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Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: a case series
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Manual Therapy 10 (2005) 164–171 www.elsevier.com/locate/math
Case report
Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: a case series$ Robert E. Boylesa,, Timothy W. Flynnb, Julie M. Whitmanc a
US Army-Baylor University Doctoral Program in Physical Therapy, AMEDDC & S, Fort Sam Houston, TX 78234, USA b Regis University, Denver, CO 80221, USA c Kirtland Air Force Base, Albuquerque, NM 87117, USA
1. Background and purpose Adhesive capsulitis (AC) of the glenohumeral (GH) joint, commonly known as ‘‘frozen shoulder’’, is a prevalent condition that is frequently treated by physical therapists (Dockrell and Wiseman, 1995; Holmes et al., 1997; van der Heijden et al., 1997; Winters et al., 1997; Connolly, 1998; Pearsall and Speer, 1998; Schwitalle et al., 1998; van der Windt et al., 1998; Siegel et al., 1999; Sandor, 2000; Vermeulen et al., 2000; Bentley and Tasto, 2001; Green et al., 2001). AC is more prevalent in women and in middle-aged individuals (Nevaiser, 1983, 1987; Siegel et al., 1999), in the diabetic patient population, with a rate of 2–5% in the non-diabetic population and 10–20% patients with non-insulindependent diabetes mellitus (Siegel et al., 1999; Carette, 2000; Bentley and Tasto, 2001). Patients with GH AC typically suffer from significant pain and progressively diminishing shoulder function (Nevaiser, 1983, 1987; Roubal et al., 1996; Placzek et al., 1998; Sandor, 2000). In a recent review on interventions for shoulder pain by the Cochrane Collaboration, Green et al. (2001), define AC as the presence of shoulder pain with restriction of passive and active GH motion. However, in their review of the literature, these same researchers found no standardized definitions for AC and reported conflicting criteria defining AC in the clinical trials reviewed. $ The views expressed in this case report are those of the authors and not the US Armed Services. Corresponding author. Tel.: +1-210-221-7387; fax: +1-210-2217585. E-mail address: [email protected] (R.E. Boyles).
1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.08.002
The recommended course of treatment for patients with AC is highly variable (Schwitalle et al., 1998; Thomas et al., 1981; Nevaiser, 1983, 1987; Parker et al., 1989; Grubbs, 1993; Dockrell and Wiseman, 1995; Holmes et al., 1997; van der Heijden et al., 1997; Winters et al., 1997; Connolly, 1998; Harwood, 1998; Tukmachi, 1999; Griggs et al., 2000; Hannafin and Chiaia, 2000; Sandor, 2000; Bentley and Tasto, 2001; Green et al., 2001; Jerosch, 2001; Kivimaki and Pohjolainen, 2001; Omari and Bunker, 2001). In 1995, Dockrell and Wiseman (1995) randomly surveyed 100 patient records from ten out-patient physical therapy (PT) clinics in an effort to determine the ‘‘typical’’ PT treatment for patients with a primary diagnosis of shoulder AC. The majority of patients received eight to 18 treatments over a 2-month period of time. The most frequently utilized treatments included exercise (98%), manual GH mobilization (93%), and thermal modalities (60%). In a retrospective descriptive study evaluating the 10-year outcomes of a cohort of 50 patients, Miller et al. (1996) reported that many patients with AC will regain motion with minimal pain following a treatment program of home-based therapy, moist heat, NSAIDs, and physician-directed rehabilitation. Griggs et al. (2000) conducted a trial of clinic and home-based stretching exercises as a treatment for a cohort of 75 consecutive patients with AC. Although 85% of the patients reported satisfactory outcomes, significant differences still existed in pain and range of motion (ROM) when compared to the unaffected shoulder. Variables associated with unfavorable outcomes were a previous unsuccessful trial of PT and the presence of severe pain and functional limitations prior to the
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initiation of treatment. Two recent, large randomized clinical trials have compared PT treatments to steroid injection (Winters et al., 1997; van der Windt et al., 1998). Van der Windt et al. (1998) in a study of painful, stiff shoulders noted greater short-term improvements in pain and disability with injections versus a combined program of mobilization, exercise, and physical agents but no long-term differences (26th and 52nd weeks). In a similar study, Winters et al. (1997) compared treatments of physiotherapy (without mobilization/ manipulation), injection, and manipulation to the entire upper quarter for 198 patients with shoulder complaints. Of those patients thought to have symptoms primarily of GH etiology, patients receiving corticosteroid injections showed quicker recovery and higher patientperceived ‘‘cure’’ rates compared to patients receiving the other treatments. However, recurrence of pain by 11 weeks was highest in the injection group (18%), followed by physiotherapy (13%) and manipulation (8%). These trials appear to indicate that steroid injections are more helpful than conventional PT for short-term pain relief and improved disability scores, but this difference in benefit diminishes in the long-term. Manipulation under anesthesia (MUA) using longlever arm techniques in physiologic planes of motion, i.e. flexion, abduction, and rotations, has been described in the treatment for AC and is considered a last resort procedure for these patients (Neviaser, 1983, 1987; Grubbs, 1993; Connolly, 1998; Pearsall and Speer, 1998; Siegel et al., 1999). In this procedure, the clinician moves the patient’s shoulder through physiologic motions while the patient is under general anesthesia. Although positive post-manipulative clinical outcomes have been reported, potential complications associated with this long-lever arm technique include rotator cuff tears, humeral fractures, and brachial plexus injuries (Neviaser, 1983, 1987; Parker et al., 1989; Roubal et al., 1996; Connolly, 1998; Placzek et al., 1998; Sandor, 2000). In contrast to this technique, Roubal et al. (1996) and Placzek et al. (1998) have reported on a total of 39 patients treated with translational manipulations immediately following a regional interscalene brachial plexus anesthetic block. The technique utilized is purported to be safe and effective because smallamplitude, high-velocity, short-lever arm manipulations are employed rather than long-lever arm techniques (Roubal et al., 1996; Placzek et al., 1998). In both of these studies, marked improvements in shoulder ROM without complication were reported. Although Roubal et al. (1996) did not report long-term outcomes, favorable outcomes were reported at the 1-year followup for the 31 patients in the Placzek et al. (1998) study. Researchers in both studies concluded that manipulation can be an effective intervention for patients with AC and that this intervention should be considered by those practitioners skilled in joint manipulation.
