Impairment/Function-Based Diagnosis

Adhesive Capsulitis

IMPAIRMENT/FUNCTION-BASED DIAGNOSIS

 Prevalence o Higher prevalence of diabetes and hypothyroidism among pts with adhesive capsulitis (AC)  Pathoanatomical features o GH capsule, coracohumeral ligament and GH ligaments comprise capsuloligamentous complex . This complex, along with the RC tendons, create intimate static and dynamic sleeve . The proximal portion of the capsuloligamentous complex and the subscapularis were found to limit ER when the GH joint was positioned up to 45° of abduction . Subscap limited ER the most with arm at 0 degrees abd o Adhesive capsulitis is marked by multiregional synovitis . Also nerve growth in the complex, which may add to pain, at rest or with motion . The entire complex can become fibrotic, but the RC are involved  Anterior restricts ER w arm at side, posterior restricts IR  Coracohumeral ligament release resulted in increase in ER o Clinicians should asses for impairments- loss of passive ROM in mult planes, esp ER and abd is imp  Risk Factors o Elevates serum cytokine levels o Type 1 or 2 diabetes mellitus o Thyroid disease (mostly women) . Inc hypothyroidism and hyperthyroidism o Age (age 40-65) o Having it on one side inc risk for other side o Prolonged immobilization o MI, autoimmune disease o **Pts with diabetes and thyroid disease are at risk for developing AC  Clinical Course o 4 stages of AC o Stage 1 . Up to 3 months, sharp pn at end range, achy at rest, sleep disturbance . Min to no ROM restrictions, and subacromial impingement is often thought bc of it . Loss of ER with intact RC is a hallmark sign o Stage 2 . “painful” or “freezing” stage, gradual loss of ROM in all directions bc of pn . 3-9 months o Stage 3 . “frozen stage” . capsuloligamentous fibrosis results in loss of ROM under anesthesia o Stage 4 . “thawing” stage . pn begins to resolve, stiffness persists 15-24 months after symptom onset o In the research, vast majority of pts were satisfied with their outcome, but 40% still reported residual shoulder disability . Conservative treatment and surgical tx were both successful o AC occurs as a continuum of pathology, characterized by staged progression of pn and mobility deficit . At 12-18 months, mild pn and deficit may persist  Diagnosis/Classification o Diagnosis . Determined from hx and physical exam . Pts present with gradual onset of pn, restricted ROM in elevation and rotation . Purpose of dx: direct intervention and inform prognosis . Pn and ROM less post op is NOT AC o Classification . Global loss of AROM and PROM  Greater than 25% in 2+ planes, and PROM loss ER >50% =AC  ER motion loss is greater than Abd  MMT is sometimes painless, sometimes painful o Component 1 . Medical screening- uses hx and phys exam to determine if pt symptoms are MSK disorder or more serious, like tumor . Should also screen for psychosocial issues, which can affect prognosis o Component 2 . Pts with shoulder pn often fi more than 1 impairment, most relevant impairment changes during pt’s episode of care o Component 3 . Dx of tissue irritability is imp- guides tx freq, intensity, duration, type  Irritability = tissue’s ability to handle physical stress  3 levels- determined by relation ptwn pn and AROM and PROM o Component 4 . Should match most app intervention to level of irritability . High irrit- tx should emphasize activity modification and appro. modalities . Mod irrit- controlled physical stress (manual therapy, stretching)  Differential Dx o 3 most common shoulder conditions: adhesive capsulitis, sprain/strain shoulder joint/dislocation, RC syndrome, o but lots of others! o Clinicians should remember there’s more conditions than AC  Imaging o Imaging can be used to rule out underlying pathology . Ex GH osteoarthritis o MRI can identify soft tissue and bony abnormalities

EXAMINATION

 Outcome measures o Many out there, not all have demonstrated acceptable measurement properties . Constant score, the DASH, the SPADI, and the ASES are widely used o Constant score- most widely used in Europe . 2 sections- pt self report and a clinician report . doesn’t comprehensively represent construct of shoulder use, only asks 4 questions about functional use o ASES- pt self report . 100 pt, 50 pts for pn and 50 for activity o DASH- pt self report o SPADI- pt self report . Had superior responsiveness when compared to DASH o Clinicians should use valid outcome measures before and after interventions  Activity Limitations o Clinicians should use easily reproduced activity and participation to assess pt shoulder pn and to see changes over episode of care  Physical Impairment measures o AROM and PROM should be measured- ER in add/abd, IR in abd, shoulder flexion and abduction

INTERVENTIONS

 Successful tx does not require full ROM o Instead, may be defined as reduced pn, improved function, and high lvl of pt satisfaction  Corticosteroid injections o Not within PT scope of practice, but pts who get it normally see PTs too o Reduce inflammatory response and pn in pts with AC o Significant improvement in jt motion immed following steroid injections  Take home: intra-articular corticosteroid injections combined with shoulder mobility and stretching exercises are more effecting in providing short-term pain relief and improved function compared to shoulder mobility and stretching exercises alone  Patient education o Central to each pt-PT interaction, critical to rehab management with pts with AC . Describing pathology can allay fears and prep them for the progression and recovery . Encourage activity modification and emphasizing functional pain free ROM is imp to prevent them from immobilizing their shoulder and making it worse o Pt education should: 1)describe the natural course of the condition, 2) promot activity mod, and func pain-free ROM, and 3)match the intensity of stretching to the pt’s level of irritability  Modalities o Heat and electrical modalities can help with pain in the tx o Impact of a single modality is hard to determine, since they’re typically applied with adjunct tx to manual therapy and exercises o Take home: clinicians can use short wave diathermy, ultrasound, or e-stim combined with mobility and stretching to reduce pn and improm shoulder ROM  Joint Mobilization o Evidence that it may be beneficial, but none to support it being better than other interventions . More research needs to be done o Can improve motion and function while reduce pn  Translational manipulation o Alternative tx to standard shoulder manipulation for unresponsive adhesive capsulitis . In study, 2 person manipulation- 1 person stabilized scapula whilt the other performed translational manip  6 of 8 experienced significant immed increase in PROM o good idea to use anesthesia  Stretching exercises o Influence pn and improve ROM but not more than other interventions o Results are inconsistent across studies, and no evidence exists to guide optimal freq, number of reps, or duration of stretching . As in joint mobs, future research is needed o Intensity of exercises should be determined by patient’s tissue irritability level.