Resolution of Adhesive Capsulitis Following Subluxation Based Chiropractic Care: A Case Series & Selective Review of the Literature

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1 Case Series Resolution of Adhesive Capsulitis Following Subluxation Based Chiropractic Care: A Case Series & Selective Review of the Literature Min Shin, D.C. 1 Joel Alcantara, D.C Private Practice of Chiropractic, Orlando, FL 2. Research Director, the International Chiropractic Pediatric Association, Media, PA and Senior Research Consultant, Life Chiropractic College West, Hayward, CA Abstract Objective: To describe the chiropractic care of two patients with shoulder pain and restriction in motion. Clinical Features: A 45-yr-old female and a 47-year-old male presented for chiropractic care with complaints of shoulder pain and dysfunction. The female patient injured her right shoulder following a fall. She did not receive medical care as her pain was tolerable. However, 2 months later, she could not move her right shoulder due to pain and experienced right-sided neck pain. Over-thecounter medication was ineffective. The male patient suffered from restricted shoulder motion following a motor vehicle collision 2 months prior. Physical therapy was ineffective and therefore sought chiropractic care. Intervention and Outcome: Chiropractic adjustments characterized as high velocity, low amplitude thrusts applied exclusively to the C0-C1 joint complex was rendered to both patients. Ultrasound was applied to the male patient only following spinal adjustments to the upper cervical spine. Baseline and comparative measures of shoulder ROM and pain rating showed significant improvements in both patients. Conclusion: This case series provides support on the use of chiropractic adjustments directed to the upper cervical spine in patients with shoulder pain and dysfunction. We support further research in the care of similar patients. Key words: Adhesive capsulitis, frozen shoulder, chiropractic adjustments, vertebral subluxation Introduction Patients seeking care for musculoskeletal complains involving the shoulder is second only to low back pain 1 with a yearly incidence of 15 new episodes per 1,000 patients as seen in the primary care setting. 2 It's been estimated that approximately 20% of the general population will suffer from shoulder pain sometime in their lifetime. 3 Despite findings of improvements in shoulder function in the long term after conservative treatment 4, more than half of those with persistent complaints do not seek additional medical treatment 4 and in the older populations, only about half who have persistent shoulder pain seek any medical care. 5-7 Among chiropractic patients, upper extremity complaints (including shoulder complaints) is 3 rd only to spinal pain and headaches as a presenting complaint. 8 Recent publications on the chiropractic care of patients with shoulder dysfunctions (i.e., pain, limited range of motion) described care beyond the usual physical therapy and manual therapy of the upper extremities with spinal adjustments to the upper cervical spine In the interest of evidence-informed practice, we describe in a case series of two patients with shoulder dysfunction cared for in a similar manner. Case Series The case presentations of our two patients are presented in Table 1. Their presenting complaints and course of care are described. In the 45-year-old female, the patient was cared for exclusively with spinal adjustments to the upper cervical spine with concomitant decrease in shoulder pain and increased range of motion. In the second patient (i.e., a 47-year-old male), the patient received care with an upper cervical adjustment with improved range of motion and decreased Adhesive Capsulitis A. Vertebral Subluxation Res. October 19,

