Evidence in practice.

?Clinical question: Is there evidence that performing joint manipulation under' local anesthetic block might be more effective than continuing a program of joint mobilization, stretching, and mobility exercises in a woman with recalcitrant adhesive capsulitis of the shoulder?

The purpose of "Evidence in Practice" is to illustrate the literature search process to obtain evidence that can guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated.

A 45-year-old woman was referred by her health care provider to our outpatient physical therapy department with a 6-month history of pain and stiffness in her left shoulder and inability to perform her normal daily activities (eg, bathing, grooming, cleaning the house, and cooking). She particularly reported difficulty with overhead tasks such as washing her hair. She reported a gradual onset of left shoulder pain and stiffness without any known precipitating incident. Previous physical therapy intervention over a period of 6 weeks--consisting of passive joint mobilization, range-of-motion (ROM) exercises, and muscle stretching--had not been effective in improving her function or diminishing her pain. In addition, this patient had received local anti-inflammatory steroid injections with no reported improvements in mobility, function, or pain. Because the injections did not produce improvements in these areas, she declined a referral for another trial of injections.

The initial examination of the patient revealed generally decreased ROM in the left shoulder. Range of motion was assessed with the patient in the supine position using procedures described by Norkin and White. (1) We found that both passive and active ROM were limited to 115 degrees of flexion, 50 degrees of abduction, 25 degrees of internal rotation, and 5 degrees of external rotation. Previous studies have found the reliability of measuring ROM with a standard goniometer in this fashion to range from moderate to high, particularly for intrarater reliability. (2-5)

Based on the work of Cyriax, (6) we measured end feels for all shoulder motions and found them to be capsular. The interrater reliability of end-feel measurements has been found to be low, whereas the intrarater reliability has been reported to be high. Based on the high levels of intrarater reliability, we believed that these measurements might be useful in determining whether the limitation in motion was due to shortened soft tissue around the glenohumeral joint, although generalizability of these findings to other therapists might be difficult. (7-8) The patient's pain increased as resistance to passive shoulder movements was encountered.

Manual muscle testing was performed as described by Kendall and McCreary? Reliability of manual muscle test assessments of the shoulder has not been studied extensively in patients similar to our patient. The report by Hayes et al (10) suggests that reliability may be moderate at best, but we believed it was our best option for assessing muscle function in this patient. The patient exhibited left shoulder weakness, with strength grades of 4/5 for the motions of abduction, internal rotation, and external rotation. She rated her current level of pain as 9 out of 10 on a numeric pain rating scale. The patient completed a Shoulder Pain and Disability Index (SPADI) questionnaire. (11) Her total SPADI score was 64/100, indicating a high degree of disability due to shoulder pain.

Magnetic resonance imaging of her left shoulder revealed minimal rotator cuff tendinopathy, fraying of the superior glenoid labrum, and mild degenerative changes in the acromioclavicular joint. The patient's general health status was good.

This patient had signs and symptoms consistent with her diagnosis of adhesive capsulitis. She had already received the management that we believe is typical for patients with this diagnosis, including passive joint mobilization and muscle stretching techniques as well as ROM exercises. Numerous authorities and textbooks have recommended this approach, (12-16) and some now consider this approach to be the accepted standard of care for patients with adhesive capsulitis. (17) We were uncertain, however, whether continuing a program of joint mobilization, stretching, and ROM exercises would be the best approach for this patient or whether we should try an alternative approach. At APTA's Combined Sections Meeting 2001, we had heard a presentation by Dr Placzek (18) on translational manipulation under a brachial plexus anesthetic block for patients with adhesive capsulitis. Because conference presentations do not constitute evidence, we decided to do a literature search to determine if this alternative might be a more effective approach for patients who are similar to our patient.

Database used for search: MEDLINE

We chose to perform the initial literature search using MEDLINE, the National Library of Medicine's computerized database. MEDLINE includes literature from a broad range of disciplines, and we believed that it would likely include studies that would examine patients with adhesive capsulitis. We searched MEDLINE through Ovid Online (www.ovid.com). * This service requires a fee, but it is available free of charge at many academic institutions. MEDLINE also can be accessed through PubMed, which is available to the public for free at www.ncbi.nlm.nih.gov/PubMed. PubMed contains citations from more than 4,600 journals published in the United States and internationally. There are more than 11 million citations in the database, which is updated daily. The search on our clinical question was performed on March 12, 2003. See the Table for a summary of our search strategy.

