ABSTRACT
Background and Purpose
Frozen shoulder is also known as Adhesive Capsulitis. This condition attacks the joints, muscles, tendons and ligaments that constitute the shoulder. The incidence is higher in those age 60 and above, as well as in women. The purpose of this case report is to define care through 3 months of physical therapy treatment based on clinical practice guidelines which include interventions such as manual therapy, range of motion (ROM) exercises, stretching, strengthening exercises and a home exercise program.
Case Description
The patient was a 47-year-old school principal who presented with right shoulder stiffness, discomfort and restrictions in ROM. This case study incorporates primary evaluation, treatment and a 3-month follow-up.
Outcome
The patient described in this case report improved with minimal functional limitations related to her job duties, leisure activities and pain at her 3-month follow-up. The improvement in symptoms and function were measured with the Shoulder Pain & Disability Index (SPADI), with higher scores indicative of greater pain and disability. The score at initial evaluation was 83/130 and at discharge was 20/130.
Discussion
Conservative treatment with physical therapy is a valuable and cost-effective solution. In comparison, there are also studies suggesting the use of invasive methods that include manipulation under anesthesia, capsule release surgery and steroids to reduce symptoms and improve function.
INTRODUCTION
The etiology of frozen shoulder, also known as adhesive capsulitis, is not clear. The pain and stiffness associated with the condition significantly limit motion and typically affect abduction and external rotation.1 It causes substantial reduction of active ROM (AROM) and passive ROM (PROM) and typically occurs without any internal shoulder pathology. It can affect up to 5% of the general population, and it occurs in higher rates among women.2 In frozen shoulder, changes occur in scapular kinematics which affect glenohumeral rhythm, ultimately reducing shoulder elevation. The scapula is depressed and rotated down due to tightness of the superior capsule, upper trapezius and rhomboids. Tightness in the pectoralis minor, the serratus anterior and the posterior capsule leads to a posterior scapular tilt.1 Frozen shoulder has three common stages; it starts with a freezing stage in which pain starts, with a progressive decrease in ROM. The second stage is the frozen stage in which pain starts to subside and there is a plateauing of stiffness with a loss of external rotation.3
The final stage is thawing in which there is a steady improvement of motion and finally a resolution of symptoms.3 A conservative approach such as physical therapy can be used as an initial treatment for frozen shoulder.1 Other conservative treatments for frozen shoulder include nonsteroidal anti-inflammatory drugs (NSAIDs), oral administration of medications such as glucocorticoids, and intra-articular injections.1,3 Patients that fail to show progress with conservative measures can be treated with invasive techniques like manipulation under anesthesia and capsule release surgery.4
CASE DESCRIPTION
Patient History
The patient was a 47-year-old woman who was referred by an orthopedist. The patient reported right shoulder pain over the last 7 months. She took 2 Aleve gel pills (220 mg each) twice a day to manage her symptoms. The patient stated she was having difficulty with overhead activities and maintaining her personal hygiene and grooming activities. She felt that she was becoming increasingly reliant on her husband. The patient reported her sleep was interrupted due to pain. She requested physical therapy as medications were giving her GI symptoms including frequent heart burn, stomach pain, and nausea. The orthopedist ordered X-rays which showed mild degenerative changes. The patient was referred for physical therapy to improve her ROM, improve her strength and functional mobility and reduce her dependency on family members. The patient had no history of trauma, diabetes or other underlying conditions.
The patient appeared to be a good candidate for physical therapy because of her motivation to achieve her functional goals.
Examination
Physical examination consisted of tests and measures selected based on problems associated with Frozen Shoulder, which include limited ROM, disabling pain levels and difficulty in performing activities of daily living (ADL). ROM was assessed with goniometry, and the patient completed the SPADI questionnaire to assess symptom severity. The minimum detectable change (MDC) for the SPADI is reported as 17 at the 95% confidence level; changes smaller than this may be attributable to test variability.5,6 The minimal clinically important difference (MCID) is reported as 8-13; changes smaller than this may not result in significant changes in clinical status.7
On observation, the patient demonstrated shoulder hiking. The bone and soft tissue appeared normal. PROM of the affected upper extremity was measured using a universal goniometer in the supine position to prevent any trick movement of the trunk and lumbar spine. The goniometer intraclass correlation coefficients range from 0.80 to 0.99, indicating high reliability in measurements.8 Lateral rotation, abduction and medial rotation were measured. PROM of abduction was 75 degrees, lateral rotation 20 degrees and medial rotation 35 degrees.
A physical therapy regimen was constructed to include ROM exercises, manual therapy, muscle strengthening exercises, stretching exercises and a home exercise program. Previous research has demonstrated the benefits of physical therapy toward improving function and pain in idiopathic frozen shoulder.3
TREATMENT
Week 1-6
In the beginning of every treatment session, a moist hot pack was used for 10 min for pain relief. Heat combined with stretching exercises can improve muscle extensibility.3
A gentle, pain-free active pendulum exercise was performed by the patient in flexion, abduction and circumduction. Passive supine forward elevation, passive external rotation, and active assisted range of motion in extension, horizontal adduction, and internal rotation were performed in a tolerable, pain-free range.
