Information Exchange: Adhesive Capsulitis (Full Version)

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TexasOrtho -> Information Exchange: Adhesive Capsulitis (February 4, 2008 9:29:29 PM)

Ok gang.  How about this.  I've been attempting to standardize some of my manual approaches to allow for more consistency and maybe even allow for some collaborative research between therapists.

I got the idea the other day when I realized I do approximately 90-100 cross friction strokes at the greater trochanter for GT bursitis.  My technique was 3 x 30 distal to proximal strokes with each set getting progressively more vigorous.  During each set of 30, I would move from the posterior to anterior portion of the GT.  I've started using this as somewhat of a benchmark to assess outcomes.

It got me thinking maybe we could get something going on this website with other manual techniques in the interest of standardizing some of our methods.  For example, what is your typical mobilization progression with a patient with adhesive capsulitis?  Does it vary by staging? If so, how do you stage it (there are several ways).

I'm not implying we should "protocolize" the therapy, but maybe we could all give our ideas on ways to standardize our methods.  We might be able to kick off some great techniques on information sharing AND improve our outcomes.  I'll post my capsulitis protocol for the shoulder here soon.  I'm sure you are all on the edge of your seats!

P.S.  This is what nerds do.



TMondale -> RE: Information Exchange: Adhesive Capsulitis (February 5, 2008 8:23:59 AM)

Rod,

I don't disagree with your notion of collaborating on information for common diagnoses that we see.  However what I would like to talk about is taking your example of greater trochanteric bursitis, and compare outcomes with your local treatment, and a package of manual therapies directed at the lumbar spine including thrust manipulation, low back exercise, and hip girdle stretching and strengthening exercises.  Both groups could use the same exercise program.  We could even apply a third group for control that receives activity modification education.  It could be a multi-center study.  Now that would be something worthwhile. 

Tim



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 5, 2008 8:38:15 AM)

quote:

notion of collaborating on information for common diagnoses that we see. However what I would like to talk about is taking your example of greater trochanteric


I think that sounds like a great idea. Other ideas along the same lines would be welcome.  Even if not for publication, we could share some of our techniques and maybe some good ideas will come out of the process.



PTupdate.com -> RE: Information Exchange: Adhesive Capsulitis (February 8, 2008 9:25:56 AM)

Count me in on the discussion...I have 3 adhesive cap patients right now, and usually always have that many.

Over 16 years of practice I've treat so many different things.  I am at the point where I get at least 95% of the motion back...usually the only deficit is about 5 deg end range passive flexion.

What do I do?  Stretch.  I experimented with doing mobilizations versus not, and just didn't see any difference.  So, for the most part, I discontinued performing mobilizations.....I'd rather spend the time and energy doing what I found works....passsively stretching.

Many feel this is more of a CNS and/or cervical problem, and again I did not find any "wow" factors when addressing the neck.  I do see a strong correlation where post menopausal women who are on  hormone replacement therapy do much better than those who are not.  The fact that 95% of these cases are women (often with "issues") indicates there is a strong hormonal and biochemical influence.

I've read PT charts/records from patients dissatisfied with their treatment elsewhere and switched to me, finding that the PT's were doing all kinds of fancy schmancy things they learned at cont ed courses...scapular "release", neck treatment, mobilizations in neutral position, etc.  Their results are what count, and they were't impressive.  Perhaps the idea of simply stretching what is lacking makes some PT's feel inferior

I covered an article on my site on 3/30/06 (Arvhive 11) from a PT journal regarding different types of mobilizations for this condition.  However, the methodology was poor (imagine that).  Somewhere buried in my Archives I know I also covered one that measured mobilizations performed at end range of motion versus resting position



Shill -> RE: Information Exchange: Adhesive Capsulitis (February 8, 2008 11:30:33 AM)

John,
I too have reflected on the results from joint mobilizations, and despite what I have read, my results sure dont compare to the results of the studied mobilizations.  I have seen some great ideas for stretches at a course by Kevin Wilk, and have come up with a few of my own variations over the years.  I have started trying to get dynamic splints for patients who want to try one.  (Dynasplint).  I can look at your site to see if you have your specific stretches posted, but do you have any pearls to share? 
Thanks,

Steve



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 8, 2008 2:44:48 PM)

I sometimes wonder if certain phases of adhesive capsulitis respond differently to mobilization and long-lever stretching.  I agree that there must be some systemic autoimmune issue at work here in a significant portion of this population similar to a Dupuytren's contracture. 

