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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 49-53

Management of frozen shoulder with oil cupping massage: A case study


1 Regional Research Institute of Unani Medicine, Patna, Bihar, India
2 Department of Pathology, Central Research Institute of Unani Medicine, Hyderabad, Telangana, India

Date of Submission03-Dec-2017
Date of Acceptance15-Jul-2018
Date of Web Publication30-Aug-2018

Correspondence Address:
Dr. Md Hashmat Imam
Regional Research Institute of Unani Medicine, Patna - 800 008, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijas.ijas_14_17

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  Abstract 


Frozen shoulder is a common condition in which the articular shoulder capsule swells and stiffens, restricting its mobility. Key characteristics are gradual onset of shoulder stiffness, pain especially at night, and restriction in movement of the shoulder. It is generally diagnosed clinically or with the help of imaging technique. Conservative treatments include analgesics, oral steroids, and intra-articular corticosteroid injections. If symptoms persist despite conservative measures, the surgical treatments were adopted. In modern medicine managing, such conditions are really a hard task. In Unani System of Medicine, there is specific treatment which can provide complete relief; for this, an Unani physician acquires different manipulative therapies such as regimental therapy (massage and cupping). In this paper, one such case is discussed in which patient was distressed by the pain and restricting movements of joints so that performing even small daily tasks are impossible for him/her. The treatment of such painful condition without aid of any analgesic with simple regimental therapy (massage and cupping) is really appreciable. The paper also gives the details of the method employed and material required of massage and cupping.

Keywords: Conservative treatments, corticosteroid injections, frozen shoulder, massage and cupping, shoulder stiffness


How to cite this article:
Imam MH, Alam MI, Perveen A, Goswami A, Khan Q, Ahmad T. Management of frozen shoulder with oil cupping massage: A case study. Imam J Appl Sci 2017;2:49-53

How to cite this URL:
Imam MH, Alam MI, Perveen A, Goswami A, Khan Q, Ahmad T. Management of frozen shoulder with oil cupping massage: A case study. Imam J Appl Sci [serial online] 2017 [cited 2018 Dec 14];2:49-53. Available from: http://www.e-ijas.org/text.asp?2017/2/2/49/240162




  Introduction Top


Frozen shoulder (also termed adhesive capsulitis, painful stiff shoulder, or periarthritis) is a common condition characterized by spontaneous onset of pain, progressive restriction of movement of the shoulder, and disability that restricts activities of daily living work.[1],[2] The incidence of adhesive capsulitis is approximately 2%–5% in the general population and 10%–20% in diabetic population. It is rare in children and more common in women especially over 40 years of age.[3],[4] Approximately 70% of frozen shoulder patients are women. In India, more than 10 million cases have been reported per year.[5]

It is a painful and disabling disorder of unclear cause, in which the shoulder capsule, the connective tissue of the shoulder joint, becomes stiff and inflamed, greatly restricting motion and causing persistent pain. Pain is usually constant, worse at night, and with cold weather. Certain movements can provoke episodes of tremendous cramping and pain. The condition is thought to be caused by trauma or injury to the area and may have an autoimmune component. People who suffer from frozen shoulder may have extreme difficulty in concentrating, working, or performing daily life activities for extended periods. Risk factors for frozen shoulder include accidents, lung disease, tonic seizures, diabetes mellitus, stroke, connective tissue diseases, heart disease, and thyroid disease.[6],[7]

Symptoms may start gradually and resolve within 2 or 3 years. People may experience pain areas in the shoulder muscles, decreased range of motion (ROM) of shoulder, or muscle spasms also common. Frozen shoulder can be described as either primary (idiopathic) if the etiology is unknown, or secondary, when it can be attributed to another cause.[6]

The objective and rationale of this paper are to provide an overview of the literature of frozen shoulder and present a case study management through regimental therapy (massage and cupping therapy).

Pathophysiology and natural history

The pathophysiology of frozen shoulder is poorly understood. The analysis of surgical specimens suggests that capsular hyperplasia and fibrosis have a role. The presence of cytokines suggests a possible autoimmune process, but the relationship is not well established.[8] The normal course of a frozen shoulder has been described as having three sequential phases:

  • First phase (pain and freezing phase): Pain is worse at night. Pain increases with any movement. It may last up to several months[9],[10]
  • Second phase (stiffness or frozen phase): ROM is limited as pain is diminishing. It may last up to 1 year[11],[12]
  • Third phase (resolution phase): It may begin to resolve over time. It may last up to 3 years[13]


Etiology

The cause for frozen shoulder is unknown. In spite of that, there are a number of risk factors include:

Diabetes

Diabetic patient has a higher rate of frozen shoulder 10%–20% compared to the general population.[14]

