Shoulder Manipulation: With Anesthesia or Without

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That is not something that we are typically doing in my clinic. The thinking behind it is to get the patient moving.  I think that the hard thing is, depending on what stage the patient is in, determining when that is appropriate or when anything aggressive, whether that is a manipulation without anesthesia or high-grade mobilization, is appropriate. The patient needs to be in that third or fourth stage, either the frozen or the thawing stage, for anything aggressive to even be considered.  I think that if it is done too early, you are probably just going to aggravate things more.  

I think that the challenge of doing a manipulation without the anesthesia is guarding.  If you think about someone under anesthesia, the only thing you have to deal with is the restriction in the capsule.  You are not dealing with them guarding against your movement.  I think that this factor is going to make it tougher to be successful.  Without anesthesia, I would be more apt to look at what the stage they are in and then start seeing them to work on grade 3 and grade 4 mobilizations.  If they are in that thawing stage, I would start adding in more multiangle type things.  I think that the decision behind any aggressive technique outside of an anesthetized scenario is really going to be determined on their reactivity.  That could be manipulation or anything all the way down to a certain grade of mobilization.

I think that the biggest change, as far as management of patients with adhesive capsulitis has probably been in making sure that we are not placing them all into the same category. There are a wide variety of patients, and they all present differently. I think that it really differs as far as what stage they are in, and more importantly, their reactivity level. That will assist in determining the most appropriate form of intervention both with what we are doing in the clinic and what we are asking them to do as part of their home program.