Osteopathy Journals and Research by Darren Chandler


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  1. Content

    • What is frozen shoulder
    • Who gets frozen shoulder
    • The treatment of frozen shoulder

    What is frozen shoulder

    The joint capsule of the shoulder encases and forms an outer ‘skin’ of the shoulder joint. A frozen shoulder occurs when scar tissue forms inside the shoulder capsule causing it to thicken, swell and tighten(1). On top of this patients’ experience tightness of the muscles and other soft tissues giving pain and restricted movement(2).

     Frozen shoulder has three stages(1). The average length of these stages without treatment is 30 months(2):

    • Stage one: the shoulder aches becoming painful when reaching out for things or when you lie on the bad side. This can last two to nine months.
    • Stage two: the shoulder becomes increasingly stiff. The pain may not get worse and could even start to decrease. The muscles around the shoulder start to waste as they're not being used. This can last for four to twelve months.
    • Stage three: slowly you’ll regain some movement in your shoulder. The pain starts to fade, although it may temporary return as the stiffness eases.

    The most common position that patients find limited is the position your arm goes into when you put it up to wave (flexion/abduction/external rotation)(2).

     Who gets frozen shoulder

    Up to 1 in 20 people in the UK may be affected by frozen shoulder.

    You are more at risk from developing a frozen shoulder if you have(1):

    • Previous shoulder injury or shoulder surgery
    • Inactivity of the shoulder
    • Diabetes (type 1 or 2)
    • Dupuytren's contracture 
    • Heart disease and stroke
    • Lung disease
    • Hyper- or hypothyroidism
    • Breast cancer (or shoulder cancer(2))

    Near enough all the frozen shoulders we see in the clinic are due to another shoulder injury or immobility of the shoulder for whatever reason. However it is good practice to be examined by your GP prior to any treatment.

    The treatment of frozen shoulder

    Conservative (non-invasive) treatment options include(1):

    • Antiinflammatories and pain killers
    • Corticosteroid injection
    • Stretch, massage and home exercises

    Surgical treatment options include(1):

    • Manipulation under anaesthetic: the shoulder is ‘numbed’ with an anaesthetic and manipulated to break up adhesions.
    • Arthroscopic capsular release: a special probe is inserted in the shoulder that emits a high-frequency radio wave which is used to cut out the thickened parts of the shoulder capsule.
    • Arthrographic distension (hydrodilation): the shoulder joint is ‘inflated’ with a steroid and saline solution to stretch the shoulder joint.

    Research grading the effectiveness of different treatment options for frozen shoulder has found manual therapy to mobilise (move) the shoulder and home exercises to be effective in reducing pain and increasing movement(3). These can be performed by your osteopath who can also use massage and manipulation to relieve any other associated problems that develop along side your frozen shoulder.


    (1) http://www.nhs.uk/Conditions/Frozen-shoulder/Pages/Introduction.aspx

    (2) Adhesive Capsulitis: use the evidence to integrate your interventions (2010). Page P Labbe A

    (3) Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study (2009). Jewell D. V., Riddle D. L., Thacker L. R. 

  2. Contents

    • Three effects of incorrect breathing: pain, digestive problems & anxiety
    • What causes and maintains faulty breathing
    • Breathing exercises
      • Correct day to day breathing technique
      • Breathing exercise to work your muscles

    Three effects of incorrect breathing: pain, digestive problems and anxiety

    If you didn’t walk correctly you’d expect to get pain when you walk. If you didn’t breath correctly, understandably, you’d expect pain or shortness of breathe when you breath. This isn’t necessarily always the case. On average we take up to 23,040 breaths a day. Multiply that over the years! Imagine if each breath required a bit more effort and didn’t quite get as much air in as it should. This is how, over the years, you develop a ‘breathing pattern disorder’.

    Breathing pattern disorders can give three main symptoms: pain, digestive problems and anxiety.


    You use 93 muscles all over your body to breath. You use them 93 muscles up to 23,040 times a day 7 days a week. It pays to use them correctly! A recent study on breathing pattern disorders found a strong correlation between incorrect breathing patterns and poor posture, shoulder blade, low back, neck and jaw (TMJ) pain(1).

