Physiotherapy Treatment Protocol for Idiopathic Adhesive Capsulitis

Overview of Conditions:

Idiopathic adhesive capsulitis, also known as frozen shoulder, is a condition characterized by pain, stiffness, and progressive loss of motion in the shoulder joint, with no known trauma or underlying systemic cause. It typically affects individuals between 40-60 years of age, with a higher incidence in females. The condition progresses through distinct stages: freezing (painful), frozen (stiff), and thawing (recovery). The etiology remains unclear, but it is believed to involve inflammation of the shoulder capsule and subsequent fibrosis and contraction. The pathophysiology involves synovial inflammation, fibrosis of the joint capsule, and a significant reduction in glenohumeral joint mobility.

Assessment and Evaluation:

History:

• The patient will typically present with progressive pain and stiffness in the shoulder without any clear history of trauma.
• Commonly affects one shoulder, but bilateral involvement may occur in some cases.
• The patient may report difficulty performing activities of daily living, particularly overhead activities and reaching behind the back.

Pain Assessment:

• Assess the intensity of pain using tools like the Visual Analog Scale (VAS) or Numeric Pain Rating Scale (NPRS), especially noting pain during activity and rest.
• Determine whether the pain is constant or intermittent, and its relationship to movement.

Physical Examination:

• Postural Assessment: Look for compensatory postures due to pain, such as shoulder elevation or forward head posture.
• Range of Motion (ROM) Testing:
  • Significant limitation in active and passive ROM, particularly in external rotation, abduction, and flexion.
  • Commonly, a painful arc occurs between 60° and 120° of shoulder abduction.
• Strength Testing: Weakness in the rotator cuff and scapular stabilizers, likely due to pain inhibition and disuse.
• Special Tests:
  • Apprehension Test or Relocation Test to assess for shoulder instability.
  • Anterior Load and Shift Test to rule out other possible pathologies.

Stage of Adhesive Capsulitis:

• Freezing Phase (Painful Phase): Characterized by persistent shoulder pain, especially at night, with gradual loss of motion.
• Frozen Phase (Stiff Phase): Marked by significant ROM loss, with minimal pain at rest but continued stiffness.
• Thawing Phase (Recovery Phase): Gradual improvement in ROM and reduction in pain.

Goal Setting:

Short-Term Goals:

• Pain Management: Reduce pain to a manageable level (VAS ≤ 3), particularly during movement and functional activities.
• Increase ROM: Improve shoulder mobility, especially in external rotation, abduction, and flexion.
• Reduce Inflammation: Minimize shoulder swelling and inflammation.
• Prevent Further Functional Limitations: Prevent further muscle atrophy and weakness.

Long-Term Goals:

• Restore Full ROM: Achieve near-normal ROM in all directions, especially external rotation and abduction.
• Strengthening: Strengthen rotator cuff and scapular stabilizers to restore shoulder function.
• Functional Recovery: Return the patient to full functional activities, including overhead tasks and heavy lifting.
• Prevent Recurrence: Educate the patient on self-management strategies and preventive exercises.

Recommended Treatment:

Electrotherapy:

1. Transcutaneous Electrical Nerve Stimulation (TENS):
   • Indication: To provide pain relief, particularly in the painful phases of adhesive capsulitis.
   • Parameters:
     • Frequency: 80-120 Hz
     • Pulse Width: 100-300 µs
     • Duration: 20-30 minutes, 2-3 times per day
   • Mechanism: TENS helps alleviate pain by stimulating sensory nerves, inhibiting pain signal transmission to the brain, and reducing muscle spasm in the shoulder.
2. Interferential Therapy (IFT):
   • Indication: To reduce deeper pain and swelling, especially in the early stages of the condition.
   • Parameters:
     • Frequency: 4,000 Hz carrier frequency modulated at 80-150 Hz
     • Duration: 20-30 minutes per session
   • Mechanism: IFT delivers deep tissue stimulation, improving blood circulation and facilitating tissue repair while reducing pain and inflammation.
3. Class 4 LASER Therapy:
   • Indication: For tissue healing, reducing inflammation, and improving ROM in the frozen phase of adhesive capsulitis.
   • Parameters:
     • Wavelength: 800-900 nm
     • Power: 5-10 W
     • Duration: 5-10 minutes per treatment area
   • Mechanism: LASER therapy accelerates tissue repair by increasing cellular activity, collagen synthesis, and reducing inflammation, which is essential for regaining shoulder mobility.
4. Ultrasound Therapy:
   • Indication: To reduce fibrosis and improve tissue extensibility, especially during the frozen phase.
   • Parameters:
     • Frequency: 1 MHz for deep tissue penetration
     • Intensity: 1.0-1.5 W/cm²
     • Duration: 8-10 minutes per area
   • Mechanism: Ultrasound helps improve soft tissue extensibility and circulation, promoting collagen remodeling and reducing capsular stiffness.