Step 1--First group of keywords: adhesive capsulitis, frozen shoulder, stiff shoulder

We first checked the Map Term to Subject Heading box to de-select this feature (which is a default setting). When this feature is selected, Ovid automatically suggests controlled subject headings similar to our keywords. We wanted to keep our search specific to the terms we entered, and we did not want Ovid to suggest alternative headings for us. The first keyword we chose was adhesive capsulitis because this was the patient's specific diagnosis. Entering this keyword into the keyword entry box and clicking on the Perform Search button resulted in 156 citations (Table, search line 1). We were also aware that other terms are used for this diagnosis, and we wanted to capture as many articles as possible dealing With the condition. We therefore chose the keywords frozen shoulder and stiff shoulder. We conducted separate searches for each of these 2 keywords, and they produced 272 and 46 citations respectively (Table, search lines 2 and 3). We decided to combine these 3 keywords using an "OR" operator in order to create one group of citations. To do this task, we clicked on the Combine icon, which sends the user to the Combine Searches screen. Once in this screen, we first clicked on the check boxes next to the corresponding lines in the search history for each keyword (lines 1, 2, and 3), selected OR from the dropdown list at the top of the screen, and clicked on the Continue button to combine the 3 sets of citations (see Fig. 1). The combination of these keywords yielded a total of 431 citations (Table, search line 4).

Step 2--Second group of keywords: physical therapy, physiotherapy

We also wanted to examine evidence related to physical therapy interventions. We entered physical therapy into the keyword entry box, producing 4,342 citations (Table, search line 5). We were aware that some journals published in other countries may use the term "physiotherapy" instead, and we therefore conducted a separate search using physiotherapy, which produced 4,296 citations (Table, search line 6). We wanted to combine these 2 sets of citations with an "OR" operator to create one set of citations related to physical therapy. Again, we used Ovid's Combine function, checked the appropriate lines (5 and 6) in the search history, and selected OR from the drop down list at the top of the search screen. This combination produced 8,505 citations (Table, search line 7).

Step 3--Third group of keywords: mobilization, manipulation

We wanted to find articles related to the type of intervention our patient had already received, which included joint mobilization and stretching. In addition, we wanted to find evidence regarding the efficacy of manipulation under anesthetic block, which was the alternative we were considering. We therefore entered mobilization and manipulation into the keyword entry box separately (Table, search lines 8 and 9). Mobilization produced 19,659 citations, and manipulation produced 23,061 citations. We then returned to the Combine function, selected lines 8 and 9, and combined these 2 keywords with an "OR" operator. This action resulted in a set of 42,525 citations (Table, search line 10).

Step 4--Combining groups of keywords

After using the Combine function to consolidate our keywords into 3 separate groups, we returned to this feature to combine the set of citations dealing with the condition (ie, search line 4: "adhesive capsulitis" or "frozen shoulder" or "stiff shoulder") with the set of citations dealing with physical therapy (ie, search line 7: "physical therapy" or "physiotherapy"). This time we used an "AND" operator, in order to narrow our list to articles that concerned both the condition of adhesive capsulitis and physical therapy. We selected search lines 4 and 7 and chose AND from the dropdown list. This action resulted in 63 citations (Table, search line 11).

We also wanted to combine the set of citations that covered the patient's previous intervention and the alternative intervention (ie, search line 10: "mobilization" or "manipulation") with the set of citations dealing with the condition of adhesive capsulitis (ie, search line 4), so that we could find articles common to both sets of citations. In Ovid's Combine feature, we selected search lines 4 and 10 and used the "AND" operator. This action produced 75 citations (Table, search line 12).

We then combined these 2 larger groups of keywords (lines 11 and 12) using an "OR" operator. This combination resulted in 114 citations that we believed would contain the potentially relevant articles. This set of citations, however, was too large to examine, and we decided to further narrow the set using MEDLINE's Limits feature.

Step 5--Limits: English, human, the past 10 years

MEDLINE permits the user to set several types of limits to searches. We clicked on the icon labeled Limit, which is located to the right of the Combine icon at the top of the main search screen, in order to activate the options for setting limits on our list of citations. In the Limit a Search screen, we first decided to limit our search to articles written in English and those involving human subjects. We did this by clicking on the checkboxes next to the Human and English Language options. In order to focus on the most recent, up-to-date research, we limited the search to the past 10 years by selecting the dates 1993 and 2003 from the dropdown lists in the Publication Year field. We then clicked on the Limit Search button at the top of the screen. These limits reduced the citation list to 59 (Table, search line 14). We decided that we could look over the titles from this list and select the most relevant articles.

