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Volume 7 | Issue 5
Can Myofascial Treatment with Pulsating Vibrations Improve Mobility for
Patients with Frozen Shoulder? A Case Study
Borg H*1, Bohlin H2 and Ranje-Nordin C3
1Physician, Private Practicing, Sweden
2Business Economics, Private Practicing Manual erapist, Sweden
3Agriculture Animal Science, Private Practicing Human & Equine erapist, Sweden
Case Report Open Access
Citation: Borg H, Bohlin H, Ranje-Nordin C (2019) Can Myofascial Treatment with Pulsating Vibrations
Improve Mobility for Patients with Frozen Shoulder? A Case Study. J Case Rep Stud 7(5): 504
*Corresponding author: Borg H, Md, Physician, Private Practicing, Skördevagen 10, Se 61146 Nyköping,
Sweden, Tel: +46708280536, E-mail: hafr@telia.com
Volume 7 | Issue 5
Journal of Case Reports and Studies
Introduction
Frozen shoulder (FS), adhesive capsulitis, is a common disease characterized by gradual decreased, active and passive movement
of the glenohumeral joint. e disease course is a gradual process that starts with inammation of the synovial uid and progresses
to brosis in the joint capsule, which contracts and solidies, which occurs in four dierent clinical stages (Hannan et al, 2000)
[1]. FS is divided into primary or secondary FS. Primary FS, also idiopathic FS, occurs spontaneously without any known cause
or trauma, while secondary FS is caused by trauma or immobilization of the shoulder (Zuckerman et al, 2011) [2]. e initiator
of synovitis in primary FS is unclear but Kanbe et al (2009) [3] found molecules related with mechanical stress in the synovium.
e rst stage, which lasts a few months, is characterized by inammatory processes in the synovial uid, but the joint capsule is
intact (Hannan et al, 2000) [1]. e patient experiences severe pain during certain movements, which results in a reduced range
of motion (ROM) but also pain at rest and during the night. is can also cause the patient to avoid moving the arm and more
immobility leads in turn to even more stiness and reduced ROM, (Stecco et al, 2013) [4]. In stage 1, the decrease in ROM appears
to be largely due to the pain and not to the joint capsule being densied. ere also were more signs of inammation in stage 1,
which begin to decline in stage 2. In the later stages, changes have begun to occur in the joint capsule's connective tissue which has
begun to densify, and scar tissue and brosis can be seen, and the inammation is declining. e pain has increased gradually and
is more persistent and this can continue for many months up to a year or more. en the pain begins to decrease but the shoulder
becomes more immobile and stier, it has "frozen". FS starts to heal and improves slowly, and this stage can continue for a long
time, up to two years. However, a certain limitation in the ROM oen remains aerwards (Hannan et al, 2000) [1].
Primary FS, without any obvious preceding cause, is diagnosed by history and physical examination while other causes of motion
loss and pain are excluded (Hannan et al, 2000) [1]. Due to the slow creeping course of primary FS, it is common for the patient
not to notice the deterioration in ROM but only to respond to slowly increasing pain in the shoulder (Manske et al, 2008) [5]. FS
is most common between the ages of 40 and 60 and aects about three percent of the population and is also more common in
Abstract
ousands of patients are annually diagnosed with Frozen Shoulder (FS) or adhesive capsulitis, where the joint capsule contracts
and becomes less exible. e condition is painful, with reduced range of motion (ROM) in the shoulder and arm and causes great
suering, oen with diculty sleeping and greatly reduced work ability. e treatment given today is partly conventional treatment
with cortisone or NSAID preparations as well as physiotherapy and other therapeutic treatment which usually have limited eect. e
study investigates whether myofascial treatment, using a device generating deep pulsating vibrations, can provide increased ROM and
facilitate for these patients. 23 patients diagnosed with FS were included in the study. ree treatments were performed, within set time
intervals. e ROM was measured before and aer each treatment, pictures were taken with a thermography camera and angles were
measured. e result showed that 87 percent got an increased ROM by 30 degrees or more, that 52 percent of the patients improved
ROM by 60 degrees or more, and that 30 percent regained full ROM. 61 percent of the patients also reported improved quality of
sleep. e study indicates that this treatment could possibly improve ROM and well-being for patients with FS. Further studies are
recommended to evaluate and validate these ndings. A validated treatment of FS could mean great socioeconomic benets and an
increased quality of life for patients diagnosed with FS.
