Why an Outsider?

I call myself an “outsider” because I am not a physical therapist, yet I am writing on the topic of physical therapy.  My special interest in shoulder rehabilitation evolved during fifteen years working as a thoracic surgeon and twenty years working as an occupational medicine physician.

While a thoracic surgeon, I performed about 3500 thoracotomy operations.  During these procedures, four major chest wall muscles are at least partially divided: the serratus anterior, latissimus dorsi, pectoralis major, and rhomboid muscles.  A fifth chest wall muscle, the intercostal muscle, is completely divided from the lateral sternum to the spine to allow the ribs to spread apart.  As a result, thoracotomy incisions are quite painful for two or three weeks and sometimes longer.  They are similar in pain level to two or three broken ribs.  No patients want to abduct or forward flex their arm after a thoracotomy incision because of the pain.  Thoracotomy patients share the same rehabilitation challenge as shoulder tendonitis or post-operative shoulder surgery patients.  Both are reluctant to abduct or forward flex their arms.

I served as a “substitute” physical therapist in rehabilitating these 3500 thoracotomy patients.  I also treated about 250 referred cases of frozen shoulder syndrome with aggressive physical therapy exercises.

Many patients with shoulder injuries or surgery complete all of their allowed physical therapy rehabilitation without reaching the desired range of motion end goals.

The Worst Complication of Shoulder Injuries

Frozen shoulder syndrome, or adhesive capsulitis, is the worst complication of shoulder injuries because: (1) it is usually preventable with aggressive physical therapy, and (2) it produces permanent functional impairment if not corrected early.

Most frozen shoulder cases occur after patients complete their authorized physical therapy sessions and after discharge from orthopedic surgery.  Therefore, the physical therapists and orthopedic surgeons may be unaware the patients have developed a range of motion restriction from their injury.

Factors Contributing to Frozen Shoulder Syndrome

The causes of adhesive capsulitis are multiple, but here is a listing of the most important factors and why this complication develops and may escape notice:

  1. Physical Therapy is usually limited to 24-30 visits for shoulder tendonitis/post-op shoulder surgery by insurance companies.
  2. Some patients (about 20%) do not reach PT goals of 100% of their pre-injury abduction and forward flexion ROM within the allowed 24-30 visits. When patients run out of authorized visits, they are discharged by PT with a parting recommendation and hope: “if you continue to do your home exercises, you should improve and eventually reach your pre-injury range of motion.” Unfortunately, “hope” is not a reliable medical plan for achieving complete restoration of shoulder function.
  3. Patients do not always fully comply with home exercise program recommendations. If they are working and receiving shoulder rehabilitation therapy, they come home tired and sore and with other home duties demanding their time.  Once working, they rarely spend more than 10 minutes per day on home exercises.
  4. Patients often have the mindset that the physical therapy sessions will “fix” their shoulder problem rather than taking responsibility for their own outcome by being self-motivated and compliant with home exercise recommendations.
  5. Physical therapy aids (rubber bands, pulleys, etc.) are used only at home and not during work hours. Using these aids at work would draw too much attention from co-workers.   The work environment emphasizes the importance of having no work injuries, and workers are often recognized or rewarded for having an “accident-free” month or quarter.  In this environment, the last thing a worker wants to do is advertise they were the person responsible for breaking their group or department’s “accident-free” record.  As a result, workers will not use PT aids at work.  Without instruction in alternate exercises they can perform “covertly” at work, they will miss out on opportunities to stretch and exercise their shoulder throughout the day.
  6. Most shoulder rehabilitation exercises are active and involve all of the shoulder muscles. They do not typically emphasize passive stretching techniques that are most effective in restoring the significant functional deficits in forward flexion and abduction.
  7. Patients should be encouraged to perform passive desk and wall stretches for 30-60 seconds on an hourly basis while at work. These exercises can be done without drawing attention to the worker because they are done quickly and without the use of PT aids.  Compliance, therefore, is generally high.  There is always a desk, a wall, or a vertical structure available to perform these exercises at work.
  8. After PT visits are discontinued, patients feel they are “done” and no longer receive continued encouragement from the physical therapist. They continue to have pain with attempts at 180-degree abduction or forward flexion, and therefore stay out of this pain zone with their exercises.  Without ongoing encouragement from their therapist, they gradually lose interest in continuing their home exercises and usually regress from their discharge active ROM measurements.
  9. Patients continue to limit shoulder motion at work and home to the comfortable ROM zone, allowing post-injury functional deficits of abduction and forward flexion to become permanent restrictions.
  10. Patients rarely return to see the orthopedic surgeon in follow-up after discharge from physical therapy. They tend to accept their function limitation as a consequence of the injury or surgery and do not realize they still have a correctable deficit.  As a result, Orthopedic Surgeons and Physical therapists are generally unaware of the number of patients who regress to develop permanent range of motion restrictions.
  11. This deficit is usually recognized by other physicians, such as primary care or Occupational Medicine providers, who continue to follow the patient and negotiate the patient’s work restrictions after discharge from physical therapy.

