Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor Imagery in an Individual With Frozen Shoulder

Abstract

Study Design Case report. Background Aggressive physical therapy in the freezing stage of frozen shoulder may prolong the course of recovery. Central sensitization may play a role in the early stages of frozen shoulder. Pain neuroscience education, tactile discrimination, and graded motor imagery have been used in a number of conditions with central sensitization. The purpose of this case report was to describe the examination and treatment of a patient in the freezing stage of frozen shoulder using pain neuroscience education, tactile discrimination, and graded motor imagery. Case Description A 54-year-old woman with a diagnosis of frozen shoulder was referred by an orthopaedic surgeon following lack of progress after 4 weeks of intensive daily physical therapy. Pain at rest was 7/10, and her Shoulder Pain and Disability Index score was 64%. She had painful and limited active range of motion and elevated fear-avoidance beliefs. Tactile discrimination and limb laterality were impaired, with signs of central sensitization. A "top-down" approach using pain neuroscience education, tactile discrimination, and graded motor imagery was used for the first 6 weeks, followed by a "bottom-up" impairment-based approach. Outcomes The patient was seen for 20 sessions over 12 weeks. At discharge, her Shoulder Pain and Disability Index score was 22%, resting pain was 0/10, and fear-avoidance beliefs improved. Improvements in active range of motion, laterality, and tactile discrimination were also noted. Discussion Intensive physical therapy in the freezing stage of frozen shoulder may be detrimental to long-term outcomes. This case report suggests that a top-down approach may allow a quicker transition through the freezing stage of frozen shoulder. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2018;48(3):174-184. Epub 19 Dec 2017. doi:10.2519/jospt.2018.7716.

A Central Nervous System Focused Treatment Program for People with Frozen Shoulder: A Feasibility Study.

“…Regarding clinical outcomes, positive effects on pain and shoulder function were observed after treatment which agrees with previous studies using a similar protocol [13]. Speci cally, improvements in shoulder pain and active shoulder exion both after treatment and follow-up measurements and disability scores at follow-up were found.…”

“…No signi cant changes were found in the LRJT and TPDT neither after treatment nor at follow-up. To our knowledge, responsiveness to treatment of these two variables in people with FS had not been previously investigated except for a single case report by Sawyer et al [13],…”

“…where a 10 mm TPDT reduction and improvement of accuracy and response time in the LRJT task were observed after intervention [13]. Fekos et al [39] investigated the e cacy of a treatment combining GMI with mirror therapy in a case-series study of ve patients with diferent shoulder painful conditions including one patient with FS.…”

“…To our knowledge, a CNS-focused treatment had not been used before speci cally for people with FS except in a case report [13]. However, the aforementioned study did not include home training sessions.…”

“…Similarly, Sawyer et al (2018) applied a combination of pain neuroscience education, tactile discrimination training and GMI in an individual with FS. The patient reported signi cant improvements in pain, fear of movement and active ROM [13]. Further high-quality research about the effectiveness of CNS-focused treatments in people with FS is needed.…”