Frozen Shoulder

Frozen Shoulder

Frozen shoulder is a condition involving considerable pain and loss of movement in the shoulder joint. Historically, this has been a difficult condition to treat due to a lack of evidence showing the best course of treatment. Left alone, the natural history of frozen shoulder generally takes 12-42 months with the average being 30 months, although the condition is somewhat self-limiting, it is not uncommon for patients to have ongoing limitation of shoulder movement. The standard approach for managing frozen shoulder has been to let the condition run its course; however it is understandable that many patients would rather have the condition resolve in less than 30 months or know the best options for treatment if they are experiencing strong and bothersome pain.

Jeremy Lewis*, a leading expert in shoulder research, published an article in 2015 reviewing evidence for the cause, diagnosis and treatment of frozen shoulder. Lewis explains there is still no known cause for frozen shoulder however there is evidence to show that diabetes, family history, hyperthyroidism, genetic predisposition and ethnicity are risk factors. There is no gold standard for diagnosis however it is generally diagnosed when passive and active ROM are equally limited in all movement directions and plain radiographs are normal. In the article Lewis supports the use of physiotherapy and shoulder joint injections to speed up the natural history of frozen shoulder and get people back to full shoulder function at lot sooner.

Rather than using the traditional three to four phases of frozen shoulder, it may be more beneficial to consider it being in two stages, the first of which is when pain is more prominent than stiffness and the second is when stiffness is more prominent than pain. This simplifies the management of frozen shoulder depending on the patients’ main symptom.

Evidence based management of the first stage involves:

  • Corticosteroid injection of the shoulder joint.
  • Gentle self-assisted shoulder movements for one week following injection.
  • Physiotherapy for joint mobilisations, soft tissue release, home exercise prescription and passive movements from one week to four weeks post injection.
  • If pain is not decreasing as expected after four weeks, consider reinjecting as long as there is at least one month between injections and there have not been more than 3 injections in one year.
The use of breathing exercises is widely accepted in the management of restrictive and obstructive breathing disorders such as asthma and Chronic Obstructive Pulmonary Disease, but Physiotherapists also commonly use breathing techniques to manage a wide range of other problems in patients. Like other functions where muscular control is involved, breathing patterns can be altered or become dysfunctional leading to problems with posture, performance (e.g. sports, speech, singing) and with breathing itself.
Chronic Hyperventilation Syndrome

Hyperventilation can be acute or chronic and refers to a breathing pattern disorder where the depth and rate of breath exceed physiological requirements.

Patients often only present when experiencing acute episode/s (often recognized as panic attacks) on top of chronic HVD . It is often poorly diagnosed and patients may have seen many specialists prior to diagnosis to exclude organic disease. Chronic HVS affects up to 10% of the normal population (Newton 2012).

Chronic HVS is characterised by an increased tidal volume (i.e. not fully expiring) leading to lowered C02 levels and  respiratory alkalosis symptoms such as changes in vasomotor tone including decreased cerebral, coronary and cutaneous blood flow, decreased availability of oxygen to tissues and increased excitability in the peripheral nervous system. When hyperventilation occurs for a period of time there is a drive by the body to restore pH balance by excreting more alkaline buffer. These individuals then become subject to reduced capacity to tolerate acidosis from any other source. This means that even a breath hold or a single sigh could trigger symptom onset.


Francis Staude

As a Physiotherapist Francis enjoys treating a wide range of musculoskeletal conditions and is particularly passionate about getting athletes back to match fitness following sporting injuries. Francis also takes hydrotherapy classes once a week Bayswater Waves, helping clients with symptom relief, rehabilitation and injury management in the pool.


1/89 Old Perth Road Bassendean 


(08) 9279 7411


Opening Hours

Monday-Friday 7am-7pm
Saturday 8am-12pm

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Low Back Pain (LBP) and Cognitive Functional Therapy (CFT)


CFT provides a patient centered targeted approach to management of LBP based on a thorough examination.  This classification based management approach for LBP considers many domains including: lower back movement and postures, psychological factors, social factors, workplace factors, comorbidities (e.g. diabetes, obesity), pain processing mechanisms: influenced by genetics and life experiences, sleep and lifestyle factors and their relative contributions to an individual’s LBP. CFT challenges thoughts and behaviours in a functionally specific and graduated manner. 

It differs from Cognitive Behavioural Therapy (CBT) as changes in beliefs, thoughts and emotions can be realized by the patient when they experience an improvement in symptoms as they move which may challenge previous beliefs, experiences and knowledge about their condition.  In a recent study CFT when compared with a manual therapy and exercise group showed clinically and statistically significant large effect sizes across multiple dimensions. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment1.

As physiotherapists, in a practical sense, it means we are considering both mechanical and non-mechanical aspects of a person’s disorder. By managing patients in this way we are helping them better understand their pain and to move and function in a way that does not perpetuate their pain.  By involving the patients in the problem solving and goal setting the longer term prognosis is improved.  Essentially this puts patients back in the “driving seat” for directing the course of their rehabilitation and Sarah and I are both excited about the results we are seeing implementing our improved skills so far….


Low back pain (LBP) is very common and is currently the leading cause of disability worldwide3. Only a very small proportion of people with LBP have serious pathology, such as vertebral fracture, cancer, infection or underlying inflammatory disorder, causing their pain2. Unfortunately using a scan to help diagnose LBP is not reliable because MRI abnormalities are as common in those with LBP as in those without. A common recommendation across all high quality LBP guidelines is routine imaging is discouraged unless serious pathology or specific disease is suspected e.g. if surgery is being considered or there has been a limited response to conservative care. There is no evidence that routine imaging improves LBP outcomes. Over time there has been a significant increase in LBP expenditure without any change in associated levels of disability.


Key positive messages supported by current best evidence regarding LBP include:

  • The causes of LBP are rarely serious
  • LBP has a good prognosis
  • Stay active and resume normal activity as soon as reasonable
  • Bed rest is specifically not advised
  • The back is a strong structure
  • Pain does not equal harm

Key management principles for LBP include:

  • Diagnosing LBP via thorough questioning and physical examination
  • Limited use of imaging
  • Advice about what’s contributing to LBP and an understanding of what’s contributing to the pain experience
  • Strategies to self-manage pain including physical activity
  • Treatment and exercise specific to the problem
  • Medication when required but not as the primary management

The key message here is the clear majority of people with LBP, including leg pain (sciatica), will have a good outcome with evidence based, non-surgical care.   Cognitive Functional Therapy is an emerging approach to deliver high quality care considering the complexity of factors that can be relevant to a patient’s lower back condition.  At Central Bassendean Physiotherapy we pride ourselves on our accurate diagnosis and evidence based, contemporary management of LBP. We are happy to have a further discussion on the material presented here.


You can BOOK HERE or Call us to make an appointment at 9279 7411


  1. Vibe Fersum, K, O’Sullivan P, Skouen J, et al. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain- A randomised control trial. Eur J Pain 2013;17;916-28
  2. Almeda M, Saragiotto B, Richards B, et al. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-275.
  3. Clark S, Horton R. Low back pain: a major global challenge. The Lancet 2018;391(10137):2302.



1/89 Old Perth Road


(08) 9279 7411

Opening Hours

Monday-Friday 7am-7pm

Saturday 8am-12pm

Social Media