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ADHESIVE CAPSULITISKIM KRAFT, PT, DPT, CHT

DEFINITION

Inflammation of the capsule’s subsynovial layer with fibrosis, contracture, and adhesion between the capsule and the humeral neck and in pockets of the capsule.

Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg, 2011; 19(9): 536-542.

Risk Factors Diabetes

Thyroid disease

Age 40-60

Gender (Female)

Upper quarter surgery

Immobilization

http://testguessandgo.com/2013/09/26/argh-frozen-shoulder/

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Shoulder CapsuleWhere is it?

The capsule lines and contains the articular space of the joint, blending with the ligaments and tendons of

the shoulder.

Adhesive CapsulitisHow does it cause loss of motion?

• Painful capsular thickening and

contracture reduces tissue excursion:

1. Axillary Recess

2. Long Head Biceps Tendon

3. Rotator Interval

Adhesive CapsulitisAxillary Recess

http://gillytherapy.com/2011/frozen-shoulder-adhesive-capsulitis/

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Adhesive CapsulitisLong Head Biceps

Adhesive CapsulitisRotator Interval

For CytologistsCollagen shortening

Fibrofatty tissue changes in the capsular recess

Ligament atrophy and stiffening

Collagen bridging across capsular recesses

Random collagen production

Reduction in sarcomeres in surrounding muscle tissue

Manske RC, Prohaska D. Diagnosis and management of adhesive capsulitis. Current reviews in musculoskeletal medicine.2008; 1(3-4): 180-189.

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Frozen Shoulder

http://lemonlimemoon.blogspot.com/2008_01_01_archive.html

http://calgaryguide.ucalgary.ca/slide.aspx?slide=Adhesive%20Capsulitis.jpg

Online Resource

Patient Education Resource

J Orthop Sports Phys Ther 2013;43(5):351. doi:10.2519/jospt.2013.0503

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ADHESIVE CAPSULITIS TYPES

PrimarySecondary

And the wisdom to know the difference!

Insidious gradual onset

Presents with pain, may not

realize stiffness

Runs a natural course of freezing,

frozen, thawing

Primary

History of trauma, surgery,

or immobilization

Stiffness and pain are related

(usually feel better after stretching)

Secondary

Differential Diagnosis

• Other causes of shoulder stiffness:

Muscular Tightness

Osteoarthritis

Regional Stiffness (UQ Surgery)

Dislocation (Especially Posterior)

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Differential Diagnosis

• Other causes of shoulder pain:

Impingement

Biceps Tendinitis/osis

Rotator cuff tear

Labral Tear

Osteoarthritis

Fracture

HALLMARK SIGN• Loss of External Rotation > Elevation > Internal

Rotation

***ER less than 50% of unaffected side***

Gagey Hyperabduction Test

• Test for inferior glenohumeral mobility

• Passive abduction in sitting with scapula stabilized

• “Normal” 105 degrees abduction

• Compare to unaffected shoulder for ROM and pain

Gagey OJ, Gagey N. An assessment of the laxity of the inferior glenohumeral ligament. J Bone Joint Surg Br, 2001;83-B:69-74.

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Difinitive Diagnosis: Arthrogram

http://shoulderdoconline.co.uk/article.asp?section=893

1⁰ ADHESIVE CAPSULITIS PHASES Freezing

FrozenThawing

http://www.bestorthopaedicsurgeonsydney.com/shoulder-conditions/frozen-shoulder/

Online Resource

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Phase Dictates Treatment

Adhesive Capsulitis

Phase

Tissue reactivity

Muscle spasm & guarding

NSAIDS? Injection?

Joint mob effects

Response to exercise

Surgical candidacy

Freezing Phase 3-9 mos, Pain 7/10,

Constant

Painful AROM, unable to asses

PROM

Stretching = worse

Neck pain from scapular

compensation patterns

http://twistedpositions.com/tag/move-like-water/

Freezing Phase Treatments

• Pain Relief PRIMARY GOAL

• POOL THERAPY

• Heat/Ice/TENS

• NSAIDS, Steroid Oral or Injections***

• Exercises

• Pendulum

• Neck and scapular AROM

• Shower AROM behind the head, behind the back, across the body

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Freezing Phase Manual Therapy

1. Extremely gentle,

• non-painful glenohumeral

• oscillations Grade I-II

• 2. Postural correction:

– Scapular ROM to reduce anterior tilt/restore retraction endurance ; Pect minor stretching

– Address UT/LS/SA pattern of upward scapular rotation

– CROM, Thoracic spine extension

Be Kind To The Freezing

Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: A prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shouder syndrome

followed up for two years. J Shoulder Elbow Surg, 2004;13:499-502.

