced mobilizations on the shoulder to increase the range of movement at the shoulder joint. This is especially beneficial to patients who have very limited movement in the shoulder.
Phase 3 – Thawing
The final phase of treatment and rehab is where movement starts to return to the shoulder. This phase is all about getting the shoulder back to normal as quickly as possible by regaining full movement and strength. After a few months with little movement, the shoulder will be considerably weakened so strengthening exercises are important.
Mobility exercises and stretches can become more aggressive, but should still be within the boundaries of pain. Aim to restore full mobility in the shoulder joint.
Strengthening exercises can progress from isometric or static contractions to exercises using a resistance band, then eventually free weights or weight machines.
Work the affected shoulder first, do as many reps as you can and then do the same number on the unaffected shoulder. This will help avoid a muscle imbalance.
Include rotator cuff exercises in treatment as well as posture exercises and exercises for the deltoid and chest muscles too. The shoulder joint is a complicated joint and correct biomechanical function between the shoulder joint and shoulder blade is important as other shoulder injuries may follow if the joint is not fully rehabilitated.
Making the correct diagnosis is crucial, and will ensure an efficient and optimum treatment for the patient.
Features of importance are;
Hand dominance
Occupation and level of activity or sports
Location, radiation, and the onset of pain
Duration of symptoms (see phases of disease in the Definition earlier above)
The global reduction in the range of motion with a capsular pattern, defined as disproportionately severe loss of passive external rotation in the affected shoulder with arm by the side, over other movements.
History of diabetes, cardiovascular disease or other associations.
Normal X-rays in two planes to rule out mechanical glenohumeral incongruity such as arthritis, avascular necrosis or dislocation of the shoulder, which produce a similar clinical picture.
Red flags for the shoulder
Acute severe shoulder pain needs a proper and competent diagnosis. Any shoulder ‘red flags’ identified during primary care assessment needs urgent secondary care referral.
A suspected infected joint needs same day urgent referral.
An unreduced dislocation needs same day urgent referral.
Suspected malignancy or tumor needs urgent referral following the local 2-week cancer referral pathway.
An acute cuff tear as a result of a traumatic event needs an urgent referral and ideally should be seen in the next available outpatient clinic.
Suspected inflammatory oligo or poly-arthritis or systemic inflammatory disease should be considered as a ‘rheumatological red flag’ and local rheumatology referral pathways should be followed.
Treatment in primary care/community triage services
Pain relief
The aims of treatment are:
Improving range of motion
Reducing the duration of symptoms
Return to normal activitiesTreatment depends on the phase of the disease, severity of symptoms and degree of restriction of work, domestic and leisure activities.
Corticosteroid injection
Domestic exercise programme
Supervised physiotherapy/manual therapyFollowing interventions are suitable for primary care:
This is a painful and debilitating condition, where the pain is often severe, mimicking malignant disease (e.g. night pain). The onset of stiffness may be rapid and cause the significant functional deficit, typically in individuals of working age. Treatment should be tailored to individual patient needs depending on response and severity of symptoms.
Beware of red flags such as tumor, infection, unreduced dislocation or inflammatory polyarthritis.
Overall, a step-up approach may be adopted in terms of degree of treatment invasiveness. Some patients may have particular treatment preferences based on their needs and referral to secondary care may need to be considered early in such circumstances. Shared decision-making is particularly important for this condition.
A proportion of patients with frozen shoulder will respond to conservative treatment, and the response needs to be monitored. The most frequent indications for invasive treatments are persistent and severe functional restrictions that are resistant to conservative measures.
Symptoms usually of up to 3 months with the failure of conservative treatment measures may trigger a referral to secondary care for consideration of more invasive treatment. The severity of symptoms may necessitate earlier referral; it would not be appropriate to persist with ineffective treatment measures and delay referral of patients who experience severe pain and restriction.
Shared decision-making is important, and individual patients’ needs are different. Failure of initial treatment to control pain, if the degree of stiffness causes considerable functional compromise, or if there is any doubt about the diagnosis, prompt referral to secondary care is indicated.
Physiotherapy rehabilitation is usually for 6 weeks unless patients are unable to tolerate the exercises, or physiotherapists identify a reason for earlier referral to secondary care. If there is a patient improvement in the first 6 weeks of physiotherapy, then a further 6 weeks of therapy is justified.
Treatment timelines should include primary care and intermediate care time. Intermediate care should not delay appropriate referral to secondary care.
Secondary care
In a UK study of patterns of referral of shoulder conditions, 22% of patients were referred to secondary care up to 3 years following initial presentation, although most referrals occurred within 3 months.16 There is little evidence available on referral patterns for frozen shoulder specifically.
Confirm diagnosis with history and examination.
Obtain imaging with plain radiographs to rule out mechanical glenohumeral incongruences such as arthritis, avascular necrosis or dislocation.
Counsel patient fully regarding operative and non-operative options.
Ensure the multidisciplinary approach to care with the availability of specialist shoulder physiotherapists and shoulder surgeons.
The most commonly used secondary care interventions are
Manipulation under anesthesia (MUA)
Arthroscopic capsular release (ACR)
Distension arthrogram (DA) or hydrosilylation
Physiotherapy and corticosteroid injection, usually to supplement any of the above interventions
If symptoms fail to resolve with conservative treatment, then MUA, DA or ACR may be considered. This choice depends mainly on expertise and clinician preference.
