A Study to Compare the Effectiveness of Capsular Stretching Versus Scapulothoracic Exercise in Patients with Adhesive Capsulitis of Shoulder

Introduction

With the evolution of human beings, the shoulder joint is privileged as the most mobile joint of the body. As joint mobility is high, vulnerability is also on the higher side, which affects its movement. But structurally it is a weak joint as the glenoid cavity is too small and shallow to hold the head of humerus in place.¹ A global decrease in shoulder’s range of motion, both active and passive in all planes is termed as Adhesive Capsulitis. Based on the radiologic appearances with arthrography, “Adhesive Capsulitis” indicates “adhesions” of the capsule of the glenohumeral joint limiting overall joint space volume.²

In 1934, Codman coined the term – Frozen Shoulder (FS); it is loosely defined as a ‘Painful Stiff Shoulder’. In 1946, Neviaser named the condition ‘Adhesive Capsulitis’.³ Over the years, adhesive capsulitis has had many different names including shoulder periarthritis, adherent subacromial bursitis, and frozen shoulder. Adhesive meaning sticky and capsulitis means inflammation of the joint capsule. When the joint becomes inflamed and adhesive making it stiff and difficult to move, that’s when patients realize the importance of shoulder as the function gets compromised.

Adhesive Capsulitis has been classified into two types: Primary (idiopathic) and Secondary.⁴ In the primary or idiopathic form, no known precipitating event can be identified. The secondary form is associated with or attributed to other illness or events. The causes can be intrinsic like Acromio-clavicular joint arthritis, Rotator cuff Tendinitis. The extrinsic causes includes cardiac diseases and cardiac surgery, neurological disease with impaired consciousness or hemiplegia, pulmonary disease (tuberculosis, antituberculosis drugs, carcinoma) and shoulder trauma or humerus fracture. The systemic diseases like hyper and hypothyroidism and Diabetes mellitus are also responsible for adhesive capsulitis.

Cyriax characterized adhesive capsulitis into three stages.⁵ The duration of each stage varies, but on an average, the first stage is 3 to 6 months, the second stage is 3 to 18 months, and the final stage is 3 to 6 months. The first stage is the “freezing” phase, characterized by the onset of an aching pain in the shoulder. The pain is usually more severe during night and with activities, and may be associated with a sense of discomfort, with referred pain down the arm. The second stage is the progressive stiffness or “frozen” phase. Pain at rest in this stage will be down and leaving the patient with a shoulder that has restricted motion in all the planes. Activities of daily living becomes severely restricted. The final stage is the resolution or “thawing” phase which has slow recovery of motion.

Adhesive capsulitis treatment primarily consists of pain relief and physical therapy techniques. Anti-inflammatory medication is helpful in pain relief, so that mobility interventions can be initiated.⁶ Therapeutic modalities include Transcutaneous Electrical Nerve Stimulation (TENS), Interferential Therapy (IFT), Ultrasound, Short Wave Diathermy (SWD) etc, and the physical therapy exercises such as stretching, Codman exercise can be used. Other treatment procedures include manipulation under general anesthesia, arthroscopic surgery etc. Exercises which may be active, passive or active assisted, play a crucial role in the early rehabilitation of these patients.

Glenohumeral Exercise: Usually, glenohumeral exercises like Codman pendulum exercises are performed with gravity and in pain-free range to avoid inflammatory reaction by forcing the joint movement.⁷ This is an exercise which can maintain the range and decrease shoulder pain. The objective is to decrease the pain and increase the arc of movement within a painful limiting range of motion.⁷

Capsular Stretching: Shoulder stiffness occurs may be due to: (1) contractures of the intra articular capsule or muscle-tendon units or (2) adhesions within the extra articular humeroscapular or scapulothoracic motion interface.⁸ These contractures or adhesions may occur independently or in combination. A detailed physical evaluation and proper history will help in the diagnosis of anatomical fibrosis that causes stiffness and to determine other associated conditions causing shoulder stiffness. Passive stretching exercises are effective in most of the patients as a home exercise program.⁸ For frozen shoulder, the increase of joint space capacity was significant and was correlated with improvement of external rotation. Range of Motion (ROM) restoration occurs independent of change in joint space capacity, which increases slightly. The stretching of other contracted soft tissues around the joint, along with adhesive capsule, may contribute to the recovery of chronic frozen shoulder.⁹ So capsular stretching can be added in the treatment for adhesive capsulitis. Designing each stretching exercise to improve capsule and shoulder girdle flexibility should be specific to area.

