Passive range of motion in patients with adhesive shoulder capsulitis, an intertester reliability study over eight weeks

The Feasibility and Efficacy of Remote App-Guided Home Exercises for Frozen Shoulder: A Pilot Study

Home exercise programs are beneficial in managing frozen shoulder (FS), yet adherence remains challenging. This pilot study introduces the remote app, Defrozen, designed for home exercises and assesses its feasibility and clinical outcomes in FS patients undergoing intra-articular and sub-acromial corticosteroid treatment. Over a four-week period, patients used the Defrozen-app, engaging in guided exercises. The feasibility of the intervention was assessed through several measurement scales, including adherence, the Technology Acceptance Model 2 (TAM2), the System Usability Scale (SUS), and User Satisfaction and Engagement (USE). Clinical outcomes included pain scale, Oxford Shoulder Score (OSS), Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) Score, and passive range of motion. The TAM2 results indicated high perceived usefulness (4.5/5), ease of use (4.8/5), and intention to use (4.4/5); the SUS score was high at 81.7/100, complemented by USE scores reflecting ease of learning (4.9/5) and satisfaction (4.3/5). Clinical outcomes showed significant pain reduction, improved shoulder function, reduced shoulder-related disability, and increased shoulder range of motion. These findings suggest the Defrozen-app as a promising solution for FS, significantly improving adherence and showing potential to enhance clinical outcomes. However, these clinical outcome results are preliminary and necessitate further validation through a large-scale randomized controlled trial to definitively confirm efficacy and assess long-term benefits.

Comparison of Kaltenborn mobilization technique and muscle energy technique on range of motion, pain and function in subjects with chronic shoulder adhesive capsulitis

Background

Shoulder adhesive capsulitis (AC) is a common musculoskeletal condition causing pain, loss of range of motion (ROM) in the shoulder, and a decrease in its functionality, yet poorly defined and understood since its identification. Kaltenborn mobilization technique (KMT) and muscle energy technique (MET) are commonly used physiotherapeutic techniques for their treatment. To the best of our understanding, there was no study found to compare the effectiveness of one technique over another.

Objective

The objective of this study was to compare the effectiveness of KMT and MET on the ROM, pain and function in subjects with chronic shoulder AC.

Methods

In this single-centred, single-blinded quasi-experimental study with a pretest-posttest design 35 subjects were randomized into two groups: Group A (n = 18 ) received KMT and Group B (n = 17 ) received MET along with the moist hot pack (MHP), supervised exercises and home exercises common to both the groups. A total of 32 subjects completed the study with three dropouts. Subjects were evaluated before and after 10 treatment sessions for the outcomes, shoulder external rotation passive range of motion (ER-PROM) and abduction passive range of motion (ABD-PROM) using the universal goniometer, intensity of pain using the numeric pain rating scale (NPRS) and functional disability using the shoulder pain and disability index (SPADI).

Results

Analysis of 32 subjects showed that both groups were homogenous at baseline. The within-group analysis showed significant improvement (p < 0 . 05 ) in both groups related to all the outcomes. But when we compared the groups, Group B showed significant (p < 0 . 05 ) improvement in NPRS and SPADI in comparison to Group A. However, there was non-significant (p > 0 . 05 ) difference found in ER-PROM and ABD-PROM.

Conclusion

Both KMT and MET are effective in improving ROM, pain and function but MET showed a significant reduction of pain and improvement in function in subjects with chronic shoulder AC, thus supporting its use as a physiotherapeutic treatment technique.

Relationship between pain and range of motion in frozen shoulder

Background

A frozen shoulder (FS) is characterized by pain and limited range of motion (ROM). Although physical assessment of ROM is important for diagnosing and staging FS, ROM cannot be accurately assessed in clinical practice because of pain and muscle contraction. This study aimed to measure changes in shoulder joint ROM before and after anesthesia (ΔROM) in patients with FS and investigate the factors affecting these changes.

Methods

This study included 54 patients (age, 55.6 ± 9.4 years; 17 males; disease duration, 6.6 ± 3.4 months) with FS before manipulation under transmission anesthesia. FS was defined as having a ROM in external rotation (ER) that was less than 50% of that in the unaffected shoulder. Pain at night and during motion was assessed using a numerical rating scale. Before anesthesia, the passive ROM of forward flexion (FF), abduction (AD), and ER were measured in the supine position. After confirming that the anesthesia was effective, passive ROM was measured again.

Results

The ROM in the FF, AD, and ER after anesthesia was significantly higher than that before anesthesia (P < .001). ΔROM in the FF, AD, and ER was significantly correlated with pain at night (r = 0.51, P < .001; r = 0.45, P < .001; and r = 0.39, P = .004, respectively). Furthermore, ΔROM in the ER was significantly correlated with pain during motion (r = 0.31, P = .023) and disease duration (r = -0.31, P = .021).

