Adhesive capsulitis is defined as the "development of adhesions, capsular thickening, and capsular restrictions, especially in the dependent folds of the capsule" (Kisner and Colby 2012). It presents slowly overtime, often without explanation, and is found most commonly in women ages 40-70. Recent literature has associated adhesive capsulitis with hyperthyroidism, heart disease, diabetes mellitus, and cervical spondylosis. Common symptoms reported by patients are lateral arm pain, the inability to sleep on the affected side, limited ability to reach arm overhead, and decreased functional use of the arm. The initial stage is the Inflammatory stage, where the hallmark signs are gradual onset of pain that is worse with movement. This stage generally lasts 3 months or less. This is followed by a Stiffening, or Frozen, stage whereall shoulder motions are limited, which causes muscular atrophy and pain with movement. This stage can last anywhere from 3-15 months. The final stage is referred to as the Thawing stage. In these final months, pain is minimal but capsular and motion restrictions are significant. However, mobility gradually improves over 15-24 months.
Medical treatment options often recommended are corticosteroid injections, surgical release, surgical manipulation under anesthesia, or translational manipulation by a physical therapist following a scalene block with regional anesthesia. The above procedures are considered only after a patient has failed conservative management (physical therapy and anti-inflammatory medication), and patients are frequently referred to physical therapy following any of the above procedures to improve and maintain the motion gains.
The concern of this blog is with the last item listed, translational manipulation by a physical therapist. This new concept is currently undergoing research for cost effectiveness and functional improvements compared to the more established interventions. The procedure begins with an anesthesiologist applying a local nerve block to the brachial plexus to block neural signal to and from the affected arm. While the patient is under the effects of the local block, a physical therapist will apply end range mobilizations and manipulations to improve joint space while protecting sensitive shoulder structures such as the acromioclavicular joint. At this time, no adverse effects have been reported in the literature1 and patients are fully awake and aware during the entire procedure. Following the end range manipulations patients will be directed in range of motion exercises and icing protocols to maximize gains while minimizing pain. Motion gains have been reported at >50% for over head motions and >75% for rotational motions. While there is limited research at this time, preliminary results show effectiveness for improved range of motion, functional scores, and decreased pain at 6 weeks and 14 months. These range of motion gains are statistically better than corticosteroid injection + PT, surgical manipulation + PT, and arthroscopic release + PT.
The Institute for Sports and Spine Rehabilitation is currently considering offering this approach to those suffering from frozen shoulder. If you have interest in this procedure please discuss it with your doctor and therapist in order to decide if it is right for you.
For more information on Frozen Shoulder, please visit the American Academy of Orthopedic Surgeons website.
1. Hando, B. Glenohumeral Joint Translational Manipulation Under Anesthesia for the Treatment of Adhesive Capsulitis: A Case Series Study and Findings from Immediate Postmanipulation Arthroscopic Visualization. J Ortho Sport Phys Ther, 2010;40(1): A12-39, OPL 50.