Selection of articles for review: As we read through our citation list, we looked for articles that reported outcome data for patients receiving interventions for adhesive capsulitis that physical therapists were licensed to perform. The majority of the articles in our citation list were either review articles that did not include any outcome data or articles that examined only those interventions that could not be performed by a physical therapist, such as corticosteroid injections or treatments involving arthroscopy. Seven articles seemed to be useful in answering our clinical question because they described outcomes of interventions that could be performed by physical therapists. We selected these articles by clicking on the checkbox next to the citation. Once we completed reviewing the list of citations, we scrolled to the bottom of the screen, and, in Ovid's Citation Manager, we clicked on the Selected Citations radio button in the Citations field, the Citation radio button under Fields, and the Ovid radio button under Citations Format. We then clicked on the Display button, and Ovid displayed the citations to the 7 articles we selected. The citations for these articles are listed in Figure 2.

Figure 2. Articles selected for review after completion of
MEDLINE search described in the Table.

(1.) Arslan S, Celiker R. Comparison of the efficacy of
local corticosteroid injection and physical therapy for
the treatment of adhesive capsulitis. Rheumatol Int.
2001;21:20-3

(2.) Griggs SM, Ahn A, Green A. Idiopathic adhesive
capsulitis. A prospective functional outcome study of
nonoperative treatment. J Bone Joint Surg Am.
2000;82:1398-407.

(3.) Vermeulen HM, Obermann WR, Burger BJ, Kok GJ,
Rozing PM, van Den Ende CH. End-range mobilization
techniques in adhesive capsulitis of the shoulder joint: A
multiple-subject case report. Phys Ther. 2000;80:1204-13.

(4.) Reichmister JP, Friedman SL. Long-term functional
results after manipulation of the frozen shoulder. Md
Med J. 1999;48:7-11

(5.) van der Windt DA, Koes BW, Deville W, Boeke AJ,
de Jong BA, Bouter LM. Effectiveness of corticosteroid
injections versus physiotherapy for treatment of painful
stiff shoulder in primary care: randomised trial. BMJ.
1998;317:1292-6.

(6.) Placzek JD, Roubal PJ, Freeman DC, Kulig K,
Nasser S, Pagett BT. Long-term effectiveness of
translational manipulation for adhesive capsulitis.
Clin Orthop. 1998;356:181-91.

(7.) Roubal PJ, Dobritt D, Placzek JD. Gleno-humeral
gliding manipulation following interscalene brachial
plexus block in patients with adhesive capsulitis.
J Orthop Sports Phys Ther. 1996;24:66-77.

After narrowing our search to these 7 articles, we reviewed the titles to select the most useful references for further consideration. The strongest evidence on the effectiveness of any treatment would come from a randomized trial. (19) In the absence of a randomized trial, a prospective study of the outcomes of intervention would provide weaker but potentially useful--evidence. (20) Retrospective studies would provide even weaker evidence. (19,20) Randomized trials provide the strongest evidence because randomization should balance the treatment groups in the study on all potentially important factors. (19) When a randomized trial is not available, a prospective report of outcomes usually is preferred to a retrospective study. (20) A prospective study permits the investigators to exercise greater control over the interventions and data collection, whereas retrospective designs often rely on chart reviews or archived data that are more likely to be incomplete. (20) We therefore were most interested in finding randomized trials or prospective studies of treatment outcome.

We were also interested in long-term functional outcomes because our patient's goals were to resume "normal daily activities." At this time, we excluded the study by Vermeulen and colleagues (citation 3) because it was a multisubject case report, which cannot show cause and effect, and because there was no indication in the title that a long-term follow-up was performed. We included the studies by Roubal and Placzek (citations 6 and 7) because these articles appeared to report information about the specific manipulative intervention that we were investigating. We also included Reichmister and Friedman (citation 4) because it appeared that the article included long-term results after a manipulative procedure; however, we were unsure at this time what specific manipulative procedure was used.

The papers by Arslan and Celiker (citation 1) and van der Windt et al (citation 5) were randomized trials comparing physical therapist management to pharmacological management (local corticosteroid injections), and the paper by Griggs et al (citation 2) was a prospective study involving nonoperative treatment with functional outcomes reported. We first decided to examine these 3 citations further to gather information about expected outcomes after conventional nonoperative interventions. If these 6 citations were not sufficient to answer our question, we would then re-examine the final 59 citations from our original search strategy to identify other potentially useful articles.

Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int. 2001;21:20-23

Adhesive capsulitis is a common musculoskeletal disorder mainly affecting middle aged adults. It is associated with generalized pain and tenderness in the shoulder joint with severe loss of active and passive ranges of motion in all planes. The aim of this study was to compare the efficacy of local steroid injection and physical therapy measures for treating this disorder. Ten male and 10 female patients were enrolled in the study. The patients were divided randomly into two groups and treated with either 40 mg methylprednisolone acetate injection with local anesthetic (group A) or physical therapy measures plus nonsteroidal anti-inflammatory drugs (group B). The mean ages of the patients were 55.6 [+ or -] 12.2 years in group A and 56.4 [+ or -] 7.1 years in group B. Clinical assessment was performed on initial visit and at the 2nd and 12th weeks. Active and passive range of motion was recorded and the visual analogue scale was used to evaluate pain intensity. At initial visit, these data in both groups of patients were not statistically different. Although both treatment regimens resulted in significant improvement in range of motion, the differences between mean external rotation at the 2nd and 12th weeks were not statistically significant in either group. The improvement in range of motion at the end of the study was similar in both groups (P>.05). All patients reported improvement during the study. The differences between mean VAS scores at the 2nd and 12th weeks were statistically significant in both groups. In conclusion, local steroid injection therapy was found to be as effective as physical therapy for the treatment of adhesive capsulitis.

[[c] 2001 Springer-Verlag GmbH. Abstract reprinted with the permission of Springer-Verlag GmbH.]

This study compared a "physical therapy program" with steroid injections in patients with adhesive capsulitis. Based on the abstract, it appears that the physical therapy program did not produce better results than the injection of steroids. The physical therapy program was not defined in the abstract, which made it difficult to judge the usefulness of the article. The OVID citation had a link to the full text of this article, so we decided to read the article to find out whether we could get more information.

After reading the article, we found that the physical therapy program consisted of heat, ultrasound, "passive glenohumeral joint stretching exercises," and active ROM exercises. The duration of intervention was not indicated. The outcomes focused on pain and impaired ROM; no functional outcome measures were used. The group receiving physical therapy experienced 25% to 75% increases in ROM and a 73% decrease in pain over a 4-week period, but these improvements were not any larger than those in the group that received a single steroid injection. This study had a small sample size and did not provide much information on the physical therapy intervention, and the results did not support the continuation of a treatment program focused on passive glenohumeral joint mobilization, stretching, and ROM exercises. We therefore decided to examine the next article.

van der Windt DA, Koes BW, Deville W, Boeke Al, de Jong BA, Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998;317:1292-6.

Objective: To compare the effectiveness of corticosteroid injections with physiotherapy for the treatment of painful stiff shoulder. Design: Randomised trial. Setting: 40 general practices. Subjects: 109 patients consulting general practitioners for shoulder pain were enrolled in the trial. Interventions: Patients were randomly allocated to 6 weeks of treatment either with corticosteroid injections (53) or physiotherapy (56). Main outcome measures: Outcome assessments were carried out 3, 7, 13, 26, and 52 weeks after randomisation; some of the assessments were done by an observer blind to treatment allocation. Primary outcome measures were the success of treatment as measured by scores on scales measuring improvement in the main complaint and pain, and improvement in scores on a scale measuring shoulder disability. Results: At 7 weeks 40 (77%) out of 52 patients treated with injections were considered to be treatment successes compared with 26 (46%) out of 56 treated with physiotherapy (difference between groups 31%, 95% confidence interval 14% to 48%). The difference in improvement favoured those treated with corticosteroids in nearly all outcome measures; these differences were statistically significant. At 26 and 52 weeks differences between the groups were comparatively small. Adverse reactions were generally mild. However, among women receiving treatment with corticosteroids adverse reactions were more troublesome: facial flushing was reported by 9 women and irregular menstrual bleeding by 6, 2 of whom were postmenopausal. Conclusions: The beneficial effects of corticosteroid injections administered by general practitioners for treatment of painful stiff shoulder are superior to those of physiotherapy. The differences between the intervention groups were mainly the result of the comparatively faster relief of symptoms that occurred in patients treated with injections. Adverse reactions were generally mild but doctors should be aware of the potential side effects of injections of triamcinolone, particularly in women.

[[c] 1998 British Medical Association. Abstract reprinted with the permission of the BMJ Medical Group.]

This article described a randomized trial and reported results that favored corticosteroid injections over physical therapy for patients with shoulder stiffness. Once again, we wanted more information on the physical therapy program used. We clicked on the full-text link next to the citation in order to view the article. Articles published in the British Medical Journal are also available online for free at the journal's Web site (www.bmj.com). According to the authors, physical therapy consisted of 12 sessions of "passive joint mobilization and exercise treatment" along with hot or cold modalities. Decreases in pain (41%) and disability (20%) were reported in the group of patients receiving physical therapy, but these improvements were smaller than the improvements in the injection group, and most of the improvements in the physical therapy group occurred immediately after the treatment program was completed, with little change occurring after that. We did not believe that this study supported the continuation of a program of mobilization and stretching exercises. We then turned to the last of our 3 articles that provided outcome data for the interventions that our patient previously received.

Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000;82:1398-407.

