Adhesive Capsulitis CPG

Question 1

Does frozen shoulder affect DM type I or II?

Answer 1

Both - no discrimination between the two

Question 2

What part of the capsuloligamentous complex may be most implicated in loss of ROM?

Answer 2

Proximal portion (superior, middle GH ligaments)

Question 3

What part of the capsuloligamentous complex makes up the RTC interval?

Answer 3

Superior GH joint ligament, coracohumeral ligament

Question 4

With the arm in 45 deg of abduction, what restricts ER with adhesive capsulitis greatest?

Answer 4

Proximal portion of capsule + subscapularis muscle

Question 5

What limits ER the most at 0 deg of abduction or neutral adduction?

Answer 5

Subscapularis

Question 6

When there is a greater loss of ER at 45 degrees of abduction versus 90 degrees of abduction, what is liable?

Answer 6

Subscapularis

Question 7

Why does there tend to be a heightened pain response with adhesive capsulitis?

Answer 7

New nerve growth, angiogenesis

Question 8

What causes the sustained, intense inflammatory/fibrotic response of the joint capsule?

Answer 8

Elevated cytokine levels

Question 9

Do those diagnosed with adhesive capsulitis due to DM have an easier or longer recovery?

Answer 9

Tends to be protracted with worse outcomes, sxs for years

Question 10

In terms of relative risk ratio, do men or women have higher risk with thyroid disease?

Answer 10

Women at 7.3 (men at 2.6)

Question 11

In terms of relative risk ratio, do men or women have higher risk with DM?

Answer 11

Fairly equal, men 5.9 - women 5.0

Question 12

What is the typical age of onset for adhesive capsulitis?

Answer 12

41-65 y.o (highest at 51-55)

Question 13

What are 3 clinical/subjective ‘signs’ of adhesive capsulitis?

Answer 13

Reports of sleep disturbance
Report of inability to sleep on affected side
Restriction in ROM

Question 14

If ROM tends to decrease during course of treatment, what is the likely outcome for the patient?

Answer 14

Surgical intervention

Question 15

What stage is the first 3 months where the patient experiences sharp pain at end range, achy pain at rest and sleep disturbance?

Answer 15

Stage 1

Question 16

What are cardinal signs of stage 1 of adhesive capsulitis?

Answer 16

1) sleep disturbance
2) sharp pain at end range
3) achy pain at rest

Question 17

During stage 1, what is the hallmark sign for adhesive capsulitis?

Answer 17

Intact RTC with loss of ER

Question 18

What stage is months 3-9, where there is painful gradual loss of ROM in all direction?

Answer 18

Stage 2

Question 19

What are cardinal signs of stage 2 of adhesive capsulitis?

Answer 19

1) gradual loss of ROM in all directions
2) angiogenesis under arthorscopy
3) painful ROM

Question 20

What stage is months 9-15 months, with a consistent loss of ROM with pain?

Answer 20

Stage 3

Question 21

What stage is months 15-24 months with resolving pain and remaining stiffness?

Answer 21

Stage 4

Question 22

Define primary/idiopathic adhesive capsulitis:

Answer 22

Not associated with systemic condition or hx of injury

Question 23

Secondary adhesive capsulitis is related to disease/pathology and has three subcategories: what are they?

Answer 23

Systemic (DM, thyroid)
Extrinsic (CVA, MI, COPD)
Intrinsic (RTC/biceps tendinopathy, calcific tendonitis, proximal humeral/ scapular fx)

Question 24

What is the clinical definition of adhesive capsulitis?

Answer 24

ROM loss of > 25% in at least 2 planes, PROM ER loss of > 50% or less than 30 deg (compared to uninvolved)

Question 25

What is the Cyriax capsular pattern for adhesive capsulitis?

Answer 25

ER loss > abduction > IR loss - not consistent though

Question 26

What are characteristics of high irritability level patients with adhesive capsulitis?

Answer 26

High pain levels, high disability, constant resting/night pain, pain before end range, more PROM than AROM

Question 27

What are characteristics of moderate irritability level patients with adhesive capsulitis?

Answer 27

Pain in 4-6/10 range, intermittent rest/night pain, moderate disability, pain at end range, AROM similar to PROM

Question 28

What are characteristics of low irritability level patients with adhesive capsulitis?

Answer 28

Pain < 3/10, no night or rest pain, minimal disability, pain with overpressure at end range, AROM = PROM

Question 29

What are interventions for high irritability level patients?

Answer 29

1) modalities (heat, stim) 2) pt education - management, activity modification 3) low intensity GH mobs 4) pain free PROM/AAROM

Question 30

What are interventions for moderate irritability level patients?

Answer 30

1) modalities PRN 2) pt education - progressing activities/function without irritation 3) moderate intensity GH mobs into resistance 4) scapulohumeral rhythm with reaching

Question 31

What are interventions for low irritability level patients?

Answer 31

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

Question 32

How can one diagnose adhesive capsulitis via radiograph?

Answer 32

Looking at joint capsule capacity, less than 10-12 mL - variable filling of axillary and subscapular recess

Question 33

What MRI findings are consistent with adhesive capsulitis?

Answer 33

Thickened coracohumeral ligament, thickened joint capsule in RTC interval

Question 34

In a recent study by Homsi, what diagnostic tool was used to identify a thickened coracohumeral ligament consistent with adhesive capsulitis?

Answer 34

Ultrasound - found thickness of 3 mm

Question 35

What is the MCID / MDC of the American Shoulder and Elbow Surgeons outcome measure (ASES)?

Answer 35

MCID - 6.4 | MDC - 9

Question 36

What is the MCID /MDC of the Shoulder pain and disability index (SPADI)?

Answer 36

MCID - 8-13 | MDC - 17-19

Question 37

Which outcome measure has better responsiveness, DASH or SPADI?

Answer 37

SPADI

Question 38

What is the MCID/ MDC of the Disabilities of the Arm, Shoulder and Hand (DASH)?

Answer 38

MCID - 10.2 | MDC - 10.5

Question 39

Is success with intervention purely based on ROM?

Answer 39

No, more on reduced pain, improved function, patient satisfaction

Question 40

Strong evidence suggests corticosteroid injections are more effective in the short or long term for adhesive capsulitis?

Answer 40

In the short term - coupled with motion/stretching exercise Grade A evidence

Question 41

Moderate evidence suggests focusing pt education on two facets of adhesive capsulitis. Those facets being:

Answer 41

1) natural course of the disease | 2) activity modification for functional, pain free ROM with matched intervention intensity

Question 42

What type of evidence exists with use of modalities with adhesive capsulitis?

Answer 42

Weak evidence - ultrasound, shortwave diathermy, electrical stimulation

Question 43

What type of evidence currently exists for GH joint mobilizations for adhesive capsulitis?

Answer 43

Weak evidence - poor match of intervention to irritability level, no evidence to support manual therapy has superior efficacy over other interventions

Question 44

In a randomized perspective study, were there benefits to higher grade joint mobilizations versus lower grade joint mobilizations?

Answer 44

Moderate evidence for lower grade mobilizations are just as effective

Question 45

What type of evidence exists for stretching and it as an intervention matched to irritability level?

Answer 45

Moderate evidence - influences pain, improves ROM, but not necessarily more than other interventions