MUA is performed under general anesthesia where the arm is manipulated to ‘tear’ the contracted shoulder capsule in a controlled fashion, thus restoring external rotation and other movements. This is supplemented with corticosteroid injection for pain relief and with physiotherapy to maintain range of motion post MUA.
ACR involves arthroscopic surgery under general anesthesia. The contracted capsule is released in a controlled fashion using arthroscopic instruments, frequently with radiofrequency ablation. The most prominent contracture occurs anteriorly and release of this improves the external rotation. The inferior capsule may be released with arthroscopic instruments, or with a controlled MUA.
DA is a procedure where the shoulder capsule is injected with saline and local anesthetic under pressure to distend and disrupt the capsule. This procedure is usually performed by an interventional radiologist and does not require general anesthesia. It is performed under fluoroscopy or ultrasound guidance and a radio-opaque dye may be used to confirm the accuracy of placement of the injected fluid. Both DA and ACR are supplemented with post-procedural physiotherapy to maintain range of motion in the affected shoulder.
It would be expected that surgical units performing ACR or MUA
Ensure patients undergo an appropriate pre-operative assessment to ensure fitness for surgery and to confirm discharge planning.
Perform surgery or MUA inappropriately resourced and staffed units.
Both procedures are typically performed as daycare or 23-hour admission (depending on the time of the day the procedure takes place) unless clinical or social circumstances dictate otherwise.
Standard postoperative care should involve the prompt start of physiotherapy and pain relief as required.
Physiotherapy services vary across the country, although up to 12 weeks of physiotherapy are typically required to maintain range of motion in the treated shoulder.
Up to three outpatient follow-up appointments may be needed, depending on progress.
Outcome metrics
Length of stay – day case (23 hours) and overnight.
Re-admission rate within 90 days.
Patient-reported outcome measure (PROM) pre-procedure, and 12 months post-procedure.
Infection/other adverse events.
Research and audit
In partnership with Centre for Reviews and Dissemination in York, BESS members were commissioned to conduct an evidence synthesis on the frozen shoulder by the National Institute for Health Research Health Technology Assessment (NIHR-HTA) Program. This report titled ‘Management of frozen shoulder: a systematic review and cost-effectiveness analysis’ has now been published, and forms a key reference document that summarises current evidence, and areas for future research on this topic.17
A recent survey of health professionals in the UK has found that the professional groups (general practitioners, a general practitioner with a special interest, physiotherapists, orthopedic surgeons) had different views on the most appropriate treatment pathway for the frozen shoulder.18. There was, however, a consensus that treatment should depend on the phase of the disease and a step-up approach would be appropriate.
In addition, a scoping review identified that most previous reviews have concentrated on one particular intervention and there is a general paucity of good primary research on frozen shoulder.19
Members of BESS involved in the above evidence syntheses are currently designing an interventional trial for frozen shoulder investigating commonly used interventions for management in secondary care.
A validated clinical score, preferably a PROM, should be used pre-operatively and the following treatment.
Acceptable scores include the Shoulder Pain and Disability Index (SPADI), Disability of Arm, Shoulder, and Hand (DASH) and the Oxford Shoulder Score (OSS). The disability subscale of the SPADI has been used by several published reports for this condition. Other measures such as EQ 5D may be used for economic analysis.
Scores should be captured pre-operatively and 1 year following intervention, which allows longitudinal analysis to determine the sustenance of treatment effect and consequences of any treatment-related adverse events.
Patient public clinician information
Patient and public information – ensure all available information is provided regarding the benefits and risks of all treatment options
Clinician information – ensure access to available evidence.
Surgery
Margery for frozen shoulder is typically offered during “Stage 2: Frozen.” The goal of surgery is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.
Manipulation under anesthesia – During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases the range of motion.
Shoulder arthroscopy – In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.
Home Exercises
Stiff or frozen shoulders are usually uncomfortable, even if the degree of stiffness is not great. That’s the bad news. The good news is that most stiff shoulders can be managed successfully by a simple exercise program conducted by the patient in the home.
Getting the shoulder moving
It is basically a question of gently and progressively getting the shoulder moving again. This program is the safest of all treatments for frozen shoulders. Although months of these specific exercises may be required, persistence almost always pays off. Even if arthritis is present, this program may help preserve and even improve the shoulder’s range and comfort. Before beginning these exercises you should consult with your physician.
There are two components to the home program for stiff shoulders. The first is a series of stretching exercises and the second relates to regular participation in a fitness program.
Your opposite arm is a great therapist for your stiff shoulder. Your “therapist arm” is always available to apply a gentle stretch in any direction of tightness. Each of these gentle stretches needs to be held up to a count of 100.
Stretching Exercises for the Frozen or Stiff Shoulder
The basic program includes the exercises illustrated below. Click any image below to enlarge and view in our photo gallery.
Fig. 1 – Getting the arm up while lying downFig. 2 – Getting the arm up overhead while sitting down.Fig. 3 – Getting the arm to externally rotate while lying down.Fig. 4 – Getting the arm to externally rotate while standing.Fig. 5 – Getting the arm up the back.Fig. 6 – Getting the arm across the body.