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On the whole, it seems that some patients improve after a program of PT, steroid injections, and/or physician- or therapist-directed home care. However, some patients fail to respond to these approaches and continue to demonstrate residual passive range of motion (PROM) and functional losses in the long term (Shaffer et al., 1992). Therefore, some patients may elect for a manipulative approach in an attempt to improve the mobility and function of the affected shoulder. In this case series, the use of manipulation to the GH joint after an interscalene anesthetic block for patients with AC is described. In addition, the use of video fluoroscopy to assess GH joint arthrokinematics is presented.
2. Case description 2.1. Patient presentation The following four patients were referred to PT at Brooke Army Medical Center and Wilford Hall Air Force Medical Center, San Antonio, TX for management of shoulder disorders: Patient #1: A 47-year-old female nurse practitioner with a 7-month history of right shoulder pain, stiffness and inability to perform her normal activities of daily living. Referral diagnosis: AC. Patient #2: A 45-year-old female homemaker with an insidious onset, 6-month history of left shoulder pain and stiffness, sleep cycle disturbances, and inability to perform daily activities such as bathing, cleaning the house, and cooking. She particularly reported difficulty with overhead tasks such as washing her hair. This patient had already been treated with steroid injections with no reported improvements in mobility, function, or pain. Referral diagnosis: rotator cuff tear. Patient #3: A 56-year-old male computer programmer with a 7-month history of right shoulder pain, sleep cycle disturbance, and inability to put on his jacket or shirt without pain, reach across his desk, or use a computer mouse. Referral diagnosis: shoulder pain. Patient #4: A 66-year-old male retired army officer with a 10-month history of left shoulder pain, stiffness, and sleep cycle disturbance. Symptoms increased with shoulder elevation, reaching behind the back, and reaching across his body (horizontal adduction). This patient had already received steroid injections without relief of symptoms or improved shoulder function. Referral diagnosis: shoulder impingement. All patients had received prior PT interventions (shoulder joint mobilization, active and passive mobility exercise programs, strengthening exercises, and/or modalities) without satisfactory improvement in function or pain. Two had received prior steroid injections and two declined this treatment option.
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2.2. Baseline examination PROM measurements as well as the Shoulder Pain and Disability Index (SPADI) were used as outcome measures. PROM measurements were used because these measurements are important in the diagnosis of AC and are frequently used as an outcome measure in clinical research. All PROM measurements were performed as described by Norkin and White (1999). The SPADI is a 100-point, 13-item self-administered questionnaire designed to quantify shoulder pain and disability. Michener and Leggin (2001) reported a high test–retest reliability and internal consistency for the SPADI, while Williams et al. (1995) have shown that the instrument is responsive to change and accurately discriminates between patients who are improving or worsening. It is reported to have a moderately strong construct validity and more responsive to change than the Sickness Impact Profile (SIP), Heald and Riddle (1997). They also recommend the SPADI over the SIP for measuring the extent of disability in patients with shoulder problems. Additionally, a tenpoint change on the SPADI has been identified as the minimally clinically important change needed to be confident that a change has actually occurred (Heald and Riddle, 1997). The MRI reports for three patients (#2, #3, #4) demonstrated various degrees of rotator cuff tears. Physical examination findings for all four patients included the following: (1) markedly decreased ROM (flexion, abduction, and internal/external rotation); (2) essentially equal impairment in both active and passive shoulder motion; (3) pain at the end of each ROM; (4) capsular end-feels with passive GH joint mobility assessment. Based on patient history and the four physical examination findings listed above, the diagnostic clinical criteria for AC were standardized by all investigators. As part of the physical examination, Patients #1 and #4 had pre-manipulation video fluoroscopy studies. Anterior to posterior views were recorded on both extremities while the patient actively and repeatedly abducted the shoulder. The pre-manipulation study for both patients demonstrated a loss of normal arthrokinematics of the GH joint on the involved side. As described by Maitland (1999) and Levangie and Norkin (2001), the humeral head should glide inferiorly as the patient abducts the shoulder. In these two patients, the humeral head on the involved side failed to move caudally during physiological shoulder abduction. In fact, in both cases, the humeral head elevated with abduction. 2.3. Intervention As recommended by Placzek et al. (1998), patients were prescribed a 6-day Medrol Dosepak (Pharmacia
and Upjohn Company, Kalamazoo, MI, USA) by their referring physicians and started this medication the day before the manipulation. Patient #3 was not prescribed this medication because he is diabetic, a contraindication for taking the drug. After the patients signed the standard consent form utilized by the facility for all patients undergoing this procedure, an anesthesiologist performed a regional interscalene block on each patient. The blocks were found to last from 4 to 6 h. This procedure is described elsewhere (Roubal et al., 1996; Placzek et al., 1998). Patients then proceeded immediately to the out-patient PT clinic for treatment. A sling was used in transit to protect the patients’ anesthetized extremities. Immediately prior to the manipulation session, the patient’s shoulder PROM was recorded for flexion, abduction, and internal and external rotation. End-feels were also assessed to ensure that (1) the restrictions were still present after the extremity was anesthetized to ensure true AC and (2) to be sure that any increase in motion was a direct result of the manipulation and not the anesthesia. The reports by Placzek et al. (1998) and Roubal et al. (1996) describe manipulations that are performed only in two directions, anterior-to-posterior and superior-toinferior. In this case series, the physical therapists performed these same manipulations. Additionally, the therapists performed mobilization/manipulation in the directions of the remaining perceived joint restriction. To assess GH joint mobility, the therapists grasped the proximal humerus as close to the GH joint as possible and then glided the humeral head in anterior, posterior, caudal, and combined directions, in an attempt