Conclusion

The ROM of the FS is susceptible to pain and muscle contraction. Interventions, such as physical therapy, may be recommended after pain relief.

Frozen shoulder

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

Randomized controlled trial of suprascapular nerve blocks for subacute adhesive capsulitis

BACKGROUND

Shoulder pain and loss of function remain a therapeutic challenge in adhesive capsulitis. Suprascapular nerve blocks, a common treatment in adhesive capsulitis, are considered a safe and effective method for the resolution of pain and restoration of shoulder range of motion (ROM). To our knowledge, no data are available on the use of suprascapular nerve blocks in adhesive capsulitis in the subacute phase.

AIM

The aim of this study was to compare the efficacy of ultrasound-guided suprascapular nerve blocks versus saline injections for treating adhesive capsulitis in the subacute phase.

DESIGN

Randomized double-blinded controlled trial; level of evidence 2.

SETTING

Out-patient consultation of Physical and Rehabilitation Medicine in a general hospital.

POPULATION

Thirty-five patients with subacute adhesive capsulitis.

METHODS

Patients were randomly allocated to receive either 3 successive (1-week interval) ultrasound-guided suprascapular nerve blocks with ropivacaine 5 mL 2 mg/mL (intervention group) or ultrasound-guided injections of 5 mL sterile saline solution (NaCl 0.9%) (control group), at the floor of the suprascapular fossa. Primary outcome was shoulder function assessed by the Constant-Murley Score. Secondary outcomes were shoulder ROM and shoulder pain intensity. Assessments were performed before each injection and 4 weeks after the last injection.

RESULTS

A significant increase of Constant-Murley Score (P<0.001), increase of shoulder ROM (all directions: P<0.011) and decrease of pain (P<0.001), were observed over time in both study groups. However, no significant differences were observed between the intervention and the control group.

CONCLUSIONS

Three successive suprascapular nerve blocks did not provide a better outcome than saline injections on shoulder function, ROM, and pain in subacute adhesive capsulitis. These negative findings warrant some considerations on the natural history of adhesive capsulitis, as well as timing, type, and placebo effects of injections.

CLINICAL REHABILITATION IMPACT

The current place of suprascapular nerve blocks in the treatment strategy of adhesive capsulitis needs to be rediscussed.

Exercise Therapy is Effective for Improvement in Range of Motion, Function, and Pain in Patients With Frozen Shoulder: A Systematic Review and Meta-analysis

OBJECTIVE(S)

To determine (1) the effect of exercise therapy alone or in combination with other interventions compared with solely exercises and programs with or without exercises and (2) what kind of exercise therapy or combination with other interventions is most effective.

DATA SOURCES

PubMed, Web of Science and Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Studies were screened in a 2-phase approach by 2 independent reviewers (M.M. and L.M.). Reference lists of included studies and interesting systematic reviews were hand searched.

DATA EXTRACTION

Two independent reviewers (M.M. and L.M.) extracted information about origin, characteristics of study participants, eligibility criteria, characteristics of interventions, outcome measures and main results in a pre-defined template.

DATA SYNTHESIS

Thirty-three studies were included in the qualitative and 19 in the meta-analysis. Preliminary evidence was found for supervised exercises to be more beneficial than home exercises for ROM and function. Multimodal programs comprising exercises may result in little to no difference in ROM compared to solely exercises. Programs comprising muscle energy techniques show little to no difference in ROM when compared with programs with other exercises. Adding stretches to a multimodal program with exercises may increase ROM. There is uncertain evidence that there is a difference between those programs regarding function and pain. Preliminary evidence was found for several treatment programs including exercises to be beneficial for improvement in both passive and active ROM, function, pain, and muscle strength. No studies used patient satisfaction as an outcome measure.

CONCLUSIONS

ROM, function, and pain improve with both solely exercises and programs with exercises, but for ROM and pain there was little to no difference between programs and for function the evidence was uncertain. Adding exercises improve active ROM compared with a program without exercises, whereas adding physical modalities has no beneficial effect. Muscle energy techniques are a beneficial type of exercise therapy for improving function compared with other types of exercise. Unfortunately, no conclusion can be drawn about the results in the long-term and most effective dose of exercise therapy.

DigitalROM: Development and validation of a system for assessment of shoulder range of motion

Assessing shoulder mobility is traditionally performed by a clinician using a goniometer, however this method suffers from inter-rater reliability issues. Wearable inertial sensors, image-based systems and 3D-cameras are proposed to objectively quantify shoulder range of motion (ROM). Standardised data collection platforms are required to ensure the consistency of measurements. This paper describes DigitalROM, a Microsoft Kinect 3D camera based system, and a standardised data collection protocol for shoulder ROM assessment optimised for multi-centre clinical trial deployments. DigitalROM is shown to compare very well against image-based ground truth measures (R²= 0.98 and RMSE≤7°) and shows slightly better performance than inertial sensor based ROM measurements (R²= 0.96 and RMSE≤9°). Additionally, DigitalROM offers the ability to ensure patient adherence to the movement protocol during data collection.