Immobilization

Frozen shoulder can develop after a shoulder has been immobilized for a period due to surgery, fracture, or other injury.[15]

Other diseases

Some other diseases increase the risk of developing frozen shoulder, including hypothyroidism, hyperthyroidism, depression, cardiovascular disease, lung disease, open heart surgery, polymyalgia, and Parkinson's disease.[16]

Management

The management of frozen shoulder focuses on restoring joint movement and reducing shoulder pain, involving medications, physical therapy, and/or surgical intervention. Treatment for frozen shoulder usually starts with nonsteroidal anti-inflammatory drugs and application of heat to the affected area, followed by gentle stretching. Ice and medicines (including corticosteroid injections) may also be used to reduce pain and swelling. Moreover, physical therapy can help increase ROM. Mostly, patients seek help of Unani medicine in such disabling chronic painful conditions with the hope of some miracle. Unani is promising healing therapy being more beneficial for such patients in which oral medicaments cannot be given for long duration. On the basis of signs and symptoms, this disease can be correlated with a disease described as Tahajjure wa salabat e kataf in Unani classical. Tahajjure wa salabat e kataf is a humoral disease in which good humor is replaced by bad humor causing frozen the entire joint structure, especially capsules. Therefore, the management of frozen shoulder with the help of regimental therapy (massage and cupping) was planned for the present case study.


  Case Report Top


A 60-year-old male presented with unilateral pain and stiffness of shoulder joint (right side) along with severe restriction of upward elevation of shoulder joints both active and passive movements of upper limbs are restricted. Pain is constant in nature that become worst at night and when the weather is colder; the patient is unable to perform even small tasks due to restricted upward movement of limbs.

History of present illness

There is no history of any trauma or physical injury. Onset is insidious starting with pain and stiffness that progress in severe restriction of shoulder joints movement. The patient did not have diabetes mellitus.

General physical examination

  • Blood pressure = 126/84 mmHg; pulse rate = 84/min
  • Pallor − ve; icterus − ve; cyanosis − ve
  • Clubbing − ve; edema − ve
  • Cardiovascular system: S1 S2 audible and normal; chest: Clear no added sound
  • Central nervous system: Level of consciousness, attention, orientation, memory recall, and speech all are normal
  • Reflexes: Upper limb – present and normal; lower limb – present and normal; ankle Jerk – present; plantar response – flexon
  • Muscle power: 2/5 in the right upper limb, 5/5 in the left upper limb, 5/5 in both lower limbs
  • Muscle tone: Normal
  • Muscular atrophy: Not present
  • Shoulder joint examination: Left side is normal and right side is as follows.


    1. Swelling: Absent
    2. Tenderness: Present
    3. Restriction of range of movement: Active ROM (AROM)/passive ROM (PROM); adduction/abduction 50/55, flexion 55/60, extension 35°/35°, internal rotation (only with adduction) 35°/40°, external rotation (only with adduction) 35°/40°.


Investigations

Radiological: X-ray right upper limb suggest inflammation of capsule and bursa, suggestive of adhesive capsulitis.

Pathological and biochemical: Hb% – 13 g/dl, total red blood cell – 4 million/cu mm, total leucocytes count (TLC) – 5 100/cumm, differential leukocyte count (DLC) (N 59%, L 36%, E 04%, M 01%, and B 00%), and erythrocyte sedimentation rate – 10 mm, serum total bilirubin – 0.65 mg/100 ml, serum glutamic pyruvic transaminase – 14 IU/L, serum glutamic oxaloacetic transaminase – 16 IU/L, serum alkaline phosphatase – 5 KA, serum creatinine – 0. 72 mg/100 ml, serum urea – 25 mg/100 ml, serum uric acid – 3 mg/dl, fasting blood glucose (at baseline only) – 99 mg/dl.

Treatment and experimental protocol

After careful assessment and examination, the patient was treated with three sitting of oil cupping massage. Oil cupping massage is combination of two regimental processes that is dalak and hijamah bila shurt. Raughan e surkh was used for dalak. Type of applied dalak was dalak sulb for 15 min, Dalak sulb was given by applying suction cup and gliding over whole upper back, neck, around the shoulder girdle, and over the chest for 15 min.

Oil cupping therapy can be used successfully for restoration of health as these techniques are very cost-effective, easy to employed and most desirable benefit is that they potentiate and enhances body's own mechanism of disrupting pathogenesis thereby restrain appearance of toxic side effects.