2 pain. The patient thereafter received ultrasound as an adjunctive therapy to the shoulder. Discussion In the case series reported, both patients were over the age of 40 with both having a history of trauma to the shoulders. Both patients demonstrated loss or restriction in ROM, diffuse pain in the deltoid region and pain with overhead activity. Based on the summary criteria by Burbank et al. 11 with a chiropractic perspective, the working diagnosis for both patients was adhesive capsulitis concomitant with subluxations of the cervical spine. More importantly according to Burbank, the age of the patient is an important initial consideration. Those <40 years of age are more likely to present with shoulder instability or mild rotator cuff disease such as impingement, tendinopathy, while patients >40 years of age are at an increased risk for advanced, chronic rotator cuff disease (partial or complete tear), adhesive capsulitis, or glenohumeral osteoarthritis. 11 In fact, for the male patient presented in this case series, the MRI demonstrated a mild acute rotator cuff tendonitis, mild to moderate osteoarthritis of the AC joint with mostly superior spurring, and tiny glenohumeral joint effusion of indefinite age. For brevity and for the benefit of the readers, we briefly review the diagnosis and common treatment approaches to shoulder dysfunction and discuss the unique contribution of this case series in the context of what has been previously published. The evaluation and diagnosis of the shoulder has been addressed by Burbank et al. 11 For those presenting with chronic shoulder pain, the relevant history examination findings are summarized in Table 2. For the female patient presented in this case report; she is over the age of 40, a history of trauma and experience radiating pain and limited ROM. The patient received a working diagnosis of rotator cuff tear with cervical spine involvement (i.e., cervical spine subluxation). The male patient was over 40 years of age, a history of trauma and loss of ROM. Given his 27-year history of right rotator cuff tendonitis, this patient received a diagnosis of adhesive capsulitis and glenohumeral osteoarthritis. In terms of the physical examination of the shoulder, inspection, palpation, ROM, and provocative testing are the hallmark procedures. Inspection of the shoulder should reveal signs of trauma, atrophy and deformity. Digital palpation of soft tissue structures and articulations for tenderness pinpoints the location of injury or dysfunction. Loss of both active and passive ROM may indicate adhesive capsulitis or moderatesevere OA of the GHJ. Loss of active ROM and preservation of passive ROM indicatives dysfunctions with the rotator cuff muscles. Provocative testing of the shoulder determines as number of possible condition. For example, Hawkin s Impingement Test for impingement or rotator cuff tears, the Drop Arm Test and the Empty Can Test for rotator cuff tears, the Cross Body Adduction Test for AC joint, OA or sprain of the shoulder and the Apprehension Test) for GHJ instability. 11 As pointed out by Alcantara et al. 9, the reliability of various test procedure for the shoulder to establish a diagnosis has generally been shown to be limited, their diagnostic validity of moderate quality and the anatomical basis for most tests have not been validated. In the case series presented as in that presented by Alcantara et al. 9, the attending clinician initiated a trial of care prior to performing a radiographic examination. A history of trauma supports the use of radiographic imaging. Given that the initial approach to patient care was not directed to the shoulder, any concerns for contraindications to care (i.e., adjustments or adjunctive therapy) to the area of chief complaint was non-existent. Furthermore, the use of radiographic examination would not have altered the initial course of care undertaken. Chiropractic Care Conservative approaches to the shoulder were reviewed by Alcantara et al. 9 and found little evidence to support or refute the efficacy of common conservative interventions for shoulder pain as utilized by chiropractors and physical therapists. 12 McHardy et al. 13 reviewed the chiropractic treatment of upper extremity conditions and found one clinical trial using cryotherapy and moist heat on active myofascial trigger points of the shoulder girdle, another involved the use of auriculotherapy and TENS for trigger points. Using the Physiotherapy Evidence Database (PEDro) scale (i.e., scores range from 0-10 with 10 being excellent and zero being poor) 14, McHardy et al. 13 found the PEDro scores for the aforementioned shoulder studies with 0.4 and 7, respectively. Pribicevic et al. 15 reviewed the literature on chiropractic care with shoulder pain and dysfunction. The authors found 22 case reports, 4 case series and 4 randomized, controlled trials. Using the PEDro rating scale. Pribicevic et al. 15 concluded that the evidence for chiropractic management of shoulder pain as limited consisting mostly of low level evidence (i.e., as per evidence-based medicine hierarchy) in the form of case reports and case series and 1 small controlled trial. Brantingham et al. 16 expanded upon and updated the review by Pribicevic et al. Using the grading system by Harbour and Miller 36, the authors found fair evidence (i.e., Grade B: Studies of appropriate designs of sufficient strength, but with inconsistencies or minor doubts about generalizability, bias, design flaws, or adequacy of sample size AND evidence solely from weaker designs, but confirmed in separate studies) the care of common rotator cuff disorders, shoulder disorders, adhesive capsulitis, and soft tissue disorders. The authors found limited (i.e., Grade C: Studies with substantial uncertainty due to design flaws or adequacy of sample size AND limited number of studies weak design for answering the question addressed) and insufficient (i.e., Grade I: No evidence that directly pertains to the addressed question either because studies have not been performed or published, or are non-relevant) evidence for chiropractic care for minor neurogenic shoulder pain and shoulder osteoarthritis, respectively. The above reviews promote a multi-modal approach to the care of the patient with shoulder dysfunction, including spinal A. Vertebral Subluxation Res. October 19, Adhesive Capsulitis

