Frozen shoulder with side affinities

Dr Ashok Yadav ¹, Dr Pravishtha Awasthi*² Dr Priya Bhardwaj⁽³⁾, Dr Pooja Shukla ⁽⁴⁾, Dr Diksha Agrahari ⁽⁴⁾

ABSTRACT-
Homeopathy is a science that follows the principle of “Similia Similibus Curantur” let like be cured by like. It provides the system of a holistic approach to the similar manifestation of different individuals. As in the case of Frozen Shoulder though the complaints are similar, but each individual requires a different approach to the treatment. This article aims at the side affinities of homoeopathic medicines in complaints of frozen shoulder.

KEYWORDS- Frozen shoulder, Homoeopathy.

INTRODUCTION
Codman (1934) coined the term of Frozen Shoulder (FS). He stated that patients with frozen shoulder have relative features. These features are: “a slow onset  of pain that can be  felt near the insertion of deltoid, an inability to sleep on the affected side, along with painful and restricted elevation with painful external rotation, with a normal radiological appearance”.^(1,2)

Frozen shoulder or peri-arthritis of the shoulder is a disease of idiopathic nature where GLENO HUMORAL JOINT becomes stiff and tenderness because of loss of resilience of joint capsule, possibly with adhesions in its folds. It produces stiffness and pain of the shoulder. In early stages, the pain is worst at night, and stiffness limited to abduction and internal rotation of the shoulder. Later, the pain is present all time, and all the movements are severely limited. Also, there is a history of preceding trauma in many cases. The disease is commoner in people with diabetes. ^{( 3)}

Adhesive capsulitis (frozen shoulder) has affected 3- 5% in the general population and up to 20% in those with diabetes. This disorder is one of the most common musculoskeletal problems seen in orthopaedics. ⁽⁴⁾  Although appropriate incidence and prevalence are not determined.  The condition is associated with; sleep deprivation, (often severe) pain, anxiety, and disability that may be massively disruptive and impacts on nearly every aspect of daily living. ⁽⁵⁾

Shoulder pain is one of the most common complaints in pain clinics and rheumatology departments, usually develops from :

1. Trauma

2. Degeneration

3. Inflammation

4. Vascular disease and also be referred from the hand and neck pain or headache. ⁽⁶⁾

Primary FS (PFS) is characterised by a gradual onset of idiopathic origin. In contrast, secondary FS is associated with a defined event, such as known intrinsic (such as rotator cuff disease) or extrinsic (such as trauma) cause. ⁽⁷⁾  A recent narrative review suggested broadening of the coracohumeral ligament (CHL), joint capsule and synovium to be the diagnostic features for frozen shoulder,⁽⁸⁾  but no systematic review has yet collected the data from imaging studies to certain the intra and peri-articular changes that are associated with the condition. ⁽⁹⁾

FS is an insidious process of the condition of pain and stiffness condition along with a decreased range of movement (ROM) of the shoulder joint with the stiffening and hardening of the glenohumeral ligament. This further involves diseases of different etiologies that results in such a painful condition. ⁽³⁾

Definition
FS or “adhesive capsulitis” is characterised by pain and reduced movement of the shoulder, usually in the absence of intrinsic shoulder disease. Adhesive capsulitis may precede bursitis or tendinitis of the shoulder or be associated with systemic disorders. Prolonged immobility of the arm serves to the development of frozen shoulder.

Pathology

• The shoulder capsule is thickened, and a mild chronic inflammatory infiltrates and fibrosis may also present.
• Age and sex- Adhesive capsulitis occurs more commonly in women and age above 50 years.

Causes

Although the exact etiology is not known yet, it can be associated along with-

• Pulmonary disease 
• Myocardial infarction
• Diabetes mellitus, etc. ⁽¹⁰⁾

Signs and Symptoms

1. Both active and passive shoulder movements are restricted

      2. Difficulty in the abduction

      3. Difficulty in raising the arm

4. Night pain often present in the affected shoulder and pain may interfere with sleep ⁽¹⁾

      5. Pain and stiffness usually develop gradually, but progress is rapidly in some patients.

      6. It is characterised by minimal discomfort and a gradual improvement of ROM due to capsular remodelling. This stage occurs between 15 and 24 months. ⁽¹¹⁾

Clinical Phases and Stages of AC.⁽¹¹⁾

Stage 1	Painful stage	Slight limitation of range of motion with pain
Stage 2	Freezing stage	Intensifies restricted range of motion along with severe pain
Stage 3	Frozen stage	Pain might be present with stiffness
Stage 4	Unfreezing stage	Pain is very slight with gradually increased range of motion

Investigations-

• Contrast technetium-99m diphosphonate bone scan –

Araised uptake on the painful side in 92% of patients is differentiated with the opposite side or with controls.

• Arthrography –

Characteristic findings of a decrease in the of the capacity of the shoulder joint (5-10 ml compared with 25-30 ml in the healthy joint) and a small or non-existent dependent axillary fold but in most units, arthrography is a useful investigation in frozen shoulder.