to detect joint hypomobility. This procedure was performed with the shoulder at various degrees of flexion, abduction, and internal/external rotation in an attempt to detect the position and direction of motion where proximal humeral translation was the most limited (joint hypomobility). Once the therapist identified what he/she perceived to be joint hypomobility when gliding the proximal humerus in a specific direction, two to three 30-s bouts of a low-velocity, oscillatory mobilization, or Maitland Grade IV–IV+ (Maitland, 1999) was applied in that direction. If this failed to result in immediate increases in PROM, high-velocity, low-amplitude (HVLA) (Maitland, 1999) manipulations were performed. To ensure the block did not wear off before completion of the intervention, it was not possible due to time constraints to record PROM measurements after the application of each mobilization/manipulation technique. However, in our four cases, the addition of these HVLA thrust techniques appeared to result in additional gains in shoulder PROM beyond those attained after the application of the two techniques previously described by Placzek et al. (1998) and Roubal et al. (1996). All manipulations performed were shortlever-arm, low-amplitude procedures. As advocated by
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Placzek et al. (1998) and Roubal et al. (1996), several measures were taken in attempt to avoid brachial plexus injury: (1) an assistant stabilized the scapula against the trunk and in an elevated position; (2) the cervical spine was positioned in ipsilateral sidebending and (3) the elbow was never fully flexed or fully extended. Following the manipulation session, PROM measurements were again recorded. Finally, with the patient resting in supine and the patient’s hand placed behind his/her head, the treated shoulder was wrapped in an ice pack for approximately 20 min. Patients were then instructed in active assisted ROM (AAROM) exercises and instructed to perform these exercises every 2 h at home, when awake, for the next 24 h. The AAROM exercises included: wand exercises for flexion, abduction, internal and external rotations. They were also instructed to apply ice packs to the shoulder for 20 min every 2 h with the ice packs circumferentially around the shoulder while lying supine, hand resting behind their head (the combined position of abduction and external rotation). Patients followed-up with the treating physical therapist daily for 1 week and received further GH joint mobilization Grade II–IV+ (Maitland, 1999), ROM exercises, and cryotherapy. Home programs included active, active assisted and passive shoulder ROM exercises. After the first week, patients were treated three times per week to address individual impairments in shoulder motion and strength, and typically discharged to a home program after 3 weeks. See Appendix A for an example of the exercise program and Appendix B for a sample clinical pathway.
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immediately after the manipulative intervention. Most initial gains in PROM and all improvement in the disability scores were maintained at the patients’ final follow-up visit. Additionally, Patients #1 and #2 had full, pain-free AROM that was equal to the opposite, non-involved shoulder and full pain-free motion with activities. Patient #3 missed several post-manipulation treatment sessions and was unable to reproduce the home exercise program. Therefore, compliance with the home program was questionable. Patient #4’s only remaining symptom was occasionally slight pain after rolling onto his affected shoulder at night. Patients #1 and #4 had follow-up video fluoroscopy studies at the 6-week follow-up visit and Patient #1 again received a video fluoroscopy study at the 12-week visit. The studies were performed in the same manner as previously described. In contrast to the baseline video fluoroscopy studies, the 6- and 12-week follow-up sessions for Patient #1 and the 6-week follow-up session for Patient #4, video fluoroscopy demonstrated a smooth, ‘‘normal’’ GH motion. Figs. 2a and b are end-range images of Patient #1’s video fluoroscopy study for the involved versus uninvolved side, respectively, prior to the initiation of the manipulative intervention. Fig. 3 shows the same patient’s involved shoulder at the 12-week follow-up evaluation and illustrates the appropriate gliding of the humeral head caudally as the patient performs active shoulder abduction.
3. Discussion 2.4. Outcomes Pre- and post-manipulation and follow-up SPADI and PROM scores at baseline, 3-week, 6-week, and 12week follow-up are reported in Fig. 1 and the Table 1, respectively. Throughout the manipulation treatment and the subsequent follow-up periods, no adverse events were reported. All patients demonstrated improvements in both PROM measurements and disability scores
Fig. 1. SPADI scores for each patient.
Although a similar treatment approach as described by Placzek et al. (1998) and Roubal et al. (1996) was utilized in this case series, several aspects of our patients’ care were unique. After using the techniques described by these authors, therapists also performed further mobilization/manipulation in the directions of remaining perceived joint hypomobility. Although not measured, the additional techniques appeared to yield immediate and substantial additional gains in shoulder ROM in every case. These gains were made in light of the study by Gokeler et al. (2003) that reported no significant changes in humeral head distances with traction force applied to the GH joint in the maximally loose pack position when compared to the closed pack position. Perhaps this is due to the specific direction and grade of the mobilization used by the authors in this study. It should be noted that Hsu et al. (2000a, b) in two separate cadaver studies reported significant increases in GH abduction immediately following anterior–posterior glides and significant increases in GH abduction immediately following caudal glides. Although outcomes for only four patients are reported, it is our opinion that the additional gains in mobility
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Table 1 PROM measurements in degrees, for patients at baseline, immediately after the manipulative intervention, and at specific follow-up sessions Patient 1
Pre-treatment Immediately post-Rx 3 weeks 6 weeks 12 weeks a
Patient 2
Patient 3
Patient 4
Flex
Abd
IR
ER
Flex
Abd
IR
ER
Flex
Abd
IR
ER
Flex
Abd
IR
ER
120 170 165 160 160
90 155 170 165 165
25 75 70 65 70
40 100 105 90 95
115 135 150 140
50 90 95 130
25 70 70 55
5 35 35 95
110 160
70 160
20 90
25 45
a
a
a
a
115 170 135 165 165
85 160 120 120 120
25 70 60 40 40
30 85 65 55 55
a
a
a
a
130 125
110 110
40 70
40 50
Denotes measurement not obtained.
Fig. 3. This figure is the same patient 12 weeks post-manipulation using the same video fluoroscopic techniques at end-range abduction. Notice the improved inferior glide of the humeral head relative to the glenoid.
