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Adhesive Capsulitis

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Contents

Definition/Description

Test edit. By definition, adhesive capsulitis is a benign, self-limiting condition of unknown etiology characterized by painful and limited active and passive glenohumeral range of motion of ≥ 25% in at least two directions[1][2][3][4][5][6] most notably shoulder abduction and external rotation.

Adhesive capsulitis, commonly referred to as frozen shoulder, is associated with synovitis and capsular contracture of the shoulder joint and can be classified as either primary or secondary. [1][2][3][4][5][7] In clinical practice it can be hard to differentiate adhesive capsulitis from other shoulder pathologies.[1] Since the physical therapy management of adhesive capsulitis is much different than that of other shoulder pathologies it can be detrimental to the patient if they are misdiagnosed. Therefore, it is important for the clinician to be aware of the ‘hallmarks’ of frozen shoulder and recognize the clinical phases that are specific to this condition [1] which are discussed below.

Epidemiology /Etiology

Glenohumeral Joint
Glenohumeral Joint

Although the etiology remains unclear, adhesive capsulitis can be classified as primary or secondary. Frozen shoulder is considered primary if the onset is idiopathic while secondary results from a known cause or surgical event.[7] Three subcategories of secondary frozen shoulder include systemic (diabetes mellitus and other metabolic conditions), extrinsic (cardiopulmonary disease, cervical disc, CVA, humerus fractures, Parkinson’s disease), and intrinsic factors (rotator cuff pathologies, biceps tendonitis, calcific tendonitis, AC joint arthritis).[2] 

Adhesive capsulitis is often more prevalent in women, individuals 40-65 years old, and in the diabetic population, with an occurrence rate of approximately 2-5% in the general population, [5][2][8][9][4][10] and 10-20% of the diabetic population.[9][10] If an individual has adhesive capsulitis they have a 5-34% chance of having it in the contralateral shoulder at some point in time. Simulatneous bilateral involvement has been found to occur approximately 14% of the time.[2] Other associated risk factors in addition to the ones mentioned above include: trauma, prolonged immobilization, thyroid disease, stroke, myocardial infarcts, and presence of autoimmune disease.[5][11]

The disease process affects the anteriosuperior joint capsule, axillary recess, and the coracohumeral ligament. It has been shown through arthroscopy that patients tend to have a small joint with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis but no actual adhesions.[1][10] Contracture of the rotator cuff interval has also been seen in adhesive capsulitis patients, and greatly contributes to the decreased range of motion seen in this population.[2]

There is continued disagreement about whether the underlying pathology is an inflammatory condition, fibrosing condition, or an algoneurodystrophic process. Evidence suggests there is synovial inflammation followed by capsular fibrosis, in which type I and III collagen is laid down with subsequent tissue contraction.[1] Elevated levels of serum cytokines have been noted and facilitate tissue repair and remodeling during inflammatory processes. In primary and some secondary cases of adhesive capsulitis cytokines have shown to be involved in the cellular mechanism that leads to sustained inflammation and fibrosis. It is proposed that there is an imbalance between aggressive fibrosis and a loss of normal collagenous remodeling, which can lead to stiffening of the capsule and ligamentous structures.[2]

Characteristics/Clinical Presentation


Patients presenting with adhesive capsulitis will often report an insidious onset with a progressive increase in pain, and gradual decrease in active and passive range of motion.[2][8] Patients frequently have difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back.[11][4] Adhesive capsulitis is considered to be a self-limiting disease with sources stating symptom resolution as early as 6 months up to 11 years. Unfortunately symptoms may never fully subside in many patients.[11][2][12][13][5][8][14][3][4]

The literature reports that adhesive capsulitis progresses through three overlapping clinical phases:[1][4][13][11][7]

  • Acute/freezing/painful phase: gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 3-9 months.
  • Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of glenohumeral motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last til about 12 months.
  • Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 1 to 3.5 years.

Differential Diagnosis

Some conditions can present with similar impairments and should be included in the clinician’s differential diagnosis. These include, but are not limited to, osteoarthritis, acute calcific bursitis/tendinitis, rotator cuff pathologies, parsonage-Turner syndrome, a locked posterior dislocation, or a proximal humeral fracture. [13] [2]

Differential Diagnosis of Adhesive Capsulitis
Osteoarthritis (OA)
Both may have limited abduction and external rotation AROM but with OA, PROM will not be limited. Also, OA will have the most limitations with flexion while this is the motion that is least affected in adhesive capsulitis. Radiography have been used to rule out pathology of osseous structures.
 
