Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor Imagery in an Individual With Frozen Shoulder.
SAWYER, ERIC E. PT, DPT 1,2; MCDEVITT, AMY W. PT, DPT 1,3; LOUW, ADRIAAN PT, PhD 4; PUENTEDURA, EMILIO J. PT, DPT, PhD 5; MINTKEN, PAUL E. PT, DPT 1,6
Journal of Orthopaedic & Sports Physical Therapy.
48(3):174-184, March 2018.
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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" impairmentbased 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.
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