Background: Idiopathic adhesive capsulitis is a commonly recognized but poorly understood cause of a painful and stiff shoulder. Although most orthopaedic literature supports treatment with physical therapy and stretching exercises, some studies have demonstrated late pain and functional deficits. The purpose of this study was to evaluate the outcome of patients with idiopathic adhesive capsulitis who were treated with a stretching-exercise program. Methods: Seventy-five consecutive patients (seventy-seven shoulders) with phase-II idiopathic adhesive capsulitis were treated with use of a specific four-direction shoulder stretching exercise program and evaluated prospectively. The initial evaluation included the recording of a detailed medical and orthopaedic history and assessment of pain, range of motion, and function. The outcome evaluation included assessment of pain, range of motion, and function; completion of the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire; and completion of the Short Form-36 (SF-36) Health Survey. The mean duration of follow-up was twenty-two months (range, twelve to forty-one months). One patient died prior to the final evaluation, and three patients were lost to follow-up. Results: Sixty-four (90 percent) of the patients reported a satisfactory outcome. Seven (10 percent) were not satisfied with the outcome, and five (7 percent) underwent manipulation and/or arthroscopic capsular release. The outcomes of the patients who did not have manipulation or capsular release were evaluated. There were significant improvements in the scores for pain at rest (from a mean of 1.57 points before treatment to a mean of 1.16 points at the final evaluation; P<.001) and pain with activity (from a mean of 4.12 points before treatment to a mean of 1.33 points at the final evaluation; P<.0001). On the average, active forward elevation increased 43 degrees, active external rotation increased 25 degrees, passive internal rotation increased eight vertebral levels, and the glenohumeral rotation arc at 90 degrees of abduction increased 72 degrees (P<.00001). The number of "yes" responses to the Simple Shoulder Test increased from a mean of 4.1 (of a possible twelve) to a mean of 10.75 (P<.00001). Despite the significant improvements and the high rate of patient satisfaction, there were still significant differences in the pain and motion of the affected shoulder when compared with those of the unaffected, contralateral shoulder (P<.00001). At the final outcome evaluation, the DASH scores demonstrated limitations when compared with known population norms, whereas the profiles of the SF-36 were comparable with those of age and gender-matched control populations. Prior treatment with physical therapy and a Workers' Compensation claim or pending litigation were the only variables that were associated with the eventual need for manipulation or capsular release. Male gender and diabetes mellitus were associated with worse motion at the final evaluation. Patients with a greater severity of pain with activity at the initial evaluation had significantly lower DASH scores at the final evaluation, and patients with lower initial scores on the Simple Shoulder Test had comparatively lower scores on the Simple Shoulder Test at the outcome evaluation. Conclusions: The vast majority of patients who have phase-II idiopathic adhesive capsulitis can be successfully treated with a specific four-direction shoulder-stretching exercise program. Although measurable limitations and deficiencies were noted at the outcome evaluation, these appeared to be acceptable to most of the patients and did not affect their general health status. Patients with more severe pain and functional limitations before treatment had relatively worse outcomes. More aggressive treatment such as manipulation or capsular release was rarely necessary, and the efficacy of early use of these treatments should be further studied.

[[c] 2000 The Journal of Bone and Joint Surgery Inc. Abstract reprinted with the permission of The Journal of Bone and Joint Surgery Inc.]

This paper described a case series (an observational study without a control group) of patients who received a program of stretching exercises. Although the abstract provided detailed information, we clicked on the full-text link to examine the text of the article. Most patients in this study did improve with the stretching program but continued to have functional restrictions. Worse outcomes were associated with higher levels of pain and disability at the initial examination. Our patient reported a very high level of pain and a great deal of disability on the SPADI questionnaire. A subset of patients in this study was considered to have failed this treatment program, and they received manipulation or capsular release. One variable associated with treatment failure was having prior physical therapy. Our patient had already had 6 weeks of physical therapy intervention.

Clinical decision related to continuing with the present physical therapy program: Up to this point, the evidence we evaluated provided modest support for continuing with the patient's current physical therapy program, which included passive joint mobilization, stretching, and ROM exercises. However, our patient had already been managed in this fashion for 6 weeks with unsatisfactory results. No evidence supported continuation of these interventions for a longer period of time, especially when 6 weeks of joint mobilization, stretching, and mobility exercises had proven unsuccessful. The results of the Griggs et al study suggest that our patient, with her high levels of pain and disability and previous unsuccessful trial of physical therapy, would have a poorer prognosis for success if the current approach to physical therapy were continued. Although the studies by van der Windt et al and Arslan and Celiker support the use of steroid injections for patients with adhesive capsulitis, our patient had already undergone a trial of steroid injections, which failed to produce satisfactory improvements, and she had declined a referral to a medical specialist for another trial of injections.