Shoulder adhesive capsulitis: diagnostic value of active and passive range of motion with volume of gleno-humeral capsule as a reference

BACKGROUND

The diagnosis of adhesive capsulitis is currently based on restricted range of motion (ROM) but its diagnostic value has only been rarely investigated.

AIM

The aim of this study is to assess the diagnostic value of active global and passive gleno-humeral ROM to diagnose shoulder adhesive capsulitis.

DESIGN

Cross-sectional descriptive study.

SETTING

One French center for Rehabilitation Medicine.

POPULATION

Patients referred for treatment of shoulder adhesive capsulitis in our center were included. Inclusion criteria were: shoulder pain; limitation of active global ROM (abduction or flexion <180°); limitation of passive gleno-humeral ROM (abduction or flexion <90° or 25% reduction at less of lateral rotation versus the opposite shoulder); no gleno-humeral arthropathy on radiography.

METHODS

The volume of the gleno-humeral capsule was assessed during a procedure of arthro-distension. The reference criterion for adhesive capsulitis was a volume <12 mL. We analyzed the correlation between the parameters of mobility and the volume of the gleno-humeral capsule; and the positive predictive value (PPV) of inclusion criteria, with the reference criterion for the diagnosis of adhesive capsulitis.

RESULTS

We included 38 patients. Passive gleno-humeral ROM in abduction only was correlated with volume of the gleno-humeral capsule: r=0.33, P=0.043. The PPV of inclusion criteria was 82% for the diagnosis of shoulder adhesive capsulitis. Rather than 90°, when we considered 80°, 60° and 40° as the threshold of passive gleno-humeral ROM in abduction, the PPV increased from 83% to 100%.

CONCLUSIONS

Passive gleno-humeral ROM in abduction is correlated with volume of the gleno-humeral capsule. The PPV is high for active global and passive gleno-humeral ROM for diagnosis of shoulder adhesive capsulitis.

CLINICAL REHABILITATION IMPACT

Limitation of active and passive shoulder ROM, especially passive abduction gleno-humeral, is a good criterion to diagnose shoulder adhesive capsulitis, in patients with shoulder pain and no gleno-humeral arthropathy on radiography.

Development of a 3D workspace shoulder assessment tool incorporating electromyography and an inertial measurement unit-a preliminary study

Traditional shoulder range of movement (ROM) measurement tools suffer from inaccuracy or from long experimental setup times. Recently, it has been demonstrated that relatively low-cost wearable inertial measurement unit (IMU) sensors can overcome many of the limitations of traditional motion tracking systems. The aim of this study is to develop and evaluate a single IMU combined with an electromyography (EMG) sensor to monitor the 3D reachable workspace with simultaneous measurement of deltoid muscle activity across the shoulder ROM. Six volunteer subjects with healthy shoulders and one participant with a ‘frozen’ shoulder were recruited to the study. Arm movement in 3D space was plotted in spherical coordinates while the relative EMG intensity of any arm position is presented graphically. The results showed that there was an average ROM surface area of 27291 ± 538 deg² among all six healthy individuals and a ROM surface area of 13571 ± 308 deg² for the subject with frozen shoulder. All three sections of the deltoid show greater EMG activity at higher elevation angles. Using such tools enables individuals, surgeons and physiotherapists to measure the maximum envelope of motion in conjunction with muscle activity in order to provide an objective assessment of shoulder performance in the voluntary 3D workspace.

Graphical abstract

Effects of two different mobilization techniques on pain, range of motion and functional disability in patients with adhesive capsulitis: a comparative study

[Purpose] This study aimed to compare the effects of two different mobilization techniques in the management of patients with adhesive capsulitis. [Subjects and Methods] Thirty non-diabetic men and women with adhesive capsulitis were randomly allocated to the reverse distraction group (n=15) or Kaltenborn group (n=15). The reverse distraction technique and Kaltenborn’s caudal and posterior glides (grades III and IV) were applied 10–15 times along with conventional physical therapy for 18 treatment sessions in 6 weeks. Pain was measured with a visual analog scale, abduction and external rotation range of motion with goniometry, hand behind back reach with inch tape, and functional disability with the Flexilevel scale of shoulder function before and after the treatment. [Results] Although all the variables improved significantly in both groups after 18 intervention sessions, reverse distraction was significantly better than Kaltenborn’s caudal and posterior glides in decreasing pain and improving abduction range of motion and functional scores. [Conclusion] This study supports the clinical use of reverse distraction as an alternative to conventional mobilization techniques to decrease pain and improve range of motion and functional scores in patients with adhesive capsulitis.

