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Chiropractic management of frozen shoulder syndrome
using a novel technique: a retrospective case series of
50 patients
Francis X. Murphy DC
a,
⁎, Michael W. Hall DC, CCST, DABCN, FIACN
b
,
Louis D'Amico
c
, Anne M. Jensen DC, ICSSD, MSc, MSc
d
a
Chiropractor, Owner and Founder, OTZ Health Education Systems LLC, Dallas, TX
b
Professor, Department of Clinical Neurology, Parker University, Dallas, TX
c
Chiropractor, Vice President and Senior Trainer, OTZ Health Education Systems LLC, Dallas, TX
d
DPhil Candidate, Department of Primary Care and Department for Continuing Education,
University of Oxford, Oxford, UK
Received 15 August 2011; received in revised form 4 July 2012; accepted 23 July 2012
Key indexing terms:
Shoulder;
Adhesive capsulitis;
Chiropractic;
Musculoskeletal
manipulations
Abstract
Objective: The purpose of this case series is to describe the treatment and outcomes of a
series of patients presenting with frozen shoulder syndrome who received a novel chiropractic
approach (OTZ Tension Adjustment).
Methods: The files of 50 consecutive patients who presented to a private chiropractic practice
with frozen shoulder syndrome were reviewed retrospectively. Two primary outcomes were
extracted from the files for initial examination and at final evaluation: (1) the 11-point
numeric pain rating scale and (2) the percentage change in shoulder abduction. Each patient
received a series of chiropractic manipulative procedures that focused on the cervical and
thoracic spine.
Results: Of the case files reviewed, 20 were male and 30 were female; and all were between
the ages of 40 and 70 years. The median number of days under care was 28 days (range, 11 to
51 days). The median change in Numeric Pain Rating Scale score was −7 (range, 0 to −10).
Of the 50 cases, 16 resolved completely (100% improvement), 25 showed 75% to 90%
improvement, 8 showed 50% to 75% improvement, and 1 showed 0% to 50% improvement.
Conclusion: Most patients with frozen shoulder syndrome in this case series appeared to
improve with the chiropractic treatment.
© 2012 National University of Health Sciences.
www.journalchiromed.com
⁎Corresponding author. 6211 W Northwest Hwy, Suite 159, Dallas, TX 75225. Tel.: +1 214 368–3030.
E-mail address: fxmdc@aol.com (F. X. Murphy).
1556-3707/$ –see front matter © 2012 National University of Health Sciences.
http://dx.doi.org/10.1016/j.jcm.2012.07.001
Journal of Chiropractic Medicine (2012) 11, 267–272
Introduction
Frozen shoulder syndrome (FSS) is a common
condition presenting to a variety of health care
practitioners including chiropractors, osteopaths, medi-
cal doctors, and physical therapists. Also referred to as
adhesive capsulitis, FSS remains one of the most poorly
understood shoulder conditions,
1
with its etiology and
pathogenesis largely disputed.
2
Recently, a consensus
definition of FSS was reached by the American Shoulder
and Elbow Surgeons to be “a condition characterized by
functional restriction of both active and passive shoulder
motion for which radiographs of the glenohumeral joint
are essentially unremarkable.…”
1
The prevalence of FSS is thought to be 2% to 5% of
the general population.
2,3
It occurs usually between 40
and 60 years of age,
3
is 3 to 7 times more prevalent in
women than men,
4
and can be classified as either primary
or secondary.
1
A diagnosis of primary (or idiopathic)
FSS is made if no causative factors are identified on
history or examination.
3
Secondary FSS is thought to
develop following some trauma or systemic condition.
1
For instance, there is a high comorbidity of FSS in
patients with diabetes, with incidence rates nearing
40%.
5
In addition, FSS is also commonly found in
those with Parkinson disease, cardiovascular disease,
thyroid disease, and stroke.
