Adhesive Capsulitis Presentation May 2009

8/3/2019 Adhesive Capsulitis Presentation May 2009

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Learning OutcomesAnatomy of the shoulder

Definition

Aetiology

Pathophysiology

Clinical Phases

Physical presentation Treatment and medication

Follow-up


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Anatomy of the shoulder


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Anatomy cont

Posterior view: Anterior view:Teres major

www.instantanatomy.net

Subscapularis


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Definition In 1934, Codman stated, "This entity [FS] is difficult to

define, difficult to treat, and difficult to explain fromthe point of view of pathology.

Two principal features:

gradual onset of pain and reduced range of motion(active and passive) of the GHJ in a capsular pattern

Uncertain aetiologyDias et al (2005)


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Epidemiology No regional variations

Prevalence is reported to be 2-5%, with an 11%prevalence in individuals with diabetes. For patientswith T1DM, the risk is approximately 40%.

FS affects women more frequently than men and themean age of onset is over 40

Brue et al (2007)


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Aetiology Idiopathic disorder.

risk factors: trauma, diabetes, hyperthyroidism, and

dyslipidemia, CVA with upper-extremity paresis,brachial plexus injury, cervical spinal cord injury, andParkinson disease.

repetitive movements of the upper extremities

active GHJ synovitis in relation to a systemicinflammatory rheumatologic disorder.

surgery to the shoulder, with post-op immobilizationDias et al (2005)


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Pathophysiology GHJ synovial capsule is often involved

hyperplastic fibroplasia and excessive type III collagensecretion that lead to soft-tissue contractures (of thecoracohumeral ligament, soft tissues of rotatorinterval, the subscapularis muscle, the subacromial

bursae). late phase dx

Why the pain precedes the contracture and why itresolves before the contracture remains unclear.


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Pathophysiology cont Neurological mechanisms: peripheral alpha-

adrenoreceptor hyperresponsiveness, dorsal-rootreflexes (DRRs), central nervous system (CNS) factors,myxoid globular degeneration, and sympatheticautonomic hyperactivity.


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Three Clinical Phases Phase 1 - freezing stage: insidious onset of

predominantly nocturnal pain (without inflammatory,exudative cellular joint processes). End of ROM can

increase pain. Lasts 2-9 months.

Phase 2 - frozen stage: pain gradually subsides andprogressive limitation in ROM occurs in a capsular pattern. ADLs can be severely affected. Last 3-12 months.

Phase 3 thawing stage - pain progressively decreases,and limitations in ROM spontaneously recover over 12-24months.


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Physical presentation Initial night pain associated with movements of the

shoulder e.g., combing one's hair, reaching overheadfor a seat belt (both use AB + ext rot), reaching forone's back pocket (ext and int rot).

Pain can be as high as 10/10 (VAS)

In ~90% of patients, the pain lasts for 1-2 years beforesubsiding.

Patients with a painful FS have pain during resistedcontraction of all of the rotator cuff tendons


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Physical presentation cont progressive limitation of PROM,

characterized by a painfulcapsular end-feel (externalrotation, followed by abduction,medial rotation and flexion).

Patients typically lift the entireshoulder girdle when trying tolift the arm.


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Treatment Patient education

dx process, including recovery time

importance of a HEP to increase ROM and function

Occupation

Deterrence (early mobilization and individuals who dorepetitive activities should pay special attention totheir posture and the ergonomics of their workstation)


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Treatment Jewell et al, (2009): a randomized clinical trial investigated

the effectiveness of joint mobilization and exercise forpatients with FS

The treatments that increased the likelihood ofpainreduction and improved function were:

- Joint mobilization performed by a PT and exercise

The treatments that decreased the likelihood of painreduction and improved function were:

- Ultrasound, Massage, Iontophoresis,

Phonophoresis


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TreatmentVermeulen et al (2000) showed that passive

mobilization at the end of range was more effective for

improving ROM and function than in the pain-freezone. However, the overall difference between theinterventions was small.

In addition, patients appeared to achieve greatestimprovement in ROM when treatment wasadministered early (Liaw et al, 2000).


