Today we finish up the adhesive capsulitis CPG by covering examination and treatment.
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Let’s get on to examination. First we have outcome measures. The three outcome measures with the strongest support for this condition are the DASH, the ASES, and the SPADI. You’re probably familiar with the Disabilities of the Arm shoulder and Hand or at least its quick form counterpart, but the DASH is a 30-question self-report questionnaire with scores from 0-100 where the lower scores indicate less disability and high scores indicate more disability. The average minimal detectable change reported in studies is 10.5, and the minimal clinically important difference is reported as 10.2. So for questions that involve whether or not a patient has improved, you’re looking for at greater than a 10 point decrease in score as your cutoff for functional improvement. The Shoulder Pain and Disability Index or SPADI is a 13-item self-report tool with scores again between 0, representing no disability or pain, and 100 representing the worst disability and pain. The MDC is 18, and the MCID is between 8 and 13. The fact that the DASH and the SPADI both have “disability” in the name reminds you that they are measures of disability, which means higher scores have worse disability. In contrast, the last OMT to be familiar with, The American shoulder and Elbow Surgeons shoulder scale or ASES, is a measure of function, meaning that higher scores indicate greater function. It also ranges from 0-100. The MDC is 9.4, and the MCID is 6.4. So if you are reading a case that uses the ASES, you’d be looking for more than 6 points of increase to know that improvement has occurred. If you’re short on time, know the most popular outcome measurement tool, which is going to be the DASH or SPADI in my opinion. There is A level recommendation for using one of these three validated functional outcome measures before and after interventions.
Moving right along, for activity limitations, there is F level recommendation for using the following activity limitations to assess changes in the patient’s function over time: pain during sleep, pain and difficulty with grooming and dressing activities, and pain and difficulty with reaching activities to the shoulder level, behind back and overhead. Sounds pretty obvious, but remember that this should be individualized to a patient’s previous and desired level of function.
For physical impairments, they give E or expert opinion recommendation for using the following active and passive range of motion measures: shoulder flexion and abduction, and glenohumeral external rotation in 0, 45, and 90 degrees of external rotation, provided they have the available abduction ROM, and glenohumeral internal rotation in 90 degrees of abduction or 45 degrees if they do not have 90. Go figure.
At this point in the exam flow you have performed medical screening and decided if the patient is appropriate for PT, referral, or both, performed differential diagnosis to confirm that this is in fact adhesive capsulitis, and examined the patient. Now comes component 3 of the evaluation/intervention paradigm, diagnosis of tissue irritability level, which will be certainly be appropriate for adhesive capsulitis. Remember that it will be more appropriate to make treatment decisions based on irritability level that what stage the timeline would put them in. High irritability will be characterized by pain at or above 7/10, consistent night or resting pain, high levels of reported disability on your outcome tools, pain occurring before end ranges of active and passive movements, and active range of motion significantly less than passive range due to pain. That is, if they let you push them past where they took it themselves, you will get further before hitting an end-feel but will likely have an empty end feel. Moderate irritability will report pain between four and six out of ten, intermittent night or resting pain, moderate levels of reported disability on your outcome tools, pain occuring at end ranges of active and passive movements, and AROM similar to PROM. Low irritability will have pain at three out of ten or lower, no night or resting pain, minimal levels of reported disability on outcome tools, pain with overpressure into end ranges of passive movements, and AROM the same as PROM.
Now for the moment we’ve all been waiting for! Interventions. I’ll first go through the actual graded intervention recommendations, and then go through how they will apply to each level of irritability. Remember that the OCS is testing your ability to think and apply the best intervention to the individual case, not just what has the strongest level of evidence.
The first we’ll discuss an intervention that, at least in typical practice in the United States, is not provided by us as physical therapists, but that we can certainly help get for the patient, intra-articular corticosteroid injections. There is A-level recommendation for intra-articular corticosteroid injections combined with shoulder mobility and stretching exercise in providing 4-6 weeks of pain relief and improved function. This may be especially important in the early stages as an injection could limit the amount of inflammation, neovascularization, synovitis and whatever else comes in that ends up causing the fibrosis that leads to longer term range of motion limitation and thus could significantly decrease overall duration of the condition. That being said, one of the better RCTs on steroid injections used only individuals that had symptoms for more than 1 year, and demonstrated significantly better outcomes in the injection plus supervised physical therapy over injection or PT alone. This highlights the utility of steroid injections even well into the natural course of adhesive capsulitis. Note that in pretty much all the studies reviewed, corticosteroid+physical therapy or at least some home stretching routine was always best, so be ready to educate patients and providers that recommend that their patient get an injection alone. Newer evidence only strengthens the case for injection plus PT. One 2017 RCT in the American Journal of Sports medicine showed faster improvement in pain, function, and range of motions continued all the way through 8 weeks compared to the non-injection group. There was also a massive trial done since this CPG was published called the UK FROST trial with 500 participants randomized either to structured PT with corticosteroid injection, Manipulation under anesthesia plus corticosteroid injection, or arthroscopic capsular release with optional corticosteroid injection. All groups got 12 sessions of physiotherapy over up to 12 weeks. The only outcome was taken at 12 months with the oxford shoulder score. Not surprising, all of the groups had pretty good outcomes, but improvement was not different enough for them to say that any group was superior. Which to me as a PT tells me that if I have to go under anesthesia and have a manipulation or a surgery, and then still have to go to just as much PT, only to be about the same at 1 year… you can guess what I’m choosing. Sadly, they didn’t look at any other measures that could have told us so much, like ROM.