Fig. 2. Video fluoroscopic image at end-range abduction in Patient #1: (a) is the uninvolved shoulder and (b) is the involved shoulder prior to manipulation. Notice the relation of the humeral head to the glenoid fossa in each figure.
attained though the utilization of our model of treatment were important enough that researchers should consider this approach in future clinical trials. Placzek et al. (1998) and Roubal et al. (1996) outlined a extensive post-manipulation protocol. These authors used many physical modalities in an attempt to decrease
pain and enhance rehabilitation. Patients were also given an extensive exercise regime to perform both in the clinic with supervision and as a home program. In contrast, our post-manipulation rehabilitation program was designed to maintain gains in shoulder mobility and specifically address each individual patient’s remaining impairments while minimizing the amount of time that the patient had to come to the facility for his/her rehabilitation. Compared to the protocols used by Placzek et al. (1998) and Roubal et al. (1996), our patients were treated with fewer exercises and the use of physical modalities (except for cryotherapy) was eliminated. Further, our patients required approximately four to five fewer post-manipulation PT visits than patients in the previous studies. In our opinion, an extensive post-manipulation rehabilitation program may not be necessary; a more parsimonious rehabilitation program may result in favorable gains in mobility and improvements in disability scores, while conserving valuable patient and clinic time and resources.
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Additionally, although many theorize about the effects that AC has on normal arthrokinematics (Maitland, 1999) and the effect of an intervention on the arthrokinematics, documented cases of patients receiving video fluoroscopy studies to demonstrate a loss of normal joint kinematics before intervention and return of more normal joint kinematics after the application of an intervention have not been found. It is believed that this is the first attempt to demonstrate this. Video fluoroscopy of anterior–posterior views during active shoulder abduction revealed increased caudal translation of the GH joint following manipulation when compared to the pre-manipulation video fluoroscopy studies. Because video fluoroscopy is a non-invasive, low-risk, and expedient imaging modality it is therefore considered that it may be an ideal tool to monitor the arthrokinematics of the GH joint. Researchers should consider including the use of video fluoroscopy in future studies when investigating the effects of interventions on the mechanics of the GH joint. Except for the regional interscalene block performed by the anesthesiologist, all interventions in this study and others (Roubal et al., 1996; Placzek et al., 1998) were performed by physical therapists. The Guide to Physical Therapist Practice (American Physical Therapy Association, 2001) defines mobilization/manipulation as ‘‘a manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small-amplitude/high-velocity therapeutic movement’’. The Guide lists mobilization/manipulation as an intervention appropriate for the care of patients with AC. Since physical therapists possess and already utilize these mobilization/manipulation skills in the care of patients with AC without anesthetic blocks, it is our belief that physical therapists are ideally suited to be the practitioner of choice to perform this treatment on patients who have received a regional interscalene block.
4. Conclusion The AC patients in this case series, treated with translational manipulation following an interscalene block, showed rapid improvement in PROM and improved levels of disability as measured by the SPADI. The results are consistent with previous reports (Roubal et al., 1996; Placzek et al., 1998) demonstrating that, in patients with AC, this type of intervention may result in positive outcomes that are considerably quicker than improvements attributed to the natural history of this disorder. It appears that translational manipulation by a physical therapist can be a safe and potentially effective
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treatment option for these patients, even those presenting with underlying rotator cuff pathology as demonstrated by MRI. It is our opinion that this intervention should be considered for patients with AC if a trial of more conventional treatment strategies has failed to produce satisfactory results. Additionally, the use of video fluoroscopy may be an ideal imaging modality for further investigation of the biomechanical changes that occur in the GH joint after the application of an intervention in patients with AC. However, before this treatment method for shoulder AC is advocated for wide spread use, randomized controlled trials comparing this treatment to competing treatments are warranted.
Appendix A. Post-anesthesia shoulder program A.1. Same day
Pre-anesthesia PROM measurements. Mobilizations/manipulations to address capsular restrictions. Post-anesthesia PROM measurements. Instruct in home exercise program of AAROM for shoulder flexion. To be performed every 2 h for 5 min to end range with 5 s holds. Ice pack around the shoulder for 20–30 min. Patient should be resting supine with hand behind the head to encourage continued stretch in external rotation and abduction. Use of ice at home 20–30 min following exercise.
A.2. 1–5 days post-manipulation
Patient to attend daily PT sessions for shoulder mobilization, exercise and ice. Instruct in AAROM wand exercises for flexion, abduction, internal and external rotation, selfstretches for horizontal flexion. Ice to the shoulder following treatment in supine with hand behind head for 20–30 min. Continue with home exercise program every 2 h for the first week. Ice 20–30 min after treatments.
A.3. Second and third weeks
Continue with clinic sessions three times per week. Continue with shoulder mobilizations to address tightness/restrictions. Advance to rotator cuff strengthening as motion and pain allows. Ice following treatment as needed. Continue with home program. Discharge at the end of third week to home program.
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Appendix B. Pre-manipulation pathway for frozen shoulder patients Pre-Manipulation Pathway for Frozen Shoulder Patients Physical Therapist (PT) determines that the shoulder condition is appropriate for manipulative treatment
PT counsels patient on risks/ benefits of the procedure, as well as other treatment options. Patient completes a Shoulder Pain and Disability Index (SPADI)
PT coordinates with anesthesia service for interscalene block and schedules patient’s manipulation session immediately following.
PT coordinates with referring physician for Medrol 6-day dose pack and instructs patient to take first dose one day prior to procedure.
PT orders plain radiographic films of affected shoulder. MRI may be considered to note any existing pathology (i.e. rotator cuff tear, labral defect, etc) prior to manipulation.
On the day of procedure, patient will report directly to anesthesia. The patient must arrange for their own escort to assist them from anesthesia to Physical Therapy, as well as to serve as designated driver to escort patient home following PT treatment.
PT will take PROM measurements both prior to, and following manipulation and instruct patient in post-manipulative care and exercise plan.
PT will follow patient daily for at least 1 week to ensure all manipulation gains are maintained and that the patient is compliant with entire program.
PT may reduce clinic patient visits as appropriate after one week, providing there are no complications and patient is progressing well with program.