Maybe a good classification-based treatment paradigm would lead to some better outcomes.  I've seen general guidelines based on the so-called phases of the disease, but nothing rock hard. 




buckeye -> RE: Information Exchange: Adhesive Capsulitis (February 8, 2008 4:01:53 PM)

I think this thread has great potential - let's keep it going.

I read an article about the staging of adhesive capsulitis with suggestions for treatment at the various stages. Will look for it and offer it to those interested. It has been a while since I read this and do not recall the specifics - but it should help with the discussion.

I tend to combine mobilization with stretching and hammer patient education to avoid impingement-type pain with exercise and reaching.

I think some adhesive capsulitis patients have some adverse neural tension component and do not respond as well to just stretching. Some of the ortho docs referring over the years do not want to recognize this as a potential problem and just focus on the musculoskeletal aspect at the shoulder.

There is also information about the diabetics and adhesive capsulitis.



PTupdate.com -> RE: Information Exchange: Adhesive Capsulitis (February 9, 2008 10:03:44 AM)

To buckeye:  Try and find that article you mentioned and share it with us.  You are right about the education part, and avoiding impingement, which only stirs up inflammation. I have always found it weird however, that one can stretch these cases causing quite a bit of pain, but it does not have the adverse effects that self-induced movement impingement has.  And, while you may note adverse neural tension issues (which could occur for so many different reasons), one really has to be careful how this is presented to a physician. When JOSPT recently related cervical problems and "Tennis elbow", and noted that treating the neck as well improved outcomes, I had no problem presenting this to the orthos.  It was legit, documented, and well tested.  However, when a PT walks up to a doc and notes they think an apparent pure orthopaedic problem is coming from the spine, they could lose credibility and get treated and viewed like a chiro.

Shill:  One "pearl" I have also used involved AC/SC joint mobilizations towards the conclusion of therapy. I have found these segments tend to stiffen over time, perhaps just due to the lack of overall motion for months.  They appear to be that culprit when I fight to get that last 5-10 degrees of end range flexion, long after the rotations have been fixed.  Those with very accessable distal clavicles that enable me to get my thumb in always do better than those where I can't find a leverage point closer than 2 inches away from the AC joint.

As far as dynamic splinting, I have always sat and mentally designed something for patients to use, as I stretch them and avoid their grimaces.  But, with liability and other issues, all I could ever do is make one, and get some crafty husband to emulate for his stricken-patient-wife



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 9, 2008 3:22:09 PM)

Here's an article on adhesive capsulitis that looks promising.  I need to wrap my head around the methods a little more, but I like the idea.

http://www.thefreelibrary.com/_/print/PrintArticle.aspx?id=169876146

I'd be curious if we could reproduce this study either formally or informally.  I'm like John in that my methods have changed over the last six years of practice.  My attitude now is that if the patient cannot tolerate the intensity of long-lever stretching required to gain more motion, a MUA would be indicated.  It seems that the pain experienced by so many patients with AC seems inflammatory and the intense stretching would further irritate and sensitize the synovium, making it very difficult to tolerate and perhaps counterproductive.  The problem is, I too have seen some good results with long-lever vigorous stretching if the patient can tolerate it. 

Maybe there is something to patient tolerance?  Pain behavior could upregulate nociceptors reducing tolerance for vigorous stress.  Whereas patients who are more stoic may allow more stress to be transmitted to the tissue without guarding.  This could be a component of the study:  Perform some kind of psychometric testing pre and post-treatment to see if there is some influence.

I'm just throwing things out there.  Forgive the rambling.




PTupdate.com -> RE: Information Exchange: Adhesive Capsulitis (February 9, 2008 4:45:38 PM)

Thanks for the article.....me will print and use on  website this week.