• Magnetic resonance imaging-

Show an increase ligament thickening of the joint capsule and the coracohumeral ligament. ⁽¹²⁾

Treatment

Conventional treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs), Oral steroid treatment, Intra-articular steroid injection, Sodium hyaluronate intra-articular injection, Mobilisation and physiotherapy, Suprascapular nerve block, Mobilisation under anaesthesia (MUA), Open release, Rehabilitation protocols^{. (11)}

Miasmatic approach
Sycotic miasm is “undoubtedly the pathological condition of excess, escape, hyperplasia, ostentation, tumour formation, acceleration”.⁽¹²⁾ In frozen shoulder, the thickening of gleno-humoral ligament leading to a loss in functions of the affected shoulder with restriction of movement without any migratory changes depicts the sycotic miasm to which Dr Ortega stated that the sycotic would wrap himself in a thick layer of fat and his perversion not only provides him to have such reserves but also prevent from eliminating that harms him as well developing a uric or lithic diathesis as well as different forms of retention and accumulation. ⁽¹³⁾ 

Homoeopathic Treatment According To Sides-

LEFT	RIGHT
Ferrum phosphoricum Bruised soreness in chest and shoulder muscles. Inflamed soft parts. Burning rawness. < Night (4-6 a.m.) , motion, jar > Lying down	Ferrum Metallicum Pain at night compels motion of the affected part. Sudden cramps or tearing sensation in the limbs. Crackling of the joint. < night, sudden motions, raising arms > Gentle motions
Ledum pal Painful, oedematous and cold joints and yet aversion from external warmth. Mainly for gouty, rheumatic and hemorrhagic diathesis. < Warmth (covers/air), injury, motion, night. < Cold air, bathing with cold water.	Kalmia latifolia Aching, bruised stiff sensation. Tingling or numb sensation  Either trembling or paralytic weakness is present. Complaints are alternating with cardiac symptoms. < motion, lying on the left side, bending forward, looking downward, heat, getting cold  > Cloudy Weather continued motion.
Magnesium carb Sharp and shooting pain along the nerves compels to the motion of the affected joint. Cannot bear covering on the hands but uncovering causes a cold sensation. < night, rest cold changes in the weather, cold winds, cold drafts. > Motion, walking around, Open-air	Sanguinaria  Right-sided pain in bones closest to the skin. General pulsation with heat in the palms and soles. < Periodically in the sun, every week and night, jar, raising arms, looking up. > Sleep, lying on the back.
Nux- moschata Trauma and pain caused by slight causes such as least jar. Dryness but no thirst along with coldness persists throughout. < Cold (in general), change of season, least jar, bruises. > Moist hot, warm room, dry weather.	Strophanthus Pain in the shoulder with heavy forearms and fingers. Strong desire for coffee. < Exertion > Rest
Sulphur Numbness of left arm. General sensation of heat with throbbing between the scapulae. < Exertion, atmospheric changes > Open-air, motion warm applications, sweating, dry heat.

Pain alternating to either side – Lycopodium

• Complaints of repeating symptoms with automated flexion and extension.
• Progressive affections.
• Pains are throbbing in nature causes jerking due to anger.
• < 4-8 p.m., warmth, wind
• > Cold applications, motion

Conventional medicines for shoulder affections- 

1. Aconitum

• Sudden pain coming into waves and goes the same way.
• The affected part feels numb and big, with a burning and tingling sensation.
• Externally sore with the sensation of heaviness internally.
• <  Night, pressure and touch, lying on the side, cold and dry winds.
• > Open-air, repose, warm sweat.

2. Bryonia

• Least motion causes painful effects on joints.
• Bursting and stitching sensation with heavy and sore pains going backwards.
• < touch, motion, raising the arms, stooping, Exertion, early morning, dry weather or room.
• Pressure with lying on the affected part.

3. Kali- Carbonicum

• Weakness of arms with backache and painful fingertips.
• Oedema of the affected joint with rheumatism and numbness.
• < Cold (air/ water/ drafts), Exertion, overheating, lying on the painful side.
• > Warmth and open air.

4. Pulsatilla 

• Unilateral shifting and changing in the symptoms, increasing to a certain intensity and ceasing suddenly.
• Edematous joints with numbness in elbows, acute periostitis
• Chilly but an aversion to heat
• < warmth (in general), rest, beginning of motion, lying on one side
• > Cold & fresh open air, gentle continued motion, uncovering

5. Rhus- Toxidendron

• Shooting and stitching pains at night must keep changing positions.
• Stiffness with sore and bruised sensation as if beaten
• Dislocated sensation
• < Exposure to Cold (air/draft), rest, beginning the motion, overexertion, sprains and before storms.
• > Continued motion, heat application, rubbing the affected part. ⁽¹⁴⁾

