Final Examination

PBL Rheumatology

1. Working Diagnosis: Capsulitis or Adhesive Capsulitis

2. Psychopathophysiology of the Disorder

3. Medical Course of Treatment

 Corticosteroid Injections
 Corticosteroid injections have been used to manage inflammation for many years. It is
recommended for adhesive capsulitis based on the belief that inflammation is key in the early
stage of the condition the corticosteroid will have an anti-inflammatory effect, diminishing the
painful synovitis occurring within the shoulder.
 Methyl-prednisolone and Triamicinolone have both been found to be effective for
injection. There is no evidence suggesting the most effective treatment dose or administration
site; however, the majority of the studies used 20-40 mg injected via an anterior or posterior
approach.
 Manipulation Under Anesthesia (MUA)
 Manipulation under anesthesia involves a controlled and forced, end-range positioning
of the humerus relative to the glenoid in physiologic planes of motion (flexion, abduction,
 Final Examination

rotation) in patients with an anesthetic block to the brachial plexus. The block allows the
shoulder muscles to completely relax so that the force may actually reach the
capsuloligamentous structures. Traditionally long lever arms were used, but now short lever arm
techniques are utilized to minimize potential risks. Although success rates are high, ranging from
75-100%, manipulations are considered a last resort and are not indicated unless symptoms
persist in spite of adequate conservative treatment for six months
 Arthroscopic Capsular Release
 Arthroscopic capsular release is highly preferred over open release in patients with
painful, disabling adhesive capsulitis that is unresponsive to at least 6 months of non-operative
treatment. It has been found to be a reliable and effective method for restoring range of motion
and is especially recommended in diabetics and in post-operative or post-fracture adhesive
capsulitis patients.
 Other
 Non-steroidal anti-inflammatory drugs (NSAIDs) have traditionally been given to
patients with adhesive capsulitis but there is no high level evidence that confirms their
effectiveness. Oral steroids have also been utilized in these patients and result in some
improvement in function, but their effects have not shown long-term benefits and combined with
their known adverse side effects, should not be regarded as routine treatment.
 Distension arthrography. This technique involves the injection of a solution (saline alone
or combined w/ corticosteroids) causing rupture of the capsule by hydrostatic pressure. It is still
undetermined whether joint distension with saline solution combined with corticosteroids
provides more benefit than distension with saline alone or corticosteroid injection alone. There is
a lack of reliable evidence when determining the effectiveness of this technique and further
research needs to be performed to verify any clinical benefit.
 Suprascapular nerve blocks are thought to temporarily disrupt pain signals to allow
"normalization of the pathological, neurological processes perpetuating pain and disability."
There is some evidence of benefit with suprascapular nerve blocks, though the exact mechanism
behind this benefit remains unclear and higher level evidence is needed to establish this as a
treatment for adhesive capsulitis.

4. Nursing Specialized Treatment

 For the treatment of adhesive capsulitis, patient education is essential in helping to reduce
frustration and encourage compliance. It is important to emphasize that although full range of
motion may never be recovered, the condition will spontaneously resolve and stiffness will greatly
reduce with time. It is also helpful to give quality instructions to the patient and create an
appropriate home exercise program that is easy to comply with because daily exercise is critical
in relieving symptoms.
 Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in
conjunction with stretching can help to improve muscle extensibility and range of motion by
reducing muscle viscosity and neuromuscular-mediated relaxation. In a randomized study by Bal
et al., patients improved with combined therapy which involved hot and cold packs applied before
and after shoulder exercises were performed. However, a study by Jewell et al., claimed that
ultrasound, massage, iontophoresis, and phonophoresis reduced the odds of improved outcomes
for patients with adhesive capsulitis. A Cochrane Review by Green et al. showed that, “There is
 Final Examination

no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or
rotator cuff tendinitis.”

5. Rehabilitative Management

 Manual Techniques
 Mechanical changes that occur as a result of mobilizations may include the break- up of
adhesions, realignment of collagen, or increased fiber glide when specific movements stress
certain parts of the capsular tissue. These techniques are intended to increase joint mobility by
inducing changes in synovial fluid formation. High-grade mobilization techniques (HGMT) have
been shown to be helpful for improving range of motion in patients with adhesive capsulitis for
at least three months. In a study by Vermeulen et al., patients were given inferior, posterior, and
anterior glides as well as a distraction to the humeral head. These techniques were performed at
greater elevation and abduction angles if glenohumeral joint range of motion increased during
treatment. Patients who received HGMT received these mobilizations at Maitland Grades III and
IV according to the subjects' tolerance with the intention of "treating the stiffness."Patients were
allowed to report a dull ache as long as it did not alter the execution of the mobilizations or persist
for more than four hours after treatment.
 However, patients who received low-grade mobilization techniques (LGMT) were given
Mailtand Grades I or II without the report of any pain. Statistically significant greater change
scores were found in the HGMT group for passive abduction (at the time of three and twelve
months), and for active and passive external rotation (at twelve months) when compared with
low-grade mobilization techniques. It can then be concluded that high-grade mobilization
techniques appear to be more effective for increasing joint mobility and reducing disability. Based
on prior knowledge regarding the use of Mailtand Grades for mobilizations, one would assume
HGMT would be more beneficial during later adhesive stages of adhesive capsulitis, while LGMT
would provide more benefit during early painful stages. However, future studies are needed to
investigate whether HGMTs applied during earlier stages of adhesive capsulitis are as effective as
in this particular study.
 Stretching
 Research regarding connective tissue stretch duration and intensity has produced three
findings. First, high intensity, short duration stretching aids the elastic response, while low
intensity, prolonged duration stretching aids the plastic response. Secondly, a direct correlation
exists between the resulting proportion of plastic, permanent elongation and the duration of a
stretch. Lastly, a direct correlation exists between the degree of either trauma or weakening of
the stretched tissues and the intensity of a stretch. Mc Clure et al., stated that the maximum TERT
(Total End Range Time) or the total amount of time the joint is held at near end range position,
will be different for each person, and is often affected by personal circumstances such as a job or
other responsibilities that may prevent a patient from increasing TERT.