Keywords: Frozen Shoulder; Adhesive Capsulitis; Fascia; Myofascial Pain; Fascia Treatment; Myofascial Treatment
ISSN: 2348-9820
Received Date: September 9, 2019 Accepted Date: October 26, 2019 Published Date: October 29, 2019
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women. Also, patients with diabetes are at increased risk of getting the disease (Manske et al, 2008) [5]. e condition is dicult
to treat and hitherto, treatments consist of corticosteroids and NSAIDs as well as physiotherapy and home exercises with limited
results. It is known that vibration and oscillation stimulate and facilitate circulation and ow in the fascia and release tension
(Comeaux, 2010) [6].
e fascia has a variety of functions, including power transmission, movement, stability, proprioceptive communication and
by providing a sliding layer and reducing friction in connection with movement (Kumka and Bonar, 2012) [7]. e fascia is
abundantly innervated and contains a large number of free nerve endings and proprioceptors (Stecco et al., 2007 [8]; Stecco
et al., 2013 [4]; Bhattacharya et al., 2011) [9]. Densication and adhesions in the fascia and its extracellular matrix (ECM) are
related to decreased glide ability due to increased viscosity (Stecco et al., 2011, 2013, 2018; Langevin et al., 2011; Chaitow, 2014)
[4,10,11-13]. Stecco et al suggest that the viscoelasticity of fascia can modify activation of the nervous receptors within fascia.
ese mechanoreceptors respond to the viscoelasticity in surrounding tissue and if they are overstimulated, they can become
nociceptors (Stecco et al, 2007, 2013) [4,8].
Cells in the fascia, specialized in producing hyaluronic acid (HA) for the ECM, like the cells in the subsynovial membrane, have
been demonstrated, together with the importance of the role of HA in maintaining the viscoelasticity of a healthy fascia and how
this aects a variety of pathological conditions such as myofascial pain, muscle contractures, densication, brosis, etc. (Stecco
et al., 2011, Stecco et al., 2013; Stecco et al., 2018) [4,10,11]. It has been known in the past that changes in HA concentration
are associated with inammation and degenerative joint diseases (Temple-Wong et al., 2016) [14] and that problems with the
facial glide function can interfere with the whole tissue's function and induce pain (Stecco et al, 2013 [4]; Bordoni et al, 2014)
[15]. It is also generally known that HA has an active role in the healing processes of the tissue. HA is a high molecular weight
polysaccharide and is a key component of the ECM in the loose fascia, including between deep fascia and muscle, within muscles
and between the collagen layers in the deep fascia. It is also a major component of articular joint synovial uid, where it provides the
viscoelasticity and lubrication to protect the joint cartilage. HA has a wide variety of physiological functions in the body, including
maintenance of a viscoelastic cushion to protect tissues and to facilitate smooth gliding during movement and in transmission
of force from muscle contraction, receptor mediated signaling, cell migration, inammation and healing properties. us, HA
has a fast turnover rate and it is also known that it behaves like a non-Newtonian uid at high concentrations and becomes more
viscous (Stecco et al, 2014; Cowman et al, 2015) [16-18]. During inammatory conditions, concentrations of HA is increased,
and the molecules are degraded to shorter chains and lower molecular weight. Changes in HA concentration, molecular weight,
inammatory modications of HA, binding interactions with other macromolecules, temperature and pH with more, aect the
viscoelastic properties of HA and can have dramatic eects on the sliding properties of the fascia. e higher the concentration,
the higher the viscosity. (Cowman et al, 2015) [18].
Immobilization of a body segment (as with pain caused by FS) can lead to an increase in the concentration of HA within and
between the epimysial fasciae and thus increase the uid viscosity which in turn decrease the fascial gliding between the layers and
give cause for stiness (Okita et al, 2004; Stecco et al, 2013) [4,19]. Reduced ROM can also give rise to shortening of sarcomere
length in muscle bers in the early stage of immobilization. ese changes can increase the number of cross bridges attached
during contraction and aer several weeks of immobilization the collagen brils arrangement in the endomysium adapts and
become more circumferential instead of longitudinal to the axis of the muscle bers (Okita et al, 2004; Cowman et al, 2015) [18,19].