Lumbar disc herniation is a common condition that frequently affects the spine in young and middle-aged patients.1,5,11 The lumbar intervertebral disc is a complex structure composed of collagen, proteoglycans, and sparse fibrochondrocytic cells that serve to dissipate forces exerted on the spine. As part of the normal aging process, the disc fibrochondrocytes can undergo senescence, and proteoglycan production diminishes. This leads to a loss of hydration and disc collapse, which increases strain on the fibers of the annulus fibrosus surrounding the disc. Tears and fissures in the annulus can result, facilitating a herniation of disc material, should sufficient forces be placed on the disc. Alternatively, a large biomechanical force placed on a healthy, normal disc may lead to extrusion of disc material in the setting of catastrophic failure of the annular fibers.5
Spinal disc herniation also is known as a slipped disc, is a medical condition affecting the spine in which a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion to bulge out beyond the damaged outer rings. Disc herniation is usually due to age-related degeneration of the outer ring, known as the anulus fibrosus, although trauma, lifting injuries, or straining have been implicated as well. Tears are almost always postero-lateral (on the back of the sides) owing to the presence of the posterior longitudinal ligament in the spinal canal .This tear in the disc ring may result in the release of chemicals causing inflammation, which may directly cause severe pain even in the absence of nerve rootcompression.
Anatomy of Spinal Disc Herniation
Herniated = from “hernia,” a part of the body that bulges out through an abnormal opening Disc = the disk-shaped cushions between the bones of the spine
The vertebral column (also called the spinal column orbackbone) is made up of 33 bones known as vertebra (plural, vertebrae). Each vertebra is separated from the adjacent vertebrae by intervertebral discs, a spongy but strong connective tissue. The intervertebral discs, along with ligaments and facet joints, connect the individual vertebrae to help maintain the spine’s normal alignment and curvature while also permitting movement.
The image at left shows the entire spinal column from beside and from the front. The bones of the spinal column are orange in color, and the intervertebral discs are white.
In the center of the spinal column there is an open channel called the spinal canal. The spinal cord and spinal nerves are located in the spinal canal, where they are surrounded by spinal fluid and protected by the strong spinal column. On each side of the spine, small openings between adjacent vertebrae called foramina (singular, foramen) allow nerve roots to enter and exit the spinal canal.
The spine is divided into the following distinct regions:
Cervicalspine – consists of seven vertebrae in the neck. These vertebrae are small and allow for the mobile nature of the neck.
Thoracic spine – consists of 12 vertebrae in the upper and mid-back. These are larger and stronger than the cervical vertebrae. Each thoracic vertebra is attached to a rib on either side. This provides significant stiffness and strength to the thoracic portion of the spine.
Lumbar spine – usually consists of five vertebrae in the lower back, but may vary between four and six. These vertebrae are the largest because they withstand the greatest amount of force in the spine. The lumbar spine is also more mobile than the thoracic spine. Because of these factors, the lumbar spine is the most frequently affected by degenerative conditions, spinal stenosis, and herniated discs.
Sacrococcygeal – the very lowest portion of the spine. The sacrococcygeal region consists of one single bone, made of fused vertebrae in the sacrum (five vertebrae) and coccyx (four vertebrae). It attaches to the pelvis on either side. In a small number of people, there may be a disc between the first and second sacral vertebrae. Alternatively, the fifth vertebra in the lumbar (lower) spine may occasionally be fused to the sacrum, leaving only 4 lumbar vertebrae.
A herniated disc occurs when the fibrous outer portion of the disc ruptures or tears, and the jelly-like core squeezes out. When the herniated disc compresses a nearby nerve, as in the image below, the result can be a pinched nerve. A pinched nerve may cause pain, numbness, tingling or weakness in the arms or legs. The substance that makes up the disc’s jelly-like core can also inflame and irritate the nerve, causing additional pain.
Prolapse of intervertebral disc closeup 3d image. (c) alexmit/Big Stock
A bulging disc occurs when the outer wall of the disc weakens but doesn’t rupture, and “bulges” outward. A herniated disc may actually begin as a bulging disc whose outer wall is then ruptured by a great amount of pressure.
Disc herniation can occur in the cervical, thoracic, or lumbar spine. The location of the pain depends on the location of the herniated disc. If the herniation occurs in the neck, for example, it can cause pain that radiates into the shoulder and arm; if it occurs in the lower back, the pain produced can radiate down into the hip and leg. Depending on the location, it can damage the spinal cord.
Symptoms of Spinal Disc Herniation
A cervical herniated disc may put pressure on a cervical spinal nerve and can cause symptoms like pain, pins and needles, numbness or weakness in the neck, shoulders, or arms. A large disc herniation in the cervical spine may compress the spinal cord within the spinal canal and cause numbness, stiffness, and weakness in the legs and possibly some difficulty with bowel and bladder control.
A thoracic herniated disc may cause pain in the mid back around the level of the disc herniation. If the disc herniation compresses a thoracic spinal nerve as it travels through the foramen, then pain or numbness may travel around the rib cage from the back to the front of the chest or upper abdomen. A large disc herniation in the thoracic spine may compress the spinal cord within the spinal canal and cause numbness, stiffness and weakness in the legs and possibly some difficulty with bowel and bladder control.