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Manual Therapy 10 (2005) 164–171 www.elsevier.com/locate/math
Case report
Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: a case series$ Robert E. Boylesa,, Timothy W. Flynnb, Julie M. Whitmanc a
US Army-Baylor University Doctoral Program in Physical Therapy, AMEDDC & S, Fort Sam Houston, TX 78234, USA b Regis University, Denver, CO 80221, USA c Kirtland Air Force Base, Albuquerque, NM 87117, USA
1. Background and purpose Adhesive capsulitis (AC) of the glenohumeral (GH) joint, commonly known as ‘‘frozen shoulder’’, is a prevalent condition that is frequently treated by physical therapists (Dockrell and Wiseman, 1995; Holmes et al., 1997; van der Heijden et al., 1997; Winters et al., 1997; Connolly, 1998; Pearsall and Speer, 1998; Schwitalle et al., 1998; van der Windt et al., 1998; Siegel et al., 1999; Sandor, 2000; Vermeulen et al., 2000; Bentley and Tasto, 2001; Green et al., 2001). AC is more prevalent in women and in middle-aged individuals (Nevaiser, 1983, 1987; Siegel et al., 1999), in the diabetic patient population, with a rate of 2–5% in the non-diabetic population and 10–20% patients with non-insulindependent diabetes mellitus (Siegel et al., 1999; Carette, 2000; Bentley and Tasto, 2001). Patients with GH AC typically suffer from significant pain and progressively diminishing shoulder function (Nevaiser, 1983, 1987; Roubal et al., 1996; Placzek et al., 1998; Sandor, 2000). In a recent review on interventions for shoulder pain by the Cochrane Collaboration, Green et al. (2001), define AC as the presence of shoulder pain with restriction of passive and active GH motion. However, in their review of the literature, these same researchers found no standardized definitions for AC and reported conflicting criteria defining AC in the clinical trials reviewed. $ The views expressed in this case report are those of the authors and not the US Armed Services. Corresponding author. Tel.: +1-210-221-7387; fax: +1-210-2217585. E-mail address: [email protected] (R.E. Boyles).
1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.08.002
The recommended course of treatment for patients with AC is highly variable (Schwitalle et al., 1998; Thomas et al., 1981; Nevaiser, 1983, 1987; Parker et al., 1989; Grubbs, 1993; Dockrell and Wiseman, 1995; Holmes et al., 1997; van der Heijden et al., 1997; Winters et al., 1997; Connolly, 1998; Harwood, 1998; Tukmachi, 1999; Griggs et al., 2000; Hannafin and Chiaia, 2000; Sandor, 2000; Bentley and Tasto, 2001; Green et al., 2001; Jerosch, 2001; Kivimaki and Pohjolainen, 2001; Omari and Bunker, 2001). In 1995, Dockrell and Wiseman (1995) randomly surveyed 100 patient records from ten out-patient physical therapy (PT) clinics in an effort to determine the ‘‘typical’’ PT treatment for patients with a primary diagnosis of shoulder AC. The majority of patients received eight to 18 treatments over a 2-month period of time. The most frequently utilized treatments included exercise (98%), manual GH mobilization (93%), and thermal modalities (60%). In a retrospective descriptive study evaluating the 10-year outcomes of a cohort of 50 patients, Miller et al. (1996) reported that many patients with AC will regain motion with minimal pain following a treatment program of home-based therapy, moist heat, NSAIDs, and physician-directed rehabilitation. Griggs et al. (2000) conducted a trial of clinic and home-based stretching exercises as a treatment for a cohort of 75 consecutive patients with AC. Although 85% of the patients reported satisfactory outcomes, significant differences still existed in pain and range of motion (ROM) when compared to the unaffected shoulder. Variables associated with unfavorable outcomes were a previous unsuccessful trial of PT and the presence of severe pain and functional limitations prior to the
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initiation of treatment. Two recent, large randomized clinical trials have compared PT treatments to steroid injection (Winters et al., 1997; van der Windt et al., 1998). Van der Windt et al. (1998) in a study of painful, stiff shoulders noted greater short-term improvements in pain and disability with injections versus a combined program of mobilization, exercise, and physical agents but no long-term differences (26th and 52nd weeks). In a similar study, Winters et al. (1997) compared treatments of physiotherapy (without mobilization/ manipulation), injection, and manipulation to the entire upper quarter for 198 patients with shoulder complaints. Of those patients thought to have symptoms primarily of GH etiology, patients receiving corticosteroid injections showed quicker recovery and higher patientperceived ‘‘cure’’ rates compared to patients receiving the other treatments. However, recurrence of pain by 11 weeks was highest in the injection group (18%), followed by physiotherapy (13%) and manipulation (8%). These trials appear to indicate that steroid injections are more helpful than conventional PT for short-term pain relief and improved disability scores, but this difference in benefit diminishes in the long-term. Manipulation under anesthesia (MUA) using longlever arm techniques in physiologic planes of motion, i.e. flexion, abduction, and rotations, has been described in the treatment for AC and is considered a last resort procedure for these patients (Neviaser, 1983, 1987; Grubbs, 1993; Connolly, 1998; Pearsall and Speer, 1998; Siegel et al., 1999). In this procedure, the clinician moves the patient’s shoulder through physiologic motions while the patient is under general anesthesia. Although positive post-manipulative clinical outcomes have been reported, potential complications associated with this long-lever arm technique include rotator cuff tears, humeral fractures, and brachial plexus injuries (Neviaser, 1983, 1987; Parker et al., 1989; Roubal et al., 1996; Connolly, 1998; Placzek et al., 1998; Sandor, 2000). In contrast to this technique, Roubal et al. (1996) and Placzek et al. (1998) have reported on a total of 39 patients treated with translational manipulations immediately following a regional interscalene brachial plexus anesthetic block. The technique utilized is purported to be safe and effective because smallamplitude, high-velocity, short-lever arm manipulations are employed rather than long-lever arm techniques (Roubal et al., 1996; Placzek et al., 1998). In both of these studies, marked improvements in shoulder ROM without complication were reported. Although Roubal et al. (1996) did not report long-term outcomes, favorable outcomes were reported at the 1-year followup for the 31 patients in the Placzek et al. (1998) study. Researchers in both studies concluded that manipulation can be an effective intervention for patients with AC and that this intervention should be considered by those practitioners skilled in joint manipulation.