In conditions of inammation, the concentration of HA increases and the HA-chains begin to entangle into complex arrays and
altering the viscoelastic properties that can give rise to myofascial pain. en, the HA becomes adhesive rather than lubricating,
and the distribution of ROM in lines of force, within the fascia become altered. By increased viscosity, the receptors within the
fascia can get over-stimulated and send a pain message from a degree of stretching of the fascia that is even within the physiological
range (Stecco et al, 2007, 2013) [4,8]. When concentration of HA is altered, it triggers a cascade of changes, leading to brosis due
to the deposition of collagen within and between muscle bundles. is in turn leads to further increase in ECM viscosity in the
surrounding tissue and restarting the circle (Stecco et al, 2013 ; Stecco et al, 2014) [4,16,17].
e study investigates whether myofascial treatment around the shoulder and myofascial chains (Myers T W, 2013) [20], (in and
between muscles, around tendons, joint capsules), using a device generating deep pulsating vibrations, can provide increased
ROM and reduced pain for patients with diagnosed primary FS.
e eect of treatment using devices generating deep pulsating vibrations has been tested clinically on horses where changes in
muscle tone were measured by multifrequency bioimpedance analysis (Harrisson et al, 2015) [21]. e eect of a similar treatment
procedure applied to the shoulders has been studied by Bhagwat, (2010) [22].
e selection of patients was made using online advertising. e inclusion criteria were a) patients diagnosed with primary FS
and b) patients willing to participate in the study. Exclusion criteria included patients who suered from trauma such as bone
fractures, ligation in the shoulder or whiplash injury over the past six months as well as those who have performed arthrodesis,
who were pregnant, had implanted prosthesis or suered from severe osteoporosis.
Materials and Methods
Patients
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3 Journal of Case Reports and Studies
52 patients applied for the study. 12 were excluded for meeting the exclusion criteria. 23 patients with FS were randomly selected.
e 23 spots were made available via an online booking system and the 40 remaining applicants were invited by email. e rst
23 patients signing up were called within two days to verify their diagnosis. e study was designed with three sets of three
treatment sessions. e rst set had ve spots and the second and third had nine spots each. At the rst session the patients were
given written and oral information regarding the study, including background, purpose, study design, consequences and data
processing. e patients gave a written consent that they had received the information as well accepting the terms and conditions
of the study stating that the study was voluntary meaning they could choose to drop out at any given time, they were to receive
no compensation other than the treatment itself and that they were not to undergo any other treatments during the study period.
Of the 23 patients who started the study, 17 completed all three treatments. ree patients interrupted and dropped o the study
aer the rst treatment and two patients dropped o aer the second treatment. One regained full ROM aer the rst treatment
and decided not to continue, three patients cancelled for personal reasons and two patients excluded themselves from the study
by getting other treatment in between the sessions. e gender distribution was 15 women and 8 men in the age range 27 - 89
years. e duration of symptoms was from two months to two years.
e devices used in the study to generate deep pulsating vibrations were Atlasbalans M1 and Atlasbalans M2. ese devices
provide mechanical vibrations at a variable frequency between 400 to 1200 pulsations per minute in a sine wave. ermography
camera FLIR T540 is used for documentation of ROM. A thermography camera was chosen to keep the patient's images
anonymous. ROM was measured using a protractor with 170-180° assessed as full ROM with the arm straight up.
e treatment included three treatment sessions. Treatment one and two were performed with 7 days intervals and the third
treatment 37 days aer the rst treatment. Before the rst treatment the patients were asked when and how the symptoms
appeared. Before the second and third treatment the patients were asked about what they had experienced since the last session.
Before each session, patients were also asked about their experience of perceived pain and their quality of sleep. No pain scales
were used to measure the answers.