A lumbar herniated disc may cause the following symptoms:
Intermittent or continuous back pain (this may be made worse by movement, coughing, sneezing, or standing for long periods of time)
Spasm of the back muscles
Sciatica — pain that starts near the back or buttock and travels down the leg to the calf or into the foot.
Muscle weakness in the legs
Numbness in the leg or foot
Decreased reflexes at the knee or ankle
Changes in bladder or bowel function
Difficulty walking
Incoordination
The symptoms of disc disease may resemble other conditions or medical problems. Always consult a doctor for a diagnosis.
Causes and Risk Factors
Herniated discs can often be the result of degenerative disc disease. As people age, the intervertebral discs lose their water content and ability to cushion the vertebrae. As a result, the discs are not as flexible. Furthermore, the fibrous outer portion of the disc is more likely to rupture or tear.
Acute disc herniations can occur in young, healthy people as a result of an injury or tear to the outer layer of the disc (called the annulus fibrosis) that allows the central, jelly-like portion of the disc (called thenucleus pulposis) to herniate into the spinal canal or foramen.
Tests and Diagnosis of Spinal Disc Herniation
Physical examination
The straight leg raise may be positive, as this finding has low specificity; however, it has high sensitivity. Thus the finding of a negative SLR sign is important in helping to “rule out” the possibility of a lower lumbar disc herniation. A variation is to lift the leg while the patient is sitting.[32] However, this reduces the sensitivity of the test.[33]
Imaging
Projection radiography (X-ray imaging) – Although traditional plain X-rays are limited in their ability to image soft tissues such as discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as tumors, infections, fractures, etc. In spite of these limitations, X-ray can still play a relatively inexpensive role in confirming the suspicion of the presence of a herniated disc. If a suspicion is thus strengthened, other methods may be used to provide final confirmation.
Computed tomography scan (CT or CAT scan) – A diagnostic image created after a computer reads x-rays. It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues. However, visual confirmation of a disc herniation can be difficult with a CT.
Magnetic resonance imaging (MRI) without contrast – A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues better than CAT scans. An MRI performed with a high magnetic field strength usually provides the most conclusive evidence for diagnosis of a disc herniation. T2-weighted images allow for clear visualization of protruded disc material in the spinal canal.
Myelogram An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs. Because myelography involves the injection of foreign substances, MRI scans are now preferred for most patients. Myelograms still provide excellent outlines of space-occupying lesions, especially when combined with CT scanning (CT myelography).
Electromyogram and nerve conduction studies (EMG/NCS) – These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression. EMG/NCS studies are typically used to pinpoint the sources of nerve dysfunction distal to the spine.
Computerized tomography (CT) scan – a series of X-rays, assembled by a computer into 3-dimensional images of the body’s structures
Myelography – a procedure that involves injecting a liquid dye into the spinal column followed by a series of X-rays and a computerized tomography (CT) scan. This procedure may provide useful images that reveal the indentations of the spinal fluid sac caused by bulging or herniated discs, or bone spurs that might be pressing on the spinal cord or nerves.
Electromyography (EMG) – tests the electrical activity of a nerve root to help determine the cause of pain.
The presence and severity of myelopathy can be evaluated by means of transcranial magnetic stimulation (TMS), a neurophysiological method that allows the measurement of the time required for a neural impulse to cross the pyramidal tracts, starting from the cerebral cortex and ending at the anterior horn cells of the cervical, thoracic or lumbar spinal cord. This measurement is called Central Conduction Time (CCT). TMS can aid physicians to:
determine whether myelopathy exists
identify the level of the spinal cord where myelopathy is located. This is especially useful in cases where more that two lesions may be responsible for the clinical symptoms and signs, such as in patients with two or more cervical disc hernias[34]
follow-up the progression of myelopathy in time, for example before and after cervical spine surgery
TMS can also help in the differential diagnosis of different causes of pyramidal tract damage.[35]
Since a herniated disc may cause similar symptoms to other degenerative spinal conditions, a surgeon may order a variety of diagnostic procedures to rule out other possible conditions.
Treatment of Spinal Disc Herniation
Before discussing surgery as an option, the surgeon may initiate the following nonoperative treatments. Specific treatment for lumbar disk disease will be determined by your health care provider based on
Your age, overall health, and medical history
Extent of the condition
Type of condition
Your tolerance for specific medications, procedures, or therapies
Expectations for the course of the condition
Your opinion or preference
Typically, conservative therapy is the first line of treatment to manage lumbar disk disease. This may include a combination of the following:
Bed rest
Patient education on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
Physical therapy, which may include ultrasound, massage, conditioning, and exercise
Weight control
Use of a lumbosacral back support
Medications of Spinal Disc Herniation
Analgesics: Prescription-strength drugs that relieve pain but not inflammation.
Antidepressants: A Drugs that block pain messages from your brain and boost the effects of eorphins (your body’s natural painkillers).
Corticosteroids: Also known as oral steroids, these medications reduce inflammation.
Muscle Relaxants: These medications provide relief from spinal muscle spasms.
Neuropathic Agents: Drugs(pregabalin & gabapentine) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
Opoids : Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
Topical Medications: These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
NSAIDs: Prescription-strength drugs that reduce both pain and inflammation.Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include aspirin, ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve).