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Maitlands mobilisations

Accessory: a movement that cannot be performed

independently by the patient but is critical to normalmovement e.g. glide, slide, spin, translate

Physiological: movements that a person can carry out

actively e.g. flexion/extension, abduction/adduction,medial/lateral rotation, circumduction


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Grading oscillatory joint mobilisation

treatment techniques

R1

Grade 1

Grade II

Grade III

Grade IV

Beginning

of range

End of

expected

rangeMaitland

freezing

stage

frozen &

thawing

stage


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Examples: mobilisations at GHJ

AP glide in abduction

AP glide when shoulder is in flexion Lateral glide in abduction

Distraction to GHJ in abduction

passive physiological to increase range of lateralrotation and flexion

Use hold and relax technique to increase flexion


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Maitlands Mobilisations

Desired effects:

Recover full range painless movement

Stretching a stiff joint to restore range

Stretching to lengthen contracted, fibrosed or

shortened muscle tissue

Relieve pain


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Successful treatment

* Increased ROM and decreased pain at end of range


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Other treatment

physical therapy associated with an intra-articularinjection of corticosteroid improves function andROM more rapidly (p < 0.005) than does intra-

articular corticosteroid injection alone (Carette et al,2003)

Medication for pain relief

OT give advice for performing ADLs (eg, dressing,bathing, grooming).


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Other treatment cont

Buchbinder et al (2004)conducted a randomised

double-blind placebo controlled trial supporting theuse of hydrodilatation for FS. Significantimprovements in function,pain, and ROM at 3 weekswere found, and this benefit was maintained at 6

weeks.


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Other treatment cont

Jones et al (1999) conducted a randomized controlled

trial compare the effectiveness of a singlesuprascapular nerve block with that of series of intra-articular corticosteroid injections. Pain decreased andROM increased more rapidly with the nerve block.


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Follow-up

Bilateral FS may find that even basic ADLs are achallenge. (eg, toileting, hygiene, dressing, driving,fastening a seat belt).

Further outpatient care (based on the patient's currentstatus and functional goals)


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Conclusion FS is of insidious onset, with progressive pain and

decreased ROM in a capsular pattern

Physical therapy treatment involves jointmobilisations and exerciseand has been shown toincrease the likelihood of pain reduction andimproved function in patients with FS


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References Jewell, et al (2009). Interventions associated with an increased or decreased

likelihood of pain reduction and improved function in patients with adhesivecapsulitis: a retrospective cohort study. Phys Therapy, 89(5):419-29.

Carette et al (2003). Intraarticular corticosteroids, supervised physiotherapy, or

a combination of the two in the treatment of adhesive capsulitis of theshoulder: a placebo-controlled trial.Arthritis Rheum., 48(3):829-38

Vermeulen et al (2000). End-range mobilization techniques in adhesivecapsulitis of the shoulder joint: A multiple-subject case report. Phys Ther.,80(12):1204-13.

Liaw SC (2000). The effect and timing of physiotherapy on change in range ofmotion and function in frozen shoulder. Physiother Singapore, 3(3):82-6.

Roy et al (2007). Adhesive Capsulitis , Available at

http://emedicine.medscape.com/article/326828-overview


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References Jones et al (1999). Suprascapular nerve block for the treatment of frozen

shoulder in primary care: a randomized trial. Br J Gen Pract., 49(438):39-41.

Buchbinder et al (2004). Arthrographic joint distension with saline and steroidimproves function and reduces pain in patients with painful stiff shoulder:

results of a randomised, double blind, placebo controlled trial. Annals of theRheumatic Diseases; 63:302-309

Dias et al (2005). Frozen shoulder. BMJ, 331:1453-1456

Brue et al (2007). Idiopathic adhesive capsulitis of the shoulder: a review.Journal of Knee Surgery, Sports Traumatology, Arthroscopy, vol 15(8), 1433-7347,

Hengeveld et al (2005). Maitlands peripheral manipulation (4th ed.).Elsevier/Butterworth Heinemann, Michigan


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Adhesive Capsulitis Presentation May 2009

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