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On the whole, it seems that some patients improve after a program of PT, steroid injections, and/or physician- or therapist-directed home care. However, some patients fail to respond to these approaches and continue to demonstrate residual passive range of motion (PROM) and functional losses in the long term (Shaffer et al., 1992). Therefore, some patients may elect for a manipulative approach in an attempt to improve the mobility and function of the affected shoulder. In this case series, the use of manipulation to the GH joint after an interscalene anesthetic block for patients with AC is described. In addition, the use of video fluoroscopy to assess GH joint arthrokinematics is presented.
2. Case description 2.1. Patient presentation The following four patients were referred to PT at Brooke Army Medical Center and Wilford Hall Air Force Medical Center, San Antonio, TX for management of shoulder disorders: Patient #1: A 47-year-old female nurse practitioner with a 7-month history of right shoulder pain, stiffness and inability to perform her normal activities of daily living. Referral diagnosis: AC. Patient #2: A 45-year-old female homemaker with an insidious onset, 6-month history of left shoulder pain and stiffness, sleep cycle disturbances, and inability to perform daily activities such as bathing, cleaning the house, and cooking. She particularly reported difficulty with overhead tasks such as washing her hair. This patient had already been treated with steroid injections with no reported improvements in mobility, function, or pain. Referral diagnosis: rotator cuff tear. Patient #3: A 56-year-old male computer programmer with a 7-month history of right shoulder pain, sleep cycle disturbance, and inability to put on his jacket or shirt without pain, reach across his desk, or use a computer mouse. Referral diagnosis: shoulder pain. Patient #4: A 66-year-old male retired army officer with a 10-month history of left shoulder pain, stiffness, and sleep cycle disturbance. Symptoms increased with shoulder elevation, reaching behind the back, and reaching across his body (horizontal adduction). This patient had already received steroid injections without relief of symptoms or improved shoulder function. Referral diagnosis: shoulder impingement. All patients had received prior PT interventions (shoulder joint mobilization, active and passive mobility exercise programs, strengthening exercises, and/or modalities) without satisfactory improvement in function or pain. Two had received prior steroid injections and two declined this treatment option.
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2.2. Baseline examination PROM measurements as well as the Shoulder Pain and Disability Index (SPADI) were used as outcome measures. PROM measurements were used because these measurements are important in the diagnosis of AC and are frequently used as an outcome measure in clinical research. All PROM measurements were performed as described by Norkin and White (1999). The SPADI is a 100-point, 13-item self-administered questionnaire designed to quantify shoulder pain and disability. Michener and Leggin (2001) reported a high test–retest reliability and internal consistency for the SPADI, while Williams et al. (1995) have shown that the instrument is responsive to change and accurately discriminates between patients who are improving or worsening. It is reported to have a moderately strong construct validity and more responsive to change than the Sickness Impact Profile (SIP), Heald and Riddle (1997). They also recommend the SPADI over the SIP for measuring the extent of disability in patients with shoulder problems. Additionally, a tenpoint change on the SPADI has been identified as the minimally clinically important change needed to be confident that a change has actually occurred (Heald and Riddle, 1997). The MRI reports for three patients (#2, #3, #4) demonstrated various degrees of rotator cuff tears. Physical examination findings for all four patients included the following: (1) markedly decreased ROM (flexion, abduction, and internal/external rotation); (2) essentially equal impairment in both active and passive shoulder motion; (3) pain at the end of each ROM; (4) capsular end-feels with passive GH joint mobility assessment. Based on patient history and the four physical examination findings listed above, the diagnostic clinical criteria for AC were standardized by all investigators. As part of the physical examination, Patients #1 and #4 had pre-manipulation video fluoroscopy studies. Anterior to posterior views were recorded on both extremities while the patient actively and repeatedly abducted the shoulder. The pre-manipulation study for both patients demonstrated a loss of normal arthrokinematics of the GH joint on the involved side. As described by Maitland (1999) and Levangie and Norkin (2001), the humeral head should glide inferiorly as the patient abducts the shoulder. In these two patients, the humeral head on the involved side failed to move caudally during physiological shoulder abduction. In fact, in both cases, the humeral head elevated with abduction. 2.3. Intervention As recommended by Placzek et al. (1998), patients were prescribed a 6-day Medrol Dosepak (Pharmacia
and Upjohn Company, Kalamazoo, MI, USA) by their referring physicians and started this medication the day before the manipulation. Patient #3 was not prescribed this medication because he is diabetic, a contraindication for taking the drug. After the patients signed the standard consent form utilized by the facility for all patients undergoing this procedure, an anesthesiologist performed a regional interscalene block on each patient. The blocks were found to last from 4 to 6 h. This procedure is described elsewhere (Roubal et al., 1996; Placzek et al., 1998). Patients then proceeded immediately to the out-patient PT clinic for treatment. A sling was used in transit to protect the patients’ anesthetized extremities. Immediately prior to the manipulation session, the patient’s shoulder PROM was recorded for flexion, abduction, and internal and external rotation. End-feels were also assessed to ensure that (1) the restrictions were still present after the extremity was anesthetized to ensure true AC and (2) to be sure that any increase in motion was a direct result of the manipulation and not the anesthesia. The reports by Placzek et al. (1998) and Roubal et al. (1996) describe manipulations that are performed only in two directions, anterior-to-posterior and superior-toinferior. In this case series, the physical therapists performed these same manipulations. Additionally, the therapists performed mobilization/manipulation in the directions of the remaining perceived joint restriction. To assess GH joint mobility, the therapists grasped the proximal humerus as close to the GH joint as possible and then glided the humeral head in anterior, posterior, caudal, and combined directions, in an attempt