Assessment and evaluation

Traditional methods of treatment

Massage techniques

Conclusion

• Freezing: Onset is usually between 10 and 36 weeks. This stage is characterized by a gradual decrease in range of motion and an increase of pain.
• Frozen: This period occurs between four and 12 months after initial onset. Motion is likely to remain limited though a gradual decrease in pain may be occur.
• Thawing: This period is characterized by a gradual return of range of motion and decreased pain. This stage may be as short as several months, but it is not uncommon for it to last for years.

Assessment and evaluation
Adhesive capsulitis is commonly evaluated through client history and physical examination. The condition affects women more often than men, and occurs more frequently in women age 45-65. A detailed client history is important to establish any characteristic patterns that indicate either a primary or secondary capsulitis. The most prominent symptoms are pain and loss of range of motion. Dysfunctional biomechanics and motion compensations. This image shows a client attempting to abduct the shoulder, with its motion limited by the adhered capsule.

An important approach to distinguishing adhesive capsulitis from similar shoulder problems is to evaluate the way in which motion is restricted at the shoulder joint. Most synovial joints of the body are enclosed in a joint capsule. When there is pathology, there is a characteristic pattern to the range-of-motion limitation in that joint. The pattern of limitation is unique to each joint. In the glenohumeral joint, the capsular pattern is for motion to be limited first in external rotation, then in abduction, and finally in medial rotation.

To understand how to apply the concept of the capsular pattern, let’s look at a common shoulder complaint where the client has trouble bringing the arm up in abduction (above figure). A person with this motion restriction could have adhesive capsulitis; however, the client has no problem externally rotating the shoulder from a neutral position with the arm at the side. Because the capsular pattern indicates that motion restriction will first be observed in external rotation, it is unlikely this person has a capsular pathology.

However, other conditions, such as sub-acromial impingement, calcific tendonitis or bursitis, are all likely to produce restriction in abduction. Assuming this problem to be adhesive capsulitis can lead to faulty methods of addressing the problem. This underscores the importance of a thorough assessment.

In addition to active and passive range-of-motion evaluations, a special orthopedic test for measuring functional range of motion in the shoulder, called the Apley scratch test (see Figure 2), is useful. In this procedure, the shoulder of the arm being held overhead is in abduction and external rotation while the shoulder of the lowered arm is in adduction and internal rotation (with a slight degree of extension). You should have the client perform this test with both sides in the upper and lower positions to compare the available range on each side.

Traditional methods of treatment
Most treatment methods begin with a conservative approach aimed at increasing the range of motion in the glenohumeral joint. Therapeutic movements, such as Codman's pendulum exercises (seen to the left), are often used. In this exercise, the patient/client will let the shoulder hang while slowly swinging it like a pendulum. This action encourages a gradual increase in range of motion. Care should be taken with rehabilitative exercise, as progress may be slow. If the exercises are performed too vigorously further capsular tearing might occur, aggravating the problem.

Strength-training programs are also used with the idea of increasing stamina in the supporting muscles. It is thought that increased muscular endurance decreases the load on the capsule in certain shoulder movements. However, overly aggressive strength training is likely to increase pain sensations and lead to further capsular restriction. In addition to strength training, anti-inflammatory medications may be used. These include oral medications as well as corticosteroid injections in the shoulder, although the benefits of this approach are controversial. The injections have long-term detrimental effects on the integrity of connective tissue. They have been proven to cause degeneration in connective tissues if done too frequently. For conditions where it is even questionable that there is a true inflammatory problem, they are often discouraged.

If conservative treatment is not successful, a more aggressive approach is sometimes used. While the capsule may be surgically mobilized, a more common procedure is forced manipulation. The shoulder is anesthetized and the joint is forcibly moved through its range of motion, essentially tearing the capsular adhesion free. Though this procedure can produce dramatic improvements in motion, it can be very painful when the anesthesia wears off. If the patient does not continue adequate movement, even more capsular adhesion may occur as a result of the treatment.

Massage techniques
Techniques that encourage relaxation of the muscles surrounding the shoulder girdle are a mainstay for massage approaches. Simple techniques, such as effleurage and broad cross-fiber sweeping strokes, are useful. Because the muscles often become fibrous and shortened due to the limited range of motion in the shoulder, restoring their proper movement is an important aspect of addressing this problem.

When muscles are unable to move through their full range of motion, restoring proper movement can be challenging. In this case, active engagement techniques work well. The image to the left shows an active engagement method for the pectoralis major, which often becomes restricted in adhesive capsulitis. The client is instructed to hold an isometric contraction (horizontal adduction) in the pectoralis major and then slowly let it go. As the client releases the contraction, the practitioner performs a longitudinal stripping technique on the pectoralis major fibers.

Myofascial trigger points in muscles such as the subscapularis may also play a role in the perpetuation of capsular adhesion. These trigger points can be treated with static compression methods or compression with active movement (Right Figure). During compression with active movement, the practitioner maintains pressure on the trigger point while the client moves through as much of the range of motion as possible (internal and external shoulder rotation).

Another goal for the massage therapist is to encourage elongation of the adhered capsular tissues. This is accomplished with various stretching procedures. However, do not expect results to come quickly. In addition to - or in conjunction with - massage techniques, stretching methods should emphasize the motions of external rotation and abduction, and will get the best results when performed slowly to stretch the adhered tissues. For example, with a passive stretch in lateral rotation, the client is taken just to the point where discomfort starts and then held there (see Left Figure). While in this position, the client is encouraged to breathe deeply and relax the shoulder as much as possible. After holding the stretch for 20 seconds or more, the client is slowly brought back to the neutral position. The procedure can be repeated several times.

Conclusion
:Adhesive capsulitis can be debilitating and cause long-term impairment. Proper treatment can mean the difference between a several-months-long disability or one of several years. Even with therapeutic results, this condition may require a long rehabilitation. As a result, the client may get depressed about the lack of improvement in his/her condition. Positive statements regarding even small amounts of improvement will go a long way toward encouraging active participation in the rehabilitation process. This is also where your knowledge of the condition will be highly valuable, as your clients attempt to learn more about their own bodies and what they can do to return to optimum health.