Alternative Therapies for Adhesive Capsulitis: A Case Study LANIE ALPHIN

Alternative Therapies for Adhesive Capsulitis: A Case Study LANIE ALPHIN

Case Background 53 year old female Chief Complaint: Right shoulder pain for 6 months Diagnosis: Adhesive Capsulitis Imagining indicated no RC tear Previous Treatment: Platelet Rich Plasma injection (2 weeks prior to first visit) Occupation: caregiver Medical History: Fibromyalgia and Osteopenia

Review of Adhesive Capsulitis Painful and restricted active and passive ROM in both elevation and rotation that occurs for at least 1 month and has either reached a plateau or worsened

Stages of Adhesive Capsulitis Freezing Inflammation PAIN is most prominent Frozen (6 weeks- 9 months) Adhesions Significant loss of motion Thawing Minimal Pain Progressive improvement with ROM Altered muscular mechanics and soft tissue tightness Not actually as self-limiting as was once thought--only 59% of people regain normal function of shoulder in 4 years!

Initial Evaluation Joint Mobility: Firm and painful with grade III mobilization to inferior, posterior, and ant capsule Palpation: R Upper Trap/ Levator Scapulae tenderness and increased tightness **Shoulder shrug noted upon elevation

International Classification of Functioning BODY STRUCTURE & FUNCTION IMPAIRMENTS: Pain Decreased strength and ROM Decreased joint mobility ACTIVITY LIMITATIONS: Reaching, carrying, rotating, hand behind back, over head or behind head PARTICIPATION RESTRICTIONS: Unable to perform duties as caregiver

Plan of Care Goals: Short term: Independent with HEP in 6 visits Long term: 8 weeks Participate in full recreational activities in 8 weeks Increase PROM: Flexion to 160, ER to 80 deg. Demonstrate proper posture and body mechanics with UE raise to reach overhead (no R shoulder shrug) Treatment: Grade II-III joint mobilizations (A-P, inferior) PROM AROM: foam roller on wall for postural cue AAROM: pulley flexion and abduction, wall walking Cryotherapy

After 3 months of Treatment Pre/ post treatment PROM measures: Flex 135/150, ER 45/ 63 Post treatment measures did not last between treatments So, in 3 months none of the ROM goals had been met Patient was unsatisfied and felt as though there was no change in her function.

My Clinical Question: Are alternative, invasive therapies more effective to increase ROM and decrease pain than traditional therapy for a 53 year old female with Adhesive Capsulitis?

The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: A systematic review Blanchard, Victoria, Steven Barr, and Frances L. Cerisola. "The Effectiveness of Corticosteroid Injections Compared with Physiotherapeutic Interventions for Adhesive Capsulitis: A Systematic Review." Physiotherapy 96.2 (2010): 95-107.

Study Background 2010 Systematic Review 6 RCTs included Inclusion Criteria: 1) 18 years or above with a stated diagnosis of adhesive capsulitis or frozen shoulder 2) Participants randomly allocated to a group receiving either corticosteroid injections alone or physiotherapeutic interventions 3) Include at least one clinically relevant and validated outcome measure

6-7 week Follow-up

12-16 weeks Follow-up

Results: 52 week Follow-up

Conclusions Corticosteroid injections > PT in the short term. The benefit is seen to a lesser extent in the longer term. Injection therapy appears to have the most significant effect after around 6 to 7 weeks. Greatest effect is seen on functional outcome

Study Limitations Variations in the type of corticosteroid used, dosages and the entry site of the injection. Difficulty with true diagnosis of Adhesive capsulitis Differences in the conventional PT performed by all studies The Ryans et al. article was the only one to also incorporate PNF into the PT treatment and that was also the only study that favored PT over injection! None of the studies took into account the STAGE of the disease that the patients were in An injection would likely be most effective in the earlier, inflammatory stages of the disease, rather than in the later stages when fibrous contracture is more apparent

Take Home Message Corticosteroid Injections are likely an effective treatment, but would probably not benefit our patient at this time because she is in the later stages of the disease process. Also, evidence suggests that conventional, conservative PT is only slightly more effective than placebo/ control We need some more ideas!