3 adjustments to the cervical spine. Noting the lack of published literature describing the singular use of high-velocity, lowamplitude (HVLA) manipulation of the extremities. McHardy and et al. 13 attacked the subluxation-based approach to the shoulder and commented that chiropractors promoting and using such an approach to patient care have poor knowledge or an understanding of evidence-based medicine. As raised by Alcantara et al. 9 and echoed by our sentiments, evidencebased medicine or more appropriately, evidence-based practice is not solely dependent on the published literature but also on the clinical expertise of the attending clinician and the needs and wants of the patient. 17 In the case series provided and similar to that by Alcantara et al. 9, the care was intentionally directed to the upper cervical spine only. To the best of our knowledge, this is the 3rd description in the scientific literature on the chiropractic care of patients with chronic shoulder pain utilizing a subluxationbased approach. The framework for such an approach involving the upper cervical spine is attributed to Murphy. 10 Abduction of the shoulder utilizes the supraspinatus muscles for the first 15 0 followed by engagement of the deltoid, trapezius and serratus anterior muscles. The trapezius muscles are innervated by cranial nerve XI (i.e., the spinal accessory nerve). Any involved nerves at or near the C 0-C 1 joint complex may undergo neuropraxia, ischemia and inflammation as a result of upper cervical subluxation. An affected nerve such as the accessory nerve will impair its function with shoulder abduction impaired. Addressing the subluxation dysfunction of the C 0-C 1 joint complex will necessarily negate the consequences to the involved nerves as was observed in the case series presented. In closing, we caution the reader on the lack of generalizability of case reports due to the presence of confounders (i.e., lacking a control group, spontaneous remission, self-limiting course and natural history of the disorder, subjective validation, and expectations for clinical resolution). However, the strength in case reports is the reporting of the clinical encounter and as such forms the epistemological foundation for our clinical experiences as chiropractors in the care of patients and ultimately provides clinicians (and their patients) an affirmation of their conviction that chiropractic can help. Conclusion This case report provides supporting evidence on the subluxation-based approach with spinal adjustments directed at the upper cervical spine in the care of individuals with shoulder pain and limited range of motion. References 1. Steinfeld R, Valente RM, Stuart MJ. A common sense approach to shoulder problems. Mayo Clin Proc. 1999;74(8): van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis. 1995;54(12): Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of shoulder pain in the community: the influence of case definition. Ann Rheum Dis. 1997;56(5): Ginn KA, Cohen ML. Conservative treatment for shoulder pain: prognostic indicators of outcome. Arch Phys Med Rehabil 2004;85: van der Windt DA, Koes BW, Boeke AJ, Deville W, de Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract 1996;46: Chard M, Sattelle L, Hazleman B. The long term outcome of rotator cuff tendinitis a review study. Br J Rheumatol 1988;27: Chakravarty K, Webley M. Shoulder joint movement and its relationship to disability in the elderly. J Rheumatol 1993;20: National Board of Chiropractic Examiners. Patient Conditions. Accessed May 26, 2015 at: 9. Alcantara JD, Alcantara J, Alcantara J. Upper cervical care of patients with chronic shoulder pain and restriction in motion: A case series. J Upper Cervical Chiropr Res: Sum 2014;2014(3): Murphy FX, Hall MW, D Amico L, Jensen AM. Chiropractic management of frozen shoulder syndrome using a novel technique: a retrospective case series of 50 patients. J Chiropr Med 2012;11(4): Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4): Green S, Buchbinder R, Glazier R, Forbes A. Interventions for shoulder pain. Cochrane Database Syst Rev 2000;(2):CD McHardy A, Hoskins W, Pollard H, Onley R, Windsham R. Chiropractic treatment of upper extremity conditions: a systematic review. J Manipulative Physiol Ther 2008;31: Bhogal SK, Teasell RW, Foley NC, Speechley MR. The PEDro scale provides a more comprehensive measure of methodological quality than the Jadad scale in stroke rehabilitation literature. J Clin Epidemiol. 2005;58(7): Pribicevic M, Pollard H, Bonello R, de Luca K. Systematic review of manipulative therapy for the treatment of shoulder pain. J Manipulative Physiol Ther. 2010;33(9): Brantingham JW, et al. Manipulative therapy for shoulder pain and disorders: expansion of a systematic review. J Manipulative Physiol Ther 2011;34: Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71-2. Adhesive Capsulitis A. Vertebral Subluxation Res. October 19,