Scapulothoracic Exercise: The scapula has the freedom to move around the thorax to enhance the potential range of movement available at the shoulder. The scapulothoracic articulation is involved and therefore its movement can be restricted, if there has been a bony injury to the scapula. Injury and shortening of serratus anterior, rhomboids, trapezius and other scapular muscles, and deformity or injury of corresponding ribs. Scapulothoracic mobility restrictions often occur due to adaptive shortening, as a consequence of long-protracted immobility caused by adhesive capsulitis. On the other hand, impairment of dynamic functional stability of the scapula during arm movements can be a major cause for the development of painful movement-related conditions of the glenohumeral, acromio-humeral and clavicular joints and the cervicothoracic spine.

Usually, the scapulohumeral rhythm rate is 2:1. It is 4:1 at the 30-600 glenohumeral flexion and it is 5:1 above 600 of flexion.¹⁰ In frozen shoulder, these rates increase in favor of scapulothoracic joint. Capsular adhesions will reduce mobility of glenohumeral joint, which effects external rotation of shoulder and prevents inferior glide of humerus below the acromion while doing shoulder elevation.¹¹ So stretching exercises restore the length of contracted muscles and mobilizations and strengthening exercises of scapulothoracic restore the external rotation and scapular protraction.¹² The scapulothoracic articulation is not a true joint but functions as an integral part of the shoulder complex. Scapulothoracic movements that include rotation, elevation, depression, protrusion, retraction, and circumduction are important for the normal functioning of the shoulder.¹³ If the glenohumeral joint does not move, elevation through abduction is limited to 600 , which occurs totally in scapulothoracic joint. If there is an absence of lateral rotation of humerous during abduction, the total movement available is 1200 , 600 of which occurs at glenohumeral joint and 600 occurs at the scapulothoracic articulation.¹⁴ So scapulothoracic exercises in addition to glenohumeral exercises can be effective in increasing glenohumeral ROM, by fixing scapulohumeral rhythm and decreasing pain.¹²

Until recently, there was no exercise program proven effective for impaired scapular movement in conservative management of frozen shoulder. As the exercises restore impaired scapulothoracic motion by scapulothoracic strengthening, mobilization, and stretching exercises, the present study investigated the effects of this program on pain, ROM, and functional status. This study aimed to compare and determine the technique which is more beneficial in reducing pain and early recovery from adhesive capsulitis. Therefore, the purpose of this study was to find the effectiveness of capsular stretching exercise versus scapulothoracic exercise in reducing pain, improving ROM and functional activities in adhesive capsulitis.

Methods

Thirty subjects who fulfilled the inclusion criteria were recruited. Inclusion criteria were as follows: 1. Subjects with known active status of second stage of adhesive capsulitis (Frozen phase), 2. Male and female subjects, 3. Age between 40 to 60 years,15 4. Subjects having inability in full ROM actively, 5. Subjects who were willing to participate in the study. Exclusion criteria were as follows: 1. History of surgical intervention on same shoulder, 2. History of severe trauma, 3. Radiculopathy, 4. Thoracic outlet syndrome, 5. Rheumatologic disorders, 6. Upper limb Fractures and any tumors in upper limb. Informed consent was obtained, after which the subjects were randomly divided into two groups, Group A (n=15) and Group B (n=15). Both the groups received equality in treatment quality, were directly supervised and performed by the Physiotherapist. Subjects in both the groups were given verbal and written instructions and demonstration by the physical therapist about treatment protocol.

Subjects were assessed thoroughly before starting the procedure. Pre-test assessment of the range was measured with Goniometer. Shoulder flexion, abduction and external rotation measurements were taken.¹⁶ The functional activities and pain in shoulder was measured by Shoulder Pain and Disability Index (SPADI) questionnaire. Similarly, the post-test assessment of the range was measured with Goniometer. The measurement was taken for flexion, abduction and external rotation of shoulder. The functional activities and pain in shoulder was measured by SPADI questionnaire.¹⁷ Subjects were explained about the SPADI questionnaire. The instructions were given for selecting the score. Patients were instructed to fill the questionnaire without omitting any question from answering. Filled questionnaires were collected and the total score was calculated.

