A NOVEL APPROACH TO TREATMENT UTILIZING BREATHING AND A TOTAL MOTION RELEASE® EXERCISE PROGRAM IN A HIGH SCHOOL CHEERLEADER WITH A DIAGNOSIS OF FROZEN SHOULDER: A CASE REPORT

Abstract

Background and purpose: Frozen shoulder (FS) is a condition of the shoulder that is characterized by gradual loss of passive and active range of motion of the glenohumeral joint. Current treatment recommendations remain unclear due to the elusive etiology of FS and absence of nomenclature in the literature. The purpose of this case report is to describe the effects of treatment guided by the assessment and treatment of a breathing pattern disorder (BPD) coupled with Total Motion Release® on a 17-year high school cheerleader with a diagnosis of frozen shoulder.

Case description: A 17-year-old female cheerleader reported left anterolateral chest pain after running during cheer practice. The subject continued to experience additional episodes of chest pain and sought out medical care at an emergency department where she was diagnosed with a FS. Clinical findings upon examination included soft tissue muscular irritability, glenohumeral internal and external rotation active range of motion (AROM) loss, and a dysfunctional breathing pattern. Intervention consisted of two types of breathing interventions and a Total Motion Release® (TMR) exercise program. The Numeric Rating Scale (NRS), inclinometer measurements to measure AROM, and breathing assessment outcomes were used to identify patient-reported outcomes and determine treatment effects.

Outcomes: The use of the coupled treatment resulted in a resolution of the patient's primary complaint, an increase in AROM, and an improvement in breathing assessment outcomes. After the first treatment, internal rotation (IR) improved by 27° exceeding a minimal detectable change (MDC) of 8°, and after the second treatment, external rotation (ER) improved by 21° exceeding a MDC of 9°. Equally important, there were improvements in flexion (11°) and abduction (45°) exceeding the MDC of 8° and 4° respectively over the course of treatment. The minimal clinically important difference (MCID) on the NRS was exceeded when the patient returned to activity.

Discussion: In this case report, breathing treatments, coupled with a TMR® exercise program, were beneficial treatments for this patient and provided a clinically meaningful resolution of her condition. Clinicians treating patients who display a similar presentation of frozen shoulder can consider this a possible treatment option.

Levels of evidence: Level 4; single case report.

Keywords: Adhesive capsulitis; breathing pattern disorder; manual therapy.

Figure 1.

The Hi‐Lo Test. The patient is directed to place one hand on their chest and the other hand on their stomach in a supine position. An apical (chest) breather will demonstrate first movement occurring at the chest.

Figure 2.

The “Clamshell” Diaphragm Reset. a. The “clamshell diaphragm reset” is performed with the patient side lying with knees flexed. The patient inhales and then at the end of exhale, the patient holds their breath. b. The patient externally rotates their top leg keeping feet together (opening the clam), while counting to 3. The patient then lowers their leg (closing the clam), while counting to 3. A large immediate inhale indicates successful treatment.^-

Figure 3.

The Optimal Reflex® Triggering Twist and Stretch (ORTTS) Starting Position. a. Starting position: the patient inhales and exhales naturally and completely. b. Ending position: the patient then performs a trunk twist to end range to either the right or left side.

Figure 4.

Arm Raise (AR). The AR involves forward shoulder flexion of the contralateral shoulder to end range. When resistance during movement was felt, the patient was asked to go further into end range releasing any restriction of body parts that were preventing further motion (i.e. cervical, thoracic, or lumbar extension).

Figure 5.

Trunk Twist (TT). The TT involves lumbar rotation to the uninvolved side (least restricted) to end range. When resistance during movement was felt, the patient was cued to go further into end range.

Figure 6.

Back 2 Dimension Side Out Bent Rotate In Arm Raise (Internal Rotation). The patient is instructed to perform shoulder internal rotation in supine on the uninvolved side for three sets of ten. When resistance during movement was felt, the patient was cued to go further into end range.

Figure 7.

Back 2 Dimension Side Out Rotate Out Arm Raise (External Rotation). The patient is instructed to perform external rotation in supine on the uninvolved side for three sets of ten. When resistance during movement was felt, the patient was cued to go further into end range.

Figure 8.

Cervical Extension. The patient is instructed to extend the neck for three sets of ten. When resistance during movement was felt, the patient was cued to go further into end range.

Figure 9.

Right Cervical Rotation. The patient is instructed to rotate the head to the uninvolved side (least restricted) for three sets of ten. When resistance during movement was felt, the patient was cued to go further into end range.

Figure 10.

Sitting 2 Dimension Straight Side Out Rotate In Arm Raise (Shoulder Abduction). The patient is instructed to perform shoulder abduction on the uninvolved side for three sets of ten seated. When resistance during movement was felt, the patient was cued to go further into end range.

Figure 11.

Arm Raise Backward. The arm raise backward involves shoulder extension of the contralateral shoulder to end range. When resistance during movement was felt, the patient was cued to go further into end range releasing any restriction of body parts that were preventing further motion (i.e. cervical, thoracic, or lumbar extension).

Figure 12.

Patient‐reported outcome on the Numeric Rating Scale for chest pain intensity level.