6,7
In the absence of other pathological processes, a
diagnosis of FSS is made if the following criteria are
present: an insidious onset, night pain, painful
restriction of passive scapulohumeral elevation causing
shoulder abduction of less than 100°, and shoulder
external rotation of less than half of normal.
3
The current medical paradigm divides the natural
history ofFSS into 3 stages (Fig 1): (1) the freezing stage,
characterized by diffuse pain and loss of motion (2-9
months); (2) the frozen stage, where pain decreases and
stiffness has maximized (4-12 months); and (3) the
thawing stage, characterized by a gradual normalization
of mobility and function (4-12 months).
3,8
Reeves,
8
who
first described the 3 stages of the condition, reported that
FSS usually lasts from 1 to 3.5 years with a mean duration
of 30 months. However, Shaffer et al reported that, after 7
years, 50% of the cohort they studied continued to have
residual pain and/or loss of shoulder function.
9
The underlying etiology of FSS is largely disputed;
but it is commonly thought that its origins lie in biologic
factors, mechanical stress, and/or neovascularization of
the shoulder joint complex.
3
However, it is hypothe-
sized that the etiology of FSS is not as the current
paradigm describes, but rather is neuromechanical in
nature, originating in the cervical spine, cranium,
occipitoatlantal joints, and/or cranial nerve 11 (CNXI)
and causing malfunction of the trapezius muscle
resulting in a breakdown of the entire dynamic shoulder
complex.
10
In fact, the literature well describes the most
common symptoms of CNXI injury as (1) reduced
shoulder abduction, (1) drooped shoulder (tie), and (3)
shoulder pain,
11
which are also common symptoms of
FSS.
1,3
The inference that CNXI might be related to
FSS is the next logical step.
Support for a chiropractic approach toward FSS is
currently limited to a small pilot study
12
and a number
of case reports.
13,14
Common medical approaches
toward intervention focus on addressing the medical
etiology, namely, the shoulder joint complex. These
include nonsteroidal anti-inflammatory drugs,
3,15
ste-
roid injection,
2,15,16
and shoulder surgery.
2,17
Inter-
ventions that physical therapists frequently use include
moist heat, ultrasonography, passive stretching, and
shoulder mobilization.
18-21
In addition, there is some
evidence in the physical therapy literature to support
manipulation of the cervical spine or cervicothoracic
spine for shoulder complaints.
22-26
Patients may
experience resolution when treated by these various
methods, but some may have residual pain and reduced
shoulder function even several years after treatment.
3
It
is clear that a more durable intervention is needed.
The purpose of this article is to describe the
outcomes of patients with FSS presenting to a private
chiropractic practice that used a novel chiropractic
treatment, the OTZ Tension Adjustment.
Case series
Case files of 50 consecutive patients presenting with
medically diagnosed FSS between May 2007 and
Fig 1. The three phases of FSS, first described by Reeves.
8
(Adapted from Hsu et al.
3
)
268 F. X. Murphy et al.
March 2008 were identified and reviewed retrospec-
tively. Institutional Review Board approval was
obtained for this retrospective case series (Parker
University IRB Approval # R03_11).
The patients initially presented with active shoulder
abduction restricted to 90° or less in the affected shoulder.
Two primary outcomes were extracted from the patient
records at 2 points in time, upon initial examination and at
the final evaluation: (1) the 11-point verbal Numeric Pain
Rating Scale (NPRS; 0 = no pain to 10 = worst pain
possible), which has been shown to be a valid and reliable
measure in patients with shoulder pain,
27
and (2) the
percentage change in active shoulder abduction, with
100% improvement meaning the patient achieved the
norm of 180° of pain-free active abduction.
28
Shoulder
abduction was measured twice, at the initial and final
visits, by the same assessor using a wall goniometer
(Fig 2) with the patient's humeral head positioned in the
center of the circle. Each patient received a series of
chiropractic manipulation treatments, by the same
practitioner, focusing on the cervical and thoracic spine.