Common Treatment for Both the Groups:

• Phonoporesis

• Glenohumeral exercises

Phonoporesis: Initially, both the group patients were treated with Phonoporesis. Patients were asked to sit on a chair. A pillow was placed under the arms to provide comfort to the patient. Procedure was performed as follows: all the jewelry and clothing around the affected shoulder was removed before the treatment. Good skin contact was maintained with the treatment head, via aqua sonic gel and diclofenac gel as coupling media.^18,19 Ultrasound was given for 5 mins at each treatment session, with parameters of 1MHz frequency, at an intensity of 1.2W/cm2 in a continuous mode.²⁰ Phonoporesis was given on alternate days for three weeks (i.e., thrice a we ek).

Glenohumeral Exercises: After Phonoporesis for patients from both the groups, glenohumeral exercises were initiated with the dosage of 5 sessions in a week for 3 weeks (15 sessions) and each exercise with 20 repetitions under the physiotherapist supervision. Glenohumeral exercises were as follows: 1. Codman Pendulum Exercises 2. Pulley Exercises 3. Shoulder Wheel 5. Finger stepping and corner stretch.²¹

Capsular Stretching for Group A: After the above two interventions, Group A patients were treated with capsular stretching for 5 sessions in a week for 3 weeks (15 sessions). The stretching was given for 15 seconds, which was repeated three times under physiotherapist supervision. Stretching exercises for capsule were: 1. External rotation at shoulder height, which stretches anterior and anterior-inferior capsule. 2. Shoulder crossbody adduction, which stretches the posterior capsule. 3. Hand-behind-back, which stretches the posterior and posterior-superior capsule. 4. Side-lying internal rotation, which stretches the posterior and posteriorinferior capsule.²²

Scapulothoracic Exercises for Group B: After the above two interventions, group B patients were treated with scapulothoracic exercises of five in a week for three weeks (15 sessions) and each exercise with 20 repetitions under the physiotherapist supervision. Exercises for Scapulothoracic were as follows: 1. Retraction of scapula with exercise rope, 2. Extension with exercise rope, 3. Adduction and elevation of scapula, 4. Wall pushups, table push-ups, and floor push-ups, 5. Adduction of scapula in prone position, 6. Shoulder extension in prone, 7. Protraction of scapula in supine position, 8. Sitting push-ups, 9. Scapular abduction in standing.¹² At the end of the treatment, differences were measured after observing ROM with Goniometer and functional activity of the shoulder.²³

Data Analysis

The entire analysis has been carried out using IBM SPSS Inc. 20.0 Version. The main objective of the work was to observe the statistical significance in the variables considered. The data was collected at two time periods i.e., pre-and post with respect to all the variables. The statistical techniques applied for the data were paired sample t-test and independent sample t-test. The paired sample t-test was used for observing the statistical significance between pre-and post-values of every parameter. The independent samples t-test was used to compare both group A and group B values.

Results

Results were analyzed in terms of increment of ROM and reduction in SPADI score for improvement in the functional ability

In the group A, the pre-test mean of flexion was 110.40, abduction was 101.60, external rotation was 42.07. The post-test mean of flexion was 121.27, abduction was 110.47, external rotation was 49.00. The p value from paired t test was found to be < 0.001, which is statistically significant.In group A, the mean of SPADI score of pre-test session on the first day was 59.99%, on post-test session, the mean was 45.2%. The p value from paired t test was < 0.001, which is statistically significant (Table 1).

In group B, the pre-test mean of flexion was 109.20, abduction was 100.40, ex-rotation was 45.13. The posttest mean of flexion was 126.60, abduction was 113.67, ex-rotation was 55.00. The p value from paired t test was found to be < 0.001, which is statistically significant.

In group B, the mean of SPADI score of pre-test session on the first day was 61.79%, on post-test session, the mean was 36.86%. The p value from paired t test was found to be < 0.001, which is statistically significant (Table 2).

To compare groups A and B, first we had considered differences between the pre-intervention and postintervention for each variable. This difference indicates the actual gain or response from the patients and comparison can be done with it. On performing the independent samples t-test, it was observed that there was a statistical significant difference (p<0.05) between group A and B with respect to flexion, abduction, rotation and SPADI score (group A: 14.7%; group B: 24.9%). Also, it was noticed that Group B performed better with a greater mean (Table 3).