Joint mobilization grade III with distraction at the end ranges of abduction and external rotation were performed. The high-grade joint mobilization techniques were used because they are more effective than low-grade mobilization in improving glenohumeral mobility and reducing disability.9
In addition, the patient was assigned self-stretching exercises using a wand, to be performed twice a day. Stretches included passive flexion, horizontal adduction, and internal rotation with the good arm moving behind the back, as well as external rotation. The home exercise program (HEP) was discussed and practiced at the clinic, and a physical copy was provided to the patient. The patient was encouraged to demonstrate the exercises to ensure that the exercises were correctly understood and performed.
Week 7-12
Hold-relax proprioceptive neuromuscular facilitation (PNF) techniques were performed by the physical therapist with the patient in a sitting position. The shoulder was passively moved into external rotation and abduction within the tolerable range. Then the patient was instructed to perform a maximal isometric contraction for 6 seconds and relaxation for 10 seconds. The stretch was performed in 3 reps, 3 times per week.1
Exercises were performed to strengthen rotator cuff muscles with 2-4 lb. dumbbells. Standing abductor exercises and side-lying rotator exercises were performed at 3 sets of 8-12 repetitions, 3 times per. Research demonstrates that rotator cuff muscle strengthening is crucial in patients with adhesive capsulitis.10
OUTCOME
The patient showed improvement in pain levels and range of motion in all planes. Mild improvement in functional activities was noted after 1-6 weeks of therapeutic treatment. A major difference was noted after the seventh week, at which point the patient reported a significant reduction in pain. Abduction was improved from 75 degrees to 120 degrees, lateral rotation 20 to 45, and medial rotation 35 to 50 as shown in Table 1. The patient resumed ADLs that had been disrupted, including straightening her hair, shaving her arm pits, opening overhead cabinets and reaching into her back pocket. At the conclusion of her rehabilitation, a significant improvement in symptoms and function could objectively be demonstrated. The Shoulder Pain & Disability Index (SPADI) score at the initial evaluation was 83/130, and at discharge it was 20/130. During weeks 7-12, strengthening exercises were emphasized. The patient reported an improvement in endurance and functional activities with a gradual reduction of symptoms.
Table 1 – ROM of the right shoulder at baseline (PRE) and at the conclusion of rehabilitation (POST).
/
Abduction
Medial Rotation
Lateral Rotation
PRE
75
35
20
POST
120
50
45
DISCUSSION
To treat frozen shoulder, different types of exercises are recommended.10 In this case study, all exercises and manual therapy techniques were selected as per recent research in order to support evidence-based practice. The combination of therapies led to an improvement in the patient’s condition. The main objective in this case was to increase ROM, reduce pain, and improve functional status through physical therapy during a 3-month treatment period. The patient showed improvement in all functional aspects. as well as in her confidence and wellbeing. The other purpose of this study was to observe the combined impact of physical therapy interventions due to a lack of previous studies in which multiple approaches were utilized. Patient education may have had a major role in the patient’s consistency in physical therapy sessions and home exercises across 3 months.
This study has some limitations. Scapular kinematics, changes in muscle strength, analysis of movements, and changes in quality of life were not examined quantitatively. Due to the long-lasting nature of the condition and patient attrition, continuous follow up is challenging. Ideally, the study period should be longer.
REFERENCES
1. Tedla J, Sangadala D. Proprioceptive neuromuscular facilitation techniques in adhesive capsulitis: a systematic review and meta-analysis. J Musculoskelet Neuronal Interact. 2019; 19(4): 482–491. PMID: 31789299. PMCID: PMC6944810
2. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg. 2011;20(2):322–5. DOI: 10.1016/j.jse.2010.07.008
3. Chan HBY, Pua PY, How CH. Physical therapy in the management of frozen shoulder. Singapore Med J. 2017;58(12):685–689. DOI: 10.11622/smedj.2017107
4. Sun Y, Lu S, Zhang P, Wang Z, Chen J. Steroid injection versus physiotherapy for patients with adhesive capsulitis of the shoulder: a PRIMSA systematic review and meta-analysis of randomized controlled trials. Medicine. 2016;95(20):e3469. DOI: 10.1097/MD.0000000000003469
5. “Shoulder Pain And Disability Index.” Ability Lab Rehabilitation Measures. (2015). www.sralab.org/rehabilitation-measures/shoulder-pain-and-disability-index.
6. Tveitå EK, Ekeberg OM, Juel NG, Bautz-Holter E. Responsiveness of the shoulder pain and disability index in patients with adhesive capsulitis. BMC Musculoskelet Disord. 2008; 9:161. DOI: 10.1186/1471-2474-9-161. PMID: 19055757. PMCID: PMC2633286
7. Roy, J. S., MacDermid, J. C., & Woodhouse, L. J. (2009). Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61(5):623–632. DOI: 10.1002/art.24396
8. Kelley MJ, Shaffer MA, Kuhn JE, et al. Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther 2013;43(5): A1-A31. DOI: 10.2519/jospt.2013.0302
9. Page P, Labbe A. Adhesive capsulitis: use the evidence to integrate your interventions. N Am J Sports Phys Ther. 2010;5(4):266-273. PMID: 21655385. PMCID: PMC3096148
10. Rawat P, Eapen C, Seema K. Effect of rotator cuff strengthening as an adjunct to standard care in subjects with adhesive capsulitis: A randomized controlled trial. J Hand Therapy. 2017;30(3):235–241. DOI: 10.1016/j.jht.2016.10.007