Bursitis
Bursitis presents very similarly to adhesive capsulitis, especially compared to the early phases of frozen shoulder. Patients with bursitis will present with a non-traumatic onset of severe pain with most motions being painful. A main difference will be the amount of PROM achieved with adhesive capsulitis being extremely limited and painful while bursitis will, while still painful, have larger ranges.
 
Parsonage-Turner Syndrome (PTS)
PTS occurs due to inflammation of the brachial plexus. Patients will present without a history of trauma and with painful restrictions of all motions. The pain with PTS usually subsides much quicker than with adhesive capsulitis, and patients eventually display neurological problems (atrophy of muscles or weakness) that are seen several weeks after initial onset of pain.
 
Rotator Cuff (RC) Pathologies
The primary way to distinguish RC pathologies from adhesive capsulitis is to examine the specific ROM restrictions. Adhesive capsulitis presents with restrictions in the capsular pattern while RC involvement typically does not. RC tendinopathy may present similarly to the first stage of adhesive capsulitis because there is limited loss of external rotation and strength tests may be normal. MRI and ultrasonography can be used to identify soft tissue abnormalities of the soft tissue and labrum.
 
Posterior Dislocation
A posteriorly dislocated shoulder can present with shoulder pain and limited ROM but, unlike adhesive capsulitis, started with a specific traumatic event. If the patient is unable to fully supinate the arm while flexing the shoulder, the clinician should suspect a posterior dislocation.

Examination

Currently the diagnosis of primary adhesive capsulitis is based on the findings of the patient history and physical examination.[7] 

The following outcome measures have been used in studies researching adhesive capsulitis.

  • Shoulder Pain and Disability Index (SPADI)
  • Disability of the Arm, Shoulder and Hand scale (DASH)
  • American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES)
  • Simple Shoulder Test (SST)
  • Penn Shoulder Scale (PSS)
  • NPRS
  • VAS
  • SF-36

In a recent systematic review, the psychometric properties of the SPADI, DASH, ASES and SST were examined.[15]Reliability, construct validity and responsiveness were all found to be favorable for various shoulder pathologies but the review did not address their strength relative to adhesive capsulitis specifically.

OBSERVATION of Posture and Positioning

  • Scapular winging of the involved shoulder may be viewable from the posterior and/or lateral views.[12]

SCREEN: Upper Quarter Exam (UQE) & Neuro Screen (dermatomes, myotomes, reflexes)

  • A full UQE should be performed to rule out cervical spine involvement or any neurological pathologies.[2]

ROM SCREEN: Active/Passive/Overpressure

Cervical, Thoracic, Shoulder ROMs with OP as well as rib mobility should be performed.

  • Scapular substitution frequently accompanies active shoulder motion.[2]

RESISTED MUSCLE TESTS 

Shoulder External Rotation (ER)/ Internal Rotation (IR) / ABduction (ABd) (seated) should be performed.

  • Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd relative to the uninvolved side.[2]
[16] [17]

FORMAL ROM: Active/Passive/Overpressure

Shoulder Flex/ABd/ER/IR

  • The method of measuring ER and IR ROM in patients with suspected adhesive capsulitis varies in the literature.[10][18][19][20]
  • Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular pattern. A capsular pattern is a proportional motion restriction unique to every joint that indicates irritation of the entire joint.[18] The shoulder joint has a capsular pattern where external rotation is more limited than abduction which is more limited than internal rotation  (ER limitations > ABD limitations > IR limitations).[18][20] In the case of adhesive capsulitis, ER is significantly limited when compared to IR and ABD, while ABD and IR were not seen to be different.

JOINT ACCESSORY MOBILITY

Glenohumeral joint:

  • Anterior 
  • Inferior
  • Posterior
  • Posterior Capsule Stretch

In patients with adhesive capsulitis, the anterior and inferior capsule will be the most limited but joint mobility will be restricted in all directions.[18]

SPECIAL TESTS 

Yang et al. investigated the reliability of three function-related tests in patients with shoulder pathologies via a non-experimental study (See Resources for scoring guide):[21] 
Figure 1. Taken from "Reliability of function-related tests in patients with shoulder pathologies." by Yang et al, 2006, J Orthop Sports Phys Ther, 36, p.572-576.
Figure 1. Taken from "Reliability of function-related tests in patients with shoulder pathologies." by Yang et al, 2006, J Orthop Sports Phys Ther, 36, p.572-576.