The manipulation included an adjustment called the
One-to-Zero (OTZ) Tension Adjustment (OTZ Health
Education Systems, Dallas, TX). The OTZ Tension
Adjustment aims to correct occipitoatlantal articular
dysfunction (C0-C1 chiropractic subluxation).
29
It is
theorized that the technique identifies aberrant align-
ment of the occipitoatlantal articulation through visual
inspection and motion palpation.
29
In the procedure,
the doctor is seated at the head of the supine patient and
first performs a specific skull glide to determine the
exact orientation of the dysfunctional joint
10
(Fig 3). A
high-velocity, low-amplitude thrust is delivered at the
level of the dysfunctional C0-C1 joint into the direction
of maximal restriction. The general line of drive is
posterior to anterior, lateral to medial, and slightly
superior to inferior (Fig 4).
10
After the adjustment is
made, the skull glide palpation is performed again to
confirm correction of the dysfunction.
Results
Of the 50 case files reviewed, 40% were male (n =
20) and 60% were female (n = 30); and all were
between the ages of 40 and 70 years. The median
number of days in the treatment program was 28 days,
with a range of 11 to 51 days, and interquartile range
(IQR) of 12.5 days. The median initial NPRS score
was 9 out of 10 with a range of 7 to 10 and an ICQ of
1.0. The median final NPRS score was 2 with a range
of 0 to 10. The median change in NPRS score was −7
with a range of 0 to −10. Of the 50 cases, 16 resolved
completely, regaining 180° of pain-free active shoul-
der abduction (and 0 NPRS score). Another 25
showed 75% to 90% improvement in active abduc-
tion, 8 showed 50% to 75% improvement, and 1
showed 0% to 50% improvement (Table 1).
Fig 2. Example of one patient with FSS before (left) and after (right) an OTZ Tension Adjustment. (Color version of figure is
available online.)
269Frozen shoulder
Discussion
Frozen shoulder syndrome is a common condition of
insidious onset affecting middle-aged persons, yet its
etiology is still unclear. The current medical approach
is slow to show progress; and also, there is presently
little evidence to support chiropractic management of
this condition. The results of this case series are
encouraging in that many of these patients’complaints
seemed to improve or resolve within 1 month of
presentation, whereas, in general, it is thought that FSS
symptoms can persist for 2 years or more.
8
It is speculated that the etiology of FSS lies in altered
neuromechanical function of the trapezius muscle.
Increased hypertonicity of the upper fibers of the upper
trapezius and sternocleidomastoideus (SCM) creates an
adverse positioning of the occipitoatlantal articulation.
30
It is posited that forward head posture results in this
abnormal tonus and may therefore cause dysfunction in
the spinal accessory nerve and/or trapezius and/or SCM.
This dysfunction may then cause the inability of the
trapezius to properly position the scapula in preparation
for shoulder abduction greater than 90°. This will
produce the first hallmark of FSS: a decrease in shoulder
range of motion (ROM). Improper positioning of the
scapula may result in the humeral head compressing
sensitive tissue in the subacromial space, which would
cause the second hallmark of FSS: pain on scapulohum-
eral elevation. This biomechanical alteration will result
in inflammation and, over time, in inter- and intraarti-
cular adhesions and fibrosis, often seen in long-standing
disease and evidenced by radiographic or arthroscopic
examinations.
3
However, it is hypothesized that the
fibrosis and adhesions are the sequelae of neurobiome-
chanical alterations involving forward head posture and
trapezius and scapulocostal articulation dysfunctions,
and not the cause of the syndrome itself (Fig 5).
It is further hypothesized that the OTZ Tension
Adjustment restores normal function of C0-C1, trape-
zius, and SCM, thereby restoring normal glenohumeral
mechanics, improving shoulder ROM, and reducing
pain on elevation of the arm.
Conservative (ie, nonsurgical) medical interventions
for FSS include nonsteroidal anti-inflammatory drugs,
steroid injections and oral steroids, nerve blockades,
hydrodilatation, heat therapy, stretching, and manipu-
lation under anesthesia.