The problem with Physical Therapy Exercise Aids

What’s wrong with using PT aids,” such as rubber bands or pulleys, in shoulder rehabilitation?  There is absolutely nothing wrong with using them — as long as the patient is spending significant periods of time at home and is unable to work.  At home, these therapy aids are useful and easy to use throughout the day, and convenient.

The problem with patients depending upon aids to perform their home exercises starts when the patient returns to work and is continuing therapy.    Patients usually return to work with restrictions within 2-3 weeks of their injury or surgery, sometimes sooner.  They, therefore, spend at least two-thirds of their entire shoulder rehabilitation period while working.

I have yet to meet any patients who will use PT exercise aids while at work because they attract too much attention.  There is a great deal of emphasis on achieving an accident-free workplace by many employers.  Employers often reward departments that have no reported injuries during the month or quarter a bonus or some other perk.

When a patient has an injury, the last thing they want to do is call attention to themselves as being the injured worker that broke the department’s otherwise perfect “no injury” record.  They do not want to be looked down upon by management, supervisors, and co-workers for being responsible for their department missing out on their “reward” for an injury-free work period.  They work with their recommended work restrictions but want to blend in with the other workers as much as possible.  They may feel guilty that they are responsible for the department not receiving a no-injury bonus or perk and also are afraid of termination if they do not improve rapidly and return to full duty.

Using PT aids as the primary mode of shoulder exercises discourages patients from continuing their shoulder exercises during a major portion of the day when they are at work.  Once back at work, the patient puts in 8 hours per day, comes home tired, and may have to prepare dinner and clean up after dinner before they can relax.  They need to unwind, and work has usually aggravated their shoulder discomfort.  They do not look forward to spending time with home exercises with a painful shoulder after a long day at work.  Therefore, it is unusual for a patient to spend more than 10 minutes total time with a home exercise program while working.  Ten minutes total shoulder exercise time is, unfortunately, not enough to ensure complete recovery of range of motion.

Of the various exercises patients are doing during their daily 10 minutes of HEP, a relatively small percentage is related to correcting their most significant impairment, limited forward flexion, and abduction.  Patients may spend two-thirds of their ten minutes on internal and external rotation exercises and pull-down exercises using rubber bands, leaving only 3-4 minutes for abduction and forward flexion.  If their only abduction and forward flexion home exercise is finger-walking on the wall, an active exercise during which time most patients avoid pushing into the painful arc region, it should be no wonder that their progress in increasing forward flexion and abduction range of motion is less than ideal.  Slow progress is the main reason they do not reach 100% of their function goals within the 24-30 PT sessions authorized.  It is difficult to get approval for more physical therapy beyond 30 sessions, even if the patient has not reached all functional goals.  Insurance companies will cite slow progress with physical therapy as the reason to deny further expenditures using the same modality.

The Most Effective Exercises for Restoring Full Shoulder Function

The most significant functional deficiency after most shoulder injuries or surgery is abduction and forward flexion.  The most effective exercises to increase abduction and forward flexion range of motion are passive abduction and forward flexion stretching, using a table or wall, depending upon the patient’s current range of motion. 

These are more effective than active forward flexion and abduction exercises, such as “finger walking the wall” or lifting light weights because the arm can be raised higher with less discomfort when raised passively.  Forward flexion and abduction exercises are usually begun in physical therapy while the patient still has symptoms of a “painful arc.” Patients will rarely push an active exercise into the “painful arc” range because, well, it hurts!  Sometimes these active exercises will aggravate the level of overall shoulder pain, forcing patients to back off these exercises for a while until pain levels subside.  The greater ROM that can be achieved performing passive stretching allows the injured tendon to moved further, lessening the tendency for adhesions to develop between this inflamed tendon and adjacent tissues.