Hand-to-neck (Figure 1A)

  • Shoulder flex + abduction + ER
  • Similar to ADLs like combing hair, putting on a neclace

Hand-to-scapula (Figure 1B)

  • Shoulder ext + adduction + IR
  • Similar to ADLs like snapping a bra, putting on a jacket, getting into back pocket

Hand-to-opposite scapula (Figure 1C)

  • Shoulder flex + horiz ADDuction

NOTE: These tests require appropriate elbow, scapulothoracic, and thoracic mobility. Be sure to clear these areas first and keep this in mind during evaluation. If a patient is unable to do the motion it is important to understand that it may be other structures outside of the shoulder joint limiting this motion.

Reliability of the three tests was excellent, ranging from 0.83-0.9. Correlation between the three was moderate (r=0.64 to 0.66). [21]

These functional measures appear to be helpful for their objectivity in measuring shoulder dysfunction. However, even though the test battery is believed to be comprised of movements fundamental to activities of daily living, the direct relationship between these tests and activities of daily living cannot be assumed.

Other:

No specific clinical test for adhesive capsulitis has been reported in the literature and there remains no gold standard to diagnose adhesive capsulitis.[7] While there are no confirmed diagnostic criteria, a recent study determined a set of clinical identifiers that achieved consensus among 70 experts in the field for the first or early stage of primary (idiopathic) adhesive capsulitis.[7] The following are tools that can be used to help determine the stage of adhesive capsulitis and/or irritability status.

Consensus was achieved on eight clinical identifiers clustered into two discrete domains (pain and movement) as well as an age component.[7]

1) PAIN

  • Strong component of night pain
  • Pain with rapid or unguarded movement
  • Discomfort lying on the affected shoulder
  • Pain easily aggravated by movement

2) MOVEMENT

  • Global loss of active and passive ROM
  • Pain at end-range in all directions

3) ONSET > 35 years of age

Medical Management (current best evidence)

Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to three years for symptoms to resolve and some patients may never fully regain full motion.[14] Therefore, it is important for patients to undergo treatment for pain, loss of motion, and limited function rather than take the 'wait-and-see' approach. Various interventions have been researched that address treatment of the synovitis and inflammation and modify the capsular contractions such as oral medications, corticosteroid injections, distension, manipulation, and surgery. Even though many of these treatments have shown significant benefits over no intervention at all, definitive management regimens remain unclear. It has been discussed that the primary treatment for adhesive capsulitis should be based on physical therapy and anti-inflammatory measures;[3] however, these outcomes are not always superior to other interventions.[2]

Corticosteroid Injections

[22]

Corticosteroid injections have been used to manage inflammation for many years. It is recommended for adhesive capsulitis based on the belief that inflammation is key in the early stage of the condition the corticosteroid will have an anti-inflammatory effect, diminishing the painful synovitis occurring within the shoulder.[2][5] This "chemical ablation of synovitis" limits the development of fibrosis (or adhesions) within the capsule, potentially shortening the natural history of the disease.[5][1] Thus they are thought to be more useful in the early, painful and freezing stage of the condition due to the involvement of inflammation, rather than in the latter stages when fibrous contractures are more apparent.[3][14][1][23]

Methyl-prednisolone and Triamicinolone have both been found to be effective for injection. There is no evidence suggesting the most effective treatment dose or administration site; however, the majority of the studies used 20-40 mg injected via an anterior or posterior approach.[14] 

Many studies have been performed and reviewed comparing corticosteroid injections to physical therapy but contradictory results have arisen. Upon further review, it has been concluded that corticosteroid injections provide significantly greater short-term benefits (4-6 weeks), especially in pain relief, but there is little to no difference in outcomes by 12 weeks compared to physical therapy.[3][5][2][14][23][24] It is important to note that the majority of studies looking at corticosteroid injection as a treatment option do not define what stage the patients are in and had variations in volumes of corticosteroid used. It has been shown that benefits may not only be dose dependent but dependent on the duration of symptoms as well,[14][1] thus the earlier the injection is received, the quicker the individual will recover. Contraindications do exist due to the use of corticosteroids and include a history of infection, coagulopathy, or uncontrolled diabetes.[14]

Ultimately, corticosteroid injections have shown to have success rates ranging from 44-80%[3] with rapid pain relief and improved function occurring mainly in the first weeks of treatment. Thus, injections should be suggested to patients with pain as their predominant complaint in the early stage of adhesive capsulitis.[5][2] Though intra-articular steroid injection may be beneficial early on, its effect may be small and not well maintained[24] and thus should be offered in conjunction with physical therapy.[5][14]

Recommendation:

  • Injection for relieving shoulder disability and pain and physical therapy for improving motion in the painful freezing stage.[2][1]
  • If patients fail to progress within 3-6 weeks with physical therapy alone or patient's symptoms worsen, should be offered the option of a corticosteroid injection.[2]