3
The evidence suggests that,
after 3 or more months of traditional treatment, patients
experience a reduction in pain and improved function.
3
In addition, although manipulation under anesthesia
has been extensively described in the medical literature,
it is routinely only performed on the shoulder joint
Fig 3. OTZ specific skull glide example positioning.
(Color version of figure is available online.)
Fig 4. OTZ Tension Adjustment setup positioning. (Color
version of figure is available online.)
Table 1 Profile of patients in study (N = 50)
Age range (y) 40-70
Male:female 20:30
Median # days in treatment (IQR) 28 (12.5)
Median # treatments (IQR) 7 (4.0)
Median treatment frequency: #/mo (IQR) 8 (2.0)
Median initial NPRS score (IQR) 9 (1.0)
Median final NPRS score (IQR) 2 (2.0)
Median change in NPRS score (IQR) −7 (2.0)
Percent improvement in active abduction ⁎(n)
90%-100% 16
75%-900% 25
50%-75% 8
Less than 50% 1
NPRS: 0 to 10 (with 0 = no pain, 10 = worst pain ever). IQR,
interquartile range.
⁎Percentage improvement in active shoulder abduction of
affected shoulder at final assessment.
270 F. X. Murphy et al.
complex, does not involve any spinal joints, and has
also been associated with a number of serious
iatrogenic complications.
3
A safer and more immediate
conservative therapy is needed.
It has been previously shown that some shoulder
complaints resolve after practitioner-applied manipula-
tion.
18,22-26,31-33
However, with regard to the efficacy
of chiropractic adjustments specifically for shoulder
complaints, the current evidence is limited,
34
consisting
of one small pilot study,
12
a qualitative study,
35
and a
number of case reports
13,14,34,36
(such as this one). It is
clear that additional efficacy research is needed.
In this case series, patients presented with medically
diagnosed FSS; however, they all exhibited some
degree of shoulder pain and reduced shoulder abduc-
tion. Because syndrome diagnoses are often vague and
confusing, there is currently a trend away from many
shoulder diagnoses, such as FSS or adhesive capsulitis,
and toward a more descriptive term such as shoulder
pain or shoulder pain and dysfunction.
24,31
Future
research should follow this trend.
Limitations and future research
Because there have been no studies yet published on
this technique, a case series format was the logical place
to start. As a result, the limitations of this study are those
for any case series, such as that the management of these
patients occurred within a private chiropractic practice,
which was not controlled.
37
Another limitation is the use
of a measure thatitself lacks evidence of validity. A more
accepted measure of joint ROM would have strength-
ened our findings, as would the use of continuous rather
than discrete data. The inclusion of additional clinical
information, such as duration of symptomatology before
presentation and number of adjustments given, would
have also strengthened this case series.
Caution is urged when drawing definitive conclusions
from these results or when generalizing to other
patients.
37
This study would have been strengthened
by the reporting of the length of time the patients had
the FSS symptoms before presentation. As well, long-
term follow up to identify if there was reoccurrence is
suggested for future studies.
Future research could include a 2-pronged approach.
First, a randomized controlled clinical trial could be
conducted to ascertain if a cause-and-effect relationship
exists between the OTZ Tension Adjustment and relief
of FSS symptoms. Second, basic science research could
be applied to determine if neurological dysfunction
(including CNXI) is involved in FSS pathogenesis.
Future research is warranted and should consist of
experimental clinical trials testing the effectiveness of
the OTZ Tension Adjustment in a controlled setting.
Conclusion
This retrospective case series of the outcome of
chiropractic treatment for patients with FSS using the
OTZ Tension Adjustment for FSS was reported with
encouraging preliminary results.
Funding sources and potential conflicts
of interest
No funding sources were reported for this study.
Francis Murphy and Louis D'Amico are principals and
owners of OTZ Health Education Systems.
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