Adhesive capsulitis (AC), also referred to as Frozen Shoulder, is characterised by an active and passive glenohumeral (GH) joint range of motion with spontaneous complete or almost complete recovery over a varied period of time that is initially painful and later gradually reduced.
Other Names for Adhesive Capsulitis
- Frozen Shoulder
- Painful Stiff Shoulder
This inflammatory disorder induces GH joint capsule fibrosis, which is followed by steadily progressive stiffness and severe reduction of the range of motion (typically external rotation). Differentiating the early stages of AC from other shoulder pathologies can be very difficult in clinical practise.
The shoulder is a very difficult joint that is important for many everyday activities. A serious clinical finding is reduced shoulder mobility. A global decrease in the range of motion of the shoulder is called adhesive capsulitis, referring to the shoulder capsule’s actual adherence to the humeral head. Adhesive capsulitis is a condition that is characterised as an idiopathic shoulder movement restriction that is typically painful at the onset. Secondary factors include alteration and autoimmune, endocrine or other systemic disorders of the supporting systems of and around the shoulder. The painful stage, the adhesive stage and the recovery period are the three specific phases of this disorder. While recovery is typically spontaneous, intra-articular corticosteroid treatment and gentle yet continuous physical therapy can provide a better outcome, resulting in little functional compromise.
Know more about Adhesive Capsulitis
The shoulder capsule thickens and becomes rigid and tight in the frozen shoulder. Thick tissue bands, called adhesions, grow. In certain cases, the joint has less synovial fluid.
Extreme pain and being unable to lift your shoulder are the signature symptoms of this disease — either on your own or with someone else’s help. It grows in three phases:
- Stage 1: Freezing – You slowly get more and more pain in the “freezing process. Your shoulder loses range of motion as the pain aggravates. Usually, freezing lasts from 6 weeks to 9 months.
- Stage 2: Frozen – During this stage, painful symptoms can actually improve, but the stiffness remains. Regular tasks may be very difficult during the 4 to 6 months of the “frozen” stage.
- Stage 3: Thawing – During the “thawing” period, shoulder motion slowly improves. Usually, a complete return to normal or near-normal strength and mobility takes from 6 months to 2 years.
Why Adhesive Capsulitis occurs?
No full description of the causes of the frozen shoulder is available. The correlation to arm dominance or occupation is not apparent. A few factors can put you at greater risk of developing a frozen shoulder.
Diabetes: In individuals with diabetes, frozen shoulder happens even more frequently. It is not known the explanation for this. In addition, diabetic frozen shoulder patients tend to have a higher degree of stiffness that lasts for a longer time before “thawing.”
- Parkinson’s disease and heart disease are several additional medical conditions associated with frozen shoulders.
Immobilization: The frozen shoulder may grow after a shoulder has been immobilised for a period of time due to surgery, injury, or other injuries. One measure is recommended to stop frozen shoulders if patients have moved their shoulders soon after injury or surgery.
Frozen shoulder pain is typically dull or aching. Usually, it is worse early in the course of the illness and when the arm is pushed. The pain is usually found in the region of the outer shoulder and the upper arm, often.
Disturbed Sleep: Sleeping is frequently disrupted and disturbed in the early and middle part of this disorder (Freezing and Frozen stages, respectfully). If the patient progresses, this can get worse and there is strong evidence that a closely intertwined triangle is created by the lack of sleep, pain and depression that improvements in one can affect the other two. It is also vital that clinicians monitor the quality of sleep and use outcome indicators to quantify signs and symptoms. The Pittsburgh Sleep Quality Index and The Medical Outcomes Research Sleep Scale (MOS-Sleep) are useful questionnaires, including 12 items measuring sleep disruption, sleep adequacy, somnolence, sleep quantity, snoring, and waking out of breath or with a headache.
Physical Therapy Management
The definitive cure for adhesive capsulitis, although several interventions have been tested, remains uncertain. Enrolling in a physical therapy programme is the path to rehabilitation for most patients.
Importance of Patient Education
Patient education is critical for the treatment of adhesive capsulitis to help alleviate frustration and facilitate compliance. It is important to emphasise that although the full range of motion can never be restored, the disorder will resolve spontaneously and stiffness will decrease dramatically over time. It is also helpful to provide the patient with quality guidance and establish an adequate home exercise programme (HEP) that is easy to comply with as daily exercise is essential for symptom relief.