Discussion

Despite interest in the disease, the etiology and treatment of shoulder stiffness remains controversial. Goals of the treatment are to decrease pain, increase motion, and improve function. Although literature data lacks a consensus on the non-operative approach for adhesive capsulitis, it is still the primary intervention. When this non-operative approach fails, operative approaches like manipulation under anesthesia, with arthroscopic capsular release are considered.^24,25,26 Adhesive capsulitis is a painful debilitating musculoskeletal condition that poses significant challenges to the health industry. Although, conservative treatment of this condition has become one of the main drives for many studies, there has been no consensus as to the most effective management strategy. The results of the study indicate that both capsular stretching exercises and scapulothoracic exercises are effective for adhesive capsulitis treatment, where glenohumeral exercises and Phonoporesis were common for both the groups. Both the groups showed improvements in SPADI and ROM.

Group A consisted of subjects who received capsular stretching, whose pre-test mean values for shoulder flexion, shoulder abduction and shoulder external rotation were 110.40, 101.60, 42.07 respectively. The post-test values of shoulder flexion, shoulder abduction and shoulder external rotation were 121.27, 110.47, 49.00 respectively. The pre-test and post-test SPADI scores were 59.99% and 45.2% respectively. This indicates that capsular stretching exercises were effective in improving ROM and reducing pain and disability. All ROM’s were compared between pre-and post-values, which showed statistical significance at p<0.05. Group B consisted of subjects who received scapulothoracic exercises, whose pre-test mean values for shoulder flexion, shoulder abduction and shoulder external rotation were 109.20, 100.40, 45.13 respectively. The post-test values of shoulder flexion, shoulder abduction and shoulder external rotation were 126.60, 113.67, 55.00 respectively. The pre-test and post-test SPADI scores were 61.79% and 36.86% respectively. This indicates that scapulothoracic exercises were also effective in improving ROM and reducing pain and disability. All ROM’s were compared between pre-and post-values, which showed statistically significance at p<0.05. Pain reduction was the main concern in frozen shoulder treatment and increase in ROM was the next goal.

There are many treatment options for the treatment of frozen shoulder. Studies suggest cold packs, NSAIDs, TENS, corticosteroids and intra articular injections to reduce synovial inflammation and are reported to be effective in the pain management of frozen shoulder. In this study, Phonoporesis was used for pain control. Klaiman et al., (1998) proved that Phonoporesis is very effective in reducing the pain.²⁷ Phonoporesis is the application of ultrasound in conjunction with a topical drug preparation as the ultrasound conduction medium. The ultrasound is intended to improve the delivery of drug through the skin, thereby delivering the drug for local or systemic effects. Transcutaneous drug delivery has several advantages over oral drug administration. It provides a higher initial drug concentration at the delivery site, avoids gastric irritation, and avoids firstpass metabolism by the liver. ²⁸

The first report of ultrasound usage to enhance drug delivery across the skin was published in 1954.²⁹ The authors of these initial studies proposed that ultrasound enhanced drug delivery by exerting pressure on it, to drive through the skin. However, as ultrasound exerts only a few grams of force, it is now thought that it increases transdermal drug penetration by increasing the stratum corneum permeability of capsule, through cavitation.³⁰ This theory is supported by the observation that ultrasound can enhance drug penetration even when the ultrasound is applied before the drug is put on the skin.³¹ Drug diffusion across the stratum corneum depends on both diffusion and partition coefficients. A recent study demonstrated ultrasound enhancement of diffusion coefficients of a variety of solutes by up to 15- fold. Ultrasound, however, did not significantly enhance partition coefficients.³² Suliman R Alballa proved in their study that Phonoporesis application of diclofenac gel is well tolerated and results in an early cure in a substantial proportion of patients with localized musculoskeletal disorders. Therefore in this study, diclofenac was used in Phonoporesis for reduction of pain.²⁰

The next purpose of the treatment was to increase ROM. For this reason, Group A patients underwent glenohumeral exercises and capsular stretching exercises, which consisted of active ROM exercises and passive ROM exercises, stretching exercises under the guidance of a physiotherapist. Self-stretching exercises, muscle strengthening exercises, patient education, and home exercises are beneficial for the improvement of frozen shoulder.¹⁰ Pendulum (Codman’s) exercises are the ones which use the effects of gravity for humeral distraction from the glenoid fossa.^33,34 They help to relieve pain through gentle traction and oscillating movements and provide early motion of joint structures and synovial fluid. Dundar U et al., proved that continuous passive motion provides good pain control in adhesive capsulitis patients.³⁵ Manish Samnani in 2004 proved that glenohumeral exercise program along with passive therapeutic activities can improve the functional activity in frozen shoulder.¹⁷ Although education regarding frozen shoulder and simple home stretching exercises have been shown to improve selfassessed shoulder function and health status in adhesive capsulitis patients.³⁶