Frozen Phase4-12 months

Pain 4-6/10, Intermittent

Tolerates stretching (end-range pain)

Loss of PROM (ER>FLEX>IR)

Disuse atrophy of glenohumeral

muscles

Limited ADL’s

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Frozen Phase Treatments

• Pain control as needed

• Heat/Ice/TENS

• NSAIDS, Injections

• Exercises to prevent further motion loss

• Increased frequency-every 2-4 hours

• AAROM with stick, at countertop, or with gravity assistance, wall climbing

• LLPS such as JAS Shoulder Unit/Flexionator

• Surgery?

Frozen Phase Manual Therapy

• Manual Therapy Tricks to Reduce Muscle Guarding and Spasm

• Joint Distraction

• Grade 1-2 Oscillations

• MWM, PNF

• Grade 3-4 Glenohumeral Mobilization as tolerated

Thawing Phase12-24 months

“Turned the corner”

Improving motion

Return to ADL’s and activities

Tolerates end-range stretching and mobilization

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Thawing Phase Treatments

• PAIN RELIEF NOT A PROBLEM

• NSAIDS/Ice only as needed after stretching/activity

• Steroid oral or injections no longer effective

• EXERCISES STIFFNESS IS A PROBLEM

• Weighted end-range stretches Flexion, IR, ER, Sleeper Stretch

• Surgery/Manipulation

Thawing Phase Manual Therapy

•End-Range Mobilization

•Grade 3-4

ORAL AGENTS & STEROID INJECTIONS

NSAIDSOral Steroids

InjectionsEtcetera

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Medications

• NSAIDs for anti-inflammatory effect/pain control to allow stretching, activity

• Oral corticosteroids : short term reduction in pain and increase in ROM

• Intraarticular injections: Ultraound/fluoroscopy ensures injection inside the joint

• STEROID TREATMENTS IMPROVE TOLERANCE TO ROM BY REDUCING INFLAMMATION

Manske RC, Prohaska D. Diagnosis and management of adhesive capsulitis. Current reviews in musculoskeletal medicine.2008; 1(3-4): 180-189.

Coticosteroid InjectionWhere Do You Put It?

• 191 Patients in 4 groups:1. Subacromial Injection

2. Intraarticular Injection

3. Intraarticular AND Subacromial Injections

4. Medication (NSAID, No injection)

• Measured differences across time between the groups

Shin SJ, Lee SY. Efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. J Shoulder Elbow Surg; 2013:

(22) 521-527.

http://communitymrinorfolk.com/2011/12/15/shoulder-arthrogram/

OUTCOMESSteroid Injection

• WEEKS 2-16

• Improved Pain and ROM ALL GROUPS

• Subacromial Injection

• Intraarticular Injection

• Intraarticular AND Subacromial Injections

• WEEKS 16+

• Medication (NSAID, No injection): the same as injection after 16 weeks.

Shin SJ, Lee SY. Efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. J Shoulder Elbow Surg; 2013: (22) 521-527.

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Problem: Patient too acute for therapy?Consider asking referral source for oral

steroid taper or injection.

In the Pipeline: Collagenase

What KIND of injection?

• Bee Venom Acupuncture in

addition to therapy

• Improved AROM, PROM, Pain, and

Function!!

• 16 sessions over 2 months

Koh PS, Seo BK, Cho NS, Park HS, Park DS, Baek YH. Clinical effectiveness of bee venom acupuncture and physiotherapy in the treatment of adhesive capsulitis: a randomized controlled

trial. J Should Elbow Surg, 2013; (22):1053-1062.