Calcium & vitamin D3, to improve bones health and healing fracture.
Glucosamaine & diacerine ,can be used to tightening the loose tenson and regenerate cartilage or inhabit the further degeneration of cartilage.
Corticosteroid to healing the nerve inflamation and clotted blood in the joints.
Diatery suppliment to remove the general weakness & improved the health.
There is little evidence to suggest that drug treatments are effective in treating herniated disc.
NSAIDs and cytokine inhibitors don’t seem to improve symptoms of sciatica caused by disc herniation.
We found no evidence examining the effectiveness of analgesics, antidepressants, or muscle relaxants in people with a herniated disc.
We found no evidence of sufficient quality to judge the effectiveness of epidural injections of corticosteroids.
With regard to non-drug treatments, spinal manipulation seems to be more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates.
Neither bed rest nor traction seems effective in treating people with sciatica caused by disc herniation.
We found insufficient evidence about advice to stay active, acupuncture, massage, exercise, heat, or ice to judge their efficacy in treating people with herniated disc.
About 10% of people have sufficient pain after 6 weeks for surgery to become a consideration.
Both standard discectomy and microdiscectomy seem to increase self-reported improvement to a similar extent.
We found insufficient evidence judging the effectiveness of automated percutaneous discectomy,laser discectomy, or percutaneous disc decompression.
Surgical Treatment of Spinal Disc Herniation
When these conservative measures fail, surgery for removal of a herniated disk may be recommended. Surgery is done under general anesthesia. An incision is placed in the lower back over the area where the disk is herniated. Some bone from the back of the spine may be removed to gain access to the area where the disk is located. Typically, the herniated part of the disk and any extra loose pieces of disk are removed from the disk space.
Surgical treatment for a herniated disc will be based on the following
The history, severity and duration of pain
Whether or not the patient has received previous treatments for disc disorders and how effective the treatments were
Whether or not there is any evidence of neurologic damage such as sensory loss, weakness, impaired coordination, or bowel or bladder problems
Surgery for patients with disc disorders of the spine is usually recommended for those patients who do not find relief with non-operative treatment over a period of 6-12 weeks. Surgery is also recommended in patients who have a neurologic deficit (numbness, weakness or reduced function due to pressure on the spinal cord or nerves). Early intervention in those cases is best in order to maximize the likelihood of neurologic recovery.
Your surgeon may perform the following surgical procedures:
Microdiscectomy: A procedure that uses a microscope and microsurgical tools to remove the portion of the disc that is pressing against the nerve, relieving the pressure caused by a herniated disc. Microdiscectomy is frequently performed for herniated discs in the certical, thoracic, and lumbosacral spine. This procedure is performed under general anesthesia through a small skin incision over the spine. The muscles of the spine are gently elevated or spread apart to expose a small segment of the spine. A small amount of the back part of the spine, called the lamina and facet joint, is trimmed under high magnification of the microscope to provide safe access to the spinal canal. Using microsurgical techniques, our neurosurgeons identify and remove the herniated piece of the disc while protecting the compressed nerve. Most patients may go home either on the day of surgery or the next morning.
Anterior (from the front) or lateral (from the side) surgical approaches may be required for large or calcified thoracic disc herniations that cause spinal cord compression.
Anterior Cervical Discectomy and Fusion (ACDF): a procedure that involves the removal of the herniated disc in the cervical spine through the front of the neck. A fusion surgery may be required to make the spine stable after the discectomy.
After surgery, restrictions may be placed on the patient’s activities for several weeks while healing is taking place to prevent another disk herniation from occurring. Your surgeon will discuss any restrictions with you.
Others Treatment of Spinal Disc Herniation
Chiropractic Care
Sixty percent of people with sciatica who didn’t get relief from other therapies and then tried spinal manipulation experienced the same degree of pain relief as patients who eventually had surgery, found a 2010 study in the Journal of Manipulative and Physiological Therapeutics. The 120 people in the study saw a chiropractor about 3 times a week for 4 weeks, and then continued weekly visits, tapering off treatment as they felt better. In people who responded to chiropractic care, benefits lasted up to a year. “Spinal manipulation may create a response in the nervous system that relieves pain and restores normal mobility to the injured area,” says study researcher Gordon McMorland, DC, of National Spine Care in Calgary, Alberta. “It also reduces inflammation, creating an environment that promotes the body’s natural healing mechanisms.”
Acupuncture
“You can get relief as soon as the first session, though it takes about 12 sessions to see improvement,” says Jingduan Yang, MD, assistant professor at the Jefferson Myrna Brind Center of Integrative Medicine at Thomas Jefferson University. A small study in the Journal of Traditional Chinese Medicine found that of 30 people with sciatica, 17 got complete relief and 10 saw symptoms improve with warming acupuncture, in which the needles are heated.
Yoga
A study in the journal Pain reported that people with chronic back pain who practiced Iyengar yoga for 16 weeks saw pain reduced by 64% and disability by 77%. Although yoga’s effects on sciatica are less clear, gentle forms may be beneficial. By strengthening muscles and improving flexibility, a yoga practice can help sciatica sufferers “move and function better so they don’t fall into a posture that aggravates sciatica,” says James W. Carson, PhD, a psychologist at the Comprehensive Pain Center at Oregon Health & Science University. For extra grip and stability, try these grip socks from Natural Fitness.