At each occasion, the movement of the arms was measured aer a specic pattern, items 1-6 and images 1-6. e movements
were performed with both right and le arm regardless of side with dysfunction. e same movements were performed before
treatment and aer treatment. e ROM was documented with a thermography camera, twelve images of the upper body at each
occasion. Images were taken in six dierent positions, six before and six aer treatment item 1-6. e thermography images
make the patient anonymous and at the same time they can give an indication of inammation (high heat) or poor circulation
(abnormally cold). In order to repeat the measurements in the same way, all images were taken from the same distance (200 cm),
height (150 cm) and from the same angle (90 degrees from the oor). Photography takes place with the patient standing against a
light-colored background on a mat with markings where the patient should set their feet. is is to ensure that the patient always
has the same starting position. e following angles were imaged in the following order (Item 1-6). is shows a patient with full
ROM, 170-180°. Angels were measured with a digital protractor placed on the images.
e study was approved by the Swedish Ethical Review Authority in the spring of 2018.
Equipments
Arrangement
Photographing
Figure 1: ermographic image on item 1-6
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Results
1. Back to the camera, arms loosely hanging straight down.
2. Back to the camera, right arm is stretched straight up in abduction.
3. Back to the camera, le arm is stretched straight up in abduction.
4. Face to the camera, arms loosely hanging straight down.
5. Face to the camera, right arm is stretched straight up in abduction.
6. Face to the camera, le arm is stretched straight up in abduction.
1. M. Supraspinatus towards the shoulder joint.
2. All muscles between scapula and thoracic spine, M.Levator scapula, M.Serratus, M.Splenius, M.Rhomboideus, M.Trapezius
thoracis.
3. Scapula's lower part, M.Infraspinatus, also M.Triceps brachii’s origin at the shoulder joint.
4. Skull base and the neck side and the whole M.Trapezius cervicis towards the shoulder joint.
5. Lateral side of the upper arm, M.Deltoideus and all muscle attachments to deltoid tuberosity of humerus.
6. e lower part of the thoracic spine, the lower part of M.Trapezius thoracis and under the scapula to reach the M. subscapularis,
with the arm behind the back.
7. M.Biceps brachii’s long tendon, bursa intertubercularis and M.Pectoralis attachment to shoulder and upper arm.
8. M.Biceps brachii.
9. M. Pectoralis major and minor
10. M. Subclavius
Of 23 patients who started the study, 17 completed all three treatments. ree discontinued aer the rst treatment (one regained
full ROM aer one treatment) and three terminated aer treatment number two. Of the 17 who completed, seven regained full
ROM. All patients were given increased ROM to varying degrees. 61 percent of total 23 patients experienced an improved quality
of sleep. Two of the patients who regained full ROM have had the problems between one to two years. e concentration of heat
in the neck noted on three patients, disappeared in all cases aer the rst treatment. Six patients had limited improvement aer
the treatment (See Table 1, Patient ID FS01, FS03, FS8, FS10, FS11 & FS20), and all of them have other issues correlated to fascia
adhesions (Table 2 and 3).
e treatment is a so and deep massage treatment. Treatment of the neck, upper back and arm was performed with two devices
for about 40 minutes. e following areas were treated.
Treatment
Patient
ID
Age Gender FS duration
in months
®ROM Day
1 before
®ROM Day
1 aer
®ROM Day
7 before
®ROM Day
1 aer
®ROM Day
37 before
®ROM Day
1 aer
∆®ROM Full
ROM
Improved
sleep
FS01 52 W 7-9 65 95 105 110 115 120 55 X
FS02 57 W 5-7 80 180 180 180 180 180 100 X
FS03 42 W 14-16 50 90 40 X
FS04 41 W 7-9 100 180 80 X
FS05 51 W 4-6 30 90 60
FS06 56 M 6-8 80 120 125 140 140 150 70 X
FS07 50 W 6-8 65 130 75 115 50 X
FS08 42 W 5-7 65 90 95 110 95 110 45 X
FS09 46 W 5-7 135 180 180 180 180 180 45 X X
FS10 48 W 4-6 50 80 70 80 30
FS11 69 M 10-11 75 90 80 90 80 100 25 X
FS12 62 M 1-2 100 180 115 170 140 140 40
FS13 89 W 11-13 65 115 100 150 150 160 95
FS14 47 W 9-11 70 140 150 160 180 180 110 X X
FS15 49 W 10-12 90 135 140 160 120 135 45 X
FS16 47 M 5-7 160 170 170 170 10 X
FS17 47 W 3-5 135 150 160 160 160 160 25
FS18 45 M 22-24 100 170 140 180 180 180 80 X
FS19 58 M 12-14 135 160 130 170 130 170 35 X
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e study shows positive results for myofascial treatment, using a device generating deep pulsating vibrations, as an alternative
for the participating patients diagnosed with Frozen Shoulder (FS). e result shows that the treatment, in a short time, provided
increased ROM in the adhesive shoulder and in some cases the ROM was fully recovered. All patients perceived the treatment as
pleasant and no patient’s condition got worse aer the treatment.