Next, we wanted to examine the articles that we had selected that included information concerning manipulative interventions (Reichmister and Friedman, Placzek et al, and Roubal et al).

Reichmister JP, Friedman SL. Long-term functional results after manipulation of the frozen shoulder. Md Med J. 1999;48:7-11.

The use of shoulder manipulation in the treatment of frozen shoulder syndrome remains controversial. Opponents cite the risk of dislocation, fracture, nerve palsy, and rotator cuff tearing as limiting the usefulness of manipulation. A retrospective study of 38 shoulder manipulations in 32 patients was performed. These patients were followed for an average time of 58 months. The patients were examined in follow up for combined shoulder range of motion, external and internal rotation strength, and status of the long head of the biceps. Manipulation was performed in all patients by the senior author and supervised physical therapy was begun within 24 hours of the manipulation. The average recovery time was 13 weeks. In this series, 97% of patients had relief of pain and recovery of near complete range of motion, although 8% required a second manipulation to obtain a successful result. Mild weakness to manual muscle testing was present in 5.3% of patients in external rotation and 10.5% of patients in internal rotation. There was no deterioration of shoulder function with time. In fact, most patients improved with passage of time, even more. There was no evidence of biceps tendon rupture or rotator cuff insufficiency at the time of follow up in any of the patients. No fractures, dislocations or nerve palsies were observed, although one patient who had no premanipulation arthrogram was found to have a rotator cuff tear a few months after failed manipulation. Manipulation of the shoulder can therefore be offered to reduce the pain and period of disability in patients who fail conservative treatment of frozen shoulder syndrome.

[[c] 1999 MedChi: The Maryland State Medical Society. Abstract reprinted with permission of MedChi: The Maryland State Medical Society.]

From this abstract, we were unable to determine what type of manipulation or other physical therapy intervention was performed. The abstract also supplied little information on the patient population studied or specific information regarding the assessment of pain. It did not appear that disability was measured. Based on the abstract, it did appear that the manipulation procedure, combined with other physical therapy interventions, was effective in improving ROM and pain. It also appears that manipulation was a safe procedure. The study was a retrospective case series, which is not as strong of a form of evidence for an intervention as a prospective case series or, ideally, a clinical trial. There was no full-text link to access this paper. Because we felt that the information in the paper was unlikely to provide strong evidence, we proceeded to review the other studies.

Placzek JD, Roubal P J, Freeman DC, Kulig K, Nasser S, Pagett BT. Long-term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop. 1998;356:181-91.

Long term effects of glenohumeral joint translational (gliding) manipulation on range of motion, pain, and function in patients with adhesive capsulitis were studied. Thirty-one patients underwent brachial plexus block followed by translational manipulation of the glenohumeral joint. Changes in range of motion and pain were assessed before manipulation with the patient under anesthesia, immediately after manipulation with the patient still under anesthesia, at early follow up (5.3 [+ or -] 3.2 weeks), and at long-term follow up (14.4 [+ or -] 7.3 months). Passive range of motion increased significantly for flexion, abduction, external rotation, and internal rotation. Significant decreases in visual analog pain scores between initial evaluation and the follow up assessments also occurred. Furthermore, Wolfgang's criteria score increased significantly between initial evaluation and follow up assessments. Translational manipulation provides a safe, effective treatment option for adhesive capsulitis.

[[c] 1998 Lippincott Williams & Wilkins. Abstract reprinted with permission of Lippincott Williams & Wilkins.]

This study was a case series that reported short- and long-term improvements in mobility, pain, and function after a joint manipulation intervention was performed following a brachial plexus anesthetic block. These improvements were consistent with the goals of our patient, the authors of this paper were mostly physical therapists, and manipulation is a procedure that physical therapists use. The study was a case series with a comparison group, but it was a prospective study and, therefore, likely to provide somewhat stronger evidence than the previous study (Reichmister and Friedman). This seemed to be a promising treatment option, so we decided to click on the full-text link to this article to get more details.

The mean age of the 31 patients in the study was 49.1 [+ or -] 7.9 years, and the subjects had an average symptom duration of 7.8 [+ or -] 20 months. Mean pretreatment ROM deficits in the subjects in this study were similar to our patient. All patients had previously received physical therapy consisting of the standard program of joint mobilization, therapeutic exercise, and physical modalities (mean visits = 7.7 [+ or -] 6.5 over the course of approximately 3 weeks). Our patient was very similar to the patient population in this study, and, in fact, our patient met all of the inclusion criteria listed by the authors. Patients in this study received the interscalene block, then were taken to an outpatient clinic for the manipulation procedure. The manipulation procedures used were translational forces applied to the humeral head parallel to the glenoid fossa. The pictures and description of the techniques appeared to be extremely similar to the passive glenohumeral joint mobilization procedures described by Hannafin and Chiaia (17) and others as being routinely performed as a part of the standard physical therapy program for patients with adhesive capsulitis; however, the patients in this study had been given an anesthetic block of the brachial plexus, which provided a complete motor and sensory blockade of the shoulder and entire upper extremity.

