Can Patients Undergo Passive and Active Shoulder Movement?
Yes, patients with trauma, diabetes, or other underlying conditions can and should undergo both passive and active shoulder movements as part of their rehabilitation, but the approach must be gentle, progressive, and properly executed to avoid causing harm. 1, 2
Evidence-Based Approach to Shoulder Movement
Initial Phase: Passive Range of Motion
Passive and active-assisted exercises should be provided that include placement of the upper limb in a variety of appropriate and safe positions within the patient's visual field. 1
Gentle stretching and mobilization techniques focusing on increasing external rotation and abduction are the foundation of treatment for shoulder pain related to limitations in range of motion. 1, 2
Active range of motion should be increased gradually in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle. 1, 2
Critical Warning About Aggressive Movement
The most important caveat is that aggressive range of motion of the complex shoulder joint, if done improperly, could do more harm than good. 1
The evidence supporting aggressive passive range-of-motion exercises to reduce or prevent shoulder problems is missing. 1
Patients with some voluntary movement in a painful shoulder have higher rates of shoulder joint tissue injury on MRI, suggesting that more physical activity can actually promote injury. 1
Overhead pulley exercises should be avoided as they can cause traction injury to the shoulder. 1
Special Considerations for Specific Populations
Post-Stroke Patients (Hemiplegic Shoulder)
Proper positioning and maintenance of shoulder range of motion are beneficial interventions for hemiplegic shoulder pain. 1
For wheelchair users, lap trays and arm troughs are useful positioning devices to reduce shoulder pain and subluxation. 1
Slings may be considered during ambulation training to protect the shoulder from traction injury. 1
Healthcare staff, patients, and family should be educated on correct protection, positioning, and handling of the affected arm. 2
Diabetic Patients
Diabetic patients are more likely to develop frozen shoulder (adhesive capsulitis) and more likely to require operative management. 3
Treatment is based on physiotherapy, NSAIDs, corticosteroid injections, and in refractory cases, surgical resolution. 3, 4
Gentle, progressive stretching exercises are the starting point for management of true capsular restriction. 5
Most diabetic patients with frozen shoulder improve with nonsurgical treatment, though insulin-dependent diabetics are more likely to require arthroscopic release than non-insulin-dependent diabetics. 6
Post-Trauma Patients
Patients with trauma history should be assessed for undiagnosed or poorly controlled diabetes, as 26% of trauma patients would benefit from intervention for improved glucose control. 7
The same principles of gentle, progressive movement apply, with careful attention to any concurrent shoulder pathology. 2
Treatment Algorithm by Phase
Phase 1 (0-6 weeks): Conservative Treatment
- Focus on gentle stretching and mobilization techniques. 2
- Implement passive ROM and pain management. 2, 8
- Use analgesics such as acetaminophen or ibuprofen for pain relief. 1
Phase 2 (6-12 weeks): Progressive Strengthening
- Progress to more advanced strengthening exercises for rotator cuff and scapular stabilizers. 2
- Address biomechanical factors such as scapular dyskinesis. 2
- Continue flexibility work for the shoulder capsule. 2
Phase 3 (12+ weeks): Return to Function
- Focus on return to sport/work-specific activities with proper mechanics. 2
- Ensure complete resolution of symptoms before returning to full activity. 2
Common Pitfalls to Avoid
Do not perform aggressive passive range-of-motion exercises without proper technique and supervision, as this can cause more harm than benefit. 1
Avoid overhead pulley exercises which can cause traction injury. 1
Do not overlook scapular dyskinesis assessment and treatment, as this is essential for resolution. 2
Screen for concurrent conditions like adhesive capsulitis or rotator cuff tendinopathy that may complicate treatment. 2
If pain significantly limits participation in physical therapy after 25 visits without clear functional improvement, consider alternative approaches or discharge rather than continuing indefinitely. 8