Now for patient education…. There is B-level recommendation the clinicians utilize patient education that:
1. Describes natural course of the disease
2. Promotes activity modification to encourage functional pain-free ROM, and
3. Matches intensity of stretching to the patient’s current level of irritability.
This recommendation is based on an interesting and important study that compared patients with adhesive cap receiving what they called “supervised neglect”, where patients got the above education only, and a group that received aggressive therapy where they had supervised therapy with exercise and manual techniques stretching up to and BEYOND pain threshold in addition to HEP of maximal reaching. At two year follow up, the supervised neglect group actually had 89% of the cohort above their cutoff of 80/100 on the Constant score (which is the most widely used shoulder function scale in Europe, though the writers of this CPG don’t like it), while in the aggressive therapy group only 64% of the cohort achieved the 80/100 cutoff score. The most important takeaways from this study are not that we should only do education and not therapy, but rather that we should be sure we educate patients that pushing harder into and through pain is not better with their stretching at home or in clinic, and that we should not utilize and promote pushing into or through pain with our manual or other interventions. If we do, I think especially in higher irritability or early stages this study would indicate we may be harming the patient and limiting their outcomes. Rather, the aggressiveness of intervention should be based on the patient’s current level of irritability.
This leads us to the next intervention recommendation - stretching exercises. There is B-level recommendation for stretching exercises which states that clinicians should instruct patients in stretching exercises that match the level of tissue irritability. Of note, the studies show that stretching exercises do appear to improve pain and ROM, but not necessarily more than other interventions and outcomes are somewhat inconsistent across studies. The authors cite the need for studies that classify patients into different treatment groups most likely to respond well to stretching, and studies that match force application to the tissue irritability of the patient to have a clearer picture of how beneficial stretching exercises are. Of note, the studies with the best outcomes on pretty much any other treatments that I have and will mention have included some form of stretching.
Joint mobilization receives a C-level recommendation and states that clinicians may utilize joint mobilization procedures primarily directed to the glenohumeral joint to reduce pain and increase motion and function. Similar to the stretching exercise recommendation, there is definite benefit, but little evidence to support its efficacy over other interventions and the authors provide the same two needs in future studies to provide a clearer picture. The studies listed used techniques such as oscillatory or sustained inferior, posterior, and anterior glide mobilizations. ne study found posterior glide to be superior to anterior glide in improving external rotation ROM. Of note, a relatively small 2016 RCT by Celik and Mutlu showed superiority of mobilization plus stretching exercise over stretching exercise alone
Now for modalities. There is a C-level recommendation for the use of heating modalities such as shortwave diathermy, ultrasound, and hot pack as well as electrical stimulation when combined with mobility and stretching exercises to reduce pain and improve shoulder range of motion. In a minute we’ll talk about the tissue irritability level recommendations for this, which in this CPG only calls for it for pain modulation with high and moderate irritability cases. However, I’ll give a little more information. The studies including ultrasound or diathermy utilized it immediately prior to stretching in order to increase capsular temperature prior to stretching, and demonstrated greater improvement in ROM when compared with superficial heating or sham treatment. One of the studies involving TENS used it during prolonged end range stretching with pulleys and was better than therapy including superficial heat with a combination of active and passive mobilization. All of this highlights a very active use of these modalities, whether it be to modulate pain in a high irritability case to allow for a period of more comfortable activity, or in moderate to low irritability case where it should be used more to prepare a tissue for stretching, or allow for more comfortable long duration stretching rather than just getting them stand alone or at the end of a session because they feel good. I will mention though that at least two small RCTs published since this CPG that compared sham to real ultrasound showed no benefit in combination with typical mobilization and stretching. Very recently there was a sham controlled RCT on high intensity laser, which showed greater improvement in pain, but not function or ROM. So, there is mixed evidence, hence the C-level recommendation, but suffice it to say that you can use it, but only in combination with mobility and stretching exercise. While we are still talking about modalities, I’ll throw in a little plug for extracorporeal shockwave therapy. Extracorporeal Shockwave therapy is growing in popularity for many conditions. Since 2013 a small handful of studies have shown utility for pain relief and improvement in function in the short term. One notable study demonstrated superiority of radial shockwave to low dose corticosteroid for pain relief and improvement in function for diabetic individuals with adhesive cap, who may not be indicated for the more effective high dose steroid injections. We may see more on this as time goes on.
