How to provide optimal care for frozen-shoulder patients.
This article describes the causes and treatment of frozen shoulder syndrome, with a look at reimbursement considerations. The implications of multilayered, multimodal treatments are of interest to doctors of chiropractic.
Source of the syndrome
Frozen shoulder (adhesive capsulitis) is a common condition characterized by insidious onset of pain, restriction of movement of the shoulder, and restrictions of activities of daily living. In frozen shoulder, the shoulder capsule thickens and becomes stiff, forming bands of tissue called fibrotic adhesions.
A patient will present to the chiro- practor’s office with an inability to move his or her shoulder due to pain, with a restricted range of motion. A comprehensive and thorough ortho- pedic examination will determine which of many potential causes has created the condition. Possible diagnoses of frozen shoulder include: arthritis, bicep tendinopathy, neoplasm, torn rotator cuff, and bursitis.
According to the American Academy of Orthopaedic Surgeons, frozen shoulder develops in three stages:
- Freezing. In this stage, the patient slowly experiences increasing amounts of pain. As the pain worsens, the shoulder loses range of motion. Freezing typically lasts from six weeks to nine months.
- Frozen. Painful symptoms may actually improve during this stage, but the stiffness remains. During the four- to-six month frozen stage, daily activities may be difficult.
- Thawing. Shoulder motion slowly improves during the thawing stage. Complete return to normal or close to normal strength and motion typically takes from six months to two years.
Routes to recovery
You have a range of modalities available to produce results for frozen shoulder syndrome:
1.Interferential electrical muscle stimulation, or interferential therapy (IFT), increases blood flow to the soft tissue and creates a pain-reducing analgesic effect due to blocking the pain receptors. IFT in combination with shoulder exercises is often effective in treating frozen shoulder patients.3
2.Extracorporeal shockwave therapy, or ultrasound therapy, creates a deep warming in the soft tissue to accelerate blood flow and healing. This modality can be an alternative treatment, at least in the short-term, for primary adhesive capsulitis of the shoulder.4 In the Chen study, the ultrasound group showed significant improvement when compared to the steroid group with regard to activities of daily living and pain levels at the sixth week of the study.4
3.Therapeutic exercises will create strength to support the shoulder joint and flexibility to enhance elasticity, which increases ranges of motion.
Therapeutic exercises and mobilization are strongly recommended for reducing pain and improving range of motion and function in patients with stages two and three of frozen shoulder.5
Review of reimbursement
In looking at reimbursement rates of a national insurance company accepted by most chiropractors, it is evident they understand chiropractors who perform extremity adjustments can enhance the glenohumeral joint function of a frozen shoulder. Expected outcomes include decreased patient pain and increased range of motion.
But the provider should also consider performing modalities to both increase patient results and practice revenue.
For example: According to the standards of the insurer in question, reimbursements (less copays) are as follows:
- Extremity adjustment: $24
- Electrical muscle stimulation: $15
- Ultrasound: $13
- Therapeutic exercise: $27
This insurer reimburses for one adjustment and three modalities or therapies per treatment. Over the course of one treatment schedule, this correlates to a substantial increase in practice revenue.
Chiropractor A, who performs an extremity adjustment with electrical muscle stimulation, can expect a reimbursement of $39 per treatment.
Chiropractor B who performs the four abovementioned billable services will see a reimbursement of $79 per treatment.
Over the course of a 16-treatment schedule (less copays and examinations), chiropractor B will be reimbursed an additional $640, enjoying increased practice revenue.
The ethical chiropractor will understand the numbers and ideas above as a call for patient education. The idea of multilayered treatments done over time with copays and insurance costs is a complex one, especially for many senior chiropractic patients. An economic analysis that does not include time for explanations to patients about value for money is incomplete. The DC who conveys the sequence of treatments in common language with the costs and benefits set out clearly is acting in the spirit of B.J. Palmer.
Jeffery Bentz, DC, is a graduate of Palmer College of Chiropractic and practices in Pittsburgh. He practices in a multidoctor corporation, in which he works directly with family physicians, orthopedists, and neurosurgeons.
V. Robert Agostino, EdD, recently retired as a professor in the School of education at Duquesne university. He works on chiropractic educational sharing ideas for professional growth with the chiropractic community.
1 Ewald A. Adhesive Capsulitis: A Review. Am Fam Physician. 2011;83(4):417-422.
2 American Academy of Orthopaedic Surgeons. “Frozen Shoulder.” http://orthoinfo.aaos.org/topic.cfm?topic=A0007
- Last updated Jan. 2011. Accessed Nov. 2015.
3 Cheing GL, So EM, Chao CY. Effectiveness of electro-acupuncture and interferential electro- therapy in the management of frozen shoulder. J Rehabilitation Med. 2008;40(3):166-170.
4 Chen CY, et al. Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis. J Shoulder Elbow Surgery. 2014;23(12):1843-51.
5 Jain TK, Sharma NK. The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: a systematic review. J Back Musculoskelet Rehabil.