In the sub-acute phase, capsular tightness starts to develop. Reduction in mobility is detected, which follows capsular pattern (external rotation of shoulder and abduction of shoulder are most affected and limited, and internal rotation of shoulder and flexion of shoulder are least affected and limited). So often, patient experiences pain at the end-point when limited range is reached. Joint-play testing gives information of limited joint play. If patient is treated at the early stage of adhesive capsulitis (acute stage), minimization of soft tissue contractures and complications can be achieved by increasing shoulder ROM and activities.^37,38 Mao CY in 1998 proved that capsular stretching is effective in the frozen shoulder treatment.⁹ Paula M Ludewig et al., used capsular stretching brace, which was worn by the patient for 30 mins everyday.¹³ But in this study, patients were performing capsular stretching exercises. This may be the reason for capsular stretching to be less effective than scapulothoracic exercise for the frozen shoulder treatment.

Similarly, glenohumeral exercises and scapulothoracic exercises were performed for Group B patients. This is supported with the findings of study conducted by Derya Celik (2009), which reported that scapulothoracic exercises along with glenohumeral exercises are effective in the adhesive capsulitis management.³ In this study, pain was reduced and ROM was improved in both the groups at the end of third week. In some studies, assessment has been done to check scapular alterations in patients with frozen shoulder and treatment which focused on ROM improvement and pain relief. Scapulothoracic exercises were not included in any of these programs, but decreased glenohumeral ROM caused increased or compensatory scapulothoracic motions. According to Nicholson, during humeral elevation, increased upper rotation has been found in patients with frozen shoulder.³⁹ In another study, early and increased external rotation was noted to compensate the ability of flexion and scapular and frontal plane abduction of glenohumeral joint.⁴⁰ Fayad et al., performed early scapular external rotation during humeral elevation using a 3-dimentional kinematic analysis system.⁴¹

The purpose of this study was to provide normal scapulothoracic rhythm while enhancing glenohumeral ROM. In general, the rate of scapulothoracic rhythm is 2:1 in normal population; at 30-60° glenohumeral flexion, it is 4:1, and above 60° of flexion, it is 5:1. But, the rate of scapulothoracic joint mobility will increase in frozen shoulder.¹⁰ Capsular adhesions causes decreased glenohumeral joint mobility, which effects external rotation of shoulder and prevents inferior glide of humerus below the acromion while doing shoulder elevation.¹¹ Throughout humeral elevation, the scapula reaches to the end range earlier than humerus because of glenohumeral impingement or restricted glenohumeral motion. In this study, we included scapulothoracic strengthening exercises and mobilizations to the patients in group B to increase scapular protraction and external rotation movements. ROM (Flexion, abduction and external rotation) was found better in the group B, who received scapulothoracic exercises. It can be hypothesized that scapulothoracic strengthening exercises restored normal scapulothoracic rhythm. In addition, the degree of pain was found significantly lower in the group B than group A.

Limitations of this study

1. Sample size was small. Only 30 subjects were taken for the study.

2. The subjects were not categorized as per their age for comparison of the effectiveness of the treatment techniques.

3. The study did not have any follow up role to check the effectiveness of intervention.

4. The study population included only patients referred to outpatient department of ITI General hospital, Bangalore

5. There was no control group in this study which could have given accuracy to the intervention.

6. Sampling was convenient in nature.

Recommendations for further studies

1. The subjects could be categorized into specific age groups on comparison for better clarity in the efficacy of various age group populations.

2. Study duration could be extended to post intervention follow up measurements to anticipate outcomes during follow up period.

3. Larger sample size may be taken for the study.

4. The sampling method would have been randomized for more accuracy.

5. A control group can be taken for the accuracy of intervention.

Conclusion

Significant improvements have been shown by both group A and group B, but group B showed greater decrease in pain and disability. In conclusion, scapulothoracic exercises in addition to glenohumeral exercises can be used for pain reduction and to increase glenohumeral ROM by fixing scapulohumeral rhythm. In future studies, scapulothoracic dyskinesis should be assessed, and myofascial trigger points and muscle imbalance should be considered a result of pain in shoulder, and planning and assessing treatment programs.

Conflict of interests

None.