Satisfaction of patients with frozen shoulder following silent manipulation: a prospective observation study

Abstract

Silent manipulation is a procedure for frozen shoulders that involves manipulating the shoulder while the patient is awake by performing C5, C6, and C7 cervical nerve root block under ultrasound guidance. This retrospective study, conducted at Yokohama City University Hospital, aimed to evaluate the clinical outcomes of silent manipulation and assess whether the experience level of the practitioner influenced treatment efficacy. Between October 2020 and January 2022, 53 patients who met the inclusion criteria underwent silent manipulation for frozen shoulder. The procedure was performed by either an experienced or a less experienced practitioner, and the patients were followed-up for up to 1 year post-treatment. Silent manipulation resulted in significant improvements in shoulder range of motion, as measured by forward flexion, abduction, external rotation, and hand-behind-back, as well as in patient-reported outcomes, including disabilities of the arm, shoulder, and hand and Shoulder 36 scores. These improvements were observed 1 week, 3 months, and 1 year after silent manipulation, indicating the short-term efficacy of the procedure. Furthermore, this study revealed that the practitioners' level of experience played a significant role in the outcomes. The experienced doctor achieved better 1st external rotation and belt tying outcomes, as well as Shoulder 36 pain, muscle strength, and activities of daily living domain scores. This suggests that technical expertise in silent manipulation is crucial to achieve optimal outcomes. Silent manipulation offers an effective therapeutic approach for frozen shoulder, leading to significant improvements in range of motion and patient satisfaction. Practitioner expertise is a vital factor in treatment success, emphasizing the importance of skilled professionals in the performance of this procedure.

Keywords: Cervical nerve root block; Frozen shoulder; Patient satisfaction; Practitioner experience; Range of motion; Silent manipulation.

Figure 1

Ultrasound-guided nerve root block. The probe was placed on the neck in the lateral position and the nerve roots of the anterior scalene muscle, middle scalene muscle, C5, C6, and C7 were identified. The needle (arrowhead) was inserted at the upper nerve trunk level and advanced between C5 and C6, below C6, and above C5 and C7; the solution was then injected.

Figure 2

Silent manipulation procedure. (1) Shoulder manipulation at 45–90 degrees of abduction with gradual external rotation. (2) After achieving 90 degrees of abduction and 90 degrees of external rotation, the arm was maximally adducted until the elbow touched the patient’s ribs. (3) The arm was abducted maximally until it touched the patient’s ear. (4) Maximum adduction was then performed, followed by maximum horizontal adduction. (5) The patient’s shoulder under maximum adduction and maximum internal rotation. (6) Full extension was performed. (7) External rotation was performed under maximum extension. (8) Internal rotation and adduction were performed under maximum extension. (9) Internal rotation was performed until the vertebral height of the dominant thumb was equal to that of the non-dominant thumb.

Figure 3

The shoulder range of movement, as evaluated by forward flexion, abduction, and external rotation angles, and the hand-behind-back, was significantly improved 1 week, 3 months, and 1 year after silent manipulation, compared with before silent manipulation. **p < 0.01. ER external rotation, L lumbar, S sacrum, Th thoracic, × Average value.

Figure 4

The DASH and Sh 36 scores were significantly improved 3 months and 1 year after silent manipulation, compared with before silent manipulation. **p < 0.01. DASH disabilities of the arm, shoulder, and hand, Sh 36 Shoulder 36, ROM range of motion. × Average value.

Figure 5

Effect of operator experience on shoulder outcomes 1 year after silent manipulation. The experienced practitioner achieved significantly improved 1st ER angles and belt tying compared with the less experienced practitioner. There were no statistically significant differences in flexion or abduction. *p < 0.05; **p < 0.01. ER external rotation, NP, × Average value.

Figure 6

Effect of operator experience on patient-reported outcomes 1 year after silent manipulation. The experienced practitioner achieved significantly improved Sh 36 pain, muscle strength, and activities of daily living domain scores compared with the less experienced practitioner. There were no statistically significant differences in DASH or Sh 36 ROM or general health scores. *p < 0.05. DASH disabilities of the arm, shoulder, and hand, NP, Sh 36 Shoulder 36, ROM range of motion. × Average value.

Figure 7

Complications of silent manipulation. (1a) Before silent manipulation, rotator cuff was intact. (1b) Immediately after silent manipulation, bursal-sided rotator cuff tears was observed. (2) Immediately after silent manipulation, bone bruise was observed on the posterior aspect of the humeral head.