As Rod indicates, perhaps those with low pain thresholds could benefit from MUA. But, in my experience, they often end up as failed cases. Why?  They could not tolerate PT due to their dislike of pain, and when they get manipulated. instead of going to PT for 5 days in a row post-manip, they often hide at home holding their arm at their side, and bind right back up again.

I also perform a technique that I have demonstrated photographically on my site, using an inferior glide at end range flexion.  An orthopod told me that is exactly how he does his manipulation as well.

As far as long lever stretching, the main drawback is risk of humeral fracture.  It really does not take a ton of stress to have this happen, and trust me when I say that from experience.

I have been frustrated over the years with the low quality of some research that has done regarding PT and adhesive capsulitis.  One physician used an article out of an ortho journal to indicate why he would not send those patients to PT.  It was published by orthos with in house PT, and it was taking them 9-12 months to get resolution....pretty much the same time frame that the condition MAY spontaneously resolve in patients anyway.  But, I felt the PT they provided sucked, and reminded him that I felt most PT's provide sucky treatment, and please not compare me to any of them.

I am certainly game for attempting to reproduce a study, and quite open to anybody who wants to work as a group to publish something that will benefit our profession.   Even the website emedicine indicates there is not strong evidence to support PT, and that's a real shame

I have heard of distention arthrography, but don't know anyone in my area using it.



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 9, 2008 4:57:38 PM)

John...there may be some grant money out there.  I'm no research guru, but it's certainly worth a look.  You and I may be too busy for a large undertaking but it's worth filing away in the back of your mind.  Here's the NIH link:

http://grants.nih.gov/grants/guide/pa-files/PA-07-393.html#PartI



buckeye -> RE: Information Exchange: Adhesive Capsulitis (February 11, 2008 9:23:54 AM)

PTupdate -
I found the article - but my memory of the content wasn't the greatest. It gives basic information on the staging of adhesive capsulitis/frozen shoulder but not specific treatment ideas. It is more of a review of information on the subject with basic treatment objectives. It is a PDF file - not an online document.



eam -> RE: Information Exchange: Adhesive Capsulitis (February 11, 2008 9:57:11 AM)

I agree John-I find the basic joint mobs are not as effective as pure stretching.  I do use higher grades (III-IV) of the quadrant mob (maitland), which I find helpful.  However, the ROM has to be somewhat functional at that point.  I find restoring ER in these patients a chore.  I have one right now-all other motions almost WNL's, except ER.  I have tried stretching, MET-when I apply a posterior glide (like the relocation maneouver) I can get her a little farther. Anybody with other ideas?
Erica



PTupdate.com -> RE: Information Exchange: Adhesive Capsulitis (February 12, 2008 9:15:13 AM)

Erica:  I hear the same thing quite often when it comes to ER, and the literature typically notes the capsular pattern of ER being the most limited and difficult to get back.  I don't know why, but I never have a problem gaining this back.  While it may often be the most uncomfortable for the patient, it always circles back to that last 5 degrees of flexion.  I do attempt to stretch the shoulder in numerous positions....90-90, 45 abduction, and even neutral, to isolate different portions of the anterior capsule.  I also tend to play a game as I stretch, taking advantage of relaxing times and backing off a little, and then re-stretching during that refractory period.  I think that's the time that we can appreciate that we're not dealing strictly with a joint capsule problem, but muscular protection and tone as well....a tight capsule will not stretch out by 30 degrees in one visit, but muscular relaxation can permit that kind of motion gain



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 12, 2008 10:58:17 AM)

I agree with John.  Muscle guarding and pain are the biggest impediments to getting through to the capsule.  I will also vary arm position significantly.  If they are very acute and sore I will peform only grade I-II in tolerable ranges until their pain levels begin to stabilize.  This also gives the patient time to learn how to relax as opposed to barreling headlong into stretching the capsule.  Again, the idea here is to minimize guarding.

I will also move from mobilizing in the scapular plane, then work my way into the pure frontal plane, finally into the sagittal plane.  I want them to have full ER in each.  I have rarely encountered patients with full flexion who also didn't have full ER with the arm in 90 degrees of frontal plane abduction.

