Physiotherapeutic management
Physiotherapy plays an important role in the prevention as well as resolution of this condition.
Preventive programme
(a) Prevention of primary capsulitis,
(b) Prevention of secondary capsulitis and (c) Prevention of further damage.
(a) Prevention of primary capsulitis: The natural history of the disease is still undecided as regards the aetiology of this condition. It is very difficult to know the onset of the disease in its early phase as the symptoms of pain and stiffness are not acute. However, from our observations we have noticed that the initial pain and stiffness were elicited when the shoulder was passively taken to its terminal range of overhead adduction in elevation .Secondly, the early symptom is pain in lying on the side of the affected shoulder.
Therefore, the regular practice of this particular movement could be instrumental in prevention, early detection and lessening the impact of this condition.
(b) Prevention of secondary capsulitis: Careful early mobilization to the extreme range of motion needs to be emphasized for the other benefits of exercise in addition to the prevention of secondary adhesive capsulitis in the following situations:
1. All the procedures around the chest and shoulder requiring prolonged immobilization.
2. All situations requiring prolonged bed rest, e.g. coro nary artery disease. Fractures in the upper limb. 3. Paralysed arm following stroke.
4. Unconscious patient following head injury. 5. Mastectomy.
(c) Prevention of further damage: (i) Suddenly applied jerky stretching and (ii) crude self-styled manipulations by a quack, result in high tensile resistance and give rise to further constriction of the already constricted capsule (Kottke et al, 1966). Thus there is an increase in pain due to muscle spasm leading to further stiffness.
Adhesive capsulitis can be arded through proper measures by education to the masses to seek proper advice on simple terminal reretching the shoulder.
Restorative programme: The bass aim of the programme is:
(a) To reduce pain,
(b) To increase extensibility of the thickened and con tracted capsule of the joint at the anteroinferior border and at the attachment of capsule to the anatomic neck of humerus,
(c) To improve mobility of the shoulder and
(d) To improve strength of the muscles. However, it may be remembered that strengthening of muscles is secondary to mobilization.
Mobilization is attained through three basic approaches:
(a) Relaxation,
(b) Specific exercise to offer graded stretching,
(c) Passive mobilization technique.
(a) Relaxation:
Through prior heating: Prior heating of the joint has been found to facilitate relaxation and mobilization (Gersten, 1955; Lehmann et al, 1954). One may use any heat mo dality suitable to the patient's response. However, ultra sound, besides deep heating, has the added advantage of increasing extensibility of the contracted soft tissues and is therefore preferred. Stanley (1972) advocated the use of ultrasound via axilla over anteroinferior border of the capsule to be closer to the seat of actual defect.
Relaxed passive mobilization: The patient is placed in position with the affected shoulder in maximum possible abduction and neutral rotation; and elbow in 90 degrees of flexion.
The physiotherapist grasping the arm below the shoulder joint carries out relaxed passive gliding move ments of the head of humerus on glenoid .Axial traction and approximation is carried out along with anteroposterior glide and abduction-adduction glide. To induce relaxation days begin with slow rhythmic movements.
Slow and rhythmic cimduct at the gleno-hu meral joint, in forward stoop son, effectively induc es relaxation and promotes mobiity. It should be done by stabilizing the shoulder girdle with one hand and grasping just above the wrist joint with the other hand .Gentle relaxed passive movements short of pain and pathologic limits of motion reduce pain.The reduction in pain occurs because of the neuromodulation effect on the mechanoreceptors within the joint .
Mobilization by passive accessory movements of acromioclavicular (AC), sternoclavicular (SC) and/or scapulothoracic joint articulations are also extremely helpful.
(b) Exercise Programme: Exercise plays an important role in the management of adhesive capsulitis
While planning the exercise programme one must give due importance to the observations of Bohanan et al (1985), Kottke et al (1966, 1983), Rizk et al (1983), Sapega et al (1981) who proved that the contracted soft tissues when subjected to repeated prolonged mild tension show extensibility and plastic elongation.
Secondly, Lee et al (1973) and Rizk et al (1983) also noted that an increase in the moment following the sessions of prolonged stretching was usually associated with a corresponding increase in the other movements too. However, Maitland (1983 though generally agreed with these findings, cautioned that improvement in the range of other movements is not always at the same rate. Our clinical experience agrees with the statement of Maitland.
Giving due weightage to these clinical observations, ideally, the specific exercise programme should include the maximum number of combinations of various movements by minimizing the number of exercises.
We advocate graduated relaxed sustained stretching based on the PNF patterns. We have designed two movement combinations of:
(i) Shoulder elevation with flexion, abduction and external rotation (Fig. 20.8A).
(ii) Shoulder internal rotation with extension, adduction and elbow flexion, i.e. attaining hand to lumbar' position (Fig. 20.8B).
Following preparatory programme of inducing relax ation, the above-mentioned regime of exercise can be done in two ways:
(1) By pulley and tolerable weight in supine or sitting, (ii) By self-assiste stretching: The patient uses normal or better tralateral arm to gradually stretch the affected shoulder, maintaining the specific groove of these two exercises after self-induced relaxed passive mobilization.
While applying weights one must be careful not to overstretch the contracted capsule which induces pain. Ideally it is better to start with minimal weight and increase it gradually, without causing any discomfort to the patient.
Remember
Stretching with pain should never be given or advised.
(c) Passive Mobilization Technique: Methods described
by Codman, manipulation and mobilization techniques by Maitland (1983) and specialized techniques of PNF by Voss and Knott (1968) could be used with great advan tage. Middleditch and Jarman (1984) reported objective response in 78% patients treated with ultrasonics, ice pads and ice massage over the hot spots detected by thermography.
However, in spite of the various reports on the doubtful periods of resolution of the stiffness, we have observed that majority of patients respond favourably within a period of 6 months with properly guided simple and specific exercise programme which ensures relaxed graduated stretching of the contracted capsule. However, it must be remembered that the ultimate results depend upon the efficacy of home treguent regime.
Irregular or nonrespondignatients are benefited by special mobilization techniques of Maitland (1983).
Caution
1. The importance of regular stretching has to be emphasized to the patient even after he is relieved of stiffness and pain to avoid recurrence.
2. Patients with diabetes respond slowly to the treatment and feel much more pain and discomfort as compared to nondiabetics. Therefore, explain the prognosis, achieve maximum relaxation, and go slow in patients with diabetes. Varying periods of total resolution from 1 to 3 years have been recorded in a number of studies (Reeves, 1975; Grey, 1978).
3. Nocturnal pain: Patients comple ning w nocturnal pain should not be treated by thermotherapy. This type of pain has a low threshold for pain, therefore, the pain increases on warming up of body at night. Thermotherapy is likely to increase pain in such patients (Lewis, 1942); if given, it should be monitored at regular intervals.
4. The contralateral normal shoulder should always be examined in the extreme ROM as a precautionary measure.
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