to detect joint hypomobility. This procedure was performed with the shoulder at various degrees of flexion, abduction, and internal/external rotation in an attempt to detect the position and direction of motion where proximal humeral translation was the most limited (joint hypomobility). Once the therapist identified what he/she perceived to be joint hypomobility when gliding the proximal humerus in a specific direction, two to three 30-s bouts of a low-velocity, oscillatory mobilization, or Maitland Grade IV–IV+ (Maitland, 1999) was applied in that direction. If this failed to result in immediate increases in PROM, high-velocity, low-amplitude (HVLA) (Maitland, 1999) manipulations were performed. To ensure the block did not wear off before completion of the intervention, it was not possible due to time constraints to record PROM measurements after the application of each mobilization/manipulation technique. However, in our four cases, the addition of these HVLA thrust techniques appeared to result in additional gains in shoulder PROM beyond those attained after the application of the two techniques previously described by Placzek et al. (1998) and Roubal et al. (1996). All manipulations performed were shortlever-arm, low-amplitude procedures. As advocated by
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Placzek et al. (1998) and Roubal et al. (1996), several measures were taken in attempt to avoid brachial plexus injury: (1) an assistant stabilized the scapula against the trunk and in an elevated position; (2) the cervical spine was positioned in ipsilateral sidebending and (3) the elbow was never fully flexed or fully extended. Following the manipulation session, PROM measurements were again recorded. Finally, with the patient resting in supine and the patient’s hand placed behind his/her head, the treated shoulder was wrapped in an ice pack for approximately 20 min. Patients were then instructed in active assisted ROM (AAROM) exercises and instructed to perform these exercises every 2 h at home, when awake, for the next 24 h. The AAROM exercises included: wand exercises for flexion, abduction, internal and external rotations. They were also instructed to apply ice packs to the shoulder for 20 min every 2 h with the ice packs circumferentially around the shoulder while lying supine, hand resting behind their head (the combined position of abduction and external rotation). Patients followed-up with the treating physical therapist daily for 1 week and received further GH joint mobilization Grade II–IV+ (Maitland, 1999), ROM exercises, and cryotherapy. Home programs included active, active assisted and passive shoulder ROM exercises. After the first week, patients were treated three times per week to address individual impairments in shoulder motion and strength, and typically discharged to a home program after 3 weeks. See Appendix A for an example of the exercise program and Appendix B for a sample clinical pathway.
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immediately after the manipulative intervention. Most initial gains in PROM and all improvement in the disability scores were maintained at the patients’ final follow-up visit. Additionally, Patients #1 and #2 had full, pain-free AROM that was equal to the opposite, non-involved shoulder and full pain-free motion with activities. Patient #3 missed several post-manipulation treatment sessions and was unable to reproduce the home exercise program. Therefore, compliance with the home program was questionable. Patient #4’s only remaining symptom was occasionally slight pain after rolling onto his affected shoulder at night. Patients #1 and #4 had follow-up video fluoroscopy studies at the 6-week follow-up visit and Patient #1 again received a video fluoroscopy study at the 12-week visit. The studies were performed in the same manner as previously described. In contrast to the baseline video fluoroscopy studies, the 6- and 12-week follow-up sessions for Patient #1 and the 6-week follow-up session for Patient #4, video fluoroscopy demonstrated a smooth, ‘‘normal’’ GH motion. Figs. 2a and b are end-range images of Patient #1’s video fluoroscopy study for the involved versus uninvolved side, respectively, prior to the initiation of the manipulative intervention. Fig. 3 shows the same patient’s involved shoulder at the 12-week follow-up evaluation and illustrates the appropriate gliding of the humeral head caudally as the patient performs active shoulder abduction.
3. Discussion 2.4. Outcomes Pre- and post-manipulation and follow-up SPADI and PROM scores at baseline, 3-week, 6-week, and 12week follow-up are reported in Fig. 1 and the Table 1, respectively. Throughout the manipulation treatment and the subsequent follow-up periods, no adverse events were reported. All patients demonstrated improvements in both PROM measurements and disability scores
Fig. 1. SPADI scores for each patient.
Although a similar treatment approach as described by Placzek et al. (1998) and Roubal et al. (1996) was utilized in this case series, several aspects of our patients’ care were unique. After using the techniques described by these authors, therapists also performed further mobilization/manipulation in the directions of remaining perceived joint hypomobility. Although not measured, the additional techniques appeared to yield immediate and substantial additional gains in shoulder ROM in every case. These gains were made in light of the study by Gokeler et al. (2003) that reported no significant changes in humeral head distances with traction force applied to the GH joint in the maximally loose pack position when compared to the closed pack position. Perhaps this is due to the specific direction and grade of the mobilization used by the authors in this study. It should be noted that Hsu et al. (2000a, b) in two separate cadaver studies reported significant increases in GH abduction immediately following anterior–posterior glides and significant increases in GH abduction immediately following caudal glides. Although outcomes for only four patients are reported, it is our opinion that the additional gains in mobility
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Table 1 PROM measurements in degrees, for patients at baseline, immediately after the manipulative intervention, and at specific follow-up sessions Patient 1
Pre-treatment Immediately post-Rx 3 weeks 6 weeks 12 weeks a
Patient 2
Patient 3
Patient 4
Flex
Abd
IR
ER
Flex
Abd
IR
ER
Flex
Abd
IR
ER
Flex
Abd
IR
ER
120 170 165 160 160
90 155 170 165 165
25 75 70 65 70
40 100 105 90 95
115 135 150 140
50 90 95 130
25 70 70 55
5 35 35 95
110 160
70 160
20 90
25 45
a
a
a
a
115 170 135 165 165
85 160 120 120 120
25 70 60 40 40
30 85 65 55 55
a
a
a
a
130 125
110 110
40 70
40 50
Denotes measurement not obtained.
Fig. 3. This figure is the same patient 12 weeks post-manipulation using the same video fluoroscopic techniques at end-range abduction. Notice the improved inferior glide of the humeral head relative to the glenoid.
