Adhesive capsulitis or "frozen shoulder" is a relatively common condition resulting in severe shoulder pain and global loss of glenohumeral joint range of motion. Incidence of the condition is approximately 3 percent in the general population. Risk greatly increases for patients diagnosed with type 1 or type 2 diabetes. Adhesive capsulitis often occurs with an insidious onset and can be idiopathic in nature. Whatever the cause, figuring out a treatment strategy often poses a challenge to manual medicine practitioners.
Classically, the natural history of adhesive capsulitis has been described in three sequential phases: a painful stage, a freezing stage and a thawing stage. However, validating evidence of this classification is lacking. Pain and limited range of motion may occur in all phases of this complex condition, which doesn't follow a stepwise course.
Adhesive capsulitis is considered to be self-limiting. However, pain and limited range of motion may persist for one to two years and 10 percent of patients never regain full range of motion.
Treatment Challenges
Treatment strategies often focus on decreasing pain and restoring range of motion. Unfortunately, there is insufficient high-level evidence to either support or refute many of the commonly employed conservative therapies, including ROM exercises, stretching, joint mobilization, and a multitude of other PT modalities aimed at decreasing pain and inflammation. Often the "phase" in which the patient is considered to be will dictate which treatment technique is used.
Although manipulation / mobilization is the mainstay therapy applied by most chiropractic physicians, most would agree that aggressive mobilization is contraindicated during the painful stage, as exacerbation of pain may occur, reducing compliance to the prescribed treatment plan. Typically, more aggressive techniques are exercised during the subacute and chronic phases, during which pain is typically less of an issue for patients.
Although glenohumeral and scapulothoracic joint manipulation continues to be the choice of manual therapy for this condition, therapeutic benefit can be minimal. At least one case study examined the use of traditional therapies in addition to thoracic spine manipulation. Traditional therapies included ROM exercises, passive stretching, and scapular / glenohumeral mobilization. With the inclusion of thoracic spine manipulation, increases in shoulder ROM were remarkable and the patient's pain decreased markedly.
Although the underlying mechanisms for this drastic improvement following spinal manipulation and manual therapy are not well-understood, it emphasizes the interconnectedness of the human body. Whether the improvement was neurophysiological, biomechanical or a combination of the two, the end result was increased ROM and reduced pain – the two primary goals of treatment.
Adjustment Techniques
Glenohumeral Joint Posterior Glide @ 90° of Shoulder Flexion
Palpation
Manipulation
Scapulothoracic Articulation: Prone Scapular Distraction
Cross Bilateral Transverse Pisiform With Torque for T4-T10
Hypothenar Spinous CT
Resources
Editor's note: This is the fourth article in a series on chiropractic techniques to treat challenging patient presentations. "The Struggle to Heal the Cervical Syndrome" kicked off the series in the June 1, 2014 issue.
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