Alternative Therapies for Adhesive Capsulitis: A Case Study L A N I - - PowerPoint PPT Presentation

L A N I E A L P H I N

Alternative Therapies for Adhesive Capsulitis: A Case Study

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

• r 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

• utcome 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

• ver 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

• f 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

• f 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 ++ (4 weeks) High- grade mobilization vs. low- grade ++ (>6 mo) Posterior Glide Mob vs. Anterior ++ (3 weeks) Arthrographic distension and PT vs. PT alone + ++ 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

• f 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 1st 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.