Previous researches in homoeopathy related with frozen shoulder 

An open, observational, non-randomised, non-controlled, clinical trial of pre-post comparison was done on 40 patients experiencing frozen shoulder at the National Institute of Homoeopathy. The trial was based upon the individualised medicine, which included the Oxford Shoulder Score (OSS) and Shoulder Pain and Disability Index (SPADI) as the primary and secondary outcome measures respectively, observed at baseline and after three months of treatment. Medicines were prescribed on the homoeopathic principles. Of the total, 10 patients dropped out, while 30 completed the trial. Protocol-compliant sample (n=30) was calculated at the end. There were statistically significant reductions in both OSS score [42.5 ± 5.5 vs. 28.5 ± 6.8; mean reduction 14.0, 95% CI 11.4 to 16.6, P < 0.001] with SPADI score [103.7 ± 17.2 vs. 52.1 ± 22.7; mean reduction 51.6, 95% CI 43.1 to 60.1, P < 0.001] after 3 months of homoeopathic treatment. ⁽¹⁵⁾

11. REFERENCES

1. Codman EA. Obscure Lesions of the Shoulder; Rupture of the Supraspinatus Tendon. The Boston Medical and Surgical Journal 1927;196:381–7. DOI:10.1056/nejm192703101961001.

2. Bunker T. Frozen shoulder: unravelling the enigma. US National Library of Medicine [Internet]. 1997 [cited 28 July 2016];79(3):210-213. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502880/

3. Maheshwari j. essential orthopaedics. 3rd edition. New Delhi: Mehta publishers; 2005, p. 258–9.

4. Teja, D. and Banshiwal, D. (2017). Frozen shoulder: evaluation of intraarticular corticosteroids injection versus suprascapular nerve block “A prospective clinical study”. International Journal of Orthopaedics Sciences, [Internet] 3(2f), pp.614-618. Available at: http://www.orthopaper.com/archives/?year=2017&vol=3&issue=2&ArticleId=348 [Accessed 26 Jul. 2019].

5. Jones, S., Hanchard, N., Hamilton, S. and Rangan, A. (2013). A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder. BMJ Open, [Internet] 3(9), p.e003452. Available at: https://bmjopen.bmj.com/content/3/9/e003452.

6. Abdelshafi M, Yosry M, Elmulla A, Al-Shahaway E, Aly M, Eliewa E. Relief of chronic shoulder pain: a comparative study of three approaches. Middle East Journal of Anaesthesiology [Internet]. 2011 [cited 28 July 2019];21(1):83-92. Available from: https://europepmc.org/abstract/med/21991738

7. Zuckerman J, Rokito A. Frozen shoulder: a consensus definition. Journal of Shoulder and Elbow Surgery [Internet]. 2011 [cited 28 July 2019];20(2):322-325. Available from: https://www.sciencedirect.com/science/article/abs/pii/S105827461000282X

8. Tamai, K., Akutsu, M. and Yano, Y. (2014). Primary frozen shoulder: a brief review of pathology and imaging abnormalities. Journal of Orthopaedic Science, [online] 19(1), pp.1-5. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929028/ [Accessed 27 Jul. 2019].

9. Ryan V, Brown H, Minns Lowe C, Lewis J. The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review. BMC Musculoskeletal Disorders [Internet]. 2016 [cited 28 July 1995];17(1). Available from: https://www.ncbi.nlm.nih.gov/pubmed/27527912

10. Langford CA. Harrison’s Principles of internal medicine. Vol. 2. 19th ed. The United States of America: Mc.Graw Hill Education; 2012. 

11. D’Orsi G, Via A, Frizziero A, Oliva F. Treatment of adhesive capsulitis: a review. Muscles Ligaments Tendons [Internet]. 2012 [cited 28 July 2019];2(2):70-78. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666515/

12. Dias R, Cutts S, Massaoud S. 1453-1456 [Internet]. US National Library of Medicine. 2005 [cited 17 June 2020]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1315655/

13. Ortega S. Notes on the miasms or Hahnemann’s chronic diseases. New Delhi: National Homoeopathic Pharmacy; 1980.

14. Boger C. ASynoptic Key of the MATERIA MEDICA. 3rd revised ed. India: B.JAIN Publishers; 2015.

15.  Nath A, De M, Singh S, Kundu N, Michael J, Sadhukhan S et al. The role of homoeopathic treatment in women suffering from post-caesarean backache: An open observational clinical trial. Indian Journal of Research in Homoeopathy [Internet]. 2019 [cited 25 July 2017];13(2):81. Available from: https://www.homoeorecorder.com/nhr-oct-dec-2018-original-research-utility-of-homoeopathic-medicines-in-treatment-of-frozen-shoulder-an-open-

Authors
1. Head, Department of Practice of Medicine, M.P.K.H.C.&R.C. a constituent college of HOMOEOPATHY UNIVERSITY, JAIPUR

 *2. MD part 1, Batch 2018, Department of Practice of Medicine, M.P.K.H.C.&R.C. a constituent college of HOMOEOPATHY UNIVERSITY, JAIPUR

3. MD part 1, Batch 2018, Department of Repertory, M.P.K.H.C.&R.C. a constituent college of HOMOEOPATHY UNIVERSITY, JAIPUR.

4.  MD part 1, Batch 2018, Department of Organon of Medicine and Homoeopathic Philosophy, M.P.K.H.C.&R.C. a constituent college of HOMOEOPATHY UNIVERSITY, JAIPUR)