Manipulation Under Anesthesia (MUA)

[25]

Manipulation under anesthesia involves a controlled and forced, end-range positioning of the humerus relative to the glenoid in physiologic planes of motion (flexion, abduction, rotation) in patients with an anesthetic block to the brachial plexus. The block allows the shoulder muscles to completely relax so that the force may actually reach the capsuloligamentous structures.[2] Traditionally long lever arms were used, but now short lever arm techniques are utilized to minimize potential risks.[2][9] Although success rates are high, ranging from 75-100%,[2] manipulations are considered a last resort and are not indicated unless symptoms persist in spite of adequate conservative treatment for six months.[1][2][3][23] This is due to the numerous risks and complications such as: dislocation, glenoid, scapular, or humeral fracture, nerve palsy, rotator cuff tear, hemarthrosis, labral tears, and traction injuries of the brachial plexus or a peripheral nerve.[1][2][3][23] However, it has been shown that manipulations are the most reliable way to improve range of motion and reduce pain and disability in patients resistant to phyiscal therapy[1][3] and these complications can be minimized with proper techniques and precautions. A good prognosis is often indicated if an audible and palpable release of the tissue occurs during the manipulation.[2]

An extensive post-manipulation program begins immediately after release of the capsule.[2][9] They are often prescribed active assisted range of motion exercises that they are to perform every two hours at home, when awake, for the next 24 hours. Patients are also instructed to ice their shoulder for 20 minutes every two hours with their hand resting behind their head. Post manipulation programs are designed to maintain gains in shoulder mobility and should specifically address each individual's impairments.[2][9]

Contraindications to manipulation under anesthesia do exist and include: history of fracture or dislocations, moderate bone loss, or an inability to follow through with post procedure care.[2] Although manipulation under anesthesia has been shown to be effective in improving function and motion in patients with adhesive capsulitis, it is necessary to have more randomized controlled trials comparing this treatment to competing treatments before widespread use is advocated.[9]


Translation Mobilization Under Anesthesia

An alternative to traditional MUA, translation mobilization under anesthesia, has been identified in the hopes of avoiding the complications associated with the traditional approach. This procedure involves the use of "gliding techniques with static end-range capsular stress, with a short-amplitude high-velocity thrust, if needed, as opposed to the angular stretching forces in manipulation under anesthesia."[2][9] In other words, two to three 30-second sets of low-velocity, oscillatory mobilizations (Maitland Grade IV-IV+) are performed initially in the same directions as traditional manipulation under anesthesia (anteriorly, posteriorly, and inferiorly). If an immediate increase in passive range of motion is not noted, a high-velocity, low-amplitude manipulation may be performed. This technique appears to be a safe and efficacious alternative for treatment of patients resistant to conservative treatment; however, higher level studies are needed for verification.[2] 

Recommendation:

  • If a patient has persistent symptoms, particularly in decreased shoulder motion, after at least 6 months of conservative treatment, manipulation under anesthesia is an effective technique to improve mobility, pain and disability.
  • Contraindications and complications do exist and should be relayed to the patient.

Arthroscopic Capsular Release

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[26]

Arthroscopic capsular release is highly preferred over open release in patients with painful, disabling adhesive capsulitis that is unresponsive to at least 6 months of non-operative treatment. It has been found to be a reliable and effective method for restoring range of motion and is especially recommended in diabetics and in post-operative or post-fracture adhesive capsulitis patients.[3][1] It has become the most popular method of treating nonresponsive adhesive capsulitis despite the lack of higher level trials comparing it to MUA.[23] This is because it allows a more controlled and selective release of the contracted capsule compared to manipulation which ruptures the capsuloligamentous structures nonspecifically and avoids the complications associated with MUA.[2][1] Debate exists over which structures should be arthroscopically released with the rotator cuff interval and coracohumeral ligament being the most common structures released.[2] 



Recommendation:

  • If patient is unresponsive to at least 6 months of conservative treatment, arthroscopic capsular release alone or in conjunction with manipulation has been shown to be effective in restoring range of motion.
  • Avoids complications associated with manipulation under anesthesia and is recommended in diabetics and post-op or post-fracture adhesive capsulitis patients.