Nine patients regained full ROM and of these, seven were most likely in stage 2 of FS (Hannan et al, 2000) [1], (one of them
regained full ROM aer the rst treatment and dropped o the study). e other two patients regaining full ROM had had FS
between one and two years, stage 3-4, and therefore might have been in a recovery phase, meaning that the treatment could have
been speeding up an already existing healing process. In stage 2 of the disease, the inammatory process in the synovial uid
begins to decrease and instead the connective tissue in the joint capsule begins to densify with increased brosis as a result. at
could indicate that the treatment aects the ow in connective tissue and reduces the brous formation in the joint capsule so
that the process turns faster as the inammation processes have decreased. 61 percent, 14 of total 23 patients, also perceived an
improved sleep.
Six of the eight patients that had limited eect of the treatment (less than 60° increased ROM) had other underlying symptoms
than FS. Two patients had peritendinitis calcarea, one had had surgery in both knees, two patients had an atrophied deltoideus
muscle and one had ceacum appendix surgery ten months prior to the rst session. ese problems may have had an eect on the
results, perhaps due to connective tissue/muscle interactions, abnormal movement pattern, fascia adhesions and so on.
e documentation of the ROM was made with a thermography camera and these images at the same time show that some
patients had a clearly increased heat image around the neck-shoulder portion before treatment which disappeared aer the rst
treatment. Inammation of the tissue gives an elevated heat image and the result indicates that as the ow in the tissue around the
painful area improves, this gives a more even temperature in the tissue. ere may be a connection between inammation in the
tissue and pain, as well as demonstrated in previous studies (Linnman et al 2011, Hoheisel et al 2015, & Wilke et al 2017) [23-25].
A major component of the fascia is HA, which aects the density in the fascia (Stecco et al, 2011, Stecco et al., 2014) [10,16,17].
HA is a high molecular weight polysaccharide in healthy tissues and is a key component of the ECM in the loose fascia, including
between deep fascia and muscle, within muscles and between the collagen layers in the deep fascia. It is also a major component
of articular joint synovial uid, where it provides the viscoelasticity and lubrication to protect the joint cartilage. It is known that
the concentration and composition of HA in the ECM of the fascia is associated with inammation and joint problems (Temple-
Wong et al., 2016) [14]. HA has an important signicance for the slide and glide function and densication and adhesions in the
fascia ECM are linked to reduced sliding ability (Langevin et al., 2011; Chaitow, 2014) [12,13]. ough HA has a non-Newtonian
behavior, it is possible that the deep vibrations and pressure aect the viscosity of the HA to decrease, in a short time. Massage,
manipulation, or physical therapies can cause disaggregation of the pathologic chain-chain interactions and a reversal of the
aggregation of the HA fragments, by an increase of the subcutis temperature to 40° there is a change in viscosity (Stecco et al,
2013) [4]. Stecco et al. assume that this increase in temperature will not alter the quantity of HA but rather its structure and
associative behavior. Treatment which only increases the temperature therefore gives short lasting eects. When HA is subjected
to mechanical stress, such as manual deep friction or vibration, it is depolymerized, and lower molecular mass polymers are
generated which help to restore the quality of HA and heal and re-establish a normal tissue sliding in the endo-, peri- and
epimysium and deep fascia. is smaller HA polymers are highly inammatory, angiogenic and immunogenic (Noble, 2002;
Discussion
Patient
ID
Age Gender FS duration
in months
®ROM Day
1 before
®ROM Day
1 aer
®ROM Day
7 before
®ROM Day
1 aer
®ROM Day
37 before
®ROM Day
1 aer
∆®ROM Full
ROM
Improved
sleep
FS20 68 W 6-8 50 130 100 125 80 85 35
FS21 27 M 3-5 70 160 135 180 180 180 110 X X
FS22 42 W 8-10 60 110 70 100 90 150 90 X
FS23 45 M 3-5 70 140 155 180 180 180 110 X X