While I do not doubt that some patients have at some point been shown passive wall abduction and forward flexion stretches by their therapists, I believe these exercises are not emphasized enough by physical therapists.  I say this because, during the past three years of following approximately 200 shoulder rehabilitation patients, I have asked virtually every patient to demonstrate the HEP exercises they are doing.  It surprised me, and may surprise you, that none of these 200 patients demonstrated a passive wall stretch exercise!   Many did demonstrate some form of “finger walking” up the wall.  However, as already noted, this is an active abduction and forward flexion exercise that few patients are willing to push into the range of the “painful arc.”   They spend their time in the “painless” ROM zone, believing they are dutifully following physical therapy advice for home exercises but accomplish little further increase in active ROM.  If passive stretching exercises were being emphasized and encouraged as part of the HEP routine, at least a few of the patients would have been able to demonstrate passive stretches.  Without such exercises, slow progress prevents many patients from reaching their pre-injury range of motion within the limits of their 24-30 authorized PT visits.

Emphasize Stretching Exercises that Patients Can Do While Working

The solution to improving shoulder rehabilitation results is emphasizing passive stretching exercises at work.  These exercises only require 30-60 seconds per stretch, and therefore can be done frequently throughout the day without attracting attention.

I recommend that patients add these passive stretches to their existing HEP routine and perform them at least a dozen times during the workday.  There is always a wall and a desk available in the workplace.  With the minimal time it takes to perform these stretches, patients have little reason not to perform these frequently during the day.  An additional motivation is provided by reminding patients that if they fail to do these exercises often, they may develop a permanent inability to raise their arms straight up.  Reinforce the concept that full functional recovery depends on how diligently exercises at home and work are performed using the correct technique.  The time spent exercising during physical therapy sessions alone is insufficient to ensure complete recovery to pre-injury status.

Key Points in Maximizing Shoulder Therapy Success

  1. Have patients take responsibility for their own improvement by emphasizing that their performance of home exercises will ultimately have a much greater effect on the success of their shoulder rehabilitation than the relatively limited time spent during therapy sessions.
  2. Counter any impression of the patient that they are attending physical therapy sessions to passively “receive” the curative therapy from the therapist. This will motivate patients to take the home exercises more seriously and spend more time on them, facilitating better results.
  3. Encourage passive abduction and forward flexion stretches, using tables initially and then walls as the range of motion increases. When the patient returns to work, passive table or wall stretches can be done easily and covertly without drawing attention from other workers.
  4. Encourage these passive stretches to be done frequently throughout the day since each stretch only takes 30-60 seconds. Stress that the more frequently they are done, the sooner full shoulder function will return.
  5. Measure active abduction and forward flexion with each PT visit, rather than once every several sessions. Failure to progress will be recognized sooner, and insurance companies will see more objective evidence of improvement, making it more likely that requests for additional therapy will be approved.
  6. Focus on the use of PT aids such as rubber bands and/or pulleys when the patient is at home, since these are not practical to use at work. Once the patient is working, with restrictions, shift the emphasis to passive stretching exercises the patient can do throughout the workday, in addition to the exercises done at home.
  7. Teach stretches to be done in the standing position or sitting position with desks, walls, or vertical structures rather than by lying down on a bed or the floor. Patients will not lie down frequently and repeatedly during the day, even if they are not working.  Both compliance and the frequency of exercises will be higher if the sitting or standing position is encouraged.  Performing these exercises while standing requires less set-up time than the same exercise performed lying down.  The resulting increased frequency of the stretches improves the rate of recovery.
  8. Don’t assume that once you demonstrate a passive abduction and forward flexion wall stretch and have the patient demonstrate this back to you, that you can assume the patient will continue to do this exercise correctly. I have been surprised how many times I have had to demonstrate passive stretches to the same patient before they get the hang of the movement required, especially the abduction wall stretch.  Each time you see the patient, ask them to demonstrate the table or wall stretches they are doing at home to ensure they are using an effective technique and that the stretch is passive.
  9. If you are doing passive abduction and forward flexion manipulations during PT sessions, measure the active abduction and forward flexion range of motion BEFORE you do the stretches. You may find it surprising how much range of motion can improve after stretches have been performed.  However, the measured active ROM before passive stretching exercises will be the most accurate estimate of the final ROM the patient will achieve once they have completed all PT sessions.   Measuring ROM only AFTER passive stretches will produce misleadingly optimistic results and may hide evidence of slow progress.
  10. Physical therapists will be unable to continue rehabilitation beyond the number of visits authorized by insurance.  Orthopedic surgeons will generally be uninterested in following patients closely with frequent visits once if they have not reached all therapy goals.  However, Occupational Medicine providers will normally continue to see patients beyond the time period of authorized physical therapy visits.  They can continue to monitor HEP progress and provide continued encouragement to patients until end-goals have been achieved.  Unlike the case with physical therapists, workman’s compensation and private insurance companies do not restrict the number of post-injury visits by Occupational Medicine providers as long as some progress is being made and the patient has not yet reached the desired range of motion goals.  Take advantage of this to extend HEP oversight once no further PT visits are authorized.