Other

Non-steroidal anti-inflammatory drugs (NSAIDs) have traditionally been given to patients with adhesive capsulitis but there is no high level evidence that confirms their effectiveness.[1][23] Oral steroids have also been utilized in these patients and result in some improvement in function, but their effects have not shown long-term benefits and combined with their known adverse side effects, should not be regarded as routine treatment.[1][23][27]

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[28]

Another technique that shows some short-term benefit with rapid relief of symptoms is distension arthrography. This technique involves the injection of a solution (saline alone or combined w/ corticosteroids) causing rupture of the capsule by hydrostatic pressure.[3] It is still undetermined whether joint distension with saline solution combined with corticosteroids provides more benefit than distension with saline alone or corticosteroid injection alone.[3] There is a lack of reliable evidence when determining the effectiveness of this technique and further research needs to be performed to verify any clinical benefit.[3][23][29]

Suprascapular nerve blocks are thought to temporarily disrupt pain signals to allow "normalization of the pathological, neurological procresses perpetuating pain and disability."[23] There is some evidence of benefit with suprascapular nerve blocks, though the exact mechanism behind this benefit remains unclear and higher level evidence is needed to establish this as a treatment for adhesive capsulitis.

Medical Management Conclusion

According to a Cochrane review by Green et al.,[30] there is little evidence to support or refute the use of any of the common interventions listed for adhesive capsulitis. There are also no studies with objective data supporting the timing of when to switch to invasive treatments such as manipulation under anesthesia or arthroscopic release, and thus these are not performed until 6 months of conservative treatment have been unsuccessful. Unfortunately this exposes more than 40% of patients with adhesive capsulitis to a long period of disability.[3]

Treatment should be tailored to the stage of the disease because the condition has a predictable progression.[1][23] During the painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs, physical therapy and steroid injection are all suggested interventions during this stage of adhesive capsulitis.[14][1] Once the patient is in the adhesive stage, injections are no longer indicated because the inflammatory stage of the disease has passed. Instead the focus should switch to more aggressive stretching and MUA or surgical release if symptoms are unresponsive to conservative treatment and quality of life is compromised.[1][2][3][23]

Physical Therapy Management (current best evidence)

The definitive treatment for adhesive capsulitis remains unclear even though multiple interventions have been studied. Previously published prospective studies of effective treatment have demonstrated conflicting results for improving shoulder range of motion in patients with this condition.[31] Non-operative interventions include patient education, modalities, stretching exercises, and joint mobilizations.[2][4] Levine et al. reported that 89.5% of ninety eight patients with frozen shoulder responded well to non-operative management.[2] Reviewed studies suggest that many patients have benefited from physical therapy and showed reduced symptoms, increased mobility, and/or functional improvement.[4] However, a Cochrane Review by Green et al. states that there is, “no evidence that physiotherapy alone is of benefit for adhesive capsulitis.”[30]

Importance of Patient Education

For the treatment of adhesive capsulitis, patient education is essential in helping to reduce frustration and encourage compliance. It is important to emphasize that although full range of motion may never be recovered, the condition will spontaneously resolve and stiffness will greatly reduce with time. It is also helpful to give quality instructions to the patient and create an appropriate home exercise program that is easy to comply with because daily exercise is critical in relieving symptoms.[2]

Modalities

Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in conjunction with stretching can help to improve muscle extensibility and range of motion by reducing muscle viscosity and neuromuscular-mediated relaxation.[2] In a randomized study by Bal et al., patients improved with combined therapy which involved hot and cold packs applied before and after shoulder exercises were performed.[5] However, a study by Jewell et al., claimed that ultrasound, massage, iontophoresis, and phonophoresis reduced the odds of improved outcomes for patients with adhesive capsulitis.[11] A Cochrane Review by Green et al. showed that, “There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis.”[30]

Initial Phase: Painful, Freezing

As stated previously, treatment should be customized to each individual based on what stage/phase of adhesive capsulitis they are in.

Pain relief should be the focus of the initial phase, also known as the Painful, Freezing Phase. During this time, any activities that cause pain should be avoided and pain-free activities should be allowed. Better results have been found in patients who performed pain-free exercise, rather than intensive physical therapy[1] In patients with high irritability, range of motion exercises performed with low intensity and a short duration can alter joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five seconds at a pain-free range, two to three times a day.[2] A pulley may be used to assist range of motion and stretch, depending on the patient’s ability to tolerate the exercise. Core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately forty degrees of abduction in the plane of the scapula, and active assisted range of motion in extension, horizontal adduction, and internal rotation.[2] (See Resources: Figure 1 and Figure 2). 