  Results Top


On examination, the right shoulder pain and tenderness along with restricted ROM were observed. Patients AROM: Adduction/abduction 50, flexion 55, extension 35°, internal rotation (only with adduction) 35°, external rotation (only with adduction) 35°, and PROM was 5° more in each direction. The patient was seen once a week for 4 weeks thereafter. After the first treatment, the patient reported 47% improvement in shoulder pain. The patient was gained full ROM with respect to extension, internal and external rotation on the 3rd week. At the end of the 4 weeks' treatment, the patient had pain free full ROM [Table 1] and [Table 2].
Table 1: Improvement of the patient's left shoulder active and passive range of motion (range of motion, in degrees) with treatment

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Table 2: Assessment of result

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  Discussion Top


Frozen shoulder is the common name for adhesive capsulitis, which is a shoulder condition that limits ROMs. Common symptoms include swelling, pain, and stiffness. It is a condition that commonly occurs in people between 40 and 60 years of age. Women tend to suffer from frozen shoulder more than men. Freezing, frozen, and resolution stages characterize the natural history of frozen shoulder. By applying appropriate treatment techniques and modalities in a creative and judicious manner, a physical therapist can do much to enhance the speed and degree of recovery from frozen shoulder. The patient in this case report is classified as primary adhesive capsulitis. Our patient was in phase two at his initial visit to the outpatient department. The history usually indicates a gradual onset of stiffness and pain. The pain is quite intense and is often referred to the insertion of the deltoid, the deltoid muscle region. The pain is aggravated by the shoulder movements, especially external rotation, and sleeping on the involved side, and is relieved by limiting the use of the extremity.

Many therapeutic regimens have been advocated for adhesive capsulitis. These include therapeutic ultrasound, utilization of heat and ice, shoulder mobilization, exercise therapy, anti-inflammatory medications, corticosteroid injections, arthrographic infiltration, and manipulation under anesthesia.[17],[18],[19],[20],[21] Mostly, patients seek help of Unani medicine in such disabling chronic painful conditions with the hope of some miracle. Unani is promising healing therapy being more beneficial for such patients in which oral medication cannot be given for long duration. For this regimental therapy, applied such as massage and cupping therapy.

Cupping is an ancient traditional Unani therapeutic technique; this is mainly two types – first is dry cupping and the second is wet cupping. Dry cupping (Hijamat Bila Shurt) in which a suction cup will be placed over the muscular surface and suctioned so as to create a negative pressure beneath the cupped area. The objective of this regime is for Imalae mawad (diversion of vitiated matter), Tanqiyae mawad (evacuation of matter), Taskeen alam (to alleviate pain) Tehleele auram (to resolve inflammation), and Tehleele riyah and Taskheene muqam (local calorific).[22],[23],[24],[25]

In Unani System of Medicine, “massage” is a process to transfer body faculties by movement and pressure to maintain equilibrium at normal body physique and tends to state of proper health. Massaging causes various physiological effects which comfort the body. A massage is done to increase blood circulation toward body organs. It is also used to liquefy putrid matters deposited in the body parts by the process of Tanqia-e-Mawaad (evacuation). It is also implies for the nutrition of the body part.[26]

Massage relieves the pain by interfering with pain signals' pathway to the brain, a process called “gate control theory.” Massage stimulates the release of endorphin, morphine-like substance that the body manufactures in the brain and spinal cord. Massage on the soft part above the joint relieves pain by emptying the lymph and blood vessels of the part. Massage relieves muscle tension and spasm. Experts suggest that tense muscles are usually deprived of oxygen because tightness reduces the blood circulation to the area. Massage increases the circulation bringing with it what the muscles need oxygen and other forms of nutrients. As a result, muscles relax and pain decrease.[27]

The present case study reveals that oil cupping massage therapy is very effective in the management of frozen shoulder. Research results show that cupping therapy has promising results in pain control, restoration of ROM, and improvement of quality of life and minimizes the potential risks of treatment. Due to the insufficient randomized controlled trials (RCTs), available till date so, the beneficial effect of oil cupping massage therapy needs to be evaluated in large and rigorously designed RCTs. It is further suggested that to scientifically validate therapeutic uses, the adverse effect and compliance also carefully observe and revive the faith and confidence of Unani practitioners in its actions to serve the large strata of the society.


  Conclusion Top


Nowadays, an increasing number of patients have shown an interest in alternative therapy for the treatment of frozen shoulder owing to their belief that it is more effective than other therapeutics. A case report is presented to illustrate the potentials of manual manipulation (oil cupping massage) of the shoulder in a patient with frozen shoulder. However, massage and cupping therapy are considered a safe and cost-effective procedure. It may be concluded that the massage and cupping therapy is an effective and safe regimen in the management of frozen shoulder. However, further research is required to identify the effectiveness of this treatment.

Acknowledgments

We acknowledge all scientist and research associates of Regional Research Institute of Unani Medicine, Patna, for his encouragement and suggestions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2]



 

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