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THERAPY PROGRAM

Use of Therapy Visits

Home Program

Conservative Care For Adhesive Capsulitis

• 89.5% of 105 patients resolved with non-operative treatment of therapy and NSAIDS alone.

• Younger (40s) and stiffer subjects did not succeed with non-operative therapy.

• Those who were not improved after 4 months of treatment elected for surgery at 12 months after onset.

• Affected shoulder never reached full ROM of contralateral shoulder but patients were satisfied with the result and did not report functional limitations.

Levine WN, Kashyap CP, Bak SF, Ahmad CS, Blaine TA, Bigliani LU. Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg; 2007: 569-573.

OUTCOMESTherapy Visits

• Supervised patients continued steady improvement for 12 weeks…those with an unsupervised home program improved for 6 weeks, then began to decline.

• Conclusion: Therapy visits to progress exercise programs as tolerated is indicated.

Gleyze P, Georges T, Flurin PH, Laprelle E, Katz D Comparison and critical evaluation of rehabilitation and home-based exercises for treating shoulder stiffness: prospective multicenter

study with 148 cases. Orthop Traumatol, 2011: 97:182-184.

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Supervised Home Therapy Program

• HOW TO:

1. Every visit: Check status of home program, pain, AROM, PROM

2. Progress exercises as tolerated

3. Use of joint and soft tissue mobilization only as needed to make gains

Supervised Home Therapy ProgramWhere are we?

• STEP 1

• Every visit

• Frequency/response to home program

• Pain 0-10/10

• PROM and AROM

Supine Standing

Flexion(0/125)

Elevation0/100

ER 45(0/10)

ERLeft ear

IR 45(0/60)

IRMidline

Supervised Home Therapy ProgramWhere are we going?

• STEP 2

• Read the numbers• Increased Pain+Decreased ROM=Exercise is too much

• Decreased Pain+No motion gain=Exercise is too little

• Decreased Pain+Increased ROM=Just right

• Progress exercises as tolerated titering out repetitions and force

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Progression of Force

Active Flexion,

extension, IR, ER, HADD

Active Assisted Add stick,

pulley, countertop

Passive

End-range mobilization, overpressure

Low-load prolonged

stretch Weighted

stretches , etc

Supervised Home Therapy ProgramUse your resources well.

• STEP 3

• Scheduling Visits

• Use manual therapy for joint and soft tissue mobilization only as needed to continue to make 5-10 degree improvements every 2 weeks.

Use of Technology

• iPhone Goniometry and HEP monitoring system

• Kinex System

• Gamify

• Exercise Log

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APPLICATION OF TENSION

Total End Range Time

Low Load Prolonged Stress

• Overstress of reactive upper extremity

tissue causes inflammation, loss of active motion from muscle spasm and

loss of passive motion from fibrosis.

Thoughtful Application of Stretch

•ST

RET

CH

INTE

NSI

TY

STRETCH DURATION

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Total End Range Time (TERT)• Six 10-minute sessions of

stretching “close to pain”

• Ermi Flexionator (Atlanta GA)

• (holds the affected arm in either ER or ABD)

• Good Results in both high and moderately irritable subjects:

• Increased motion, Improved function in all subjects

Dempsey AL, Mills T, Karsch RM, Branch TP: Maximizing total end range time is

safe and effective for the conservative treatment of frozen shoulder patients. Am J Phys Med Rehabil 2011;90:738-745.

Low Load Prolonged Stretch (LLPS)

• Literature supports use of

• 5-10 minute stretches in the shoulder,

• 30 minutes 4 times per day for the elbow.

Donatelli R, Ruivo RM, Thurner M, Ibrahim MI. New concepts in restoring shoulder elevation in a stiff and painful shoulder

patient. Phys Ther Sport, 2014; 15: 3-14.

LLPS MethodsDonatelli R, Ruivo RM, Thurner M, Ibrahim MI. New concepts in restoring shoulder

elevation in a stiff and painful shoulder patient. Phys Ther Sport, 2014; 15: 3-14.

