Physical Therapy for Adhesive Capsulitis

Summary

Objective

To review recent research on the efficacy of physical therapy for patients with adhesive capsulitis.

Design

Search of Medline and CINAHL databases for studies published between January 1990 and December 2000.

Inclusion criteria

Non-operative experimental or descriptive research-based outcomes studies of physical therapy.

Main outcome measures

Methodological quality scoring using 16 predetermined criteria with 100% (16/16) indicating highest quality.

Results

Quality scores of the 12 studies that met inclusion criteria ranged from 38% to 69% (mean 54%). By design, scores were highest for the reviewed retrospective and randomised controlled studies.

Conclusions

How efficacious physical therapy is for patients with adhesive capsulitis is uncertain. Reviewed studies suggest that many patients treated with physical therapy benefited from reduced symptoms, increased mobility, and/or functional improvement. However, the lack of rigour and poor standardisation of terminology, methodology, and outcome measurements in these investigations undermines their validity and clinical application. More rigorous investigations are needed to compare the effects and costs of individual physical therapy interventions.

Introduction

Adhesive capsulitis is a pathology of often unknown aetiology characterised by painful and gradually progressive restriction of active and passive gleno-humeral joint motion (Baslund et al, 1990; Pearsall and Speer, 1998). Approximately 2-3% of adults aged between 40 and 70 years develop adhesive capsulitis with a greater occurrence in women (Anton, 1993; Connolly, 1998; Stam, 1994). Full or partial restoration of motion may occur over months or years with or without medical intervention (Ogilvie-Harris et al, 1995).

Duplay is credited with publishing the first case report of adhesive capsulitis, or ‘periarthrite-scapulo-humerale’, more than 125 years ago (Melzer et al, 1995). Iron-ically, Duplay reported treating many patients successfully with manipulation under anaesthesia, a procedure still commonly performed for recalcitrant cases of adhesive capsulitis. Codman labelled the pathology ‘frozen shoulder’ in 1934, describing the presentation as a ‘slow onset of shoulder pain, an inability to sleep on the affected side, restricted glenohumeral elevation and external rotation, and a normal radiological appearance’ (Pearsall and Speer, 1998). Neviaser and Neviaser (1987) coined the term ‘adhesive capsulitis’, theorising that this pathology results from thickening and eventual contracture of the gleno-humeral capsule. Hannafin and Chiaig (2000) hypothesised that adhesive capsulitis stems from synovial inflam-mation that progresses to a reactive capsular fibrosis. Bunker (1997) identified via arthroscopy a fibrous contracture of the rotator interval and coracohumeral ligament, which markedly limited motion, primarily external rotation. Histological evaluation of the fibrous tissue revealed a dense collagen matrix consisting of mainly type 3 collagen, remarkably similar to tissue found in Dupuytren's contracture.

Adhesive capsulitis has been sub-divided into primary (insidious) and secondary (traumatic) syndromes, which have similar clinical presentations but distinct precipitating factors (Stam, 1994). Primary adhesive capsulitis is char-acterised by an insidious progressive pain-ful loss of active and passive glenohum-eral joint motion (Hannafin and Chiaia, 2000). Secondary adhesive capsulitis has an identical histopathological appearance but stems from a known intrinsic or extrinsic cause (Hannafin and Chiaia, 2000). With either sub-type the pre-cipitating factor may be a chronic in-flammatory process that results in capsular adhesions (Grubbs, 1993).

Diagnosis of adhesive capsulitis is often made through the history and physical examination. Individuals with adhesive capsulitis typically complain of poorly localised shoulder pain with focal tender-ness adjacent to the deltoid insertion and occasional pain radiation to the elbow and at times into the lateral forearm (Grubbs, 1993; McClure and Flowers, 1992). This pain is usually aggravated by shoulder movement and alleviated by limiting use of the arm (Hannafin and Chiaia, 2000; Seigel et al, 1999). Occasionally the pain is most intense at night and may disturb the patient's sleep (Neviaser and Neviaser, 1987; Stam, 1994). Functional impairments include difficulty with dressing, particularly with garments that require fastening behind the back (eg a brassière) (Connolly, 1998; Murnaghan, 1988).

A frequently reported finding during physical examination is multi-directional limitation of active and passive gleno-humeral joint motion (Grubbs, 1993; Pearsall and Speer, 1998). Losses of range of motion over 50% have been reported (Reeves, 1975). Compensatory increases in scapulothoracic joint movement are common (Roubal et al, 1996). Cyriax proposed that pathologies involving the glenohumeral joint capsule result in a predictable pattern of joint restriction (capsular pattern) with lateral rotation most restricted, abduction next most restricted, and medial rotation third most restricted (Cyriax and Cyriax, 1983).

Classically, the natural history of frozen shoulder has been divided into three stages: the painful, adhesive and thawing phases. In stage 1 (2½ to nine months) there is a gradual onset of shoulder pain at rest, with a sharp pain at the extremes of motion. During stage 2 (four to 12 months) the pain begins to subside but there is a characteristic progressive loss of glenohumeral flexion, abduction, internal and external rotation. The thawing stage (five to 26 months) is characterised by a progressive improvement in functional range of motion (Pearsall and Speer, 1998).

Prospective randomised controlled clinical trials comparing the outcomes of various treatments for adhesive capsulitis are few and often involve small numbers of patients (Murnaghan, 1988; Van der Windt et al, 1998; Winters et al, 1997). Despite being frequently involved in the care of patients with adhesive capsulitis, physical therapists have failed to elucidate the extent to which their interventions are effective in ameliorating this condition. This literature review was performed to summarise findings of recent outcomes investigations of physical therapy in the treatment of patients with adhesive capsulitis; and to examine systematically the quality (or rigour) of the investigations, since this affects the validity of the results.