Fig. 2. Video fluoroscopic image at end-range abduction in Patient #1: (a) is the uninvolved shoulder and (b) is the involved shoulder prior to manipulation. Notice the relation of the humeral head to the glenoid fossa in each figure.
attained though the utilization of our model of treatment were important enough that researchers should consider this approach in future clinical trials. Placzek et al. (1998) and Roubal et al. (1996) outlined a extensive post-manipulation protocol. These authors used many physical modalities in an attempt to decrease
pain and enhance rehabilitation. Patients were also given an extensive exercise regime to perform both in the clinic with supervision and as a home program. In contrast, our post-manipulation rehabilitation program was designed to maintain gains in shoulder mobility and specifically address each individual patient’s remaining impairments while minimizing the amount of time that the patient had to come to the facility for his/her rehabilitation. Compared to the protocols used by Placzek et al. (1998) and Roubal et al. (1996), our patients were treated with fewer exercises and the use of physical modalities (except for cryotherapy) was eliminated. Further, our patients required approximately four to five fewer post-manipulation PT visits than patients in the previous studies. In our opinion, an extensive post-manipulation rehabilitation program may not be necessary; a more parsimonious rehabilitation program may result in favorable gains in mobility and improvements in disability scores, while conserving valuable patient and clinic time and resources.
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Additionally, although many theorize about the effects that AC has on normal arthrokinematics (Maitland, 1999) and the effect of an intervention on the arthrokinematics, documented cases of patients receiving video fluoroscopy studies to demonstrate a loss of normal joint kinematics before intervention and return of more normal joint kinematics after the application of an intervention have not been found. It is believed that this is the first attempt to demonstrate this. Video fluoroscopy of anterior–posterior views during active shoulder abduction revealed increased caudal translation of the GH joint following manipulation when compared to the pre-manipulation video fluoroscopy studies. Because video fluoroscopy is a non-invasive, low-risk, and expedient imaging modality it is therefore considered that it may be an ideal tool to monitor the arthrokinematics of the GH joint. Researchers should consider including the use of video fluoroscopy in future studies when investigating the effects of interventions on the mechanics of the GH joint. Except for the regional interscalene block performed by the anesthesiologist, all interventions in this study and others (Roubal et al., 1996; Placzek et al., 1998) were performed by physical therapists. The Guide to Physical Therapist Practice (American Physical Therapy Association, 2001) defines mobilization/manipulation as ‘‘a manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small-amplitude/high-velocity therapeutic movement’’. The Guide lists mobilization/manipulation as an intervention appropriate for the care of patients with AC. Since physical therapists possess and already utilize these mobilization/manipulation skills in the care of patients with AC without anesthetic blocks, it is our belief that physical therapists are ideally suited to be the practitioner of choice to perform this treatment on patients who have received a regional interscalene block.
4. Conclusion The AC patients in this case series, treated with translational manipulation following an interscalene block, showed rapid improvement in PROM and improved levels of disability as measured by the SPADI. The results are consistent with previous reports (Roubal et al., 1996; Placzek et al., 1998) demonstrating that, in patients with AC, this type of intervention may result in positive outcomes that are considerably quicker than improvements attributed to the natural history of this disorder. It appears that translational manipulation by a physical therapist can be a safe and potentially effective
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treatment option for these patients, even those presenting with underlying rotator cuff pathology as demonstrated by MRI. It is our opinion that this intervention should be considered for patients with AC if a trial of more conventional treatment strategies has failed to produce satisfactory results. Additionally, the use of video fluoroscopy may be an ideal imaging modality for further investigation of the biomechanical changes that occur in the GH joint after the application of an intervention in patients with AC. However, before this treatment method for shoulder AC is advocated for wide spread use, randomized controlled trials comparing this treatment to competing treatments are warranted.
Appendix A. Post-anesthesia shoulder program A.1. Same day
Pre-anesthesia PROM measurements. Mobilizations/manipulations to address capsular restrictions. Post-anesthesia PROM measurements. Instruct in home exercise program of AAROM for shoulder flexion. To be performed every 2 h for 5 min to end range with 5 s holds. Ice pack around the shoulder for 20–30 min. Patient should be resting supine with hand behind the head to encourage continued stretch in external rotation and abduction. Use of ice at home 20–30 min following exercise.
A.2. 1–5 days post-manipulation
Patient to attend daily PT sessions for shoulder mobilization, exercise and ice. Instruct in AAROM wand exercises for flexion, abduction, internal and external rotation, selfstretches for horizontal flexion. Ice to the shoulder following treatment in supine with hand behind head for 20–30 min. Continue with home exercise program every 2 h for the first week. Ice 20–30 min after treatments.
A.3. Second and third weeks
Continue with clinic sessions three times per week. Continue with shoulder mobilizations to address tightness/restrictions. Advance to rotator cuff strengthening as motion and pain allows. Ice following treatment as needed. Continue with home program. Discharge at the end of third week to home program.
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Appendix B. Pre-manipulation pathway for frozen shoulder patients Pre-Manipulation Pathway for Frozen Shoulder Patients Physical Therapist (PT) determines that the shoulder condition is appropriate for manipulative treatment
PT counsels patient on risks/ benefits of the procedure, as well as other treatment options. Patient completes a Shoulder Pain and Disability Index (SPADI)
PT coordinates with anesthesia service for interscalene block and schedules patient’s manipulation session immediately following.
PT coordinates with referring physician for Medrol 6-day dose pack and instructs patient to take first dose one day prior to procedure.
PT orders plain radiographic films of affected shoulder. MRI may be considered to note any existing pathology (i.e. rotator cuff tear, labral defect, etc) prior to manipulation.
On the day of procedure, patient will report directly to anesthesia. The patient must arrange for their own escort to assist them from anesthesia to Physical Therapy, as well as to serve as designated driver to escort patient home following PT treatment.
PT will take PROM measurements both prior to, and following manipulation and instruct patient in post-manipulative care and exercise plan.
PT will follow patient daily for at least 1 week to ensure all manipulation gains are maintained and that the patient is compliant with entire program.
PT may reduce clinic patient visits as appropriate after one week, providing there are no complications and patient is progressing well with program.
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