1. Joint Active Systems Shoulder Unit

2. Use of weighted ER or IR stretches in variable degrees of Abduction

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MANUAL THERAPY

Maitland

MWM

PNF

NAT

Effects Of Manual Therapy1. Increased Glenohumeral ROM

– Stretches capsular tissue– Breaks adhesions– Initiates fibroclastic activity – Reduces muscle spasm

2. Decreased pain– Peripheral mechanoreceptor stimulation and

nociceptor inhibition– Improves synovial fluid to articular cartilage,

reducing the deep ache associated with shoulder immobility

3. Synovial Stress– Changes synovial fluid viscosity– Increases synovial turnover time

Glenohumeral End-Range Joint Mobilization

Venneulen HM, Obermann WR, Burger BJ, Kok GJ. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: a multiple-subject case report. Physical Therapy. 2000; 18:1204-1213.

Active abduction, flexion, and lateral rotation ROM increased in each of 6 patients 12 weeks of end-range mobilization.

Correlation of increased motion with increased joint capacity from 10cm3 to 14cm3!

6 subjects treated twice per week for 12 weeks of end-range mobilization.

Inclusion: More than 50% limitation in elevation or lateral rotation and greater than 3 months since onset.

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Proprioceptive Muscular Technique (PNF)

• Home Exercise and PNF Stretching both improve ER and ABD ROM and SPADI scores after 2 & 4 weeks.

• PNF alone is significantly better than Home Program Alone.

• Effective Techniques:

• Slow Reversal

• Contract/Relax1

Harshit M, Paras J, Hardik T. Effectiveness of PNF stretching and self stretching in patients with adhesive capsulitis-a comparative study. Ind J Physio & Occupat Ther, 2013; 7:47-51.

Mobilization With Movement (MWM)

Less Painful because physiological movements normalize accessory joint motion(Arthrokinematics)

Neural Pain inhibition loop

Reduction in antagonistic muscle cocontraction

MWM also improves scapulohumeral rhythm

• Yang JJ, Chang CW, Chen SY, Wang SF, Lin JJ. Mobilization techniques in patients with frozen shoulder syndrome: randomized multiple treatment trial. Phys Ther, 2007; 87:1307-1315.

MWM

• Traditional End-Range Mobilization plus MWM worked better than either one alone (Improved ROM and SPADI scores) after 3 weeks.

Goyal M, Bhattacharjee S, Goyal K. Combined effect of end-range mobilization (ERM) and mobilization with movement (MWM) techniques on range of motion and disability in frozen shoulder patients: a randomized controlled trial. - J Exercise Science Physio, 2013; 9:74-82.

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Niel-Asher Technique (NAT)

“Trigger Point Based” A la Travel and Simons 1999Improvements in AROM (Flexion and Abduction) after pressure or deep stroking to tender points in the muscleAppointments 7-10 days apart, 25-40 minutes each+/- Home Exercise Program of passive stretchingLight Painfree Use of the involved arm

Niel-Asher S, Hibberd S, Bentley S, Reynolds J. Adhesive capsulitis: prospective observational multi-center study on the Niel-Asher Technique (NAT) - International

Journal of Osteopathic Medicine, 2014; In Press.

NAT

1. Sitting, to Upper Trapezius

2. Side-Lying, To Lateral Humeral MyofascialBand, Elbow to SHoulder

3. Sidelying IRBB, To Posterior Cuff

4. Passive Circumduction

5. Supine, Biceps

6. Supine, Infraspinatus

Niel-Asher S, Hibberd S, Bentley S, Reynolds J. Adhesive capsulitis: prospective observational multi-center study on the Niel-Asher Technique (NAT) - International Journal

of Osteopathic Medicine, 2014; In Press.

Bonus! Subscapularis Trigger Point

Subscapularis is palpable in the dorsal axillaApply direct pressure to tender spots for 30-60 seconds

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Dry NeedlingCase Study:13 Therapy Visits Over 6 WeeksRestored IR, ER, FLEX, ABDImproved SPADI and QuickDASH

Exercise, Manual Therapy ,Stretching Program

Dry needling, upper trapezius, levator scapula, deltoid, and infraspinatus trigger points

Clewley D, Flynn TW, Koppenhaver S. Trigger point

dry needling as an adjunct treatment for a patient with

adhesive capsulitis of the shoulder. J Orthop Sports Phys

Ther, 2014; 44: 92-101.