Table 1: Summary of the results
No >30° >45° >60° >90° Full Imp sleep
Tota l 23 20 16 12 9 9 14
Percent 100 % 87% 70% 52% 39% 39% 61%
Table 2: Increased ROM in degrees calculated on all 23 patients in the study
No >30° >45° >60° >90° Full Imp sleep
Tota l 17 15 13 12 10 9 12
Percent 100% 88% 76% 59% 53% 41% 71%
Table 3: Increased ROM in degrees calculated on 17 patients who continued the whole study
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Conclusion
Conict of Interest
e study has a lot of decits. It is a small study with a few patients, but it indicates a clear improvement in the ROM and
the patients perceived reduced pain. Also, it is dicult to get patients to complete the treatment, as it may feel unjustied to
continue as they have improved or got rid of their pain. ere is also uncertainty with determining diagnosis, as there may
be other underlying causes than FS to the shoulder problems. e duration period that the patients have had problems varies,
which means that they have been in dierent phases (Hannan et al, 2000) [1] and this most likely gives dierent eects of
the treatment. Photographing and measurement of ROM are also a source of misinterpretation, in some cases the movement
is not entirely pure abduction when the patients strain themselves and folded the body. Additional sources of error are the
measurement of the angles with the protractor.
Stecco et al, 2013, 2014) [4,16,17,26]. Stecco et al. suggest that manual manipulation with deep compression and friction is able
to catalyze this reaction and that this self-resolving inammatory reaction is the mechanism that restores the correct quantity
and quality of substances in the fascia. e results indicate that myofascial treatment using a device generating deep pulsating
vibrations reaches deeper in the tissue than manual manipulation and massage, but the physiological mechanism behind the
successful treatments have to be further investigated. Ness et al. [27] and Usuki et al. [28] also have found that treatment with
vibratory stimulation for spasticity gives promising results.
e study indicates that myofascial treatment with deep pulsating vibrations could be a valuable alternative for shortening the
healing process and providing increased ROM and thus quality of life for patients diagnosed with FS. Using this type of treatment
in the care process for these patients could be an easy and pleasant way to shorten the course of the disease. Further studies are
recommended with larger patient groups as well as clinical studies to evaluate and validate the treatment eect in general and
the ndings of this study. If validated, a treatment method for patients with FS, could mean great socioeconomic benets and an
increased quality of life [29].
is study was initiated by physician Håkan B aer discovering that more than y patients got increased mobility as a result
of myofascial treatment with deep pulsating vibrations. As the main author, Håkan B receives no nancial contribution and
guarantees the publishing ethics and the unbiasedness of the study. Camilla RN has been working independently with myofascial
treatment since 2015 and receives no nancial contribution. Hans B has been working with myofascial treatment since 2012 and
has invented the myofascial treatment devices and the treatment process used in this study.
5. Manske RC, Prohaska D (2008) Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med 1: 180-9.
6. Comeaux Z (2011) Dynamic fascial release and the role of mechanical/ vibrational assist devices in manual therapies. J Bodyw Mov er 15: 35-41.
7. Kumka M, Bonar J (2012) Fascia: A morphological description and classication system based on a literature review. J Can Chiropr Assoc 56: 179-91.
1. Hannan JA, Chiaia TA (2000) Adhesive capsulitis. A treatment approach. Clin Orthop Res 372: 95-109.
2. Zuckerman J D, Rokito A (2011) Frozen shoulder: a consensus denition. J of shoulder elbow surg 20: 322-32.
3. Kanbe K, Inoue K, Inoue Y, Chen Q (2009) Inducement of mitogenactivated protein kinases in frozen shoulders. J Orthop Sci 14: 56-61.
4. Stecco A, Gesi M, Stecco C, Stern R (2013) Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep 17: 352.
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