Initial Phase: Painful, Freezing
The emphasis during this process is pain relief and the exclusion of all possible causes of your frozen shoulder. During this painful inflammation process,
- very gentle shoulder mobilisation,
- muscle releases,
- dry needling,
- and kinesiology taping;
for pain-relief may help. It has been shown that applying a TENS machine decreases discomfort and increases the range of motion.
Modalities may be applied before or during treatment, such as hot packs. By decreasing muscle viscosity and neuromuscular mediated relaxation, moist heat used in combination with stretching can help to increase muscle extensibility and range of motion. Patients improved with combination therapy in a randomised study by Bal et al. that included hot and cold packs applied before and after shoulder exercises were carried out. Jewell et al, however, stated that the chances of positive results were decreased by ultrasound, massage, iontophoresis, and phonophoresis. There is no evidence of the influence of ultrasound on shoulder pain (mixed diagnosis), adhesive capsulitis, or rotator cuff tendinitis, suggested by Green et al.
As stated, counselling should be personalised to each person depending on the stage of the disorder.
The emphasis of the initial stage also referred to as the painful, freezing phase, should be pain relief. Any activities which cause pain should be avoided during this period. In patients who performed basic pain-free exercise, rather than intensive physical therapy, better outcomes were observed. Low-intensity and short-term range of motion exercises in patients with high irritability can alter the input of the joint receptor, minimise pain, and decrease muscle safety. Stretches can be kept in a pain-free range for one to five seconds, 2 to 3 times a day. Depending on the capacity of the patient to withstand the exercise, a pulley can be used to sustain a range of motion and stretch. Key exercises include pendulum exercise, passive supine forward elevation, passive external arm rotation in the scapula plane at around 40 degrees of abduction, and active-assisted range of motion in extension, horizontal adduction, and internal rotation.
Physical therapy can also be a supplement to other therapies (such as steroid injections as mentioned above in the case of adhesive capsulitis, especially to improve the range of motion of the shoulder. Bal et al proposed that isometric strengthening in all ranges should be used in concomitant exercises for steroid injections until motion returned to 90% of normal ranges, theraband exercises in all planes, scapular stabilisation exercises, and later, advanced muscle strengthening with dumbbells.
2nd Phase: Decreased ROM
For a prompt return to work, the gentle and precise shoulder joint mobilisation and stretches, muscle release strategies, acupuncture, dry needling, and exercises to recover your range and strength are used. It is important to take caution not to implement any exercises which are too aggressive. Movement mobilisation (MWM) type strategies, in particular, tend to be the most effective and more effective than stretching exercises alone. MWM’s are basic procedures conducted by adequately-trained physiotherapists in the shoulder.
Prospective research by Griggs et al found that non-operative care was successful through a four-direction shoulder stretching exercise programme in which a satisfactory result was recorded by 90% of the patients. Movement with mobilisation and end-range mobilisation is prescribed during the second phase of treatment. Mobilisation with motion can also substantially better correct the scapulohumeral rhythm than the mobilisation of the end range. The purpose of end-range mobilisation is not only to restore the joint range but also to extend the peri-articular structures contracted, while movement mobilisation aims to restore pain-free movement to the joints that have antalgic motion range limitation.
Gaspar and Willis found that compared to physical therapy alone or dynamic splinting alone, physical therapy combined with dynamic splinting had stronger results. Physical therapy twice a week and a Shoulder Dynasplint Device (SDS) for daily end-range stretching were obtained by the patients in this community of combined treatments. In patients with adhesive capsulitis, the combination of physical therapy with dynamic splinting demonstrated substantial changes in successful external rotation.
3rd Phase: Resolution
Provide you with progressive exercises to monitor and sustain an increased range of movement, including strengthening exercises.
During this thawing process, physiotherapy is most effective. It improved mainly by increasing the pace and length of the stretch while retaining the same severity as the patient tolerated. For longer periods, the stretch can be retained and the sessions per day can be raised. As the irritability level of the patient decreases, it is possible to perform more vigorous stretching and exercises using a system, such as a pulley, to affect tissue remodelling.