In a single-patient case-report by Ruiz et al.,positional stretching of the coracohumeral ligament was performed for a patient in the first phase of adhesive capsulitis.[31] The patient's Disabilities of Arm Shoulder and Hand (DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation from 20 degrees to 71 degrees. The stretches performed focused on providing positional low load and prolonged stretch to the CHL and the area of the rotator interval capsule following anatomical fiber orientation. The rationale behind this was to produce tissue remodeling through gentle and prolonged tensile stress on the restricting tissues. While a cause and effect relationship cannot be inferred from a single case, this report may help with further investigation regarding therapeutic strategies to improve function and reduce loss of range of motion in the shoulder and the role that the CHL plays in this.[31] (See Resources: Figure 3).

In the case of adhesive capsulitis, physical therapy can also be a complement to other therapies (such as steroid injections as discussed previously), especially to improve the range of motion of the shoulder.[3] In a study by Bal et al., concominant exercises to steroid injections included isometric strengthening in all ranges once motion was reached in 90% of normal ranges, theraband exercises in all planes, scapular stabilization exercises, and later, advanced muscular strengthening with dumbbells.[5]

Second Phase: Adhesive 

During the adhesive phase, the focus of treatment should be shifted towards more aggressive stretching exercises in order to improve range of motion. The patient should perform low load, prolonged stretches in order to produce plastic elongation of tissues and avoid high load, brief stretches, which would produce high tensile resistance.[1]

A prospective study by Griggs et al., demonstrated success of a non-operative treatment through a four-direction shoulder stretching exercise program in which 90% of the patients reported a satisfactory outcome.[3] During the second phase of treatment, movement with mobilization and end range mobilization have shown to be successful, according to a randomized multiple treatment trial by Yang et al.[12] In this trial, the patients had statistically significant improvements in the Flexi-Level Scale of Shoulder Function (FLEX-SF), arm elevation, scapulohumeral rhythm, humeral external rotation, and humeral internal rotation. Mobilization with movement also corrected scapulohumeral rhythm significantly better than end range mobilization did. The goal for end range mobilization was not only to restore joint play, but also to stretch contracted periarticular structures, whereas the goal for mobilization with movement was to restore pain-free motion to the joints that had painful limitation of range of motion.[12]

A controlled, cohort study, performed by Gaspar and Willis[8], showed that physical therapy paired with dynamic splinting had better outcomes compared to physical therapy alone or dynamic splinting alone. The patients in this group of combined treatments received physical therapy twice a week and a Shoulder Dynasplint System (SDS) for daily end-range stretching. The physical therapy was standardized, based on the protocols of Vermeulen, Hsu, and Mulligan. Methods for this treatment include moist heat, patient education and re-evaluation of symptoms, joint mobilization (limited to progressive end-range joint mobilization), passive range of motion, active range of motion and PNF, and therapeutic exercise. The SDS was worn twice each day for seven days per week and was set at #1 for the first week in order to allow the patient to accommodate to the stretching. After accommodation, the setting was increased to #2, which equals three foot lbs of force. The progression of the stretch as well as the adjustment for pain or soreness was standardized, and instructions were given to the patient to follow accordingly. Patients were instructed to increase the duration in the SDS unit for 20 – 30 minutes twice each day (with the intention to stretch 60 minutes each day. The combination of physical therapy with dynamic splinting had significant improvements in active, external rotation in patients with adhesive capsulitis.[8]

Third Phase: Resolution

During stage three, also known as the Resolution Phase, treatment is progressed primarily by increasing stretch frequency and duration, while maintaining the same intensity, as the patient is able to tolerate. The stretch can be held for longer periods, and the sessions per day can be increased. As the patient’s irritability level becomes low, more intense stretching and exercises using a device, such as a pulley, can be performed to assist tissue remodeling influence [2]. (See Resource: Figure 4).

Helpful Manual Techniques 

Mechanical changes that occur as a result of mobilizations may include the break- up of adhesions, realignment of collagen, or increased fiber glide when specific movements stress certain parts of the capsular tissue. These techniques are intended to increase joint mobility by inducing changes in synovial fluid formation. High-grade mobilization techniques (HGMT) have been shown to be helpful for improving range of motion in patients with adhesive capsulitis for at least three months.[10] In a study by Vermeulen et al., patients were given inferior, posterior, and anterior glides as well as a distraction to the humeral head. These techniques were performed at greater elevation and abduction angles if glenohumeral joint range of motion increased during treatment. Patients who received HGMT received these mobilizations at Maitland Grades III and IV according to the subjects' tolerance with the intention of "treating the stiffness." Patients were allowed to report a dull ache as long as it did not alter the execution of the mobilizations or persist for more than four hours after treatment. However, patients who received low-grade mobilization techniques (LGMT) were given Mailtand Grades I or II without the report of any pain. Statistically significant greater change scores were found in the HGMT group for passive abduction (at the time of three and twelve months), and for active and passive external rotation (at twelve months) when compared with low-grade mobilization techniques. It can then be concluded that high-grade mobilization techniques appear to be more effective for increasing joint mobility and reducing disability.[10] Based on prior knowledge regarding the use of Mailtand Grades for mobilizations, one would assume HGMT would be more beneficial during later adhesive stages of adhesive capsulitis, while LGMT would provide more benefit during early painful stages. However, future studies are needed to investigate whether HGMTs applied during earlier stages of adhesive capsulitis are as effective as in this particular study.[10]