Massage
Don’t expect a chilled-out spa massage if you have sciatica. In this instance, trigger-point therapy is best, says Jeff Smoot, vice president of the American Massage Therapy Association. The sciatic nerve sits underneath a muscle called the piriformis, which is located beneath the glutes. “When the piriformis muscle gets tight, it pinches the sciatic nerve, causing tingling and numbness down into the leg,” says Smoot. He applies pressure to irritated and inflamed areas, or trigger points, in the piriformis muscle, as well as in muscles in the lower back and glutes. Typically, Smoot schedules treatments 7 to 10 days apart. If patients don’t see progress by the fourth visit, “they need to try another form of therapy,” he says.
Topical Preparations
St. John’s wort oil, a liniment, is “one of my favorites for nerve pain,” says Tieraona Low Dog, MD, director of the fellowship at the Arizona Center for Integrative Medicine. Apply the anti-inflammatory oil two or three times a day where there’s pain. Another option: an OTC cayenne pepper plaster or cream; capsaicin, found in chiles, hinders the release of pain-causing compounds from nerves. For severe cases, Low Dog uses the prescription chile patch Qutenza, designed for shingles pain. “One application is effective for weeks,” says Low Dog.
Ice or Heat
Because the sciatic nerve is buried deep within the buttock and leg, ice or heat on the surface of the body won’t ease that inner inflammation. But the timehonored treatments can act as counterirritants—that is, “they give your body other input in the painful area, and that brings the pain down a notch,” says Ruppert. Apply an ice pack or a heating pad as needed for 15 minutes.
Devil’s Claw
The herbal medication devil’s claw is “quite a potent anti-inflammatory, working like ibuprofen and similar drugs to inhibit substances that drive inflammation,” says Low Dog. She generally starts patients on 1,500 to 2,000 mg twice a day. Look for a brand that has a standardized extract of roughly 50 mg of harpagoside, the active compound. Safety reviews show that the supplement is well tolerated by most people but should be avoided by patients with peptic ulcers or on blood-thinning medications.
Epidural Steroid Injections
People whose pain doesn’t lessen within about a month and who aren’t helped by other therapies may find their pain remedied by an x-ray-guided injection of steroid into the lower back near the sciatic nerve, says Raj Rao, MD, a spokesperson for the AAOS. “The hope is to reduce inflammation within that nerve branch,” explains Rao. Because of concerns about side effects, such as loss of bone density, the epidural shots are limited to three a year.
Physiotherapy in Harniated Disc
In stage 1&2 of harniated disc physiotherapy must applied to cure harniated hisc .In case of stage 3&4 ,physiotherapy can’t applied due to adoining the another case of foot drop.
In accordance of NIH journal
Physiotherapy for a lumbar disc bulge
Physiotherapy treatment for a lumbar disc bulge is vital to ensure an optimal outcome and may comprise:
soft tissue massage
electrotherapy (e.g. ultrasound)
lumbar taping
the use of a back brace
mobilization
traction
the use of a lumbar roll for sitting
dry needling
exercises to push the disc back ‘in’ and to improve strength, core stability and flexibility
education
activity modification advice
biomechanical correction
ergonomic advice
clinical Pilates
hydrotherapy
a functional restoration program
a gradual return to activity program
Physical therapy often plays a major role in herniated disc recovery. Its methods not only offer immediate pain relief, but they also teach you how to condition your body to prevent further injury.
There are a variety of physical therapy techniques. Passive treatments relax your body and include deep tissue massage, hot and cold therapy, electrical stimulation (eg, TENS), and hydrotherapy.
Your physical therapy program will usually begin with passive treatments. But once your body heals, you will start active treatments that strengthen your body and prevent further pain. Your physical therapist will work with you to develop a plan that best suits you.
Passive Physical Treatments for Herniated Discs
Deep Tissue Massage
There are more than 100 types of massage, but deep tissue massage is an ideal option if you have a herniated disc because it uses a great deal of pressure to relieve deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.
Hot and Cold Therapy
Both hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results.Your physical therapist may use heat to increase blood flow to the target area. Blood helps heal the area by delivering extra oxygen and nutrients. Blood also removes waste byproducts from muscle spasms.Conversely, cold therapy (also called cryotherapy) slows circulation. This reduces inflammation, muscle spasms and pain. Your physical therapist may place an ice pack on the target area, give you an ice massage, or even use a spray known as fluoromethane to cool inflamed tissues.
Hydrotherapy
As the name suggests, hydrotherapy involves water. As a passive treatment, hydrotherapy may involve simply sitting in a whirlpool bath or warm shower. Hydrotherapy gently relieves pain and relaxes muscles.
A TENS machine uses an electrical current to stimulate your muscles. It sounds intense, but it really isn’t painful. Electrodes taped to your skin send a tiny electrical current to key points on the nerve pathway. TENS reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body’s natural pain killers.
Traction
The goal of traction is to reduce the effects of gravity on the spine. By gently pulling apart the bones, the intent is to reduce the disc herniation. The analogy is much like a flat tire “disappearing” when you put a jack under the car and take pressure off the tire. It can be performed in the cervical or lumbar spine.