    Digestive problems

    The main muscle you use to breath is your diaphragm. Your diaphragm separates your chest from your stomach. When you breath in your diaphragm pushes down on your stomach to massage your organs. If you’re breathing correctly and your diaphragm is moving correctly then the organs in your stomach are getting a daily massage! Correct breathing also regulates the nerve that goes to your bowels(2). How you breath can also affect heart-burn(3) as well as bloating associated with Irritable Bowel Syndrome (IBS)(4).


    Not getting enough breathe in makes our body more acidic (respiratory acidosis)(5) and breathing too heavily (getting too much breathe in) makes our body more alkaline (respiratory alkalosis)(1,6). Unless in extreme cases where you can’t get enough air breathed in (e.g. disease of your airways) or you breath too heavily (e.g. anxiety attack) this acid-alkaline shift is quite subtle. However breathing incorrectly day to day can impact the acid-alkaline balance in our body and affects anxiety or panic disorders (6,7).

    What causes and maintains faulty breathing

    • Psychological causes: depressed or anxious mood states affects our use of breathing(5-7) and sighing(7).
    • Biochemical: Asthma suffers can find their symptoms exacerbating just before or during their period. Asthma can also start around puberty in females and around/during the menopause(8). Hormones during pregnancy (and because when the ‘bump’ develops your diaphragm, chest and stomach doesn’t move as well) compromises your breathing (9).
    • Posture: a faulty posture in standing or sitting affects how you use your breathing muscles
    • Mechanical constraints: anything that impedes the chest and stomach from moving properly can affect your breathing pattern e.g. tight fitting bra’s and jeans.


    Breathing exercises: correct breathing technique & breathing exercises to work your muscles

    You should not follow any form of exercise, including the two below, until you’ve been assessed by an appropriate healthcare practitioner. Any exercise that affects your breathing may have side effects if you have, amongst other things, any heart, blood pressure, breathing problems or prone to fainting/dizzy spells. Once you’ve been assessed try these two exercises.

    Read through the instructions first before following them. Some people try to perform the exercise whilst reading the instructions and end up holding their breath as they read!

    Exercise one: Correct breathing technique

    Do not breath heavily when performing this exercise just at your normal rate and depth.

    • Put your left hand on your chest.
    • Put your right hand on your stomach.
    • Take a breath in. Your right hand on your stomach should move and your left hand on your chest should stay still.
    • When you breath out everything should relax so you get a natural breathe out - don’t try to blow or force the air out.

    By making your right hand on your stomach move when you breath in and not the hand on your chest ensures you are using your diaphragm.

    Exercise two: Breathing exercise to work your muscles

    As an exercise to really stretch and work all 93 of the muscles you use for breathing perform this exercise just once or twice sporadically throughout the day.

    • Put your left hand on your chest
    • Put your right hand on your stomach
    • Take a breath in so the right hand on your stomach moves but not the left hand on your chest
    • Before breathing out - breath in a bit more so the left hand on your chest moves to really fill up your lungs
    • Now breath out
    • If you don’t feel dizzy/faint and you want to repeat the exercise once more breath normally for 10 seconds first so you don’t end up hyperventilating


    (1) Breathing pattern disorders and functional movement (2014).  Bradley H, Esformes J

    (2) Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity (2016). Frøkjaer JB et al

    (3) Influence of breathing pattern on the esophagogastric junction pressure and esophageal transit (1995). R. K. Mittal, et al

    (4) Abdominothoracic mechanisms of functional abdominal distension and correction by biofeedback. (2015). Barba E et al. 

    (5) Respiratory mechanics and ventilatory control in overlap syndrome and obesity hypoventilation (2013). Verbraecken J McNicholas W

    (6) Acid–base dysregulation and chemosensory mechanisms in panic disorder: a translational update (2015). L L VollmerJ R Strawn, and R Sah

    (7)The Integrative Role of the Sigh in Psychology, Physiology, Pathology, and Neurobiology (2014). Jan-Marino Ramirez

    (8) https://www.asthma.org.uk/advice/triggers/hormones/. Accessed 4.8.2016

    (9) Respiratory physiology of pregnancy (2015). Antonella LoMauro, A and Aliverti A