Following the manipulation, patients in this study were instructed in mobility exercises to be performed hourly for the first day. The patients attended physical therapy sessions daily for a week, then 3 times per week for 1 to 5 additional weeks. All patients, except those with diabetes, started a 6-day Medrol Dosepak ([dagger]) (4 mg methylprednisolone) the day before the manipulation. No complications were reported.

The long-term follow-up was performed at a mean of 14 months after treatment. At that time, there remained substantial improvements in ROM, pain, and disability. Flexion passive ROM improved from a pretreatment mean of 100 degrees to 163 degrees. Pain ratings decreased from 7.6 to 1.5, and the Wolfgang score, a 0-to-16 scale measuring functional status of patients with shoulder pain, improved from 5.5 to 14.1 in this same time frame. The improvements reported in this study indicated that this procedure might be useful in helping our patient to achieve her goals.

Roubal PJ, Dobritt D, Placzek JD. Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis. J Orthop Sports Phys Ther. 1996:24:66-77.

Previous studies describing nonconservative treatment of shoulder adhesive capsulitis include distention arthrography, brisement techniques, arthrotomy of the anterior/inferior axillary fold and subscapularis tendon, and manipulation under general anesthesia. The purpose of this study was to develop and describe an alternative treatment method that utilizes glide manipulation under interscalene brachial plexus block. Eight patients (four females and four males), age 31-55 years, with a mean age of 44 years, were treated conservatively for adhesive capsulitis of the shoulder and failed to produce increased measurable objective active or passive ranges of motion. Symptoms of adhesive capsulitis in these patients range from 3 to 16 months, 7 months average. Premanipulation treatment ranged from 1 to 21 weeks, with an average of 9 weeks. Two additional patients were considered for manipulation after a trial of conservative treatment, but the interscalene brachial plexus block and manipulation were not performed. One patient was eliminated from the study due to excessive osteoarthritis in the shoulder girdle, and the other patient was eliminated from the study due to a high cardiac risk. The eight patients chosen for manipulation underwent interscalene brachial plexus blocks. They were immediately sent to the physical therapist for manipulation under anesthesia following the interscalene brachial plexus blocks. Immediately following manipulation, the average increases in passive range of motion for flexion, abduction, external rotation, and internal rotation were 68 degrees, 77 degrees, 49 degrees, and 45 degrees, respectively. At the time of discharge, average increases in passive range of motion/active range of motion for flexion, abduction, external rotation, and internal rotation were 76/67 degrees, 82/73 degrees, 50/44 degrees, and 49/40 degrees, respectively. All patients manipulated showed increases in function, such as overhead activities, dressing activities, and hair care. These preliminary findings show that effective gliding manipulation can be carried out under regional blockade and performed in an office setting by practitioners knowledgeable in manipulation techniques.

[[c] 1996 Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association. Abstract reprinted with the permission of the Journal of Orthopaedic and Sports Physical Therapy.]

This prospective case series was performed by the same group of authors, apparently using the same procedures, as the previous study. As in the previous study, the patient population described in this case series was similar to our patient with respect to age,. duration of symptoms, and the failure to respond to a trial of physical therapy. After interscalene brachial plexus anesthetic blocks, the manipulation technique was performed by a physical therapist. Substantial increases in mobility after manipulation were reported. These increases in ROM were maintained at discharge, and patients also demonstrated increases in function. No long-term follow data were reported in this study. No full-text link was available. Because this study appeared to have used the same procedures as the study by Placzek et al and because this study did not report long-term outcomes, we did not feel that any additional useful information would be gained by reading the entire text, and we did not go to our medical library to get a full-text article.

Clinical decision related to offering a manipulation intervention: The treatment approach described by Placzek et al and Roubal et al appeared to be a treatment option that should be offered to our patient. As we discussed, our patient was similar to the patients described in both studies with respect to demographics, signs and symptoms associated with adhesive capsulitis, and failure to respond satisfactorily to previous physical therapy interventions. Although these studies were not randomized trials and did not use comparison groups (and therefore cannot show cause and effect), these patients, who had a condition that can be chronic and resistant to treatment, did improve in mobility, pain, function, and disability in both the short term and long term. We believed this approach had more support in the literature than a continuation of the "standard" interventions of joint mobilization, stretching, and ROM exercises. Furthermore, our patient had not responded positively to previous steroid injections and did not want to pursue this line of treatment any further.