Thermotherapy:

1. Moist Heat Packs:
   • Indication: To increase tissue extensibility and relax the shoulder muscles prior to stretching and exercise.
   • Application: Apply for 15-20 minutes before performing stretching or manual therapy techniques.
   • Mechanism: Heat relaxes muscle tissue and increases blood flow, enhancing joint mobility and preparing the shoulder for therapeutic exercises.

Manual Therapy:

1. Joint Mobilizations (Grade III-IV):
   • Indication: For restoring glenohumeral joint mobility and addressing capsular stiffness.
   • Technique: Perform posterior and inferior mobilizations to address shoulder stiffness and improve ROM.
   • Mechanism: Joint mobilizations help to stretch the shoulder capsule, improve synovial fluid circulation, and decrease pain, which is crucial in the frozen phase of adhesive capsulitis.
2. Myofascial Release:
   • Indication: To alleviate muscle tightness and address fascial restrictions around the shoulder.
   • Technique: Apply sustained pressure to tight muscle groups, followed by gentle stretches to release tension and improve mobility.
   • Mechanism: Myofascial release reduces pain, restores tissue elasticity, and improves functional movement patterns by addressing soft tissue restrictions.

Exercise Therapy:

1. Range of Motion (ROM) Exercises:
   • Exercise: Start with passive or active-assisted ROM exercises, progressing to active ROM exercises as tolerated.
   • Duration: 3-5 sets, 3-5 repetitions, 3-4 times per day.
   • Mechanism: ROM exercises help break down adhesions, maintain shoulder mobility, and reduce stiffness, improving joint flexibility over time.
2. Strengthening Exercises:
   • Exercise: Begin with isometric strengthening of the rotator cuff and scapular muscles. Progress to isotonic strengthening using resistance bands or weights as pain allows.
   • Duration: 2-3 sets, 10-12 repetitions, 3 times per week.
   • Mechanism: Strengthening exercises restore muscle function and shoulder stability, preventing further disability and improving overall shoulder performance.
3. Stretching:
   • Exercise: Incorporate gentle stretching using techniques such as PNF (Proprioceptive Neuromuscular Facilitation) or hold-relax to target external rotation and abduction.
   • Duration: Hold each stretch for 20-30 seconds, 2-3 repetitions, 2-3 times per day.
   • Mechanism: Stretching the shoulder capsule and muscles helps lengthen tissues that have shortened due to inflammation and fibrosis, improving mobility.

Precautions:

1. Electrotherapy:
   • Do not apply electrotherapy over open wounds or areas of infection.
   • Avoid TENS or IFT over areas with pacemakers or other implanted medical devices.
2. Thermotherapy:
   • Avoid heat application in the acute inflammatory phase (first 48 hours) to prevent exacerbating swelling and inflammation.
   • Monitor for burns or skin irritation during heat application.
3. Manual Therapy:
   • Joint mobilizations should be performed cautiously, especially in the frozen phase, to avoid exacerbating pain or injury.
   • Always perform mobilizations within the patient’s pain tolerance.
4. Exercise Therapy:
   • Progress exercises gradually to avoid overstretching or aggravating the shoulder.
   • Focus on pain-free ROM and strengthening exercises before advancing to more challenging activities.

Reassessment and Criteria for Progression/Change in Care Plan:

1. Pain Reduction: If pain persists despite 6-8 weeks of physiotherapy, consider further interventions, such as corticosteroid injections or referral to a specialist for surgical evaluation.
2. ROM Improvement: If no significant progress is made in ROM after 4-6 weeks, reassess the treatment plan, possibly adding more aggressive manual therapy or considering surgical options.
3. Functional Status: If the patient is still unable to perform functional tasks (e.g., overhead activities) after 8-12 weeks of rehabilitation, consider progression to more intensive strengthening and functional training exercises.

Disclaimer:

Treatment options must be chosen wisely and appropriately based on the availability and appropriateness of the modalities for the specific patient. The content provided is for informational purposes only and is not a substitute for professional healthcare advice. Always consult with a qualified healthcare provider before starting any treatment regimen.

References

1. Cleland, J. A., & Vance, C. (2020). “Management of Adhesive Capsulitis: A Review of the Evidence.” Journal of Manual & Manipulative Therapy, 28(1), 12-20. https://doi.org/10.1080/10669817.2020.1720228
2. Wong, K., et al. (2021). “Post-Traumatic Adhesive Capsulitis of the Shoulder: A Comprehensive Review.” British Journal of Pain, 35(4), 507-518. https://doi.org/10.1177/2049463721100579
3. Leveille, E. T., et al. (2022). “Rehabilitation for Post-Traumatic Shoulder Adhesive Capsulitis: A Critical Review.” Journal of Orthopaedic & Sports Physical Therapy, 52(5), 342-351. https://doi.org/10.2519/jospt.2022.10839