These are all for passive motions.  As the study referenced earlier mentioned, even with a significant return of passive motion, scapulohumeral rhytm stays out of wack for a while.  I strengthen as much as possible really reinforcing the need for good mechanics.  Just like not letting an ACL patient limp, I try not to let the AC patient actively elevate with hiking the shoulder.

Just a few additional thoughts.  This is a good discussion.



Shill -> RE: Information Exchange: Adhesive Capsulitis (February 12, 2008 11:40:44 AM)

I have a question. 

Can there actually be "impingement pain", which is what the pain is often called at end range flexion/ABDuction in the capsulitis patient? 

If there is little to no dissociation between the humeral head and glenoid, minimal inferior roll or glide, how could the greater tuberosity roll and/or glide enough to come in contact with the acromion and cause impingement?  I have often had the thought that I should probably not routinely create this "impingement" pain, but is that even what it is?  If so, can someone please explain how that is mechanically possible when the scapula is hyperrotated and the humerus is not moving much at all?  I am currently thinking that this is pain of other origin than impingement, as you might have guessed.....perhaps a capsular stretch pain.

Thoughts?



gerry -> RE: Information Exchange: Adhesive Capsulitis (February 12, 2008 12:08:17 PM)

I am also interested in this thread.  I work in peds, and have never treated a patient with this diagnosis.  But I was treated for this a couple years ago.  I think there is a thread on this site about it.  I'll search for it later.  It seemed there were distinct phases of this process, and therapy in each phase had a very different effect. 

Shill, in my case, the initial problem seemed to be an impingment type of scenario, and the lack of movement between the humerus and scapula gradually worsened, and became the primary problem.  For the record, I have most of the motion back now, but still have some end range limitation and "discomfort". 



PTupdate.com -> RE: Information Exchange: Adhesive Capsulitis (February 12, 2008 1:45:32 PM)

I think the pain is just impingement pain, and can easily reproduce a good degree of that pain on my own, healthy body, just by taking to it's end range and pushing.....either a sleeper stretch, or towel IR behind the back, or even end range ER.  I will often demonstrate on patients using their healthy shoulder.  While not as painful as their injured side, it's very similar.  It's just that the injured side is more irritable, and I use the thumb-hammer example.  Squeezing your thumb does not hurt much.  Whack it with a hammer, and then squeeze, and you'll see a marked increase in sensitivity, be it tendon tissue, or even a nerve root



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 12, 2008 1:58:42 PM)

quote:

ORIGINAL: Shill

I have a question. 

Can there actually be "impingement pain", which is what the pain is often called at end range flexion/ABDuction in the capsulitis patient? 

If there is little to no dissociation between the humeral head and glenoid, minimal inferior roll or glide, how could the greater tuberosity roll and/or glide enough to come in contact with the acromion and cause impingement?  I have often had the thought that I should probably not routinely create this "impingement" pain, but is that even what it is?  If so, can someone please explain how that is mechanically possible when the scapula is hyperrotated and the humerus is not moving much at all?  I am currently thinking that this is pain of other origin than impingement, as you might have guessed.....perhaps a capsular stretch pain.

Thoughts?


We typically think of straight tuberosity-anterior acr. impingment.  There are other sites of impingement as well which may account for the different presentations:  Undersurface of the acromion, coracoid, greater tubercle, upper edge of the glenoid, posterior glenoid.  Also numerous tissues can become impinged under these various sites such as burase, distal supraspinatus, infraspinatus, distal subscap, and biceps.  I think the multiple sites and tissues associated with impingement create a nonuniform presentation.  This is particularly so when you have a strong capsular involvement in my opinion.  My additional 2 pesos.



Shill -> RE: Information Exchange: Adhesive Capsulitis (February 13, 2008 2:35:50 PM)

I think fluoroscopy would shed some light on this.  I am still thinking that without true dissociation of movement at the glenohumeral joint, ANY impingement is nearly impossible.  Maybe its just humeral head compression into the glenoid?



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