We discussed the possibility of using a brachial plexus anesthetic block for this patient, to be delivered by an anesthesiologist. The anesthesiologist and referring health care provider reviewed the evidence for the procedure and agreed it might be helpful for our patient. We discussed the potential risks and benefits of receiving this translational glenohumeral manipulation after a brachial plexus anesthetic block with the patient. The patient decided that she wanted to receive the intervention, and all medical providers agreed with this plan of care.

We decided to use the protocol described by Placzek et al as the basis for our intervention program. As suggested by Placzek et al, the referring physician prescribed a 6-day, oral Medrol Dosepak, with instructions to begin the medication the day before the manipulation was performed. On the treatment day, our patient received a brachial plexus anesthetic block from the anesthesiologist. With the anesthetized upper extremity supported in a sling, the patient was then escorted to physical therapy where we performed the translational manipulation to the glenohumeral joint.

The immediate post-manipulation ROM measurements were 135 degrees of flexion, 90 degrees of abduction, 70 degrees of internal rotation, and 35 degrees of external rotation. By 3 weeks after treatment, the patient's SPADI score was 3/100, and mobility had further increased to 150 degrees of flexion, 95 degrees of abduction, 70 degrees of internal rotation, and 35 degrees of external rotation. Mobility and function continued to improve, and, by 12 weeks after the manipulation, the patient had pain-free active ROM that was equal to the opposite shoulder, and she could perform all activities of daily living without pain or restriction.

Table. Description of MEDLINE Search Performed on March 13, 2003

                                                              No. of
Search                                                        Citations
Line No.   Action                                             Produced

 1         Typed adhesive capsulitis into keyword entry box         156
 2         Typed frozen shoulder into keyword entry box             272
 3         Typed stiff shoulder into keyword entry box               46
 4         Used Combine feature to combine lines 1, 2, and          431
           3 with "OR" operator (ie, 1 or 2 or 3)
 5         Typed physical therapy into keyword entry box          4,342
 6         Typed physiotherapy into keyword entry box             4,296
 7         Used Combine feature to combine lines 5 and 6          8,505
           with "OR" operator (ie, 5 or 6)
 8         Typed mobilization into keyword entry box             19,659
 9         Typed manipulation into keyword entry box             23,061
10         Used Combine feature to combine lines 8 and 9         42,525
           with "OR" operator (ie, 8 or 9)
11         Used Combine feature to combine lines 4 and 7             63
           with "AND" operator (ie, 4 ["adhesive
           capsulitis," "frozen shoulder," or "stiff
           shoulder"] and 7 ["physical therapy" or
           "physiotherapy"])
12         Used Combine feature to combine lines 4 and 10            75
           with "AND" operator (ie, 4 ["adhesive
           capsulitis," "frozen shoulder," or "stiff
           shoulder"] and 10 ["mobilization" or
           "manipulation"])
13         Used Combine feature to combine lines 11 and 12          114
           with "OR" operator (ie, 11 or 12)
14         Typed 13 (ie, line 13 in the search history)              59
           into keyword entry box on main search screen,
           clicked on Limits icon, and added the
           following limits: Human studies, English
           Language, publication years: 1993-2003

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(18) Placzek JD. Pathogenesis, evaluation, and treatment of adhesive capsulitis. Presentation at: Combined Sections Meeting of the American Physical Therapy Association; February 19, 2001; San Antonio, Tex.

(19) Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone Inc; 2000:105-154.

(20) Guyatt G, Rennie D, eds. Users' Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, Ill: AMA Press; 2002:81-100.

? In the next Evidence in Practice: David A Scalzitti, PT, MS, OCS, will seek evidence to answer the question, "Because of the risk of developing heterotopic ossification, are passive range of motion exercises contraindicated following traumatic injuries?" (Coming in July 2003)

* Ovid Technologies, 333 Seventh Ave, 4th Fl, New York, NY 10001.

([dagger]) Pharmacia & Upjohn Co, Kalamazoo, MI 49001.

Julie M Whitman, PT, DSc, OCS, FAAOMPT, is Element Chief Physical Therapy Element, Kirtland Air Force Base, Albuquerque, NM, and Assistant Professor, US Army-Baylor University Postprofessional Doctoral Program in Orthopaedic and Manual Physical Therapy, Ft Sam Houston, Tex.

Julie M Fritz, PT, PhD, ATC, is Assistant Professor, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pa.

Robert E Boyles, PT, DSc, OCS, is Staff Therapist, Brooke Army Medical Center, Ft Sam Houston, Tex.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force, the Department of the Army, the Department of the Navy, or the Department of Defense.

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