SURGICAL INTERVENTIONS

Manipulation under Anesthesia

Capsular Release

Recommending Plan B Completed >12 weeks therapy & home

program

VERY stiff (great loss of IR/ER)

Phase: “Frozen” Phase, After approximately 8 months duration

Younger (40’s/early 50’s)

More active, higher shoulder demand

Diabetic

Rill BK, Fleckenstein CM, Levy MS, Nagesh V. Predictors of outcome after nonoperative and operative treatment of adhesive capsulitis. Am J Sports Med 2011; 39: 567-574.

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Manipulation Under Anesthesia (MUA)• Procedure

1. Patient supine, one hand stabilizes the scapula of the affected side

2. Affected arm is held at the humerus, externally rotated (to clear the greater tuberosity from beneath the acromion and prevent fracture), then elevated

3. Arm returned to 90⁰, and internally rotated, continue until symmetrical motion

• Risks

• Humeral fracture, brachial plexus injury, glenohumeral dislocation

Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg, 2011; 19(9): 536-542.

Capsular Release

Anterior & Posterior

http://knie-schulter.info/frozenshoulder/frozen_shouldertxt.htm

Capsular Release

• Anterior Capsule

• Rotator Interval

• Restore External Rotation

• Not Subscapularis

• Close to the axillary nerve

• Posterior Capsule

• Restores Internal Rotation and Horizontal Adduction

Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg, 2011; 19(9): 536-542.

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Expected Progress

Excellent ROM, Pain, Function results with “early rehabilitation”

Best ROM observed within 48 hours of surgery because of the anesthetic

Dip in ROM at 1 month post-operatively (post-op adhesion formation)

Nearly complete ROM, Minimal functional deficit and pain at 6 months post-op

Trsek D, Cicak N, Zunac M, Klobucar H. Functional result and patient satisfaction after arthroscopic capsular release of idiopathic and post-traumatic stiff shoulder. Int Orthop, 2014;38:1205-1211.

Therapy After MUA• INPATIENT, 3 days:1. Head of bed 30⁰

2. 90⁰ Shoulder abduction and ER at night for two weeks

3. Hand on top of the head as much as possible all day

4. IR/ER/Flex AROM 2x/day

5. Then, Begin outpatient therapy 3x/week “full go”

6. Home program 3x/day

Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg, 2011; 19(9): 536-542.

Therapy After MUA/Capsular Release

• OUTPATIENT

• Daily therapy with range of motion in all planes as tolerated the first 1-2 weeks,

• Reduce to 2-3 visits per week as indicated by progress

• Features adherence to home program:

• 3x30 minutes per day

• Vs.

• “Do something” for 10 minutes every 2 hours

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Axillary Nerve Evaluation

• Resisted Test: Abduction of the arm, (palpating anterior, middle, and posterior Deltoid eliminates the possibility of supraspinatus substitution)

• Sensation Test: Lateral aspect of the upper arm

SPECIAL CASES OF SECONDARY ADHESIVE CASPULITIS

Hemiplegic Shoulder Pain

Post-Mastectomy Shoulder Stiffness

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Hemiplegic Shoulder Pain• Painful

• Loss of ER and ABD

• Loss of motor control

• Subluxation

• Brachial plexus traction

• Therapy:

• NMES

• Support to reduce traction

• Gentle ER Stretches

Griffin JW. Hemiplegic Shoulder Pain. Phys Ther, 1986; 66: 1884-1893.

Post-Mastectomy Shoulder StiffnessSurgical scarring

Radiation fibrosis

Pain, lymphedema, refer out as needed

Increased scapular excursion and upward rotation with humeral elevation

Crosbie J, Kilbreath SL, Dylke E, Refshauge KM, Nicholson LL, Meith JM, Spillane AJ, White, K. Effects of Mastectomy on shoulder and spinal

kinematics during bilateral upper-limb movement. Phys Ther, 2010; 90:679-692.

WRAP IT UP

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Referral Source Talking Points

• Define the terms “what do you consider frozen shoulder”

• Practice patterns: View of Injection, NSAID, low load prolonged stress devices

• Pros and Cons of therapy in the past

• Capsular release: anterior only or anterior and posterior?

• Use of steroids to reduce acute inflammation