In a randomized clinical trial, Johnson et al. reported that joint mobilizations, in particular posterior glenohumeral glides, can help decrease deficits in external rotation, more so than anterior glenohumeral glides.[19] A significant difference in external rotation was shown between the two groups (anterior glide treatment vs. posterior glide treatment) by the third treatment session. The individuals in the anterior mobilization treatment group had a mean improvement in external rotation range of motion of three degrees (SD 10.8 degrees) , whereas the individuals in the posterior mobilization treatment group had a mean improvement of 31.3 degrees (7.4 degrees). Both groups had a significant decrease in pain, but there was more improvement in external rotation range of motion in the group with the posterior mobilization treatment.[19] (See Resources: Figure 5 and Figure 6)

Another randomized controlled trial, performed by Zimmerman et al., found results consistent with the trial by Johnson et al., in which posteriorly directed joint mobilizations showed greater improvements in external rotation that anteriorly directed joint mobilizations.[31] Yang et al. performed a multiple treatment trial using combinations of end-range mobilization, mid-range mobilization, and mobilization with motion in patients with adhesive capsulitis.[12] Improved motion and function was found at 12 weeks with end-range mobilization. It was concluded that end range mobilization was more effective than mid-range mobilization in increasing motion and functional mobility.[12] The results in a study by Jewell et al., are also consistent with these randomized control trials and studies that have demonstrated the beneficial effects of joint mobilization and exercise for patients with adhesive capsulitis.[11]

Rationale Behind Stretching

Research regarding connective tissue stretch duration and intensity has produced three findings. First, high intensity, short duration stretching aids the elastic response, while low intensity, prolonged duration stretching aids the plastic response. Secondly, a direct correlation exists between the resulting proportion of plastic, permanent elongation and the duration of a stretch. Lastly, a direct correlation exists between the degree of either trauma or weakening of the stretched tissues and the intensity of a stretch. Mc Clure et al., stated that the maximum TERT (Total End Range Time) or the total amount of time the joint is held at near end range position, will be different for each person, and is often affected by personal circumstances such as a job or other responsibilities that may prevent a patient from increasing TERT.[31]

Progression

Manual techniques and exercise should only be progressed as the patient’s irritability reduces. Patient response to treatment should be based on their pain relief, improved satisfaction, and functional gains, rather than restoration of range of motion. Usually, patients are discharged when significant pain reduction is reached, a plateau of motion gains are noticed for a period of time, and after improved functional motion and satisfaction have reached their peak.[2] Progression for stretching via dynamic splinting is based on patient tolerance, as well. In the controlled cohort study by Gaspar and Willis, if the patients experienced discomfort or stiffness lasting more than an hour after the splint was removed, the duration of treatment was reduced for the next two scheduled stretching sessions. After the patient was able to tolerate stretching for a total of 60 minutes (30 minutes twice a day), the patient then increased the tension every two weeks based on tolerance, without discomfort lasting more than one hour following every stretching session.[8]

What We Need

“Despite extensive research, we still need prospective randomized studies comparing different treatments to formulate precise guidelines about the diagnosis and treatment of idiopathic adhesive capsulitis."[3] The lack of validity, poor standardization of terminology, methodology, and outcome measures in the investigations undermines clinical application. Therefore, more rigorous investigations are needed to compare the cost and effectiveness of physical therapy interventions.[4]

REHABILITATION PROTOCOL FOR ADHESIVE CAPSULITIS


File:Rehabilitation Protocol for Adhesive Capsulitis.doc [2][31][1][5][12][10][8]

From the information we have gathered from the literature review of rehabilitation for adhesive capsulitis, we have put together an example of a physical therapy protocol for practicing clinicians. It is broken up by phase of the disorder and also includes suggestions for the home exercise program.

