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ADHESIVE CAPSULITIS
   
Adhesive capsulitis is an enigmatic condition characterized by painful, progressive, and disabling loss of active and passive glenohumeral joint range of motion in multiple planes.It is characterized by the development of dense adhesions, capsular thickening, and capsular restrictions, especially in dependent folds of the capsule, rather than arthritic changes in cartilage or bone, with rheumatoid arthritis or osteoarthritis. The causes of frozen shoulder could be Primary(idiopathic ) or Secondary( Problems directly related to shoulder joint). The clinical entity progresses through a series of four stages following a classic continuum-Stage 1 for less than 3 months , Freezing stage, Frozen stage & Thawing stage. This condition also cause some common functional limitations/disabilities like inability to reach overhead, behind head, out to the side, and behind back, etc.


IMPAIRMENTS


Body structures

Direct

  1. Inflammation of joint capsule.

  2. Capsular adhesions

  3. Reduction in synovial fluid

  4. Reduction in joint capsule

Indirect

  1. Diffuse muscle atrophy

  2. Inflammation of the joint capsule

  3. Associated deformities

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Body Functions

  1. Pain on motion and often at rest during acute flares

  2. Decreased joint play and ROM, usually limiting external rotation and abduction with some limitation of internal rotation and elevated and protracted shoulder.

  3. Posture: possible faulty postural compensations with protracted and anteriorly tilted scapula, rounded shoulders, and elevated and protracted shoulder.

  4. Decreased arm swing during gait.

  5. Muscle performance: General muscle weakness and poor endurance in the glenohumeral muscles with overuse of the scapular muscles leading to pain in the trapezius, levator scapulae and posterior cervical muscles.

  6. Substitution for limited glenohumeral motion with increased scapular motion especially elevation.

  

GOALS

 

  • Short term

  1. Patient and family education

  2. Reduction of pain and swelling

  3. Maintain and Improve mobility of shoulder

  4. Improve soft tissue mobility

  5. Inhibit muscle spasm and correct faulty mechanics

  6. Improve muscle strength

  7. Improve the flexibility of the muscles and capsule

  8. Prepare for functional demands

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  • Long term

  1. Maintain joint integrity

  2. Maintain functional activities and functional ROM

  3. Maintain muscle strength

  4. Maintain the flexibility of the muscles and capsule

  5. Functional rehabilitation

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MANAGEMENT


The interventions for adhesive capsulitis depend upon the phase of the patient, in the progression of the condition. So, it is important to know the stage of the condition with the appropriate cause (if secondary), using your assessment skills.
 

Patient and family education

  • Educate the patient about the condition 

  • Explain do’s and dont’s like continuing with exercises and avoiding pain aggravating actions in the initial stages.

 

Protection Phase

 

To Control Pain

  • Sling

 

To  Control Edema and Muscle Guarding

  • Active/Active assisted or Passive -ROM

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To maintain Soft Tissue and Joint Integrity and Mobility

  • Passive ROM

  •  A-AROM or AROM (Using activities as the pain decreases)

  • Passive joint distraction and glides

    • Grade I and II with the joint placed in a pain-free position 

  • Pendulum (Codman’s) exercises 

  • Shoulder Isometrics

Be sure the patient is taught proper mechanics and avoids faulty patterns

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To maintain Integrity and Function of Associated Areas

  • Squeezing a ball or other soft object.

  • Exercises of the elbow, forearm, wrist, and fingers several times each day

  • If tolerated, active or gentle resisted ROM is preferred to passive ROM for a greater effect on circulation and muscle integrity.

  • If edema, instruct the patient to elevate the hand, whenever possible, above the level of the heart.

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Controlled Motion Phase
 

To Control Pain

  • Ultrasound

    • Pulsed mode  

    • Duration: 2-3 mins

    • Intensity: 0.25 to 0.4 Wb/cm3

    • Site- Anterior aspect of the shoulder shoulder (covering the capsule)

  • Cryotherapy

    • Direct Ice

    • Duration- 10-15mins

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To decrease Edema and Joint Effusion

  • Functional activities-If the joint was splinted, the amount of time the shoulder is free to move each day is progressively increased.

  • Range of motion- Wand exercises or hand slides on a table. (progressed up to the point of pain. lnclude all shoulder and scapular motions.)

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To Progressively Increase Joint and Soft Tissue Mobility

  • Passive joint mobilization techniques

    • Stretch grades

    • Grade III sustained or grade III and IV oscillation

  • End-of-range techniques –

    • Rotating the humerus and then applying either a grade III distraction or a grade III glide

  • Self-mobilization techniques

    • The following self-mobilization techniques may be used for a home program

    • CAUDAL GLIDE: Patient position and procedure: Sitting on a firm surface and grasping the fingers under the edge. The patient then leans the trunk away from the stabilized arm.

    • ANTERIOR GLIDE: Patient position and procedure: Sitting with both arms behind the body or lying supine supported on a solid surface. The patient then leans the body weight between the arms 

    • POSTERIOR GLIDE: Patient position and procedure: Prone, propped up on both elbows. The body weight shifts downward between the arms.

  • Manual stretching

  • Self-stretching exercises

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To Inhibit Muscle Spasm and Correct Faulty Mechanics

  • The head of the humerus may be held in a cranial position in the joint, making it difficult and/or painful to abduct. Thus, re-positioning the head of the humerus with a caudal glide is necessary 

  • Avoid “hiking the shoulder” when abducting or flexing the arm. 

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To Improve Joint Tracking

  • Mobilization with movement (MWM) techniques

    • Postero-lateral Glide

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To Improve Muscle Performance 

  • Any faulty postures or shoulder girdle mechanics the patient should be identified and exercises to correct the muscle imbalances.

  • Stabilization exercises

  • Flexibility exercises

  • Strengthening exercises- of shoulder-girdle musculature

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Minimum Protection/Return to Function Phase

 

To Progressively Increase Flexibility and Strength

  • Stretching exercises

  • Strengthening exercises 

Emphasis of treatment should be on correct mechanics, safe progressions, and exercise strategies for return to function.

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To Decrease the capsular tissue restriction

  • Vigorous manual stretching

  • Joint mobilization techniques

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To Prepare for Functional Demands

  • If the patient is involved in repetitive heavy lifting, pushing, pulling, carrying, or reaching, when joint range and strength allow, exercises are progressed to replicate these demands.

  • Post manipulation Under Anesthesia
     

To increase the mobility and decrease the capsular tissue restrictions

  • Joint play techniques

  • Passive ROM techniques 

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OTHER ADVANCE TECHNIQUES
 

  • Maitland mobilization[1]

  • Kinesiotaping with Maitland mobilization[1] 

  • Low level laser treatment (highly effective with respect to pain and disability)[2]

  • Mulligan’s Technique- (Mulligan’s technique offers advantages over conventional stretching exercises and offers advantages that are sustained after completion of the treatment.)[3]


REFERENCES

  1. Smita B Kanase , S. Shanmugam , Effect of Kinesiotaping with Maitland Mobilization and Maitland Mobilization in Management of Frozen Shoulder , International Journal of Science and Research (IJSR)

  2. Dr. Apostolos Stergioulas , Low-Power Laser Treatment in Patients with Frozen Shoulder: Preliminary Results, Photomedicine and Laser Surgery Volume 26, Number 2, 2008

  3. Gokhan Doner, Zeynep Guven, Ayçe Atalay , et al , EVALUATION OF MULLIGAN’S TECHNIQUE FOR ADHESIVE CAPSULITIS OF THE SHOULDER, J Rehabil Med 2013; 45: 87–91

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