Peri arthritis shoulder non operative thearapy

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Peri arthritis shoulder non operative thearapy

  1. 1. DR M S GOUD PROFESSOR OF ORTHOPAEDICS GANDHI MEDICAL COLLEGE SECUNDERABAD
  2. 2.  DEFINITION:it is a syndrome defined in its purest sense as an idiopathic pain ful restriction of shoulder movements resulting in global restriction of gleno humeral joint.  CODMAN in 1934 coined the term frozen shoulder and described as “difficult to define,difficult to treat,difficult to explain”.
  3. 3. CLINICAL FEATURES  Slow onset of pain near the insertion of the deltoid.  Inability to sleep on the affected side.  Pain relatively more in the night.  Restriction of abduction and external rotation followed by global restriction.  Normal radiological appearance.
  4. 4. CLINICAL COURSE  Runs for 1 to 3 years.  Usually selflimiting  It is divided in to three phases a)freezing phase (2-6 months) b)frozen phase (4 -12 months) c)thawing phase (4 -18 months)  If not treated will end up in permanent restriction of some movement.
  5. 5. EPIDEMIOLOGY  Not common before 4th decade.  More common in women.  Non dominant extremity.  Bilateral 34%.  More common in hyper anxiety personalities with low pain tolerence.
  6. 6. CAUSATIVE FACTORS  Primary : idiopathic.  Secondary contributing factors  1)injury not treated properly  2)after shoulder surgery  3)diabetes  4)autoimmune disorders.  5)poor posture-specially when recovering from chronic illnesses like CVA,MI etc…
  7. 7. DIFFERENTIAL DIAGNOSIS  IT HAS TO BE DIFFERENTIATED FROM OTHER PAIN FUL SYNDROMES. 1)tuberculosis 2) osteo arthritis. 3)rheumatoid arthritis 4)painful arc syndrome. 5) rotator cuff injuries
  8. 8.  CONSERVATIVE MANAGEMENT:  1)physical therapy.  2)drug therapy  3)intra articular steroid(methyl prednisolone)  4)intra articular saline injection with breakage of the capsule fibres and adhesions(brisement)  5)closed manipulation under G.A.
  9. 9. PHYSICAL THERAPY  1)Electro therapy (ultrasound,IFT).  2)Hydro therapy.  3)exercises to improve flexibility and strength.  4)ice and heat treatment.  5)soft tissue massage.  6)dry needling  7)postural correction.  Councelling and motivation.
  10. 10. ELECTRO THERAPY Interferential therapy:it is a current used for thereupetic purposes obtained by passing two medium frequency currents where the currents intersect with tissue to produce a new current.
  11. 11.  PHYSIOLOGICAL EFFECTS OF IFT:  Relieves pain  Promotes healing.  Stimulates muscles.  Promotes relaxation.  Improves circulation.
  12. 12.  ULTRA SOUND THERAPY:  Mechanical vibrations of sound waves of frequency ranging from 0.5 to 5 MHZ.  The theurepetic ultra sound works on reverse piezo electric effect.  THERMAL EFFECTS: are useful for treatment.  a)increased extensibility of connective tissue.  b)decreased joint stiffness and muscle spasm.  c)relieves pain  d)promotes healing of tissues.
  13. 13. ULTRA SOUND THERAPY
  14. 14. DRUG THERAPY  Anlgesics  Muscle relaxants  Sedatives  Tranquilisers  Medicated patches (diclofenac sodium,fentanyl,lidocaine)
  15. 15. MANAGEMENT OF FREEZING STAGE( STAGE 1)  Gentle physiotherapy (mostly pendular exercises)  Intra articular methyl prednisolone
  16. 16. MANAGEMENT OF FROZEN AND THAWING STAGE  Ideal for active and passive physiotherapy  Distension of the shoulder joint with 50 -100 ml of saline will break some fibres of the adhesions(brisement force).  MANIPULATION :if there is no response with above treatment.
  17. 17.  PHYSIOTHERAPY:short period for 5 to 10 min per hour around 10 cycles per day is better than a continuous physiotherapy for long time.  Application of heat before physiotherapy( ultrasound and IFT ) will cause vasodilatation that helps in muscle relaxation.  Application of ice after physiotherapy (vasoconstriction) reduces the inflammation.
  18. 18.  INTRA ARTICULAR INJECTIONS  Methyl prednisolone  saline
  19. 19. CLOSED MANIPULATION-GA(MUA)  INDICATION:adhesive stage.  Patient needs absolute relaxation under GA.
  20. 20. BETTER AVOID- MUA  Grossly osteoporotic  Rotator cuff tear.  Arthritis involving gleno humeral joint(RA,OA)  Sympathetic osteodystrophy
  21. 21. POST MANIPULATION MANAGEMENT  Patients limb should be kept in 160 degrees of abduction and 90 degrees of external rotation for 48 hours(ROBERT ET AL).  Patient should have an inter scalene block catheter insitu for 48 hours.
  22. 22.  COMPLICATIONS OF MUA:  Fracture surgical neck of humerus.  Rupture of sub scapularis.  Rupture of long head of biceps.  Nerve injury  FACTORS THAT MAY INCREASE RISK OF COMPLICATIONS:  Recent chronic illness  Chronic smokers and alcoholics  Previous shoulder surgery.
  23. 23. SUMMARY  It’s a vascular based inflammatory pathology with formation of adhesions.  Unknown etiology.  Natural history-variable duration.  chronic pain with stiff shoulder with restriction of daily living activities  NO SINGLE TREATMENT REGIME HAS BEEN PROVED TO BE THE BEST SOLUTION.  What ever regime we adopt “PHYSIOTHERAPY IS THE MAIN STAY OF THE TREATMENT”.
  24. 24.  There is a role for surgical release (arthroscopy) for chronic and resistant cases.

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