Key Research

Vermeulen et al. (2006). Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: Randomized clinical trial.
The purpose of this RCT was to compare high-grade and low-grade mobilization techniques in patients with adhesive capsulitis. One hundred subjects who had symptoms for >3 months and >50% loss of passive range of motion were included and assessed at baseline as well as 3, 6, and 12 months post-treatment. Primary outcome measures included the Shoulder Rating Questionnaire (SRQ), Shoulder Disability Questionnaire (SDQ), active and passive range of motion. Overall, both groups showed improvements at 12 months with the high-grade mobilization group being slightly more effective at reducing disability and improving joint mobility.


Blanchard et al. (2010). The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitits: A systematic review.
The authors of this study deemed six articles eligible for inclusion according to the PEDro scale for methodological quality. All studies had random allocation to either an injection group or a physical therapy intervention group. There was a medium effect for corticosteroid injections compared to physical therapy for the outcomes of pain, passive external rotation and shoulder disability at six weeks. There was a small effect favoring corticosteroid injections for pain, passive external rotation and shoulder disability at 12-16 weeks and 26 weeks, and pain and shoulder disability at 52 weeks.

Cleland et al. (2002). Physical therapy for adhesive capsulitis: A systematic review.
The authors of this study reviewed 12 non-operative experiemental or descriptive research-based outcomes studies published between 1990 and 2000 to determine the efficacy of physical therapy for patients with adhesive capsulitis. Quality scores from the 12 studies ranged from 38-69% (mean 54%). Of the studies that were reviewed, physical therapy was beneficial at reducing symptoms, increasing mobility and/or improving function. However, poor standardasion of terminology, methodology and outcome measures undermines the validity of these studies and limits their clinical application.

Resources

FIgure 1: Forward Flexion; External Rotation; Extension
FIgure 1: Forward Flexion; External Rotation; Extension
 
Figure 2: Internal Rotation; Horizontal Adduction; Pulleys for Elevation
Figure 2: Internal Rotation; Horizontal Adduction; Pulleys for Elevation
Figure 3: Coracohumeral Ligament Stretch
Figure 3: Coracohumeral Ligament Stretch
 
Figure 4: Elevation and ER with Cane
Figure 4: Elevation and ER with Cane
Figure 5: Posterior Mobilizations
Figure 5: Posterior Mobilizations
Figure 6: Anterior Mobilizations
Figure 6: Anterior Mobilizations































Description and scoring of the three function-related tests for the first stage of primary adhesive capsulitis. (Note: Adapted from "Reliability of function-related tests in patients with adhesive capsulitis" by Yang et al., 2002, JOSPT, 36, p.573)

Hand-to-neck (shoulder flexion + external rotation)*

0   The fingers reach the posterior median line of the neck with the shoulder in full abduction and external rotation without wrist extension.
1   The fingers reach the median line of the neck but do not have full abduction and/or external rotation.
2   The fingers reach the median line of the neck but with compensation by adduction in the horizontal plane or by shoulder elevation
3    The fingers touch the neck
4   The fingers do not reach the neck

Hand-to-scapula (shoulder extension + internal rotation)¤

0   The hand reaches behind the trunk to the opposite scapula or 5cm beneath it in full internal rotation
1   The hand almost reaches the opposite scapula, 6-15 cm beneath it
2   The hand reaches the opposite illiac crest
3   The hand reaches the buttock
4   Subject cannot move the hand behind the trunk 

Hand-to-opposite scapula (shoulder horizontal adduction)§

0   The hand reaches to the spine of the opposite scapula in full adduction without wrist flexion
1   The hand reaches to the spine of the opposite scapula in full adduction
2   The hand passes the midline of the trunk
3   The hand cannot pass the midline of the trunk
* This test measures an action essential for daily activities, such as using the arm to reach, pull, or hang an object overhead or using the arm to pick up and drink a cup of water.
¤ This test measures an action essential for daily activities, such as using the arm to pull an object out of a back pocket or tasks related to personal care.
§  This test measures an action important for daily activities, such as usin gthe arm to reach across the body to get a car's seat belt or using the arm to turn a steering wheel.

Clinical Bottom Line

There is no definitive treatment for adhesive capsulitis. However, the literature suggests interventions should be tailored to the stage of the disease based on its progressive nature. During the initial/painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs and steroid injection, stretching, strengthening and range of motion exercises, as well as Maitland Grade I-II mobilizations have been shown to improve function and reduce pain and disability. As the patient progresses to the adhesive stage, intervention should focus on aggressive, end-range stretches combined with Maitland Grade III-IV mobilizations. At six months, if functional disability persists despite conservative treatment, mobilizations under anesthesia (MUA) or arthroscopic capsular release may be indicated.

Recent Related Research (from Pubmed)

References

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Ageing and Parkinson's Disease

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