Active Treatments You May Try in Physical Therapy
Active treatments help address flexibility, posture, strength, core stability, and joint movement. An exercise program may also be prescribed to achieve optimal results. This will not only curb recurrent pain but will also benefit your overall health. Your physical therapist will work with you to develop a program based on your specific diagnosis and health history.
Core stability
Many people don’t realize how important a strong core is to their spinal health. Your core (abdominal) muscles help your back muscles support your spine. When your core muscles are weak, it puts extra pressure on your back muscles. Your physical therapist may teach you core stabilizing exercises to strengthen your back.
Flexibility
Learning proper stretching and flexibility techniques will prepare you for aerobic and strength exercises. Flexibility helps your body move easier by warding off stiffness.
Hydrotherapy
In contrast to simply sitting in a hot tub or bath like its passive counterpart, active hydrotherapy may involve water aerobics to help condition your body without unnecessary stress.
Muscle strengthening
Strong muscles are a great support system for your spine and better handle pain.
Your physical therapist will teach you ways to condition and strengthen your back to help prevent future pain. You may learn self-care principles so you understand how to best treat your symptoms. The ultimate goal is for you to develop the knowledge to maintain a pain-free lifestyle.
It’s essential that you learn how to exercise and condition your back after the formal physical therapy ends. If you don’t implement the lessons you learned during physical therapy, you won’t enjoy its long-term results. By taking care of your back on your own, you may prevent further herniated disc pain
8 Best Exercises For Slipped Disc In Lower Back
Our spinal cord is supported by a number of muscles. Relevant exercises help relieve the pain and reduce the symptoms. Muscle exercises of those muscles associated with the affected area is necessary. Patients must know the region that has a slipped disc and then opt for exercises related to that muscle. The list of best exercises for the slipped disc are mentioned as follows:
Abdominal Isometrics – It can be performed either on floor, mat or bed. This exercise involves moving your lower back towards the surface at which you are performing this exercise. Leg movement must be reduced in this exercise and stomach muscles must be made active. This reduces pain in lower back because of the attachment of abdominal muscles to the lower side of the vertebral column. Ten repetitions are effective.
Crunches – Lie on a flat surface with knees bent. Cross your arm under your head, raise your head and chest in such a manner that your rib cage curl interiorly towards your backbone. Perform this exercise slowly and gradually. In the beginning, perform fewer crunches and repeat it daily and increase the number of turns as you gain strength.
Lower back extension – Lie in an upside down position, raise your upper body with the help of elbow and hold up yourself in an elevated position for a short span of time and then slowly lower down. Please make sure that during this exercise you do not raise your pelvis girdle (hip region).
Bilateral knee to the chest – Lay down on a flat surface and draw your knee towards your abdominal region, repeat it 5 times and then switch leg. You can also increase the number of turns each time you repeat it.
Iso-hip flexion – Lay down over a flat surface and draw your knees towards your chest region in a 90 degree position with your stomach. Place your hands over your knees and then exert your hand pressure to lower your knee. Then utilize the knee pressure to resist the downward movement of your legs, in all both movements should just exert pressure and allow no movements. This position should be maintained for few seconds and then lowered slowly and gradually.
Air bike – Sit on a chair with your chest and shoulders supported. Align your knees and feet together and then bring them towards your body and perform a pedaling motion in air then repeat the same motion while moving your knees farther away from body. Follow ten repetitions each time and increase its number as you gain strengths
Ham string stretch: Lie on a flat surface with your knees bend, place your hands under your knees and then slightly pull your leg towards your chest, repeat it with other leg. This exercise must involve a stretch over lower thigh muscle
Lumbar roll: Lie on a flat surface with your knee bent and your feet lying on the floor then move your legs together towards the right side and then towards your left side. Repeating these movements 5 times on each side.
The above mentioned best exercises for slipped disc can be followed but if pain increases or muscle pain is persisting then quit these exercises right away. These exercises not only help in reducing the pain but they also activate efficient muscle movement. Along with these exercise tips, proper body postures must be also maintained to prevent further disc damages.
Home Remady for Herniated Disc/Slip Disc
Consciousnes
Incase of PLID home remedies are not special treatment just only home practice & creating public awareness. All should be done in PLID stage 1&2
Walking
Walking every day keeps muscle disorders away. Walking can also help to prevent herniated disc. Walk on a flat road for 20 minutes as many times as you can in a day. Take longer steps as it will help you to keep away the pain of herniated disc. Do not give strain to yourself as it might increase the pain.
Rest
www.rxharun.com
Rest is essential for patients suffering from herniated disc. Take short rest periods from time to time. When you are sleeping make sure you don’t stay in the same position for a long time. Do not sleep on your stomach. Also, take care of the mattress you are sleeping on. Don’t let it be too soft and spongy. Buy a mattress that has good surface area and is soft in nature.
Physiotherapy And Yoga( only home practice)
Physiotherapy is a very cheap and good way of getting rid of herniated disc from itself. Therapists will teach your proper exercises and stretches which will improve the disc shape to a great extent.
You will notice good differences while performing daily chores after just 4-5 sessions of therapy.
Physiotherapy also promotes faster healing of the disorder.