Intertester reliability of shoulder complaints diagnoses in primary health care

OBJECTIVE

Shoulder complaints are frequently encountered in general practice, but precise diagnosing is challenging. This study investigated agreement of shoulder complaints diagnoses between clinicians in a primary health care setting.

DESIGN

Cross-sectional study.

SETTING

Four primary health care clinicians used patients' history and functional examination of the shoulder by selective tissue tension techniques (STTs), to diagnose shoulder complaints.

SUBJECTS

62 patients, aged 18-75 years.

MAIN OUTCOME MEASURE

Reliability of diagnoses was assessed by observed intertester agreement and Cohen's kappa. A total of 372 diagnostic pairs were available for intertester comparisons.

RESULTS

Six diagnoses were assigned by all clinicians; supraspinatus-, infraspinatus-, subscapularis-tendinopathies; chronic subacromial bursitis; glenohumeral capsulitis, and acromioclavicular joint lesion. The observed agreement on these diagnoses ranged from 0.84 for glenohumeral capsulitis to 0.97 for acromioclavicular joint lesion. Kappa scores were 0.46 (95% CI 0.33, 0.58) for chronic subacromial bursitis; 0.53 (95% CI 0.34, 0.68), 0.59 (95% CI 0.47, 0.70), and 0.68 (95% CI 0.53, 0.82) for infraspinatus -, supraspinatus -, and subscapularis-tendinopathy, respectively. For glenohumeral capsulitis and acromioclavicular lesion kappa scores were 0.66 (95% CI 0.57, 0.73) and 0.78 (95% CI 0.61, 0.90). Kappa scores were higher for individual diagnoses than for individual tests, except for limitation in passive abduction (0.70, 95% CI 0.62, 0.78) and passive lateral rotation (0.66, 95% CI 0.57, 0.73).

CONCLUSIONS

Although experienced clinicians showed substantial intertester agreement, precise diagnoses of shoulder complaints in primary health care remain a challenge. The present results call for further research on refined diagnoses of shoulder complaints. Key points   Based on medical history and a systematic functional examination by selective tissue tension techniques (STTs), we investigated the agreement of shoulder complaints diagnoses across four primary health care clinicians and 62 patients. • Agreements on diagnoses were generally better than the agreement on individual tests. • Good kappa scores were obtained for the diagnoses glenohumeral capsulitis, rotator cuff tendinopathy, and acromioclavicular lesion. • Further research is necessary to investigate the diagnostic validity of functional shoulder examination by the STTs method.

Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care

BACKGROUND

Optimal management for adhesive shoulder capsulitis (frozen shoulder) is currently unclear. We intended to explore whether treatment by intra-articular injections with corticosteroid and distension is more effective than treating with corticosteroids alone or treatment-as-usual in a primary care setting in Norway.

METHODS

In this prospective randomised intention to treat parallel study, 106 patients were block randomised to three groups; 36 (analysed 35) receiving steroid injection and Lidocaine (IS), 34 receiving steroid and additional saline as distension (ISD) and 36 had treatment-as-usual (TAU). Intervention groups received four injections within 8 weeks, assessed on 1st visit, at the 4th and 8th week. Outcomes were Shoulder Pain and Disability Index (SPADI), Numerical pain rating scale (NPRS) and passive range of motion (PROM). Postal assessment was repeated after 1 year for SPADI. Patients in the IS and ISD groups were "blinded" for intervention received and the assessor was "blinded" to group allocation.

RESULTS

At baseline there were no differences between groups in outcome measures. There were no statistical significant differences between the intervention groups in SPADI, NPRS and PROM at baseline, at short-term (4-and 8 weeks) or long-term (12 months). There were statistically significant differences (p < 0.01) in change scores at short-term for SPADI when comparing the IS and TAU groups (-20.8; CI-28.9 to -12.7), and the ISD and TAU groups (-21.7; CI-29.4 to -14.0), respectively for NPRS (-2.0; CI-2.8 to -1.1 and -2.2; CI-3.0 to -1.4), and for PROM, but not at long-term for SPADI (p > 0.05). Effect size (ES) at 8 weeks was large between both injection groups and TAU (ES 1.2). At 12 months ES was reduced to 0.3 and 0.4 respectively. Transitory side effects as flushing and after-pain were reported by 14 % in intervention groups.

CONCLUSION

This intention to treat RCT in primary care indicates that four injections with corticosteroid with or without distension, given with increasing intervals during 8 weeks, were better than treatment-as-usual in treatment of adhesive shoulder capsulitis. However, in the long run no difference was found between any of the groups, indicating that natural healing takes place independent of treatment or not.

TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov/ identifier: NCT01570985.