Adhesive Capsulitis CPG Flashcards
Does frozen shoulder affect DM type I or II?
Both - no discrimination between the two
What part of the capsuloligamentous complex may be most implicated in loss of ROM?
Proximal portion (superior, middle GH ligaments)
What part of the capsuloligamentous complex makes up the RTC interval?
Superior GH joint ligament, coracohumeral ligament
With the arm in 45 deg of abduction, what restricts ER with adhesive capsulitis greatest?
Proximal portion of capsule + subscapularis muscle
What limits ER the most at 0 deg of abduction or neutral adduction?
Subscapularis
When there is a greater loss of ER at 45 degrees of abduction versus 90 degrees of abduction, what is liable?
Subscapularis
Why does there tend to be a heightened pain response with adhesive capsulitis?
New nerve growth, angiogenesis
What causes the sustained, intense inflammatory/fibrotic response of the joint capsule?
Elevated cytokine levels
Do those diagnosed with adhesive capsulitis due to DM have an easier or longer recovery?
Tends to be protracted with worse outcomes, sxs for years
In terms of relative risk ratio, do men or women have higher risk with thyroid disease?
Women at 7.3 (men at 2.6)
In terms of relative risk ratio, do men or women have higher risk with DM?
Fairly equal, men 5.9 - women 5.0
What is the typical age of onset for adhesive capsulitis?
41-65 y.o (highest at 51-55)
What are 3 clinical/subjective ‘signs’ of adhesive capsulitis?
Reports of sleep disturbance
Report of inability to sleep on affected side
Restriction in ROM
If ROM tends to decrease during course of treatment, what is the likely outcome for the patient?
Surgical intervention
What stage is the first 3 months where the patient experiences sharp pain at end range, achy pain at rest and sleep disturbance?
Stage 1
What are cardinal signs of stage 1 of adhesive capsulitis?
1) sleep disturbance
2) sharp pain at end range
3) achy pain at rest
During stage 1, what is the hallmark sign for adhesive capsulitis?
Intact RTC with loss of ER
What stage is months 3-9, where there is painful gradual loss of ROM in all direction?
Stage 2
What are cardinal signs of stage 2 of adhesive capsulitis?
1) gradual loss of ROM in all directions
2) angiogenesis under arthorscopy
3) painful ROM
What stage is months 9-15 months, with a consistent loss of ROM with pain?
Stage 3
What stage is months 15-24 months with resolving pain and remaining stiffness?
Stage 4
Define primary/idiopathic adhesive capsulitis:
Not associated with systemic condition or hx of injury
Secondary adhesive capsulitis is related to disease/pathology and has three subcategories: what are they?
Systemic (DM, thyroid)
Extrinsic (CVA, MI, COPD)
Intrinsic (RTC/biceps tendinopathy, calcific tendonitis, proximal humeral/ scapular fx)
What is the clinical definition of adhesive capsulitis?
ROM loss of > 25% in at least 2 planes, PROM ER loss of > 50% or less than 30 deg (compared to uninvolved)
What is the Cyriax capsular pattern for adhesive capsulitis?
ER loss > abduction > IR loss - not consistent though
What are characteristics of high irritability level patients with adhesive capsulitis?
High pain levels, high disability, constant resting/night pain, pain before end range, more PROM than AROM
What are characteristics of moderate irritability level patients with adhesive capsulitis?
Pain in 4-6/10 range, intermittent rest/night pain, moderate disability, pain at end range, AROM similar to PROM
What are characteristics of low irritability level patients with adhesive capsulitis?
Pain < 3/10, no night or rest pain, minimal disability, pain with overpressure at end range, AROM = PROM
What are interventions for high irritability level patients?
1) modalities (heat, stim)
2) pt education - management, activity modification
3) low intensity GH mobs
4) pain free PROM/AAROM
What are interventions for moderate irritability level patients?
1) modalities PRN
2) pt education - progressing activities/function without irritation
3) moderate intensity GH mobs into resistance
4) scapulohumeral rhythm with reaching
What are interventions for low irritability level patients?
1) pt education - progressing to high demand, recreational activities
2) end range joint mobs - high amplitude, long duration
3) continue to focus on ST/GH joints rhythm
How can one diagnose adhesive capsulitis via radiograph?
Looking at joint capsule capacity, less than 10-12 mL - variable filling of axillary and subscapular recess
What MRI findings are consistent with adhesive capsulitis?
Thickened coracohumeral ligament, thickened joint capsule in RTC interval
In a recent study by Homsi, what diagnostic tool was used to identify a thickened coracohumeral ligament consistent with adhesive capsulitis?
Ultrasound - found thickness of 3 mm
What is the MCID / MDC of the American Shoulder and Elbow Surgeons outcome measure (ASES)?
MCID - 6.4
MDC - 9
What is the MCID /MDC of the Shoulder pain and disability index (SPADI)?
MCID - 8-13
MDC - 17-19
Which outcome measure has better responsiveness, DASH or SPADI?
SPADI
What is the MCID/ MDC of the Disabilities of the Arm, Shoulder and Hand (DASH)?
MCID - 10.2
MDC - 10.5
Is success with intervention purely based on ROM?
No, more on reduced pain, improved function, patient satisfaction
Strong evidence suggests corticosteroid injections are more effective in the short or long term for adhesive capsulitis?
In the short term - coupled with motion/stretching exercise
Grade A evidence
Moderate evidence suggests focusing pt education on two facets of adhesive capsulitis. Those facets being:
1) natural course of the disease
2) activity modification for functional, pain free ROM with matched intervention intensity
What type of evidence exists with use of modalities with adhesive capsulitis?
Weak evidence - ultrasound, shortwave diathermy, electrical stimulation
What type of evidence currently exists for GH joint mobilizations for adhesive capsulitis?
Weak evidence - poor match of intervention to irritability level, no evidence to support manual therapy has superior efficacy over other interventions
In a randomized perspective study, were there benefits to higher grade joint mobilizations versus lower grade joint mobilizations?
Moderate evidence for lower grade mobilizations are just as effective
What type of evidence exists for stretching and it as an intervention matched to irritability level?
Moderate evidence - influences pain, improves ROM, but not necessarily more than other interventions