Turmeric
Turmeric contains curcumin which is a very good anti-oxidant and anti-inflammatory agent. This is why it stops the gel-like fluid inside the discs from coming out and bulge. It also shows antihistamine properties which help to reduce pain because of slowed blood circulation to the area of pain.
Dimethyl Sulfoxide (DMSO)
Dimethyl sulfoxide is a derivative from sulphur which has antioxidant properties as well as the organic sulphur present in it helps in the growth of new cells and detoxification of the body. The growth of new cells helps to replace the old cells of the discs and prevent the fluid from leaking outside.
Massage With Essential Oils
Massage with essential oils on the full body, especially on the spine and lower back regions, will help in good blood circulation and promote the growth of new cells. It will help relieve pain and promote better absorption of oxygen and nutrients. Essential oils will also regenerate the cells of the disc and hence stop the disc from getting slipped.
Acupressure And Acupuncture
In both techniques, pressure is used for relieving the pain from the swelled area. In acupressure fingers, tips and elbow are used and acupuncture needles are used. But this should be done with the help of an experienced practitioner and not alone.
This is not recommended for patients having high blood pressure and for women who are pregnant.
TENS
TENS stands for Transcutaneous Electrical Nerve Stimulation and this is one of the best remedies for herniated disc at home. This treatment uses low voltage electric current which is applied to the affected area and helps the body to release endorphin which decreases the pain.
Cayenne Pepper
It is a very effective ingredient for the treatment of herniated disc.You can drink its tea or make a paste of the pepper using water and apply on the affected area.
Diet
Diet is necessary to keep away all types of bad conditions that might affect you.Drink a lot of water and eat a balanced diet. Take excess of fibres and proteins. During this condition, you should avoid dairy products and red meat. Also, avoid fat-free foods.
Epsom Salt
Epsom salt is one of the widely used natural painkiller and anti-inflammatory agent.
You can use this by adding 3-4 cups of salt in a hot water bath. Stay inside the bath for 15 minutes. It will help you achieve maximum relaxation.
Do not use this remedy if you are diabetic or pregnant. If you are on any type of medication consult your doctor before bathing in Epsom salt.
Horsetail
Horsetail is a herb which has high quantities of minerals in it. It nourishes our tissues and has the ability to heal broken bones and torn ligaments.
All you need to do is add some horsetail leaves to half a litre of water. Boil on low heat till the water quantity reduces to half its quantity. Cool the solution and filter it off. You can drink 5 ml of the solution thrice a day.It will heal herniated disc very fast.
California Poppy
California poppy is anti-inflammatory and analgesic in nature. This is what makes it a good treatment for herniated disc.
You can tear the leaves of California poppy into small pieces and make a paste out of it using water. Use little hot water so that when you apply the paste on the affected area it is still warm.
White Willow Bark
White willow bark is used for reducing the discomfort of herniated discs. The chemical structure of this drugs shows a marked similarity to aspirin hence acts as an analgesic but doesn’t irritate your gut. It is also astringent and anti-inflammatory in nature.
This herb might react with drugs hence do consult your doctor if you are on any kind of medication.
Comfrey Leaves
Comfrey leaves have power to heal bones and connective tissues of the body.All you need to do is take some fresh leaves and add it to cold water. Let it remain undisturbed for around 12 hours. After 12 hours heat the above solution and filter it. Add the filtrate to bath water and take a bath in it 2 times a day.Do not consume it orally because it contains hepatic-toxin alkaloids.
Boswellia
Boswellia is a naturally occurring painkiller which is a very effective remedy for herniated disc.
All you can do is make a decoction of Boswellia and consume it 2 times a day to reduce pain and discomfort associated with herniated discs.
Boswellia is an organic painkiller that effectively treats the problem of herniated disc. It is also an herbal cure for osteoarthritis.
Omega-3 Fatty Acids
Omega-3 Fatty acids are helpful in decreasing the inflammation and pain experienced due to herniated disc disorder. This acid forms collagen which is used by the broken discs for repairing itself.
Eat foods that are high in this kind of fats like fish, almonds, sprouts and walnuts.
Colchicine
Colchicine is an active amino-alkaloid found in the plant of Kurchi or autumn crocus. This powder is obtained by crushing the seeds of the plant. It has anti-inflammatory properties which are effective against the slipped disc.
Make a paste with kurchi powder and honey and consume it once a day.
You can also make tea out of the powder or mix the powder in milk and have it once or twice a day.
Burdock
Burdock contains a lot of anti-oxidants which is helpful to detoxify the body and remove all kinds of harmful substances and decrease the pain and inflammation in your body. It also treats arthritis.
Burdock can be consumed as a decoction once or twice a day.
Passionflower
Passionflower is helpful for slipped discs because the essential oils present is antispasmodic in nature. It reduces pain and inflammation.
You can massage with passionflower essential oil or take capsules made from it, however, do consult your doctor before taking capsules.
Additional Tips
If you are overweight, try to lose some pounds.
Exercise every day.
Lift things in a proper way, as guided by a therapist. Do not lift heavy weights.
Stop smoking and drinking.
Always make sure you are in the right posture whatever activity you may be doing.
Wear flat and soft shoes. Avoid heels.
Walk and move around cautiously.
Slipped discs can be really painful but with the right treatment and precautions you can become as fit as you were before. So start taking home remedies and consult a doctor whenever you feel any kind of severe pain.