Finally, we have a C-level recommendation for translational manipulation. This is kind of an odd one. This is presented as a less risky alternative to long lever manipulation under anesthesia for individuals with unresponsive adhesive capsulitis, and consists of an anesthesiologist performing an interscalene block and then performing grade 3 inferior and posterior glide mobilizations and then going for a grade 5 manipulation into those planes if motion didn’t improve with the aggressive mobilization alone. This is presented as a more practical and lower risk alternative to manipulation under anesthesia that can be done outpatient, but I’m guessing it’s a pretty low percentage of PT’s that work in a setting that would allow for this. Also, the patients were on oral steroids and were supposed to do passive long duration stretches every hour while the block was still in effect and did a lot of PT right after. It’s probably not practical for most PT’s but it does get a C-level recommendation and for individuals with adhesive capsulitis who are not responding to conservative interventions.
To wrap it all up, let’s go through the fourth and final component of the evaluation/intervention paradigm, which applies these intervention strategies to tissue irritability level:
First, high irritability cases (again, think 7 or more out of 10 pain, consistent night and resting pain, high disability, pain before end range, and AROM significantly less than PROM due to pain):
● Modalities available include heating and electrical stimulation modalities for pain modulation.
● Self-care/home management training consisting of education on positions of comfort and activity modification to limit tissue inflammation and pain
● Manual therapy can including low-intensity joint mobilization procedures in the pain-free accessory ranges and glenohumeral positions.
● And mobility exercises should consist of pain-free passive ROM exercises, and pain-free active assisted ROM exercises.
● Oddly, it doesn’t mention the corticosteroid injection combined with stretching/mobility exercise recommendation, likely because we wouldn’t be performing it, but these high irritability cases are going to be very indicated for it provided they would be a candidate medically.
For Moderate irritability cases, (again, 4-6/10 pain, intermittent night or rest pain, moderate disability, pain at end range, and AROM the same as PROM), they recommend…
● Modalities include heating and electrical stimulation modalities for pain modulation on an as needed basis
● Self care/home management training consists of progressing activities to focus on gaining motion and function without producing signs of tissue inflammation and pain.
● Manual therapy should have moderate intensity joint mobilization procedures, progressing amplitude and duration into tissue resistance without producing posttreatment tissue inflammation and pain
● Stretching exercises including gentle to moderate stretching, again progressing intensity and duration without creating inflammation and pain
● And finally, neuromuscular re-education procedures to integrate gains in mobility into normal scapulohumeral movement while performing reaching activities. You might notice that I didn’t mention neuro re-ed when going through the graded recommendations, because there wasn’t enough evidence to have a specific graded section on this, but it is included in a few of the studies compared with stretching or some other modality. I think you can consider it an expert opinion recommendation to be used only alongside of the other treatments listed. There have been a couple studies since that have found positive effects with neuro re-ed programs focused on improving upward rotation of the scapular upward rotation, so maybe this will get its own recommendation in the future.
● Overall, the thing to remember in moderate irritability cases is that we are progressing into some tissue limitation, but monitoring closely for setting off pain and inflammation. I could certainly see an OCS question asking you how to modify an intervention that created increased pain and soreness for say 24 hours. In other conditions we would probably be saying that’s fine, but remember with adhesive capsulitis, we’d be decreasing the intensity, duration, and or amplitude of an intervention if it produces signs of post-treatment tissue inflammation.
Finally, for low irritability cases (remember, 3 or less out of 10, no resting or night pain, minimal disability, pain only with overpressure, and AROM the same as PROM):
● They drop the modalities section, which does make sense when you consider it only being used for pain modulation. However, as I alluded to before, this does seem like somewhat of a contradiction as many of the studies used the heating modalities as a prep for stretching/mobilization or to make long duration stretching more comfortable. Both of which would be appear to be indicated in this stage. So take that as you will.
● Next, self-care and home management strategies including progressing to high-demand functional activities.
● Manual therapy including end-range joint mobilization, high amplitude and long duration procedures into tissue resistance.
● Stretching exercises progressing duration into tissue resistance without producing post-treatment tissue inflammation,
● And finally they include neuro re-ed again including procedures to integrate mobility gains into normal scapulohumeral movements during functional and/or recreation