Frozen shoulder: the effectiveness of conservative and surgical interventions systematic review Favejee, M. M., B. M. A. Huisstede, and B. W. Koes. "Frozen Shoulder: The Effectiveness of Conservative and Surgical Interventions--systematic Review." British Journal of Sports Medicine 45.1 (2010): 49-56. Web.

Article Background 2010 Systematic Review 5 Cochrane reviews and 18 RCTs fit inclusion criteria Inclusion Criteria: 1) the study included patients with frozen shoulder 2) the disorder was not caused by an acute trauma or systemic disease 3) an intervention for treating frozen shoulder was evaluated 4) results on pain, function or recovery were reported 5) the article was written in English, French, German or Dutch.

Results Intervention Effectiveness Laser vs. Placebo +++ Steroid Injections vs. Placebo/ no tx +++ Electroacupuncture vs. Placebo + Interferential Acupuncture vs. Placebo Steroid Injection vs. PT +/- + Acupuncture and Exercise Vs. Exercise alone ++ (4-6 mo) Key: + limited evidence, ++ moderate, +++ strong, +/- conflicting

Results Continued Intervention Effectiveness MUA and exercise vs. exercise alone ++ Mobilization + exercise vs. exercise alone High- grade mobilization vs. lowgrade Posterior Glide Mob vs. Anterior Arthrographic distension and PT vs. PT alone ++ (4 weeks) ++ (>6 mo) ++ (3 weeks) + ++ for active PT vs. passive Key: + limited evidence, ++ moderate, +++ strong, +/- conflicting

Recommendations Based on the Stage of Disease Freezing: pain relief Intra-articular Corticosteroids Frozen: increase ROM (6 weeks- 9 months) Joint Mobilizations Distension Thawing: Address compensatory movements of the scapula Pain and muscular inhibition result in altered mechanics Both the treatment modality and the evaluation of treatment effects should be individualized based on the stage of the frozen shoulder.

Study Limitations Lack of true definition for frozen shoulder Different studies included participants in different stages of the disease Multiple differences in study designs and outcome measures Unclear in many of the studies if measurements were of total ROM (scapular movement+ glenohumeral movement) or only the ROM of the glenohumeral joint.

Take Home Message: It Depends! Different treatments are appropriate at different stages of Adhesive Capsulitis.

Relating it All Back to the Patient Symptoms now present for 9 months Typical end of the Frozen stage, but still no improvements in ROM Maybe our focus needs to shift from capsular to muscular She sees improvements with ROM at the end of the treatment session, but it does not carryover So, we know she has some motion available, but why would it not last?? Muscular tightness and altered mechanics!

Trying Something New Trigger Point Dry Needling: Initiated 3.5 mo after 1 st tx ( 9.5 months after symptoms began) Subscapularis (supine) Upper Trapezius Teres Major/minor Infraspinatus Electrotherapy used with needles Manual STM Joint Mobilizations, AROM/PROM on days that Dry Needling was not performed Scapular re-education, PNF

Outcome After Dry Needling Prior to Trigger Point Dry Needling: 3 months post evaluation Pre treatment measures: Flex: 135 ER: 45 Post Dry Needling: 6 months post evaluation Pre treatment measures: Flex: 164 Abduction: 137 IR: 70 ER: 82 Currently the patient has 0/10 shoulder pain even while sleeping. The patient s only complaint is tightness at end range.

So, back to my question Are alternative, more invasive therapies more effective to increase ROM and decrease pain than traditional conservative physical therapy for a 53 year old female with Adhesive Capsulitis? Yes they can be, but it is highly dependent on the stage of disease!

Resources Blanchard, Victoria, Steven Barr, and Frances L. Cerisola. "The Effectiveness of Corticosteroid Injections Compared with Physiotherapeutic Interventions for Adhesive Capsulitis: A Systematic Review." Physiotherapy 96.2 (2010): 95-107. Favejee, M. M., B. M. A. Huisstede, and B. W. Koes. "Frozen Shoulder: The Effectiveness of Conservative and Surgical Interventions-- systematic Review." British Journal of Sports Medicine 45.1 (2010): 49-56. Neviaser, A. S., and J. A. Hannafin. "Adhesive Capsulitis: A Review of Current Treatment." The American Journal of Sports Medicine 38.11 (2010): 2346-356.