4 Three months prior to presentation, the patient was injured on the right shoulder following a falling. She did not attend medical care as the pain was tolerable. However, the pain worsened with time. Two months later, she could not move her right shoulder more than 95 0 (abduction) due to pain and experienced pinching pain on with the right side of her right neck referring to her right shoulder. Over-the-counter pain medication provided temporary and minor relief. On presentation, the patient could not move her neck due to shooting pain on the right, and could not move her right shoulder no more than 95 0 (abduction). On initial presentation, the patient rated her pain complaint as 9/10 (0=no pain; 10=maximum pain). She was provided a diagnosis of adhesive capsulitis. The patient was adjusted ASR using the cervical chair. Immediately following the adjustment, the patient rated her pain complaint as 2/10 and move her shoulder on abduction to On the 2 nd visit, the patient indicated her shoulder pain complaint at 0/10 and could move her neck in all ROM with shoulder abduction to The examination findings indicated an ASR subluxation at C1 and was again adjusted using the cervical chair. Table 1. A case series presentation of patients with shoulder disorders Age/Gender Clinical Presentation Intervention & Outcome 45-yearold/Female 47-yearold/Male At age 20 years, the patient injured his right shoulder by throwing a baseball. The medical diagnosis provided for this patient was right shoulder rotator cuff tendonitis resulting in anti-inflammatory and painkiller medications. Approximately 2 months prior to presentation, the patient was involved in a motor vehicle collision, The patient sustained an injury to the right shoulder resulting in pain and lack of movement such that abduction was limited to no more than The patient received physical therapy until for approximately two months. Physical therapy consisted of one hour per week. Despite the physical therapy, the patient still could not move his right shoulder as described. On initial presentation, the patient rated his pain complaint at 9/10 (o=no pain; 10=maximum pain). Chiropractic examination determined an ASR subluxation and the patient adjusted using the cervical chair. The result was immediate relief of pain rated at 0/10 and movement of the right shoulder to abduction. On the 2 nd and 3 rd visit, the patient maintained the range of motion in the right shoulder and rated his pain complaint at 2/10. The patient was not adjusted but received ultrasound therapy. Magnetic resonance imaging identified the following: 1. Mild acute and chronic rotator cuff tendonitis. 2. Mild to moderate osteoarthritis of the AC joint with mostly superior spurring, which is a chronic process. 3. Tiny glenohumeral joint effusion of indefinite age. The patient thereafter was seen three times per week for 4 weeks. The patient s shoulder pain was rated at 5/10 4 weeks since his initial visit and was able to abduct the involved shoulder to Following an adjustment (i.e., ASR) in the seated chair, the patient s shoulder abduction increased to and his pain rating subsided to 0/10. The patient continued to receive care thereafter on a regular basis with adjustments exclusively to the C 1 vertebral body. The patient eventually attained full range of motion of the right shoulder with no pain. A. Vertebral Subluxation Res. October 19, Adhesive Capsulitis

5 Table 2. History Findings and Associated Shoulder Disorders. 11 Reproduced with Permission from the American Academy of Family Physicians. History Associated Condition Age If younger than 40 years: instability, rotator cuff tendinopathy If older than 40 years: rotator cuff tears, adhesive capsulitis, glenohumeral osteoarthritis Diabetes or thyroid disorders Adhesive capsulitis History of trauma If younger than 40 years: shoulder dislocation/subluxation If older than 40 years: rotator cuff tears Loss of ROM Adhesive capsulitis, glenohumeral osteoarthritis Night pain Rotator cuff disorders, adhesive capsulitis Numbness, tingling, pain radiating past elbow Cervical etiology Pain location Anterior-superior shoulder pain associated with acromioclavicular joint pathology Diffuse shoulder pain in deltoid region associated with rotator cuff disorders, adhesive capsulitis, or glenohumeral osteoarthritis Pain with overhead activity Rotator cuff disorders Sports participation Shoulder instability associated with overhead sports (e.g., baseball, softball, tennis), and collision sports (e.g., football, hockey) Acromioclavicular joint pathology associated with weight lifting Weakness Rotator cuff disorders, glenohumeral osteoarthritis Adhesive Capsulitis A. Vertebral Subluxation Res. October 19,

Shoulder examination. P Sripathi Rao Arthroscopy & Sports Injuries Unit Dean, Kasturba Medical College

Shoulder examination. P Sripathi Rao Arthroscopy & Sports Injuries Unit Dean, Kasturba Medical College Shoulder examination P Sripathi Rao Arthroscopy & Sports Injuries Unit Dean, Kasturba Medical College Manipal University, Manipal Common symptoms Tingling Numbness Pain Loss of movements Weakness Approach